THE ENCYCLOPEDIA OF

STRESS AND STRESS-RELATED DISEASES

Second Edition

THE ENCYCLOPEDIA OF

STRESS AND STRESS-RELATED DISEASES

Second Edition

Ada P. Kahn, Ph.D.

Foreword byDelbert H. Meyer, M.D.

The Encyclopedia of Stress and Stress-Related Diseases, Second Edition

Copyright © 2006, 1998 by Ada P. Kahn, Ph.D.

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means,electronic or mechanical, including photocopying, recording, or by any information storage or retrieval

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Library of Congress Cataloging-in-Publication DataKahn, Ada P.

The encyclopedia of stress and stress-related diseases / Ada P. Kahn ; foreword by Delbert H. Meyer.—2nd ed.p. cm.

Rev. ed. of: Stress A–Z.Includes bibliographical references and index.

ISBN 0-8160-5937-3 (hc: alk. paper)1. Stress (Physiology)—Encyclopedias. 2. Stress (Psychology)—Encyclopedias. 3. Stress management—

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CONTENTS

Foreword vii

Entries A–Z 1

Appendixes 399

Bibliography 410

Index 417

The topic of stress seems now to be discussedmore frequently in homes, workplaces, and

schools than ever before. As the world becomesmore complex in terms of changing economies,organizational structure, competition, and safety,stress appears to be escalating.

Issues of personal, family, and national safetyarise daily. Airline travelers experience frustrationwaiting in lines, then again at check-in points withthe many questions to answer and procedures tofollow. Workers in factories and high-rise buildingsmust undergo elaborate safety precautions in orderto enter and leave the workplace. Young people inmany schools must pass through metal detectorsbefore entering buildings. These are just a few ofthe everyday challenges that can cumulativelyincrease the stress level for people of all ages.

In this edition of The Encyclopedia of Stress andStress-Related Diseases, author Ada P. Kahn hasadded entries about numerous contemporaryissues that contribute to stress. Many of the newterms relate to technological advancements, aging,work-related issues, family life, and mental health.

Although technology has produced excitingdevelopments in computer and telecommunica-tions capabilities, it has also caused stress in manypeople. How many older folks experience exasper-ation when trying to use electronic gadgets that areused so facilely by younger people? How manyemployers now ban camera phones from companyproperty? Telecommunication capabilities havesurged ahead. But at the same time, annoyancesrelated to recorded messages, particularly in servicesectors, are overwhelming. While some of these sit-

uations fall into the category Kahn refers to as“random nuisances,” the cumulative effects on anindividual can interfere with good health.

As people live longer, aging becomes an increas-ingly contemporary stressor for the elderly, as wellas their middle-aged children who themselves mayalso be approaching senior status and early infirmi-ties. Debilitating illnesses and loss of capabilities aremajor stressors for the elderly. In many families,middle-aged children live far from their elderlyparents and become long-distance caregivers. Thetechnology of communication cannot competewith the old-fashioned comfort of personal visits,kind words, and handholding in familiar surround-ings. Moving a surviving parent closer may relievesome stresses but could also create new ones. Itmay be difficult for the parent to make new friendsin strange surroundings and for the children tohave a new boarder or more immediate anddemanding responsibilities.

In the area of work-related stress, issues aboundon a global scale. In many sectors, mergers andacquisitions may reduce the number of availablejobs. Outsourcing, while creating jobs elsewhere,may reduce opportunities for work locally. Askingfor service assistance by telephone can be stressfulfor the information seeker when connected to atechnician for whom English is a second language.

As the author of The Encyclopedia of Work-RelatedInjuries, Illnesses, and Health Issues, Kahn hasresearched and described many work-relatedsources of stress. She has included a number ofthese topics in this edition of The Encyclopedia ofStress and Stress-Related Disorders. Readers will find

FOREWORD

vii

entries on bullying, Employee Assistance Programs,smoking in the workplace, violence, and challengesfaced by accountants, lawyers, taxi drivers, miners,and construction workers, among many others.

In looking at family situations, Kahn includestopics relating to domestic violence, commutermarriages, and changing patterns of children’sactivities. Are children still allowed to be children?Overscheduling of after-school activities can be asource of stress for young people and their parents.

Finally, this edition of The Encyclopedia of Stressand Stress-Related Diseases includes comprehensiveexplanations of many mental health issues thatcaused 40 million people to schedule office visitswith physicians in 2002. Indeed, anxiety disordersare the most common mental health concern in theUnited States. Kahn draws on her background ofresearch as coauthor of three books on fears andanxieties (The Encyclopedia of Phobias, Fears and Anx-ieties, 2nd Edition, Facts On File, Inc., 2000; FacingFears, Facts On File, 2000; and Phobias, Scholastic,2003) to provide readers of this book with infor-mative details to help differentiate fears from pho-bias, both of which are serious sources of stress thatthreaten good health. Common fears, such asearthquakes and terrorism, and specific phobias,such as public speaking and heights, are explainedin order to help readers recognize their fears andphobias. They can then take steps to cope withthese stressors in effective ways.

Stress is inevitable in human beings. Understand-ing that stress can overload a person’s physical andmental systems can help us better cope with dailychallenges. However, as Kahn explains, the key tohealthy living is how one adapts and copes witheveryday and ongoing stressors. These can rangefrom serious situations (such as a life-threatening ill-ness) to everyday random nuisances (such as trafficdelays or telemarketing calls at dinnertime).

As a physician, I see many patients whose con-cerns may stem from personally stressful issues.

Some people cope effectively with difficult situa-tions, while others find that ongoing stress leads todigestive problems, headaches, difficulty sleeping,and ineffective and destructive coping methods,such as eating disorders, alcoholism, and substanceabuse. I had a patient who suffered a myocardialinfarction with documented cardiac muscle destruc-tion. However, when the coronary angiogramswere done, there was not a plaque or thrombosisseen, suggesting that coronary spasm was the etiol-ogy that in turn was most likely the result of anacute, very stressful event.

In taking a medical history, physicians can bet-ter serve patients by including questions abouttheir home, workplace, community, or school. Isthere marital discord? Are there concerns aboutelderly parents? Are difficulties at work or schoolpresent? When linking the stressful challenge tothe presenting symptom, a physician can alsoprovide suggestions for relaxation rather than (orin addition to, where appropriate) anxiolyticmedications.

Kahn describes many strategies for relaxation,such as aromatherapy and breathing exercises,physical exercise, meditation, music, yoga, and t’aichi. Indeed, learning to relax and to deal witheveryday challenges in a calmer manner may bethe best advice for many stressed individuals.

Being properly informed is the key to copingeffectively with daily challenges in the many areasof contemporary life that could lead to stress. Tothis end, Kahn’s work on this second edition of TheEncyclopedia of Stress and Stress-Related Disorders istruly outstanding. The book will be useful for con-cerned individuals, reference librarians, employers,human resource personnel, therapists, and physi-cians, as well as all curious readers.

—Delbert H. Meyer, M.D.University of California at Davis,

Mercy San Juan Hospital

viii The Encyclopedia of Stress and Stress-Related Diseases

ENTRIES A–Z

Aabortion The interruption or loss of any preg-nancy before the fetus is capable of living outsidethe womb. However, the term usually refers toinduced or intentional termination of pregnancy,while spontaneous abortion, the natural loss ofpregnancy, is usually referred to as “miscarriage.”

The subject of abortion is stressful to society aswell as to individuals. In the early 2000s, there areissues of social pressure as well as differing reli-gious, moral, and political points of view. Someviewpoints hold that life begins at conception andregard abortion as a criminal act. Other viewpointshold that life begins when the baby is capable ofsustaining itself beyond the womb.

In 1973, the United States Supreme Courtdeclared that under the Constitution a woman wasentitled to undergo an abortion at any time duringthe first trimester (three months) of pregnancy; theindividual states retained the right to regulate forhealth reasons where and by whom abortionscould be performed during the second trimester.Since then, those who oppose abortion on moraland religious grounds (known as pro-lifers) havefought to reverse and limit this decision, and theissues themselves have become incorporated intopolitical party platforms during presidential andcongressional campaigns.

Throughout history, many women have copedwith the stress surrounding the decision to abort,and the method to use. Until the Supreme Courtdecision, society at large condemned women whohad intercourse outside of marriage and ignoredthe dilemma arising from an unwanted pregnancy.The choice to abort was made secretly and oftenwithout the knowledge and support of family orthe man involved. Today, however, there is a largegroup (known as pro-choicers) who, whether they

are for or against abortion, campaign for the rightof a woman to make that choice.

In the United States, procedures used for elec-tive termination depend on the length of the preg-nancy. In the early stages, procedures are relativelysimple, involve minimal pain and discomfort, andrarely require an overnight hospital stay. For laterstages, procedures are more complicated, but all ofthese procedures, when performed in a sterileenvironment by competent physicians, are safe.

The key to relieving the stress of an abortion isknowing where to turn for information and coun-seling. If at all possible, the support of family andfriends should be sought as early as possible. Orga-nizations such as Planned Parenthood, with officesin many large cities, local health departments,women’s and other health clinics, family doctors,or local hospital gynecology staff are resources forhelp. While the lasting effects of an unwantedpregnancy cannot be completely eliminated, mak-ing a decision that is based on knowledge of all theoptions is more likely to reduce the stress. Inmany cases, the subject of abortion also causesstress for the fathers-to-be who may share in thedecision-making process regarding continuationof the pregnancy.

See also PREGNANCY.

FOR FURTHER INFORMATION:Planned Parenthood Federation of America434 West 33rd StreetNew York, NY 10001(212) 541-7800http://www.plannedparenthood.org

SOURCE:Kahn, Ada P., and Linda Hughey Holt. The A to Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.

1

absenteeism Absenteeism or frequent absencefrom work may be related to employees’ stress onthe job and/or in their personal lives.

Another source of stress for employees is theneed to balance time for work, family, and self. Thisstressor can lead to health problems, decreased pro-ductivity, and employee turnover. It can be expectedto remain a major factor since the hours spent bymen and women in the workplace are increasing.

Employees experiencing stressors may exhibitpersistent physical symptoms such as irregularsleep patterns, fatigue, anxiety, and weight change.There is also evidence that these employees may bemore subject to colds, flu, headaches, gastricupsets, and other illnesses, all of which lead to anincrease in absenteeism.

The high rate of absenteeism among the nation’sworkers results in high losses for business and indus-try. Many corporations have undertaken preventiveefforts, such as health examinations, health riskappraisals and employee assistance (EAPs) and well-ness programs for weight control, smoking cessation,exercise, and stress reduction. Because there is a pos-itive correlation between absences and the attitudesof employees to their superiors, some employeeshave introduced programs aimed at job enrichment,career ladders, and worker participation.

See also EMPLOYEE ASSISTANCE PROGRAMS; MARI-TAL THERAPY; PRESENTEEISM; SCHOOL; WORKING

MOTHERS; WORKPLACE.

FOR FURTHER INFORMATION:American Industrial Hygiene Association (AIHA)2700 Prosperity Avenue, Suite 250Fairfax, VA 22031(703) 849-8888http://www.aiha.org

abuse See ADDICTION; DOMESTIC VIOLENCE.

accident An unexpected, unintentional, chancehappening. These stressful undesirable events ormishaps occur in homes, schools, workplaces,while traveling, in water, or many other places.Some accidents may result in injuries; others aremerely inconveniences. The stress caused by anaccident disrupts one’s schedule and, depending onits seriousness, may affect family members,employers, or insurance companies.

In homes, falls and burns are common acci-dents. In workplaces, machinery accidents and eyeinjuries are common accidents.

According to the Centers for Disease Control andPrevention, injuries are a leading cause of death forAmericans of all ages, regardless of gender, race, oreconomic status. Many of these injuries are theresult of accidents. For many, the injury causestemporary pain and inconvenience, but for some,the injury leads to the ongoing stress of disability,chronic pain, and a profound change in lifestyle.

The best way to cope with the stress of accidentsis prevention. In homes, attention should be givento loose rugs, electrical cords and other objects onwhich a person may trip. In workplaces, adherenceto safety standards of the specific industry is a pri-mary way to prevent accidents and their stressfulaftermaths.

See also ELECTRICITY; FALLING MERCHANDISE;INDUSTRIAL HYGIENE; PERSONAL PROTECTIVE EQUIP-MENT; SLIPS, TRIPS, AND FALLS.

accountants Accounting is a very stressful field ofemployment. Accountants begin their careers withgreat expectations. At some stage, they may start anindependent practice with a new sense of freedomand many misgivings, worries, and fears. A large partof accountants’ self-esteem is involved in the successor failure of the accounting practice. There is also thestress of making enough money to pay the bills and

2 absenteeism

STRESSFUL FACTORS AT WORK THAT MAY CAUSE ABSENTEEISM

• Lack of recognition by superiors• Role conflict (particularly with peers)• Deadlines• Job unsuitability or unpreparedness• Concerns about job security and career paths• Environmental discomforts (“sick building

syndrome”)• Sexual concerns• Marital difficulties• Concerns about children/grandchildren• Concerns about elderly parents• Financial problems• Health problems (self or family members)• Other family pressures

working long hours at risk of becoming a worka-holic. A support system sometimes exists in a corpo-rate environment if partners or team workers sharefeelings, hopes, and disappointments. However, inprivate practice, an accountant may feel isolated andeven overwhelmed.

Whether an accountant experiences the stressof burnout depends on his or her tolerance forfrustration and boredom. It also depends on thesocial connections and creative outlets theaccountant has in his or her life.

A poll of accountants in England found 82 per-cent of respondents working more than 40 hours aweek and 30 percent working 45 hours or more.Many also take work home. However, more thanhalf believed accountancy gave them a good work-life balance, and that the rewards made the sacri-fices worthwhile. One firm said “There’s littledoubt that accountancy is a more demanding envi-ronment today than it has ever been. Events suchas 9/11 and the Enron scandal, and the ensuingincrease in regulation have put finance profession-als right in the firing line.”

Tips for Accountants to Avoid Stress

SmartPros Ltd., a provider of accredited professionaleducation for accounting and finance professionals,has some tips for accountants to avoid stress:

• As you build or expand your accounting prac-tice, do not neglect friends.

• If you have a spouse, significant other, children,or pets, set aside a time of day that belongs tothem alone.

• Join professional support organizations thatserve the dual functions of helping you developyour accounting business and giving you a socialoutlet.

• Take a vacation. Leave the business at home.

• Develop a nonbusiness hobby that provides youwith a creative outlet, such as community the-ater or stand-up comedy.

FOR FURTHER INFORMATION:SmartPros Ltd.12 Skyline DriveHawthorne, NY 10532(914) 345-2620

SOURCE:Fox, Jack. “Accountants Can Learn to Overcome Burnout

and Stress,” SmartPros Web site. Available online.URL: http://accounting.smartpros.com/x26464.xml.Downloaded on August 22, 2005.

acculturation The process of adjusting to a newculture. In situations where there are linguistic orcultural communication barriers or an individual’sexpectations are not congruent with what takesplace, stress can be heightened.

The stress of adjusting to an unfamiliar culturemay lead to behavior changes, such as increasedalcohol and tobacco consumption. Furthermore,when various family members become accustomedto the new culture at different rates, conflicts canarise between the generations, contributing to ten-sions within the family.

There are many community service programsavailable in cities in the United States designed tohelp acquaint newcomers to the country with cus-toms, costs, and ways to locate needed services.Many are geared to helping newcomers learn thelanguage, while others emphasize the socioculturalaspects of relocating. Local public libraries are agood source of such programs. Frequently, ethnicgroups welcoming newcomers in their communi-ties will help them learn how to shop in local mar-kets, find good merchandise at a discount, andobtain legal services and medical care.

Health Care Needs of Immigrants

Many immigrant patients in the United States donot use the Western medical model. Some of thesepatients see Western medicine as one of manyhealing systems. Cultural expectations can causestress for these individuals as well as the physicianswho treat them. For example, some East Indianwomen will not allow pelvic examination by malephysicians, even those from their own culture.Because such procedures can be construed asgrounds for divorce, a relatively simple physicalexamination becomes both a cultural and a med-ical issue.

Health care professionals should address theclinical issues surrounding folk beliefs and behav-iors in a culturally sensitive manner, according toan article in The Journal of the American Medical Asso-ciation (March 1, 1994). Lee M. Pachter, D.O., St.

acculturation 3

Francis Hospital and Medical Center, Hartford,Connecticut, wrote: “A culturally sensitive healthcare system is one that is not only accessible, butalso respects the beliefs, attitudes and culturallifestyles of its patients. It is a system that is flexi-ble and acknowledges that health and illness are inlarge part molded by variables such as ethnic val-ues, cultural orientation, religious beliefs and lin-guistic considerations.”

Dr. Pachter explained that most medical folkbeliefs and practices are not harmful and do notinterfere with biomedical therapy. Under these cir-cumstances the clinician should not attempt to dis-suade the patient from these beliefs, but instead

educate him or her as to the importance of the bio-medical therapy in addition to the patient-heldbelief. Any ethnomedical practice that has thepotential for serious negative outcome needs to bediscouraged, but this must be done in a sensitiveand respectful way. Replacing dangerous practiceswith alternatives that fit into the patient’s ethno-cultural belief system is often met with acceptance.

As reported in an editorial in Canadian FamilyPhysician (October 1995), the stress of the accul-turation experience is especially severe for indi-viduals whose future residency status is inquestion, such as those entering a new country asa student, or those hoping to find work andremain on a permanent basis. Local communityagencies can help relieve some of the stressesthese individuals encounter.

See also ALTERNATIVE THERAPIES; MIGRATION; PER-SONAL SPACE.

SOURCES:Cave, Andrew, et al. “Physicians and Immigrant

Patients.” Canadian Family Physician 41 (October1995): 1,685–1,690.

Pachter, Lee M. “Culture and Clinical Care: Folk IllnessBeliefs and Behavior and Their Implications forHealth Care Delivery.” Journal of the American MedicalAssociation 271, no. 9 (March 1, 1994): 690–694.

acne Very common skin condition; occurs on theface but can also occur on the back, chest, shoul-ders, neck, and buttocks. It consists of blackheads,whiteheads, pimples, and deeper, boil-like lesionscalled nodules and can be a source of extremestress for the sufferer.

It has been estimated that 80 percent to 90 per-cent of teenagers suffer from acne at one time oranother, and about one in every five young peoplevisit a dermatologist because of acne. The prevalenceof the problem is no comfort to the high school stu-dent who feels that the blemishes will keep him orher from being socially accepted. Although primarilya disease of adolescence, acne occurs among olderpersons as well. In many cases untreated acne clearsup after several years; however, it can leave lifelongscars that affect the person’s self-image.

Coping with Acne

In addition to seeking help from a dermatologist, aperson who has acne might relieve some of his or

4 acne

TIPS TO REDUCE STRESS OF MEDICALENCOUNTERS WITH IMMIGRANT PATIENTS

• Become aware of the commonly held folkmedical beliefs and behaviors of the patient’scommunity.

• Assess the likelihood of a particular patient orfamily acting on these beliefs during a specificillness episode.

• Arrive at a way to successfully negotiatebetween the two belief systems.

• Be aware of your own cultural biases.• Determine whether language will be an issue

during office visits.• Develop an office guide for immigrant patients,

including typical questions asked during anexamination, needs for disrobing, and types ofexaminations and testing procedures and theirimportance.

• Prepare a list of local agencies that are availableto help with multicultural issues.

• Encourage patients to share their culture andlife-style with you so that you have informationfor accurate diagnoses and appropriate therapy.

• Ask before going ahead with any procedures. Byseeking permission and explaining the proce-dures you remove the mystery and patientsbecome partners in the activity rather thanobjects of scrutiny. Compliance improves withunderstanding.

• Take advantage of opportunities for cross-culturallearning in group discussions with other profes-sionals from different cultural backgrounds.

her stress by joining a peer support group at schoolor at a local community center, or visiting a psy-chotherapist who counsels adolescents. Parentscan be particularly helpful to their son or daughterwho has acne by being supportive, offeringencouragement for treatment, and contributing tothe young person’s self-esteem. In cases of extremescarring a plastic and/or reconstructive surgeon’sopinion on treatment might be sought.

Diagnosis and Treatment

Dermatologists recommend that sufferers not pick,scratch, pop, or squeeze pimples, which may leadto additional inflammation and scarring. However,when treating acne, the dermatologists may openpimples or remove blackheads and whiteheads.

Depending on the type of acne, a dermatologistwill recommend different therapies. In some cases,an acne-like rash is due to another cause, such asmakeup, lotions, or medications. When visiting adermatologist, it is important to provide a historyof relevant habits.

For milder cases of acne, many non-prescriptionlotions and creams may be helpful. If used toooften, however, many of them lead to excessivelydry skin. Dermatologists advise that when buyingmakeup, people should choose noncomedogenicor nonacnegenic products. Noncomedogenic meansthat using the cosmetic should not result in the for-mation of whiteheads and blackheads. Topicalpreparations in cream or lotion form are some-times prescribed by dermatologists to help unblockthe pores and reduce the bacteria.

In more severe cases, female-type hormonesand other medications that decrease the male-typehormones are used. Another oral medication,isotretinoin (Accutane), is sometimes used to treatacne that has not responded to other treatments.However, frequent visits with the dermatologistare necessary to monitor and control the sideeffects; the drug can cause severe birth defects iftaken during pregnancy.

Self-Care to Relieve Acne

There is no instant or permanent cure for acne, butit can be controlled and sufferers should be encour-aged to follow appropriate care and treatment toprevent permanent scars. Washing the face withsoap and warm water no more than twice a day is

a good routine to follow. Men with acne who shaveand prefer using a safety rather than an electricrazor have particular concerns. They should softenthe beard thoroughly with soap and warm water.To avoid nicking pimples, they should shave aslightly as possible, and shave only when necessary,always using a sharp blade. Dermatologists havediffering opinions on the importance of diet inmanaging acne. Some people however, find thattheir acne becomes worse when they eat certainfoods, such as chocolate, milk products, or nuts.Individuals can often determine what foods causetheir acne and learn to avoid them.

FOR FURTHER INFORMATION:American Academy of DermatologyP.O. Box 4014Schaumburg, IL 60168(847) 330-0230http://www.aad.org

SOURCE:Acne. Schaumburg, Ill.: American Academy of Dermatol-

ogy, 1993.

acquired immunodeficiency syndrome (AIDS)AIDS is a deficiency of the IMMUNE SYSTEM due toinfection with HIV (HUMAN IMMUNODEFICIENCY

VIRUS). As yet, there is no curative treatment andno vaccine for AIDS; however, in many individu-als, symptoms and complications respond in vary-ing degrees to antiviral agents, antibiotics,radiation therapy, and anticancer drugs.

AIDS is considered by many the “plague” of the20th century. No other disease in modern timeshas had such an impact on the world. It is a sourceof stress for those who are infected, for all who fearacquiring it, and for family and friends of AIDSpatients.

Nearly 5 million people across the world con-tracted the virus that causes AIDS in 2003, morethan in any year previously recorded, according toa United Nations report released in July 2004.According to the report, estimates are that 38 mil-lion people were living with HIV across the worldin 2003, up from 35 million in 2001. Of the 20 mil-lion people who have died of AIDS since 1981,when the disease was first reported, 5.6 milliondied since 2002.

acquired immunodeficiency syndrome 5

In the United States and western Europe, infec-tions have risen since 2002. According to the U.S.Centers for Disease Control and Prevention, about950,000 people are now living with HIV and AIDSin the United States, up from 900,000 in 2001; halfof all those who are newly infected are AfricanAmericans. In western Europe, 580,000 peoplehave the virus, a rise from 540,000 two yearsbefore. Since the early 1980s, 500,000 Americanshave died from AIDS. While the death rate hasgone down, the rate of new infections is increasing.

In 2003, the estimated number of diagnoses ofAIDS in the United States was 43,171. Adult andadolescent AIDS cases totaled 43,112, with 31,614cases in males and 11,498 cases in females. Also in2003, there were 59 AIDS cases in children underage 13.

How the Virus Is Transmitted

The virus is transmitted through body fluids—usu-ally semen or blood, but also through saliva andtears. AIDS is also transmitted from mother toinfant in utero or via passage through the birthcanal or via infected breast milk. More rarely, doc-tors and nurses exposed to infected patients havecaught the virus. There have also been isolatedcase reports of infection through organ donations,artificial inseminations, and exposure to infecteddentists. In the early 1980s, when AIDS was firstrecognized as a syndrome and the full extent of thedisease acknowledged, most of the patients werehomosexual males and intravenous drug users ortheir partners. Within a few years, there was recog-nition that the disease was also spreading into theheterosexual population, and that women andchildren were dying of AIDS.

In many developed countries, public healthmeasures have helped to level off the rate of AIDS.For example, donated blood and semen samplesare screened for AIDS. Also, guidelines have beendeveloped for “safe sex” between partners in riskgroups. “Safe sex” eliminates the exchange of bodyfluids through such means as using condoms,avoiding oral intercourse, and limiting to a single,steady partner. Western medical centers advise“universal precautions,” which mean carefullycovering any body surfaces that might be exposedto an infected person’s body fluids.

Stresses of HIV on Mental Health

Individuals at high risk for developing the diseaselive in fear and have concerns about acquiring thedisease through casual contact. Death from AIDShas touched many families in the United States.For most, it has meant recognizing their children’shomosexual behavior as well as facing their illnessand death in their 20s, 30s, and 40s.

The period of time after learning that a person isinfected with the HIV virus is characterized by anx-iety and stress stemming from his or her ownDENIAL, family reactions, the homophobia of bothfamily and friends, and employment and insuranceconcerns. HIV patients need nonjudgmental, for-ward-looking sources of support, people skilled inLISTENING carefully, letting them speak their fears,and dealing with their physical symptoms. SUPPORT

GROUPS, helping the person maintain as much CON-TROL as possible, counseling them in legal decisionsbefore dementia sets in, and identifying referralprograms, are extremely helpful.

Stresses on Health Care Professionals

There is enormous personal stress among manyhealth care professionals who work with AIDSpatients. There is the medical complexity of thedisease, as well as the stigma of AIDS and AIDS riskbehaviors. Some health care workers fear contract-ing the disease from the patients, while someinwardly rebel against caring for people whoseconcepts of behavior differ so radically from theirs.

Pediatric AIDS

Pediatric AIDS causes special stresses for theinfected child and his or her family. Many infectedchildren require foster care because of parentalinability to provide the needed care. Unfortu-nately, many AIDS-infected children do not livelong, and parents must face grief after watchingthe child suffer. Although it is controversial, mostcommunities have accepted the opinion of theCenters for Disease Control that infected childrenin a normal classroom would not pose a hazard totheir classmates. However, the reality is that fewinfants or young children with AIDS live longenough to be in school for very long. Meanwhile,schoolchildren with AIDS live with the stresses ofbeing different and have difficulties maintainingthe grade level because of frequent treatment. In

6 acquired immunodeficiency syndrome

many cases, they are cut off from teachers andother students, which leads to FRUSTRATION,despair, and DEPRESSION.

Runaway adolescents, many of whom subsistthrough prostitution, are especially vulnerable toHIV infection. These teenagers have few supportsystems, are usually school dropouts, and havesevered family connections.

AIDS in the Aging Population

HIV/AIDS is increasing among people age 50 andover. According to the U.S. Centers for DiseaseControl and Prevention, 17 percent of new casessince 2002 are among Americans 50 and older, upfrom 15 percent from 1991 through 2001. OlderAmericans “are probably the least educated groupabout AIDS,” according to Nathan Link, an AIDSresearcher at the University of Illinois at Chicago.Additionally, most physicians do not ask elderlypatients about their sex lives or drug use, nor dothey routinely test them for HIV/AIDS.

AIDS and Pregnancy

Recommendations by the Centers for Disease Con-trol included testing of pregnant women for theHIV virus who acknowledge having engaged inhigh-risk behavior. More recently, researchershave suggested that HIV screening be routinelyoffered to all pregnant women.

See also CHRONIC ILLNESS.

FOR FURTHER INFORMATION:AIDS-Hotlines NationalAZT Hotline(800) 843-9388

CAIN (Computerized AIDS Information Network)San Francisco AIDS Foundation54 Tenth StreetSan Francisco, CA 94103(415) 864-4368

Centers for Disease Control andPrevention/American Social Health Association(800) 341-AIDS

National Prevention Information Network (NPIN)Centers for Disease ControlP.O. Box 6003Rockville, MD 20849(800) 458-5231

Physician Link (List of MDs with expertise inAIDS treatment and research)(800) 344-5500

SOURCES:Andre, Pierre. People, Sex, HIV & AIDS: Social, Political,

Philosophical and Moral Implications. Huntington, W.Va.: University Press, 1995.

Donovan, Catherine A., and Elizabeth Stratton. “Chang-ing Epidemiology of AIDS.” Canadian Family Physician40 (August 1994).

Epstein, Steven. Impure Science: AIDS, Activism and the Pol-itics of Knowledge. Berkeley: University of CaliforniaPress, 1996.

Gifford, Allen. Living Well with HIV & AIDS. Palo Alto,Calif.: Bull Publishers, 1997.

Goldfinger, Stephen E., ed. “AIDS: A Glimmer of Hope.”Harvard Health Letter 20, no. 9 (July 1995).

“Panel Backs New AIDS Drug.” Chicago Tribune, Novem-ber 7, 1995.

acrophobia A fear of heights. It is one of themost common PHOBIAS and is a source of stress tophobic individuals. The fear, which may includebeing on top of mountains, on high floors of sky-scrapers, or even of riding to a high floor in an ele-vator is usually out of proportion to the realdanger. There is a high level of stress and anxietyeven when these individuals approach overlooksor bridges. Some individuals who experience acro-phobia may also fear being injured or falling,which are related phobias.

See also ANXIETY DISORDERS.

acupressure Sometimes referred to as ACUPUNC-TURE without needles, acupressure embraces thesame concepts of energy flow and point stimula-tion as the original science but uses the pressure ofthe therapist’s fingers for point stimulation. Acu-pressure is used by many people for relief of phys-ical and psychological stresses. It is thought tocombine the science of acupuncture with thepower of the healing touch and has been mostwidely used for pain control.

In Oriental medicine, acupressure is helpful inconditions where the body’s energy balance hasbeen upset by a variety of physical and/or emotionalstresses. Because it is an extremely gentle technique,acupressure is sometimes used by the therapist withindividuals who are fearful of needles.

See also ALTERNATIVE MEDICINE; SHIATSU.

acupressure 7

acupuncture A technique used to relieve stressfor many people. It has been used for thousands ofyears as a component of Chinese medicine, and isbased on the theory that the body’s “vital energy”(chi) circulates through “meridians” along the sur-faces of the body. The ancient theory holds that ill-ness and disease result from imbalances in vitalenergy, which can be remedied when therapy isapplied to “acupuncture points” located along themeridians. The goal of acupuncture is to rebalancethe flow of energy, promoting health and prevent-ing future imbalance. The points are believed tohave certain electrical properties, which whenstimulated can alter chemical neurotransmitters inthe body and bring about a healing response. Prac-titioners of acupuncture insert hair-thin stainlesssteel needles into the patient’s body surfaces atacupuncture points.

In addition to stress reduction and relaxation,many people have used acupuncture for a varietyof conditions, including osteoporosis, asthma, backpain, painful menstrual cycles, and migraineheadaches.

Research with Acupuncture

Over the last two decades in the 20th century,acupuncture became one of the most intensivelystudied medical procedures, said Dr. Bruce Pomer-anz, professor of medicine, University of TorontoMedical School. He reported to the Toronto Star(September 10, 1995) that scores of scientificallyrigorous animal experiments and clinical studiesallowed researchers to uncover a mechanism toexplain how acupuncture controls chronic pain.Evidence points to a similar mechanism accountingfor acupuncture’s success in treating addictions toalcohol, cocaine, and opiate, he said. The acupunc-ture points on the body and ear correlate to siteswhere there are unusually large concentrations ofnerves. The needles stimulate the nerves, whichsend an electrical message to the brain. Dr. Pomer-anz explains that the brain releases endorphins(morphine-like brain chemicals), which block painmessages from getting through and take away theemotional components of pain.

Further, the endorphin system is linked to a sys-tem that releases cortisone, a chemical that alleviatesinflammation in the body. Heroin and cocaine

addicts suffer from depressed endorphin levels. Theirbodies compensate for the high levels of narcotics intheir blood by producing less of the naturally-occur-ring substance. The agonies of withdrawal resultfrom low levels of the painblocking endorphins.Stimulation of the endorphin system throughacupuncture gets it going in a natural way, said Dr.Pomeranz. He also pointed out that acupuncture hasbeen successful in treating alcoholism.

Increasing Acceptance of Acupuncturists

In the early 2000s, acupuncture is permitted in all50 states. In some states, only physicians are per-mitted to practice acupuncture, while other statesallow the procedure to be performed by layacupuncturists under medical supervision or byunsupervised laypersons. In the United States, anestimated 3,000 medical doctors and osteopathshave studied acupuncture and use it in practice, upfrom 500 a decade before. Additionally, some7,000 nonphysicians use acupuncture for a widearray of problems, sometimes in conjunction withmassage, herbal therapies, and other traditionalEastern techniques. In 1990, the U.S. secretary ofeducation recognized the National AccreditationCommission for Schools and Colleges of Acupunc-ture and Oriental Medicine as an accreditingagency. However, the Food and Drug Administra-tion considers acupuncture needles to be investiga-tional devices and has not approved the use ofacupuncture for any disease treatment.

Choosing an AcupuncturistIndividuals choosing a therapist to performacupuncture should be examined by their physi-cian first. Some conditions are beyond the scope ofacupuncture treatment and demand immediatemedical attention. However, many physicians mayagree to have their patients undergo acupuncturealong with traditional treatment. In some casesthey will agree that a patient try acupuncture first,if postponing traditional treatment will not be inju-rious. When arranging to meet with an acupunc-turist, follow the suggestions on page 9.

See also ACUPRESSURE; ADDICTION; ALTERNATIVE

MEDICINE.

SOURCES:Martyn, Peter. “Acupuncture Successful in Treating

Addictions.” The Toronto Star, September 10, 1995.

8 acupuncture

Weiss, Rick. “Medicine’s Latest Miracle.” Health, January/February 1995.

addiction Usually refers to psychological orphysical dependence on a chemical substance orbehavior. Some individuals develop addiction toalcohol, tobacco, drugs, food, and sedatives pre-scribed by physicians. Others are addicted to activ-ities such as dieting, exercising, GAMBLING, and sex.An addiction is often the result of stressful situa-tions and the inability of the individual to cope

with them. Once addicted, he or she suffers fromnew stresses, including the physical or mentalsymptoms of the addiction or obtaining the moneyfor his or her habit. In the meantime, family,friends and employers also suffer from stress,which can lead to situations such as DIVORCE, lowjob productivity or loss of job.

Criteria for addiction are a compulsive or obses-sive craving leading to persistent substance use orrepeated actions; a need to increase the substancedose or level of activity as the addict’s toleranceincreases; and, with certain drugs (alcohol, nar-cotics, barbiturates, etc.), possibly acute with-drawal symptoms if the drug is reduced orwithdrawn abruptly. Withdrawal symptoms alonedo not necessarily imply addiction. However, phys-ical dependence can develop with prolonged use ofa drug (e.g., morphine for pain). Psychologicaldependence can involve a loss of control of thesubstance use, and a tendency to orient behavioror life priorities toward obtaining the drug or pur-suing the addictive behavior.

Recognizing an Addiction

Warning signs of drug or alcohol addiction includewithdrawal from responsibilities; deterioration offamily relationships, school or work performance;negative personality changes, such as depression;changes in sleep patterns, such as insomnia orsleeping too much; and legal problems, such asshoplifting or stealing money.

Overcoming Addictions

To overcome an addiction the addict must recog-nize that it exists and acknowledge his or herresponsibility for the situation. Once the addict hasconfronted his/her problem, relief from addictionsis usually best accomplished with a multidimen-sional approach. This may include psychological,medical, and spiritual therapies. Additionally,ALTERNATIVE MEDICINE, such as MEDITATION andGUIDED IMAGERY, may be of use.

The addict also needs help from family membersand an outside support group. Many self-helporganizations exist to help recovering addicts andcan be located through local public health depart-ments or libraries. Groups are available to help theaddicts themselves as well as spouses and children,who will also experience anxiety and stress

addiction 9

TIPS TO AVOID STRESS WHEN USING ACUPUNCTURE

• Discuss your expectations with the acupuncturist.Ask how long until you can expect to see achange in your condition. Be suspicious of prom-ises of a quick cure, especially if you have hadyour problem for some time. If you don’t seeprogress after six to eight treatments, reevaluateyour choice of treatment and the practitioner.

• Check the credentials of the acupuncturist youare considering. Ask whether he or she is certi-fied by the National Commission for the Certifi-cation of Acupuncturists. To become certified,an acupuncturist must pass both a written andpractical exam. To be eligible to take the exam,he or she must be licensed, have at least twoyears of training at an acupuncture school, ormust have worked as an apprentice acupunctur-ist for at least four years.

• If your prospective acupuncturist is a physician,ask whether he or she belongs to the AmericanAcademy of Medical Acupuncture, whichrequires at least 200 hours of acupuncture train-ing for membership. Approximately 500 of the3,000 physicians practicing acupuncture in theUnited States belong to the AAMA.

• Discuss the costs of the procedure. Dependingon the area of the country, and whether or notthe acupuncturist is a physician, fees vary. Usu-ally the first visit is considerably higher than sub-sequent visits.

• Weigh the risks of acupuncture. There havebeen reports of serious complications attributedto acupuncture needles. However, mostacupuncturists use sterile, disposable needlesthat come in a sealed package.

because of the addict’s behaviors. In many cases,relief from certain stressors, such as work pressureand family problems, can help an addict recoverfrom his or her dependency.

Addiction Severity Index

The addiction severity index is a tool that mentalhealth professionals generate from a questionnairethat gathers information about an individual’sstressors leading to or resulting from the addiction,as well as social, legal, employment, drug and alco-hol use, and other habits. Using the index, themental health professional can assess the individ-ual’s function and level of stress in each dimensionindependently at the beginning of treatment andlater, after treatment interventions.

See also AGING; ALCOHOLISM AND ALCOHOL

DEPENDENCE; ANXIETY; BEHAVIOR THERAPY; PSY-CHOTHERAPIES.

FOR FURTHER INFORMATION:American Society of Addiction Medicine4601 North Park AvenueUpper Arcade #101Chevy Chase, MD 20815(301) 656-3920http://www.asam.org

SOURCE

E’Archangelo, E. “Substance Abuse in Later Life.” CanadianFamily Physician 39 (September 1993): 1,986–1,993.

adolescence See PUBERTY.

adoption When individuals take by choice achild of other parents as their own child. Couplesor singles choose to adopt for various personal rea-sons; some are unable to have children and mayhave undergone a variety of tests and treatmentsto no avail. Adopting a child is a stressful processand with each step new anxieties appear to replaceprevious ones.

Planning for adoption puts stress on personalrelationships. Referring to emotional highs andlows, the book Adopting Your Child suggests, “Mostadoptions are roller coaster rides. There are longstraight stretches, sudden lurches upward, andswooping plunges to the ground. There are peoplefor whom adoption seems to go like clockwork, but

they are in the minority. Because there are somany areas over which you have no control, youcannot plan your way to a certain result.”

Next, the avenue of adoption must be chosenand the many players involved in aiding andapproving adoptive parents identified. Adoptiveparents have many choices to make: private chan-nels versus public agencies versus adoptionthrough intermediaries, adoption directly frombirth mother, or domestic versus international.Furthermore, far more adoption litigation is takingplace today, in courtrooms in the United States,and far more stories of birth parents changing theirminds permeate our media than in earlier times.Other issues that could arise include disqualifica-tion after a study of the adoptive home by a socialworker, refusal of a child that is referred, and courtdenial of the adoption.

Finally, once adoption occurs, there will be themany stresses that are the norms of parenthood.However, for adoptive parents other stressfulevents may lie ahead: deciding how and when totell children they are adopted, dealing with theanxiety this information may bring to them at var-ious stages of their lives, and recognizing the possi-bility that when they are older they may want tofind their birth parents.

See also COMMUNICATION; INFERTILITY; PARENTING.

FOR FURTHER INFORMATION:National Adoption Center1500 Chestnut Street, Suite 701Philadelphia, PA 19102(800) TO-ADOPT (toll-free)http://www.adopt.org

SOURCE:Reynolds, Nancy Thalia. Adopting Your Child: Options,

Answers, & Actions. Bellingham, Wash.: Self-CounselPress, 1993.

adrenaline A catecholamine (also known as epi-nephrine) produced and released by the adrenalmedulla in response to stimulation from the nervoussystem, such as stressful events. Regulated by thesympathetic nervous system, it is a potent stimulatorof the organs and may play a role in controlling cer-tain aspects of immune functions. Adrenaline pro-duces an increase in heart rate, rise in blood pressure,and contraction of abdominal blood vessels. These

10 adolescence

sympathetic changes can be reversed by activation ofthe parasympathetic system.

See also IMMUNE SYSTEM; NEUROTRANSMITTERS;STRESS.

advance directives See DEATH; END-OF-LIFE CARE.

advertising Propaganda for commercial pur-poses, designed to influence the consumer in mak-ing decisions to buy by emphasizing advantages ofone particular product over its competitors. Choos-ing from the wide array of products and servicesavailable in the marketplace today can be anextremely stressful experience.

Advertising is just one part of a complicatedprocess of marketing that includes determiningwhat goods and services should be created for aspecific segment of customers, finding suitablepricing structures and methods of distribution, andinfluencing prospective purchasers.

In an ideal world, consumers would be edu-cated and use technical guidelines and consumerguides to help in making purchasing decisions.Unfortunately, there are few educated consumersand most live their lives prey to the pressures andstresses of advertising. Children, particularly, canbe victims since they are unable to discriminatebetween what is real and what is unreal, what isgood and what is bad. In turn, children may placedemands on parents for products that can beunhealthy or poorly made, and which the parentscannot afford.

Direct mail and telemarketing, are playing anincreasingly important role in the advertisingprocess. Both tend to apply greater pressure intheir selling messages and often produce a greatdeal of stress for potential customers in the form ofunwelcome mail and telephone calls both at theoffice and at home.

Advertising campaigns are usually a combina-tion of print ads and radio and TV commercials.They nudge, tease, scold, amuse, prod, and pro-voke potential customers in order to get them totry and then buy. Often, the campaign is centerednot on the product itself, but on surroundingissues—how or where it is being used or who isusing it. Techniques used to accomplish thisinclude testimonials by well-known spokesper-

sons, often athletes or movie stars who are paid tolend their names or faces as an endorsement forproducts. In many cases, products are merelyrepackaged and promoted as new and improved.

Advertising campaigns are usually directed towomen, who have, since the turn of the century,accounted for more than 80 percent of all con-sumer spending. Until recently, Madison Avenuein New York City, long the center of the advertis-ing business, was dominated by males, and theimages of women in the advertising they createdreflected their fantasies and fears. Advertisers havetold consumers what they should and should notbe and/or do, and advertising has spun pictures ofperfection that often reminded consumers of theirmany shortcomings. Advertising, at its best, reflectsstyles and values. But it also can be overbearingwhen it takes the lead, sets the agenda, andattempts to dictate consumer behavior.

See also MONEY; SHOPAHOLISM.

FOR FURTHER INFORMATION

(INQUIRIES AND COMPLAINTS):Federal Trade CommissionPennsylvania Avenue 600 NWWashington, DC 20580(202) 326-2222http://www.ftc.gov

aerobic activities See EXERCISE.

affective disorders An individual who has anaffective disorder (also known as mood disorder)may have feelings of extreme sadness or intense,unrealistic elation with corresponding disturbancesin mood that are not due to any other physical ormental disorder. It is stressful enough for the indi-vidual as well as those around him or her at workor at home to warrant professional attention.

Affective disorders differ from thought disorders;schizophrenic and paranoid disorders are primarilydisturbances of thought, although individuals whohave those disorders may also have some distor-tion of mood or affect.

The death rate for individuals with chronicallydepressed moods is about 30 times as high as thatfor the general population because of the higherincidence of SUICIDE. Manic individuals also have a

affective disorders 11

high risk of death, which can be attributed to theirtendencies to exhaust themselves physically, toneglect their health, and to have accidents (oftenalcohol related).

Types of Affective Disorders

Affective disorders can be subcategorized as majordepression and bipolar disorders. These disorderscan be acute or chronic; both show symptoms bychanges in the biological, psychological and socio-logical functioning of the individual. In some indi-viduals, bipolar disorders and DEPRESSION occuraccording to a seasonal pattern, with a regularcyclic relationship between the onset of the moodepisodes and particular seasons.

A mood syndrome (depressive or manic) is agroup of associated symptoms that occur togetherover a short duration. For example, major depres-sive syndrome is defined as a depressed mood orloss of interest, of at least two weeks’ duration,along with several associated symptoms, such asdifficulty in concentrating and sleeping, fatigue,hopelessness, loss of pleasure, and weight loss orgain, with suicidal thoughts sometimes present.

A mood episode (major depressive, manic, or hypo-manic) is a mood syndrome not due to a knownorganic factor and not part of a non-mood psychoticdisorder such as schizophrenia, schizoaffective dis-order, or delusional disorder. Psychiatrists diagnosea mood disorder by the pattern of mood episodes.For example, the diagnosis of major depression,recurrent type, is made when an individual has hadone or more major depressive episodes without ahistory of a manic or hypomanic episode.

Manic episodes are distinct periods during whichthe individual experiences a predominant moodthat is either elevated, expansive, or irritable. Suchindividuals may have inflated self-esteem, increasedenergy, accelerated and loud speech, flight of ideas,distractibility, grandiose delusions, and decreasedneed for sleep. The disturbance may cause markedimpairment in working, social activities, or rela-tionships; an episode may require that the affectedperson be hospitalized to prevent his harming him-self or others. There may be rapid shifts of mood,with sudden changes to depression or anger. Themean age for the onset of manic episodes is in theearly 20s, but many new cases appear after age 50.

Hypomanic episodes are mood disturbances lesssevere than mania, but they may be severe enough

to cause several symptoms: marked impairment injudgment; financial, social or work activities associ-ated with increased energy and busyness; exagger-ated self-confidence; hypertalkativeness; euphoriaor increased sense of humor. Often not recognizedas illness by others, these behaviors are neverthe-less associated with what are known as hypomanicepisodes. Hypomanic episodes may be followed bydepressions of moderate to great severity.

Major Depressive Episodes

Major depression affects approximately 10 percentof the adult population. A major depressive episodeincludes either depressed mood (in children or ado-lescents, sometimes irritable mood) or loss of inter-est or pleasure in all, or almost all, activities for atleast two weeks. Associated symptoms may includefeelings of worthlessness or excessive or inappro-priate guilt, difficulty in concentrating, restlessness,appetite disturbance, change in weight, sleep dis-turbance, decreased energy, an inability to sit still,pacing, hand-wringing, and recurrent thoughts ofdeath or of attempting suicide.

Depressive episodes are more common amongfemales than among males. The average age ofonset of depressive episodes is the late 20s, but amajor depressive episode may begin at any age.

Bipolar disorders (episodes of mania and depres-sion) are equally common in males and females.Bipolar disorder seems to occur at much higherrates in first-degree biologic relatives of people withbipolar disorder than in the general population.

Cyclothymia involves numerous periods of hypo-manic episodes and numerous periods of depressedmood or loss of interest or pleasure that are notsevere enough to meet the criteria for bipolar dis-order or major depressive episode.

Dysthymia involves a history of a depressedmood for at least two years that is not severeenough to meet the criteria for a major depressiveepisode. This is a common form of depression, andthe person who has this condition may have peri-ods of major depressive episodes as well.

Causes of Affective Disorders

There are many explanations for affective disor-ders, including the psychoanalytic, interpersonal,cognitive, behavioral, learned helplessness, bio-logic, and genetic theories.

12 affective disorders

All these theories have common points of focusthat can be roughly categorized as biological, psy-chosocial, and sociocultural. Personality character-istics of some individuals, such as lack ofself-esteem and negative views of themselves andtheir future, predispose them to affective disorders.A stressful life event can also activate previouslydormant negative thoughts.

Individuals who become manic generally areambitious, outgoing, energetic, care what othersthink about them, and are sociable before theirepisodes and after remission. However, depressiveindividuals appear to be more anxious, obsessive,and self-deprecatory. They often are prone to feel-ings of self-blame and guilt. Depressed individualstend to interact with others differently from theway manics do. For example, some manic individ-uals dislike relying on others and try to establishsocial roles in which they can dominate others. Onthe other hand, depressed individuals take on a roleof dependency and look to others to provide sup-port and care. Feelings of a loss of hope and help-lessness are central to most depressive reactions. Insevere depression, “learned helplessness” mayoccur in which the individual sees no hope andgives up trying to cope with his or her situation.

Biologic factors also play an important role.There was considerable research during the 1970sand 1980s to explore the view that depression andmanic episodes both may arise from disruptions inthe balance of the levels of brain chemicals calledbiogenic amines. Biogenic amines serve as neuraltransmitters or modulators to regulate the move-ment of nerve impulses across the synapses fromone neuron to the next. Two such amines involvedin affective disorders are NOREPINEPHRINE and 5-hydroxytryptamine (SEROTONIN). Some drugs areknown to have antidepressant properties and tobiochemically increase concentrations of one orthe other (or both) of these transmitters.

In many individuals, psychosocial and biochem-ical factors work together to cause affective disor-ders. For example, stress has been considered as apossible causative factor in many cases. Stress mayalso affect the biochemical balance in the brain, atleast in some predisposed individuals. Some indi-viduals experience mild depression following sig-nificant life stresses, such as the death of a familymember. Other major life events, especially those

involving reduced self-esteem, physical disease orabnormality, or deteriorating physical condition,may precipitate changes in mood.

Treatment of Affective Disorders

A variety of treatments including pharmaceuticalmedications and BEHAVIOR THERAPY are used to treataffective disorders. Some behavioral approaches,known as cognitive and cognitive-behavioral ther-apies, include efforts to improve the thoughts andbeliefs (implicit and explicit) that underlie thedepressed state. Therapy includes attention tounusual stressors and unfavorable life situations,and observing recurrence of depression.

Prescription medications used to treat affectivedisorders include antidepressants, tranquilizers, andantianxiety drugs. Lithium carbonate, a simple min-eral salt, is used to control manic episodes and is alsoused in some cases of depression where the under-lying disorder is basically bipolar. For many individ-uals, lithium therapy is often effective in preventingcycling from depressive to manic episodes.

Support groups for the affected individuals aswell as their families are available in many areas.

See also AGORAPHOBIA; ALCOHOLISM AND ALCOHOL

DEPENDENCE; MANIC-DEPRESSIVE DISORDER; PHARMA-COLOGICAL APPROACH; PSYCHOTHERAPIES; SEASONAL

AFFECTIVE DISORDER SYNDROME (SADS).

FOR FURTHER INFORMATION:Depression and Bipolar Support Alliance730 North Franklin Street, Suite 501Chicago, 60610(312) 642-0049http://www.dbsalliance.org

National Institute of Mental HealthOffice of Scientific InformationPublic Inquiries Section5600 Fishers Lane, Room 15C-17Rockville, MD 20857(301) 443-4513

National Mental Health Association2001 North Beauregard Street, 12th FloorAlexandria, VA 22311(703) 684-7722

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

affective disorders 13

age discrimination Usually refers to adults ages55 to 65 and older who are often the first workersto be let go in company downsizings and MERGERS

and are overlooked as potential employees whenapplying for new jobs. Both of these factors of agediscrimination are a source of stress.

Although Congress banned age discriminationwith the Age Discrimination in Employment Act of1967, discrimination has continued and there havebeen increasing numbers of unemployed adults.Polls conducted by the Commonwealth Fund, aNew York–based foundation, showed that thereare 6 million unemployed Americans older than55, half of whom are women who want to con-tinue working.

Despite the fact that there has been muchresearch to disprove the stereotypes attributed toaging, they continue to influence judgments madeconcerning employment. Statistics have shown thatworkers age 40 and older take less time off than anyother age group and are less accident-prone thanyounger workers. Members of this age group havealso experienced more massive changes in technol-ogy over their lifetime than any past generationand are no less—if no more—adept at learning andusing technology than those who are younger.

For those older adults in the age 55 to 65 andolder range, loss of work may also mean loss ofhealth insurance and/or pension benefits at a timewhen they need them most. These losses and theefforts older adults make to seek new employmentare sources of great stress. Corporations who haveignored the stereotypes and made a point of hiringolder workers have said it pays. For a decade, Trav-elers Corporation, an insurance company, hasoperated an in-house temporary service staffedmainly by its retirees who need little training andare highly productive because of their knowledgeof the company.

See also AGING; JOB SECURITY.

FOR FURTHER INFORMATION:National Institute on AgingNational Institutes of HealthDepartment of Health and Human ServicesBuilding 31, Room 5C2731 Center Drive, MSC 2292Bethesda, MD 20892(800) 222-2225

ageism See AGE DISCRIMINATION.

Agent Orange An herbicide used during theVietnam conflict between 1962 and 1971 toremove unwanted plant life and leaves that pro-vided cover for enemy forces. The effects of AgentOrange have been a cause of stress for individualsand their families because shortly following mili-tary service in Vietnam, some veterans reportedhealth problems and concerns that many attrib-uted to exposure to Agent Orange or other herbi-cides. Some of the illnesses included chemicalacne, non-Hodgkin’s lymphoma, Hodgkin’s dis-ease, soft-tissue sarcoma, prostate cancer, orperipheral neuropathy, a degenerative nerve disor-der. Agent Orange contains varying amounts ofdioxin, a known carcinogen.

According to the U.S. Veterans Health Adminis-tration, more than 105,000 veterans or their sur-vivors filed claims. Afflicted veterans brought aclass-action suit against manufacturers of AgentOrange that was settled out of court. A fund wasestablished to compensate them and their familiesfor any disabilities.

The Department of Veterans Affairs developed aprogram to respond to these medical problems andconcerns. The program includes health care serv-ices, disability compensation, scientific research,and education. Veterans need not prove they wereexposed directly to Agent Orange. Service any-where in Vietnam is presumed as sufficient expo-sure and qualifies veterans for benefits.

aggression A general term for a variety of behav-iors that appear outside the range of what is sociallyand culturally acceptable. It includes extreme self-assertiveness, social dominance to the point of pro-ducing resentment in others, and a tendencytoward hostility. Individuals who show aggressionmay do so for many reasons including stress, frus-tration, as a compensatory mechanism for low SELF-ESTEEM, lack of affection, hormonal changes, orillness. Aggression may be motivated by ANGER,overcompetitiveness or a need to harm or defeatothers. Aggression is stressful for the victim of theaggressor as well as for the aggressor him- or herself.

An individual with an aggressive personalitymay behave unpredictably at times, causing stress

14 age discrimination

for those around him or her. For example, such anindividual may start arguments inappropriatelywith friends or members of the family and mayharangue them. The individual may write letters ofan angry nature to government officials or otherswith whom he or she has some quarrel. In additionto stressful circumstances, hormonal imbalancesmay account for some aggression. Excessive andro-gens, the male sex hormones, seem to promoteaggression (e.g., the use of androgenic steroids topromote development of muscle mass in athleteshas been known to make the user more aggres-sive). Individuals who are continuously aggressivemay show changes in brain wave patterns in elec-troencephalograms (EEG).

The term passive aggression relates to behaviorthat seems to be compliant, but in which “errors,mistakes, or accidents” for which no direct respon-sibility is assumed result in difficulties or harm toothers. Patterns of behavior such as making “mis-takes” that harm others are considered “passiveaggressive.” (“Gee, I’m sorry, I didn’t mean to ruinall your work.”)

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

aging The aging process begins the day one isborn, but for many individuals, stress related toaging increases as the years go by. Anxieties aboutthe health status, financial capabilities, standard ofliving, and surviving loved ones mount as onegrows older. Additionally, the aging process oftenbrings with it a decrease in the body’s ability toadapt to stress. Consequently, there is an increasein the body’s vulnerability, often resulting in moresusceptibility to colds, headaches, and minor gas-trointestinal upsets. Stress also affects a person’slikelihood of developing more serious diseases inolder age, including high blood pressure, heart dis-ease, arthritis, ulcers, and possibly cancer. Stresshas also been shown to worsen diseases such asdiabetes in people who already have them.

Some characteristics associated with aging canbe slowed down by regular exercise programs.Exercise strengthens the body while improvingone’s mental outlook and widening one’s social

contacts. Older adults are now jogging, walking,bicycling, and swimming. These exercises improvethe condition of the heart and lungs, aid in weightcontrol, and decrease many stress factors.

Planning for retirement helps one stay active. Ina study by the American Association of RetiredPersons, members ranked BOREDOM as one of themost serious problems of retirement.

Many healthy people move into RETIREMENT

communities or buildings during their later yearsso that they will have companionship as well asavailable health care nearby. Among the concernsof the aging population are the ability to continuemanaging one’s own affairs, the desire to remainindependent and not be a burden to children orsociety, and the dread of living out one’s last yearsin a nursing home.

Mental Health in an Aging Population

The prevalence, nature, and course of mental dis-orders in older adults may be very different fromthose in other adults. Assessment and diagnosis oflater life mental disorders are challenging becauseof several distinctive characteristics of older adults.Clinical presentation of mental disorders may bedifferent from that of other adults, making detec-tion of treatable illness more difficult. For example,many older individuals present with somatic com-plaints and experience symptoms of depressionand anxiety that do not meet the full criteria fordepressive or anxiety disorders.

aging 15

COPING WITH THE STRESSES OF AGING

• Maintain friendships and relationships withothers.

• Keep physically and intellectually active.• Make constructive use of time.• Eat a proper diet with a reasonable amount of

fiber.• Reduce intake of salt and cholesterol.• Avoid smoking and excessive alcohol intake.• Do a reasonable amount of exercise.• Protect skin from the sun.• Undergo periodic health examinations.• Examine risk factors; determine necessary life-

style changes.

Detection of mental disorders in older adults iscomplicated further by high comorbidity withother medical disorders. Symptoms of somatic dis-orders may mimic or mask psychopathology, mak-ing diagnosis more difficult. Additionally, olderindividuals are more likely to report somatic symp-toms than psychological ones, leading to furtherunderidentification of mental disorders.

Stereotypes about normal aging also can makediagnosis and assessment of mental disorders inlater life challenging. For example, many peoplebelieve that senility is normal and therefore maydelay seeking care for relatives with dementing ill-nesses. Similarly, patients and their families maybelieve that depression and hopelessness are natu-ral conditions of older age.

Depression is strikingly prevalent among olderpeople. According to the surgeon general’s report,8 to 20 percent of older adults in the communityand up to 37 percent in primary care settings expe-rience symptoms of depression. Depression is amajor risk factor for suicide in older adults. Olderpeople have the highest rates of suicide in the U.S.population; suicide rates increase with age, witholder white men having a rate of suicide up to sixtimes that of the general population.

Medication-Related Concerns in the Aging Population

As people age, there is a gradual decrease in gas-trointestinal motility, gastric blood flow, and gastricacid production. This slows the rate of absorption,but the overall extent of gastric absorption is prob-ably comparable to that in other adults. The agingprocess is also associated with a decrease in totalbody water, a decrease in muscle mass, and anincrease in adipose tissue. Drugs that are highlylipophilic, such as neuroleptics, are therefore morelikely to be accumulated in fatty tissues in olderpatients than they are in younger patients.

Pharmacodynamics, or the drug’s effect on itstarget organ, also can be altered in older individu-als. An example of aging-associated pharmacody-namic change is reduced central cholinergicfunction contributing to increase sensitivity to theanticholinergic effects of many neuroleptics andantidepressants in older adults.

Prevention of medication side effects and adversereactions is an important goal of treatment-related

prevention efforts in older adults. Comorbidity andthe associated polypharmacy for multiple conditionsare characteristic of older patients. Many olderpatients require antipsychotic treatment for man-agement of behavioral symptoms in Alzheimer’s dis-ease, schizophrenia, and depression. Body sway andpostural stability are affected by many drugs. Mini-mizing the risk of falling, therefore, is another targetfor prevention research. Falls represent a leadingcause of injury deaths among older persons.

In addition to the effects of aging on how med-ications work and the increased risk of side effects,older individuals are also more likely than otheradults to be medicated with multiple compounds,both prescription and nonprescription. Older adults(over the age of 65) fill an average of 13 prescrip-tions a year (for original or refill prescriptions),which is approximately three times the numberfilled by younger individuals. Drug interactions areof concern, both in terms of increasing side effectsand decreasing efficacy of one or both compounds.

Compliance with the treatment regimen also is aspecial concern in older adults, especially in thosewith moderate or severe cognitive deficits. Physicalproblems, such as impaired vision, make it likely thatinstructions may be misread or that one medicinemay be mistaken for another. Cognitive impairmentmay also make it difficult for patients to rememberwhether or not they have taken their medication.

See also CAREGIVERS; DEPRESSION; ELDERLY PAR-ENTS; MENTAL HEALTH; RETIREMENT; SUICIDE.

FOR FURTHER INFORMATION:American Association of Retired Persons601 E Street NWWashington, DC 20049(202) 434-2277

SOURCES:Hyman, Steven E., M.D. “Mental Health in an Aging Pop-

ulation,” American Journal of Geriatric Psychiatry. Avail-able online. URL: http://www.ajgp.psychiatryonline.org/cgi/content/full/9/4/330. Downloaded on June20, 2005.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Mental Health: A Report of the Surgeon General. Avail-able online. URL: http://www.surgeongeneral.gov/library/mentalhealth/home.html. Accessed January24, 2006.

16 aging

aging parents See AGING; CAREGIVERS; ELDERLY

PARENTS.

agoraphobia An ANXIETY DISORDER; it is a com-plex syndrome characterized by extreme ANXIETY

about being in situations from which escape may bedifficult or embarrassing or in which help may notbe available in the event of having a PANIC ATTACK.Agoraphobia includes fears of losing control ofoneself and of developing embarrassing or incapac-itating symptoms, such as dizziness, fainting, orsudden illness.

Typically, the anxiety leads to a pervasive avoid-ance of situations that may include being aloneoutside or in the home; being in a crowd of people;traveling in an automobile, bus, or airplane; orbeing on a bridge or in an elevator. According toDiagnostic and Statistical Manual of Mental Disorders,Fourth Edition, some individuals are able to exposethemselves to the feared situations but endurethese experiences with considerable dread. Oftenan individual is better able to confront a feared sit-uation when accompanied by a companion.

Agoraphobia causes stress for the sufferer aswell as for family members and friends. Individu-als’ avoidance of situations may impair their abilityto travel to work or to carry out homemakingresponsibilities, such as grocery shopping and tak-ing children to the doctor. Agoraphobia can besocially disabling. Many agoraphobics refuse invi-tations or make excuses for not going out. Thus,adjustments are necessary to compensate for theagoraphobic’s lack of participation in family lifeand activities outside the home.

Prevalence

Agoraphobia usually occurs in adults; the ratio ofagoraphobia in women vs. men is three to one. Shy,anxious women form the group of individuals mostprone to agoraphobia. Many agoraphobics are inde-cisive, lack initiative, feel guilty because they areunable to get out of situations themselves, and maygradually withdraw into a restricted lifestyle.

The majority of agoraphobics are married at thetime they come for treatment. In most cases involv-ing agoraphobics, spouses seem well-adjusted andintegrated individuals. Agoraphobia may strain amarriage because the agoraphobic person may ask

the spouse to take over chores that require goingout, such as shopping or picking up children; spousesoften must fulfill social obligations without thecompanionship of their mates. Spouses are addi-tionally stressed by having to be “on call” in caseanxiety attacks occur that require an emergencytrip home to soothe the agoraphobic. Thus, a cou-ple that may have been happy may be driven apartby the disorder, with each blaming the other for alack of understanding. The husband may think thatthe wife is not trying to overcome her phobic feel-ings, and the agoraphobic wife may think that herhusband does not understand her suffering. Thewife may become so preoccupied with fighting herdaily terrors that she focuses little attention on theirmarital relationship and her husband’s needs. How-ever, in cases where the agoraphobic has an under-standing, patient, and loving spouse, this supportcan be an asset in overcoming the agoraphobic con-dition. The spouse can attend training sessions withthe therapist, attend group therapy sessions, and actas the “understanding companion” when the ago-raphobic is ready to venture out.

Symptoms

Many agoraphobics were formerly active, sociable,outgoing persons; however, when they seek treat-ment, they are often in a constant state of extremestress. Typically, the agoraphobic admits to beinggenerally anxious and expresses feelings of help-lessness and discouragement. In some cases, agora-phobics abuse alcohol and drugs.

Characteristic symptoms in addition to generalanxiety include an intense fear of dizziness orfalling, loss of bladder or bowel control, vomiting,palpitations, and chest pain. There may be a fear ofhaving a heart attack because of the rapid heartaction, of fainting if the anxiety becomes toointense, and of being surrounded by unsympa-thetic onlookers. The individual then develops afear of the fear, which brings about anxiety inanticipation of a panic reaction, resulting in avoid-ance of the feared situation.

Occasionally, depersonalization occurs; deperson-alization is a change in the perception or experienceof the self so that the feeling of one’s own reality istemporarily lost. Often in agoraphobia there is a his-tory of panic attacks; however, agoraphobia mayoccur with or without a history of panic attacks.

agoraphobia 17

Many agoraphobics have episodes of DEPRES-SION. The first episode may occur within weeks ormonths of the first panic attack. Individuals com-plain of feeling “blue,” having crying spells, feelinghopeless and irritable, lacking interest in work, andhaving difficulty in sleeping. Agoraphobia is oftenaggravated during a depressive episode. Theincreased anxiety may make individuals less moti-vated to work hard at tasks (such as going out) thatthey previously did without difficulty.

Some agoraphobics are also claustrophobic. Usu-ally CLAUSTROPHOBIA is present before the agora-phobia develops. The common factor between thetwo phobias is that escape is blocked, at least tem-porarily. Symptoms of the phobic anxiety in agora-phobia may include many physical sensations thataccompany other anxiety states, such as dry mouth,sweating, rapid heart beat, hyperventilation, faint-ness, and dizziness. Many women report that gen-eralized anxiety and panic in agoraphobia tends tobe worse just prior to and during MENSTRUATION.

Some agoraphobics experience obsessions,which are persistent and recurrent ideas, thoughts,impulses, or images that occur involuntarily andinvade the consciousness. Obsessional behavior isusually present before an individual develops ago-raphobia. Individuals may develop obsessionalthinking about certain places, situations, or objectsthat might stimulate their fear reaction. Obses-sional thinking is difficult to control, often distortsor exaggerates reality, and causes much anticipa-tory anxiety. Individuals may develop compulsivebehavior in an attempt to reduce obsessionalthoughts and resultant stress and anxiety.

Causes of Agoraphobia

Agoraphobia frequently results from panic attacks,which are attacks of overwhelming anxiety, lead-ing the victim to fear a fatal heart attack or loss ofmental control. After repeated panic attacks, suf-ferers avoid crowds, enclosed places (tunnels, air-planes, large groups of people, even leaving home)for fear that a repeat panic attack might occur.

Some individuals regard the world as a danger-ous place because of learned experiences. Manyagoraphobics had at least one agoraphobic parentand many have had at least one parent who issomewhat fearful. In some cases, they receivedmixed messages from their parents. While they

were encouraged to achieve, they were not wellprepared to deal with the world, either becausethey were overprotected and taught that home isthe only safe place, or underprotected, having totake on too much responsibility at an early age.

Additionally, there may be a genetic predisposi-tion to panic disorder; it may be as much as 10times more frequent in the biological relatives ofthose with panic disorder as among those withoutsuch a family history.

The biological basis for panic attacks and result-ant agoraphobia is being researched, and there aremany theories. For example, symptoms of panicattacks, such as palpitations, sweating, and tremu-lousness, have lead to a theory that they are theresult of massive discharges from the adrenergicnervous system (part of the autonomic nervous sys-tem, which controls activities of organs, blood ves-sels, glands and many other tissues in the body).

Treatments for Agoraphobia

Treatment for agoraphobia is usually directed towardseveral aspects of the agoraphobic syndrome: agora-phobia, panic attacks and anticipatory anxiety. Avariety of treatments are often used for the sameindividual, sometimes in sequence or combination.

BEHAVIOR THERAPY includes educating individu-als about their reactions to anxiety-producing situ-ations, and teaching BREATHING exercises to helpovercome HYPERVENTILATION. In many cases, threeto six months of behavior therapy is effective, andsubsequent supportive and behavioral techniquesreduce the anxiety level and help individuals mas-ter fears of recurrent attacks in specific situations.

Many treatments for agoraphobia are based onvarieties of techniques known as exposure therapy.Typically, treatment involves exposing the agora-phobic to situations that are commonly avoidedand frightening in order to demonstrate that thereis no actual danger. Treatment may include directexposure, such as having the individual move awayfrom a safe place or person, or enter a crowdedshopping center in a structured way. Indirect expo-sure is also used; this may involve use of films withfear-arousing cues. Systematic desensitization is aprocedure characterized by exposure (either inimagination or in “real life”) to the least reactiveelements of a situation or object until the anxietyresponse no longer occurs. Another imaginal proce-

18 agoraphobia

dure for anxiety treatment includes flooding, orcontinuous presentation of the most reactive ele-ments of a situation until anxiety reduction occurs.

Facing the fearful situation with appropriatereinforcement may help an individual undo thelearned fear. For example, some therapists set pro-gressive goals for the patient for each week, such aswalking one block from home, then two and three,and taking a bus. In the early stages of treatment,many therapists accompany their patients as theyventure into public places, and in some casesspouses or family members are trained to accom-pany them. Other therapists recommend struc-tured group therapy with defined goals and socialskill training for agoraphobics and their families.

Involvement of spouses and family membersusually produces better results than treatmentinvolving the agoraphobic alone. Home-basedtreatment, where individuals proceed at their ownpace within a structured treatment program, pro-duces fewer dropouts than the more intensive, pro-longed exposure or pharmacological treatments.

Some agoraphobics develop ways to live morecomfortably with their disorder. For example,those who go to church or a movie theater mayprefer aisle seats so that they can make a fast exitif they experience a panic attack. Having a tele-phone nearby is another comfort.

Pharmacological Approach

The treatment of choice today for agoraphobiainvolves use of both behavior therapy and phar-maceutical medication, with the latter withdrawnas progress is made. Particularly for those whohave panic attacks, drug therapy initially seems toenhance results of exposure-based treatments. Inmany cases, drugs are used for three to six monthsand then discontinued once the individual hassome control over bodily sensations. Some individ-uals never experience recurrence of attacks, whileothers experience a return months or years later.When attacks recur, a second course of drug ther-apy is often successful.

Agoraphobia and Alcoholism

Some agoraphobics use alcohol in an unsuccessfulattempt to avoid anticipatory anxiety and panicattacks. However, alcohol may exacerbate panic bybringing about a feeling of loss of control both men-

tally and physically. Also, use of alcohol may inter-fere with effective treatment of the agoraphobia, ascentral nervous system depressants in alcoholreduce the efficacy of exposure treatment. However,some agoraphobic people believe that alcohol helpsto calm them before they venture out into public.

There is some evidence that both agoraphobicswho abuse alcohol and agoraphobics who don’tmay have histories of disturbed childhoods thatinclude familial ALCOHOLISM and depression. Also,children whose early attachments to caretakerswere non-supportive as well as frightening or dan-gerous may fail to develop a sense of trust andsecurity. Such individuals may be particularly vul-nerable to later psychopathology, including panicattacks and agoraphobia; alcoholism may be onemode of coping for such individuals.

The clinical picture of both agoraphobia andalcoholism often involves depression. Agorapho-bics who are alcohol abusers may also be moresocially anxious than their non-alcoholic peers.High rates of SOCIAL PHOBIA have been notedamong inpatient alcoholics, and major depressionhas been found to increase both the likelihood andintensity of agoraphobia and social anxieties.

Self-Help Groups for AgoraphobicsAs recovery from agoraphobia is a long-termprocess, self-help groups can provide valuable sup-port. Participating individuals share common expe-riences and coping tips, and have an additionalsocial outlet. Some agoraphobic SUPPORT GROUPS gettogether for outings, help take each other’s childrento and from school, arrange programs, and retrainthemselves out of their fears and anxieties.

See also PHARMACOLOGICAL APPROACH; PSY-CHOTHERAPIES.

FOR FURTHER INFORMATION:American Psychiatric AssociationDivision of Public Affairs1000 Wilson Boulevard, Suite 1825Arlington, VA 22209-3901(703) 907-7300http://www.psych.org

Anxiety Disorders Association of America8730 Georgia Avenue, Suite 600Silver Spring, MD 20910(240) 485-1001http://www.adaa.org

agoraphobia 19

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Washington,D.C.: American Psychiatric Association, 1994.

Frampton, Muriel. Agoraphobia: Coping with the World Out-side. Wellingstorough, Northamptonshire, England:Turnstone Press, Ltd., 1984.

Kahn, Ada P. “Panic Attacks.” Chicago Tribune, June 23,1991.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

AIDS See ACQUIRED IMMUNODEFICIENCY SYN-DROME; HUMAN IMMUNODEFICIENCY VIRUS.

AIDSinfo A free reference service for health careproviders as well as people living with HIV disease.The service, which began in 1995, is sponsored bythe U.S. Department of Health and Human Ser-vices (HHS). The service resulted from the mergerof two previous HHS projects: The AIDS ClinicalTrials Information Service (ACTIS) and theHIV/AIDS Treatment Information Service (ATIS).

The mission of AIDSinfo is to offer the latest fed-erally approved information on HIV/AIDS clinicalresearch, treatment, and prevention, and medicalpractice guidelines for HIV/AIDS patients, theirfamilies and friends, health care providers, andresearchers.

Specialists answer questions about the latest treat-ment options, provide customized database searches,and link inquirers to other HIV/AIDS informationresources.

Information seekers can obtain copies of the lat-est federally approved treatment guidelines, includ-ing recommendations for HIV counseling andvoluntary testing for pregnant women, guidelinesfor prevention of opportunistic infections in personsinfected with HIV, and study results concerning anti-HIV therapy that lowers risk of AIDS and death inpatients with intermediate-stage HIV disease. Evalu-ations of clinical trials using experimental drugs andother therapies for adults and children at all stagesof HIV infection are provided.

Information can be obtained about Food andDrug Administration (FDA)–approved anti-HIVmedications. Links to literature citations and clini-cal trials are provided for each of the FDA-approved medications.

AIDSinfo maintains an extensive Web site use-ful for information seekers.

AIDSinfo developed the Glossary of HIV/Aids-Related Terms to help people understand the techni-cal terms related to HIV, its associated treatments,and the medical management of related conditions.

See also HUMAN IMMUNODEFICIENCY VIRUS.

FOR INFORMATION:AIDSinfoP.O. Box 6303Rockville, MD 20849-6303(800) 448-0440 (toll-free)(301) 519-6616 (fax)(888) 480-3739 (TTY)http://aidsinfo.nih.gov

airplanes Many individuals are phobic about fly-ing. Estimates indicate that one of every six adultsis afraid to fly. Some people choose to spend daystraveling by train or experience the stresses ofhighway travel in place of flying.

Anticipation of taking an airplane flight is amajor source of stress for many people. Some arefearful of being in an enclosed place (CLAUSTRO-PHOBIA), while others fear being out of CONTROL orbecoming ill, and are just generally anxious aboutall the safety and weather factors associated withtraveling by air.

Many common phrases related to flying in air-planes, such as “terminal,” “final boarding,” “finalapproach,” and “departure lounge,” have a morbidconnotation and produce stress. These terms areaugmented by oxygen masks, life jackets, emergencyexits, crash procedures, and other reminders ofadverse consequences of flying. In addition, newsreports of air crashes and television and movie pro-ductions centering on trouble on airplanes can con-tribute to the ANXIETY.

Reasons for Stress

There are two major areas of stress relating to fly-ing. One is anticipating the situation and the otheris the flying situation itself. Anticipatory anxietyoccurs when one makes a commitment to fly bymaking the reservation, purchasing the ticket, andtelling people about the trip. People experiencinganticipatory anxiety usually feel dread, rapid pulse,body sensations such as tension and warmth, andhave fear-producing images and thoughts.

20 AIDS

The anticipatory fear is usually not of the air-plane itself but of uncontrollable outcomes such asfear of losing control of oneself in the plane,embarrassing oneself in public, fear of separationfrom loved ones, fears of relinquishing control tothe pilot, or thoughts of falling from the sky anddying in a crash.

People who fear flying can learn to become lessfearful. Flying can be viewed as an opportunity tobegin overcoming this fear. Skills can be acquiredto visualize flying comfortably, and relaxationtechniques can be learned to help cope with thefears. One can practice desensitization; thisinvolves going to the airport, watching planes takeoff and land and imagining feeling comfortable inthe planes being watched. Finally, one can make atape to relax with reminders and ideas to help copewhile flying. With preparation, practice, and moreflying, this fear can be diminished.

Since September 11, 2001, stress associated withairline travel has increased significantly because ofsecurity and fears of terrorism. Baggage cannot belocked except with special locks that securityagents can open. Baggage is X-rayed and, at manyairports in the United States, often searched beforeone boards the plane. In many cases, peopleundergo a body search with a wand that can detectmetal or explosives, or with a pat-down of theirbody. Pat-down procedures have been controver-sial when pat-downs of women are performed bymale security personnel. At times passengers arechosen randomly for these more thorough searches.Additionally, passengers are often asked to removetheir shoes while going through the final securitycheckpoint. After exiting the checkpoint, passen-gers must remove their baggage from the conveyorbelt and then find a chair on which to sit whilethey tie their shoes. However, although still stress-ful for many people, by 2005, this routine becamehabit for most travelers.

Treating Stresses and Fears Surrounding Airplanes

Treatments for the stresses involved in airplanetravel includes behavior therapies, particularlyexposure therapy, HYPNOSIS, RELAXATION techniques,and use of some pharmacological approaches. Pro-pranolol and ALPRAZOLAM are two drugs commonlyused for fear of flying. They are both fast-actingand produce relatively few side effects.

Many people turn to alcohol to relieve theirstresses and fears related to flying. While alcoholreduces autonomic arousal, it tends to produceanxiety-like sensations including dizziness, loss ofbalance, mental confusion, and lack of control ofperceptual-motor functions, which in turn cantrigger more stress and an anxiety response.

There may also be stress related to feelingsabout a place or person the individual associatedwith either the point of departure or of arrival.

See also AIRPORT SCREENING MACHINES; ALCO-HOLISM AND ALCOHOL DEPENDENCE; BEHAVIOR THERAPY;PHOBIAS; PHARMACOLOGICAL APPROACH; POST-TRAU-MATIC STRESS DISORDER.

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Encyclopedia of Pho-

bias, Fears, and Anxieties. New York: Facts On File, 1989.

air pollution An air quality that is a source ofstress because it contributes to lung disease, includ-ing respiratory tract infections, asthma, and lungcancer. People who have health problems such asasthma, heart disease, and lung disease may alsosuffer more when the air is polluted. The extent towhich an individual is harmed by air pollutionusually depends on the total exposure to the dam-aging chemicals, the concentration of the chemi-cals, and the duration of exposure.

Short-term air pollution can aggravate medicalconditions of those who have asthma and emphy-sema. Short-term effects include irritation to theeyes, nose, and throat, and upper respiratory infec-tions such as bronchitis and pneumonia. Othersymptoms can include headaches, nausea, and aller-gic reactions. Long-term effects can include chronicrespiratory disease, lung cancer, heart disease, andeven damage to the brain, nerves, liver, or kidneys.

Types of Air Pollution

There are many types of air pollution, includingsmog, particulate matter, smoke, and acid rain. Theexhaust from burning fuels in industries and auto-mobiles is a major source of pollution in the air.For example, diesel smoke contains particulatematter; this type of pollution is sometimes referredto as “black carbon” pollution.

The release of noxious gases into the air, such assulfur dioxide, carbon monoxide, nitrogen oxides,

air pollution 21

and chemical vapors, is another type of pollution.These substances can take part in further chemicalreactions once they are in the atmosphere, formingsmog and acid rain.

Indoor air pollution may be caused by biologicalpollutants such as molds, bacteria, viruses, pollen,dust mites, and animal dander. In large buildings,heating, cooling, and ventilation systems are fre-quent sources of biological substances that areinhaled, leading to breathing problems.

“Secondhand smoke” is also a major indoor airpollutant. It contains about 4,000 chemicals, includ-ing 200 known poisons, such as formaldehyde andcarbon dioxide, as well as 43 known carcinogens.Estimates are that environmental tobacco smoke(ETS) causes 3,000 lung cancer deaths and 35,000 to50,000 heart disease deaths in nonsmokers in theUnited States each year.

The release of formaldehyde into the air maycause health problems, such as coughing; eye, nose,and throat irritation; skin rashes; headaches; anddizziness. Formaldehyde is a common chemicalfound primarily in adhesive or bonding agents formany materials used in buildings, including carpets,upholstery, particleboard, and plywood paneling.

Asbestos fibers can be inhaled into the lungsand cause asbestosis (scarring of the lung tissue),lung cancer, and mesothelioma, a relativelyuncommon cancer of the lining of the lung orabdominal cavity. Roofing and flooring materials,wall and pipe insulation, heating equipment andacoustic insulation products are a potential prob-lem indoors if the asbestos-containing material isdisturbed and becomes airborne.

Carbon dioxide in the air can impede coordina-tion, worsen cardiovascular conditions, and pro-duce fatigue, headaches, confusion, nausea anddizziness, depending upon the amount present.Very high levels can cause death. Nitrogen dioxideis a colorless, odorless gas that irritates mucousmembranes in the eyes, nose, and throat andcauses shortness of breath after exposure to highconcentrations. Prolonged exposure to high levelsof nitrogen dioxide can damage respiratory tissueand may lead to chronic bronchitis.

Research into the health effects of air pollutionis ongoing. Medical conditions arising from air pol-lution are expensive in terms of health care.

See also ASTHMA.

FOR FURTHER INFORMATION:American Lung Association61 Broadway, Sixth FloorNew York, NY 10006(800) LUNG USA(212) 315-8872 (fax)

SOURCE:Kahn, Ada P. The Encyclopedia of Work-Related Injuries, Ill-

nesses, and Health Issues. New York: Facts On File, 2004.

airports See AIRPLANES; RANDOM NUISANCES;VACATIONS.

airport screening machines X-ray screeningmachines are used to search carry-on and checkedbaggage for possible explosives and dangerousobjects. Passengers experience stress while waitingin lines at checkpoints and when officials open theirluggage and view its contents. Employees findworking with the machines stressful because of thetedium of the activity. They might also have con-cerns about possible radiation exposure from work-ing with the cabinet X-ray system. The cabinet isintended to protect the public from the X-rays.

In November 2001, Congress enacted the Avia-tion and Transportation Security Act (ATSA). UnderATSA, the responsibility for inspecting persons andproperty carried by aircraft operators and foreign aircarriers was transferred to a newly formed agency,the Transportation Security Administration (TSA).In March 2003, the TSA requested that the NationalInstitute for Occupational Safety and Health(NIOSH) conduct an independent study to deter-mine the potential radiation exposures to employeeswho operate X-ray-generating machines. Monitor-ing of the machines began in 2003. A completereport is expected during 2005.

NIOSH has determined that it is safe for a preg-nant employee to work around the machines ifproper work practices are followed and if themachine is not leaking radiation above the FDAlimits. Sometimes employees must reach inside theentrance and exit tunnels of the machines to load,unload, or clear bag jams. However, if an employeereaches into the entrance or exit tunnels while cer-tain indicator lights are on, there may be some radi-ation exposure. The amount of exposure dependson how long the employee reaches into the tunnel,

22 airports

the size of the baggage (which could serve as ashield), how far and how often the employeereaches into the tunnel, and the type of machine.

Passengers’ Concerns

Some passengers are concerned if their lunch orother food goes through a cabinet X-ray system.According to the Food and Drug Administration’sCenter for Food Safety and Nutrition and the U.S.Department of Agriculture Food Safety InspectionService, there are no known adverse effects fromeating food that has been irradiated by a cabinet X-ray system used for security screening. The radia-tion dose typically received by objects scanned by acabinet X-ray system is one millirad or less. Theaverage dose rate from background radiation is 360millirads per year. The minimum dose used in foodirradiation for food preservation or destruction ofparasites or pathogens is 30,000 rad.

Electronic equipment is also not harmed by theX-ray dose received when a piece of equipment isscanned by a cabinet X-ray system. While it isunlikely that photographic film will be damaged, itis possible. Most cabinet X-ray systems used in theUnited States for security screenings are built to besafe for film speeds below 1,000. Multiple expo-sures of film even in film-safe X-ray systems mayeventually result in fogging or grainy images.However, some systems, usually those scanningchecked baggage, and some X-ray systems used inother parts of the world are not designed to befilm-safe. Manufacturers are not required by fed-eral regulation to build their systems to be film-safe. Film manufacturers can provide more specificrecommendations about the storage and transportof exposed and unexposed film.

Health Effects from Radiation Exposure

According to the Environmental ProtectionAgency (EPA), radiation can damage genetic mate-rial (DNA) in the body’s cells, especially dividingcells. If a small amount of radiation is absorbed inthe body, it does not always damage the cells. If itdoes, the cells can sometimes repair themselves.Damaged cells can die right away or, if they sur-vive, may be transformed into cells that couldcause a tumor.

No one is sure how much radiation can causecancer, but it is assumed that the risk of cancer is

proportional to the absorbed dose. Even low dosescould cause cancers five to 30 years or longer afterexposure, according to NIOSH.

See also AIRPLANES; AIRPORTS; CANCER; RADIA-TION; TERRORISM.

FOR FURTHER INFORMATION:The Nuclear Regulatory CommissionOffice of Public Affairs(800) 368-5642 (toll-free)(301) 415-8200(301) 415-5575 (TDD)http://www.nrc.gov/what-we-do-/radiation.html

U.S. Environmental Protection AgencyOffice of Radiation and Indoor AirRadiation Protection Division1200 Pennsylvania Avenue NWMC 6608JWashington, DC 20460-0001(202) 343-9290(202) 343-2304 (fax)

U.S. Food and Drug AdministrationCenter for Devices and Radiologic Health1350 Piccard DriveRockville, MD 20850-4307(800) 638-2041http://www.fda.gov/cdrh/comp/cabinetxrayfaq.html

SOURCE:John Candarelli, et al. “NIOSH Airport X-Ray Study

Update,” Available online. URL: http://www.cdc.gov/niosh/topics/airportscreener. Downloaded on June 4,2005.

Alcoholics Anonymous See ALCOHOLISM AND

ALCOHOL DEPENDENCE.

alcoholism and alcohol dependence Alcoholism(alcohol dependence) is characterized by compul-sive, habitual, long-term and heavy consumptionof alcohol and with withdrawal symptoms whenintake of alcohol suddenly ceases.

Many factors interact to lead to alcohol depend-ence. People who abuse alcohol often begin todrink to relieve personal, social, or businessstresses. When they find temporary relief, even atthe cost of occasional hangovers, they may gradu-ally begin to drink whenever they feel tense oranxious. The more they need alcohol to fight their

alcoholism and alcohol dependence 23

ANXIETY, the less they can do without it. Some indi-viduals may start out as moderate drinkers andthen begin to depend on alcohol during times ofextreme STRESS, such as bereavement, loneliness,job difficulties, DIVORCE, or their illness or an illnessof a close family member.

Some agoraphobics become alcoholic as a wayof coping with their fears. Because some agora-phobic individuals do not go out, it is fairly easy forthem to conceal their alcoholic habit. Somedepressed individuals turn to alcohol to temporar-ily improve their mood; instead of mood elevation,it results in sedation.

Genetic factors as well as personality and envi-ronmental factors play a role in causing depend-ence in some cases, but it is widely understood thatanyone can become addicted to alcohol if she or hedrinks heavily and regularly for a prolonged periodof time.

Stress on Family MembersWhen an individual drinks to excess, it can causestress on family members as well as employers. Forexample, abusers may neglect home or child careresponsibilities and may often be absent from theirjobs. They may be difficult to live with becausethey are often irritable and sometimes violent.Abusers may be drunk under physically hazardouscircumstances, such as operating machinery. Theremay be legal difficulties, such as an arrest for driv-ing while under the influence of alcohol. Alcohol isan important factor in deaths and injuries fromindustrial and motor vehicle accidents, suicides,domestic violence, marriage breakdown, childabuse, and other types of crime.

Physical tolerance for alcohol varies betweenindividuals. The shift from social drinking to alco-holism can happen almost imperceptibly over along period of time, or may occur rapidly. Drinkinghabits vary too. Some individuals are “binge”drinkers who go on drinking sprees, while othersdrink constantly and are never quite sober.Spouses, friends, and employers of binge drinkersmust cope with the stresses of unpredictable varia-tions in the mood behavior of the drinker, makingeveryday life a challenge.

Alcoholism: Public Health Problem

The number of American adults who abuse alcoholor are alcohol dependent rose from 13.8 million

(7.41 percent) in the period 1991–92 to 17.6 million(8.46 percent) in the period 2001–02, according toresults from the 2002–03 “National EpidemiologicSurvey on Alcohol and Related Conditions”(NESARC), a study directed by the National Insti-tute on Alcohol Abuse and Alcoholism (NIAAA).

The NESARC study, a representative survey ofthe U.S. civilian noninstitutionalized populationaged 18 years and older, showed that the rate ofalcohol abuse increased from 3.03 to 4.65 percentduring the decade while the rate of alcoholdependence, commonly known as alcoholism,declined from 4.38 to 3.81 percent.

The NIAAA defines alcohol abuse as a conditioncharacterized by failure to fulfill major role obliga-tions at work, school, or home; interpersonal, social,and legal problems; and/or drinking in hazardoussituations. The NIAAA defines alcohol dependence,also known as alcoholism, as a condition character-ized by impaired control over drinking, compulsivedrinking, preoccupation with drinking, tolerance toalcohol, and/or withdrawal symptoms.

NESARC survey questions are based on diag-nostic criteria for alcohol abuse and alcoholdependence contained in the American PsychiatricAssociation’s Diagnostic and Statistical Manual of Men-tal Disorders, Fourth Edition (DSM-IV). Fieldwork forthe NESARC was performed by the U.S. CensusBureau, which interviewed 43,093 respondents.The combined household and individual responserate was 81 percent.

According to Elias Zerhouni, M.D., director ofthe National Institutes of Health, “Change or stabil-ity in the prevalence of alcohol disorders has impor-tant public health implications for researchers,policy makers, and the public.”

“The NESARC report reinforces the need forongoing research to define genetic and environ-mental factors that contribute to alcohol abuse anddependence, as well as current NIAAA initiativesfor the early identification of at-risk drinkers andthe application of research-based interventions invulnerable populations, especially underagedrinkers,” according to Ting-Kai Li, M.D., director,National Institute on Alcohol Abuse and Alco-holism. “The fact that alcohol disorder rates arehighest among young adults underscores the needfor concerted research on drinking patterns thatinitiate in adolescence.”

24 alcoholism and alcohol dependence

Overall, the NESARC data show that rates ofalcohol abuse and dependence in the period2001–02 were substantially higher in men than inwomen and among younger study participantsaged 18–29 and 30–44 years. Alcohol abuse ismore prevalent among whites than among Hispan-ics, Blacks, and Asians. Alcohol dependence ismore prevalent among Native Americans, Hispan-ics, and whites than among Asians.

The prevalence of alcohol dependence declinedduring the 1990s for men but remained almoststatic for women, effectively narrowing the gendergap for that diagnosis. Alcohol dependence ratesdecreased significantly among whites and Hispanicsoverall but, at the subpopulation level, the changeswere significant only for white men overall and forHispanic men both overall and in the 18–29 and45–64 age groups. Alcohol dependence prevalenceremained relatively stable among blacks, NativeAmericans, and Asians overall. In contrast, blackwomen and Asian men aged 18–29 years showedsignificant increases in alcohol dependence.

Alcoholism as a Disease

Most authorities, including the American MedicalAssociation and the American Bar Association, rec-ognize alcoholism as a disease; others say that it isa self-inflicted condition and cannot properly bedesignated a disease. However, as a physiologicaland psychological dependence on alcohol, alco-holism must be considered an ADDICTION.

Contrary to popular belief, alcohol is a depres-sant, not a stimulant. The effects of alcohol are feltmost noticeably in the central nervous system. Assensitivity is reduced in the nervous system, thehigher functions of the brain are dulled, leading toimpulsive actions, loud speech, and lack of physi-cal control. The drinker’s face may turn red or pale.While drinking, the alcoholic loses any sense ofguilt or embarrassment, gains more self-confi-dence, and sheds inhibitions as the alcohol deadensrestraining influences of the brain. Large quantitiesof alcohol impair physical reflexes, coordination,and mental acuteness.

Symptoms and Stages of Alcoholism

There are four stages of alcoholism. In the firstphase, the heavy social drinker may feel no effectsfrom alcohol. In the second phase, the drinker

experiences lapses of memory relating to drinkingepisodes. In the third phase, there is lack of CON-TROL over alcohol and the drinker cannot be cer-tain of discontinuing drinking by choice. The finalphase begins with long binges of intoxication andobservable mental or physical complications.

Behavior symptoms may include aggressive orgrandiose actions, irritability, jealousy or uncon-trolled anger, frequent changing of jobs, repeatedpromises to give up drinking, hiding of bottles, andneglect of proper eating habits and personal appear-ance. Physical symptoms may include unsteadi-ness, confusion, poor memory, nausea, vomiting,shaking, weakness in the legs and hands, irregularpulse, and redness and enlarged capillaries in theface. In general, alcohol-dependent persons aremore susceptible than others to a variety of physi-cal and mental disorders.

Professional Treatment and Self-Help Groups

Medical help for alcohol dependence includesdetoxification, which is assistance in overcomingwithdrawal symptoms, and psychological, social,and physical treatments. Psychotherapy is usuallydone in groups and uses a variety of techniques.Therapists for alcoholic dependent persons may bepsychiatrists, psychologists, or social workers. Fam-ily members are involved in the treatment process.

Many alcohol dependent persons benefit frominvolvement in SELF-HELP GROUPS. These groups arealso available for other family members.

Alcoholics Anonymous (AA) is an internationalorganization, founded in 1935, devoted to main-taining the sobriety of its members and helpingthem control the compulsive urge to drink thoughself-help, mutual support, fellowship, and under-standing. Medical treatment is not used. The pro-gram includes the individual’s admission that he (orshe) cannot control his (her) drinking, the sharingof experiences, problems, and concerns at meetings,and helping others who are in need of support.

At the core of the AA program is the desire tostop drinking. Members follow a 12-step programthat stresses faith, disavowal of personal responsi-bility, passivity in the hands of God or a higherpower, confession of wrongdoing, and response tospiritual awakening by sharing with others.

The first step involves the idea of despair and abreakdown of denial concerning alcohol. Second is

alcoholism and alcohol dependence 25

the idea of hope, or seeing the light. Third is the shift-ing of responsibility from oneself to a higher author-ity figure. The next steps involve confessing, makingamends, continuing confirmation of a new image ofoneself, and redirecting energy to help others.

Life Expectancy May Increase with Abstinence

Alcoholics who go dry may increase their lifeexpectancy, according to results of a study pub-lished in the Journal of the American Medical Associa-tion (January 4, 1992). Results supported thenotion that achievement of stable abstinencereduces the risk of premature death among alco-holics. Kim D. Bullock, Psychiatry and ResearchServices, Veterans Affairs Medical Center, SanDiego, and colleagues reported on 199 men whohad histories of at least five years of drinking atalcoholic levels. All were current or formerpatients of the V.A. Alcoholism Treatment Programand/or members of Alcoholics Anonymous. Fol-low-up on relapse and mortality was obtained; 101men had relapsed and 98 were abstinent. A controlgroup of 92 nonalcoholics equated for age, educa-tion, and sex was also studied for mortality. Therewere 19 deaths among the relapsed alcoholicscompared with the expected number of 3.83.Among abstinent alcoholics there were fourdeaths. Alcoholic men who achieved stable absti-nence did not differ from nonalcoholic men inmortality experience. However, alcoholics whorelapsed died at a rate 4.96 times that of an age-,sex-, and race-matched representative sample.

See also AGORAPHOBIA; CODEPENDENCY; DEPRES-SION; SUPPORT GROUPS.

FOR FURTHER INFORMATION:AL-ANON Family Group Headquarters1600 Corporate Landing ParkwayVirginia Beach, VA 23454-5617(757) 563-1600http://www.al-anon.alateen.org

Alcoholics Anonymous World ServicesGrand Central StationP.O. Box 459New York, NY 10163(212) 686-1100http://www.alcoholics-anonymous.org

Children of Alcoholics Foundation200 Park Avenue, 31st FloorNew York, NY 10166Phone: (212) 949-1404http://www.coaf.org

Mothers Against Drunk Driving511 E. John Carpenter Freeway, Suite 700Irving, TX 75062(214) 744-6233http://www.madd.org

National Institute of Alcohol Abuse and Alcoholism

National Clearinghouse for Alcohol Information5635 Fishers Lane, MSC 9304Bethesda, MD 20892http://www.niaaa.nih.gov

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Washington,D.C.: American Psychiatric Association, 1994.

Clayman, Charles B., ed. Encyclopedia of Medicine. NewYork: Random House, 1989.

O’Brien, Robert, and Morris Chafetz. The Encyclopedia ofAlcoholism. New York: Facts On File, 1982.

Tarini, Paul. American Medical Association newsreleases, Oct. 1, 1991, January 4, 1992, and February4, 1992.

National Institutes of Health. “Alcohol Abuse Increases,Dependence Declines.” Available online. URL:http://www.alcoholism.about.com/od/homework/a/blnih040610.htm. Downloaded on June 4, 2005.

Alexander technique Method of realigning bodyposture for relief of stress, chronic pain, or muscletension, and to increase well-being and health.With verbal and gentle physical instruction fromtrained teachers, individuals learn how to elimi-nate common habits such as hunching, slouching,and tensing the spine that often accompany peri-ods of stress.

The technique was developed by F. MatthiasAlexander (1869–1955), an Australian Shake-spearean actor who moved to England and estab-lished his first school for the technique in Englandin 1924. It has drawn many actors, dancers, andmusicians who experience the stresses of tightness,injuries, or physical ailments related to the practiceof their arts. The technique also appeals to people

26 Alexander technique

suffering from orthopedic or neurological prob-lems, joint pain, headaches, and fatigue.

With Alexander exercises, individuals becomeaware of their bodies and learn to make consciouschanges. They are taught that when they are ableto release muscles, the muscles will work effi-ciently and without strain for the task at hand.Additionally, some of them find it helpful to liedown for 15 to 20 minutes each day and visualizethe Alexander instructions.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MEDITATION.

allergic rhinitis See HAY FEVER.

allergies A collection of disease symptomscaused by exposure of the skin to a chemical, orthe respiratory system to particles of dust or pollen,or of the stomach or intestines to food. Allergiesare sources of stress for many people becausesymptoms of allergies are unpredictable and maymake people uncomfortable.

Allergies are often exacerbated by emotionalstress. Though apparently not a direct cause, stresscan trigger allergic attacks. If individuals are prone toallergies, it is likely that they will have less troublewith them if they can reduce the stress and tensionin their lives. While they cannot eliminate an allergy,they can usually learn how to live with it, sometimeswith the aid of RELAXATION techniques and GUIDED

IMAGERY, or with prescription medications.

Allergic Reactions

Some allergic reactions limit the sufferer’s participa-tion in certain activities, such as hiking in forests orpartaking of certain foods. Such seemingly harm-less, everyday encounters as with a vase of flowers,a glass of milk, or the neighbor’s cat can bring onmisery for the sufferer. Depending on the allergy,the reactions can vary greatly, from coughing,sneezing and a runny nose to skin irritations suchas HIVES and rashes, to vomiting and diarrhea. Somepeople must curtail their social activities duringperiods when their allergy symptoms are severe.

According to the American Academy of Allergyand Immunology, 41 million American people(one in six) have ASTHMA and allergies. Of these,22.4 million have hay fever and 10 million are

affected with eczema, urticaria (hives) andangioedema (swelling); and by allergic reactions tofood, medications, and insect stings. These last aredangerous as well as uncomfortable, accountingfor at least 50 deaths a year.

The most common type of allergy, known asallergic rhinitis, affects the upper respiratory tract.Sufferers of this type of allergy often complain ofcold-like symptoms such as runny eyes, drippynoses, coughing, and congestion. Since allergicrhinitis is often caused by pollen, molds, andspores, it is primarily a seasonal affliction, strikingin spring and fall.

Asthma is an allergic reaction that affects thelungs and afflicts some 10 million Americans. Suffer-ers complain of “attacks,” in which the chest tightensand breathing becomes extremely difficult. Somepeople gasp and feel that they might die at anymoment. Asthma is also stressful for those aroundthe sufferer. An asthma attack may be brought on bya wide variety of allergens, including house dust, cer-tain foods, and feathers. Exercise as well as stress canalso induce attacks. Effective prescription medica-tions are available for asthma. Other common aller-gies include those that affect the skin, which arecaused by a number of allergens, and those thataffect the digestive system, most often caused byfoods such as dairy and wheat-based products.

Pets, especially cats, can trigger severe reactions,usually within the allergic rhinitis and skin allergyrange of symptoms.

Foods can set off reactions. For example, eggs,even in tiny quantities, make many people ill. Ifyou have an allergy and suspect that food is respon-sible, you can leave one item at a time out of yourdiet for periods of several weeks, then reintroduceit until you discover the allergen or allergens.

Allergic contact dermatitis is a skin conditionproduced by substances that touch the skindirectly, in contrast to eruptions that occur on theskin from an internal or systemic reactions. Fabricsand dyes may do this. POISON IVY is another exam-ple of allergic contact dermatitis. Knowing that oneis allergic to poison ivy makes for a stressful situa-tion while walking in a wooded or forested area.

Diagnosis and Treatment

Most allergies begin during childhood, some 80percent before the age of 15 years. The first step is

allergies 27

to identify the allergen and then to remove it fromthe person’s environment if possible, or else to takethe person away from the allergen. Sometimes achange of climate works but may result in otherallergies. Some hay fever sufferers have moved tothe opposite end of the country, only to find a newallergen there.

Air conditioners and filters help persons allergicto pollen. In other cases, more radical measuresmay be called for; for example, work-related aller-gens may require a change in occupation or, at theleast, a face mask on the job. Hypoallergenic cos-metics (preparations that are compounded withoutthe most common allergens) help many peoplewho are allergic to makeup and perfume.

Many people mistake allergies for other prob-lems and only after recurring episodes seek med-ical help. Being examined by an allergist, or aphysician who specializes in allergies, is a wisemove for people who think they have an allergybut do not know its cause. In many cases, the aller-gist conducts skin tests in which the skin is exposedto minute amounts of various materials to seewhich one causes a reaction. Efforts are thenmade, wherever possible, to eliminate or reducecontact with that allergen. Prescription medica-tions are available to relieve allergies.

See also ALTERNATIVE MEDICINE.

FOR FURTHER INFORMATION:American Academy of Allergy and Immunology555 East Wells Street, Suite 1100Milwaukee, WI 53202(414) 272-6071http://www.aaai.org

American College of Allergy and Immunology85 West Algonquin Road, Suite 550Arlington Heights, IL 60005(708) 359-2800http://www.acaai.org

National Institute of Allergy and Infectious Diseases

Public Response6610 Rockledge Drive, MSC 6612Bethesda, MD 20892(301) 496-5717http://www.niaid.nih.gov

alopecia See HAIR LOSS.

alprazolam Antianxiety drug (also referred to asan anxiolytic or sedative) marketed under thetrade name Xanax. A member of drug groupknown as the benzodiazepines, it has been usefulin treating some individuals who suffer fromeffects of extreme stress, anticipatory ANXIETY orPANIC ATTACKS AND PANIC DISORDER, and DEPRESSION,particularly in mixed states of depression and anx-iety. The clinical reasons for its antidepressanteffects are still unknown. Studies have shown thatit has no effect on nerve cell receptors that are tar-gets of some antidepressive drugs.

Alprazolam is comparable to tricyclic antide-pressant medications and is used as an antidepres-sant for individuals who have an extremely highdegree of anxiety and agitation; alprazolam causessedation and lethargy. Because it has no apparentcardiac side effects, it is applicable in treatment ofanxious or depressed cardiac patients. As withother drugs of this class, dependency develops withprolonged use and withdrawal effects can occurwhen treatment ends. These can be prevented bygradually tapering off the dosage of the drug.

See also BENZODIAZEPINE DRUGS; PHARMACOLOGI-CAL APPROACH.

SOURCES:Fawcett, Jan A., and Howard M. Kravitz. “Alprazolam:

Pharmacokinetics, Clinical Efficacy and Mechanism ofAction.” Pharmacotherapy no. 5 (September–October1982).

Kahn, Ada P., and Jan A. Fawcett. Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

alternative medicine A set of practices that,depending on the viewpoint, either complement orcompete with conventional medicine in the pre-vention and treatment of stress-related disorders aswell as other diseases.

According to the National Center for Comple-mentary and Alternative Medicine (NCCAM),based on a 2002 study, 36 percent of adults in theUnited States used some form of complementaryand alternative medicine (CAM). When megavita-min therapy and prayer specifically for health rea-sons were included in the definition of CAM, thatnumber rose to 62 percent. More women than

28 alopecia

men were likely to use CAM; people with highereducational levels, people who were hospitalizedin the past year, and former smokers were likeliestto use CAM.

According to the study, people use CAM formany diseases and conditions. People were mostlikely to use CAM for back, neck, head, or jointaches, and other painful conditions; colds; anxietyor depression; gastrointestinal disorders, or sleepingproblems. It appears that CAM is most often used totreat or prevent musculoskeletal conditions or otherconditions involving chronic or recurring pain.

Alternative therapies for dealing with stress andhealing mind as well as body, include emotionalrelease therapies with or without body manipula-tion, emotional control or self-regulating therapies,religious or inspirational therapies, cognitive-emo-tional therapies, and emotional expression throughcreative therapies. Some of these have been knownby such names as encounter groups, gestalt ther-apy, primal therapy, EST, bioenergetic psychother-apy, ROLFING, TRANSCENDENTAL MEDITATION, andBIOFEEDBACK. It is important to note that alterna-tive therapies are not subject to scientific scrutinythrough controlled efficacy studies with placebo orcomparisons of treatments. They are accepted andpromoted as helping on the basis of “anecdotal evi-dence” stemming from individual reports of suc-cess. Some may be truly helpful while others maybe useless or ineffectual.

Many individuals find relief for stress-inducedconditions from one or from a combination of alter-native therapies either along with or after seekingtraditional care. For example, MENTAL IMAGERY israted one of the six most commonly used alterna-tive treatments among cancer patients and isbelieved by physicians as well as patients to reduceboth the pain and distress of symptoms. However,as with other medical conditions, individualsshould not overlook traditional psychiatric or med-ical treatments in favor of alternative therapiesbecause they may be robbing themselves of valu-able time as their condition progresses.

Alternative vs. Conventional Care

Conventional medical practitioners adhere to sci-entific models and methodologies that many alter-native medical practitioners believe focus tooexclusively on reductionist and physiochemical

explanations of biological phenomena. Proponentsof alternative medicine suggest that this approachshows limited understanding of health and diseaseand, in particular, of interactions among mind-body connections, psychological, social, and bio-logical factors that influence coping with stress anddisease processes.

Advocates of alternative approaches, in recentdecades known also as “holistic” (or “wholistic”)medicine or complementary medicine, regard theinfluence of psychological factors and cognitiveprocesses as equal to, if not more powerful than,the insights and methods of conventional medicinein coping with stress and disease and improvingclinical outcomes.

For most of the 20th century, the generallyaccepted model for understanding biological phe-nomena and intervening therapeutically was theallopathic method. It achieved scientific, economic,and political primacy over the competing modelssuch as osteopathic medicine, homeopathy, andchiropractic as well as other alternative approaches.However, the public’s interest in alternative thera-pies has grown tremendously during the last twodecades of the 20th century.

In a survey by Harvard Medical School,researchers reported that more than a quarter ofthe people they interviewed saw a physician regu-larly but were also employing another treatment,usually with their doctor’s knowledge. One in 10respondents were relying on nontraditional treat-ments exclusively. The study emphasized the wide-spread acceptance of “alternative medicine,” avariety of unrelated practices from acupuncture toyoga that are promoted as having healing benefits.The common factor between them is that they havenot yet been subjected to scientific review, theprocess most of the Western world uses to deter-mine whether a treatment is safe and effective.

Herbal and “Folk” Therapies

In many cultures, herbs and other natural andbotanical products are used to relieve stress-induced health conditions instead of modern diag-nostic techniques and pharmacological treatments.Herbs are used both to cure specific illnesses,improve health, lengthen life, and increase sexualvigor and fertility.

alternative medicine 29

Herbal medicine in the West may have begunwith the Greeks and spread across Europe with theRoman conquests. However, the development ofan organized approach to using herbs took place incentral Europe and the British Isles. Practices andbeliefs in folk medicine are preserved in isolated,traditional cultures such as in Appalachia andamong Native American tribes. Folk medical treat-ments have developed by trial and error andserendipity without benefit of the scientificmethod. Since folk cultures generally mix religiousor spiritual beliefs with concepts of health and ill-ness, they attribute disease to causes other than thenatural causes recognized by conventional medi-cine. In folk beliefs, mental or physical illness maybe caused by divine retribution for transgression orby the will of spirits or other magical beings. Folkhealers pass down techniques from one generationto the next and may jealously guard their secrets.

Because of the cultural and other exchangesthat took place at the end of the 20th century,many practitioners of Western medicine learnedabout folk medicine, leading to better communica-tion with patients from other cultures.

Increasing Interest by Government and Insurers

In 1991 the National Institute of Health’s Office ofAlternative Medicine (OAM) (now the Office ofComplementary and Alternative Medicine) wascreated within the National Institutes of Health.The goal of the OAM is to research and evaluatethe many alternative or unconventional medicaltreatments.

Increasingly, some health insurers are paying foralternative therapies, removing some of the finan-cial stress involved in seeking these treatments. Astudy reported in the Journal of Health Care Marketing(spring 1995) included insurers from government,third-party insurance companies, and HMOs; resultsindicated the mechanisms through which each ofthree alternative therapies (chiropractic, ACUPUNC-TURE, and biofeedback) gained some credibility andacceptance by insurers. Results indicated that thesetherapies have each achieved at least moderate suc-cess in obtaining third-party reimbursement.

Choosing Alternative Therapies

Individuals who decide to take an unproven ther-apy should let their physician know what they are

doing. He or she will need to take the effects of thattreatment into account when evaluating their care.Be wary when encountering claims that a treat-ment works miracles, such as rejuvenating skin orcuring cancer with no pain or side effects. Watchout for contentions from proponents of a treatmentthat the medical community is trying to keep their“cure” a secret from the public. Also, be wary of anydemands by the practitioner that an alternativetreatment be substituted for a currently acceptedpractice. According to Harvard Women’s Health Watch(June 1994), while there may be little harm inadding an alternative practice such as MEDITATION ormassage therapy to a therapeutic regimen, replac-ing a valid treatment with one that has no provenefficacy may have serious consequences.

Watch out for claims that the treatment is betterthan approved remedies just because it is “natu-ral.” Natural products are not necessarily morebenign than agents synthesized in a laboratory. Adrug is any substance that alters the structure orfunction of the body, regardless of its source. It isimportant to remember that many plants containtoxic substances that can be harmful when takenin uncontrolled doses.

See also ACCULTURATION; AYURVEDA; CHIROPRAC-TIC MEDICINE; GUIDED IMAGERY; HOLISTIC MEDICINE;MIND-BODY CONNECTIONS; RELAXATION.

FOR FURTHER INFORMATION:Ayurvedic Institute1311 Menaul Boulevard NEAlbuquerque, NM 87112(505) 291-9698http://www.ayurveda.com

National Center for Complementary and Alternative Medicine

National Institutes of HealthNCCAM ClearinghouseP.O. Box 7923Gaithersburg, MD 20898(888) 644-6226http://nccam.nih.gov

Sharp Institute for Human Potential and Mind/Body Medicine

8010 Frost Street, Suite 300San Diego, CA 92123(800) 82-SHARP (toll-free)

30 alternative medicine

SOURCES:Eisenberg, D., et al. “Unconventional Medicine in the

United States: Prevalence, Costs, and Patterns of Use.”New England Journal of Medicine 328 (1993): 246–252.

Facklam, Howard. Alternative Medicine: Cures or Myths?New York: Twenty-First Century Books, 1996.

Gellert, George. “Global Explanations and the CredibilityProblem of Alternative Medicine,” ADVANCES: TheJournal of Mind-Body Health 10, no. 4 (fall 1994).

Goldfinger, Stephen, ed. “Alternative Medicine: InsurersCover New Ground.” Harvard Health Letter 22, no. 2(December 1996).

Gordon, James S. Manifesto for a New Medicine: Your Guideto Healing Partnerships and Wise Use of Alternative Thera-pies. Reading, Mass.: Addison-Wesley, 1996.

Morton, Mary and Michael. 5 Steps to Selecting the BestAlternative Medicine. Novato, Calif.: New WorldLibrary, 1996.

Weil, Andrew. Eight Weeks to Optimum Health: Proven Pro-gram for Taking Full Advantage of Your Body’s HealingPower. New York: Alfred A. Knopf, 1997.

Alzheimer’s disease At least 50 percent of alldementia cases are due to Alzheimer’s disease, aprogressive, irreversible disorder that attacks thebrain and has sometimes been called “death of themind.” Families of Alzheimer’s disease suffererscope with stresses of caregiving that are physical,emotional, social, and financial. These stressesbecome worse as the disease advances. The suffer-ers themselves experience stress, particularly dur-ing the onset of the illness when they are still ableto recognize some of the symptoms of the disease.

The disease was named in 1906 by Dr. AloisAlzheimer (1864–1915), after diagnosing a 51-year-old patient. Although it may occur as early as age 40,Alzheimer’s more commonly strikes people 65 yearsand older. It is the fourth leading cause of death forpeople between the ages of 75 and 84 (after heartdisease, cancer, and stroke). Once diagnosed, manyindividuals live an average of three to 20 years.

An estimated 4 million Americans haveAlzheimer’s disease and a reported 100,000 deathsare due to the disease each year. As the populationof older Americans increases, so will the number ofpeople at risk for this disease.

Symptoms

Symptoms of Alzheimer’s should not be confusedwith age-associated memory impairment (AAMI),

a term health care professionals use to describeminor memory difficulties that come with age.

Although Alzheimer’s symptoms vary in rate ofchange from person to person, there are three pro-gressive stages of the disease. In Stage One, whichcan last two to four years, mild symptoms begin tobe noticeable. There may be memory loss, but oftenthis is associated with the AGING process. Recentmemory is affected and the ability to learn andretain new information is impaired. Individualsmay resort to writing themselves notes and labelingdrawers and cabinets to remind themselves of itemsused in everyday living. There may be difficulty inconcentrating or engaging in conversation withoutlosing train of thought. Individuals exhibit tirednessand an unkempt appearance, and often blame oth-ers for what is happening to them. They feel out ofCONTROL and many become depressed. Personalitychanges include being quick to anger, particularlyat the inability to communicate thoughts clearly.

In Stage Two, symptoms become more severe,memory losses increase, and there are moremarked changes in behavior. There is less ability tocomprehend what is being said. Words are usedwrong and in senseless combinations (paraphasia),and there is an inability to recognize objects (visualagnosia). Supervision of daily activities maybecome necessary. There is increasing disorienta-tion regarding time and place. Some sufferers donot recognize themselves in the mirror and othersdo not recognize their spouses or children. Confu-sion often increases in the late evening (sundownsyndrome). Bladder or bowel incontinence maydevelop; the individual may forget where the bath-room is or how to undress and use the facilities.Impaired gait develops and the body weakens.

In Stage Three, signs and symptoms continue toprogress until deterioration causes the person tobecome bedridden.

Diagnosis

Before diagnosis of Alzheimer’s disease is made,the physician will want to rule out other condi-tions, such as potentially reversible DEPRESSION,adverse drug reactions, metabolic changes, nutri-tional deficiencies, head injuries, and stroke. Untilthe last decade, when more technologically sophis-ticated testing procedures became available, manysufferers were misdiagnosed and consequently

Alzheimer’s disease 31

treated incorrectly. For example, screen star RitaHayworth was misdiagnosed with alcoholicdementia in the 1970s and only later was diag-nosed as suffering from Alzheimer’s disease, fromwhich she died in 1987. Her film career endedwhen she could not remember her lines.

Diagnosis usually begins with a search for treat-able causes for memory loss and mental changes.Evaluation includes screening for depression, previ-ous history of mental illness, and an assessment ofthe overall mental state. Many diagnostic proceduresmay be used, including blood studies, computerizedaxial tomography (CT scan), or electroencephalo-gram (EEG). In some cases a lumbar puncture isdone to rule out neurosyphilis, which can causeinability to carry out purposeful movements(aproxia), inability to express thoughts (aphasia) andan inability to recognize items (agnosia). The CT scanfor an individual who has Alzheimer’s disease typi-cally shows brain shrinkage. The EEG is typicallyslow in a person with Alzheimer’s disease.

Stresses Facing Caregivers of Alzheimer’s Patients

The National Alzheimer’s Disease and Related Dis-orders Association has characterized Alzheimer’s as“the disease that robs the mind of the victim andbreaks the heart of the family.” For caregivers ofAlzheimer’s sufferers, it is a very frustrating anddehumanizing condition to witness. Alzheimer’sdisease can be an extraordinarily demanding andfrustrating experience, both for those afflicted withthe disease and for their families. Caring for a par-ent, grandparent, or spouse whose mind is deteri-orating requires stamina and patience. Confrontedwith a disease that afflicts the mind of a loved one,caregiving family members often feel alone andhelpless. However, SUPPORT GROUPS and friends canbe helpful, as can senior day-care centers.

In addition to the emotional strain on the CARE-GIVER, there may be financial expenses, such asreconstructing living arrangements for the safetyand convenience of the patient, giving up a job todevote full time to care, hiring people to providepart-time care or do household chores, and possi-bly providing nursing home care, which may ormay not be covered by health insurance.

Information Line and Support Groups

The Alzheimer’s Association has a national, toll-free information and referral service telephone

number. It offers callers the most current informa-tion available on Alzheimer’s disease and supportservices through the association. The number is:(800) 272-3900.

The Alzheimer’s Disease and Related DisordersAssociation (ARDRA) is a privately fundednational voluntary health organization, foundedin 1980 and headquartered in Chicago. ARDRAhas over 1,000 support groups and 160 chaptersand affiliates nationwide. ARDRA’s board ofdirectors comprises business leaders, health pro-fessionals, and family members. A medical andscientific advisory board consults on and monitorsrelated issues.

Alzheimer’s Disease International was formed in1984 to share program and research developmentson Alzheimer’s disease worldwide. The nationwidehotline number is: (800) 621-0379.

FOR FURTHER INFORMATION:Alzheimer’s Association225 North Michigan Avenue, Floor 17Chicago, IL 60601(800) 272-3900 (toll-free)http://www.alz.org

32 Alzheimer’s disease

GUIDELINES FOR CAREGIVERS OF ALZHEIMER’S PATIENTS

• Take one day at a time, tackling each problemas it arises. One cannot know how anAlzheimer’s patient will behave the next day.

• Try to put yourself in the patient’s shoes. You willfeel less annoyed the tenth time you are askedwhat day it is if you imagine how unsettling itmust be not to be oriented in time and space.

• Maintain a sense of humor. This is especiallyvaluable in getting through potentially embarrass-ing situations.

• Arrange for time for yourself. Get another familymember or friend to relieve you for an hour ortwo each day. Hire a part-time caretaker.Arrange for the patient to spend time at a seniorday-care facility.

• Pay attention to your own needs. Be sure tomaintain good nutrition and get regular exercise;develop hobbies and outside interests. Find peo-ple you can talk to, such as family members,friends or, if needed, professional counselors.

ADEAR Center Alzheimer’s Disease Education and Referral

P.O. Box 8250Silver Spring, MD 20907-8250(800) 438-4380http://www.alzheimers.org

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

ambivalence Refers to the simultaneous exis-tence of two sometimes contradictory feelings, atti-tudes, values, or goals. Feelings of ambivalence arestressful for many people. For example, some indi-viduals have feelings of ambivalence toward amate whom they love but who abuses them. Otherindividuals may be ambivalent about work andother major life issues.

The term “ambivalence” was introduced byEugen Bleuler, a Swiss psychiatrist (1857–1939), torefer to the simultaneous feeling of antagonisticemotions, such as approach or avoidance of thesame activity or goal.

See also EMOTIONS; PHOBIAS.

amenorrhea See MENSTRUATION.

Americans with Disabilities Act of 1990 A lawprotecting the rights of disabled persons; it appliesto architectural designs of public buildings, remov-ing stressful limitations from the daily activities ofmany disabled persons who previously had little orno access to public buildings or jobs.

In 1991, the U.S. Equal Employment Opportu-nity Commission issued regulations to enforce theprovisions of Title I of the Americans with Disabil-ities Act (ADA) and covered employers with 25 ormore employees. The threshold dropped to includeemployers with 15 or more employees in 1994.

According to Title I of the act, an individual witha disability is a person who has a physical or men-tal impairment that substantially limits one ormore major life activities, one who has a record ofsuch an impairment, or one who is regarded ashaving such an impairment.

The law prohibits private employers, state andlocal governments, employment agencies, and laborunions from discriminating against qualified indi-

viduals with disabilities in job application proce-dures, hiring, firing, advancement, compensation,job training, and other terms, conditions, and privi-leges of employment. A qualified employee or appli-cant with a disability is an individual who, with orwithout reasonable accommodation, can performthe essential functions of the job in question. Rea-sonable accommodation may include, but is not lim-ited to, making existing facilities used by employeesreadily accessible to and usable by persons with dis-abilities, job restructuring, modifying work sched-ules, and reassignment to a vacant position.

Disclosure and Inquiry about Disability

Applicants may be asked about their ability to per-form specific job functions. A job offer may be con-tingent on results of a medical examination, butonly if the examination is required for all enteringemployees in similar jobs. Medical examinations ofemployees must be job-related and consistent withthe business needs of an employer.

Current employees or job applicants using ille-gal drugs are not covered by the ADA when anemployer acts on the basis of such use. Tests forillegal drugs are not subject to the ADA’s restric-tions on medical examinations. Employers mayhold illegal drug users and alcoholics to the sameperformance standards as other employees.

FOR FURTHER INFORMATION:Equal Employment Opportunities Commission1801 L Street NWWashington, DC 20507(202) 663-4001(202) 663-4110 (fax)http://www.eeoc.gov

SOURCE:Kahn, Ada P. The Encyclopedia of Work-Related Injuries, Ill-

nesses, and Health Issues. New York: Facts On File, 2004.

amnesia See FORGETTING; MEMORY.

anger For most individuals, anger is an intenseemotional state in which there is a high level ofdispleasure and FRUSTRATION. It can be caused bySTRESS or can be a reaction to stress and is indicatedby feelings ranging from slight irritation to explo-sive HOSTILITY that are directed to other people,objects, or oneself.

anger 33

Physiological changes occur when one feelsangry. For example, anger increases heart rate,blood pressure, and flow of ADRENALINE. Suppressedanger may result in HEADACHES, HIGH BLOOD PRES-SURE, and skin rashes. More clearly visible signsinclude frowning, gritting the teeth, pacing, andclenching the hands. There may be changes in vocaltone; one may yell or shout, or, on the otherextreme, speak in short, clipped sentences. Throughsuch displays, an angry person attempts to gainCONTROL of a situation but at the same time clearlydemonstrates that he or she has lost control.

Negative AngerThere are two attitudes—positive and negative—with regard to anger. On the negative side, angercan be destructive, leading to inappropriate or illegalbehavior. Negative anger seems to be directly relatedto frustration and feelings of inferiority. SigmundFreud observed in his book Mourning and Melancho-lia that DEPRESSION is actually anger turned inward,directed at the self. Bigotry, for instance, appears tobe anger turned against specific groups or humanityas a whole. Adults may express anger directly withphysical violence or verbal abuse behavior on othersin their environment or because there seems to be areward for violent behavior. Since in most situationsit is unacceptable to express anger directly, manypeople react by becoming sulky or indifferent, or byadopting a superior, patronizing attitude toward theperson or situation that angered them.

The first cries of a baby may be an expression ofanger or simply a less focused reaction to the birthexperience. Small children react directly to situationsthat make them angry, sometimes by simply scream-ing, pulling, or striking the object or person who hasangered them. As children mature, angry behaviorbecomes focused on retaliation. By the early teens,sulking and impertinence replace retaliation.

Many people who have a chronic illness reactwith anger. For example, some rheumatoid arthri-tis sufferers also have a situation of longtime,repressed anger. These people, particularly womenwho have been brought up to think anger is unla-dylike, tend to say that everything is okay evenwhen the opposite is true. Repressed anger andother personality and behavior patterns are thesubjects of continued study, as researchers try toidentify the role of psychological forces that exist inautoimmune diseases.

Positive Anger

Anger may be helpful and constructive. There arepsychological and medical opinions indicating thatsuppressing anger is physically and psychologicallydamaging. Further, limiting the expression ofanger may bring regrets later. If an individualchooses to work off anger in an exercise program,it may do him good in other ways. For example,releasing an angry feeling sometimes brings with ita sense of pleasure. Some mental health profes-sionals equate ambition and attempts to improvesociety with a healthy expression of anger.

Among athletes, anger can have both a harmfuland positive effect on athletic performance. Angerat the opposition can drain energy and divert atten-tion from winning the game. However, professionalathletes such as members of the Chicago Bulls andother championship teams are competitive and ableto turn their anger into playing more forcefully.

How to Overcome AngerAn individual in psychotherapy who expressesextremely stressful and angry feelings might be giventhree goals: first, to identify the feelings of anger; sec-ond, to use constructive release of the energy ofanger; and third, to identify thought processes thatlead to anger. For example, to identify thoughtprocesses that lead to anger and the resulting feelingsof anger, one might keep a diary of what led to theangry feelings and how they were handled. By doingthis, the individual will learn to recognize angerbefore losing control, take responsibility for his orher own emotions and stop blaming others. Also,with validation from a therapist, the individual willlearn to accept that some anger is justified in certainsituations. In learning to use constructive release ofthe energy of anger, the individual may benefit fromASSERTIVENESS TRAINING, and learn to express angerverbally to the appropriate source. Assertive tech-niques may help the individual increase feelings ofself-esteem, demonstrate internal control overbehavior, and harness energy generated by theanger in a nondestructive manner.

Also, individuals can learn to use energythrough physical activity that involves the largemuscles, such as running, walking, or playing ten-nis or racquetball. Other techniques that are help-ful in controlling stress and anger are ALTERNATIVE

MEDICINE therapies such as BIOFEEDBACK, GUIDED

IMAGERY, and MEDITATION.

34 anger

Relationship of Anger to Grief

It is common to feel angry and stressed after thedeath of a loved one. The anger may be directedtoward the deceased person for leaving themourner alone, the medical care system for notbeing able to cure a disease or mend a body, God,or the fatal disease itself. In cases of accidents,there is often anger at the perpetrator of the lovedone’s death, whether a drunk driver, a drug-induced criminal, or the person who sold themdrugs or alcohol. Anger is a normal part of thecycle of GRIEF reaction. However, prolonged angerthat leads to depression may indicate a need toconsult a mental health professional.

See also AGGRESSION; ANXIETY; HOSTILITY.

angina pectoris A chest pain usually caused by alow supply of oxygen to the heart muscle resultingfrom hardening and narrowing of the coronaryarteries. It is stressful and disturbing to the suffereras well as family or friends who are there when itoccurs.

The term unstable angina refers to an accelerat-ing pattern of chest pain where previously stableangina now occurs with less exertion, lasts longer,and is less responsive to medication. It can be asign of an impending HEART ATTACK and immediatetreatment by a physician should be sought.

See also HIGH BLOOD PRESSURE; TYPE A PERSON-ALITY.

anniversary reaction The feeling of DEPRESSION

that arises around the anniversary of a significantevent such as a divorce or the death of a familymember or close friend. The reaction brings stressbecause it may involve the recall and reliving ofthe events. Some individuals experience dreams orminor illness at the same time each year as part ofthis reaction.

See also GRIEF.

anorexia See EATING DISORDERS.

anorgasmia Old term meaning an inability toachieve an orgasm. This term has been replacedwith psychosexual dysfunction, and refers to lackof orgasm in men or women, which may resultfrom stress, sociocultural attitudes of the partners,

anatomical or neurophysiological problems, or fearof painful intercourse. SEX THERAPY is helpful inmany such cases.

See also FRIGIDITY; SEXUAL DIFFICULTIES.

anthrax An infectious disease of animals that canbe secondarily transmitted to humans. Anthraxbecame a source of stress in the United States inthe early 2000s when anthrax spores weredetected in mailed objects and a few deathsresulted. Postal facilities were shut down and mail-rooms across the United States instituted specialprecautions for detecting the substance. One can-not catch anthrax from someone else. At present,anthrax vaccine is only available to the military.

It is caused by a bacillus (Bacillus anthracis) thatprimarily affects sheep, horses, hogs, cattle, andgoats and is almost always fatal in animals. Trans-mission to humans normally occurs through contactwith infected animals but can also occur throughbreathing air laden with the spores of the bacilli.

The disease is almost entirely occupational, as itis usually restricted to individuals who handlehides of animals, such as farmers, butchers, andveterinarians, or workers who sort wool. However,in 2001, several humans contracted anthrax froman unknown source when several anthrax-lacedletters were mailed to government and mediaoffices. The perpetrator of the anthrax dissemina-tions has not been identified. More than one postoffice and other office buildings were closed forinspection because of detected anthrax spores.Many people who handled mail at work chose towear gloves and face masks as protection againstpossibly anthrax-tainted letters.

There are different kinds of anthrax. The twokinds of anthrax reported as part of the taintedmailings are skin anthrax and inhaled anthrax.With skin anthrax, spores enter the body througha cut or other opening in the skin. Inhaled anthraxcomes from breathing in the spores and is moreserious and requires hospitalization.

See also FARMING; TERRORISM.

anticipatory anxiety See AGORAPHOBIA; ANXIETY;STRESS.

antidepressant medications See AFFECTIVE DIS-ORDERS; DEPRESSION; PHARMACOLOGICAL APPROACH.

antidepressant medications 35

antidepressants and suicide rate See DEPRESSION;SUICIDE.

anxiety Feeling of tension and/or apprehensionthat comes from anticipating a situation, whichmay be known or unknown. Anxiety is differentfrom fear: Fear is a response to a consciously rec-ognized and usually external threat or danger,whereas anxiety is typically caused by an “inter-nal” threat not apparent to any but the anxiousindividual.

Most people experience the stresses of anxietyin everyday life. For example, they may experienceanxiety about getting to a job interview on time,going on a first date, or wearing the right clothes atan important social event. Other become anxiousabout being held up in traffic or when they hearreports of incoming bad weather.

Possible Causes of Anxiety

Individuals who face a threat or change in theirhealth status often become anxious and feelstressed. These stresses may relate to the possibilityof unpleasant treatment, pain, and possible disabil-ity. Many abused and psychologically traumatizedindividuals, such as victims of DOMESTIC VIOLENCE

or RAPE, have lifelong anxiety symptoms. Anxietiesalso occur for socioeconomic reasons. For example,threats of job layoffs cause many people stress andanxieties, while others become anxious overchanges in stock market prices and develop con-stant fears that their fortunes will diminish.

Coping with the Stress of Anxiety

Most people learn to relieve some stress by COPING

with transient anxieties; this includes taking moretime, doing additional preparations, and facing thefact that most situations are temporary and/or reallynonthreatening. Unfortunately, some people turn tosmoking and alcohol or drug use to cope with thestress caused by their anxieties. These habits are notconsidered healthy coping mechanisms, as they canlead to health hazards and addictions. Physiciansmay prescribe anti-anxiety drugs or anxiolytic drugsfor some individuals who, at certain times, are expe-riencing severe anxieties.

See also GENERAL ADAPTATION SYNDROME.

anxiety disorders These are disorders that arecharacterized by anxiety and, at times, avoidancebehaviors. According to the American PsychiatricAssociation’s Diagnostic and Statistical Manual of Men-tal Disorders, Fourth Edition, they include general-ized anxiety disorder, PHOBIAS, PANIC DISORDER,OBSESSIVE-COMPULSIVE DISORDER, and POST-TRAU-MATIC STRESS DISORDER. Anxiety disorders mayresult from extreme STRESS. They also produceongoing stress for sufferers and those aroundthem. An individual can have one or more anxietydisorders at the same time.

Generalized Anxiety Disorders (GAD). Excessivelevels of anxiety and apprehension often are themain characteristics of GAD suffered by both menand women. Symptoms generally appear whenindividuals are 20 to 40 years old. GADs are causedby the fear of life circumstances such as the possi-ble death of a loved one or losing one’s job, eventhough there is no evidence these stress-producingevents will actually happen.

36 antidepressants and suicide rate

SYMPTOMS ASSOCIATED WITH GENERALIZED ANXIETY DISORDER

Motor tension• Trembling, twitching, feeling shaky• Muscle tension, aches, soreness• Restlessness• Easily tired

Autonomic hyperactivity• Shortness of breath or smothering sensations• Palpitations or accelerated heart rate• Sweating, cold, clammy hands• Dry mouth• Dizziness, light-headedness• Nausea, diarrhea, other abdominal distress• Flushes (hot flashes) or chills• Frequent urination• Trouble swallowing or “lump in the throat”

Hypervigilance• Feeling keyed up or on edge• Exaggerated startle response• Difficulty concentrating or “mind going blank”• Trouble falling asleep or staying asleep• Irritability

Phobias. People who suffer from phobias feel ter-ror, dread or panic when confronted with anobject, situation, or activity that they fear. Somepeople have such an overwhelming desire to avoidthe source of their fear that it causes stress on thejobs and in family and social relationships.

SOCIAL PHOBIAS, such as fear of public speaking,meeting new people or eating in public, are verycommon. Simple phobias involve fear of one activ-ity, such as flying, or of an object, such as snakes.AGORAPHOBIA is fear of going into public places, rid-ing on public transportation, and entering shopsand restaurants where one feels far from safety.Sufferers fabricate any number of excuses toremain at home. People seek help for agoraphobiamore than for any other phobia and are usuallysuccessfully treated by psychotherapy and pharma-ceutical medications.

Panic Disorder. Sufferers from panic disordersexperience intense but brief acute anxiety domi-nated by a fear of dying or being out of control.Because many of the symptoms of panic disorderare also symptomatic of a heart attack, many peo-ple rush to emergency rooms. Treatment of panicdisorder is important; untreated panic sufferers canbecome suicidal.

Obsessive-Compulsive Disorder. People with this dis-order usually suffer from obsessions or from per-sistent ideas such as fear of infection by germs ordirt, which make them carry out compulsive, repet-itive, ritualized acts such as hand washing, count-ing, and checking. These involuntary responses totheir obsessions cause stress for sufferers and, par-ticularly, the people with whom they live.

Post-traumatic Stress Disorder (PTSD). This anxietydisorder comes after a stressful or frightening eventthat causes an unusual, severe physical or mentaltrauma. This may result from such events as mili-tary combat, natural disasters, violence, rape, orserious injury. Most people recover when givencounseling and support; however, some post-trau-matic stress disorders last a lifetime.

Causes of Anxiety Disorders

There are several theories about the causes of anx-iety disorders. No single condition or situationcauses them; a person may even inherit or developa biological susceptibility to anxiety disorders.

Psychoanalytic theory suggests that anxiety stemsfrom unconscious conflicts in infancy or childhood.For example, a person may carry the unconsciousconflict of sexual feelings toward the parent of theopposite sex, or may have developed problems fromexperiencing illness or fright as a child. According tothis theory, anxiety can be resolved by identifyingand resolving the unconscious conflict.

The learning theory suggests that anxiety is alearned behavior that can be unlearned. Peoplewho feel very stressed in a given situation or neara certain object will begin to avoid it. However,such avoidance can limit a person’s ability to livenormally. In many cases, sufferers learn that theiranxiety diminishes by persistently facing the fearedobject or situation.

Another theory is that biochemical imbalancesmay lead to anxiety disorders. There may be com-plex eletrochemical interactions in the central nerv-ous system. Some studies indicate that infusions ofcertain biochemicals can bring on a panic attack insome people. According to this theory, treatment ofanxiety should correct these biochemical imbal-ances. Biochemical changes can occur as a result ofemotional, psychological or behavioral changes.

Diagnosing and Treating Anxiety Disorders

A good diagnostic approach for anxiety disorders fol-lows the same guidelines as for any other medical ill-ness: a complete history, physical examination, andlaboratory tests and mental status assessment.

In most cases, anxiety disorders are treatedwith a combination of therapies that are individ-ualized for each person. There is no cure-all foreveryone. Treatment focuses on teaching theindividual how to identify feelings, counteractnegative thinking, and apply what they havelearned to real-life situations. Also, treatmentenables the sufferer to gain skills to control thebehavior that brings about the anxiety through agradual process of identifying and controlling theanxiety-provoking situations.

Phobias and obsessive-compulsive disorders oftenare treated by BEHAVIOR THERAPY. This may involveexposing the sufferer to the feared object or situationunder controlled circumstances until the fear is sig-nificantly reduced or cured. With this method, manyphobic individuals have long-term recoveries.

anxiety disorders 37

Prescription medications can help reduceextreme symptoms so that an individual can makethe best use of behavior therapy and other psy-chotherapeutic techniques. In addition to behaviormodification techniques and medications, talkingwith a therapist during psychotherapy can be impor-tant for relief and improvement.

Medications

Below is a chart listing the names of drugs com-monly prescribed for anxiety disorders, the disorderfor which they are indicated, and how they arethought to work. Medications approved by the Foodand Drug Administration for the treatment of thevarious anxiety disorders are identified with a “†”.

Note: The information provided in this tableapplies to the treatment of anxiety disorders inadults 18 years of age and older, and does notapply to the treatment of these conditions in chil-dren and adolescents.

Key:GAD = Generalized Anxiety Disorder

* Generic commercially availableOCD = Obsessive Compulsive Disorder

† FDA approved for the treatment of one ormore anxiety disorders

PD = Panic DisorderPTSD = Post-traumatic Stress DisorderSAD = Social Anxiety Disorder

38 anxiety disorders

Target Drug Class Brand Name Generic Name Anxiety Disorder How Is Thought to Work

AntidepressantsSelective Serotonin Celexa Citalopram PD, OCD, SAD, Affects the concentration

Reuptake Inhibitors Lexapro† Escitalopram GAD, PTSD and activity of the neuro-(SSRIs) Luvox† Fluvoxamine transmitter serotonin, a

Paxil*† Paroxetine chemical in the brain thought Prozac*† Fluoxetine to be linked to anxiety Zoloft† Sertraline disorders

Tricyclic Antidepressants Adapin* Doxepin PD, PTSD, GAD Affects the concentration and (TCAs) Anafranil* Clomiprimine OCD (Anafranil activity of the neurotransmit-

Aventyl* Nortriptyline only) ters serotonin and norepi-Elavil* Amitriptyline nephrine, chemicals in the Ludiomil* Maprotiline brain thought to be linked to Norpramin* Desipramine anxiety disordersPamelor* NortriptylineSinequan* DoxepinSurmontil* TrimipramineTofranil* ImipramineVivactil* Protriptyline

Monoamine Oxidase Marplan* Isocarboxid PD, SAD, PTSD Blocks the effect of an important Inhibitors (MAOIs) Nardil* Phenelzine brain enzyme, preventing the

Parnate* Tranylcypromine breakdown of serotonin and norepinephrine

Other Antidepressants Cymbalta Duloxetine PD, OCD, SAD, Affects the concentration of the Desyrel* Trazodone GAD, PTSD neurotransmitters serotonin Effexor† Venlafaxine (data in PTSD and/or norepinephrine, chem-Remeron MIrtazapine is sparse) icals in the brain thought to be

linked to anxiety disordersWellbutrin Bupropion No current indica- Exact mechanism unknown.

tion for any Effects may be mediated anxiety disorder. through the neurotransmitters Depression, norepinephrine and dopaminepossibly ADHD

anxiety disorders 39

Target Drug Class Brand Name Generic Name Anxiety Disorder How Is Thought to Work

AnxiolyticsAzapirones BuSpar*† Buspirone GAD Enhances the activity of

serotoninBenzodiazepines Ativan* Lorazepam GAD, SAD, PD Exact mechanism unknown.

Dalmane* Flurazepam Some research shown to Klonopin*† Clonazepam enhance the function of Halcion* Triazolam gamma aminobutyric acid Librium* Chlordiazepoxide (GABA)Restoril* TemazepamSerax* OxazepamTranxene* ClorazepateValium* DiazepamXanax*† Alprazolam

Antihistamines Atarax, Vistaril* Hydroxyzine GAD Sedative effects through block-ade of histamine receptors inthe brain

AnticonvulsantsAugmentation These medications may be

therapy added when symptoms only partially respond to another medication to increase the overall response to treatment

Gabitril Tiagabine Enhances the function of GABANeurontin GabapentinDepakote* Valproate Exact mechanisms unknown. Lamictal Lamotrigine Possible effects include: Topimax Topiramate enhancing or inhibiting effects

of neurotransmitters believedto be associated with anxiety;blockade of sodium channelsin the brain

Noradrenergic AgentsBeta blockers Propranolol Performance Blocks receptors associated

Inderal* Atenolol anxiety, possibly with physiologic symptoms Tenormin* Prazosin PD of anxiety

Alpha Blocker Minipress* Prazosin PTSD (nightmares)Catapres Clonidine Some evidence in Tenex Guanfacine PTSD, antici-

patory anxiety

Atypical AntipsychoticsAugmentation These medications may be

therapy added when symptoms onlypartially respond to anothermedication to increase theoverall response to treatment

(Table continues)

Research reported by the American PsychiatricAssociation indicates that 90 percent of phobic andobsessive-compulsive individuals who cooperatewith their therapists and comply with instructionsrecover with behavior therapy. Studies haveshown that while they are on medications, 70 per-cent of individuals who suffer from panic attacksimprove. Medication is effective for about half ofthose suffering from obsessive-compulsive disor-der. RELAXATION training, self-hypnosis, BIOFEED-BACK and GUIDED IMAGERY are also effectivetherapies for many individuals.

If one has a friend or a loved one who won’t gofor treatment, it is important to find out why he orshe will not go. Often people think that going fortreatment means that they are mentally ill, andthey find that stressful to accept. Such peopleshould be assured that seeking treatment for ananxiety disorder is the same as seeking treatmentfor any medical concern.

Role of Support Groups

Support groups are very helpful in the treatment ofanxiety disorders because many people develop asecondary feeling of reduced morale, which resultsin lower levels of functioning. Support groups areeffective in raising that morale as well as the self-esteem of their participants. Also, in learning aboutother people’s problems, an individual’s own feel-ings of unique inadequacy and inferiority often canbe dispelled.

Social Costs of Anxiety Disorders

The social costs of anxiety disorders far outweigh theexpenses incurred for direct treatment, concluded astudy reported in 1995 by Andrew C. Leon, Ph.D.,

Cornell University Medical College, and Myrna M.Weissman, M.D., of Columbia University. An esti-mated 10 million adult Americans have had an anx-iety disorder at some point in their lives. In the sixmonths prior to the study, those who suffered froman anxiety disorder were more likely to have higherrates of drug and alcohol abuse, as well as higherrates of financial dependence and unemployment,than those who had not experienced an anxiety dis-order. In particular, the researchers found that thosewith panic disorder or obsessive-compulsive disor-der were more likely to be chronically unemployedor to receive disability or welfare payments thanthose without. “One problem,” said Dr. Leon, “is thecurrent lack of implementation of recently devel-oped screening procedures. Sufferers of anxiety dis-orders often use the general medical system andemergency rooms for treatment; unless primarycare and emergency care settings employ thescreening procedures for these disorders, the burdenon the health care system will remain substantial.”

See also AFFECTIVE DISORDERS; COPING; PANIC

ATTACKS AND PANIC DISORDER; PHARMACOLOGIC

APPROACH.

FOR FURTHER INFORMATION:American Psychiatric AssociationDivision of Public Affairs1000 Wilson Boulevard, Suite 1825Arlington, VA 22209(800) 368-5777 (toll-free)http://www.apa.org

Anxiety Disorders Association of America8730 Georgia Avenue, Suite 600Silver Spring, MD 20910

40 anxiety disorders

Target Drug Class Brand Name Generic Name Anxiety Disorder How Is Thought to Work

Atypical AntipsychoticsAbilify Aripiprazole Affects the concentration and Geodon Ziprasidone activity of the neurotransmitter Risperdal Risperidone serotonin, a chemical in the Seroquel Quetiepine brain thought to be linked to Zyprexa Olanzapine anxiety disorders

Disclaimer: This information is for educational purposes only. Speak with your doctor if you have questions about a medicationor are experiencing side effects from your medication.

http://www.adaa.org/AnxietyDisorderInfor/chart.htm

(240) 485-1001http://www.adaa.org

National Alliance for the Mentally IllColonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22201(703) 524-7600http://www.nami.org

National Institute of Mental HealthOffice of Communications6001 Executive BoulevardRoom 8184, MSC 9663Bethesda, MD 20892(301) 443-4536

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Margolis, Simeon, ed. “Living Without Anxiety.” Health

After 50, August 1997.Ross, Jerilyn. Triumph over Fear: A Book of Help and Hope

for People with Anxiety, Panic Attacks, and Phobias. NewYork: Bantam Books, 1994.

Warneke, Lorne. “Anxiety Disorders: Focus on Obses-sive-compulsive Disorder.” Canadian Family Physician39 (July 1993).

arithmetic See MATHEMATICS ANXIETY.

aromatherapy The art and science of usingessential oils from plants and flowers to reducestress and enhance health. Essential oils areessences extracted from flowers and plants, as wellas herbs, roots, leaves, bark, and wood, by distilla-tion; they deeply penetrate the skin and havepowerful medicinal and psychological effects. Prac-titioners of aromatherapy assess the patient’scurrent physical, emotional, and bioenergetic con-dition. Then they blend essential oils from aroundthe world and apply them with a specialized mas-sage technique focusing on the nervous and lym-phatic system. Aromatherapy massage has beenused to treat conditions ranging from job stress tomuscle soreness to varicose veins and allergies.

How Essential Oils Are Used

Essential oils almost always require dilution withwater or carrier oils, such as almond oil, apricot oil,jojoba oil, or grapeseed oil.

As inhalation therapy, the oils can be usedeither by steam or ambient. For steam inhalation,three to seven drops of oil can be added to one-halfcup of boiling water. Inhale the vapors with yourhead about a foot away from the solution. Alter-nate breathing in the vapors and fresh air. Forambient inhalation, add one to three drops of oil toa tissue or cotton ball and place the item about oneto two feet from your nose. Alternately inhale thevapors and fresh air.

As part of massage therapy, 10 to 20 drops ofessential oil can be added to one ounce or more ofcarrier oil. Massage into yourself or have someonemassage you. Avoid getting the oils into your eyesor genital areas.

During bathing, five to seven drops of essentialoil can be mixed with one ounce of carrier oil andadded to the bathwater, making sure that it is mixedinto the water well before climbing into the tub.

Household uses include room freshening, gen-eral freshening, and as an insect repellent. Forroom freshener, add 10 drops of essential oil to oneto two cups of boiling water and place around theroom. Be careful to keep out of the reach of pets.For household freshening, add a few drops of oil tothe trash containers, vacuum bags, drains, or on acotton ball to place in drawers and closets. Laven-der, citronella, and peppermint are natural insectrepellents. Place a few drops on windowsills anddoorways. Avoid letting pets near the drops.

The art of aromatherapy is fairly new in theUnited States, but has been used for centuries else-where in the world, particularly in Egypt andGreece. During World War I, Dr. Jean Valnet, aParisian physician, used essential oils to treatinjured soldiers. He also influenced MargueriteMaury, a biochemist who developed a special wayto apply the penetrating oils with massage.

Finding a Practitioner of Aromatherapy

Techniques vary from practitioner to practitioner.Many therapists are employed in spas in large citiesor resort areas. If you are seeking this therapy, lookfor someone who is a licensed, certified massagepractitioner and who can show proof of training inthe use of essential oils.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MASSAGE.

aromatherapy 41

SOURCES:Cooksley, Valerie Gennari. Aromatherapy. A Lifetime Guide

to Healing with Essential Oils. Englewood Cliffs, N.J.:Prentice Hall, 1996.

Griffin, Katherine. “A Whiff of Things to Come.” Health,November/December 1992.

arrhythmia An abnormal heart rhythm, usuallydetected by an electrocardiogram. When some indi-viduals hear this diagnosis, they became anxiousand find the diagnosis stressful. An arrhythmia mayor may not be of potential significance, and can becaused by several factors, such as coronary arterydisease, heart valve problems, or hyperthyroidism.Individuals with this diagnosis should questiontheir physician carefully about what it means,about possible lifestyle changes, ways to eliminatestress and the need for medication.

See also BIOFEEDBACK; BREATHING; HEART

ATTACK; HIGH BLOOD PRESSURE; RELAXATION; TYPE APERSONALITY.

arthritis A painful, debilitating chronic conditionthat afflicts more than 40 million Americans, mostof them women. When doctors diagnose arthritis,they are identifying painful inflammation in a joint,which in some forms brings with it swelling andredness. The most common of these forms areosteoarthritis and rheumatoid arthritis. Osteoarthri-tis typically affects older adults and is caused bywear and tear on the joints, particularly hands,knees, feet, hips, and back. Rheumatoid arthritis isthe most severe form and is caused by the body’sIMMUNE SYSTEM attacking the joints and surround-ing tissues, often leading to severe deformity of theshoulders, elbows, hands, wrists, feet, and ankles.Unlike osteoarthritis, rheumatoid arthritis strikeschildren as well as adults, and it is estimated thatmore than 250,000 children have juvenilerheumatoid arthritis.

Since the early 1900s, doctors have recognizedthat rheumatoid arthritis can be provoked or exac-erbated by stress, continuous worry, or anxiety.Results of studies since then have agreed that emo-tional stress can trigger rheumatoid arthritis in asusceptible child or adult and, once the disease hasestablished itself, can make it worse. The stressinvolved is usually acute, often resulting from such

crises as the death of a family member, loss of a job,or a divorce.

According to the Epidemiology Section, Centersfor Disease Control and Prevention, Atlanta, Geor-gia, arthritis and other rheumatic conditions willincrease in prevalence by 50 percent by the year2020, with the number affected growing from 40million to 60 million people. The number of peopleaffected will grow because of the aging population.Most people probably think that arthritis is part ofnormal aging and there is nothing you can do aboutit. But there are things that can be done to reduceits impact, such as losing weight and limiting therisk of joint injuries from sports and occupation.

Pharmacological Approaches and Alternative Therapies

Many pharmacological approaches are availablefor treating individuals who have arthritis. Newprescription medications are being developed andmany over-the-counter remedies are available.Increasingly, researchers are trying ALTERNATIVE

MEDICINE, either in conjunction with prescriptionmedications or as sole therapies.

As a result of early research in PSYCHONEU-ROIMMUNOLOGY, a few behavioral, stress-reducingprograms to treat arthritis have been developed.One activity is exercise; the chief benefit is tomove the blood flow to the affected joints andkeep them flexible. Arthritic individuals may beadvised to do stretching exercises to keep theirjoints moving smoothly and do strengtheningexercises to maintain muscle tone. Walking andnon-weightbearing exercises such as swimmingare also helpful.

At the Stanford University Arthritis Center,physicians suggest relaxation tapes that also reducePAIN for patients with arthritis. The logic behindthese tapes is that if the mind is distracted by men-tal exercise, it will not feel the arthritis pain. Addi-tionally, some researchers believe that therelaxation response increases the body’s produc-tion of endorphins, which are natural painkillers.

Other researchers have used BIOFEEDBACK as atechnique to help people deal with stress and totrain people with arthritis to relax. In one study,one group of arthritics had biofeedback training;the other had a standard physical therapy program.

42 arrhythmia

Those in the group using biofeedback and relax-ation felt better; additionally, their erythrocyte sed-imentation rate (ESR), a blood test measuring theactivity of the disease, showed that their immunesystems held stable against the disease or that thedisease had somewhat abated.

Many psychological forces seem to have a rolein autoimmune diseases. Psychotherapy can helparthritis patients understand the possible emo-tional factors associated with their symptoms. Inconjunction with psychotherapy, or by themselves,techniques including RELAXATION exercises, MEDI-TATION, and biofeedback can be helpful.

See also ANGER; AUTOIMMUNE DISORDERS; CHRONIC

ILLNESS.

FOR FURTHER INFORMATION:Arthritis FoundationP.O. Box 7669Atlanta, GA 30357(404) 872-7100http://www.arthritis.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases

1 AMS CircleBethesda, MD 20892-3675(301) 495-4484http://www.niams.nih.gov

SOURCES:Kahn, Ada P. Arthritis. Chicago: Contemporary Books,

1983.Locke, Steven, and Douglas Colligan. The Healer Within.

New York: New American Library, 1986.

artificial insemination See INFERTILITY.

asbestos Asbestos is a stressful topic becausefibers released from minerals in the material causeirritation and inflammation of the lungs. Morethan 3,000 products in use today contain asbestos,including carpet underlays, roofing materials,brake pads and linings, pot holders and ironingboard pads, hair dryers, floor tiles, cement, toastersand other appliances, furnaces, and furnace doorgaskets. Asbestos has been used in heat andacoustic insulation, on boilers and steam pipes,fireproofing or structural steel and decking, and/orsprayed or troweled on plaster material for

acoustic, decorative, or other purposes on ceilings,walls and other surfaces.

Certain workers in construction, ship and boatbuilding, railroads, maintenance trades, and partic-ularly those who have done plastering, fireproof-ing or pipe or duct insulation may have had heavyexposure to asbestos. The health risk from asbestosis also high for people who work in asbestos-con-taminated buildings. Building renovation work canalso release asbestos fibers into the air.

The Environmental Protection Agency (EPA)reports that about 20 percent of all public and com-mercial buildings in the United States contain someasbestos material. In about two-thirds of thosebuildings, at least some of the asbestos material isdamaged, and almost half have significantly dam-aged asbestos. It is not possible to tell whether abuilding material contains asbestos by looking at itbecause asbestos and asbestos-substitute materialslook very similar. The only way to tell for certainwhether material contains asbestos is to have asmall sample examined under a microscope.

Asbestos that is tightly bound or sealed into build-ing material does not pose a health hazard. It is onlywhen the asbestos material becomes friable, or capa-ble of becoming crumbled and releasing asbestosfibers into the air, that the danger of asbestos diseaseexists. This can happen when asbestos-containingmaterial becomes damaged or deteriorated due toage, heat, water leaks, vibration, maintenance work,or renovation.

According to the Safety and Health Department,International Brotherhood of Teamsters (IBT),another potential hazard exists where asbestosfireproofing is exposed to airflow, when the airspace between a ceiling and the floor above is usedas part of the air conditioning system of a building.This air movement can pick up asbestos fibers andcirculate them throughout the building. Accordingto the American Lung Association, there is noknown safe exposure to asbestos.

The Occupational Safety and Health Adminis-tration (OSHA) has separate standards governingworker exposure to asbestos in general industryand for construction. The construction asbestosstandard covers asbestos removal, demolition, andrenovation work. These standards are designed pri-marily for people who work directly with asbestos,

asbestos 43

not for people who work in asbestos-contaminatedbuildings.

Asbestosis: A Crippling Disease

Caused by inhaling asbestos fibers, asbestosis is aprogressively crippling disease. It is not a cancer; itis caused by the scarring of the lung tissue by heavyexposures to asbestos fibers. The body attempts toneutralize the foreign fibers of asbestos in variousways, and some of these processes lead to furtherinflammation and cell damage. Eventually a fibro-sis or scar tissue develops in the interstitial spacesaround the small airways and alveoli. This thicken-ing and scarring prevents oxygen and carbon diox-ide from traveling between the alveoli and theblood cells, so breathing becomes more difficult.

Asbestosis affects both lungs and, although it ismainly in the lower fields of the lungs, it is usuallywidespread. The condition is detected by X-ray.Symptoms typically include shortness of breathand coughing. It can be a progressive disease,worsening even after exposure to asbestos hasstopped. In some cases it is fatal.

The condition is usually caused by heavy expo-sure to asbestos, such as sustained exposure over aperiod of years (for example, a longtime job at anasbestos textile plant) and/or intense exposureduring a shorter period (for example, workers inthe engine rooms of ships under construction dur-ing World War II).

Asbestos has been found to cause cancer. Themost common asbestos-related cancer is lung can-cer. Asbestos also causes cancer of the mouth andthroat areas, larynx, esophagus, stomach, colon,rectum, and kidneys. Asbestos is the only knowncause of mesothelioma, cancer of the lining of thelungs or the lining of the abdomen. Even a verysmall amount of asbestos exposure can lead to can-cer. People who have worked with asbestos foronly a few days and members of the families ofasbestos-exposed workers have been known tocontract asbestos-related cancer. According to theIBT, asbestos related cancers usually do not showup until 20, 30, or more years after the person isfirst exposed. There is currently no effective treat-ment or cure for asbestosis.

Some uses of asbestos have been banned: spray-ing of asbestos-containing materials (1973); certainpipe coverings (1975); certain patching compounds

and artificial fireplace logs (1977); sprayed-onasbestos decorations (1978); and asbestos-containinghair dryers (1979).

See also AIR POLLUTION; CANCER; SICK BUILDING

SYNDROME.

FOR FURTHER INFORMATION:American Lung Association61 Broadway, Sixth FloorNew York, NY 10006(800) LUNG USA (toll-free)(212) 315-8872 (fax)http://www.lungusa.org

SOURCE:Kahn, Ada P. The Encyclopedia of Work-Related Injuries, Ill-

nesses, and Health Issues. New York: Facts On File, 2004.

Asperger’s syndrome (AS) A neurobiological dis-order also known as Asperger’s disorder, which mayinclude a wide range of characteristics on a spec-trum ranging from mild to severe, such as markeddeficiencies in social skills, difficulties with transi-tions or changes, and preference for sameness.These characteristics may be a source of stress forparents and teachers because they may not under-stand the reasons for a particular child’s behaviors.

Individuals who have AS may follow obsessiveroutines and may be preoccupied with a particularsubject of interest. They have difficulty readingnonverbal cues (BODY LANGUAGE) and may havedifficulty determining proper body space. Overlysensitive to sounds, tastes, smells, and sights, theperson with AS may prefer soft clothing, certainfoods, and be bothered by sounds or lights no oneelse seems to hear or see.

Asperger’s syndrome was named for HansAsperger, a Viennese physician, who in 1944 pub-lished a paper describing a pattern of behavior inseveral young boys who had normal intelligenceand language development, but who also exhibitedautistic-like behaviors and marked deficiencies insocial and communication skills. It is only since1994, when the American Psychiatric Associationadded Asperger’s syndrome to the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition,that the disorder has been generally recognized.

There is controversy as to exactly where AS fitscategorically. It is currently described as an AUTISM

44 Asperger’s syndrome

spectrum disorder, while others consider it a non-verbal learning disability. AS shares many of thecharacteristics of PDD-NOS (pervasive develop-mental disorder, not otherwise specified). Becauseof the differences of opinion on classifying the dis-order, parents and teachers experience stress whendiagnosing a child with symptoms of Asperger’ssyndrome.

See also DIAGNOSTIC AND STATISTICAL MANUAL OF

MENTAL DISORDERS; SENSORY INTEGRATIVE DYSFUNCTION.

assertiveness training A process through whichindividuals can change unwanted behaviors thatcause them stress. It teaches individuals to seethemselves as equal human beings, with rightsregardless of their roles and titles. It raises SELF-ESTEEM and clarifies the choices that are availableto individuals when responding to others. Manypeople who are too inhibited or anxious to expressthemselves honestly in social situations can benefitfrom assertiveness training.

By teaching individuals to act upon their real feel-ings, assertiveness training helps them improve spe-cific situations. Such situations might involve anover-demanding boss; a friend who takes advantageof one’s generosity; the wife who resents that herhusband does not do his share of housework, but istoo meek to confront him with her true feelings; orthe employee who wants to ask for a raise but lacksthe courage to do so. Training sessions, conductedeither with a therapist or through self-help tech-niques, include rehearsing how to act and what tosay in common situations.

Assertiveness training can help people act moreeffectively in their own best interests, to make lifedecisions, take the initiative, trust their self-judg-ment, set goals and work to achieve them, and askfor help from others when necessary. It canempower them to stand up for themselves withoutundue anxiety, set limits on time and energy,respond to others’ put-downs or anger, and expressor defend personal opinions. It allows them to becomfortable and honest when expressing agreementor disagreement; when showing anger, affection, orfriendship; and when admitting fear or anxiety.

Assertive behavior is self-expressive, honest,direct and firm, and respectful of the rights of oth-ers without unfair criticism or hurtful behavior,

manipulation or undue CONTROL. Nonassertivebehavior, on the other hand, involves suppression,frustration, and thinking of a proper response toolate. As a result, nonassertive individuals feeluneasy and guilty and become stressed becausethey are not able to express their real feelings.

See also AGGRESSION.

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

assisted-living facilities See AGING; ELDERLY PAR-ENTS; LONG-TERM CARE INSURANCE.

assisted reproduction techniques See INFERTILITY.

asthma A chronic, allergic, inflammatory lungdisease characterized by recurrent breathing prob-lems. It is a source of STRESS to the sufferers, manyof whom become depressed due to the chronicallyrecurring condition and the ANXIETY experiencedduring asthma attacks. Families, too, becomestressed and anxious as they learn to deal with thesymptoms of the disease.

People with asthma typically have recurrentattacks or flare-ups of breathlessness, accompaniedby wheezing. Some people have mild to moderatesymptoms that can be life threatening. Even in thesame individual, asthma attacks vary in severityfrom day to day. In many individuals, attacks beginin childhood and tend to become less severe inadulthood; however, asthma attacks can begin atany age. Often attacks are brought on by stress oranxiety. Asthma is a major cause of lost time fromschool and work and of sleep disturbances.

During a severe attack, as breathing becomesincreasingly difficult, there is wheezing, sweating,rapid heartbeat, and an increasingly high anxietylevel. The individual cannot lie down or sleep,breathes rapidly, wheezes loudly, and may beunable to speak. He/she may fear dying, and thosewatching and trying to help the sufferer may addto the overall stress level by showing their ownanxieties. Asthma may get worse at night becauseat that time chemical changes in the body narrowairways, the airways become cooled, and theremay be delayed allergic reactions.

asthma 45

Contrary to a popular notion, asthma is not apsychosomatic illness. It is a disease and not a signof emotional disturbance. Understanding the phys-iology involved in asthma can help one managethe disease, reduce the stress it brings about, andimprove the quality of life. During an asthmaattack, several things occur to inhibit the flow ofair in and out of the airways. Inflammation causesa swelling in airways that blocks the passage ofoxygen to the lungs, and this is turn is exacerbatedby the contraction of pulmonary muscles and theproduction of thick mucus.

Asthma may be extrinsic, in which an allergy(usually to something inhaled) triggers an attack,or intrinsic, in which there seems to be no apparentexternal cause. Intrinsic asthma tends to developlater in life than extrinsic asthma.

About 10 million Americans have asthma; ofthese, about 3 million are children under the age of18. Asthma affects women and men equally. In theUnited States, the reported number of cases ofasthma is increasing but the death rate for asthmais still one of the lowest in the world.

What Triggers an Asthma Attack

Many people get warning signs hours or daysbefore an attack. Signs may include tiredness, achange in breathing, coughing, change in mucuscolor, trouble sleeping, itching of the chin orthroat, sneezing, headache, dark circles under theeyes, and moodiness. Triggers vary from person toperson, and many people with asthma have morethan one. Common triggers include:

Excitement or stressful situations. Emotional factorsthemselves do not cause asthma. However, laugh-ing, crying, or yelling may bring on symptoms.

Airborne allergens. An allergen is a substance thatcauses an allergic response. Common airborneallergens include pollen, dust mites, mold, and ani-mal dander.

Common irritants. These include cigarette smoke(as well as secondhand smoke); smoke from othersources, such as candles, burning leaves, or wood-burning stoves; aerosol sprays and other chemicals;and strong odors.

Exercise. Exercise is a trigger for many people;however, most people with asthma can lead activelives, including playing sports. There are steps onecan take to reduce the risk of problems.

Respiratory infections. Respiratory infections canbe particularly troublesome for children who tendto get more colds than adults.

Cold air. Cold air is a trigger for many people.Covering the nose and mouth when outdoors canhelp.

Reduce Stress by Managing Asthma Triggers

A physician can help the asthma sufferer identifytriggers and learn to reduce them. For example,one can reduce exposure to mold by ventilatingthe kitchen, bathroom, and other damp areas, run-ning a dehumidifier in the basement, and fre-quently cleaning areas where mold is likely togrow. Airborne allergens can be shut out by keep-ing doors and windows closed or they can bereduced by an air filtration system. To deal withdust mites, the asthma sufferer should clean upclutter, remove carpets, cover fabric upholsterywith plastic or replace it with leather or vinyl, usesynthetic bedding instead of cotton, and havesomeone else do the vacuuming. The asthmaticshould live in a home that is smokefree, and avoidpublic places where smoking is permitted.

Diagnosis, Treatment, and Self-Help

Asthma is sometimes difficult to diagnose becausemany of its symptoms resemble EMPHYSEMA, bron-chitis, and lower respiratory infections. For someindividuals, the only symptom is a chronic cough,especially at night, or coughing or wheezing occur-ring only with exercise. Diagnosis is made by con-sideration of medical history, thorough physicalexamination and certain laboratory tests.

Asthma cannot be cured, but it can be con-trolled with proper treatment. With current drugtherapies, people who suffer repeated attacks canlearn to manage episodes. Quality of life need notbe impaired, as demonstrated by the successes ofathletes who have had asthma. There are two maingroups of medications. One is anti-inflammatorymedications; these can help prevent asthma attacksby reducing swelling. Anti-inflammatory medica-tions include corticosteroids (usually inhaled), cro-molyn, and nedocromil. Inhaled steroids areabsorbed primarily by the lungs. That means littlegets into the bloodstream, lowering the risks of sideeffects. The second group is the bronchodilators.These medications can open airways during

46 asthma

asthma attacks. They include beta2 agonists andtheophylline. Asthma sufferers should have abronchodilator handy.

Asthma sufferers should follow their health careprovider’s instructions for when to take the med-ication and how much to take. If they have ananti-inflammatory medication, it should be takenregularly, even when they feel fine.

Exercise can improve lung power and wellness.However, before embarking on an exercise pro-gram, asthmatics should talk with their health careproviders who may provide extra medication. Awarm-up before exercising in cold air is necessaryas well as a scarf or mask over the nose and mouth.

Hospitals and local health departments offerbreathing improvement programs and supportgroups for asthma sufferers and members of theirfamilies. Topics for discussion typically includecoping with the stresses asthma produces on thesufferer as well as family members, avoidingasthma triggers, and new developments in med-ications. Groups can be helpful for parents of asth-matic children; family counseling is also useful forall concerned.

Research Under Way

Research on asthma is under way at the NationalInstitutes of Health. Projects focus on identifyingbasic abnormalities that cause asthma, developingbetter drug treatments and emergency measures,educating people with asthma to help themselvesmore effectively, and training patients in asthmaself-management techniques while under medicalsupervision.

See also ALLERGIES; CHRONIC ILLNESS; DEPRESSION;GUIDED IMAGERY; MEDITATION.

FOR FURTHER INFORMATION:American Lung Association61 Broadway, Sixth FloorNew York, NY 10006(212) 315-8700http://www.lungusa.org

Asthma and Allergy Foundation of America1233 20th Street NW, Suite 402Washington, DC 20036(202) 466-7643http://www.aafa.org

SOURCES:Adams, Francis V. The Asthma Sourcebook: Everything You

Need to Know. Los Angeles: Lowell House, 1995.Garnett, Leah R., ed. “Chronic Conditions: Asthma

Increases, but So Do Treatments.” Harvard Health Let-ter, June 1997.

Litin, Scott C., ed. “Management of Adult Asthma.” MayoClinical Update 13, no. 2 (1997).

atherosclerosis Common disease in whichdeposits of plaque containing fatty substances,such as CHOLESTEROL, are formed within the innerlayers of the arteries. Commonly known as “hard-ening of the arteries,” it produces anxieties andstress because potential complications may includecoronary artery disease and strokes. The diseaseprogresses over decades, chiefly affecting the arter-ies of the heart, brain, and extremities.

See also CHRONIC ILLNESS; HEART ATTACK; HIGH

BLOOD PRESSURE.

attention-deficit/hyperactivity disorder (ADHD)A persistent pattern of inattention and/or hyperac-tivity-impulsivity, occurring mostly in school-agechildren and occasionally in young adults. It is asource of stress to the children, their parents, andteachers because it interferes with the child’s learn-ing in school, causes disruptions in the classroom,and brings about anxieties for the parents.

ADHD sufferers are often overactive, impulsive,and easily distracted. Estimates are that ADHD affects3 percent to 5 percent of the school-age population,and is more common in boys. Data on prevalence inadolescence and adulthood are limited.

According to the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, attention deficit isthe central feature of the disorder and the othersymptoms are variable; the book also recognizesthat ADHD exists as a separate entity from conductdisorder. The essential feature of conduct disorder isa persistent conduct pattern in which rights of oth-ers and age-appropriate societal norms or rules areviolated. While the two conditions often occur inthe same individual, it is not assumed that one is anecessary concomitant of the other. Making the dis-tinction has important implications for outcome.

Diagnosing ADHD

To warrant the diagnosis of ADHD, according to theDSM, some of the hyperactive-impulsive or inatten-

attention-deficit/hyperactivity disorder 47

tive symptoms must have been present in the childbefore age seven, although many children are diag-nosed only after symptoms have been present for anumber of years. Additionally, there must be clearevidence of interference with developmentallyappropriate social, academic, or occupational func-tioning, and the disorder cannot be better accountedfor by another mental disorder, such as ANXIETY DIS-ORDER, dissociative disorder, or personality disorder.Diagnosis is usually made by a pediatrician, psychol-ogist, or neurologist. Often other health and educa-tion professionals, such as special education teachersor social workers, become involved in the diagnosisand treatment plan. Diagnosis is usually based ondescription of the child’s behavior from parents andteachers, as well as observation of the child’s behav-ior in the health professional’s office. Often the chil-dren are restless while the physician talks withparents. Many parents look back and report thattheir child was hyperactive from a very early age,even from one to two years of age. However, manyparents do not seek medical attention until the childis in first or second grade, and this presents difficul-ties. In children with a later onset, the disorder ismore likely to be associated with social disruption orspecific behavior at school.

To determine whether the child has an associ-ated disorder, such as a learning disorder or mildmental retardation, psychological tests are useful.

Treating ADHD

Individualized management, on a case by casemethod, is most effective. No one approach totreatment is universally accepted. Successful treat-ment depends on multimodal therapy involvingparents, teachers, and mental health professionals.

In an effort to reduce stress levels of both thechild and the family, the physician usually explainsthe nature of ADHD, with the objective of reducingthe family’s feelings of guilt and blame while at thesame time improving the child’s self-esteem. Whenthere are disorders of family dynamics or learningdisorders underlying the symptoms, these must beaddressed.

Physicians counseling families with an ADHDchild usually address behavior management andhow to avoid confrontation with the active, restlesschild. Such a child should be encouraged to chan-nel energy into productive activities, such as doing

errands, taking out the garbage or walking the dog.Support groups can be helpful to the child, parents,and siblings.

Behavior modification and COGNITIVE THERAPY

are used in some cases of ADHD. Other approachesinclude dietary restrictions of food additives orrefined sugar (Feingold diet) or supplementation ofdiet with megavitamins, trace elements, or aminoacids. However, best results have been noted withmultimodal therapy, including behavior manage-ment, special educational intervention, and, insome cases, use of stimulant drugs. Symptomatictreatment with stimulant medication in selectedpatients is effective and safe, but not curative.

A widely used but controversial stimulant med-ication is methylphenidate hydrochloride (tradename, Ritalin). The drug is effective for three tofour hours and is often prescribed for use in themorning and at noon. Individualizing dosage isimportant because high doses may help hyperac-tivity but have also been found to impair learning.When the dose is too high, some children becomeexcessively quiet, indecisive, and cry easily. Whensymptoms occur only in school, the medicationmay be given only on school days. A child on stim-ulant medication should be evaluated by the pre-scribing physician with some regularity.

When young people are untreated in childhood,they may develop very negative attitudes towardschool and patterns of failure. Even with treat-ment, some develop behavioral problems in laterlife, including substance abuse.

FOR FURTHER INFORMATION:Attention Deficit Information Network58 Prince StreetNeedham, MA 02492(781) 455-9895http://www.addinfonetwork.com

National Attention Deficit Disorders AssociationP.O. Box 543Pottstown, PA 19464(484) 985-2101http://www.add.org

SOURCES:American Medical Association. Archives of General Psychi-

atry 52, no. 66 (June 1, 1995).American Medical Association. The Journal of the American

Medical Association 273, no. 23 (June 21, 1995).

48 attention-deficit/hyperactivity disorder

American Psychiatric Association. Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition. Washington,D.C.: American Psychiatric Association, 1994.

autism A neurological disorder that affects devel-opment of social abilities, communication, andbehavior in characteristic ways. It is stressful forthe child or adult involved, and also for parents,family members, teachers, and others who interactwith the autistic person. Autism has an effect oneducation and community services.

Autism, also known as autistic spectrum disor-der (ASD), can range from relatively mild tosevere. People with the disorder face challenges inunderstanding and relating to others. Problemswith language comprehension may make commu-nication difficult. Language difficulties may also bea problem in social situations, for example, notbeing able to begin or keep a two-way conversa-tion going. People with the disorder may haverepetitive patterns of thinking and behaving and alimited variety of interests and activities.

Research shows that ASD is a genetic disorder,but the specific causes are not yet known. In severeforms it is usually recognized by age two or three,because the child is not yet speaking and shows lit-tle interest in people. However, subtle signs of mod-erate autism may not be recognized until later,often when the child enters school. Estimates indi-cate that one of every 200 children may be affected.

Diagnosing and Treating Autism

Autism is usually diagnosed by a clinical child psy-chologist or a specialist physician. Diagnosis ismade by gathering information about the child’sdevelopment from parents and others and by mak-ing systematic observations of the child’s behavior,including what he or she does as well as what hedoes not that would be expected of a typically-developing child.

Advances in psychological research haveimproved understanding of the challenges faced bypeople with autism. Methods of recognizing as wellas psychological assessment of children’s abilityprofiles and areas of relative strengths and weak-nesses can guide the development of appropriateintervention programs for children with ASD.

Major areas for interventions include socialskills, communication, daily living skills, academics,

self-management or coping skills, and family sup-port. Teaching opportunities arise naturally everyday in the home and community and structuredteaching, which emphasizes organizing schedules,materials, and settings helps optimize the individ-ual’s ability to learn and function. Peer interven-tion, in which other children are taught effectiveways to interact with a child with ASD, can pro-mote more positive social opportunities. For olderand more able individuals with autism, modifiedcognitive behavioral strategies in which behavioris changed by changing the way the personthinks, as well as systematic relaxation therapies,can be used to help manage the anxiety that isoften associated with social situations and dailyliving challenges.

Autism: Study and Research

The Center for the Study of Autism (CSA) providesinformation about autism to parents and profes-sionals, and conducts research on the efficacy ofvarious therapeutic interventions. Much of theresearch is in collaboration with the AutismResearch Institute in San Diego.

The nonprofit Autism Research Institute (ARI)was established in 1967 and conducts research anddisseminates the results on causes of autism andmethods of preventing, diagnosing, and treatingautism and other severe behavioral disorders ofchildhood.

FOR FURTHER INFORMATION:Autism Research Institute4182 Adams AvenueSan Diego, CA 92116(619) 563-6840 (fax)http://www.autism.com

Autism Society of America7910 Woodmont Avenue, Suite 300Bethesda, MD 20814-3067(800) 3AUTISM (toll-free)(301) 657-0881http://www.autism-society.org

Canadian Psychological Association141 Laurier Avenue West, Suite 702Ottawa, Ontario K1P 5J3(888) 472-0657(613) 237-2144

autism 49

Center for the Study of AutismP.O. Box 4538Salem, OR 97302http://www.autism.org

National Institute of Mental Health6001 Executive Boulevard, Room 8184Bethesda, MD 20892-9663(800) 421-4211 (toll-free)(301) 443-4513(301) 443-4279 (fax)http://www.nimh.nih.gov/publicat/autism.cfm

SOURCE:Canadian Psychological Association. “Psychology Works

for Autism,” Available online. URL: http://www.cpa.ca/factsheets/autism.htm. Downloaded on June 4,2005.

autogenic training RELAXATION and STRESS man-agement technique developed in 1932 by JohannesHeinrich Schultz (1884–1970), a German neurolo-gist. Dr. Schultz used it successfully for the treat-ment of high blood pressure, digestive disorders, andmusculoskeletal problems. Since then, its therapeu-tic applications have expanded to include a widevariety of cardiovascular, respiratory, endocrine,gastrointestinal, metabolic, and sleep disorders.

In autogenic training, the individual self induces ahypnotic-like state and achieves relaxation throughbreathing and muscular decontraction exercises. Thetechnique is often accompanied by MEDITATION andaffirmative statements regarding feelings of relax-ation, warmth, inner quietness, and calm.

A basic assumption behind autogenic training isthat people are innately equipped with “self-regu-latory brain mechanisms” that maintain a dynamicbalance in all bodily functions. When this balanceis disrupted, the body’s self-regulating mechanismshave the capability of restoring a healthy equilib-rium, whether by calming an escalated heart rate,lowering elevated blood pressure, or healing anulcer.

See also ALTERNATIVE MEDICINE; BEHAVIOR THER-APY; BIOFEEDBACK; PROGRESSIVE MUSCLE RELAXATION.

SOURCES:Kerman, D. Ariel (with Richard Trubo). The H.A.R.T. Pro-

gram: Lower Your Blood Pressure without Drugs. NewYork: HarperCollins, 1992.

Lehrer, Paul M., and Robert L. Woolfolk, eds. Principlesand Practice of Stress Management. New York: GuilfordPress, 1993.

autoimmune disorders Diseases caused by areaction of the individuals’ immune system againsttissues or organs of that person’s own body. Suchdisorders include rheumatoid ARTHRITIS, systemiclupus erythematosus, and insulin-dependent dia-betes mellitus. Autoimmunity refers to the condi-tion in which the body’s immune system fails torecognize its own tissues and attempts to reject itsown cells as if they were foreign matter. Autoim-munity increases with age as the immune systemdeteriorates.

Treatment of autoimmune disorders mayinclude correcting major deficiencies; replacementof hormones such as thyroxin or insulin that arenot being produced by a gland may be necessary.At times treatment may involve replacing compo-nents of blood by transfusion. Treatment may alsoinclude reducing the activity of the immune sys-tem, controlling the disorder while maintainingthe body’s ability to fight disease. Corticosteroiddrugs are commonly used; in more severe cases,immunosuppressant drugs are prescribed.

Autoimmune disorders are sources of stress forthe sufferer as well as family members becausesome of the disorders are difficult to diagnose andsome drugs may cause serious side effects, such asdamaging bone marrow.

automated teller machines (ATMs) Machinesused by the banking industry to receive and dis-pense funds. The technology, developed during the1960s, changed the way banking business is con-ducted, bringing about convenience but also thestresses of impatience and frustration.

There are times when ATMs are closed becauseof technical problems or lack of funds, causingpatrons to seek another machine. At times thereare long waits for machines in popular locations,particularly before major holidays. Some peopleare wary of using machines and prefer completingtheir transaction with a bank teller.

In 2004 there were 371,000 ATMs in the UnitedStates. According to Fortune magazine (July 16,2004), there are ATMs on the South Rim of theGrand Canyon and above the Arctic Circle.

50 autogenic training

The advent of ATMs did not reduce the numberof tellers or reduce the need for bank branches, asdevelopers of the machines had anticipated. Thereare now about 75,000 bank branches as comparedto 58,000 in 1985, while the number of tellers is539,000 compared to 484,000 back then.

SOURCE:Florian, Ellen. “The Money Machines.” Fortune 150, no.

2 (July 16, 2004): 100.

automation in the workplace Automated pro-duction and service systems where machines dothe repetitive elements of the work process thatused to be handled by people. As a result ofautomation, workers may be displaced or left withmainly supervisory functions.

The introduction of automation is generallyconsidered a positive step, if the worker is assistedby the machine but maintains some CONTROL overits services. However, if operator skills and knowl-edge are taken over by the machine, the resultingmonotony, lack of control, and social isolation mayresult in stress for the worker.

Even when automation requires high skill fromprocess operators, the monitoring of machines canbecome monotonous. Skills are used only during asmall percentage of the work hours, and mechani-cal breakdowns can mean loss of work alreadycompleted. All of these elements constitute sourcesof stress at both the psychological and physiologi-cal level.

Many industries, particularly manufacturing,have experienced displacement of workers sincethe advent of computerization and as a result ofautomation in their production lines; offices havebeen automated as well. It is estimated that officeworkers spend as much as 90 percent of their timeat computers. Use of computers has also meantautomation of delivery of services. A good exampleis the automatic bank teller, which not only casheschecks and deposits money, but can also providethese services 24 hours a day.

See also AUTONOMY; BOREDOM; CHANGING NATURE

OF WORK; JOB CHANGE; JOB SECURITY.

automobiles Americans spend an increasingamount of time in their automobiles—commutingto work, running errands, chauffeuring children,

shopping, banking, and seeking recreation. It hasbeen estimated that the typical American drivercovers 12,000 miles each year; stress begins whendrivers realize that they are handling a machinethat is potentially deadly to themselves and others.

Even the purchase of the automobile may be astress-filled situation. The buyer is faced with deci-sions whether to buy or lease; purchase new orused. Next comes a multitude of choices relating todealer, brand, model, and optional features.Finally, before the purchase is consummated, thebuyer worries whether he/she has used the bestbuying strategy and obtained lowest possible price.Car ownership carries with it the stresses of copingwith repair scams, gas-pump ripoffs, and car thefts.

Stresses of driving include unending traffic, stoplights, poor road conditions, road repairs, detours,competition for parking spaces, and ANGER at thedriving mistakes of others. Driving also involvesconstant decisions. Steering, passing, turning,braking, and looking out for other drivers puts onein a highly reactive state. Thus many drivers, whengiven sufficient reason, are ready to release theirpent-up frustrations, let their tempers soar, andexhibit aggressive behaviors. Some vent their stressby using the horn, shouting out their windows, ormaking gestures to other drivers. These techniquesdo little to reduce the stress inherent in the situa-tion. Better alternatives include patience, self-con-trol, and keeping a sense of humor.

Continued exposure to traffic jams and long-dis-tance commuting can have many adverse effectssuch as higher blood pressure and greater incidenceof colds and flu. Driver tensions can lead to whatresearchers call “inter-domain transfer.” That meansthat drivers who are stressed going to and fromwork are likely to carry a negative mood into theoffice or back to their families when they get home.

With today’s new car equipment and gadgets,drivers are encouraged to add to existing stressors bytalking on car phones, dictating memos, eating“one-handed” food, and sipping hot and cold drinks.Others who have overslept and are already understress because they are late to work may be seen intheir cars combing hair, flossing teeth, applyingmakeup, or tying ties. Keeping attention focused onthe task at hand is probably the best antidote to thestresses involved in driving an automobile.

automobiles 51

See also GUIDED IMAGERY; RELAXATION; ROAD

RAGE.

autonomy A feeling of being in CONTROL alongwith feelings of independence and freedom. Whenpeople lose their sense of autonomy, they may loseSELF-ESTEEM, become frustrated, and feel verystressed.

Many stressful situations throughout life cancontribute to loss of autonomy. Individuals mayexperience automation on the job, job loss, code-pendent relationships, sickness and disabilities, andold age. In most cases, autonomy can be regained,at least to some degree, by taking assertive steps,such as learning a new skill or forming new rela-tionships or finding a new job.

In developing a sense of autonomy, peer groupsplay an important role. Children with peer grouprelationships in which all group members play anequal role in leadership generally acquire goodfeelings about themselves and develop confidencethat others will like them. They will also developthe ability to realize what others expect of themand to make choices about meeting those expecta-tions in a flexible way and without stress.

For some individuals, particularly teenagers,peer groups may be destructive to autonomy. Theyare individuals whose experiences with their peershave not enabled them to develop self-confidence.Under these circumstances, their desire forapproval or acceptance may lead to taking drugs,smoking cigarettes, or other unhealthy behaviorsthat seem to make them feel part of the group.

See also AGING; ANGER; ASSERTIVENESS TRAINING;CODEPENDENCY; ELDERLY PARENTS; FRUSTRATION.

SOURCES:Johnson, D. S., and R. T. Johnson. “Peer Influences,” in

Corsini, Raymond J., Encyclopedia of Psychology, vol. 2.New York: Wiley, 1984.

Kahn, Ada P., and Sheila Kimmel. Empower Yourself: EveryWoman’s Guide to Self-Esteem. New York: Avon Books,1997.

May, Rollo. Freedom and Destiny. New York: W. W. Norton,1981.

Vinack, W. E. “Independent Personalities.” In Corsini,Raymond, ed. Encyclopedia of Psychology. Vol. 2. NewYork: Wiley, 1984.

aversion Dislike for certain situations or things.When individuals face something they extremelydislike—whether food, loud music, or a certainperson or animal—it can be stressful. Aversiontherapy helps them overcome habits andunwanted behaviors that cause stress by associat-ing those habits or behaviors with painful experi-ences or unpleasant feelings.

Aversion therapy has been used to treat manystressful situations, including ALCOHOLISM, BEDWET-TING, SMOKING, sex addiction, and NAIL BITING. Themost widely used form is chemical therapy, inwhich the individual receives a drug to inducenausea and is then exposed to smoking, nail biting,or other stressful habits that he or she is trying toovercome. The chemical method has been usedmost widely in the treatment of alcoholism.

A more modern form of aversion therapy isknown as covert sensitization. Based on modifica-tion of behavior, this therapy requires the individ-ual to imagine the unwanted stressful habit andthen to imagine some extremely undesirable con-sequence, such as pain or nausea.

The word aversion is commonly misused in placeof PHOBIA, which is a more severe reaction.

See also BEHAVIOR THERAPY; PSYCHOTHERAPIES.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

avian flu A type of influenza produced by avianinfluenza viruses; also known as “bird flu.” In Feb-ruary 2004, different strains of avian flu weredetected among several flocks of birds in theUnited States, and state officials ordered thedestruction of hundreds of thousands of birds. Pre-

52 autonomy

TIPS FOR REDUCING DRIVING STRESS

• Allow more time than you think you need.• Avoid the peak morning and evening commutes.• Keep your mind on the task at hand.• Practice patience and self-control.• Listen to music or audiotapes.• Keep your sense of humor.• Relax before or after driving by using MEDITATION

or another form of BREATHING exercise.

viously, outbreaks had been reported in severalcountries in Asia. Cases of avian influenza in birdswere confirmed in Cambodia, China, Indonesia,Japan, Laos, Russia, South Korea, Thailand,Turkey, and Vietnam. Human cases of avianinfluenza have been reported in China. Duringthese outbreaks, it was not determined that avianflu is spread from person to person; however, thesituation is a source of stress for many people con-cerned about birds in their area and the spread ofthe disease. The strain of avian influenza A (H5N1)affecting Asia has not been found in the UnitedStates. The current outbreak of avian influenzaprompted the killing of more than 25 million birdsin Asia, according the U.S. Department of Labor.

Wild birds are the natural hosts for the virus.Avian flu viruses circulate among birds worldwideand are highly contagious among birds. TheUnited States annually imports an estimated20,000 birds from countries with current avianinfluenza outbreaks, according to the U.S. Fishand Wildlife Service.

How Avian Flu Spreads

Most human influenza infections are spread byvirus-laden respiratory droplets that are expelledduring coughing and sneezing. They are carried inrespiratory secretions as small-particle aerosols.

In agricultural settings, animal manure contain-ing influenza virus can contaminate dust and soil,causing infection when the contaminated dust isinhaled. Contaminated farm equipment, feed,cages, or shoes can carry the virus from farm tofarm, and it can also be carried on the bodies andfeet of animals such as rodents.

In food handling/preparation settings, there isalso some concern that avian influenza could betransmitted from uncooked birds or bird products.The World Health Organization has also reported astudy that found avian influenza A (H5N1) inimported frozen duck meat. Eggs from infectedpoultry could also be contaminated with the virus.

Ban on Importation of Potentially Infected Animals

According to the U.S. Department of Labor, Occupa-tional Safety and Health Administration, the U.S.government (as of July 2004) issued an order for aban on importation of all birds from the following

Asian countries: Cambodia, Indonesia, Japan, Laos,People’s Republic of China, including Hong Kong,South Korea, Thailand, and Vietnam. The banapplies to all birds, whether dead or alive, and allbird products, such as eggs. This step was takenbecause birds from these affected countries poten-tially can infect humans with influenza A (H5N1).This order is enforced by the U.S. Department ofAgriculture (USDA), the Centers for Disease Controland Prevention (CDC), and other federal agencies,such as the Animal Plant Health Inspection Serviceof the U.S. Department of Agriculture, Bureau ofCustoms and Border Protection of the Departmentof Homeland Security, and the U.S. Fish and WildlifeService of the Department of Interior.

Precautions for Travelers

The CDC has issued precautions for travel to coun-tries that are reporting outbreaks of avian influenzaA in humans and animals. While the CDC does notrecommend the general public avoid travel to anyof the countries affected by avian influenza A, itmakes the following recommendations:

• Assemble a travel health kit containing basicfirst-aid and medical supplies, including a ther-mometer and alcohol-based hand sanitizer forhand hygiene.

• Become educated about influenza. Informationabout influenza is available on CDC’s influenzaWeb site: http://www.cdc.gov/flu

• Update your shots, and see your health careprovider at least four to six weeks prior to travelto get any additional shots or information youmay need. CDC’s health recommendations forinternational travel are available on CDC’s Trav-elers’ Health Web site: http://www.cdc.gov/travel

• Check with your health insurance plan or getadditional insurance to cover medical evacua-tion in the event of illness. Information aboutmedical evacuation services is available on theU.S. Department of State Web site: http://www.travel.state.gove/medical.html

• Prior to your trip, identify in-country health careresources.

• In countries where outbreaks of this disease areongoing, avoid areas with live poultry, such aslive animal markets and poultry farms. Large

avian flu 53

amounts of the virus are known to be excretedin the droppings from infected birds.

• If you develop respiratory symptoms or any ill-ness requiring prompt medical attention, a U.S.consular officer can assist in locating appropriatemedical services and informing family or friends.

• After your return, monitor your health for 10days. If you become ill with fever or respiratorysymptoms during this 10-day period, consult ahealth care provider and tell the provider thatyou have traveled to an area reporting avianinfluenza.

Precautions for Airline Flight Crews

Airline flight crews must be aware of symptoms ofavian influenza. Experience with human infectionis limited, but persons infected with avianinfluenza would likely have fever and respiratorysymptoms (cough, sore throat, shortness ofbreath). Personnel should wear disposable glovesfor direct contact with blood or body fluids of anypassenger. According to the CDC, the captain of anairliner bound for the United States is required bylaw to report the illness to the nearest U.S. quar-antine station prior to arrival or as soon as illness isnoted. Quarantine officials will arrange for appro-priate medical assistance to be available when theairplane lands and will notify state and local healthdepartments and the appropriate CDC officials.

FOR FURTHER INFORMATION:U.S. Department of LaborOccupational Safety and Health Administrationhttp://www.osha.gov

SOURCE:Nicholson K. G., et al., “Influenza.” The Lancet 362, no.

9397 (November 23, 2003): 1,733.

Ayurveda Ayurveda (“the science of life,” as ittranslates literally) originated at least 3,000 yearsago in India and is considered to be the oldest sys-tem of natural medicine. Ayurveda employs thehealing powers of breathing exercises, naturalfoods, massage, herbs and aromas to reduce stressand promote health and long life.

While Western medicine works on illness,Ayurvedic medicine focuses on the person as a

complex being, and treatment is highly individual-ized. For a person who feels well, Ayurvedic activi-ties make the most of mental, physical, and spiritualwell-being, enabling better COPING skills against thestresses of daily life. When a person is fighting ill-ness or coping with stress, Ayurvedic therapy worksby enhancing the healing potential within himselfor herself. Ayurvedic beliefs hold that life is a rela-tionship between body and mind. In the UnitedStates, Ayurvedic health care is considered a formof ALTERNATIVE MEDICINE (or complementary medi-cine), meant to complement, not replace, modernmedicine. Ayurveda is an art of insight that bringsharmony to daily life and relationships and to suchstressful EMOTIONS as pain, grief, and sadness.

A characteristic element of Ayurveda is thedetermination of an individual’s mind/body type.It is a combination of three fundamental principles,known as doshas, which govern thousands of men-tal and physical processes. These three principles—Vata (movement), Pitta (metabolism) and Kapha(structure)—are the controlling agents of nature.Permutations of the doshas determine an individ-ual’s subtype; through careful history taking andpulse diagnosis, a practitioner can determineimbalances of energy. Disease is diagnosed throughquestioning, observation, palpitation, percussion,and listening to the heart, lungs, and intestines.Another diagnostic technique associated withAyurveda reveals the status of internal organsmerely by observing the surface of the tongue. It isconsidered the mirror of the viscera and can reflectmany pathological conditions.

Ayurveda classifies seven major causative fac-tors in disease: heredity, congenital factors, inter-nal factors, external trauma, seasonal influences,natural tendencies or habits, and supernatural fac-tors. Disease can also result from misuse, overuse,and underuse of the senses: hearing, touch, sight,taste, and smell. It also can result from imbalancedemotions, such as unresolved anger, fear, anxiety,grief, or sadness.

Prana, the Ayurvedic term for energy, has coun-terparts in Oriental medicine (Qi) and homeopathy(Vital Force). Pranic energy is mental and physicaland can be changed by diet, exercise, herbs, or spir-itual practices such as MEDITATION. Pranic energyflows along specific paths, called nadis, which con-

54 Ayurveda

verge and cross in energy centers called chakraslocated along the length of the body. During anAyurvedic examination, chakras are studied anddoshas may be determined to be out of balance,leading to ill health.

In the United States, physician training inAyurveda is under the direction of the MaharishiTraining Program in Fairfield, Iowa, and directedby Dr. Deepak CHOPRA, who is also a contemporarywriter about Ayurvedic medicine.

See also ALTERNATIVE MEDICINE; IMMUNE SYSTEM;MIND-BODY CONNECTIONS; PSYCHONEUROIMMUNOLOGY.

FOR FURTHER INFORMATION:Ayurvedic Institute11311 Menaul Boulevard NEAlbuquerque, NM 97192-1445

(505) 291-9698http://www.ayurveda.com

Sharp Institute for Human Potential and Mind/Body Medicine

8010 Frost Street, Suite 300San Diego, CA 92123(800) 82-SHARP (toll-free)

SOURCES:Anselmo, Peter. Ayurvedic Secrets to Longevity and Total

Health. New York: Prentice Hall, 1996.Chopra, Deepak. Perfect Health. New York: Harmony

Books, 1990.Lad, Vasant. Ayurveda: The Science of Self-Healing. Santa Fe:

Lotus Press, 1984.Morrison, Judith M. The Book of Ayurveda. New York:

Fireside, 1995.

Ayurveda 55

Bbaby boomers The 76 million Americans bornbetween 1946 and 1964. They are products of thepopulation explosion that began during World WarII, peaked following the war, and lasted until themid-1960s.

The baby boom has been attributed to severalcauses, including the wartime prosperity that fol-lowed the Great Depression, increased births asservicemen husbands returned after the war, alower MARRIAGE age than for previous generations,and a tendency to have children in quick succes-sion early in marriage rather than spacing child-bearing over a period of years.

This generation has experienced many stresses,both individual as well as societal. These stresseshave not been static but have been influenced bythe changing times in which baby boomers havelived. As young adults, their protest against theVietnam War labeled them as hedonistic, rebel-lious, and undisciplined. When they reached col-lege age, they were fighting for civil rights andwere active in the women’s movement. Improvedbirth control, more permissive sexual standards,and an emphasis on education for both sexesplunged young women of the baby boomer gener-ation into a world of choices. The resulting ques-tions about pursuing careers, entering marriage,and having children are issues of stress that con-tinue to haunt women into the 21st century.

The concept of family has not been totallyattractive to baby boomers, who frequently havesubstituted networks of FRIENDS and LIVE-IN orcommunal arrangements for the traditional mar-riage and family. When marriages occur, they areoften at a later age than in previous generations.For many couples, this has meant stress that isbrought about by INFERTILITY problems because ofthe later age or, for single women, stress broughtabout by the ticking of their BIOLOGICAL CLOCK.

A good job market and a rapidly expanding econ-omy greeted baby boomers upon graduation fromcollege, and they were soon described as having ten-dencies toward materialism that included acquiringpossessions at an early stage and “HAVING IT ALL.” Inreaction, baby boomers tended to become entrepre-neurial and viewed a job as something that shouldbe fulfilling and stimulating rather than simply ameans to the end of supporting themselves and theirfamilies. However, the sheer numbers of the babyboom generation created a population bulge thatincreased competition for the remaining corporateand government positions. A changing economy,DOWNSIZING, the future of Social Security, risinghealth care costs, and the need for RETIREMENT sav-ings, has led to frustrations and additional stress.

See also COMMUNICATION; INTERGENERATIONAL

CONFLICTS; SEXUAL REVOLUTION; WOMEN’S MOVE-MENT; WORKING MOTHERS.

SOURCES:Mills, D. Quinn. Not Like Our Parents: How the Baby Boom

Generation Is Changing America. New York: WilliamMorrow, 1987.

Silver, Don. Baby Boomer Retirement: 65 Simple Ways to Pro-tect Your Future. Los Angeles: Adams-Hall Publishers,1994.

back pain Discomfort in the spinal column andsupporting structures. Estimates are that 50 per-cent to 80 percent of the population have backproblems significant enough to cause them to beout of work at some point during their lifetime. Ofthese, only a handful of backache sufferers, per-haps 10 percent to 20 percent, ever discover a rea-son for their pain. Diagnosis often remains anunsolved mystery because the causes of backinjury vary widely and the pain usually goes awayon its own.

56

The STRESS that occurs because of back pain canaffect the individual and his or her family andWORKPLACE. Often appearing at a particularlystressful time in a person’s life, back pains can bethe result of a one-time injury, or they can occurafter years of poor posture, OBESITY, emotionalstress, or simple wear and tear. Back pain can leadto the loss of work days. People who do heavy lift-ing, carrying or sitting in one place, or are over-weight, often develop backaches. Understandinghow work habits can lead to back pain and makingappropriate changes is a step toward alleviatingchronic discomfort and the accompanying stress.

Stress, Muscle Strain, Ligament Injuries, and Disk Damage

The most common one-time injury is muscle straincaused by falling, twisting, or improper lifting ofheavy objects. When muscles are pulled and do nothave strength to support the trunk of the body,they can contract into painful spasms.

Ligament injuries can also trigger back prob-lems. Years of poor body mechanics can perma-nently stretch the ligaments, bands of fibrous tissuethat connect bone and muscle to strengthen thejoints of the back. When they are sprained, themuscles have to work harder to support the back.

Disk damage affects only a small percentage ofbackache sufferers. Disks are located between eachvertebra. They are composed of a strong, fibrousring of tissue. When enough pressure is placed on adisk, the ring can be torn. If the ring has becomeweakened through long and strenuous use, the tearcan occur with only a slight pressure or strain. Aslipped, or ruptured, disk occurs when the spongyinterior of the disk seeps out and puts pressure onthe nerves coming from the spine, causing severepain in the back and often down the leg. As peopleage, ruptured disks are more likely because the diskslose some of their fluid and become less elastic.

In rare cases, back pain may indicate more seri-ous health problems, such as disease or injury tothe spine itself, pelvic or abdominal disorders, andkidney disease.

When simple self-help techniques do not work,one should consult a physician about back pain.

When back pain persists over time, many indi-viduals experience sufficient stress to lead to mildDEPRESSION and withdrawal. Persistent pain with-

out relief makes one feel out of CONTROL of one’sbody. Taking a positive attitude and pursuingavenues of relief can give the individual more con-trol over the situation.

See also ALEXANDER TECHNIQUE; ALTERNATIVE

MEDICINE; BODY THERAPIES; MASSAGE THERAPY;RELAXATION.

SOURCES:Goodfriend, Judy, ed. “Getting a Grip on Back Pain.” Vital

Signs 9 (March 1995).Jetter, Alexis. “Fighting Back Pain.” Health, September

1996.Sinel, Michael S. Win the Battle against Back Pain: An Inte-

grated Mind-Body Approach. New York: Dell, 1996.

barbiturate drugs Medications that provide seda-tion and induce sleep. They have been prescribedby physicians for stress, tension, and anxiety; theyact as depressants to the CENTRAL NERVOUS SYSTEM.These drugs slow down the activity of nerves thatcontrol many mental and physical functions, suchas EMOTIONS, heart rate, and BREATHING.

barbiturate drugs 57

TIPS FOR PREVENTING STRESS DUE TO BACK PAIN

• Stay in good physical condition and exerciseregularly to keep muscles strong, particularlyabdominal muscles, as they are important inback support.

• Stand tall, with your chin and abdomen tuckedin and the curve of your lower back as straightas possible. When standing in one place for anylength of time, put one foot up on the rung of astool, box, or some other object to adjust yourweight.

• When sitting, sit well back in your seat withyour back straight. Do not slouch. Change yourposition from time to time.

• Sleep on your side with your knees bent, or onyour back with only a small pillow under yourknees to release stress on your lower back.Avoid sleeping on your stomach.

• When lifting objects, squat down with yourknees and hips bent. Use your leg muscles torise, keeping your back straight and elbowsbent. Hold the object as close to your body aspossible to avoid strain on other muscles.

Some sleeping pills are “short-acting” barbitu-rates; their effects last only five or six hours and, ifproperly used, produce little or no aftereffects.When abused, barbiturates can cause addictionand exacerbate the sleeping difficulties.

There are many serious disadvantages to barbi-turates, which have led to a sharp decline in theiruse by physicians. They are very toxic. Deaththrough overdose, accidental or intended, is a sig-nificant danger, particularly when they are com-bined with alcohol. Physical and psychologicaldependency and mood changes can result from toomuch use.

In recent years, physicians are prescribing drugsin a newer class known as benzodiazepines formany stress and anxiety conditions. Benzodi-azepines can produce dependency but not to thedegree of dependency, toxicity, or cell death thatoccurs with the barbiturates.

See also BENZODIAZEPINE DRUGS; PHARMACOLOGI-CAL APPROACH.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

battered child syndrome See DOMESTIC VIOLENCE.

battered women See DOMESTIC VIOLENCE.

bed-wetting Medically known as enuresis;means unconscious or unintentional urinating by achild over the age of three while asleep. This prob-lem is a major source of stress for the child, whomay be embarrassed or feel guilty, as well as for theparent, who may feel confused about how to han-dle the situation. About 10 percent of children stillwet the bed at age five; many more continue to doso until the age of eight or nine. The situationseems more prevalent among boys than amonggirls.

Bed-wetting in young children may also be asymptom of other stresses, ranging from the arrivalof a new sibling to moving to a new house, fromstarting nursery school to the absence of a parent.Punishing or shaming a child for bed-wetting is notadvisable. Parents should not focus undue atten-tion on the situation, as doing so may make thechild feel more stressed and anxious, worsening

the problem. Instead, parents should try to reas-sure the child and relieve his or her fears.

Understanding the Causes of Bed-Wetting

In coping with the attendant stresses on child andparent, an understanding of some possible causesfor the problem may be helpful. For example, if thecause of bed-wetting seems to be emotional, theparent can begin to identify contributing factorsand start taking positive steps to correct the situa-tion. In some cases, a skilled counselor may be ableto help locate and explain the habits and reactionsof the child, parents, and/or other caretakers. Allconcerned should try to reinforce a child’s suc-cesses and reward good behavior by complimentsand encouragement.

Some little children fear bed-wetting, or mayhave reacted severely to embarrassment from aprevious accident. As a result, they may have badDREAMS about the accident and during such dreamsmay urinate in the bed. In other cases, childrensleep very deeply and cannot awaken to normalurinary impulses. A new schedule can be anothercause of bed-wetting, particularly when a childwho is accustomed to napping has just begunnursery school or kindergarten.

Making a Diagnosis and Beginning Treatment

In cases of repeated bed-wetting, a physician willtry to determine whether or not the cause is emo-tional or physical. Physical causes such as infectionor illness can be detected by assessing bladder func-tion. There may be a structural abnormality of theurinary tract present from birth, diabetes mellitus,or an infection in the urinary tract. In these cases,the child may also have difficulty controlling urineduring the day.

Because bed-wetting may lead to further shameand stressful situations, other symptomatic treat-ments have been used. For example, medicationssuch as imipramine, a tricyclic antidepressant,have helped some children. The decision to med-icate should be made by a pediatrician.

A nighttime alarm system is available, whichconsists of a moisture-sensitive pad to be placed inthe child’s bed between the mattress and the lowersheet. This triggers an alarm when urine is passed,and awakens the child, who can then use the toilet.After a while, the child awakens whenever the urge

58 battered child syndrome

to pass urine is felt. This is more useful to childrenover seven years old than to younger children.

Whether the causes are physical or emotional, achild can be retrained regarding toilet habits tohelp restore coordination of mental, neurological,and physical impulses.

The National Enuresis Society is a self-helporganization to help parents cope with the stressesof children’s bed-wetting.

See also TOILET TRAINING; URINARY INCONTINENCE.

FOR FURTHER INFORMATION:National Enuresis Society7777 Forest Lane, Suite C-737Dallas, TX 75230-2518(800) NEW-8080 (toll-free)

SOURCES:Brownstone, David, and Irene M. Franck. The Parent’s

Desk Reference. New York: Prentice Hall, 1991.Glenzer, Milton W. How to End Bedwetting: Facts Not Fancy.

Des Plaines, Ill.: Habit Publications, 1980.

beepers See ELECTRONIC DEVICES.

behavior therapy Behavior modification; includesseveral techniques intended to change the way anindividual responds to stressful situations by influ-encing actions, thoughts, and feelings that resultfrom such situations. Maladaptive (negative or self-

defeating) behaviors often can be reduced or elim-inated through behavior modification techniques.This therapy form became a widely used alterna-tive to psychodynamic theory during the 1950s. Itdeveloped because mental health professionals rec-ognized a lack of specificity and verifiability in thetreatment outcomes of other approaches to stressand anxiety problems.

Behavior therapy focuses on behaviors andresponses rather than on underlying causes. Ther-apists in this area believe that behaviors are notinherited but learned in response to environment.They help individuals learn to relax, to overcomestress, and to avert ANGER, panic, and undesirablebehaviors such as avoidance and anxiety.

Instead of trying to alter the personality byprobing into unconscious reasons that may moti-vate a person’s behavior, behavior therapy is oftenused in conjunction with therapies such as PSY-CHOTHERAPY and medication. It has proven effec-tive in treating anxieties, DEPRESSION, PHOBIAS,obsessions, compulsions, ALCOHOLISM and sexualproblems as well as other stress-related disorders.

The goal of behavior therapy is to help the indi-vidual develop self-control and an increased numberof revised, adaptive behaviors. The therapist andpatient together define treatment goals, often in con-junction with the family of the patient. The therapistacts as a coach or instructor and encourages thepatient to make choices about how and when tolearn new behaviors. Behavior therapists tailor spe-cific treatment techniques to the needs of theirpatients, focusing on measurable aspects of observ-able behaviors such as frequency or intensity (forexample, of ritualistic hand washing), physiologicalresponses (such as sweating) and self-rating scalesand verbal reports by the patient. Therapists may uti-lize any one or more of many techniques, includingclassical CONDITIONING, exposure therapy or desensi-tization, flooding, HYPNOSIS, and BIOFEEDBACK.

Exposure Therapy (Desensitization)

Exposure therapy employs several techniques toreshape an individual’s responses to stress-produc-ing situations. A therapist may choose systematicdesensitization, exposure at full intensity (floodingand implosive therapy) or exposure with modifica-tion of thought processes (contextual therapy).Systematic desensitization gradually exposes the

behavior therapy 59

TIPS FOR HELPING A CHILD OVERCOME THESTRESS OF BED-WETTING

• Estimate the approximate times when bed-wetting occurs and consider contributing factorsbefore bedtime.

• Give the child less liquid in the few hours beforebedtime.

• Plan on awakening the child a few hours afterhe has gone to sleep and have him go to thebathroom.

• Help him train reflexes during waking hours byhaving him visit the bathroom immediately onfeeling the first impulse.

• Reward the child with a gold star on a chart foreach dry night.

• For an older child, consider use of an alarm padin the bed.

individual to stress or anxiety-producing situa-tions. Such exposure may take place in the indi-vidual’s imagination or in real life. To retrain thethought processes, this technique is often com-bined with relaxation training.

In contextual therapy, developed by Americanpsychiatrist Manuel Zane (1913– ), the therapisttries to keep the patient anchored in the presentsituation and works with individual internal cues,which present stresses and anxieties.

Systematic Desensitization

In 1958, John Wolpe (1915–97), an American psy-chiatrist with a background in learning theory,reported successful results in treating adults with avariety of stress and anxiety concerns, includingphobic anxiety, reactive depression, and obsessive-compulsive disorder, with a process he called “sys-tematic desensitization.” He adapted his processfrom a technique developed in the 1920s for help-ing children overcome animal phobias. This processtrains the individual to relax muscles, imagineincreasing degrees of anxiety-producing stimuli,and then face these stimuli in real life until themaximum stimulus no longer causes great anxiety.Thus, an individual who fears sexual intercoursemight place coitus at the top of the list of anxiety-producing stimuli; thinking about sitting with adate in a bar might rank at the bottom of the list.After going through a series of relaxation trainingexercises, the patient is asked to imagine, with asmuch detail as possible, the least anxiety-producingitem from the list. While relaxing and imaginingthe situation, the patient tries to weaken the asso-ciation between it and his or her anxieties. Afterbecoming comfortable with imagining the leastthreatening situation, the patient gradually movesup the hierarchy of stress-producing situations.

While many therapists believe that facing astress-producing situation in the imagination maybe just as effective as facing it in reality, othersbelieve that it is not. Once the patient has com-pleted desensitization treatment and goes on toface the real stress-producing situation, he or shemay regress slightly down the hierarchy of stress-producing events. For example, a socially phobicindividual who has learned to remain calm whilewalking into a party and meeting new people, maybe comfortable in small groups but not at large

cocktail parties. However, eventually that individ-ual will be able to move from nonthreatening smallgroup social events to a larger setting and progressto a desired level of social behavior.

Flooding

Like desensitization, the technique known as flood-ing involves the patient imagining or experiencingstress-producing situations in real life. The tech-nique was developed in the 1960s by ThomasStampfl, an American psychologist at the Universityof Wisconsin. The patient is exposed directly to amaximum level of stress-producing stimulus with-out a graduated approach. The therapist, rather thanthe patient, controls when and which stressful sce-narios are to be imagined. The therapist describesvivid scenes in a purposeful effort to make them asdisturbing as possible to the patient, with no instruc-tions for the patient to relax. Such prolonged andrepeated exposure to feared situations helps elimi-nate the individual’s stress-filled response andreplace it with another that is more acceptable.

Implosive therapy, or implosion, is a variationand extension of the flooding technique. The patientis repeatedly encouraged to imagine a stress-producing situation at maximum intensity in orderto experience as intense a stress response as possi-ble. Assuming that there is no actual danger in thesituation, the stress response is not reinforced andthus becomes gradually reduced.

While flooding and implosive techniques helpreduce stress-filled responses in some individualswho have simple anxieties, for others, desensiti-zation appears to be more effective and morepermanent.

Modeling and Covert Modeling

Modeling therapy is also known as social learningor observational learning. The anxious individualwatches another person, often of the same sex andage, successfully carry out a particular stress-pro-ducing action, such as speaking in front of a groupof people or being introduced to members of theopposite sex. In some cases, the therapist modelsthe action. The “cure” occurs when the patientexperiences vicarious extinction of the previouslystress-filled and anxiety-producing responses.

With COVERT MODELING the patient simply imag-ines another person facing the stress-producing sit-uation without experiencing undue stress.

60 behavior therapy

Biofeedback

Biofeedback is a technique that enables the indi-vidual undergoing therapy to monitor psychophys-iological changes through an electrical feedbackdevice. It offers an individual a way to self-regulatecertain processes, such as reactions to stress-pro-ducing situations. The technique is useful withsome individuals who get headaches in response tostress or become extremely nervous when thinkingabout potentially stressful situations such as publicspeaking.

By noting physiological reactions to stressfulevents, biofeedback techniques help establish adiagnostic baseline that enables therapists to relatethis information to an individual’s verbal reports,fill gaps in the individual’s history, and encouragerelaxation of the body part to which the biofeed-back equipment is applied. In many cases, relax-ation training is used in conjunction withbiofeedback to give the patient a better sense ofcontrol and to break the cycle that elicits unwantedresponses to stress-filled situations.

Aversion TherapyThis form of therapy helps the individual focus onthe negative consequences of self-defeating behav-ior. For example, when alcoholics are treated withmild electrical shocks or given a nausea-inducingmedicinal substance every time they taste alcohol,they develop an aversive reaction to the smell andtaste of the alcoholic beverage.

Hypnosis

Hypnosis is considered a behavioral techniquebecause the role of the therapist is active. When suc-cessful, hypnosis produces a trance-like state inwhich the patient becomes very receptive to sugges-tions for behavior changes. With use of posthyp-notic suggestion, an individual may learn to changea response to a stressful situation, such as meetingnew people. Hypnosis is usually considered anadjunctive therapy, because it is used in conjunc-tion with other therapies. It is also considered analternative therapy because it makes use ofprocesses outside of the mainstream of medicineand psychiatry.

See also AGORAPHOBIA; ALTERNATIVE MEDICINE;AVERSION; COVERT REHEARSAL; COVERT REINFORCEMENT;MIND-BODY CONNECTIONS; PANIC ATTACKS AND PANIC

DISORDER; PSYCHOTHERAPIES.

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Kaplan, Sheldon J. The Private Practice of Behavior Therapy:

A Guide for Behavioral Practitioners. New York: PlenumPress, 1986.

belching See INDIGESTION.

Benson, Herbert, M.D. (1935– ) Foundingpresident of the Mind/Body Medical Institute; asso-ciate chief, Division of Behavioral Medicine, HarvardMedical School; and chief, Division of BehavioralMedicine, New England Deaconess Hospital.

He is a cardiologist who discovered anddescribed how the RELAXATION response is a protec-tive mechanism against overreaction to stress. He isthe author or coauthor of several books relating torelaxation and stress, including The RelaxationResponse and The Mind/Body Effect; hundreds of hisarticles have appeared in medical journals andpopular magazines.

Dr. Benson discovered the relaxation responsewhile studying people who practiced TRANSCENDEN-TAL MEDITATION. As a specialist in HIGH BLOOD PRES-SURE, Dr. Benson’s particular interests have includedhow the relaxation response can help people withhigh blood pressure and other health concerns. Hewarns that people with high blood pressure shouldnot just give up their medication. What MEDITATION

and the relaxation response do, he maintains, isimprove upon the benefit of the medication.

See also ALTERNATIVE MEDICINE.

FOR FURTHER INFORMATION:Mind-Body Medical InstituteNew Deaconess HospitalHarvard Medical School185 Pilgrim RoadCambridge, MA 02215(617) 632-9530

SOURCES:Benson, Herbert. Beyond the Relaxation Response. New

York: Berkeley Press, 1985.———. The Mind/Body Effect: How Behavioral Medicine Can

Show You the Way to Better Health. New York: Simonand Schuster, 1979.

———. The Relaxation Response. New York: Avon Books,1975.

Benson, Herbert, M.D. 61

benzodiazepine drugs A class of prescriptionmedications widely used to help relieve symptomsof stress and anxiety. They act as sedatives, musclerelaxants, and anticonvulsants. Different drugs inthis class are approved for different conditions. Forexample, ALPRAZOLAM (trade name, Xanax) isapproved for use in panic disorder.

Benzodiazepine drugs have less toxicity andfewer drug interaction problems than barbituratesand non-barbiturate sedative-hypnotic drugs. Also,benzodiazepines have a lower risk of cardiovascularand respiratory depression compared with barbitu-rates and are often used before general anesthesia.

Persons taking benzodiazepine drugs shouldavoid alcohol because interaction may result indepression of the central nervous system.

See also ANXIETY DISORDERS; PANIC ATTACKS AND

PANIC DISORDER; PHARMACOLOGICAL APPROACH.

bereavement See GRIEF.

bibliotherapy A form of supportive or alterna-tive therapy in which carefully chosen readings arerecommended for helping the individual gaininsight into personal sources of stress. Bibliother-apy also includes learning through reading aboutthe MIND-BODY CONNECTIONS in stress management.It is used in conjunction with many other thera-pies, such as BIOFEEDBACK, GUIDED IMAGERY, andRELAXATION training.

See also ALTERNATIVE MEDICINE; GUIDED IMAGERY.

binge drinking Excessive consumption of alco-holic beverages that is a major factor in nearly allthe leading causes of death for youth. Hazardousdrinking has been implicated in automobilecrashes, homicide, suicide, and fatal injuries amongyour people. Dangerous drinking is a source ofstress and anxiety for parents, school and collegeadministrators, and for young people themselves.

Approximately 10 million Americans under theage of 21 drink alcohol; nearly half of them drinkto excess, consuming four or more drinks in a rowone or more times in a two-week period. Alcoholis most frequently used by high school seniors, andits use is increasing. The stress of peer pressure is afactor. Studies show that one of three Americancolleges has a majority of students who engage in

high-risk drinking. More than two of every fivecollege students are binge drinkers, with excessivedrinking accounting for 1,400 student deaths,500,000 injuries, and 70,000 sexual assaults ordate rapes every year according to a study by theNational Institute on Alcohol Abuse and Alco-holism (NIAAA). Alcohol also has harmful effectson the brains of adolescents, according to Zeigler,et al., writing in Preventive Medicine.

“Today’s college students face powerful socialand commercial influences to drink. If we are toreduce the dangerous levels of campus drinkingand its consequences, college and surroundingcommunities must cooperate to reduce the numer-ous environmental factors that contribute to alco-hol abuse,” said AMA president J. Edward Hill,M.D., in 2004.

Traditional efforts to reduce underage drinkinghave focused primarily on youth education andprevention techniques, often simply trying to con-vince youth not to drink. Research shows that thismodel has been only marginally successful.

To combat alcohol abuse among underage youthand college students and the health risks and socie-tal harms associated with it, the American MedicalAssociation (AMA) and the Robert Wood JohnsonFoundation (RWJF) have joined forces to helpcommunities throughout the country find solutionsthat go beyond simply admonishing youth to sayno to alcohol. The AMA and RWJF are working tocreate solutions through two national programs: “AMatter of Degree: The National Effort to ReduceHigh-Rish Drinking among College Students” and“Reducing Underage Drinking through Coalitions.”“We are finally taking decisive action against amajor public health crisis that has taken the livesand futures of young Americans,” said Percy Woot-ton, M.D., a past president of the AMA.

A Matter of Degree

With funding from the RWJF and management bythe AMA, the two entities have been workingtogether since 1996 with 10 university-communitycoalitions in a national effort to reduce bingedrinking among college students. A Matter ofDegree (AMOD) is an $8.6 million, multiyear pro-gram designed to foster collaboration between par-ticipating universities and the communities inwhich they are located to address this issue and

62 benzodiazepine drugs

improve the quality of life for all community resi-dents. Participants in the program identify envi-ronmental factors such as alcohol advertising andmarketing, institutional policies and practices, localordinances, social and cultural beliefs, and behav-iors that converge to encourage alcohol abuse, andwork together to create positive changes. Forexample, coalitions may seek to curb the practiceof alcohol discounting, such as two-for-one drinkspecials, ladies’ nights, and other promotions intheir communities that encourage excessive drink-ing. They also work to limit alcohol industry spon-sorship of social events, including sports and othercelebrations.

According to an evaluation conducted by theHarvard School of Public Health published in theAmerican Journal of Preventive Medicine (October2004), college students at universities participatingin AMOD are less likely to miss class, be assaultedby a drunk student, or hurt themselves after drink-ing. The study also found a decline in the drinkingrates themselves at college incorporating the mostAMOD policies or interventions.

Further findings indicated that the five collegesthat had achieved a high level of implementation by2001 saw significant reductions, not only in actualrates of drinking, binge drinking, and frequentdrunkenness relative to 32 comparison schools, butalso in the direct and secondary harms of alcoholuse, including reports of missing a class, falling

behind in schoolwork, vandalizing property,injuries due to drinking, being assaulted by a fellowcollege student who is drinking, and experiencingan unwanted sexual advance by someone drinking.

According to Richard A. Yoast, Ph.D., director ofthe AMA Office of Alcohol and other Drug Abuse,AMOD’s national office, “Levels of implementationwere affected by numerous obstacles common onand around campuses such as alcohol industryresistance, little or no cooperation from the com-munity, lack of student support, and high drinkingrates common in the states themselves. However,findings in this study validate the environmentalprevention model and offer hope to colleges, uni-versities and their surrounding communities seek-ing ways to confront the academic and publichealth problems causes by high-risk drinking.”

Reducing Underage Drinking through Coalitions

This second initiative embraces an approach thatfocuses on how the social environment encouragesand even enables alcohol abuse among young peo-ple. Through this $10.2 million initiative, 12 coali-tions of youth, business civic organizations, thereligious community, and other leaders identifyfactors in the environment that contribute most tounderage drinking in their communities and worktogether to create positive influences. These factorsmay include illegal alcohol sales to minors, pricingof alcohol in bars, cultural norms, and marketingand advertising promotions.

Young people see almost as much televisionalcohol advertising as adults. According to the Cen-ter on Alcohol Marketing and Youth, young people(ages 12–20) saw two beer and ale ads in 2001 forevery three seen by an adult, and an estimated 30

binge drinking 63

TEN CAMPUS-COMMUNITYPARTNERSHIPS IN AMOD

Florida State University and Tallahassee, FloridaGeorgia Institute of Technology and Atlanta, GeorgiaLehigh University and Bethlehem, PennsylvaniaLouisiana State University and Baton Rouge, LouisianaUniversity of Colorado and Boulder, ColoradoUniversity of Delaware and Newark, DelawareUniversity of Iowa and Iowa City, IowaUniversity of Nebraska at Lincoln and Lincoln,

NebraskaUniversity of Vermont and Burlington, VermontUniversity of Wisconsin and Madison, Wisconsin

Source: http://www.alcoholpolicysolutions.net/overview_amod.htm

SUGGESTIONS FOR CAMPUS, LAWENFORCEMENT, AND COMMUNITIES

• Alcohol advertising and promotion controls• Keg registration• Mandatory training for responsible beverage

service• Stronger, more consistent campus-university

enforcement and policy collaboration• Curbs on selling alcohol without a license• Alcohol-free activities and residence halls

percent of youth saw at least 780 alcohol commer-cials in 2001.

Examples of environmental policy changes thatcoalitions may seek include enforcement to assurethat merchants are not selling alcohol to minors, orsocial host liability laws, which addresses adultsproviding alcohol to minors (usually supplied atparties) and making the adults liable for any prob-lems that occur.

Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation, based inPrinceton, New Jersey, is the largest philanthropydevoted exclusively to health and health care. Itconcentrates its grant making in four areas: to assurethat all Americans have access to quality health careat reasonable cost; to improve the quality of careand support for people with chronic health condi-tions; to promote healthy communities andlifestyles; and to reduce the personal, social, andeconomic harm caused by abuse of tobacco, alcohol,and illicit drugs. The foundation supports scientifi-cally valid, peer-reviewed research on the preven-tion and treatment of illegal and underage substance

use, and the effects of substance abuse on the pub-lic’s health and well-being.

See also ALCOHOLISM.

FOR FURTHER INFORMATION:American Medical AssociationRichard A. Yoast, Ph.D., DirectorOffice of Alcohol and Other Drug AbuseAmerican Medical Association515 North State StreetChicago, IL 60610(312) 464-4202(312) 464-4024 (fax)http://www.ama-assn.org

Janet Williams, Deputy DirectorReducing Underage Drinking Through CoalitionsAmerican Medical Association515 North State StreetChicago, IL 60610(312) 464-5073

Robert Wood Johnson FoundationP.O. Box 2316College Road East and Route 1Princeton, NJ 08543(888) 631-9989http://www.rwif.org

Donald W. Zeigler, Ph.D., Deputy DirectorA Matter of DegreeOffice of Alcohol and Other Drug AbuseAmerican Medical Association515 North State StreetChicago, IL 60610(312) 464-5687

SOURCES:Weitzman, Elise R., et al. “Reducing Drinking and

Related Harms in College: Evaluation of the ‘A Matterof Degree’ Program.” American Journal of PreventiveMedicine, 27, no. 3 (October 2004): 196–197.

Zeigler, Donald W., Claire C. Wang, and Richard A. Yoast,et al. “The Neurocognitive Effects of Alcohol on Ado-lescents and College Students.” Preventive Medicine 40,no. 1 (2005): 23–32.

binge eating See EATING DISORDERS.

binge-purge syndrome See EATING DISORDERS.

biofeedback Technique that enables a person touse information about a normally unconscious

64 binge eating

REDUCING UNDERAGE DRINKING THROUGH COALITIONS

12 coalitions include:The Connecticut Coalition to Stop Underage DrinkingThe Georgia Alcohol Policy PartnershipThe Indiana Coalition to Reduce Underage DrinkingThe Louisiana Alliance to Prevent Underage DrinkingThe Minnesota Join Together Coalition to Reduce

Underage Alcohol UseMissouri’s Youth/Adult Alliance Against Underage

DrinkingThe National Capital Coalition to Reduce Underage

Drinking (Washington, D.C.)The North Carolina Initiative to Reduce Underage

DrinkingThe Oregon Coalition Initiative to Reduce Underage

DrinkingPennsylvanians Against Underage DrinkingThe Puerto Rico Coalition to Reduce Underage DrinkingTexans Standing Tall, a Statewide Coalition to Reduce

Underage Drinking

Source: American Medical Association http://www.ama-assn.org

physical function, such as blood pressure, todevelop conscious control over that function. Thistechnique is often used as a STRESS MANAGEMENT

tool in conjunction with other stress reductiontherapies, such as MEDITATION and GUIDED IMAGERY.

Biofeedback operates by detecting physiologicalchanges in the individual and, by means of audi-tory or visual signals, informing him/her of thesechanges. The individual, using the information,then endeavors to make the signals change in thedesired direction. With the biofeedback tool as aguide, the individual learns fairly quickly how tocontrol the biological response system generatingthe biofeedback signals. For example, he or shemight learn to control heart rate or body tempera-ture. Biofeedback can be effective in treating cer-tain types of hypertension, anxiety and migraine.

Training for biofeedback involves three basicstages. The first is acquiring awareness of the mal-adaptive response. The person learns that certainthoughts as well as certain physical events influ-ence the response. In the second stage, guided bythe biofeedback signal, the person learns to controlthe response. In the third stage, the person learnsto transfer the control into everyday life and tomanage stress without the biofeedback instrument.

In addition to helping individuals improve theirphysiological activities into better ranges of function,biofeedback also helps them realize that it is possibleto control events that affect their well-being andtheir capacity to cope with stressful circumstances.

Early work with biofeedback helped peoplerelax before a BEHAVIOR THERAPY procedure knownas “systemic desensitization,” which involvescounterconditioning of anxiety with relaxation.

See also ALTERNATIVE MEDICINE; HEADACHES; HIGH

BLOOD PRESSURE.

FOR FURTHER INFORMATION:Association of Applied Psychology and

Biofeedback10200 West 44th Avenue, #304Wheat Ridge, CO 80303(303) 422-8436

SOURCES:Basmajian, John V., ed. Biofeedback: Principles and Practice

for Clinicians. Baltimore: Williams & Wilkins, 1983.Lehrer, Paul M., and Robert L. Woolfolk, eds. Principles

and Practice of Stress Management. New York: GuilfordPress, 1993.

biological clock For the many women in theirmid- to late thirties who hope to bear a child, thewords biological clock refer to the limited period oftime in which they are biologically able to producechildren. As their biological clock “runs out,”women in their late thirties or early forties who arehaving difficulty in becoming pregnant experiencea great deal of stress and anxiety. Statistics showthat a woman’s fertility is reduced and her abilityto conceive becomes more difficult with age, andbirth defects occur more frequently in infants bornto older mothers.

See also BABY BOOMERS; INFERTILITY; PARENTING.

SOURCE:McKaughan, Molly. The Biological Clock. New York: Pen-

guin Books, 1989.

biological hazards See HEALTH CARE WORKERS;NEEDLESTICK INJURIES.

biorhythms Physiological functions, such asmenstrual cycles, that follow a regular temporalpattern. These biological rhythms regulate psycho-logical as well as physiological functions in theindividual: energy level, hunger, sleep, and elimi-nation can all be affected. These rhythms vary con-siderably from person to person and within a singleindividual at different times. Such external factorsas changing travel and time zones or changing rou-tines in unpredictable and unfamiliar ways, candisrupt biorhythms and lead to stress.

To deal with the stress caused by disruptions inbiorhythms, individuals develop their own tech-niques. For example, some traveling through timezones may prepare by waking earlier for severaldays before the trip, or getting more rest uponreturn. Some develop particular dietary patternsthat they find helpful, such as eating small mealsmore often and drinking lots of water.

See also CIRCADIAN RHYTHMS; JET LAG; MENSTRU-ATION; SHIFT WORK.

birth control The term birth control refers to con-trolling the number of children born by preventingor reducing the chance of conception by natural orartificial means. The issue is stressful for many peo-ple, including those making a choice of birth con-trol methods or those whose religious convictions

birth control 65

are counter to using birth control as a practical andeconomic plan for their families.

Methods of Birth Control

Each method of birth control has advantages, disad-vantages, and sources of stress. They should be dis-cussed by couples before they engage in sexualintercourse. Women and men must weigh the fac-tors in a birth control method, including effective-ness in preventing unwanted PREGNANCY, protectionfrom a sexually transmitted disease, freedom fromside effects, costs, and spontaneity of use.

According to the 1995 National Survey of Fam-ily Growth by the National Center for Health Sta-tistics, the most popular method of birth control isfemale sterilization (29.5 percent), followed by thebirth control pill (28.5 percent), male prophylactics(17.7 percent), vasectomy (12.5 percent), thediaphragm (2.8 percent), the IUD (1.4 percent)and all other methods (4.9 percent). The numberstotal more than 100 percent because some womenuse more than one method.

See also SEXUALLY TRANSMITTED DISEASES; UNWED

MOTHERS.

FOR FURTHER INFORMATION:American College of Obstetricians and

Gynecologists409 12th Street SWWashington, DC 20024-2188(202) 638-5577

SOURCES:Franklin, Deborah. “The Birth Control Bind.” Health,

July/August 1992.Kahn, Ada P., and Linda Hughey Holt. The A–Z of Women’s

Sexuality. New York: Facts On File, 1990.

birth order Studies of birth order have led tosome generalizations about how a child’s positionin relation to his parents and siblings may affect hisstress level, personality, and view of the world.

The first child born to a FAMILY has the advan-tage of undivided attention and resources.Whether that child becomes the only child of thefamily or the oldest child with a sibling(s) to follow,he or she may tend to be more adult in behaviorand more interested in goals and personal achieve-ment. As a group, first children are strongly repre-sented in the ranks of the successful and powerful.

They also tend to score highest on intelligencetests.

Only children often have characteristics andresulting stresses of their own. Having been the cen-ter of their parents’ attention, they are in danger ofbecoming selfish and spoiled. Likewise, their par-ents’ expectations for them to succeed at anythingthey do may be unreasonably high. With moreexposure to adults, they may not relate well to otherchildren and may have problems with sharing.

For older children, the arrival of a sibling, eventhough happily anticipated, has the ultimate effectof making them feel dethroned. They often assumea certain amount of responsibility for younger chil-dren in the family and may be responsible for set-ting a good example, showing younger childrenhow to do things and baby-sitting. Older childrenare frequently more aware of family difficulties andproblems and their own parents’ insecurities. As aresult, they tend to be more anxious, conservative,and responsible than younger brothers and sisters.

The middle child position in the family has morevariables since the age and sex of siblings may havea profound effect on him or her. Middle childrenusually become good at sharing, but also guard theirprivacy. They may perceive that they are too youngfor the privileges of the oldest and too old for thecoddling of the youngest. As a result, middle chil-dren may show off to get attention and may alsoseek rewarding relationships outside the family. Theneed to belong to a peer group is strong in middlechildren and they are team players, frequently quitepopular. To compete with an older sibling, a middlechild will develop his abilities in an area quite dif-ferent from the talents of his older brother or sister.

The youngest child of a family never has theexperience of having his position usurped. Youngerchildren tend to preserve and use childish character-istics such as crying, acting cute, or emphasizing theirdependence and inadequacy to get what they want.Younger children frequently have very positive feel-ings about themselves because of their position inthe family and tend to be charming and popular.They have the best sense of humor in the family.Their disadvantage is that they often obtain informa-tion and opinions from other children rather thanfrom adults and therefore lack the wisdom and real-ism they might gain from adult contact.

66 birth order

Another type of younger child is the “change oflife” baby, who arrives several years after the othersiblings. This younger child is really more in the posi-tion of being the only child, but with several parents,since usually one or more of his or her siblings actsas a parent. These children grow up with a great dealof attention and support, but may also have the addi-tional stress of a confused sense of themselves, froma variety of images and ideas from siblings they per-ceive as adult but who are, in fact, children.

Other positions in the family that can have long-lasting effects on personality are the “only daughter”or “only son” syndromes. Only daughters have tra-ditionally had the “feminine” chores of the familyand, in many cultures, are expected to take care ofthe parents as they grow old, even if it means a per-sonal sacrifice. “Only sons” were expected to enterthe family business or succeed at some profession.

See also COMMUNICATION; SIBLING RELATIONSHIPS.

SOURCES:Brownstone, David, and Irene Franck. The Parent’s Desk

Reference. New York: Prentice Hall, 1991.Franklin, Deborah. “Why Are Siblings So Different?” In

Health, March/April 1991.Richardson, Ron, and Lois A. Richardson. Birth Order and

You: How Your Sex and Your Position in the Family AffectsYour Personality and Your Relationships. Bellingham,Wash.: Self-Counsel, 1990.

bisexuality See SEXUAL PREFERENCES.

bladder difficulties See BED-WETTING; URINARY

INCONTINENCE.

bloating See INDIGESTION.

blog (Web log) A blog is a Web site on whichsomeone writes their thoughts, usually daily, onany topic, ranging from personal life, family newsand opinions to sports or politics. Blogging is theact of communicating through a blog. As of 2004,there were an estimated 5 million blogs, with some15,000 new ones appearing each day, according toTechnorati.com, a research company attuned tothe blogosphere.

The word blog is a short form of “Web log.”Since 2000, writing and reading blogs has gonefrom an obscure fad to a routine alternative to

mainstream news outlets, rivaling networks andnewspapers in power and influence.

Because blog writers can expound on any sub-ject, blogging may be an outlet for stress in theirlives. Those who find attention useful for theirown self-image enjoy putting forth their ideas forthe world to see. Web logs provide the opportunityfor almost anybody to be a foreign correspondent,behind-the-scenes leader of information, or justsomeone seeking to share personal stories over theInternet. On the other hand, web logs can causestress for politicians, writers, filmmakers, and oth-ers who are criticized on widely read blogs. Theremay be up to 3 million family-oriented blogs, andbaby blogs are becoming common. According to anOctober 2002 study by the Pew Internet andAmerican Life Project, parents are more likely to beonline than nonparents, and 53 percent of parentssay the Internet has improved the way they con-nect with family.

Blogging may be a natural extension of today’sconfessional culture. For many ordinary Ameri-cans who divulge their innermost secrets or hearthose of others on television talk shows, bloggingabout one’s personal situations seems natural.According to Sherry Turkle, director of the Initia-tive on Technology and the Self at the Massachu-setts Institute of Technology, even people whonormally guard their privacy can experience a kindof disinhibition with blogs, in which boundariesseem to disintegrate. Bloggers may lose sight of thefact that they are publishing to a potential world-wide audience of millions.

Parents who struggle with a particular issue,such as a child with a chronic illness, may findblogging helpful as an outlet and a way to connectwith others who face the same problems. Bloggingparents form a community society linking to oneanother’s sites and posting helpful words.

bloodborne pathogens See HEALTH CARE WORK-ERS: HOSPITAL HAZARDS; NEEDLESTICK INJURIES.

blood pressure See HIGH BLOOD PRESSURE.

body image The mental picture an individual hasof his or her body at any moment. Many people are

body image 67

stressed by their own body image, thinking that oneor more parts are too big, too small, or misshapen.Perception of their own body often determinestheir level of SELF-ESTEEM and self-confidence. Mis-perception of their body image can lead to avoid-ance of social or sexual activities and EATING

DISORDERS, such as anorexia nervosa or bulimia.When a normal-appearing individual becomes

preoccupied with some imagined defect in appear-ance, the individual is said to have dysmorphic dis-order. Any slight anomaly evokes a grossly excessiveconcern. This is often associated with anorexia ner-vosa and other eating disorders in which the personperceives herself or himself as obese.

See also ACNE.

SOURCES:Hillman, Carolynn. Love Your Looks: How to Stop Criticizing

and Start Appreciating Your Appearance. New York:Simon & Schuster, 1995.

Kahn, Ada P., and Sheila Kimmel. Empower Yourself: EveryWoman’s Guide to Self-Esteem. New York: Avon Books,1997.

body language A form of COMMUNICATION throughfacial expression, posture, gestures or move-ments, accompanied with or without words.Both the communicator and the listener mayemploy body language. It can be a device used toexpress emotion or a reaction to the meaning ofcommunication.

Body language may be an indicator of the stressthat the communicator and the listener are experi-encing. According to Gay Turback in The Rotarian(April 1995), “Without uttering a syllable, it’s pos-sible to communicate love, hate, fear, rage, deceit,and virtually every other emotion in the humanrepertoire.” The article goes on to describe howbody signals have been around for more than amillion years, with some researchers having cata-logued 5,000 hand gestures and 1,000 postures,each with its own message. Says Turback,“Although some body language is nearly universal,much of it is an accoutrement of one culture oranother. Certain actions may have one meaning inMexico, a different meaning in the United States,and no relevance in Canada. Other examples givenin the article that are especially common amongNorth Americans are shown in the table.

body therapies Body therapies encompass ancientEastern traditions of spirituality and cosmologyalong with contemporary Western neuromuscularand myofascial systems of skeletostructural andneuroskeletal reorganization. They postulate thatthe traumas absorbed by the psyche from “falseunderstanding” are simultaneously absorbed astraumas in specific areas of the body. The bodyremembers after the mind forgets. Thus body ther-apies facilitate clarification of these traumasthrough the use of physical manipulations, move-ment awareness training, energy-flow balancing,and emotional release techniques. Body therapiesare used by many people to prevent effects of stressas well as relieve them.

Ancient disciplines in the category of body ther-apies include YOGA, T’AI CHI, Zen, Taoism, Tantra,and samurai. In the 20th century, Wilhelm Reichobserved that clinical patients with emotional dis-turbances all demonstrated several postural distor-tions. This observation helped to uncover moreconnections between the body-psyche and led tothe development of the Reichian school of bodytherapy.

Another modern pioneer in the field was MosheFeldenkrais, who postulated that the humanorganism began its process of growth and learningwith one built-in response, the “fear of falling.” Allother physical and emotional responses werelearned as the human organism grew andexplored. To attain the full potential of the body-mind-emotions-spirit, there must be, according to

68 body language

EXAMPLES OF BODY LANGUAGE THAT ARE INDICATORS OF STRESS

Action Meaning

Toes pointed outward ConfidenceToes pointed inward SubmissionA jutting chin BelligerenceLip and nail biting DisappointmentLip licking NervousnessFoot tapping ImpatienceLeaning backward A relaxed attitudeLeaning forward InterestOpen palms HonestyRubbing hands together Excitement

Feldenkrais, “reeducation of the kinesthetic senseand resetting of it to the normal course of self-adjusting improvement of all muscular activity.”This would “directly improve breathing, digestion,and the sympathetic and parasympathetic balance,as well as the sexual function, all linked togetherwith the emotional experience.” Feldenkraisbelieved that reeducation of the body and its func-tions was the essence of creating unity of thebeing. His method has helped many people withproblems of BACK PAIN, whiplash, and lack of coor-dination. The method is also used to help peoplewho have TEMPOROMANDIBULAR JOINT SYNDROME

(TMJ), which is a collection of symptoms includingpain, that affect the jaw, face, and head, oftenbrought about by stress and tension.

Four Systems of Body Therapies

Although many systems overlap and emcompassaspects of the others, body therapies can be dividedinto four general categories, based on their methods.

Physical manipulation systems include the connec-tive tissue work of the Ida Rolf school (Rolfing)and the deep tissue release systems such asmyofascial release used by John Barnes, an Amer-ican physical therapist.

Energy balancing systems include ChineseACUPUNCTURE and ACUPRESSURE, polarity, and JinShin Jystu.

Emotional release systems include bioenergetics,primal therapy, and rebirthing.

Movement awareness systems include those ofAston, Feldenkrais, Trager, and Aguado.

See also ALTERNATIVE MEDICINE; AYURVEDA; MAS-SAGE THERAPY; MIND-BODY CONNECTIONS.

FOR FURTHER INFORMATION:The Feldenkrais FoundationP.O. Box 70157Washington, DC 20088(301) 656-1548

North American Society of Teachers of the Alexander Technique

P.O. Box 517Urbana, IL 61801(217) 367-6956

Rolf InstituteP.O. Box 1868

Boulder, CO 80306(303) 449-5903

SOURCES:Feldenkrais, Moshe. Awareness Through Movement. San

Francisco: Harper & Row, 1972.———. Explorers of Humankind. San Francisco: Harper &

Row, 1979.Feltman, John, ed. Hands-On Healing. Emmaus, Pa.: Rodale

Press, 1989.

books as stress relief Therapy with books, or bib-liotherapy, is an interdisciplinary field that combinesthe skills of psychotherapists, librarians, and educa-tors. In the course of a bibliotherapy stress-reliefprogram, books are selected to change disturbedpatterns of behavior. The books may be directly con-cerned with mental health or may be fiction or non-fiction works relating to and interpreting thereaders’ problems and stress-producing concerns. Ithas been suggested that reading about a disturbingsubject such as death, divorce, or aging may givereaders a sense of control over their problems and away of mentally working them out. Use of selectedbooks with children may alleviate concerns aboutfrightening topics by clearing up misconceptions andgiving information about the unknown. Readingmay also give children the comforting knowledgethat others share their concerns and may promotecommunication with their parents.

See also CONTROL.

boredom According to HANS SELYE (1907–82),Austrian-born Canadian endocrinologist and psy-chologist, as well as pioneer researcher in the fieldof stress, boredom is not a defense against stress.Instead, as he reported in a research project,“bored subjects experienced an intense desire forextrinsic sensory stimuli and bodily motion,increased suggestibility, impairment of organizedthinking, DEPRESSION, and in extreme cases, HALLU-CINATIONS, delusions and confusion.”

Normal function of the brain, Selye said,depends on constant arousal generated by contin-uous sensory input. Hallucinations, which maycause accidents, have been noted in pilots andlong-distance truck drivers, presumably becausethe monotony of their work acts as a form of sen-sory deprivation.

boredom 69

What is Boredom?

Boredom can be a self-imposed prison that keepspeople from trying new things or having new, life-enriching experiences. An essential characteristicof boredom is that it is almost always the creationof the person who is bored. As a result, there arethose who are bored by everything while manyothers are never bored.

Some people view things as boring because theyreally are afraid of failure. In his book, A New Guideto Rational Living, Dr. Albert Ellis said: “Viewing fail-ure with fear and horror, some people avoid activ-ities that they would really like to engage in.” Therationale of such people is: If life is boring, nothingis worth doing. Thus, if nothing is worth doing, aperson can hardly fail.

Overcoming Boredom

Overcoming boredom depends on whether peopleare bored because they cannot live without excite-ment or because they have chosen to remain in ashell of inaction. Life is not supposed to be thrillingall the time. If people crave continuous thrills, theyshould reduce their expectations for excitement. Ifpeople are experiencing stress because of boredom,they should try to face reality. They should get outand do one new thing each day, such as talking tounfamiliar people, volunteering in a nonprofitorganization, learning a new skill, or writing let-ters. Boredom carried to the extreme can be athreat to health and lead to depression.

See also GENERAL ADAPTATION SYNDROME; HOB-BIES; VOLUNTEERISM.

FOR FURTHER INFORMATION:The Boring InstituteP.O. Box 40Maplewood, NJ 07040(201) 763-6392

bowel movements See CONSTIPATION; DIARRHEA;INDIGESTION; IRRITABLE BOWEL SYNDROME.

brainstorming A specialized approach to problem-solving, by group or team effort. It is based on theconcept that a person alone may not be able toarrive at a solution to a problem because of a blockin the thinking process or external distraction, butseveral people working together will be more likelyto reach a solution.

When properly conducted, brainstorming ses-sions can be an important management tool.Employees who take part in a brainstorming ses-sion feel a part of the company. Furthermore, bygiving employees entree to problems and solu-tions, they develop a feeling of CONTROL and own-ership in what they do. As such, employeeparticipation in brainstorming sessions may help toalleviate stress in the WORKPLACE.

In a typical brainstorming session, the coordina-tor who is in charge of collecting the ideas indicatesthat there should be a free flow of ideas, with noright or wrong answers or suggestions. All partici-pants are encouraged to be a part of the process.However, if this brainstorming rule is not estab-lished, participants can be made to feel self-con-scious and may experience a great deal of stressand anxiety.

The basic proposition of brainstorming is thatone idea can lead to another and thus increase thecreative output. When successful, this approachgenerates enthusiasm and a large number of sug-gestions, as one person expands upon ideas of oth-ers. Often, brainstorming sessions backfire.Participants never see the results of a brainstorm-ing session carried out. This leads to an increase ofemployee stress and the lowering of morale.

See also CREATIVITY.

brainwashing Form of mind control related topropaganda or political indoctrination. It is anextremely stress-provoking situation in which allof a person’s COPING skills are called into use.Although situations and techniques of brainwash-ing vary, there are common elements that are usedto change thought patterns and deeply held values.

For example, subjects of brainwashing can bemade to feel totally out of CONTROL and to knowthat their needs and actions are subject to anauthority before which they are powerless.

They may be subjected to mental or physicalharassment and experience ridicule of deeply heldbeliefs. As much as possible, their persecutorsmake them feel that their future is uncertain. Ifthey feel that one of the group who is controllingthem is somewhat kinder than the others, theymay begin to feel somewhat dependent on thatperson. Since subjects of brainwashing are usually

70 bowel movements

kept in isolation, kept as inactive as possible anddeprived of food and sleep, their bodies weaken,their thought processes become disorganized, andthey will agree to almost anything. As their sug-gestibility increases, their SELF-ESTEEM decreases.They begin to feel guilty about past behavior that isat odds with their captors’ standards.

An example of brainwashing is the treatmentgiven American prisoners held captive by the Viet-namese during the Vietnam War. Another exampleis the religious CULTS that flourished in the yearsfollowing the 1960s. Members of religious cultsshowed evidence of brainwashing techniques,such as changed speech and behavior patterns,obedience to an authoritarian leader, and rejectionof friends and family outside of the cult.

See also ADVERTISING; AUTONOMY.

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.Somit, Alters. “Brainwashing,” in Sills, David, ed., Inter-

national Encyclopedia of the Social Sciences, vol. 1. NewYork: Macmillan, 1968.

breast cancer The anxiety, fear, and apprehen-sion each woman faces when she discovers a lumpin her breast is the beginning of a long, stressfulperiod in her life, and one that deeply affects herfamily as well. According to an article in NationalWomen’s Health Report, “It (finding a lump) maywell be the reason that women resist establishing aroutine for examining their breasts each month.”

Once a lump has been discovered eitherthrough self-examination or mammography, thewoman enters a world of baffling terminology inwhich she must depend on others for understand-ing. Next, she must deal with the stress of tests andprocedures used to identify a breast symptom andthe time lapse before a final diagnosis is made. If amalignancy is found, she must select from a varietyof treatment options and find the right resources toassure that the best decision is made. The moreinformation she has, the easier it may be to deter-mine the advantages and disadvantages of varioustherapies. Inherent at this point is the tremendousphysical and emotional adjustments a womanmust make regarding removal of a breast(s).Finally, when treatment is completed, she is faced

with the fear that the CANCER is out of control andshe must deal with the continuing anxiety overrecurrence of the disease.

More Aggressive Therapy Wanted

According to a report in Y-ME Hotline (Novem-ber–December 1995) final results of a survey ofwomen with advanced breast cancer reveal that 77percent are willing to do whatever it takes to getmore aggressive drug therapy, despite the finan-cial, emotional, and physical side effects of thetreatment. In addition, 93 percent of the womensurveyed believed that the Food and Drug Admin-istration is too slow in approving treatmentoptions. The findings were announced in 1995 bythree national information and advocacy organiza-tions participating in the Roper Search mail survey:the National Alliance of Breast Cancer Organiza-tions (NABCO), the Susan G. Komen Foundation,and the Y-ME National Breast Cancer Organiza-tion. The survey was conducted by sending ques-tionnaires to women with advanced breast cancer;results were tabulated from 256 responses.

The majority of women (53 percent) in theRoper survey stated that they themselves are themost influential party in selecting their medicaltreatments. Seventy-seven percent felt that thechance for a favorable response (shrinking of thetumor) is the most important consideration in theirtreatment decision, 11 times the number for whomside effects are most important. The most encour-aging aspect of chemotherapy, according to 41 per-cent of respondents, is feeling hope for their future.

According to another Gallup poll, 80 percent of1,500 women receiving chemotherapy want theirchemotherapy treatment to be as aggressive as theycan tolerate. Sixty-one percent said that chemother-apy is worth the discomfort and inconvenience.

Role of Psychoneuroimmunology

In the early 1980s, researchers in the BehavioralMedicine Branch of the National Cancer Institutetested an observation on breast cancer patients.They believed that women with better survivalrates were also those who were fighters, or thosewho had an aggressive attitude toward conqueringthe disease and were active in choosing theirphysicians and their treatments.

Even before that, in the 1970s, Britishresearchers followed the health of breast cancer

breast cancer 71

patients. They found that breast cancer patientsoften seemed to hold their emotions, especiallyANGER, in check. Those women who survivedlongest with no recurrence of disease were alsothose who initially reacted to the news that theyhad cancer in one of two ways: denying there wasanything serious wrong with them or showing“fighting spirit,” a determination to do everythingpossible to conquer cancer. In contrast, womenwho succumbed had reacted to the news of theircancer either by demonstrating a stoic attitude andliving their lives as though nothing had changed orhaving a helpless, hopeless response.

Studies conducted at Stanford University duringthe 1980s demonstrated that breast cancer patientswho were in SUPPORT GROUPS while undergoingtherapy lived longer than those who received med-ical treatment alone. Although there are no hardscientific data that other complementary treat-ments, such as RELAXATION, BIOFEEDBACK, massage,herbal remedies and many others similarly extendsurvival, there is little evidence that they are harm-ful. They can be helpful supplements to, but notsubstitutes for, conventional therapy. Choosing touse an “alternative” therapy in addition to the pre-scribed medical therapy also gives a woman moreof a sense of control over her situation.

See also ALTERNATIVE MEDICINE; CHRONIC ILLNESS;PSYCHONEUROIMMUNOLOGY.

FOR FURTHER INFORMATION:Susan G. Komen Breast Cancer Foundation5005 LBJ, Suite 370Dallas, TX 75244(214) 450-1777

Y-Me National Breast Cancer Organization212 West Van Buren StreetChicago, IL 60607(312) 986-8338

SOURCES:Love, Susan M. Dr. Susan Love’s Breast Book, 2nd ed. Read-

ing, Mass.: Addison-Wesley, 1995.Merz, Beverly, ed. “Breast Cancer.” Harvard Women’s

Health Watch. October 1995.———. “The Mammography Muddle.” Harvard Women’s

Health Watch 4, no. 7 (March 1997).“Patients Want Aggressive Therapy,” Y-ME Hotline, 534

(November/December 1995).

breast reconstruction Depending on their prog-nosis after removal of a breast (or breasts), womencan choose an additional procedure during whichthe breast is reconstructed with artificial substancesor with tissue from another body part, such as theabdomen. For those who are candidates for recon-struction, making the choice of methods can be avery stressful situation.

“Preserving the breast after cancer can reducestress and increase the quality of life,” said plasticsurgeon John Bostwick, M.D., in a clinical studyreleased by the American Society of Plastic andReconstructive Surgeons (ASPRS) in October1995. The study explored immediate partial breastreconstruction using endoscopic surgery. It recom-mended such construction after lumpectomy andradiation treatments for women with smallerbreasts when primary tumors are 2.5 centimeters,as well as for women who had large portions oftheir breasts removed leading to considerabledeformity and asymmetry of the breast. “The abil-ity to examine the breast with a mammogram isextremely important,” said Dr. Bostwick. “Sincewomen have elected to keep as much of the breastas possible, they need to know that reoccurrence ofthe cancer can be detected.” However, just as inwomen who have very dense breasts, detectingearly cancerous changes behind an implant withmammography may, in some cases, be difficult.There is some controversy regarding the effective-ness of mammography following reconstructionwith an implant.

Because women do not always choose or have achoice of reconstruction after surgery, they returnto a society that places a high value on the breastas a sex symbol and fashion statement. Marriagesor relationships can be put under a terrific strainand often do not last. For these women, the stressof maintaining a sense of BODY IMAGE and self-worth follows them throughout their lives.

On the other hand, many women who are ableto make a choice of breast reconstruction find thattheir sense of SELF-ESTEEM is enhanced. They havefewer concerns about looking attractive in cloth-ing, entering relationships, or preserving theirmarriages.

See also BREAST CANCER; CHRONIC ILLNESS; SUP-PORT GROUPS.

72 breast reconstruction

breath-holding spells Childhood breath-holdingspells, a common and frightening phenomenonthat occurs in healthy, otherwise normal children,are a source of stress for parents and child alike.Treatment of children with breath-holding spellshas largely focused on providing reassurance tofamilies after a diagnosis has been made.

Some children use breath-holding as an act ofrebellion or a demonstration of AUTONOMY. Whenchildren know that they can terrify their parentswith this behavior, the behavior becomes some-what reinforced. According to Francis DiMario, Jr.,M.D., Department of Pediatrics, University of Con-necticut Health Center, Farmington, “It is neitherfeasible nor helpful for parents to attempt to avoidcircumstances that may provide emotional upset intheir child. Even though pain and fear may serveas provocatives, simple frustration and the expres-sion of autonomy are both normal and expected inyoung children.”

If parental stress leads to continuous attempts atappeasement, the child may soon learn to manip-ulate the parent with the threat of crying. This doesnot imply a willful attempt at breath-holding, sincein some cases these spells are reflexive and unpre-dictable. There is, nonetheless, the potential forparents to reinforce behavioral outbursts if appro-priate, calm firmness is not displayed at times ofcustomary disciplining.

Breath-holding spells pose no physical danger tothe child. If spells are causing anxiety to the par-ents, a physician should be consulted.

See also BREATHING; PARENTING.

SOURCES:Brownstone, David, and Irene Franck. The Parent’s Desk

Reference. New York: Prentice Hall, 1991.Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.

breathing The major features of breathing arerespiration and ventilation. Respiration puts oxy-gen into body cells and ventilation removes theexcess carbon dioxide. Poor breathing habitsdiminish the flow of gases to and from the body,making it harder for individuals to cope withstressful situations. With increased awareness ofhow people breathe and by incorporating certaincontrolled breathing techniques into relaxation

practice, they will be able to quiet thoughts, calmemotions, deepen relaxation, and control bloodpressure and other physical functions. Althoughbreathing seems very easy and very normal,relearning breathing techniques can help manyindividuals who suffer from STRESS, PHOBIAS, anxi-eties, and panic attacks. Some performers and ath-letes learn this technique in order to combat STAGE

FRIGHT or PERFORMANCE ANXIETY.Breathing is controlled by the autonomic or

involuntary nervous system. Breathing patternschange during different psychological states. Forexample, in a state of calm and relaxation, breath-ing becomes deeper and more rhythmic. Understress, breathing is shallow and irregular. Whenfrightened, an individual may even hold thebreath. However, breathing patterns can be con-sciously controlled in order to influence the auto-nomic system toward relaxation, therebyinterrupting the physiological arousal that can leadto stress-related disorders and high blood pressure.

Breathing Styles

Most people breathe in one of two patterns: One ischest or thoracic breathing; the other is abdominalor diaphragmatic breathing. Chest breathing,which is usually shallow and often rapid and irreg-ular, is associated with anxiety or other emotionaldistress. When air is inhaled, the chest expandsand the shoulders rise to take in air. Anxious peo-ple breathing in this manner may experiencebreath holding, HYPERVENTILATION or constrictedbreathing, shortness of breath, or fear of passingout. When an insufficient amount of air reachesthe lungs, the blood is not properly oxygenated,the heart rate and muscle tension increases, andthe stress response is triggered.

Abdominal or diaphragmatic breathing is thenatural breathing of sleeping adults. Thediaphragm contracts and expands as inhaled air isdrawn deep into the lungs and exhaled. Whenbreathing is even and unconstricted, the respira-tory system performs efficiently in producingenergy from oxygen and removing waste products.

Symptoms of Inefficient Breathing

Many people who feel stressed also have breathing-related complaints. Some can’t seem to catch theirbreath or get enough air. Others may frequently

breathing 73

sigh, yawn, or swallow. Some breathe too deeplyand hyperventilate. Symptoms associated withhyperventilation resemble those of PANIC DISORDER.Researchers have noted the overlap betweenhyperventilation, anxiety, and stress symptoms. Ithas been found that patients will hyperventilatejust by asking them to think back on unpleasant orstressful events.

Physical conditions associated with breathingdifficulties, particularly hyperventilation, includehypertension, ALLERGIES, anemia, angina, ARTHRI-TIS, ARRHYTHMIAS, ASTHMA, colitis, diabetes, gastri-tis, HEADACHES, heart disease and IRRITABLE BOWEL

SYNDROME.Deep, diaphragmatic breathing is a cornerstone

for many relaxation therapies. Many therapeutictechniques (many known as ALTERNATIVE MEDICINE)and BEHAVIOR THERAPIES incorporate control ofbreathing as a basis because the cycle of stress can bealtered with breath control. Individuals who havemastered these techniques find that as soon as theyare aware of a stressor, they become aware of theirbreathing, and try to control their stress by deep,slow breaths. By contrast, holding the breath, as

well as shallow, irregular breathing, can initiate aswell as augment many stressful feelings and physio-logical responses. Posture can also affect breathing.Keeping the body in alignment allows greater lungcapacity.

Breathing and Yoga

YOGA is a more than 2,000-year-old method fordeveloping and unifying mind, body, and spirit.Yoga practitioners have long recognized the rela-tionship between breathing and health and main-tain that the life force is carried in the breath.Exercises to control breathing are incorporatedinto yoga postures (asanas) and practices. Yogapractitioners believe that extending and deepeningthe breathing process draws breath all the waydown to one’s heels and that deep and slowbreathing can increase longevity.

See also BIOFEEDBACK; GUIDED IMAGERY; MEDITA-TION; PANIC ATTACKS AND PANIC DISORDER.

FOR FURTHER INFORMATION:American Lung Association61 Broadway, Sixth FloorNew York, NY 10006(212) 315-8700

SOURCES:Kerman, D. Ariel. The H.A.R.T. Program: Lower Your Blood

Pressure without Drugs. New York: HarperCollins, 1993.“RX: Breathing for Health and Relaxation.” Mental Medi-

cine Update 4, no. 2 (1995): 3–6.

bronchial asthma See ASTHMA.

bruxism See TEETH GRINDING.

bulimarexia See EATING DISORDERS.

bulimia See EATING DISORDERS.

bullies People who are habitually cruel or intim-idating to those who are weaker and subordinate.Their aggressive behavior is a source of stress inhomes, schools, the community, and the work-place. Men who are bigger, taller, and stronger mayuse their physical size to intimidate; female bulliesare more likely to use verbal harassment.

74 bronchial asthma

TIPS FOR DIAPHRAGMATIC OR ABDOMINALBREATHING FOR STRESS REDUCTION

• Lie down comfortably on your back on apadded floor or on a firm bed, with eyes closed,arms at your sides and not touching your body,palms up, legs straight out and slightly apart,and toes pointed comfortably outward.

• Focus attention on your breathing. Breathethrough your nose. Place your hand on the partof your chest that seems to rise and fall the mostas you inhale and exhale.

• Place both of your hands lightly on yourabdomen and slow your breathing. Becomeaware of how your abdomen rises with eachinhalation and falls with each exhalation.

• If you have difficulty breathing into yourabdomen, press your hand down on yourabdomen as you exhale and let your abdomenpush your hand back up as you inhale.

• Observe how your chest moves; it should bemoving in synchronization with your abdomen.

Bullies are often overly self-confident peoplewho feel superior to their victims. Some may becompensating for their own anxieties or failures byfeeling and behaving this way. Many who show bul-lying behavior as adults were also bullies in school.

Bullying incidents could not be ignored inschools or workplaces. In schools, uncontrolledbullying can lead to further aggression and vio-lence. In the workplace, replacing people whombullies drive away can be an economic cost to theemployer. Intangible costs, such as a bad reputa-tion, can make it harder to replace bully victims.

See also BODY LANGUAGE; STRESS.

bureaucracy Bureaucracy involves organizationsthat are made up of tightly structured hierarchiesbound up in structured procedures marked bydelay or inaction. Examples of bureaucracies aregovernment agencies, insurance companies, acade-mia and higher education, banks, health careproviders and hospitals, pharmaceutical and chem-ical companies, utilities, and most heavily regulatedindustries. They have been criticized by modernmanagement theorists as rigid and easily co-optedby power structures to serve ends other than eco-nomic efficiency. In a bureaucracy, management’sexpectations for employees can be stressful.

Employees valued in bureaucracies play by therules and are punctual and detail-oriented. They donot question authority. They follow orders and pro-cedures regardless of the consequences, and theyspend long hours in meetings in which the mosttrivial as well as the most important decisions aremade. They do not know if they are doing a goodjob until someone blames them for something. As aresult, employees often suffer from the stress ofcovering for themselves regarding how the job wasdone rather than what the final outcomes were.

Doing business with a bureaucracy as a citizen,client, or customer can be equally frustrating andstressful. Finding the right person who knows theanswer to questions or can give information and get-ting through to him/her, particularly when a record-ing is giving directions, has become a major feat.

See also AUTONOMY; BOREDOM; CONTROL; WORK-PLACE.

burnout Contemporary term for a progressiveloss of energy, purpose, and idealism resulting fromoverexposure to a job or other stimulus that leadsto STRESS, stagnation, FRUSTRATION, and BOREDOM.It may result from ongoing, chronic stress, and it isalso a cause of stress for the sufferer as well as hisor her family and coworkers. It can strike anyone,from top executives, surgeons, defense attorneys,and airline pilots, to occupiers of such monotonouspositions as assembly-line worker and postalemployee. Burnout has no relationship to intelli-gence, money, or social position.

Burnout victims are often high achievers,workaholics, and idealists and are competent, self-sufficient, and overly conscientious individuals.Their common denominator is the assumption thatthe real world will be in harmony with their ideals.They often hold unrealistic expectations of them-selves, their employers, and society, and often havea vague definition of personal accomplishment.

Burnout begins slowly and progresses graduallyover weeks, months, and years to become cumulativeand pervasive. Physical symptoms of burnout includeexcessive sleeping, eating, or drinking, physicalexhaustion, loss of libido, frequent colds, headaches,backaches, neck aches, and bowel disorders. Theburnout victim desires to be alone, is irritable, impa-tient, and withdrawn, and complains of boredom,

burnout 75

REDUCE STRESS CAUSED BY BULLIES

• Stand up to the bully or report the situation to ateacher or supervisor.

• Consider changing your response to the bullyingbehavior.

• Practice some negotiation techniques and com-munication skills.

• Role play and know how you will respondbefore the bully next attacks.

• Work on remaining calm but firm with anybully. Exert self-control.

• Do not let the bully get away with it. Tell otherswhat is happening.

• Separate tactless putdowns from constructivecriticism.

• Pick your conflict: raise only issues that reallymatter to you.

• Watch your body language; do not transmit cuesof defensiveness or subservience.

difficulty concentrating, and burdensome work. Fel-low workers may notice indecisiveness, indiffer-ence, impaired performance, and high ABSENTEEISM.Intellectual curiosity declines and interpersonal rela-tionships deteriorate. “Overloaded,” “tired of think-ing,” and “I don’t know what I’m doing anymore”are some phrases that express the inner agony andstress of burnout sufferers.

Key Areas Identified by Research

Burnout involves six key areas: workload, control,reward, community, fairness, and values. The firsttwo areas are reflected in the demand-controlmodel of job stress. Increased workload has a con-sistent relationship with burnout, particularly withthe dimension of exhaustion, and problems in con-trol, such as restricted autonomy, decisionmaking,and role conflict. The area of reward refers to thepower of reinforcements to shape behavior; insuf-ficient reward (whether financial, institutional, orsocial) increases people’s vulnerability to burnout.

Community captures all of the work on social sup-port and interpersonal conflict. Findings show thatburnout is predicted by a lack of support and a lackof a sense of community in the work environment.

The area of fairness relates to situations of per-ceived unfairness or inequitable social exchange.Finally, the area of values picks up the cognitive-emotional power of job goals and expectations, andinitial research suggests that value conflicts may bea critical predictor of burnout, according to ChristinaMaslach, Ph.D., University of California, Berkeley.

Various forms of negative responses to the jobcontribute to burnout. These include job dissatisfac-tion, low organizational commitment, absenteeism,intention to leave the job, and turnover. People whoare experiencing burnout can have a negative impacton their colleagues, both by causing greater personalconflict and by disrupting job tasks. According toMaslach, the few studies that have looked at per-formance outcomes have found that burnout leadsto poor job performance. However, the actual causallink between burnout and negative job outcomes isstill a matter of speculation. For example, Maslachquestions whether burnout causes people to be dis-satisfied with their job or low satisfaction serves asthe precursor to burnout. However, both burnoutand job dissatisfaction may be caused by another fac-tor, such as poor working conditions.

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Maslach, D., W. B. Schaufeli, and M. P. Leiter. “Job

Burnout,” Annual Review of Psychology. 52, no. 1 (Feb-ruary 2001): 397–422.

butterflies in the stomach The uneasy sensationpeople refer to as “butterflies in the stomach” iscaused by a contraction of the abdominal blood ves-sels and is a response to STRESS. It is a common sen-sation experienced by people who must perform infront of an audience, go for a job interview, or par-ticipate in any type of activity that causes ANXIETY.

The feeling can be overcome, at least in part, byappropriate and adequate preparation for the per-formance, speech, or interview. Paying attention toBREATHING by taking regular and deep breathsbefore the event can also provide relief.

See also ALTERNATIVE MEDICINE; RELAXATION; YOGA.

76 butterflies in the stomach

TIPS FOR COPING WITH THE STRESS OF BURNOUT

• Recognize that no one job (or personal relation-ship) is a total solution for life. Strive for varietyin work, avoid routine.

• Put priorities into perspective; stop trying to be“all things to all people.”

• Take responsibility for change.• Set personal goals by answering these vital ques-

tions, “Where am I going?” “What do I want toachieve?” and “How am I going to do it?”

• Learn a new skill to enhance your optimism.• Create an “outside life,” interest and activities

unrelated to your work.• Develop a support system, people you can turn

to for help in problem solving.• Consider switching careers.• Learn how to manage your personal time.• Take breaks during the workday; go out for

lunch, take walks, etc.• Establish an exercise program at least three times

a week.• Look into alternative therapies such as relaxation

techniques.• Take mini vacations.

Ccaffeine One of several stimulants that affect thecentral nervous system by causing a rise in heartrate, blood pressure, and muscular tension. Drink-ing caffeine-containing drinks—such as coffee, tea,cola, and cocoa—or taking over-the-counter med-ications such as NoDoz or Vivarin and certainheadache and diet pills may actually increase theindividual’s stress level because of caffeine’s stimu-lating effect on all organs and tissues. Peak bloodlevels are reached in about 30 minutes after con-sumption. Caffeine directly affects individual cellsby causing chemical reactions within them. It actsindirectly on the adrenal glands by increasing therelease of epinephrine (adrenaline) and norepi-nephrine (noradrenaline), hormones that stimu-late cell activity into the circulation system.

When taken in small amounts, caffeine canstimulate brain cells, helping reduce drowsinessand fatigue. Concentration may be improved andreactions speeded up. However, taken in largeamounts, caffeine is known to cause overstimula-tion, ANXIETY, irritability, and restlessness. Manypeople who consume caffeine before going to bedcomplain of having INSOMNIA, which is a delay inthe onset of SLEEP, a shortened sleep time, or areduction of the average “depth of sleep.” Caffeinealso may increase the amount of dream sleep(REM) early in the night, while reducing it overall.People who feel stressed by insomnia should con-sider the amount of caffeine that they consume inthe course of a day.

Additional Effects of Caffeine

While caffeine, in moderate doses, may increasealertness and decrease fatigue for some individuals,regular use of 350 milligrams or more per day mayresult in a form of physical dependence. Coffeecontains 100 to 150 milligrams of caffeine per cup;

tea contains about half and cola about one-third ofthat amount. Interruption of this physical depend-ence on caffeine can result in withdrawal symp-toms such as severe HEADACHES. Many people whodrink large amounts of coffee on weekdays haveheadaches on weekends because they may be con-suming less caffeine.

Caffeine has been known to produce panicattacks in susceptible individuals. About half of thepeople who suffer from panic disorder have attacksafter consuming the caffeine equivalent of four tofive cups of coffee. Research has yet to determinewhether caffeine has a direct or causative effect onpanic or whether it simply alters the body to a statethat triggers a panic cycle. It may be that caffeineproduces its effects by blocking the action of abrain chemical known as adenosine, a naturallyoccurring sedative.

Caffeinism is a disorder caused by an individ-ual’s recent consumption of over 250 milligrams ofcaffeine. Symptoms of caffeinism may include rest-lessness, increased anxiety, increased phobic reac-tions in people with that diagnosis, nervousness,excitement, insomnia, frequent and increased uri-nation, gastrointestinal complaints, ramblingthoughts and speech, and cardiac arrhythmia.

See also PANIC ATTACKS AND PANIC DISORDER.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

call forwarding See ELECTRONIC DEVICES; TELE-PHONES.

call waiting See TELEPHONES.

camera phones See TELEPHONES.

77

cancer It is not easy today to live without thefear of cancer. Changing reports of things in ourdiet, lifestyle, or environment that do or do notcause or cure cancer have placed a great deal ofstress on many people. Yet in the last few decades,the outlook for those with cancer has improvedconsiderably.

Cancer is a condition in which abnormal bodycells reproduce uncontrollably. The defective cellsgrow slowly and are open to attack bymacrophages, large cells in the IMMUNE SYSTEM thatcharacteristically consume foreign debris and for-eign bodies. When they are successful in takingover the invading cells, cancer is averted. Whenthey fail, a tumor grows.

The defensive cells are inhibited by corticos-teroids, biochemicals released under stress.Research on stress and coping shows that generallypeople who do not cope well in stressful situationshave a decline in the activity of their natural killercells. Many individuals with TYPE C PERSONALITY

also may fall into this category.Physicians have recognized significant associa-

tions between stress and development of malig-nancies for as long as 2,000 years. In the 19thcentury, British physicians believed that emotionaldistress was the most powerful cause of cancer, andincreased rates of the disease were subsequentlycorrelated with the psychosocial stresses that haveprogressively developed along with lifestylechanges.

As reported in Stress, the newsletter of the Amer-ican Institute of Stress, studies since 1950 havedemonstrated that stress accelerates developmentand growth of different malignancies without actu-ally causing them. Similarly, stress reduction strate-gies have been shown to retard tumors in laboratoryanimals and to prolong life in cancer patients.

In a publication of the EHS Hospital and MedicalCenter, Oak Lawn, Illinois, strategies were listed thatcan “make a difference.” An adaptation follows:

There is increasing focus on another importantstrategy, affirmation. Research reports that state ofmind may be more important than the seriousnessof the disease in predicting longevity. Keeping apositive attitude through strong faith, participationin SUPPORT GROUPS, and using mind/body treat-ments such as HYPNOSIS, GUIDED IMAGERY, visualiza-

tion, and other adjunctive treatments, mayimprove the quality and extend the length of acancer patient’s life. Positive emotions elicited bythese positive approaches seem, in some cases, toretard or even reverse malignant growths.

Stress on Families of Cancer Patients

Family members of cancer patients are open toconsiderable stress as they watch their loved onesundergo uncomfortable procedures and wonderabout possible outcomes. At times, family mem-bers may wonder whether or not the proceduresare worth the suffering they inflict on the patient.While it may be difficult to keep up a cheerful,optimistic outlook, doing so is usually helpful to allconcerned.

Family members and friends who observe theprogression of the disease in a cancer patient mayhave feelings of confronting their own mortality.There may be subconscious (or even conscious)fears of contagion. Support groups for family mem-bers as well as the patient can be helpful.

See also ALTERNATIVE MEDICINE; BREAST CANCER;CHRONIC ILLNESS; MIND-BODY CONNECTION; PROSTATE

CANCER; PSYCHONEUROIMMUNOLOGY; SIEGEL, BERNIE.

78 cancer

STRESS AND CANCER: HOW TO MAKE A DIFFERENCE

• Change or modify your lifestyle. Since 75 per-cent of all cancers can be rooted in individualbehavior, prevention is key. It is important to eata healthy diet, not smoke, and use sunscreenwhen outdoors.

• See your doctor for regular checkups and whensymptoms arise. Cancer caught early generallyrequire less treatment and have better odds forsurvival. That’s why early detection can be cru-cial. Screening for colon, prostate, ovarian,breast, and lung cancer is particularly importantfor those over 40.

• Be sure you are receiving the most up-to-datecare. The best way to do that is through inter-vention, learning about how diagnoses aremade, what the latest treatments and followupsare, and where the best research is being done.Information on cancer is readily available foronline computer users.

FOR FURTHER INFORMATION:American Cancer Society1599 Clifton Road NEAtlanta, GA 30329(404) 320-3333; (800) 227-2345

Cancer Information Clearinghouse (NCI/OCC)Building 31, Room 10A189000 Rockville PikeBethesda, MD 21205(301) 496-5583

National Cancer Institute9000 Rockville PikeBethesda, MD 20982(800) 4CANCER; (800) 422-6237 (toll-free)

Sloan Kettering Institute for Cancer Research1275 York AvenueNew York, NY 10021(212) 639-2000

SOURCES:Locke, Steven, and Douglas Colligan. The Healer Within:

The New Medicine of Mind and Body. New York: NewAmerican Library, 1986.

McAllister, Robert M., Sylvia Teich Horowitz, and Ray-mond U. Gilden. Cancer. New York: Basic Books, 1993.

Terkel, Susan Neiburg, and Marlene Lupiloff-Brass.Understanding Cancer. New York: F. Watts, 1993.

carbonless copy paper A frequently used prod-uct in many businesses and offices that producesstress for many people due to mild to moderatesymptoms of skin irritation and irritation of themucosal membranes of the eyes and upper respira-tory tract. In most cases, adequate ventilation,humidity, and temperature controls can reducethis situation. Also, periodic cleansing of hands andminimal hand to mouth and hand to eye contactcan reduce the problem.

See also ALLERGIES.

FOR FURTHER INFORMATION:National Institute for Occupational Safety and

HealthCenters for Disease Control and PreventionU.S. Department of Health and Human ServicesRobert A. Taft Laboratories4676 Columbia ParkwayCincinnati, OH 45226

(800) 356-4674(513) 533-8573 (fax)http://www.cdc.gov/niosh/topics/ccp

cardiac arrest See HEART ATTACK.

caregivers In contemporary society, caregiversinclude family members or friends of a child, eld-erly adults, or an ill or disabled person who cannotcompletely care for himself. The term also appliesto individuals who are health care professionals orsocial workers.

Stresses of Caregiving

The caregiver role can be extremely stressfulbecause of its physical and emotional demands. Forexample, family members who are caregivers mayfeel powerless and depressed in the face of the suf-fering of a loved one. Professional caregivers maybuild a wall around themselves or go to the otherextreme and allow the pain and suffering they seeto overwhelm them.

Caregivers have a considerable amount ofpower and work in a close, personal relationshipwith their charges, frequently with little or nosupervision. Unfortunately, some situations ofabuse have occurred with elderly adults as well aswith children. Children are frequently victims ofsexual abuse by their caregivers, while the elderlyare often subjected to neglect or emotional andfinancial abuse. When an elderly person, disabledperson, or child is entrusted to the care of another,credentials and references should be carefullychecked and verified.

Caregiving to the Elderly

Even though institutional options are available, 75percent of care for the elderly is still provided by afamily member. Increased longevity means manyspouses will be caring for each another. Socialmobility and shrinking family size put some womenin the sole caregiver role for both their own andtheir husbands’ aging parents. The Older Women’sLeague in Washington, D.C., reported that at least athird of all women over age 18 can expect to becontinuously in the caregiver role from the birth oftheir first child to the death of their parents. At thesame time, women are moving into highly respon-

caregivers 79

sible professional positions at the time in life thattheir parents need care. According to the AmericanAssociation of Retired Persons, some women turndown promotions, avoid traveling, and even takeearly retirement to care for aging parents, addingstress to all concerned.

Individuals who have ELDERLY PARENTS or areover the age of 65 may be able to relieve somestress by planning ahead. Planning and preparationcan deter the emotional and financial stress thatoften accompanies caring for an elderly loved one.

Identify Needs: Disabled Children, Adults, or Elderly Persons

When an individual realizes that she or he will be inthe caregiver role, stress can be relieved by identify-ing the kinds of assistance the disabled or elderly per-son wants and needs. Some needs that can be met bya family member or by outside sources includemeals, shopping, cleaning, yard work, householdrepairs, finances, living arrangements, personalcare, and home health care.

An elderly person or disabled child or adult mayneed services to help him or her maintain socialinteraction or participation in the community.These services may include transportation to thedoctor, shopping, or church; psychological supportsuch as cutting through the red tape of healthinsurance carriers and Medicare, Medicaid, SocialSecurity, and other governmental bureaucracies;and protective services such as safety devices. Adisabled child may also need home tutoring or spe-cial education.

If possible, the caregiver and disabled elderlyperson or child can explore how needs, once iden-tified, may best be met. They can consider theresources of other family members, and their will-ingness and/or ability to help. Together they maylook at possibilities for blending resources withinthe family with those from outside the family.When caregiving is a shared responsibility amongfamily and/or friends, it leads to greater under-standing of the difficulties, sharing of stress, devel-opment of positive relationships, and enhancementof communication. Community and social services,such as Meals on Wheels, respite programs, supportgroups, and elderly day care, can also supplementcaregivers’ efforts.

FOR FURTHER INFORMATION:Care Options (Elder Care Management)2012 Business Center Drive, Suite 130Irvine, CA 92715(714) 254-4140

SOURCES:“Caregiving Solutions.” Care Options 2, no. 3 (summer

1993).Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

carpal tunnel syndrome A chronic conditioncharacterized by numbness, tingling, and pain inthe thumb, index, and middle fingers, and some-times by weakness in the thumb. It may affect oneor both hands. This syndrome results from pres-sure on the median nerve where it passes into thehand via a gap (the carpal tunnel), under a liga-ment at the front of the wrist. The median nervecarries sensory messages from the thumb and somefingers and also motor stimuli to the muscles in thehand. Damage to the nerve results in sensory dis-turbances, particularly the numbness and tinglingsensations.

Carpal tunnel syndrome is one of several possi-ble repetitive stress injuries (RSIs) common to cer-tain occupations in which the wrist is subjected torepetitive stresses and strains, particularly thoseinvolving gripping or pinching with the wrist heldflexed. For example, computer operators, typists,carpenters, factory workers, meat cutters (meatcleaver’s elbow), violinists, and even hobbyistssuch as golfers or canoers may develop carpal tun-nel syndrome. This injury is stressful for some suf-ferers because they may experience confusion overwhether to continue or quit a job or activity thatcontributes to their discomfort. The number ofworkers with disorders caused by repeated traumaon the job is increasing. Some severely injuredcarpal tunnel victims qualify for help under theAmericans for Disabilities Act. However, proof ofthe source of injury may be difficult, as two peoplemay perform the identical job with only one ofthem developing carpal tunnel syndrome.

Carpal tunnel syndrome is especially commonamong middle-aged women and in women whoare pregnant or have just started using birth-con-trol pills, as well as among people who suffer fromrheumatoid arthritis, myxedema, or acromegaly.

80 carpal tunnel syndrome

Treatment

With appropriate treatment, the pain can berelieved and there may be no permanent damageto the wrist or hand. Resting the affected hand atnight in a splint may alleviate symptoms. Somehealth professionals may recommend ACUPUNC-TURE. If symptoms persist, a physician may inject asmall quantity of a corticosteroid drug under theligament in the wrist. If this does not help, surgicalcutting of the ligament may be performed torelieve pressure on the nerve.

See also WORKPLACE.

FOR FURTHER INFORMATION:American Physical Therapy Association /PR-IH1111 North Fairfax StreetAlexandria, VA 22314(703) 684-2782

Association for Repetitive Motion SyndromesP.O. Box 514Santa Rosa, CA 95402(707) 571-0397

SOURCE:Spooner, G. Richard, et al. “Using Pyridoxe to Treat

Carpal Tunnel Syndrome.” Canadian Family Physician39 (October 1993).

catastrophize The habit of imagining that theworst cases scenario will happen. People who fre-quently catastrophize have little self-confidence,low SELF-ESTEEM, and have difficulties making pos-itive and desirable life changes. An example of cat-astrophizing is saying to oneself, “If I go to theparty no one will know me and I won’t have agood time,” or “If I take this new job I’ll failbecause I don’t have the right computer skills.”

Catastrophizing causes stress because it keepspeople in situations they might really prefer tochange, such as improving their social life, chang-ing jobs, or moving to a new city. With positiveSELF-TALK and learned techniques to improve self-esteem, the habit of catastrophizing can be over-come. In severe cases, various PSYCHOTHERAPIES

may be helpful.

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

changing nature of work Job demands, intellec-tual and psychological demands, and the design,implementation, and monitoring of work processeshave all increased over the last several decades.These changes contribute to stress in all categoriesof workers and employers. Results of these changesinclude fewer workers with job security and healthand pension benefits.

According to Edward Yelin, Ph.D., University ofCalifornia, San Francisco, in his presentation at theforum on “The Way We Work and Its Impact onOur Health,” April 2004, in Los Angeles, majorissues in the changing nature of work includequantity of employment, distribution of jobs byoccupations and industries, and the shifting natureof the employment conditions.

Quantity of Employment

Overall, a larger proportion of the working-agepopulation is employed, the average worker is put-ting in more hours per year, and fewer are work-ing a standard full-time workweek.

There have been changes in the age of theworking population. In 1965, 58.9 percent of theworking-age population was in the labor force, butby 2000, 67.2 percent were, an increase of 14.1percent in relative terms. This overall increase isthe result of a 7.4 percent decrease among men(mostly among men aged 55–64) and a 53.2 per-cent increase among women. The overall result ismore women in the labor force.

Average hours worked per week among U.S.workers have stayed relatively constant, (accord-ing to the International Labor Office, 2001), whileweeks worked per year have increased, resulting ina net increase in the amount worked per year. Atthe same time, there has been an increase in theproportion working more than 40 hours per weekand nonstandard shifts.

Distribution of Jobs Has Changed

There has been a shift from production of goodsand blue-collar occupations to service industriesand white-collar occupations. Within white-collaroccupations, there has been a shift to professionaland managerial positions and a slight decrease inthe proportion in clerical occupations, probablydue to computerization of offices.

According to Yelin, between 1960 and 2000, thenumber of nonfarm workers increased from 54.2

changing nature of work 81

to 131.8 million. During that time, the number orworkers in goods-producing sectors rose onlyslightly, while the number in the service sectorsincreased more than three times. Thus workers ingoods production represented 38 percent of theworkforce in 1960, but less than 20 percent by2000.

Shifting Nature of Work Responsibilities

Many firms now maintain a small core of perma-nent workers and hire outside workers for specificprojects. Many functions of permanent employeesare farmed out to contractors that may be locatedoverseas. In recent years, there has been a shift inthe types of jobs performed by outside workers.Initially, day-to-day production activities were per-formed outside the firm, such as manufacturing ofgoods or the provision of services. Now, somehigher-level design functions such as computerprogramming have shifted outside. A decreasingshare of workers is hired long term and givenhealth and pension benefits.

In some industries there has been significantdown trend in wages as a result of internationalcompetition, while for other workers with skillsin high demand, wages have risen. For workers inoccupations that are in demand, the increasein opportunities for contingent forms of labor mayallow them to move among jobs rapidly and tointersperse periods of work with leisure. However,for a larger number of workers, the combination ofhigher demands on the job, lower levels of jobsecurity, and decline in real wages make the cur-rent labor market stressful.

See also SHIFT WORK; WORKPLACE.

SOURCE:Yelin, Edward. “The Changing Nature of Work,” Forum

on “The Way We Work and Its Impact on OurHealth,” Los Angeles, Calif., April 22–23, 2004.

chemical dependencies See ADDICTION.

chemical hazards Substances in workplaces,offices, and homes that contribute to allergic reac-tions or illness and stress. The Occupational Safetyand Health Administration (OSHA) defines haz-ards as those chemicals that are capable of causingharm. In this definition, the term “chemicals”

includes dusts, mixtures, and common materialssuch a paints, fuels, and solvents. The harm mayinclude allergies due to contact with or inhalingformaldehyde vapors and other synthetic or natu-ral allergenic substances; exposure to metallic, sol-vent, and other fumes; exposure to variouscarcinogenic, mutagenic, and teratogenic agents;mercury poisoning; and skin irritations due to con-tact with chemicals, such as solvents, pesticides,herbicides, detergents, and disinfecting agents.

Additionally, chemical hazards include exposureto anesthetic gases administered to patients, leadpoisoning, and blood changes as a result of expo-sure to solvents such as benzene.

See also HEALTH CARE WORKERS.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses

and Health Issues. New York: Facts On File, 2004.

chemical warfare See RICIN; SARIN; TERRORISM.

Chernobyl A city in Ukraine in which a largenuclear power plant accident occurred on April 26,1986. It was the most dangerous accident of itskind in the world until then and contributed topublic fears about nuclear power plants. Effects ofthe Chernobyl incident were acute, short-term,and long-term, both locally and in distant places.Although the death toll was officially 32, countlessillnesses occurred years later.

In 1990, thyroid pathology was noticed in chil-dren and adolescents. There was a positive correla-tion between the exposure to caesium-137 andthyroid pathology. Years later, thyroid cancer con-tinued to appear in adults who had been exposed.

At least 5 million people were exposed to lowlevels of ionizing radiation as a result of the acci-dent. Because of the politics of the Soviet Union atthat time, the term “radiophobia” was applied toexplain fearful reactions in the population, despiteevidence of objective reasons for a considerabledegree of stress and fear. Years later, many peoplefeared getting cancer and other diseases because oflack of information from their government.

The explosion produced acute stress reactionsand subsequent POST-TRAUMATIC STRESS DISORDER

(PTSD) for countless individuals. Many people hadto be evacuated from their homes and underwent

82 chemical dependencies

disruption in communities and social connections.They worried about housing and employment.Many moved to new settlements, feared isolation,and were concerned for the health of their chil-dren. Symptoms noted during the first few yearsafter the accident included fatigue, loss of memory,depression, headaches, loss of appetite, increasedillness awareness, lowered thresholds for illnessroles, increased help-seeking behaviors, and psy-chosomatic symptoms. Several terms have beenproposed to describe the health problems occurringafter toxic exposure, according to Lars Weisaeth,University of Oslo, writing in the Encyclopedia ofStress. These terms include chronic environmentalstress syndrome, radioactive contamination syndrome,and toxic stress syndrome.

See also ENVIRONMENT; NUCLEAR WEAPONS.

SOURCE:Lars Weisaeth. “Stress Effects of Chernobyl,” in Fink,

George, ed., Encyclopedia of Stress. San Diego: Acade-mic Press, 2000.

childbirth The birth of a child, usually by passagethrough the birth canal. Individuals about to par-ticipate in the childbirth experience may find itstressful. Many women experience stress in han-dling some of the most practical details surround-ing the birthing experience, such as recognizingthe start of labor and getting to the hospital ontime. Some women approach childbirth with anx-ieties exacerbated by reports of difficulties fromfriends and relatives. First-time mothers, in partic-ular, feel stressed by the unknown aspects of child-birth. Some first-time fathers, planning to attendthe birth, may be stressed by a fear of blood, as wellas the uncertainties of parenthood.

Possible Relief for Some Stressors: Natural and Prepared Childbirth

The term natural childbirth specifically refers to amovement toward unmedicated deliveries startedby Fernand Lamaze (1891–1957), a French obste-trician. Interest in natural childbirth began devel-oping during the 1940s and 1950s when use ofdrugs for pain relief and medical procedures suchas routine episiotomies and enemas requiredremoving women from their families, who had nosense of participation in the childbirth process.

While the specific methods for childbirth outlinesby Lamaze and Grantly Dickread (1900–59), aBritish obstetrician and advocate of natural child-birth, vary, they both incorporate nonmedicalrelaxation techniques as a “natural” method ofpain control during labor. In addition, they ques-tioned the need for routine medical proceduresand advocated a more active participation in laborby the woman and her lay labor coach, oftenmeaning the father of the baby or a nurse-midwife.

The natural childbirth movement has expandedto include the use of birthing rooms (in which laborand delivery take place in a homelike setting) andthe presence of extended family and friends at thedelivery. Some women choose to have their babiesdelivered at home to assure being surrounded byfamily members. Some opt for delivery by speciallytrained nurse-midwives rather than physicians.Nurse-midwives, however, require the back-up ofphysicians in case of medical emergencies.

The term prepared childbirth became popular inthe early 1990s, and includes prenatal exerciseclasses and a wide variety of breathing and relax-ation techniques.

See also PARENTING; POSTPARTUM DEPRESSION;PREGNANCY.

FOR FURTHER INFORMATION:Informed Homebirth/Informed Birth and

ParentingP.O. Box 3675Ann Arbor, MI 48106(313) 662-6857

American College of Obstetricians and Gynecologists

409 12th Street SWWashington, DC 20024-2188(202) 638-5577

SOURCES:Eisenberg, Arlene, and Heidi Murkoff. What to Expect

When You’re Expecting. New York: Workman Publish-ing, 1984.

Kahn, Ada P., and Linda Hughey Holt. The A to Z of Women’sSexuality. Alameda, Calif.: Hunter House, 1992.

child care See DAY CARE.

child labor Across the world, an estimated 246million children between ages five and 14 are

child labor 83

engaged in child labor, according to the UnitedNations Children’s Education Fund (UNICEF). Ofthose, almost three-quarters work in stressful andhazardous situations or conditions, such as in run-ning rug looms, in agriculture, or working withdangerous machinery. Millions of girls work asdomestic servants and unpaid household help andare especially vulnerable to exploitation and abuse.Many of these children cannot go to schoolbecause they work, and they suffer undue stress.Child labor issues and reports of child exploitationare also a secondary stressor for individuals con-cerned about human rights.

In the United States, more than half of 16- and17-year-olds and more than a quarter of 15-year-olds are part of the workforce. Estimates are thatsome 5.5 million youths are working. This numberdoes not include those under 12 years old whowork illegally.

According to the Bureau of Labor Statistics,almost four out of five young workers aged 16through 19 are concentrated in three types ofemployment: retail sales and service (particularlyfood service), as administrative support staff, andas laborers and handlers.

Working youths are involved in many accidentsand injuries. The National Institute of Occupa-tional Safety and Health (NIOSH) estimates thateach year more than 64,000 teenagers are treatedin emergency rooms for occupational injuries,exclusive of agricultural injuries. Adolescents suf-fer an estimated occupational injury rate of up to16 per 100 full-time employees, compared withthe adult rate of less than nine per 100 full-timeemployees. The most common youth injuries atthe workplace are cuts and lacerations, usually ofthe fingers and hands, followed by bruises andcontusions, and strains and sprains. However,these injuries result from inexperience, not age. Alarge proportion of workplace injuries, some 30percent, occur to workers in their first year ofwork, regardless of their age.

Child Labor Laws Aim to Reduce Stress

Regulations by federal and state governments con-cerning conditions under which minors may work,as well as hours and wages, help reduce the stressupon these young people. Child labor laws areimportant now because more teenagers are work-

ing at more types of jobs, during more weeks of theyear for longer weekly hours than has even beentrue in the past.

Child labor laws evolved out of the movementto prevent exploitation of children. Exploitativechild labor is presently defined by the Child LaborCoalition as employment whether paid or unpaidthat is coerced, forced, bonded, or otherwiseknown to be unfair in wages, injurious to thehealth and safety of children, and/or obstructs achild’s access to education.

The Fair Labor Standards Act of 1938 (FLSA), asamended, administrated by the U.S. Department ofLabor’s Wage and Hour Division, is applicable inmost instances in every U.S. state. Additionally,each state has its own child labor laws, which varywidely. Some were enacted in the 19th century,and some address every type of labor and manyworking conditions. Other states have enacted min-imal child labor provisions. Universally, the morecommon form of enforcement is the “complaintmethod,” in which state labor investigators respondto complaints received by letter or telephone.Investigating complaints helps assure that youngpeople are safe, legal, and healthy on their jobs.

Child Labor Coalition

The Child Labor Coalition (CLC) begun in 1989, pro-vides a forum and a unified voice on protectingworking minors from stress and ending childlabor exploitation. It is a national network for theexchange of information about child labor. CLC alsodevelops informational outreach to the public andprivate sectors to combat stressful child labor abusesand promote progressive legislation and initiatives.Among the objectives of the CLC are influencingpublic policy on child labor issues through anincreased understanding of the effect of work onchildren’s health, increasing recognition of how childlabor exploitation reinforces and promotes stress,adult unemployment, and low literacy rates. TheCLC works for stronger protection, guarding youthfrom excessive, inappropriate, and stressful labor.

The CLC also aims to educate the public, busi-ness, and governments, and broaden awarenessand understanding about the nature of child laborexploitation in the United States and other coun-tries. The CLC also hosts conferences, creates edu-cational and public awareness materials, testifies

84 child labor

before state and federal legislatures and agencieson child labor, presents comments in response toregulatory initiatives, and initiates research.

See also TEENAGE WORKERS.

FOR FURTHER INFORMATION:The Child Labor Coalitionhttp://www.stopchildlabor.org

National Consumers League1701 K Street NW, #1200Washington, DC 20006(202) 835-3323(202) 835-0747 (fax)http://www.nclnet.org

chiropractic medicine Chiropractic medicinedeals with the relationship between the skeletonand the nervous system and the role of this rela-tionship in restoring and maintaining health.Many people visit chiropractors to relieve stress aswell as physical discomforts.

According to chiropractic philosophy, the bodyis a self-healing organism and all bodily function iscontrolled by the nervous system. Abnormal bod-ily function may be caused by interference withnerve transmission and expression. This interfer-ence can be caused by pressure, strain or tensionon the spinal cord, spinal nerves or peripheralnerves as a result of a displacement of the spinalsegments or other skeletal structures.

The art of the chiropractic practitionerinvolves detecting and correcting problems of thevertebral subluxation complex. Subluxationrefers to a slight dislocation or biomechanicalmalfunctioning of the vertebrae (bones of thespine). According to the International Chiroprac-tors Association, subluxation can irritate nerveroots and blood vessels, which branch off fromthe spinal cord between each vertebrae. The irri-tation causes pain and dysfunction in muscle,lymphatic and organ tissue as well as imbalancein normal body processes.

Causes of subluxation include stress, falls,injuries, trauma, inherited spinal weaknesses,improper sleeping habits, poor posture, poor liftinghabits, OBESITY, lack of rest, and exercise.

Chiropractors restore misaligned vertebrae totheir proper position in the spinal cord through

procedures known as “spinal adjustments” ormanipulation. The adjustment itself does notdirectly heal the body. Rather, it is the resultingalignment of misaligned spinal vertebrae thatrestores balance so that the body can functionmore optimally.

Although chiropractic is often chosen as therapyfor headache, TEMPOROMANDIBULAR JOINT SYN-DROME (TMJ), whiplash, and bursitis, it may not bethe treatment of choice for all medical problems orconditions.

Choosing a Chiropractor

Before choosing a chiropractor, ask him or her tofully explain the benefits, risks, and costs of alldiagnostic and treatment options. Interview morethan one doctor of chiropractic medicine beforemaking a decision on the practitioner. Chiroprac-tors are licensed by each state’s Board of Chiro-practic Examiners. The American ChiropracticAssociation has a membership directory listingACA members.

See also ALTERNATIVE MEDICINE.

FOR FURTHER INFORMATION:American Chiropractic Association1701 Clarendon Blvd.Arlington, VA 22209(703) 276-8800

SOURCES:McGill, Leonard. The Chiropractor’s Health Book: Simple,

Natural Exercises for Relieving Headaches, Tension andBack Pain. New York: Crown, 1997.

Rondberg, Terry A. Chiropractic First: The Fastest GrowingHealthcare First . . . Before Drugs or Surgery. Chandler,Ariz.: Chiropractic Journal, 1996.

chlamydia See SEXUALLY TRANSMITTED DISEASES.

choices See DECISION MAKING.

cholesterol A complex fatlike substance in thebody, most of which is produced naturally in theliver. Cholesterol is needed to survive, but toomuch of the wrong kind, LDL (low-densitylipoprotein) cholesterol, can be a risk to health anda source of personal stress. When LDL cholesterolbuilds up in the walls of the arteries, it forms

cholesterol 85

plaque. The technical name for this is atherosclero-sis or “hardening of the arteries.” If plaque buildsup, causing arteries to become thicker, harder, lessflexible and less efficient at transporting blood, itcan lead to a HEART ATTACK or STROKE. There are noobvious symptoms of high LDL cholesterol. Theonly way to find out if a person has a problem is tohave cholesterol checked by a blood test and eval-uated by a doctor or health care professional.

The stress of learning that a person’s cholesterollevel is too high can be relieved by understandingwhat contributes to the level and how it can becontrolled. Many factors raise cholesterol, includ-ing certain inherited tendencies as well as lack ofexercise. One of the most common and control-lable factors is diet. Eating saturated fats can raisethe LDL cholesterol. Saturated fats come from ani-mal sources, such as meat, butter, milk, andcheese, as well as the oils in tropical plants, suchas coconuts and palms.

Reducing Cholesterol Level

The first step in reducing cholesterol is to follow alow-fat, low-cholesterol diet. A low-fat diet gener-ally requires that a person eat less high-saturatedfat and high-cholesterol foods, such as meats, eggs,and dairy products, and more fruits, grains, andvegetables. This diet can contain small portions ofturkey and chicken without the skin, and well-trimmed lean beef. Fish, broiled or baked withoutbutter, is another low-fat source. The AmericanHeart Association recommends limiting the totalfat in your diet to less than 30 percent of your calo-ries each day.

Some people worry needlessly that they may beeating too much cholesterol. These individualsmay be interested to know two important facts: (1)On average, one’s body absorbs only half the cho-lesterol in the food eaten; and (2) when theamount of cholesterol from food increases, thebody produces less of its own cholesterol and willincrease the amount of cholesterol it excretes.

Regular exercise raises the level of “good” cho-lesterol, HDL. HDL helps remove LDL, the “bad”cholesterol from the blood. Exercise also helpskeep the heart muscle active and healthy. The mostcommonly stated goal for a heart-healthy exerciseis 20 minutes of moderate exercise three times aweek.

Several types of cholesterol-lowering medica-tions are available. Medications should always beused along with a low-fat, low-cholesterol diet. Aphysician will decide whether medication is nec-essary and which medication is best for eachindividual.

See also ATHEROSCLEROSIS; CORONARY ARTERY

DISEASE.

SOURCES:Giles, Wayne H., et al. “Cholesterol.” The Journal of the

American Medical Association 9 (March 3, 1993):1,133–1,138.

Grover, Steven A., et al. “HDL Cholesterol Level IsImportant Indicator of Potential Heart Disease.” TheJournal of the American Medical Association, September12, 1995.

Chopra, Deepak (1947– ) Indian-born physi-cian whose philosophy of healing, disseminatedthrough books, tapes, lectures, and clinics, is basedon the Indian holistic system called AYURVEDA. Hewas once a disciple of Maharishi Mahesh Yogi, butformed his own organization in 1993. Among hisbooks are the best-selling Ageless Body, TimelessMind: The Quantum Alternative to Growing Old (1993)and a work of fiction, The Return of Merlin (1995).

Chopra claims the MIND-BODY CONNECTION canreduce stress, facilitate healing, lead to inner peaceand even reverse the aging process. His mind/bodyprograms incorporate massage, YOGA, MEDITATION,herbal supplements, nutritional guidelines, andexercise regimens. He recommends doing some-thing that brings joy, concentrating fully on that

86 Chopra, Deepak

HIGH CHOLESTEROL: ONE OF SEVERAL RISKFACTORS FOR HEART DISEASE

• High LDL cholesterol• Smoking• Age (a man 45 or older; a woman 55 or older)• High blood pressure (treated or untreated)• Hereditary (father, brother or son had heart

disease before 55; mother, sister, or daughterbefore 65)

• Low HDL cholesterol

activity, reducing distractions at work and findinginner satisfaction in daily tasks.

In one chapter on longevity in Ageless Body,Chopra outlines some suggestions that may be use-ful for those wishing to reduce stress in their lives.Techniques include listening to your body’s wis-dom, living in the present, taking time to be silent,and meditating to quiet the internal dialogue.

See also ALTERNATIVE MEDICINE; IMMUNE SYSTEM;RELAXATION.

FOR FURTHER INFORMATION:Chopra Center for Well Being7590 Fay Avenue, #403La Jolla, CA 92037(619) 551-7788

Sharp Institute for Mind/Body3131 Berger AvenueSan Diego, CA 92123(619) 541-6737

SOURCES:Chopra, Deepak. Ageless Body, Timeless Mind: The Quantum

Alternative to Growing Old. New York: Crown, 1993.———. Creating Health. Boston: Houghton Mifflin, 1991.———. Quantum Healing. New York: Bantam, 1989.———. Unconditional Life. New York: Bantam, 1992.

chronic fatigue syndrome (CFS) Illness charac-terized by fatigue that occurs suddenly, improvesand relapses, bringing on debilitating tiredness oreasy fatigability in an individual who has no appar-ent reason for feeling this way. It is stressful to thesufferer because the profound weakness caused byCFS does not go away with a few good nights ofsleep, but instead steals a person’s vigor overmonths and years. Because many individuals whohave CFS experience frustration both before beingdiagnosed and on learning that there is no cure,DEPRESSION often accompanies the disease.

While the illness strikes children, teenagers, andpeople in their fifties, sixties, and seventies, it ismost likely to strike adults from their mid-twentiesto their late forties. Women are afflicted abouttwice to three times as often as men; the vastmajority of those who suffer this illness are white.Because young urban professionals were mostafflicted during the 1980s, the name “yuppie flu”was attached to CFS. However, individualsregarded this name as trivializing their illness.

CFS Symptoms

CFS can affect virtually all of the body’s major sys-tems: neurological, immunological, hormonal, gas-trointestinal, and musculoskeletal. According tothe National Institutes of Health, CFS leaves manypeople bedridden, or with headaches, muscularand joint pain, sore throat, balance disorders, sen-sitivity to light, an inability to concentrate, and inex-plicable body aches. Secondary depression, whichfollows from the disease rather than causing it, isjust as disabling. However, knowing that there is achemical basis for mood swings and that they aredirectly related to illness, can be reassuring.

Symptoms wax and wane in severity and lingerfor months and sometimes years. Some individualsrespond to treatment, while others must functionat a reduced level for a long time. However, for allsufferers, the cumulative effect is the same—trans-forming ordinary activities into tremendouslystressful challenges. They cannot tolerate the leastbit of exercise, their cognitive functions becomeimpaired, and their memory, verbal fluency,response time, and ability to perform calculationsand to reason show a marked decrease.

Disruption of sleep patterns causes the CFS suf-ferer additional stress. Despite constant exhaustionand desire for sleep, they rarely sleep uninterrupt-edly and awake feeling refreshed. Some have severeINSOMNIA, while others have difficulty maintainingsleep. There is often not enough rapid-eye move-ment sleep (REM), which is considered necessaryfor a good night’s rest.

Many CFS sufferers experience stressful disor-ders of balance, or of the vestibular system, whichis modulated by the inner ear. They sometimes feeldizziness, light-headedness, or nausea. Even walk-ing can be difficult, with sufferers tilting off balanceor stumbling for no apparent reason. Some indi-viduals who have balance disorders develop PHO-BIAS, such as a fear of falling. Some who have thisfear even become housebound.

CFS causes stresses on sufferers, family, andfriends. Those in a sufferer’s support circles canreduce their stress by being helpful, understanding,and available to listen. Sufferers are likely to feelestranged from some of their friends because theybelieve that no one really understands their feel-ings of emotional and physical exhaustion. Thisbelief is exacerbated because many sufferers think

chronic fatigue syndrome 87

that others do not take their illness seriously. Inaddition, some friends and family members mayfear that CFS is contagious and try to maintain adistance from the sufferer. (Medical opinion seemsto indicate that CFS is not contagious.) Spousesface the issue of reduced sexual activity, althoughboth partners can satisfy their needs by engaging insexual activity during peak periods of energy.

Diagnosing CFSDiagnosing CFS is stressful for physicians as well aspatients because many of the symptoms are likethose of other disorders. Until the mid-1980s,many CFS patients were misdiagnosed as sufferingfrom depression, accused of malingering, encour-aged to undergo stressful, costly, and inappropriatelaboratory tests, or simply pushed aside by themedical community because of lack of understand-ing of the disease. In recent years, however, stud-ies on the immune system, viruses, and thephysiological effects of stress have contributed tobetter understanding of CFS. Individuals with CFSno longer have to feel abandoned by their physi-cians or fear that they are going crazy because noone takes their illness seriously.

Treatment for CFSMany therapies have been tried on CFS sufferers.Usually a plan is devised for each patient, depend-ing on symptoms. Pharmcological therapiesinclude use of antidepressant drugs, pain relievingdrugs, and muscle relaxing drugs.

Other therapies that have been tried includedeep relaxation, YOGA, BIOFEEDBACK, and visualiza-tion therapy to relieve stress and chronic pain.Nutritional therapies have included emphasizingcertain vitamins, such as Vitamins A, B6, B12, C andE, as well as zinc, folic acid, and selenium, all ofwhich are said to have immune-boosting potential.

Oil extract from the seeds of the evening prim-rose plant is another medicine that some CFSpatients have found helpful. The theoretical basisfor its use (although not yet scientifically proven)is that evening primrose oil contains gamma-linolenic acid (GLA), which converts in the body toprostaglandin, a vital substance in the regulation ofcellular function.

Role of Support Groups and Self-HelpSeveral nationwide organization encourage researchand political advocacy and also provide lists of local

SUPPORT GROUPS. CFS sufferers may find relief fromsome stressors and help with practical and emotionalneeds through these organizations.

See also CHRONIC ILLNESS.

FOR FURTHER INFORMATION:The CFIDS Association of AmericaP.O. Box 220398Charlotte, NC 28222(704) 365-2343

National Chronic Fatigue Syndrome Association919 Scott AvenueKansas City, KS 66105(913) 321-2278

SOURCES:Feiden, Karyn. Hope and Help for Chronic Fatigue Syndrome.

New York: Prentice Hall, 1990.McSherry, James. “Chronic Fatigue Syndrome: A Fresh

Look at an Old Problem.” Canadian Family Physician 39(February 1993).

chronic illness Disorder or set of symptoms thathas persisted for a long time with progressive dete-rioration. In addition to the stresses of physicalpain, chronic illness often brings with it emotionalconsequences that can be more far reaching thanthe illness itself. These affect not only the patientbut also cause stress for the immediate CAREGIVERS.Some, particularly close family members, let ill-ness-related anxieties take over their lives, andtheir DEPRESSION arises from COPING with illnessand the threat of possible long-term disability ordeath of a loved one.

Reactions to illness are similar to the stages ofGRIEF after the death of a loved one. First there isthe patient’s shock and a feeling of loss of CONTROL

and of AUTONOMY and of the way things used to be.In addition, they experience physical losses rang-ing from having to give up their job or favoritesport to impaired speech or vision. Stress andsymptoms of depression may follow, includinghopelessness, self-blame, shattered self-esteem, orwithdrawal. Some ill persons may develop manyfears. They may fear exercise and being activeagain, while others may deny the realities of theircondition and overdo activities too soon.

The stresses of PAIN and fears about disabilityand death lead some ill people to substance abuse

88 chronic illness

as a form of escape. Anger, denial, or perceivedhelplessness lead others to abandon medical treat-ment or assume a “why me” attitude that givesthem a pessimistic view of their world.

The crucial issue is “whether you can get pastthe stage of rage, sadness, and overwhelming anx-iety,” says Lloyd D. Rudley, M.D., an attending psy-chiatrist at the Institute of Pennsylvania Hospital,Philadelphia. “Will you resume the initiative forliving or become psychologically paralyzed?” Manypeople become trapped by emotions that do notserve them well, according to Dr. Rudley.

Unfortunately, there are chronically ill peoplewho do not comply with instructions from theirphysicians. This may take the form of not showingup for physical therapy, refusing medication, ordriving a car against the physician’s advice. Indi-viduals with emphysema may continue to smoke.According to Dr. Rudley, “People want to thinkeverything will be normal again if they follow thedoctor’s orders. When things don’t work this wayand there is no magic formula, a patient may giveup on treatment.”

Some individuals neglect medical advice as ameans of getting more attention. Others who har-bor shame or guilt about their condition may pun-ish themselves, in effect, by not complying withprescribed treatment. Forces of denial may be atwork, too, in those who try to “bargain with ill-ness” by following some recommendations, butnot others.

How individuals coped with life stress beforethe illness will determine how well they respondwhen illness occurs. However, even when symp-toms of illness go into remission or people haveadjusted to their illness, a whole new set of exter-nal stressors may arise or family dynamics canchange dramatically.

“Patients need to accept that chronic illnesschanges them permanently, that a change inlifestyle is necessary,” advises Dr. Rudley. Healthyacceptance is achieved when people come to termswith the stresses of their illness as a part of who theyare, “forming a sort of coexistence with it,” he says.

Some individuals feel certain “benefits” frombeing chronically ill. Such motivations are referredto as secondary gains and increase the likelihood oftheir continuing to be ill or to have symptoms.

Common “benefits” of illness include receivingpermission to get out of dealing with a trouble-some problem, situation, or responsibility of life;getting attention, care, or nurturing; and not hav-ing to meet their own or others’ expectations.

Every area of a person’s life is affected by illhealth, including marriage, family, work, financialaffairs, and future plans. Professional counselingcan help individuals and their families adapt tostresses brought on by chronic illness. Counselingmay also help individuals who feel a need to hidetheir illness, to increase their use of drugs or alco-hol, or who fail to follow treatment recommenda-tions or exhibit a fear of resuming their activities.It can help those who have insomnia and disruptedsleep, who experience prolonged depression, shownegative personality changes, and have obsessiveanxiety or preoccupation with death.

See also ELDERLY PARENTS; GENERAL ADAPTATION

SYNDROME.

SOURCE:Rudley, Lloyd D. “Conquering the Psychological Hurdles

of Chronic Illness.” The Quill, fall 1991.

chronic pain See CHRONIC ILLNESS; PAIN.

circadian rhythms Cycles of sleep and wakeful-ness coordinated by an inherent timing mechanismknown as the body’s internal clock. The circadianrhythm of a person’s body temperature is a markerfor those clocks. Body temperature rises and falls incycles parallel to alertness and performance effi-ciency. When body temperature is high, which itusually is during the day, alertness and perform-ance peak—and sleep is difficult. A lower tempera-ture (generally during the night) promotes sleep,but hinders alertness and performance. Stress mayresult when tasks are attempted that are not in syn-chronization with circadian rhythms.

Alertness and mental capability seem to be bestwhen people follow their internal clocks, whichare synchronized to the Sun’s 24-hour cycle. Forexample, sunrise means waking and working,while sundown means dinner and sleep. However,individuals who work night shifts find that their“day” is reversed. Many shift workers go home tosleep during the day when their bodies want to beawake and they have to work at night when their

circadian rhythms 89

bodies want to sleep, according to Charmaine I.Eastman, Ph.D., in her report, Insights into Clinicaland Scientific Progress in Medicine.

Circadian rhythms affect many performances ofmental feats. For example, different skills follow dif-ferent cycles, so that at any time a person’s mind isnaturally sharp for certain tasks and dull for others.Memory varies though the day, and short-termmemory is at its peak at nine in the morning whilememorizing for the long term works best aroundthree in the afternoon. Problem-solving peaks in themorning and falls during the afternoon andevening. However, reaction time improves through-out the day and finally peaks in the evening.

Readjusting from Jet Lag

Jet lag—the discrepancy between an individual’sinternal clock and the exaggerated passage of timebrought on by air travel across time zones—is awell-known disruption of circadian rhythms. Phys-ical as well as mental stress may result. Symptomsof jet lag may include insomnia, headache, loss ofappetite, or nausea. A conventional rule says thateach time zone passed takes one day of recovery.Generally, recovering from jet lag is easier whenone flies west, rather than east. That is because itseems easier to delay the body’s schedule thanforce it to advance. Exposure to daylight can helpthe body resynchronize more quickly.

For similar reasons, most people have an easiertime changing from daylight savings time back tostandard time in the fall than the reverse in thespring. Setting clocks back in the fall allows anhour more of sleep. However, in the spring, whenclocks are set ahead and people have to get up anhour earlier than is customary, sleep deprivationmay make them tired.

Adjusting to Night Work

People who work at night can adjust more easilyand reduce stressful effects if they have darknessduring the day and bright light at night. Nightworkers can also adjust more quickly if they canmaintain a schedule of work-sleep-leisure, ratherthan the work-leisure-sleep pattern of day workers.

See also AIRPLANES; SHIFT WORK.

SOURCES:“Circadian Rhythms.” Mayo Clinic Health Letter, March 1995.

Dolnick, Edward. “Snap out of It.” Health, February/March 1992.

Eastman, Charmaine I. “Bright Light, Dark Goggles andCircadian Rhythms.” Insights into Clinical and ScientificProgress in Medicine 14, no. 3 (1991).

claustrophobia From the Latin word claustrum,meaning “lock” or “bolt”; an intense fear of beingconfined in spaces such as elevators, phone booths,airplanes, small rooms, and very crowded areaswith no perceived possibility of escaping to a safeplace. Most people feel mildly stressed in closed-inspaces. However, claustrophobics experienceextreme stress, fearing that they will suffocate inan elevator or that an airplane carrying them maysuddenly fall.

These extremely high levels of stress may lead toPANIC ATTACKS AND PANIC DISORDER for some claus-trophobics. Such individuals may experience palpi-tations and fear that they are having a HEART

ATTACK. True phobics may tend to avoid places inwhich panic attacks might occur.

The origins of claustrophobia vary. For somesufferers, it begins after a bad experience involvingan enclosed space, such as being locked in a closetor room, while for others, the fear develops for noknown reason. Using BEHAVIOR THERAPY tech-niques, many people overcome claustrophobia.

See also AGORAPHOBIA; ALTERNATIVE MEDICINE;ANXIETY DISORDERS; BREATHING; PHOBIAS.

FOR FURTHER INFORMATION:Anxiety Disorders Association of America8730 Georgia Avenue, Suite 600Silver Spring, MD 20910(240) 485-1001

Clean Air Act of 1990 A law passed by Congressto assure that Americans have safe air to breathewithout the stress of inhaling harmful substances.The law also protects the environment from dam-age caused by AIR POLLUTION. Public health protec-tion is the primary goal of the law. Although thebasic provisions of the act were written in 1970and amended in 1977, the 1990 act specifies newstrategies for assuring cleaner air.

The U.S. Environmental Protection Agency(EPA) specifies limits on how much of a specificpollutant can be in the air. Individual states may

90 claustrophobia

have stronger pollution controls, but are notallowed to have weaker controls than those set forthe whole nation. States are assisted by the EPA inscientific research, engineering designs, and fundsto support clean air programs.

climacteric See MENOPAUSE.

climate Climate influences health, work, hous-ing, transportation, dress, sports, and leisure activi-ties and the types of products and businesses thatare necessary to satisfy basic human needs. Somepeople prefer to live in a warm climate; othersthrive on seasonal changes. Unless there are physi-cal reasons that make it necessary to live in a warmclimate, people generally live where they can findwork and where they have family and friends.

Factors of climate and changes in climate inducestress for many people. Cooler climates require thebody to burn and produce energy more quickly.On the other hand, cold weather raises blood pres-sure, is generally hard on the circulatory system,and tends to make people crave foods high in fatand starch. Warmer climates slow the body’smetabolism and, if humidity is added to the heat,produce a more languid lifestyle.

In the last quarter of the 20th century air-con-ditioning was perfected and became widespread inmost industrialized countries. Being able to controlthe environment through the use of air condition-ing or heating reduced the stress level for manyindividuals and gave greater impetus to industri-ousness and change.

Stormy and changeable weather, which is usu-ally accompanied by sudden barometric changes,may produce in individuals the stresses of irritabil-ity and mood changes because the rising andfalling pressure affects body fluids. A disturbingcorrelation between climate and human activitythat is supported by statistics is the relationshipbetween hot weather and violence. Figures showthat crimes and riots are far more likely to occur inhot weather than in cool or rainy weather.

Climate affects the elderly and those who haveweakened immune systems more than other indi-viduals. The near-record-breaking heat wave inthe summer of 1995 in Chicago, during which

more than 500 inner-city residents died in theirhomes, is a testimonial to the possibly dramaticeffects of climate stress.

See also RANDOM NUISANCES; SEASONAL AFFECTIVE

DISORDER.

SOURCE:Sherrets, S. D. “Climate and Personality,” in Corsini,

Raymond, ed., Encyclopedia of Psychology, vol. 1. NewYork: Wiley, 1984.

clinical depression See DEPRESSION.

clinical psychology See PSYCHOLOGY; PSYCHO-THERAPIES.

club drugs The term club drugs refers collectivelyto a group of various drugs synthetically concoctedby underground chemists and commonly used byyoung adults at parties, “raves” (giant dance partiesfeaturing loud, pulsating music), dance clubs, andbars. Two of the more popular club drugs aremethamphetamine (methylenedioxymethamphet-amine, MDMA) known as Ecstasy, and gammahydroxybutyrate, GHB.

Persons concerned about the health of youngpeople view the club drug scene as a stressful one.There may be temptation by peers to try thesedrugs without knowledge of the possible harmfuleffects. Club drugs can cause serious health prob-lems and possibly death, especially when com-bined with the use of alcohol.

Both MDMA and GHB are swallowed and comein the form of tablets or capsules. GHB can also befound as a liquid or a power. MDMA is a stimulantand GHB is a depressant, but both drugs cause asimilar high. The drugs induce feelings of warmthand openness, greatly enhance the sense of touch,and increase the desire for sex. In low doses, GHBcan also relieve anxiety and produce relaxation.Ecstasy is a stimulant sometimes called Adam,XTC, hug, beans, and love drug.

Warning Signs of Methamphetamine Use

Warning signs may include insomnia, decreasedappetite and weight loss, increased agitation and

club drugs 91

physical activity, excited speech, compulsive actionssuch as cleaning and grooming or sorting and disas-sembling objects, intense paranoia, hallucinationsand delusions, episodes of sudden violent behavior,presence of inhaling paraphernalia (razor blades,mirrors, and straws), and presence of injectingparaphernalia (syringes, spoons, or surgical tubing).

See also ADDICTION; ADOLESCENCE.

FOR FURTHER INFORMATION:Partnership for a Drug-Free America405 Lexington Avenue, 16th FloorNew York, NY 10174(212) 922-1560http://www.drugfreeamerica.org

SOURCE:National Institute on Drug Abuse. “NIDA Community

Drug Alert Bulletin—Club Drugs,” Available online.URL: http://165.112.78.61/ClubAlert/Clubdrugalert.html. Downloaded on June 17, 2005.

cluster headaches See HEADACHES.

COBRA (Consolidated Omnibus Budget Recon-ciliation Act) This law, enacted in 1986, enablesworkers to keep their health coverage during timesof voluntary or involuntary job loss, reduction inhours worked, or transition between jobs. In cer-tain cases, it may alleviate much of the stress fromthese events.

COBRA generally requires that group healthplans sponsored by employers with 20 or moreemployees in the preceding year offer employeesand their families the opportunity for a temporaryextension of health coverage (called continuationcoverage) in certain instances where coverageunder the plan would otherwise end. Events thatcan cause workers and their family members tolose group health coverage may result in the rightto COBRA coverage. These include:

• Voluntary or involuntary termination of the cov-ered employee’s employment for reasons otherthan gross misconduct

• Reduced hours or work for the covered employee

• Covered employee becoming entitled to Medicare

• Divorce or legal separation of a covered employee

• Death of a covered employee

• Loss of status as a dependent child under planrules

Coverage under COBRA may be for 18 or 36months, depending on circumstances. Qualifiedindividuals may be required to pay the entire pre-mium for coverage up to 100 percent of the cost tothe plan. Premiums may be higher for personsexercising the disability provisions of COBRA. Pre-miums may be increased by the plan; however,premiums generally must be set in advance of each12-month premium cycle. Individuals subject toCOBRA coverage may be responsible for paying allcosts related to deductibles and may be subject tocatastrophic and other benefit limits.

See also HEALTH INSURANCE; HEALTH MAINTENANCE

ORGANIZATIONS.

cocaine An addictive drug that stimulates thecentral nervous system and induces feelings ofeuphoria. Some people erroneously try to combatthe stresses in their lives with this and other addic-tive drugs, and become further stressed if they can-not find the money for supplies of cocaine. Some,recognizing their ADDICTION, become stressed whentrying to give up the drug.

Cocaine is most often used in the form of whitepowder and is typically ingested by inhaling, or“snorting,” usually through a straw or other tubein the nose. It can also be injected into the veins.After conversion to its base form, cocaine can besmoked, which is known as “freebasing.”

Different users react to the drug in different ways.However, many experience an instant feeling ofenormous pleasure known as a “rush.” Some usersalso may initially feel energetic and self-confident.However, the pleasurable feelings produced bycocaine are followed by depression and fatigue,known as a “crash.” To avoid a “crash,” users takemore cocaine, establishing a stressful and expensivecycle of use and dependency, which is extremely dif-ficult to end and often requires lengthy treatment.

Use of cocaine can lead to severe psychologicaland physical dependence. It can increase the pulse,blood pressure, body temperature, and respiratoryrate. Paranoid psychosis, hallucinations, and otherstressful problems can result from cocaine use,

92 cluster headaches

which also causes bleeding and other damage tonasal passages. Cocaine is sometimes used withother drugs. The cocaine/heroin combination iscalled a “speedball,” and the cocaine/PCP mixtureis known as “space base.” Cocaine-related heartand respiratory failure can lead to death.

Crack is the street name given to tiny chunks or“rocks” of freebase cocaine in smokable form.Crack is even more rapidly addicting than pow-dered cocaine. Extremely high blood levels ofcocaine delivered to the brain by smoking crackincrease the likelihood of serious toxic reactions,including potentially fatal brain seizures, irregularheartbeat, and HIGH BLOOD PRESSURE. Congestion inthe chest, wheezing, black phlegm, and hoarsenessmay also result from smoking crack.

Use of crack by pregnant women can cause fetalloss or damage, and lead to babies with low birthweights who are extremely sensitive to noise,touch, and other stimuli, and cry frequently. Thestresses involved in parenting such babies can beeliminated by avoiding use of addictive substances.

FOR FURTHER INFORMATION:Cocaine Anonymous3740 Overland Avenue, Suite CLos Angeles, CA 90034-6337(310) 559-5833

SOURCES:Carroll, Marilyn. Crack and Cocaine. Hillside, N.J.: Enslow

Publishers, 1994.Nuckols, Cardwell C. Cocaine: From Dependency to Recovery.

Blue Ridge Summit, Pa.: Tab Books, 1989.

codependency A RELATIONSHIP in which the par-ticipants have a strong need to be needed, as wellas to create mutual needs in a detrimental, weak-ening manner. Such an interplay of needs isrequired to preserve the dependent relationship.Codependent relationships are extremely stressfulon at least one or both of the partners. In manycases, an individual would like to eliminate thestressors caused by the codependent relationshipbut is too addicted to the situation to change.

An example of a codependent relationship isone in which the husband covers up for his wife’sALCOHOLISM. He does the household chores, drivesthe children to their activities, and explains herproblem as an “illness.” He is an “enabler,” because

he makes it possible for her to continue with herADDICTION. The enabler promotes the codependentrelationship by compensating for or covering updifficulties or flaws in the behavior of the other outof an addictive need to be needed and to keep therelationship going.

There are many kinds of codependent relation-ships: a parent who continues to support an adultchild who should be responsible for himself becausethe parent wants the child to feel dependent onhim or her; a husband who does all the householdchores, shopping, and driving children to activities,while explaining that his agoraphobic wife is “notfeeling well.” Such a husband is an enabler to hiswife. It is difficult for an individual to live with AGO-RAPHOBIA without an enabler. Many alcoholics anddrug addicts also have enablers.

When a parent continues to compensate for orcover up a child’s difficulties in school or with thelaw, thinking that they are protecting the child,that is also a co-dependent relationship. It is ofteninterpreted that this behavior persists because pre-serving the child’s flaws and immature behaviorwill keep him or her forever dependent on the par-ent. Since codependency is viewed as a type ofaddiction, advocates of the codependent theoryfeel that these tendencies can be overcome with aprocess similar to the recovery process used byAlcoholics Anonymous.

FOR FURTHER INFORMATION:Co-Dependents AnonymousP.O. Box 33577Phoenix, AZ 85067-3577(602) 277-7991

SOURCES:Becnel, Barbara. The Co-Dependent Parent. San Francisco:

HarperCollins, 1991.Rieff, David. “Victims All?” Harper’s (October 1991): 49–56.

coffee See ANXIETY; CAFFEINE; GUIDED IMAGERY;HEADACHES; INSOMNIA; MEDITATION.

cognitive therapy Centers on the concept thatin some people, unwanted behaviors or moodscan result from distorted patterns of thinking andthat these behaviors or moods can be altered bychanging thinking patterns. It is an approach some-

cognitive therapy 93

times used to treat individuals who experience thestresses of ANXIETY DISORDERS or DEPRESSION.

The therapy focuses on the individual’s owncognitive appraisals. Stressful ideas, thoughts andperceptions are directly examined and tested todetermine their validity. The therapeutic benefit isthat the individual’s thinking may be restructured,so that situations or circumstances that were onceperceived as extremely stressful are viewed in aless stressful and more realistic light.

The cognitive therapy approach was introducedin the 1970s by Aaron Beck (1921– ), an Ameri-can psychiatrist.

See also BEHAVIOR THERAPY; PSYCHOTHERAPIES.

cohabitation Situation of unmarried individualsliving together. This arrangement can lead to stresswhen one of the partners desires MARRIAGE and theother does not, or when, after living together for anumber of years, the couple decides to separate. Asin a DIVORCE, there may be additional stress whendivision of property, including real estate, and con-sequent legal arrangements occur.

There have been dramatic increases in cohabita-tion during the last decades of the 20th century.Greater approval and societal acceptance of livingtogether without benefit of marriage has resultedfrom general attitudinal changes, including fears ofpermanent commitment, effectiveness of contra-ception during a long-term sexual relationship,and the havoc raised by divorce.

Many couples sign a cohabitation contract thatis intended to remove some of the stresses in thepracticalities of the living together arrangement.The cohabitation contract is a legal document inwhich unmarried partners agree to specifiedarrangements, such as how much each partnerpays toward specified expenses. It may also specifydivision of belongings, should the couple split up.

See also LIVE-IN.

cold stress People who work or spend a greatdeal of time in cold temperatures face the stress ofexposure. Prolonged exposure can result in healthproblems such as frostbite, trench foot, andhypothermia. Cold-related disorders are a constantsource of stress for workers in such industries asconstruction, commercial fishing, and agriculture.

Frostbite, Hypothermia, and Trench Foot

Frostbite occurs when the skin tissue actuallyfreezes, causing ice crystals to form between cellsand draw water from them which leads to cellulardehydration. Although this typically occurs at tem-perature below 30° F (–1° C), wind chill effects cancause frostbite at temperatures above freezing.General hypothermia occurs when body tempera-ture falls to a level where normal muscular andcerebral functions are impaired. Hypothermia isgenerally associated with freezing temperatures,but it may occur in any climate if a person’s bodytemperature falls below normal. Trench foot is

94 cohabitation

SOURCES OF COLD STRESS

• Inadequate or wet clothing increases the effectsof cold on the body.

• Certain drugs or medications such as alcohol,nicotine, caffeine, and medication inhibit thebody’s response to the cold.

• Certain diseases such as diabetes and heart,vascular, and thyroid problems may make aperson more susceptible to the winter elements.

• Effects of the cold may be enhanced by becom-ing exhausted or immobilized, especially due toinjury or entrapment.

• The elderly are more vulnerable to effects ofharsh, cold weather.

Source: Occupational Health and Safety Administration

COPING WITH COLD-RELATED SOURCES OF STRESS

• Protect hands, feet, face, and head.• Footgear should be insulated.• Wear at least three layers; an outer layer will

keep wind out and allow some ventilation.• The middle layer of wool or synthetic fabric will

absorb sweat and retain insulation.• Down is a useful lightweight insulator; however,

it is ineffective when it becomes wet.• An inner layer of cotton or synthetic weave

allows ventilation.

Source: Occupational Safety and Health Administration

caused by long, continuous exposure to a wet, coldenvironment, or actual immersion in water. This isa source of stress for commercial fishermen, whoexperience these types of cold, wet environmentson a regular basis.

colic The causes for colic are unknown, althoughthere are reasons to believe that it is due to a spasmin the newborn baby’s intestines. It appears aroundthe third or fourth week of life and usually goesaway on its own by the age of 12 weeks. Signs thatthe baby is experiencing colic are irritability, exces-sive screaming, and tightening of the body.

There are few solutions to the problem, and par-ents are placed under the stress of trying to makethe baby comfortable. Feeding, cuddling, or chang-ing diapers does not seem to help. Because episodesof colic seem to be worse in the evening, both par-ents and baby suffer from deprivation of sleep.

Handling the Colicky Baby

Parental anxiety may make the infant even moreirritable. Feeding the baby when he or she criescould worsen the situation by causing the stomachto bloat. Rhythmic, soothing activities, such asrocking the baby, carrying the baby in a front slingor pouch, or taking the baby for a ride in the car,usually work best.

To avoid compounding the stress caused by thesituation, new parents should try to avoid fatigueand exhaustion. They may find that sleeping inshifts, where one parent deals with the baby andthe other gets rest, will be helpful.

See also PARENTING.

color Studies have determined that colors havecertain psychological and physical effects on thehuman body. Under certain circumstances, colorcan produce stress or induce relaxation. For exam-ple, red is the strongest and most stimulating ofcolors. It has been shown to increase hormonalactivity and to raise blood pressure. Red stimulatescreative thought and is a good mood elevator, butis not conducive to work. Orange shares many ofthe qualities of red, but it is considered more mel-low and easy to live with.

Blue has the opposite effect of red. It lowersbodily functions and creates a restful atmosphere,

although, if used too extensively, may have adepressing effect. Participants in psychologicaltests, when surrounded by blue, tend to underesti-mate time periods and the weight of objects. Pur-ple, a combination of red and blue, has a neutraleffect. When used in large amounts, for instance asa typeface, the eye does not focus on purple easily.

Having the characteristic of visibility, yellow isuseful for road safety signs. Green and blue-greenpromote an atmosphere of relaxation, concentra-tion, and MEDITATION. Monotonous use of the samecolor has been found to be more disturbing than avariety of colors.

With age, attraction to colors and their stressfuland soothing effects seems to change somewhat.Babies tend to be attracted to yellow, white, pink,and red. Older children are less attracted to yellowand tend to like colors in the order of red, blue,green, violet, orange, and yellow. As adultsmature, blue tends to become a favorite color, pos-sibly because of changes in the eye itself and theway it sees color.

Colors carry with them stressful, psychologicalassociations, which are expressed in language. Forexample, we are “green with envy,” “see red” and“have the blues.” Certain clear shades of red,orange, and yellow are associated with food andare very appetizing, while tinting foods with blue,violet, or a mixtures of colors, has the adverseeffect, making the foods unappetizing.

Throughout history, mystical and healing prop-erties have been ascribed to color. For example, theancients associated colors with the houses of thezodiac and with the elements. They were highlyimportant in the practice of magic. Some supersti-tious people believe that blue and green divert thepower of the evil eye. Part of a religious symbolismand ritual, red, blue, purple, and white have beenconsidered divine colors in Judaism, while green,the color of life and rebirth, is important in Chris-tianity. In many cultures, surrounding a patientwith red clothing, red furniture and coverings andgiving him red food and red medicine was thoughtto aid the healing process.

See also COLOR BLINDNESS.

color blindness Inability to recognize any colorsor certain colors; usually a genetic defect located in

color blindness 95

the cones, small color-sensitive cells in the retina ofthe eye. Some individuals who are color blind maynot be aware of their condition and experiencestress when mistaking signs and symbols. Theyconfuse color changes with dark and light shades,not understanding the nature of colors they havenever seen. People who are color blind reduce thestress of the disability by training themselves to useother visual clues. For example, they learn shapesand sizes of safety signs and memorize vital infor-mation such as that the red light is usually abovethe green.

Other disorders of the eye may result in tempo-rary or permanent color blindness, includingdegeneration of the optic nerve due to neuritis oranemia, and also infectious diseases such assyphilis or malaria. Malnutrition and ingestion ofpoisonous chemicals or drugs can also cause colorblindness or a limited perception of colors. Whilecataracts and other eye diseases that result in opac-ities (nontransparent areas) of the lens and corneawill reduce color vision, when underlying diseasesare relieved, color vision may improve.

SOURCE:Birren, Faber. Color Psychology and Color Therapy. Secau-

cus, N.J.: Citadel Press, 1961.

combat fatigue (battle fatigue, combat neurosis)Anxieties occurring after the extreme stresses ofwar or battles. The term has been replaced in con-temporary usage with POST-TRAUMATIC STRESS DIS-ORDER (PTSD). Veterans of World War I were said tohave “combat fatigue,” or “shell shock,” while Viet-nam veterans with the same symptoms have PTSD.

See also ANXIETY DISORDERS.

comfort foods Under stress, people may reachfor foods they enjoyed as a child. Comfort foodssuch as meat loaf, mashed potatoes, macaroni andcheese, and chocolate chip cookies are availableprepackaged and ready to eat or may be readilyavailable at fast-food restaurants.

The inclination to seek comfort from food has ascientific basis, according to a study that appearedin the Proceedings of the National Academy of Sciences.The researchers suggested that high fat, high carbo-hydrate comfort foods actually fight stress by stem-ming the tide of stress-related hormones that are

released when people are exposed to stress.Researchers determined that 24 hours after activa-tion of the chronic stress system, which stimulatesa flood of hormonal signaling from the hypothala-mus to the adrenal glands, glucocorticoidsprompted rats to engage in pleasure-seeking behav-iors, which included eating high-energy foods(including sucrose and lard). The negative aspectsof the chronic stress response system, otherwiseushered in by the glucocorticoids, were blunted.The downside of this behavior is weight gain, obe-sity, and a tendency toward developing diabetes.

In humans, over time, elevated stress levels caninitiate many harmful effects on the body, such asa loss or gain of weight, depression, obesity, and aloss of brain tissue.

The study suggests that comfort food slows akey element of chronic stress, according to MaryDallman, a professor of psychology at the Univer-sity of Southern California, San Francisco. It alsomay help explain why solace is often sought insuch foods by people with stress, anxiety, ordepression, and also bulimic and night-bingeingeating disorders.

According to the researchers the drive to eatcomfort foods makes sense from an evolutionaryperspective. In the animal kingdom, it is an “eat orbe eaten” world, and an animal under constant orchronic stress may prefer to eat high-energy foodsto stay in the game. Under the model proposed bythe researchers, glucocorticoids would bothprompt vigilance to threats and send a signal to thebrain of a chronically stressed animal to seek high-energy food. If it were successful in finding suchfood, stress and its attendant feelings would be cutback.

See also ANXIETY; DEPRESSION; DIET; EATING DISOR-DERS; STRESS; WEIGHT GAIN.

SOURCES:Dallman, Mary F., Norman Pecoraro, Susan F. Amana, et

al. “Chronic Stress and Obesity: A New View of Com-fort Food.” Proceedings of the National Academy of Sci-ences 100, no. 20 (September 2003): 11,696–11,701.

Raloff, J. “Stress Prone? Altering the Diet May Help.” Sci-ence News 158 (July 8, 2000): 23.

commitment See COHABITATION; DATING; INTI-MACY; MARRIAGE; RELATIONSHIPS; SELF-ESTEEM.

96 combat fatigue

communication Process through which mean-ings are exchanged between individuals. Whenindividuals feel understood, they are communicat-ing effectively. They are in control of events; otherpeople trust and respect them; in work settings,they feel valued. Communicating effectivelyenhances health and SELF-ESTEEM, nurtures rela-tionships and helps people cope with stress.

Failure to Communicate

When individuals do not communicate well, theyfeel misunderstood, frustrated, distressed, defen-sive, and often hostile, which increases their stresslevel. Faults and flaws in communication habits, orcommunication gaps, cause stress to many people,to those they love and those with whom they inter-act on all levels, from the most intimate to the mostdistant of acquaintances. People who don’t com-municate effectively are more vulnerable to disease;they can be hostile and confrontational and are atincreased risk for heart disease. People who feelmisunderstood report more DEPRESSION and moremood disorders of the kind shown to weaken theirimmune function. When communication breaksdown, heart rate speeds up, cholesterol and bloodsugar levels rise, and they become more susceptibleto HEADACHES and digestive problems and are moresensitive to pain. In work settings, communicationgaps can reduce productivity, make workers irritableand even increase the risk of accidents.

Differences in Male-Female Communication Styles

According to Bee Reinthaler, a personnel communi-cations specialist, in business, differences betweenthe communications styles of male and femalemanagers can cause problems in efficiency and inaccomplishing goals. Males in the corporate worldoften use a complex combination of business,sports, and military jargon. Their behavior isaction-oriented and competitive. On the otherhand, women generally are more demonstrativeand express their feelings. Many women frametheir speech with qualifiers, questions, and ques-tioning intonations. They express doubts anduncertainties more frequently than men.

According to Reinthaler, when women wait formen to speak first, they create an image of incom-petence. “Men may then fall into the stereotypicalrole of treating women as incompetent and thestereotypical interaction continues in a destructive

way. It would be more effective if both genders ofmanagers would ‘speak the same’ language.”

“Many women attempt to crack the male com-munication code in the workplace until somethinghappens that shows they have underestimated its

communication 97

OVERCOMING STRESS BY AVOIDINGCOMMUNICATION GAPS

• Learn to cope with criticism. Receiving criticismcauses stress. The impact on our mood and bodydepends more on how we describe the negativefeedback to ourselves. Ask yourself: Does thisseem reasonable? Is it fact or opinion? Are thereothers who might confirm or dispute this view?How would others have behaved?

• Learn to listen. Listening is an active processrequiring openness and receptivity. Keep yourmind free of distracting reactions, responses,judgments, and questions and answers.

• Observe your own body language. Researchshows that more than half of what we commu-nicate is conveyed by BODY LANGUAGE. Smiling,frowning, sighing, touching, or drumming fin-gers give out strong messages. Women tend tosmile more than men, nod their heads, andmaintain more continuous eye contact while lis-tening and speaking than men. Under stress orin new situations, this tendency becomes evenmore pronounced.

• Recognize and respect differences in conversa-tional styles. Styles of conversing play a majorrole in triggering misunderstandings. For exam-ple, women tend to ask more personal questionsthan men. Men more often give opinions andmake declarations of fact.

• Become more assertive. Speak and act fromchoice and stand up for your rights withoutbeing aggressive.

• Learn to say no when you want to. Avoid feelingresentful, frustrated, or guilty. Take time beforeyou respond to a request. You need not givelengthy explanations for saying no.

• Try to resolve conflicts when you recognizethem. Use “I” statements whenever possible,rather than attacking the other person with a“you” statement. Make sure you understandeach other’s concerns, positions, or feelings bysummarizing what you heard.

complexities,” says Candiss Rinker, an expert inthe science and practice of change management.She explains that women have been socializedfrom childhood to avoid direct communicationabout difficult issues, so they often use a sugar-coated approach that other women understand,but men do not.

Deborah Tannen, a linguistics professor, saysgender differences put women in a double bind atwork that is not as evident in personal RELATION-SHIPS. “Workplace communication norms weredeveloped by men, for men, at a time when therewere very few women present. The situation isaggravated when women hold positions of author-ity. If they talk in ways expected of women, theymay not be respected; if they talk in ways expectedof men, they may not be liked,” says Tannen,author of Talking from 9 to 5: How Women’s and Men’sConversational Styles Affect Who Gets Heard, Who GetsCredit and What Gets Done at Work.

Removing the Stress from Your Communication Style

Individuals should apply the old “golden rule” incommunicating with others. They should speak inthe way in which they would like to be spoken toand listen to others the way they hope others willlisten to them. It is important that they learn toexpress their likes and dislikes in a tactful anddiplomatic way. They will find that when they aremore direct, other people will be more responsive.With slight adaptations, these suggestions may beuseful in communicating with children, siblings,parents, coworkers, bosses, or acquaintances andshould be helpful in most situations.

See also ASSERTIVENESS TRAINING; IMMUNE SYSTEM.

SOURCES:Reardon, Kathleen Kelley. They Don’t Get It, Do They?:

Communication in the Workplace—Closing the GapBetween Women and Men. Boston: Little, Brown, 1995.

Reinthaler, Bee. “Verbal Communications.” The Profes-sional Communicator, fall 1991.

Sobel, David S. “Rx: Prescriptions for Improving Com-munication.” Mental Medicine Update 3, no. 2 (1994).

Tannen, Deborah. Talking from 9 to 5: How Women’s andMen’s Conversational Styles Affect Who Gets Heard, WhoGets Credit and What Gets Done at Work. New York:William Morrow, 1994.

Tingley, Judith C. Genderflex, Men and Women Speaking EachOther’s Language at Work. New York: Amacom, 1995.

commuter marriage See MARRIAGE.

competition One of the many dichotomies pres-ent in American life today that induces stress. Itencourages individual achievement and the needto win. As such, it is the extreme opposite ofanother American concept—teamwork—whichteaches us to respect others, appreciate theirstrengths and weaknesses, share our skills andknowledge, and help others meet their goals.

Early in life, children on the playing field expe-rience the contradiction of competition and team-work. Thus begins a source of stress we carrythrough much of our adulthood. Competitionencourages comparisons between ourselves andothers, both on a social and economic level; this inturn affects our feelings of SELF-ESTEEM.

See also AUTONOMY; CONTROL; TYPE A PERSONALITY.

compulsions See GAMBLING; OBSESSIVE-COMPUL-SIVE DISORDER; SHOPAHOLISM.

computers When introduced into the workplace,computers were promoted as tools to simplify tasksand thus save time and effort and the stress relatedto getting jobs done the “old way.”

Nominally, the computer is designed to serve asan extension of employees’ skills and capabilities.Implied is that the user is in control and the com-puter maintains the burden of adaptation. In fact,in many cases, the opposite has occurred.

For lower-level employees, use of computersmay diminish skill levels and autonomy andincrease morale and health problems. While theseworkers report that the computer makes theirwork more enjoyable, they also report job changesassociated with computers that involve stressors,including increased time pressures and reducedpossibilities for control of the task. Added to that isthe stress of having their work on the computermonitored by the computer itself, which collects allaspects of employees’ activities and centralizes theinformation for management review.

For higher-level employees, computers seem tohave increased the work done and set new stan-dards of higher quality for doing it. With theadvent of desktop and laptop computers, profes-sionals in all fields are expected to do their own

98 commuter marriage

word processing, spread sheets, electronic mail,and presentation preparation. This has allowedmanagement to cut back on staff. Although com-puters are a powerful technology, they are contin-uously changing the way we do business and, thus,have become a major stressor for employees at alllevels.

See also AUTOMATION; ELECTRONIC DEVICES;INFORMATION EXPLOSION; REPETITIVE STRESS INJURY.

conditioning Frequently used in BEHAVIOR THER-APY as a technique to reduce stress in unwantedconditions, such as phobias and anxieties.

Conditioning occurs in two major ways: classicand operant. In classic or Pavlovian conditioning,two stimuli are combined: one adequate, such asoffering food to a dog to produce salivation (anunconditioned response), and the other inade-quate, such as ringing a bell, which by itself doesnot have an effect on salivation. After the twostimuli have been paired several times, the inade-quate or conditioned stimulus comes to elicit sali-vation (now a conditioned response) by itself.

In operant conditioning, consequences areintroduced that strengthen or increase the rate orintensity of the desired activity (reinforcement) orweaken or decrease the rate or intensity of theundesired activity (punishment). Partially reinforc-ing or punishing the activity will increase its resist-ance to extinction.

condom A cylindrical sheath of rubber, placed onthe penis prior to sexual intercourse, which catchesseminal fluid and prevents sperm from entering awoman’s vagina and impregnating her. For someindividuals, the use of a condom becomes a stress-ful issue. Some couples say a condom interfereswith their enjoyment of sexual intercourse; in somecases, the man refuses to wear one.

In the 1980s and throughout the 1990s, duringthe escalation of the AIDS (ACQUIRED IMMUNODEFI-CIENCY SYNDROME) epidemic, condoms were pro-moted as a SAFE SEX measure and means of reducingthe risk of the spread of AIDS and SEXUALLY TRANS-MITTED DISEASES (STDs) between partners.

Advantages of use of a condom as a contracep-tive include relatively low cost, availability withouta physical examination or prescription, and some

protection against STDs. Disadvantages may be thepossibility of a dulling sensation in the penis andthe care in which condoms must be used.

Invention of the condom is often attributed toDr. Condom (1650–85), a physician in the court ofCharles II. However, the first published report ofuse of a condom to prevent venereal disease was inthe work of the Italian anatomist Fallopius in 1564.

SOURCE:DiClemente, Ralph J., and Gina M. Wingood. “Sexual

Assertiveness Training Produces More ConsistentCondom Use.” Journal of the American Medical Associa-tion, October 25, 1995.

confined spaces Fear of being in a confinedspace is known as CLAUSTROPHOBIA. In addition tothe stressful fear aspect of enclosed places, consid-erations include attention to any area where itmight be possible for a person to become trapped,such as walk-in freezers or elevators, or wherethere is a possibility of anything collapsing or over-turning and causing considerable stress to them-selves, their employer, or a home owner.

Areas of low head height such as cellars andmezzanine floors should be identified and appro-priate precautions taken to prevent risk of injury topersons entering these areas. If there is no alterna-tive to working in a confined space, it is essentialthat the persons carrying out such work be prop-erly trained, competent, and physically capable ofdoing so. Working alone is not recommended insuch situations; if it cannot be avoided, a means ofcommunication must be available.

Where there is a possibility of oxygen deficiencyor a contaminated atmosphere, suitable breathingapparatus must be used, and at least one other per-son who is trained and equipped to carry out res-cue procedures and sound an alarm for help in caseof an accident must be present.

See also PHOBIAS.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.

conflict resolution The ability of people to comeout of a stressful encounter respecting and likingeach other. This is a win-win situation in which thestress of ANGER and confrontation are minimized,

conflict resolution 99

and those involved are able to be heard, to expresstheir position, and articulate their needs.

See also COMMUNICATION.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Injuries. New York: Facts On File, 2004.

congestive heart failure The end result of manydifferent types of heart disease where the heart can-not pump blood out normally. This results in conges-tion (water and salt retention) in the lungs, swellingin the extremities, and reduced blood flow to bodytissues. Living with congestive heart failure is a verystressful situation for the sufferer as well as thosearound him or her. Medical treatment can improvethe quality of life for many of these patients.

See also CHOLESTEROL; CHRONIC ILLNESS; CORONARY

ARTERY DISEASE; HEART ATTACK; HIGH BLOOD PRESSURE.

FOR FURTHER INFORMATION:American Heart Association7272 Greenville AvenueDallas, TX 75231-4596(800) 242-USA1 (toll-free)(214) 373-6300(214) 987-4334 (fax)www.americanheart.org

constipation Abnormally delayed or infrequentpassage of hard, dry feces. Many people feel verystressed because they do not have a bowel move-ment every day. Parents become anxious and causetheir children to be stressed. Yet, many healthypeople may not have a bowel movement for sev-eral days and suffer no ill effects.

Today, advertising seems to have created an “ill-ness” called “irregularity” for which laxatives are

the cure. A better approach to solving the consti-pation problem is through diet and regular exer-cise. At any age, a persistent change in the patternof bowel movements should be investigated by aphysician to rule out a serious disorder.

Causes of Constipation

Emotional factors, such as frustration and resent-ment may result in constipation. Tension maycause the muscles of the intestine to tighten, orcontract, in what is called spastic constipation. Thisis often part of the syndrome known as IRRITABLE

BOWEL SYNDROME. Constipation is also caused bylack of fiber in the diet. Fiber is found in foods suchas whole-grain breads, fresh fruit, and vegetables.it provides the bulk that the muscles of the largeintestine needs to stimulate propulsion of the fecalmatter along its way.

Some individuals who have continuouslyignored the urge have trouble with bowel move-ments. Disabled and elderly people often sufferfrom constipation, in some cases because of thediminishing tone of intestinal and other muscles,slowing down of body signals from reduced effi-ciency of the nervous system, and immobility.Hemorrhoids or an anal fissure result in pain andmay inhibit an individual’s efforts to begin a bowelmovement. Atonic constipation may be the resultof constant use of laxatives and enemas. These leadto weakening of the intestinal wall, making theindividual even more dependent on laxatives orenemas than ever before.

Many medications have a side effect that leadsto constipation. These include medications con-taining morphine and codeine, verapamil (a cal-cium channel blocker used in the treatment of highblood pressure, angina, and cardiac rhythm disor-ders); any of the beta blockers (used for the samereason, but they can also cause DIARRHEA); varioussedatives and tranquilizers; calcium supplements(especially the carbonate variety); and severalantacid products. Being aware of the side effectmay help reduce the stress of constipation.

Coping with Constipation

If constipation is accompanied by alternatingattacks of diarrhea, a physician should be con-sulted. This sometimes occurs in people who havediabetes. An examination will reveal if there is an

100 congestive heart failure

HOW TO USE CONFLICT RESOLUTION

• Think before speaking.• Say what you mean and mean what you say.• Listen carefully to the other person.• Do not put words in the other person’s mouth.• Stick to the problem at hand.• Refrain from fault-finding.• Apply the same rules to handling business and

personal conflicts.

obstruction, such as a polyp or a tumor in thecolon, or the constipation may be a symptom ofirritable bowel syndrome. In hypothyroidism,chronic constipation may result. Try a change indiet, such as eating grainy products at breakfast, oreat them later in the day.

For many people, being aware of their ownstress levels helps. Try to reduce stress by tech-niques such as MEDITATION and BIOFEEDBACK. LearnRELAXATION training techniques. With these tech-niques, in conjunction with diet and regular exer-cise, constipation should improve.

consumer privacy See IDENTITY THEFT.

contraception See BIRTH CONTROL.

control A feeling of control over people’s livesmeans that they are directing the outcomes ofeveryday events. While life is going well, most peo-ple do not consciously think about their level ofcontrol. However, when that sense of control isthreatened, they become aware and this loss ofcontrol leads to stress, ANGER, and FRUSTRATION.

Issues of loss of control involve situations inwhich people who could help themselves, do notdo so. They may lose motivation because of previ-ous failures or may be experiencing what sociolo-gists call “learned helplessness.” They feel thatwhatever they do will not make any difference.Their learned response is to not try to gain controlover their lives. But they continue to feel the stressof the anger, frustration, and hostility, which maylead to physical problems.

The stress in some people’s jobs is caused by nocontrol over the pace of work, or the work envi-ronment, or DECISION MAKING. People living in insti-tutions or other such situations are frustratedbecause they can’t change their environments andfeel that things are being done to them or for them.An example is patients in hospitals who feel thattheir sense of control and AUTONOMY has beentaken away from them because of the hospital rou-tine. Other people do not recognize their ownoptions for making decisions and feel trapped byinvisible forces. People who always try to pleaseothers in an effort to gain validation and self-esteem are an example of this. Those who fear fly-

ing do so because, when they put themselves in thehands of the pilot, they feel totally out of control.

Although individuals cannot always control allevents happening around them, they can learnhealthier responses to these stressful situations.RELAXATION, BREATHING, or BIOFEEDBACK techniquescan help a person gain a feeling of control.

See also HARDINESS.

coping The psychological as well as practicalsolutions that people must find for extremely dis-tressing as well as everyday situations. Examples ofthese situations are dealing with cancer, caring foran aging relative, readjusting after the death of aloved one, facing unemployment, and dealing withRANDOM NUISANCES. Different individuals developdifferent ways of coping and learn to adapt theirresponses and reduce their stress and anxieties.

Stone and Porter, writing in Mind/Body Medicine(March 1995), defined coping as “constantlychanging cognitive and behavioral efforts to man-age specific external and/or internal demands thatare appraised as taxing or exceeding the resourcesof the person.”

To some, “coping” means getting on with lifeand letting things happen as they may. To others, itis consciously using the skills they have learned inthe past when facing problem situations. Copingcan mean anticipating situations, or it can meanmeeting problem situations head-on. For example,managers who are able to handle employees ineveryday situations become nervous and jitteryjust anticipating giving a public speech. In a seriousmedical crisis, some people cannot cope with theirown illness but manage to muster strength whenthey need to care for a loved one.

Individuals can learn new coping skills frompsychotherapists as well as those who practicealternative or complementary therapies such asMEDITATION and RELAXATION training. Relaxationand deep BREATHING techniques can help overcomethe stress involved in a difficult situation.

Better Coping for Better Health

When Hans Selye (1907–82), an Austrian-bornCanadian endocrinologist and psychologist, wrotehis landmark book The Stress of Life, he describedthe GENERAL ADAPTATION SYNDROME. The secret of

coping 101

health, he said, was in successful adjustment toever-changing conditions.

Research studies have shown that people whocope well with life’s stresses are healthier thanthose who have maladaptive coping mechanisms.In his book, Adaptation to Life, George Valliant, aHarvard psychologist, summarized some insightsabout relationships between good coping skills andhealth. He found that individuals who typicallyhandle the trials and pressures of life in an imma-ture way also tend to become ill four times as oftenas those who cope well.

Stone and Porter reported that coping effortsmay have direct effects upon symptom perceptionand may have indirect effects on physiologicalchanges and disease processes, as well as on moodchanges, compliance with physician’s instructions,and physician-patient communication.

See also BEHAVIOR THERAPY; COMMUNICATION;EXERCISE; HARDINESS.

SOURCES:Locke, Steven, and Douglas Colligan. The Healer Within.

New York: Mentor, 1986.Selye, Hans. The Stress of Life. New York: McGraw-Hill,

1956.———. Stress without Distress. Philadelphia: Lippincott,

1974.Stone, Arthur A., and Laura S. Porter. “Psychological

Coping: Its Importance for Treating Medical Prob-lems.” Mind/Body Medicine 1, no. 1 (March 1995).

coronary artery disease Caused by ATHEROSCLE-ROSIS (hardening) of the arteries that supply bloodand oxygen to the heart. The disease is a source ofstress to the sufferer as well as those who are care-givers. It is preventable to a great extent by lifestylemodifications and dietary changes.

See also CHOLESTEROL; CONGESTIVE HEART FAIL-URE; HEART ATTACK; HIGH BLOOD PRESSURE; TYPE APERSONALITY.

corporate buyout The purchase of a controllinginterest in a company by either the employees oranother company. The word originated in the mid-1970s when there was a marked increase in com-pany takeovers and tender offers. When corporatebuyouts occur, employees are under stress due tothe possibility of downgrading of their jobs, dupli-

cation of their job functions, and loss of jobs thatmay come during and following reorganization.

See also DOWNSIZING; LAYOFFS; WORKPLACE.

cortisol See DEPRESSION.

cosmetic surgery Procedures performed by plas-tic and reconstructive surgeons to improve appear-ance in a healthy person. Many people undergocosmetic surgery to overcome negative and stress-ful feelings about parts of their face or bodies.

In a society that worships beauty, being beauti-ful has long been a goal of women of all ages and,more recently, men as well. At the same time,older adults are waging their battles against wrin-kles and other signs of aging. Nearly 400,000 cos-metic procedures were performed in 1994. Thestress of maintaining looks and appearing youngerhas created a multibillion-dollar market for cos-metic, clothing, food, and health care products.

For plastic and reconstructive surgeons, theincrease in patient demand for cosmetic surgery hasbeen both a blessing and a curse. According to theAmerican Society of Plastic and Reconstructive Sur-geons, “The 1990s have changed the way themedia—and the public—view PLASTIC SURGERY andits practitioners. From the breast implant coverage tohealth care reform to chemical face peels, the profes-sion has moved farther into the public eye, with allthe opportunities—and drawbacks—that entails.”

Choosing a Cosmetic Surgeon

The consumer considering cosmetic surgery canremove some of the stress from the situation byfollowing a few guidelines. First, find a physicianwho has a great deal of experience in performingthe procedures; be sure the surgeon is certified bythe American Board of Plastic Surgery. This certifi-cation means that the surgeon has had at least fiveyears of surgical training after medical school,including a minimum two-year plastic surgery res-idency. To determine the doctor’s experience, talkwith the doctor and with other patients and look atthe diplomas. A reputable doctor will not onlyallow prospective patients to interview him/her,but will question them as well as to what theirmotives are and, if appropriate, offer alternativenonsurgical procedures.

102 coronary artery disease

New techniques and surgical tools such as lasersnow being used for facelifts, liposuction, breastreduction and augmentation, and nose jobs allevi-ate much of the stress connected to aesthetic sur-gery and herald a new century in which suchprocedures will become even more commonplace.

See also BODY IMAGE; SELF-ESTEEM.

FOR FURTHER INFORMATION:American Academy of Facial Plastic &

Reconstructive Surgery310 South Henry StreetAlexandria, VA 22314(703) 299-9291

American Society of Plastic and Reconstructive Surgeons

444 E. AlgonquinArlington Heights, IL 60005(708) 228-9900Referral Service: (800) 635-0635

SOURCES:Elson, Melvin L., and John H. Harley. The Good Look Book:

Today’s Options for Prolonging the Prime of Life. Atlanta:Longstreet Press, 1992.

Willis, Jan. Beautiful Again: Restoring Your Image andEnhancing Body Changes. Santa Fe: Health Press, 1994.

co-therapy See PSYCHOTHERAPIES.

counseling Many varied professional servicesavailable to individuals seeking help in some areaof their life, including stress. These services mayrange from those of a trained social worker to apsychiatrist. Individuals, couples and families canfind appropriate counseling services. They may beprovided in situations such as a school, the work-place, a hospital, clinic, or a community center.

To seek counseling assistance, call a local hospi-tal or look in the yellow pages of the telephonedirectory under psychologists or psychiatrists.Some listings have the heading “counselors.” Thereare also many community self-help and SUPPORT

GROUPS in which members share their experiences.For participants in these groups, sharing meansthey are not alone with their problems, and theylearn from one another to problem-solve.

Before beginning therapy with any counselor,ask what his or her credentials are and whether

they are certified by any state agency or profes-sional board. As with any other professional, somemay meet an individual’s needs better than others.Individuals should not be afraid to change coun-selors if they are not meeting their needs.

See also BEHAVIOR THERAPY; MARITAL THERAPY;PSYCHOTHERAPIES.

Cousins, Norman (1915–1990) American author,professor of medical humanities, and leader inbiobehavioral healing. Cousins managed to healhimself of a life-threatening disease and a massivecoronary attack. Both of these times, he used hisown regimen of nutritional and emotional supportsystems as opposed to traditional methods of treat-ment. The experiences are detailed in his books,including Anatomy of an Illness as Perceived by thePatient, a worldwide best-seller, and The HealingHeart: Antidotes to Panic and Helplessness.

Cousins is sometimes described as the man wholaughed his way to health, a simplified descriptionof the controversial healing method he employedwhen he was diagnosed in the mid-1960s as hav-ing ankylosing spondylitis. This degenerative dis-ease causes the breakdown of collagen, the fibroustissue that binds together the cells of the body.Almost completely paralyzed and given only a fewmonths to live, Cousins checked himself out of thehospital and moved into a hotel room. Whilemaintaining a positive mental outlook, he tookmassive doses of vitamin C and exposed himself tohigh doses of HUMOR, including old movies andbooks by James Thurber, P. G. Wodehouse, andRobert Benchley. In Anatomy of an Illness, Cousinswrote: “I made the joyous discovery that ten min-utes of genuine belly LAUGHTER had an anestheticeffect and would give me at least two hours ofpain-free sleep.”

In 1980, about 15 years after his major illness,Cousins suffered a near-fatal heart attack in Cali-fornia. According to an article in the SaturdayReview, Cousins told his physicians at the UCLAIntensive Care Unit that they were “looking atwhat is probably the darndest healing machinethat has even been wheeled into the hospital.” Thearticle said that “Cousins makes his body a per-sonal laboratory and befriends the society withinhis skin. He refused morphine; he asked for a

Cousins, Norman 103

change in the visiting routine to ensure rest. Grad-ually he improved.”

When facing the treadmill stress test with fear,Cousins realized that his fear was a factor in slow-ing his progress, so he adopted a more relaxedlifestyle, changed his diet, and specifically avoidedstress-producing situations. When he did thetreadmill test again, he approached it in a relaxedmanner, listened to classical music and comedytapes, and had a better result.

A Saturday Review article commenting on TheHealing Heart said that “It was not a medical text-book, but a study of awareness, listening, trust,choice, and intention about the intelligent use of abenevolent, centering will. It is about communica-tion and partnership between the healer and thehealed. It addresses as complementary the art ofmedicine and the science of medicine, the personand the institution, and freedom of choice and pro-fessional responsibility. The book affirms hope andbelief as biologically constructive forces, with beliefguided by knowledge and tempered by reason.”

At one point, Cousins interviewed 600 peoplewith malignancies and found that in many casestheir disease took a sharp turn for the worse whenthey received their diagnoses. He determined thata physician can activate the healing process bybuilding up both his or her and the patient’s confi-dence and creating a partnership for healing.

See also ALTERNATIVE MEDICINE; IMMUNE SYSTEM;RELAXATION.

SOURCES:Cousins, Norman. Anatomy of an Illness as Perceived by the

Patient. New York: Bantam, 1981.———. The Healing Heart: Antidotes to Panic and Helpless-

ness. New York: Norton, 1983.

covert modeling Imagining or observing anotherperson performing a behavior or action and thenimagining the particular consequences. For exam-ple, a person who feels extremely stressed aboutspeaking in public can imagine another person get-ting up on the stage, delivering a talk, answeringquestions, and feeling successful about the situa-tion. The next step in the concept is when the indi-vidual imagines himself or herself doing the samething at a reduced stress level.

See also BEHAVIOR THERAPY; COVERT REHEARSAL;PSYCHOTHERAPIES.

covert rehearsal An imagery technique in whichan individual in therapy is asked to imagine him-self or herself effectively doing a stressful task. Theindividual may repeat the visualization manytimes, and consider different alternatives. This pro-cedure often follows COVERT MODELING. The goal ofthe technique is to motivate the individual tobelieve that he or she can face the situation or dothe task at a reduced level of stress.

See also BEHAVIOR THERAPY; COVERT REINFORCE-MENT; PSYCHOTHERAPIES.

covert reinforcement A technique used in psy-chotherapy in which the individual imagines tworesponses to an action or situation, one stressfuland another less stressful. For example, the personwho first imagines seeing another give a publicspeech (COVERT MODELING) and then practicesCOVERT REHEARSAL (imagining giving the speech),now imagines that the speech has been given andthat there was a favorable audience response with-out an undue level of stress.

See also BEHAVIOR THERAPY; PSYCHOTHERAPIES.

coworkers The quality of a person’s work rela-tionships, particularly with colleagues, relates tohis/her level of job stress. Colleagues who don’tpull their weight and complain constantly canmake work life miserable. Backstabbers, gossips,and tattletalers damage reputations and can bringinnocent people’s careers to a halt.

One of the stresses relating to the unemployedworker today is lack of companionship. The day-to-day interactions with coworkers are gone, and theunemployed worker often becomes withdrawn,spending less and less time with peers. On the otherside of the coin are the coworkers who are left inthe corporation after DOWNSIZING or LAYOFFS haveoccurred. Research has shown that their productiv-ity is reduced, they develop poor work attitudesand they often seek new positions. Factors influ-encing these reactions include: when the layoff isseen as unnecessary, when workers receive infor-mation about termination in a degrading or unfairway, when criteria used to select workers in a lay-off is perceived as politically motivated or biased inany way, and when termination benefits and com-pensation are not considered adequate.

See also CORPORATE BUYOUT.

104 covert modeling

crack See COCAINE.

creativity Creativity involves unusual associa-tion of ideas or words and ingenious methods ofproblem solving. It may involve using everydayobjects or processes in original ways or mayinvolve using an imaginative skill to bring aboutnew thoughts and ideas. Some creative ideas areahead of their times and may never be appreciatedor are not appreciated until after their creator’sdeath. These creative people may be stressed byfeelings of inadequacy and lack of self-esteem. Onthe other hand, there are those who overestimatetheir creativity and feel stress from thinking theyare undervalued and underappreciated.

Creativity and Work

While creativity is strongly associated with the arts,it is equally important in fields such as science,business, or manufacturing. People who try to becreative and cannot, feel stressed. This is particu-larly true of people who were hired because oftheir creativity. Fortunately, in corporations today,a free and voluminous flow of ideas is thought tobe an important part of the creative process, eventhough many of the ideas may not be truly cre-ative. Techniques such as brainstorming and othergroup approaches encourage the flow of ideas.These techniques bring in new people who havenever been a part of the creative process andencourage a fresh viewpoint.

The Creative Process

Biographers and researchers of creative individualshave identified certain stages in the creative

process. Often the scientist or artist identifies anarea of work or a project but, after approaching it,feels dissatisfied and returns to less creativeendeavors. Suddenly during this incubationperiod, a solution or artistic concept emerges. Itthen must be fleshed out, elaborated or tested.

Creativity has been found to correlate with cer-tain personality and intellectual characteristics.Although intelligence and creativity are thought tobe separate mental gifts (and not all intelligentpeople are creative), intelligence does seem to benecessary for creativity. Creative people have beenfound to be leaders and independent thinkers.They are self-assured, unconventional and have awide range of interests. Since they are frequentlyinvolved in their own thoughts and inner life, theytend to be introverted and uninterested in sociallife or group activities. Passion for their field ofwork and a sense that what they do will eventuallybe recognized and make a difference are also qual-ities that support creativity.

The Creativity Theory

Many behaviorists have adopted the position thatthere is no such thing as a creative act, that whatappears to be new is, in fact, “old wine in new bot-tles” or arrived at by luck and random experimen-tation. For example, Shakespeare created dramaticmasterpieces without using original plots. Othershave come up with the theory that a necessary ele-ment of creativity is a relationship with reality. Awork of art may be original, but not truly creativeunless it relates somehow to experiences, feelings,or thoughts, even though previously undefined, ofthe observer.

Mental health professionals have been inter-ested in creativity for years. For example, J. P. Guil-ford (1897–1987), who explored this area in the1960s, described two areas of thinking: conver-gent, or narrow, focused thinking, and divergentthinking, which allows the individual to let his orher mind roam and explore a broad spectrum ofideas. Guilford felt that the latter type of thinkingwas most creatively productive. Under his direc-tion, the Torrance Tests of Creative Thinking weredeveloped at the University of Southern California.

Stimulation to increase creativity also is of inter-est to researchers. It has been found that people’screativity may increase or decrease according to

creativity 105

TIPS FOR AVOIDING STRESS WHEN WORKINGWITH TROUBLESOME COWORKERS

• Tell them, in a nonconfrontational manner, howtheir actions affect your work.

• Avoid providing the complainer with an audi-ence and the bully with a target.

• Consider talking to your supervisor about theproblem, but be prepared for possible negativeresults.

• Remember that you cannot change someoneelse’s behavior, but you can change how youreact to that behavior.

their environment and work habits. For example,certain people can be more or less productive atwork depending on the atmosphere, the time ofday and even the clothing they wear.

See also BRAINSTORMING.

SOURCES:Weisberg, Robert. Creativity, Genius and Other Myths. New

York: W. H. Freeman, 1986.Wilmer, Harry A. Creativity: Paradoxes and Reflections. Wil-

mette, Ill.: Chiron Publications, 1991.

credit record See IDENTITY THEFT.

crime, witnessing People witnessing a crime canbe subjected to stress on many levels. First, theymay be faced with a decision to come to the aid ofthe victim. Once the decision for involvement hasbeen made, they may face the stress of being ques-tioned by the police, exposed to threats of harass-ment from the associates or family of the criminal,and harried by postponement and rescheduling ofthe trial with no regard for their work scheduleand other personal responsibilities.

A decision not to become involved is oftenmade. These people may feel that there are otherwitnesses to the crime, and they want to avoid adifficult and personally dangerous situation. Someof them may later feel the guilt of doing nothingand they will experience extreme stress.

Watching a violent crime may also result inPOST-TRAUMATIC STRESS DISORDER, with symptomsof anxiety, nightmares, insomnia, and other fears.Recovery can be aided with a variety of PSY-CHOTHERAPIES administered by professionals. Vic-tim/witness assistance programs, whose servicesinclude psychological counseling, have been initi-ated in some areas of the United States. During atrial, program administrators may make arrange-ments for witnesses to get in and out of courtbuildings with minimum public and media expo-sure and intervene with the court on behalf of thewitness when he or she is a victim of stressfulthreats or intimidation.

See also ANXIETY DISORDERS.

crisis A turning point for better or worse in anacute disease, or an emotionally significant eventor radical change in status in a person’s life. The

stress involved in a crisis situation may result froma combination of the individual’s perception of anevent as well as his or her ability or inability tocope with it. Some people will cope with a crisissituation better than others.

Crisis intervention is often necessary to provideimmediate help, advice, or therapy to individualswith acute stress or psychological or medical prob-lems. Many crisis intervention centers utilize tele-phone counseling. For example, in cities throughoutthe United States, there is a SUICIDE hotline for thosecontemplating ending their lives. In some cases, aRAPE victim’s first step toward seeking professionalassistance is to call a rape crisis hotline. When abombing or shooting occurs in a public place, crisisintervention services are provided for survivors whowitnessed the event in an effort to prevent the onsetof, or ameliorate, POST-TRAUMATIC STRESS DISORDER

(PTSD).The goal of crisis intervention is to restore the

individual’s equilibrium to the same level of func-tioning as before the crisis, or to improve it. Manydifferent types of therapists and SELF-HELP GROUPS

provide crisis intervention. Therapy may includetalking to the stressed individual and appropriatefamily members or short-term use of appropriateprescription medications. However, crisis interven-tion is not a substitute for longer-term therapy. Theindividual may learn to immediately modify cer-tain environmental factors as well as interpersonalaspects of the situation causing the crisis. Emphasisshould be on reducing stress and anxiety, promot-ing self-reliance and learning to focus on the pres-ent. Longer-term therapy is helpful after theindividual has regained some degree of composureand COPING skills.

See also CRIME, WITNESSING; GENERAL ADAPTATION

SYNDROME; SUPPORT GROUPS.

criticism Comments directed to individualsregarding behavior, appearance, performance,quality of work, or other characteristics that reflecton their SELF-ESTEEM. Criticism may be favorable,but usually is regarded as the opposite of praiseand, as such, can be very stressful.

Fear of being criticized makes many individualsreluctant to do or try certain activities. For exam-ple, when children receive negative criticism

106 credit record

regarding singing ability from a teacher, they maycarry this message for the rest of their lives. Self-criticism can be just as harsh. After judging them-selves a failure at public speaking, some adults willnot try it again. Often, criticism can be stressful forthe critic as well. In employment settings, forexample, there are supervisors who find it difficultand very stressful to criticize employees.

An ability to accept criticism that is appropriate,and then alter behavior associated with that criti-cism, is considered self-improvement. Childrenthrive on encouragement, even when it is tingedwith criticism, particularly when they receive itfrom a parent or teacher. On the other hand, somepeople take criticism very badly, and the stress ofthe experience results in defensiveness or feelingsof helplessness and low self-worth. Constant criti-cism can lead to an INFERIORITY COMPLEX, which arefeelings of inadequacy in most social situations.

Constructive criticism should genuinely explainand define what is desirable as well as what is not.Focusing criticism on the task or skill rather thanon the person is useful. Comparing children withtheir siblings should be avoided to prevent furtherstressful situations.

See also ANXIETY DISORDERS; PHOBIAS; SOCIAL

PHOBIA.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

crowding The gathering of large numbers ofpeople or animals in a mass. In HANS SELYE’s land-mark book, The Stress of Life (1976), he suggestedthat in humans, crowding may make men morecompetitive, somewhat more severe and to likeeach other less, whereas women tend to be morecooperative and lenient and like each other more.

Selye speculated that residential crowding initself does not produce psychological or physicalsymptoms of STRESS. In fact, under certain condi-tions, interpersonal contact is supportive, as long asthe people know they have the space to get awayfrom each other when they want to. His studies,however, did not reflect such later 20th-centurystresses as heavy traffic, high-rise living, air pollu-tion, and noise, associated with contemporaryWestern society urban life.

See also AUTONOMY; CONTROL; GENERAL ADAPTA-TION SYNDROME; PERSONAL SPACE.

cruise ship virus Vacation cruises are intended toreduce stress and induce relaxation; however,many people either worry about or experience avexing stomach illness on cruise ships. In June2004, the cruise industry’s newsletter Cruise Weekreported that 1,355 cases of a norovirus-like illnessoccurred on 12 ships during the first five months ofthe year. That report was newsworthy because thenumber was almost double the 700 cases recordedon seven ships during the same period the yearbefore.

In June, 2004, 66 passengers on an Alaskancruise aboard the Island Princess were felled withthe stomach illness, after a wider breakout on theship the week before that affected 425, the indus-try’s largest recorded incident since 1994. Otherships reporting outbreaks in 2004 included theNorwegian Crown, Holland America’s Veendam andRyndam, Celebrity’s Zenith and Horizon, Cunard’sQueen Mary 2, Carnival’s Celebration, and RoyalCaribbean’s Brilliance of the Seas.

Outbreaks made headlines in late 2002 whenthe disease ran though seven ships, causing 1,340reported cases.

crying Vocal expression of emotion, accompa-nied by tears. It is both a cause of stress and a stressreliever, depending on the situation. For example,at funerals, it is a normal response to express GRIEF;at weddings, it is a response to happiness. As a nat-ural reaction based in social custom and personalexperience, people cry when they are very sad orvery glad. Sometimes, people cry because theycannot cope any longer with stressful situations.There may be stress from pain or from real oranticipated loss of status, security, or friendship.

According to William Frey, a biochemist, givingin to a good cry is cathartic. “Emotional tears con-tain a higher protein concentration than tears thatare shed when the eye is irritated by onion vapor.We are quite literally crying it out, removing chem-icals that have built up in the body due to stress.”

Certain emotional disorders include crying as asymptom. In a depressive state, an individual maycry easily and without cause. In severe DEPRESSION,

crying 107

an individual may lose the capacity to cry or weep,despite a feeling of profound sadness. In a newbornbaby, crying serves to inflate the lungs and clearsecretions from both the eyes and the lungs. Forthem, hunger and pain stimulate crying.

See also COLIC.

cubicles Workspaces defined by walls, usuallynot reaching to the ceiling. Often the walls are ofsoft material intended to deaden noises. Officeworkers in cubicles may experience stress becausetheir space is small and crowded, they lack privacy,and they overhear conversations and noise fromadjacent cubicles.

Small plants may help to improve the cubicleworker’s mood. The addition of a small table lamp,desk lamp, or floor lamp will also help. If the areauses fluorescent lights, taking a walk outside eachday will increase exposure to natural light and mayhelp reduce effects of stress.

People who work in a cubicle should try to organ-ize their workspace using file cabinets, drawers, andbookshelves. Put items you work with frequentlycloser at hand and put others away for storage. Clut-ter may include too many personal items, such asphotos or toys. These items pose a distraction.

Many offices use grays, beiges, and other neu-tral colors for cubicle walls. A cubicle can be bright-ened by tacking a few yards of colorful fabric onthe walls. Adding a throw rug can also add somecolor to a cubicle.

See also FENG SHUI; PERSONAL SPACE; STRESS;WORKPLACE.

cults Groups of people who frequently have areligious philosophy and are often started by reli-gious leaders or self-appointed, pseudoreligiousindividuals. Cults also may have social and politicalreform or terrorism as their goals. Family andfriends of cult recruits are usually very stressed bytheir affiliations. Some new cult members sever allclose ties and disappear without warning.

Cults share certain similarities. They seem tohave arisen from a time period in the 1960s when

social values were questioned and considered inad-equate. Depending on the cult, new recruits arepeople who may not be emotionally stable, maylack family and close friends, and are searching forrelief from the confusion and emotional stress ofmodern life. Cult leaders welcome new memberswith an attitude of caring and acceptance, creatinga strong emotional experience for them. The moralbehavior and attitudes of the cult are dictated bystrong peer pressure. Members are made to feelthat there are continually higher levels of commit-ment or sanctity that they can attain. Leaving orquestioning the values of the group are lookedupon as evil or sinful. Members are reminded thatto return to the outside would be to return to theconfusion and stress they had formerly faced.

Deprogrammers who specialize in trying toextricate cults members are often hired by theirfamilies. These deprogrammers may use force orcoercion to remove members from the cult envi-ronment, and then implement BRAINWASHING tech-niques similar to those used by the cults in theirtraining.

FOR FURTHER INFORMATION:Cult Hotline and Clinic1651 Third AvenueNew York, NY 10028(212) 860-8533

Task Force on Cults711 Third Avenue, 12th FloorNew York, NY 10017(212) 983-4977

SOURCES:Johnson, Joan. The Cult Movement. New York: Franklin

Watts, 1984.Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.

culture shock See ACCULTURATION; MIGRATION.

cyberstress See CHANGING NATURE OF WORK; COM-PUTERS; ELECTRONIC DEVICES.

108 cubicles

Ddance therapy Dance therapy permits release ofstress and expression of emotion through bodymovement. It can be used effectively with a widevariety of individuals, from those who have mildstress symptoms to those who have severe mentalhealth disorders. Many individuals who will notspeak about their stressful concerns will indicatesomething about them with movement.

Therapists who use this technique are usuallytrained in dance and body movement as well aspsychology. Dance therapy alone does not relievesymptoms of extreme stress, but may be used inconjunction with other therapies or medication.

See also ALTERNATIVE MEDICINE; CREATIVITY.

FOR FURTHER INFORMATION:National Dance Association1900 Association DriveReston, VA 22091(703) 476-3436

Center For Dance Medicine41 East 42nd Street, Room 200New York, NY 10017(212) 661-8401

date rape See RAPE.

date rape drugs See RAPE.

dating A social process by which individualsbecome acquainted with each other and develop aRELATIONSHIP that may lead to friendship, romance,a sexual relationship, and/or marriage, is stressfulfor participants of all ages.

For young people, dating is a rite of passagefrom childhood to adulthood. Some young peoplebegin dating during their teen years while others

wait until their college years. There are often issuesof SELF-ESTEEM, and many are often held back fromdating because of negative feelings about them-selves. Others may have the additional stressors ofCRITICISM of their dates by their parents. Addition-ally, peer pressure can make young people drink,smoke, or enter sexual relationships before theyare ready and they may suffer the stresses of painand guilt because of their actions.

Individuals who are divorced or widowed findthemselves back in the dating scene. Many of theyoung people’s issues also hold true for older peo-ple, such as concern about self-esteem and appear-ance. For single parents, dating presents particularstresses as young children often “screen” their par-ents’ dates. Some children ask embarrassing ques-tions, such as “Are you going to marry my Daddy?”

Despite the stresses inherent in dating, theprocess allows people a socially acceptable way ofgetting acquainted with others.

Internet Dating

Many Web sites promote introductions of peoplevia their computers. There are Web sites for certaininterest groups, such as graduates of certain col-leges, religious groups, and affinity groups, such asmusic or book lovers. While many people meet

109

TIPS TO REDUCE STRESS IN DATING

• Know something about the person’s backgroundbefore the date.

• Accept “blind” dates arranged only by peopleyou know and trust.

• Seek out people who treat others with respect.• Date people who agree with your values.• Avoid people who are overly critical or abusive.

compatible others this way, Internet dating involvesparticular stresses not inherent in traditional dat-ing. For example, first introductions, read on com-puter screens, may include false information andexaggerated claims. The photo provided on theWeb site may be very old or actually of someoneelse. There have been instances where young peo-ple are deliberately lured into unwholesome situa-tions by someone on the Internet giving falseidentification about their gender or age.

See also DIVORCE; INTIMACY; PUBERTY; REMARRIAGE.

SOURCE:Vedral, Joyce L. Boyfriends; Getting Them, Keeping Them,

Living without Them. New York: Ballantine, 1990.

day care System of caring for children or otherdependents in other people’s homes, in churches,and in other community centers while parentswork. Changes in the economy, employment, andfamily patterns during the last years of the 20thcentury have made day care an important yetstress-filled issue for many people.

Today, when both parents need or want towork, they are faced with the dilemma of seekingday care. Some parents, traditionally the mother,feel some degree of guilt about seeking day care fortheir children. However, as a practical matter, it hasbecome more difficult to support a family on oneincome. Additionally, wives and mothers who arenot forced to work for financial reasons have beenencouraged by contemporary media and theWomen’s Movement to believe the position ofhousewife and mother is not rewarding. Still oth-ers, faced with the specter of a high divorce rate,may want to keep up their skills and have theirown employment benefits “just in case.” For thesingle working parent with small children, sometype of child care is a necessity.

Many children whose parents work are stillcared for by a relative or sitter in their own home;however, the day-care alternative does offer cer-tain benefits. Children learn to socialize with theirpeers before entering school. Day care may offereducational programs, toys, and equipment. Day-care centers are licensed and run by professionals.

However, there have been some cases of abuseand negligence in day-care centers. Parents shouldtake extreme care in choosing a day-care facility bychecking it out with local authorities, interviewing

families that have children at the facility, andclosely monitoring the facility when their childrenare enrolled.

Social mobility has also increased the need forsome type of daytime child care. At one time, stay-at-home mothers depended on grandmotherswhen they needed child care. Now, grandmothersmay be hundreds of miles away and may be work-ing themselves.

To meet the needs of sick children, some day-care centers have separate areas. Also, some day-care centers specifically for sick children have beenset up either independently or in pediatric wards ofhospitals.

Among some employers, day care has become acorporate responsibility. A day-care center in themother or father’s place of employment solvestransportation problems and allows the parent tovisit with the child during the day. The Stride RiteCorporation in Cambridge, Massachusetts, is anexample of a company that started a program thatcombines for care small children and elderlydependents of employees in the same facility.

Studies of the effect of day care on childrenhave not shown that children suffer any real diffi-culties from participation in day care and that, insome cases, children from deprived backgroundsbenefit from day care; however, putting children inthe hands of CAREGIVERS may lessen the extent towhich mothers can influence their child with theirown values and standards.

Day Care for the Elderly

At the end of the 20th century, a trend in day carehas been the establishment of facilities for care ofelderly persons, whose condition does not necessi-tate institutional care, but who need assistance thattheir family cannot provide during the day.Although many midlife children experience thestress of guilt about placing an elderly parent inday care, they understand that there are benefits.For example, senior day care offers socialization,learning opportunities, and encouragement of bet-ter nutritional patterns for the midday meal.

See also AGING; DIVORCE; ELDERLY PARENTS; WORK-ING MOTHERS.

SOURCES:Deutsch, F. “Day Care Centers.” In Corsini, Raymond, ed.,

Encyclopedia of Psychology. Vol. 1. New York: Wiley, 1984.

110 day care

Edmundson, Brad. “Where’s the Day Care?” AmericanDemographics 12 (July 1990): 17–19.

Gallo, Nick. “Too Sick for School?” Better Homes and Gar-dens, September 1990, 62–65.

Kantrowitz, Barbara. “Day Care Bridging the GenerationGap.” Newsweek, July 16, 1990, 52.

daydreaming When people daydream, they areawake and experiencing a pleasant reverie, usuallyof wish fulfillment. Daydreaming occurs duringidle moments or when people are unconcernedabout the activity around them. In these ways,daydreaming, which may be a form of stress relief,differs from serious, logical, and controlled think-ing which is done in a more deliberate manner.

Some people may daydream about developinggreat ideas or inventions, or taking new directions inlife; in daydreaming, their mind is free to roam with-out inhibition and self-censorship. Different views ofwork and family situations are often developed dur-ing moments of daydreaming, because daydreamsare usually concerned with ends, not means.

People of all ages daydream. Young and old maybe caught staring out the window, putting down abook and gazing at nothing in a trance-like state.Unless they share their dream, it is difficult to tellif they are lost in their reveries or just bored.

See also BOREDOM; CREATIVITY.

deadlines Most people have experienced stress inmeeting or failing to meet a date or time at whichsomething must be done. Once they have fallenbehind, it is difficult to catch up. They find thatrushing tends to add to the stress and decreaseeffectiveness. Ineffectiveness leads to frustration.Some people become moody and emotional andblame themselves or others for the deadline failure.

The key to avoiding the stress produced bydeadlines is setting realistic time schedules, enlist-ing the help needed when deadlines go awry, andnegotiating new deadlines when it appears that,for one reason or another, deadlines are going tobe missed. For individuals to keep a positive out-look, they should break deadlines down to a seriesof small steps. As each step is completed, they willfeel some success, and that success, in turn, willkeep them motivated toward their final goal.

See also AUTONOMY; CONTROL; WORKPLACE.

deafness Loss of hearing, either complete or par-tial. Hearing loss becomes a stressor for many indi-viduals who begin to lose their hearing and try todraw attention away from their loss or cover it up.While hearing aids help many individuals, some areembarrassed to wear them or find them uncomfort-able. Some people associate loss of hearing withAGING, and hence postpone getting a hearing aid topreserve their image of youthfulness.

Deafness and hearing loss is a major societalproblem. Estimates are that about a quarter of amillion persons in the United States are completelydeaf, and about three million have major hearingproblems.

Causes of Hearing Difficulties

Hearing difficulties are related to many things,including problems within the ears themselves,overall body health, emotions and external envi-ronment. People tend to shut off certain sounds atcertain times and will hear only what is interestingor significant. For example, a man may hear all ofa sports newscast but not hear a request to fixsomething around the house. In some nursinghomes, it has been observed that individuals saythey cannot hear, but when asked whether theywant ice cream they are able to answer. The termpsychogenic deafness pertains to such mental “shut-ting off” of hearing carried to an extreme. Somepatients may have such a strong subconsciousdesire not to hear that they become completelydeaf, yet have physically normal ears.

The term psychosomatic deafness relates to situationsin which actual physical deterioration occurs in theear as a reaction to a mental or emotional problem.There also may be combinations of both physical andpsychologically induced hearing difficulties.

See also DISABILITIES.

FOR FURTHER INFORMATION:American Speech-Language-Hearing Association10801 Rockville PikeRockville, MD 20852(800) 638-8255; (800) 638-TALK

SHHH (Self-Help for Hard of Hearing People, Inc.)7910 Woodmont Avenue, Suite 1200Bethesda, MD 20814(301) 657-2248

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death One of the most stressful life experiences isthe death of a spouse, parent, child, close relative,or beloved friend. Another serious source of stressis when we are told that our own death is immi-nent. On a scale of life-stressing events, death ratesa top position. People of all ages fear death as wellas the process of dying.

Included in the specific sources of stress relatedto death are shock, GRIEF, necessity for makingfuneral arrangements, and perhaps the practicali-ties of handling the deceased person’s personalaffairs. How people deal with the stressors broughton by another’s death vary. Many factors influenceindividual responses. For example, when a seriesof losses have occurred or if the death is suddenand unexpected, the reaction may be moreextreme. If the deceased had been ill and the sur-vivor regards the death as the loved one’s libera-tion from pain and suffering, the grief may besomewhat tempered with those thoughts,although the loss nevertheless creates an irreplace-able void in the survivor’s life.

Making funeral arrangements is extremelystressful. In the midst of extreme emotionalupheaval, the survivor is faced with choosingfuneral arrangements, selection of a casket, heavyexpenses, and contacting friends and relatives.Calling upon relatives or friends to assist in thesetasks can lighten the burden.

The stress of making funeral arrangements canbe alleviated somewhat by developing a pre-needplan, which may include selection of type offuneral and burial, selection of casket, and writtenwishes for a service. In some cases, the individualherself/himself makes these arrangements, whilethese arrangements can also be made by anotherwhen a death seems imminent. Making thesearrangements ahead of time relieves some of thestress during a heavily emotion-laden time.

Mourning, the period of grief that follows theloss of a loved person, is a stressful period. Themourner may have a period of feeling numb. Grad-ually, one’s personality reestablishes itself, but dur-ing mourning the intensity of grief may lead topsychological disturbances, such as depression, andphysiological disturbances, such as headaches ordigestive disturbances. The mourner may with-draw from others and be almost completely preoc-

cupied with thoughts of the loss, spending a greatdeal of time recalling experiences, meanings, andthe emotional significance of the lost relationship.

To help a grieving person, friends shouldencourage the survivor to express emotions andtalk about the deceased. It is important for the sur-vivor to maintain adequate nutrition and do somephysical exercise during the grief process. A strongbody contributes to clearer thinking and animproved emotional state. Encourage the person tostay involved with family and friends and to recon-nect with familiar routines and interests.

Those who have lost a spouse need to begin tolearn to do the things for themselves that theirspouse may have done before. This may meanlearning new skills, such as cooking, maintainingthe car, balancing the checkbook, and paying thebills. As one does these things, a new and healthysense of mastery over life can be gained.

When facing the stressors brought on by thedeath of a loved one, many people find relief intheir personal faith, PRAYER, or SUPPORT GROUPS.

Facing One’s Own Death

When one is faced with the fact of his ownapproaching death, reactions, and sometimes thoseof family members, may follow a pattern. Manypeople go through a serious of emotional stages atsuch times. The initial reaction is denial, whichusually lasts a short time in a mentally healthy per-son. After the initial shock, the patient becomesangry and asks, “Why me?” If these feelings cannotbe expressed, the anger may turn inward and thepatient may become extremely depressed. Thenext stage is negotiation, and one may try to makea deal with the doctors or with his or her God hop-ing that if he or she cooperates or devotes time tonoble causes, he or she will survive. As the patientbecomes aware that demise is inevitable, he or shewill admit what is happening and either give up tohopelessness or try to discover some sense ofmeaning and purpose. Next comes a stage of com-mitment, characterized by acceptance; at thispoint, many patients find new courage. As deathnears, one has either a sense of fulfillment or afeeling of forlorness and depression. If one has ade-quately worked through the first stages and reactswith fulfillment, one’s last moments can be peace-ful and tranquil.

112 death

Ethical, Moral, and Legal Aspects

Death is an ethical and legal issue and how peopledie can be stressful for health care professionals aswell as the individuals concerned and their fami-lies. Some patients who are near death may ask fora death-inducing potion or instrument. Physiciansare stressed by the dilemma of providing assistancein such cases. There have been instances in whichfamily become involved in a loved one’s death,sometimes incriminating themselves in subsequentunpleasant legal situations. The question ofassisted suicide is both a moral and legal issue.

Legal definitions of death vary, causing stress forfamily members, physicians, lawyers, and courts.At one time death was simply when the heartbeatand breathing stopped. Now it is recognized thatthe brain is the basis for life. People whose heartsand lungs have stopped working can be main-tained for years on machines, but no one is really“alive” when they are brain dead. Brain deathmeans an unconscious state, in which the personhas no reflexes and cannot breathe or maintain aheartbeat. The electroencephalogram (EEG) of theperson would be flat, without any regular oscilla-tions indicating function of the brain. Brain deathoccurs naturally within a few minutes after theheart stops, because oxygen necessary for life is notcarried through the blood to the brain.

In most states a physician must certify death,and indicate the time, place, and cause. In somecases, circumstances of death play a major role ininsurance payments; when there are suppositionsof homicide or SUICIDE, the death takes on addi-tional stressful dimensions for the family.

In the latter part of the 20th century, many indi-viduals choose the place for their death. Some whohave terminal illnesses opt to go home, rather thanstay in the hospital with its impersonal surroundings.

Advance Directives and Dying with Dignity

While medical science has created ways to prolonglife even in terminal cases, an increasing numberof people are beginning to take charge of their owndeaths by advance directives so that they will notbe kept alive on respirators or by other artificialmeans. On these legal documents, they can specifythe types of life support systems they do and do notwant. For example, one man may say he will not

tolerate being tube-fed when he can no longerkeep food down in the normal way, while anotherwill want nutrition provided but not assistance inbreathing. This permits a physician to omit heroictreatment efforts without civil or criminal liability.

“Dying with dignity” is a phrase that gainedpopularity during the 1980s and 1990s when hightechnology enabled health care practitioners tomaintain terminally ill people on life support sys-tems. Wanting to “die with dignity,” individualscan plan ahead by executing a document known asan advance directive, in which they make treat-ment wishes known while still healthy. In 1991,the federal Patient Self-Determination Act wasenacted, under which health care providers mustgive patients information about advance directives,including living wills and durable power of attor-ney for health care.

Living will. A living will allows people to specifywhen and under what conditions they want treat-ment to be withheld, should a terminal illness besuffered. They can spell out, for example, that if anirreversible coma occurs, they do not want heroiclifesaving measures to be taken. In some states, theliving will must be signed by the person executingit, as well as two witnesses who are at least 18years old.

When the physician determines and notes in themedical record that the patient has met four specificconditions, a living will goes into effect. The fourcriteria are that the patient has a condition that isterminal, incurable, and irreversible, and death isimminent. Additionally, some state laws regardingliving wills do not recognize the withdrawal ofhydration and nutrition. Individuals who do notwish fluids and nutrition to be administered whenthey meet the four conditions required for a livingwill, either cross those items off from the living willdocument or execute a durable power of attorneyfor health care, spelling out this wish.

Durable power of attorney for health care. This doc-ument allows people, as principals, to appointanother person, known as the agent, to make med-ical care decisions in case they become mentally orphysically incompetent. The document permitsone to determine at what point the power of attor-ney becomes effective and the scope of the agent’sdecision-making powers. Durable powers of attor-

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ney enable people to give very specific directionsabout what treatment they want and do not want.

Advance directives may be revoked at any timewhile one is still competent. If it is necessary torevoke a durable power of attorney after individualsbecome incapacitated, legal action may be neces-sary. Advance directives become part of the perma-nent medical record. However, health care providersare not bound to carry out an advance directive thatconflicts with state legislation, and it is important forconcerned individuals to check the laws of eachstate involved for optimal peace of mind.

See also END-OF-LIFE CARE.

SOURCES:Kübler-Ross, Elisabeth. On Death and Dying. New York:

Macmillan Company, 1996.Logue, Barbara. Last Right: Death Control and the Elderly in

America. New York: Lexington Books, 1993.

decision making Some decisions are made easily,while others are arrived at after considerable strug-gle. Decision making is stressful because it involvesaddressing alternatives, options, and possibilitiesfor reassessment at a later time.

The most important decisions people can makeusually focus on their health and well-being, affectother people, involve large amounts of money, andrequire risk taking. Because many people areuncomfortable taking risks, doing so many gener-ate stress and, in turn, that stress can interfere withmaking the best decisions.

Information used in making decisions isextremely important. How people perceive a situa-tion, past experiences with like situations, as wellas their own background and culture, play a largepart in the decision-making process. Problems mayoccur when complete information is not gatheredor not carefully analyzed in terms of where it is hascome from.

See also COPING; GENERAL ADAPTATION SYNDROME.

defense mechanisms Part of an unconscious men-tal process that individuals use to reach compromisesolutions with stressful problems. Individuals have awide variety of defense mechanisms, ranging fromprojection, which is blaming someone else for one’ssituation, and rationalization, which is justifyingquestionable behavior by defending its propriety, to

sublimation, which is rechanneling energy into cre-ative projects. DENIAL is another defense mechanism.The presence of pathological denial (for example, ofa drinking problem) is often seen in people withalcoholism or substance abuse problems.

In cases of extreme child abuse, dissociation(splitting of one’s mind from the physical circum-stance) becomes a defense mechanism. Whiledefense mechanisms can be helpful in coping withdaily life, excessive use of such devices anddependence on them can lead to higher levels ofSTRESS for the individual.

In follow-up studies of the Harvard Universityclass of 1934, Dr. George Vaillant found that,though virtually all of his subjects had significantlife crises, those who overcame them tended tohave “mature” defenses such as suppression (thecapacity to focus on only the most important issueat the time, suppressing thought or worry aboutother problems until the one of high priority issolved) and a good sense of HUMOR. Those whowere overwhelmed by the stresses of life crisestended to employ “less mature—more primitive”(blaming others) and denial (not admitting thepresence of a problem to oneself).

See also COPING; GENERAL ADAPTATION SYNDROME.

defibrillators (automated external defibrillator;AED) Portable devices used by emergency med-ical personnel on cardiac arrest victims. In recentyears the portable devices have been available inmany public places, including office buildings, air-ports, and restaurants. The availability of thedevices relieves stress for some persons who mayfear having a cardiac arrest while they are far fromhelp. More than 80 percent of cardiac arrests occurin the home, with 60 percent of them witnessed bya family member or others. The potential for sav-ing lives with home AEDs is huge.

In November 2002, the U.S. Food and DrugAdministration (FDA) approved an AED designedby Phillips Electronics for home use. Also, since2004 Medicare has covered the cost of home AEDsfor individuals with certain heart conditions.

Each year about 250,000 Americans collapseand die of cardiac arrest; the survival rate is about5 percent. During cardiac arrest, the rhythm of theheart suddenly becomes erratic and the heart can-

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not pump blood effectively. A defibrillator canrestore the heart’s normal rhythm with a jolt ofelectricity, but must be used within the first fewminutes of collapse. The AEDs have voice cues andvisual prompts. They deliver a shock only if theydetect a life-threatening heart rhythm.

A study of use of AEDs is underway by theNational Heart, Lung and Blood Institute.

See also HEART ATTACK.

FOR FURTHER INFORMATION:National Heart, Lung and Blood Institute9000 Rockville PikeBuilding 31#5A52Bethesda, MD 20891-2486(301) 496-5166(302) 402-0818 (fax)http://www.nhlbi.nih.gov

denial A DEFENSE MECHANISM in which individu-als do not admit to themselves that a problem orevent produces STRESS and ANXIETY. Additionally, adenial of a situation by some people can be asource of stress to others.

See also CHRONIC ILLNESS; COPING; ELDERLY PAR-ENTS; GENERAL ADAPTATION SYNDROME.

dentists Many people experience stress whengoing to a dentist or even thinking about it. In fact,many people are so fearful of dentists and dentistrythat they wait until they have a severe toothacheor other dental problem before seeking help.

Stress relating to dentistry is fairly common.According to the American Dental Association,35,000,000 Americans experience moderate tohigh anxiety about dentistry. Estimates are thatpossibly 12,000,000 people experience such severeanxiety that they avoid going to the dentist, somefor many years.

Some people may have had bad experiences in adental chair as a child and developed a fear of den-tistry. Others are afraid of pain and blood, of havinga shot, or of the sound of the dentist’s drill. Othersfear being out of CONTROL while seated in the dentalchair. Some are truly dental phobics and experiencequeasy feelings in their stomach, trembling hands,sweaty palms and increased pulse rate; others mayfear having a panic attack while in the chair.

Fears surrounding dentistry that are most fre-quently expressed by individuals include (indescending order) the injection needle, seeing thelocal anesthetic syringe, feeling vibrations from thedrill in their mouths, the dentist using a probe toexamine their teeth, seeing the dentist walk in,being taken into the dental chair, hearing the drillsounds while in the waiting room, entering thewaiting room, driving to the dentist’s office, seeingthe calendar showing one day left before anappointment, calling for an appointment, and beingreminded that a dental appointment is needed.

Managing Dental Stress

Many people overcome their stressful feelings withcomplete explanations of procedures that will bedone, how anesthetics will be administered, and ofhow long the procedure will take. Knowing thatthey can ask the dentist to stop a procedure for amoment helps many people feel more CONTROL

about their situation. Some individuals choose touse deep BREATHING and RELAXATION techniques,including their own audio tapes, BIOFEEDBACK

devices, or HYPNOSIS. BEHAVIOR THERAPY helps manywho are phobic about dentistry.

See also ANXIETY DISORDERS; PANIC ATTACKS AND

PANIC DISORDER; PHOBIAS.

FOR FURTHER INFORMATION:American Dental Association211 East Chicago AvenueChicago, IL 60611(312) 440-2500

depression A mood or AFFECTIVE DISORDER char-acterized by a wide range of symptoms, includinghopelessness, helplessness, personal devaluation,and extreme sadness. Some depressions aremarked by extreme stress, anxiety, withdrawalfrom others, and changes in sleep patterns. Theperson suffering from depression may exhibitlethargy or agitation, loss of appetite or compulsiveeating, loss of sexual desire, an inability to concen-trate and make decisions, exaggerated guilt feel-ings, and thoughts about SUICIDE.

Depression causes stress for family members aswell as the sufferer. Symptoms may change orincrease over days or weeks. Depressed personsmay withdraw from human contact but not admit

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to symptoms. Others are so disabled by their con-dition that they cannot call a friend, relative, ormedical help. If another person calls a doctor forthem, they may refuse to go because they do notbelieve that they can be helped. Many depressedpersons will not follow a doctor’s advice, and mayrefuse help and comfort. Persistence on the part offamily and friends is essential, although stressful,because in many cases depression is the illness thatunderlies suicide.

Defining Depression

The term depression applies to a condition on a con-tinuum of severity; it can be a temporary moodfluctuation, a symptom associated with a numberof mental and physical disorders, or a clinical syn-drome encompassing many symptoms, such asmajor depression or dysthymic disorder.

Clinical depression refers to a depression that lastsfor more than a few weeks or includes symptomsthat interfere with job performance and the abilityto handle everyday decisions and routinely stressfulsituations. Clinical depression is a term that overlapswith the terms major depression, dysthymia, unipolardepression, and exogenous depression.

SEASONAL AFFECTIVE DISORDER. Some individualshave mood symptoms related to changes of season,with depression occurring most frequently duringwinter months and an improvement in the spring.Many of these individuals experience periods ofincreased energy, productivity, and even euphoriain the spring and summer months. This type ofdepression often responds well to light therapy.

Melancholia. Melancholia is a severe form ofdepression that may originate without any precip-itating factors, such as stress. This is in contrast toa reactive depression, which occurs after somestressful life event such as loss of a job or divorce.

Age of Onset and Incidence

People of all ages can become depressed, althoughmajor depressive episodes peak at age 55 to 70 inmen and at age 20 to 45 in women. About 20 per-cent of major depressions last two or more years,with an average of eight months. About half ofthose experiencing a major depression will have arecurrence within two years.

Estimates are that 2 percent to 3 percent of menand from 4 percent to 9 percent of women in the

United States suffer a major depression. The life-time risk may be as high as 10 percent for men and25 percent for women. Unfortunately, about 66percent of those who suffer from depression fail torecognize the illness and do not seek treatment.

Some individuals may have only one episode ofclinical depression during their lifetimes. Others haveepisodes that are separated by several years or sufferclusters of episodes over a short time span. Betweenepisodes, such individuals function normally. How-ever, 20 percent to 35 percent of sufferers havechronic depression that prevents them from func-tioning totally efficiently. For these people, it is arecurrent disorder that may require maintenance onmedication to prevent additional episodes.

Depression in Older Adults

Of the nearly 35 million Americans age 65 and older,an estimated 2 million have a depressive illness(major depressive disorder, dysthymic disorder, orbipolar disorder) and another 5 million may havesubsyndromal depression, or depressive symptomsthat fall short of meeting full diagnostic criteria for adisorder. Subsyndromal depression is especially com-mon among older persons and is associated with anincreased risk of developing major depression. In anyof these forms, however, depressive symptoms arenot a normal part of aging and are a constant sourceof stress. In contrast to the normal emotional experi-ences of sadness, grief, loss, or passing mood states,they tend to be persistent and to interfere signifi-cantly with an individual’s ability to function.

Depression often occurs with other serious ill-nesses such as heart disease, stroke, diabetes, can-cer, and Parkinson’s disease. Because many olderadults face these illnesses as well as various socialand economic difficulties, health care professionalsmay mistakenly conclude that depression is a nor-mal consequence of these problems, an attitudeoften shared by patients themselves. These factorstogether contribute to the underdiagnosis andundertreatment of depressive disorders in olderpeople. Depression can and should be treatedwhen it occurs along with other illnesses, becauseuntreated depression can delay recovery from orworsen the outcome of these other illnesses.

Research has revealed varying patterns of clin-ical and biological features among older adultswith depression. As compared to older persons

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whose depression began earlier in life, those whosedepression first appears in late life are likely to havea chronic course of illness. Additionally, there isgrowing evidence that depression beginning in latelife is associated with vascular changes in the brain.

Both antidepressant medications and short-term psychotherapies are effective treatments forlate life depression. Existing antidepressants areknown to influence the functioning of certainneurotransmitters in the brain. The newer med-ications, chiefly the selective serotonin reuptakeinhibitors (SSRIs), are generally preferred over theolder medications, including tricyclic antidepres-sants (TCAs) and monoamine oxidase inhibitors(MAOIs), because they have fewer and less severepotential side effects. Both generations of medica-tions are effective in relieving depression,although some people will respond to one type ofdrug, but not another.

According to the National Institute of MentalHealth, research has shown that certain types ofshort-term psychotherapy, particularly cognitive-

behavioral therapy and interpersonal therapy, areeffective treatments for late life depression. Addi-tionally, psychotherapy alone has been shown toprolong periods of good health free from depres-sion. Combining psychotherapy with antidepres-sant medication, however, appears to providemaximum benefit.

Causes of Depression

Many factors can lead to depression, including afamily history of depression, psychosocial stressors,diseases, alcohol, drugs, and anxiety disorders.Individuals who have personality disorders, espe-cially obsessive-compulsive, dependent, avoidant,and borderline personality disorders, may tendto be more susceptible to depression than otherindividuals.

Psychosocial factors. Depression can come from anindividual’s lack of confidence in his or her inter-personal skills, overdependency on others, perfec-tionism, unrealistic expectations, and psychosocialevents, such as the death of a spouse, loss of a job,or, for some, the stresses of urban living.

Environmental influences. Researchers viewdepression as the result of an interaction of envi-ronmental and biological factors. Historically,depression has been viewed as either internallycaused (endogenous depression) or externallyrelated to environmental events (exogenous orreactional influences). Major changes in the indi-vidual’s environment, such as a move or jobchange, or any major loss, such as a divorce ordeath of a loved one, can bring on depression.Feeling depressed in response to these changes isnormal, but when depression lasts over one monthand interferes with effective functioning, treat-ment can be helpful.

Some environmental factors relating to depres-sion include being unemployed, elderly, alone,poor, and having financial problems.

Illness. Psychological stressors caused by chronicillness can lead to depression. For example, a debil-itating disease that severely restricts usual lifestyleor any illness that impinges on cerebral function-ing and impairs blood flow to the brain can pro-duce depression. Such illnesses may includeadrenal cortex, thyroid, and parathyroid dysfunc-tions, and many neurologic, metabolic, and nutri-tional disorders, as well as infectious diseases.

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SIGNS AND SYMPTOMS OF DEPRESSION

Psychological• Loss of interest• Unexplained anxiety• Inappropriate feelings of guilt• Loss of SELF-ESTEEM

• Worthlessness• Hopelessness• Thoughts of death and suicide• Tearfulness, irritability, brooding

Physical• Headache, vague aches and pains• Changes in appetite and changes in weight• Sleep disturbances• Loss of energy• Psychomotor agitation or retardation• Loss of libido• Gastrointestinal disturbances

Intellectual• Slowed thinking• Indecisiveness• Poor concentration• Impaired memory

Medications. Some medications can cause depres-sion. For example, during the 1950s, doctors learnedthat some people taking reserpine, a medication forhigh blood pressure, suffered from depression. Sincethen, depression has been noted as a side effect ofsome tranquilizers and hormones and, of a numberof medications. However, alcohol is more likely tocause depression than any medication.

Social learning theory. Stress can disrupt involve-ment with others, resulting in less positive rein-forcement, which in turn leads to more negativeself-evaluation and a poor outlook for the future.Depressed people view themselves and their worldnegatively; this leads to a further sense of low self-worth, feelings of rejection, alienation, depend-ency, helplessness, and hopelessness.

Cognitive theory. Unrecognized negative attitudestoward oneself, the future and the world can resultin feelings of failure, helplessness, and depression.Especially under stress, such attitudes may activatea prolonged and deepening depressive state. Nega-tive attitudes are usually distorted; learning whatthey are can help reverse both depression and atendency for future depression.

Interpersonal theory. This theory emphasizes theimportance of social connections for effective func-tioning. An individual develops adaptive responsesto the psychosocial environment at an early age.When early attachment bonds are disrupted orimpaired, the individual may be vulnerable lateron to depression. An example is a young child wholoses a parent to death or through divorce.

Psychoanalytic theory. A psychoanalytical positionregarding depression is that a loss, or a real or per-ceived withdrawal of affection in childhood, maybe a predeterminant for depression in later life.

Other theories suggest that unrealistic expecta-tions of self and others and loss of self-esteem areessential components leading to depression.Depression that arises following a loss may resultfrom failure to fully come to terms with the realityof the loss.

Genetic factors. Some individuals may be biologi-cally predisposed to develop depression, based ongenetic factors that researchers do not yet fullyunderstand. There are genetic markers that indi-cate susceptibility to manic-depressive illness, andthere has been considerable research in the lastdecades of the 20th century focused on under-

standing the biochemical reactions influenced bythese genes.

Evidence indicates that depression runs in fami-lies; among more severe depressives, family is amore significant factor. For example, if one identi-cal twin suffers from depression or manic-depres-sion, the other twin has a 70 percent chance of alsohaving the illness. Research studies looking at therate of depression among adopted children supportthis finding. Depressive illnesses among children’sadoptive family have little effect on their risk for thedisorder; however, among adopted children whosebiological relatives suffered depression, the disorderis three times more common than the norm.

Neurotransmitter theory. Recent research indicatesthat people who have depression have imbalancesof NEUROTRANSMITTERS, natural biochemicals thatenable brain cells to communicate with each other.Biochemicals that often are out of balance indepressed people include SEROTONIN, NOREPINEPH-RINE, and dopamine. An imbalance of serotoninmay cause anxiety, sleep problems, and irritability.An inadequate supply of norepinephrine, whichregulates alertness and arousal, may contribute tofatigue and lack of motivation. Dopamine imbal-ances may relate to a loss of sexual interest andinability to experience pleasure. Researchers con-tinue to find other neurotransmitters that may beimportant in clinical depression.

Cortisol. Another body chemical that may be outof balance is cortisol, a hormone produced by thebody in response to extreme cold, fear, or anger. Inmost people, cortisol levels in the blood peak in themorning, then decrease later in the day. In peoplewho have depression, however, cortisol peaksearly in the morning and does not level off ordecrease in the afternoon or evening.

Psychotherapies for Depression

Estimates are that between 80 percent and 90 per-cent of all depressed people can be effectivelytreated for depression by a variety of types of ther-apist. In general, therapists use “talk” treatment totry to understand the individual’s personal andsocial relationships that may have caused or con-tributed to the depression. Depression, in turn,may make these relationships more stressful.

Psychoanalysis. Treatment of depression withpsychoanalysis is based on the theory that depres-

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sion results from past conflicts pushed into theunconscious. Psychoanalysts work to help thepatient identify and resolve past conflicts that ledto depression.

Short-term psychotherapy. In the mid-1980s,researchers reported effective results of short-termpsychotherapy in treating depression. They notedthat cognitive/behavior therapy and interpersonaltherapy were as effective as medications for somedepressed patients. Medications relieved patients’symptoms more quickly, but patients who receivedpsychotherapy instead of medication had as muchrelief from symptoms after 16 weeks, and theirgains may last longer. Data from this and otherstudies may help researchers better identify whichdepressed patients will do best with psychotherapyalone and which may require medications.

Behavior and cognitive therapy. These therapies arebased on the understanding that people’s emotionsare controlled by their views and opinions of them-selves and their world. Depression results whenindividuals constantly berate themselves, expect tofail, make inaccurate assessments of what othersthink of them, CATASTROPHIZE, and have negativeattitudes toward the world and their future. Ther-apists use techniques of talk therapy to help theindividual replace negative beliefs and thoughtpatterns with positive ones.

Electroconvulsive therapy (ECT). Use of ECT totreat depression declined in the last two decades ofthe 20th century as more effective medicationswere developed. However, ECT is still used forsome individuals who cannot take medications dueto their physical condition, or who do not respondto antidepressant medication. ECT is considered asa treatment when all other therapies have failed orwhen a person is suicidal.

If psychotherapy is not helpful or the depressionis at such a severe level that there is a loss of workor of function, or persistent and increasing suicidalideation over one to three months, medicationsmay be needed to lift the depression in conjunctionwith therapy.

Pharmaceutical Approach to Treating Depression

Effectiveness of medication depends on overallhealth, metabolism, and other unique characteris-tics. Results are usually not evident right away;antidepressant medications usually become fully

effective in about 10 to 20 days after an individualbegins taking them. Approximately 70 percent ofpatients will improve or recover while taking anti-depressant medications, but some may need tocontinue medication over a six-month or year-longperiod to prevent relapse or recurrence.

The major types of medications used to treatdepression are tricyclic antidepressants, MAOinhibitors (MAOIs), lithium, and “novel anti-depressants.”

Tricyclic antidepressants are often prescribed forindividuals whose depressions are marked by feel-ings of hopelessness, helplessness, fatigue, inabilityto experience pleasure, and loss of appetite andresulting weight loss.

Monoamine oxidase inhibitors (MAOIs) are oftenprescribed for individuals whose depressions arecharacterized by anxiety, phobic and obsessive-compulsive symptoms, increased appetite andexcessive sleepiness, or those who fail to improveon other antidepressant medications.

Lithium is sometimes prescribed for people whohave manic-depressive illness (a severe affectivedisorder characterized by a predominant mood ofelation or depression, and in some cases an alterna-tion between the two states). Sometimes it is pre-scribed for people who suffer from depressionwithout mania. Those most likely to respond totreatment with lithium are depressed individualswhose family members have manic-depression orwhose depression is recurrent rather than constant.

“Novel antidepressants.” During the 1990s, morespecifically active antidepressant drugs with lesspropensity for side effects were developed. Sero-tonin reuptake inhibitors (SRIs), for example, flu-oxetine (Prozac) and sertraline (Zoloft), are oneclass; buproprion (Wellbutrin) is another class.Many other new medications are under develop-ment to treat depression.

Anticonvulsants as antidepressants. For patientswith manic-depressive illness (bipolar disorder)where lithium is not effective, drugs used to pre-vent temporal lobe seizures are sometimes used.

Side effects of antidepressant medications. Some peo-ple experience side effects from antidepressantmedications, which in themselves may be stressful.Common side effects include dry mouth, constipa-tion, drowsiness, and weight gain; these effects

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usually diminish somewhat or disappear as thebody makes adjustments. The more recently devel-oped “novel antidepressants” have a lower inci-dence of these side effects.

Depression in Adolescents

Depression in teenagers may be somewhat differentfrom that in adults. Some adolescent symptomsmay be overlooked as part of growing up. Teenagersmay be depressed because of being in trouble, or introuble because of being depressed. Their depres-sion is sometimes linked to poor school perform-ance, truancy, delinquency, alcohol and drugabuse, disobedience, self-destructive behavior, sex-ual promiscuity, rebelliousness, GRIEF, and runningaway. They may feel a lack of support from familyand other significant people, and a decrease intheir ability to cope effectively.

Adolescence is a period of demanding and com-plicated conflicts that lead many young people todevelop anxieties, negative self-esteem, and fearsabout their future. Some develop depression whenoverwhelmed by the stresses of peer pressure, feel-ings of loneliness, powerlessness, and isolation.Low performance in school can lead to a feeling ofrejection, social expectations may be unrealistic,and conflicting messages from family may magnifystruggles for independence and assertiveness.

Contributing factors to adolescent depressionmay include exaggerated concerns, mispercep-tions, and continual self-criticism. The lack of abil-ity to embrace what life has to offer results inboredom, which may be an indicator of vulnerabil-ity to depression.

Suicide and Adolescent Depression

In 2004, the news media pointed to the apparentrelationship between certain antidepressant medica-tions and teen suicide. Some advocacy groups saythat clinical studies indicate increased suicidalbehavior in teens on antidepressants. British regula-tors banned most antidepressants for minors inDecember 2003. However, the U.S. Food and DrugAdministration (FDA) says there is no proof that thepills cause suicidal behavior in children. Still, theFDA in 2004 asked drug makers to add warnings towidely used antidepressants that instruct parentsand doctors to closely monitor patients for suchbehavioral and emotional changes as increased anx-iety, impulsiveness, or aggression.

A 2003 World Health Organization study foundthat the teen suicide rate dropped in 15 nations by33 percent in the past 15 years, coinciding with thewidespread use of antidepressant medications. Inthe United States, the suicide rate among adoles-cents dropped 25 percent during the 1990s,according to the Centers for Disease Control andPrevention (CDC).

Five widely used antidepressants dispensed tothose under age 17 in 2002 included sertaline(Zoloft), paroxetine (Paxil), bupropion (Wellbutrin),citalopram (Celexa), and fluoxetine (Prozac).

Self-help for Individuals and Their Families

Self-help and support groups allow individuals ofall ages to share ideas for effective COPING and self-care. Benefits of these groups include increasingcontacts with other people, for example, by partic-ipation in special interest groups; learning to copewith exaggerated thoughts; and following regularexercise programs.

The National Depressive and Manic-DepressiveAssociation is a national self-help organization, withchapters throughout the country that meet locallyto help members cope effectively with depression.

The Depression and Related Affective DisordersAssociation (DRADA) is a nonprofit organization

120 depression

RECOGNIZING ADOLESCENT DEPRESSION

• Sadness; feelings of helplessness or hopelessness• Poor SELF-ESTEEM and loss of confidence• Overreaction to criticism• Extreme fluctuations between boredom and

talkativeness• Sleep disturbances• Anger, rage, and verbal sarcasm; guilt• Intense ambivalence between dependence and

independence• Feelings of emptiness in life• Restlessness and agitation• Pessimism about the future• Refusal to work in school or cooperate in general• Increased or decreased appetite; severe weight

gain or loss• Death wishes, suicidal thoughts, suicide

attempts

focusing on manic depressive illness and depres-sion. DRADA distributes information, conductseducational meetings, and runs an outreach pro-gram for high school counselors and nurses.DRADA helps organize support groups and pro-vides leadership training programs and consulta-tion for those groups (see below).

See also AGORAPHOBIA; DEFENSE MECHANISMS;PHARMACOLOGICAL APPROACH; PSYCHOTHERAPIES;PUBERTY.

FOR FURTHER INFORMATION:Depression and Related Affective Disorders

Association2330 West Joppa Road, Suite 100Lutherville, MD 21093(410) 583-2919

National Alliance for the Mentally IllColonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22201(703) 524-7600

National Depressive and Manic Depressive Association

222 South Riverside Plaza, Suite 2812Chicago, IL 60606(312) 993-0066

National Institute of Mental HealthOffice of Scientific InformationPublic Inquiries Section5600 Fishers Lane, Room 15C-17Rockville, MD 20857(301) 443-4513

National Mental Health Association1020 Prince StreetAlexandria, VA 22314(703) 684-7722

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Karp, David Allen. Speaking of Sadness: Depression, Discon-

nection, and the Meanings of Illness. New York: OxfordUniversity Press, 1996.

Klerman, Gerald. Suicide and Depression among Adolescentsand Young Adults. Washington, D.C.: American Psychi-atric Press, 1986.

Mitchell, Philip B. “Is Antidepressant Prescribing Associ-ated with Suicide Rates?” Psychiatric Times xxi, no. 5(May 2004): 53–59.

Robb-Nicholson, Celeste. “Depression.” Harvard Women’sHealth Watch, March 1995, 2–3.

dermatitis Inflammation of the skin, sometimesdue to allergy, but sometimes occurring withoutany known reason. It can result in painful itchingand the distress of extreme discomfort. For someindividuals, if the itching persists without relief,dermatitis leads to a feeling of helplessness andDEPRESSION.

Many types of dermatitis are better known aseczemas, such as atopic, common in babies; num-mular, which occurs in adults, cause unknown;and dermatitis of the hand, the result of householddetergents and cleansers.

Other types of dermatitis include seborrheic,which appears on the face, scalp, and back, devel-ops during stress, and is a reaction to somethingthat comes in contact with the skin.

See also ALLERGIES; CHRONIC ILLNESS; HIVES; POI-SON IVY.

FOR FURTHER INFORMATION:American Academy of Dermatology930 North Meacham RoadSchaumburg, IL 60168(708) 330-0230

desensitization, systematic See BEHAVIOR THER-APY; PHOBIAS.

diabetes (diabetes mellitus) Disorder in whichthe pancreas produces too little or no insulin forthe body’s needs. Insufficient insulin results in anabnormally high glucose level in the blood, leadingto excessive urination, constant thirst, and hunger.When the body cannot store or use glucose, thereis weight loss and fatigue, and accelerated degen-eration of small blood vessels.

Diabetes is not contagious, although it tends torun in families. While there is no cure for it, withappropriate medical care and patient compliance,the disease can be kept under control.

Coping with the Stresses and Treatment of Diabetes

Diabetes brings with it the stresses and conse-quences of a CHRONIC ILLNESS for the individual aswell as the family. When diabetes is diagnosed,

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many highly charged feelings enter into its accept-ance. There may be ANGER, GUILT, or anxieties, bothexpressed and unexpressed, and these feelingsshould be discussed with family members. If it is achild who is diabetic, encourage discussion so thatthe child understands that having such feelings ispart of the COPING process. Stable mental health isimportant for proper control of diabetes becauseemotional stresses affect secretions of hormonesthat may counteract or interfere with the helpfuleffects of insulin.

Diabetic health care teams will have suggestionsto help individuals reduce their stress levels. Theymay suggest ALTERNATIVE MEDICINE, such as RELAX-ATION exercises and BIOFEEDBACK. They may encour-age participation in group therapy sessions withother families to learn how others cope with dia-betes. Such groups foster exchanges of helpful ideasconcerning the practical aspects of diabetes. Theymay suggest use of the “buddy system,” workingwith another diabetic to reinforce support and pro-vide a model for adjustment to life with diabetes.There are groups run by local affiliates of the Amer-ican Diabetes Association, hospitals, and communityhealth departments. Awareness of existing services isthe first step toward obtaining assistance and main-taining a good mental attitude about the disease.

The health care team of the diabetic will con-sider individual emotional needs along with menuand exercise plans, and therapy with insulin andother medications. Problems such as mishandlingthe food plan, refusing to take insulin injections,consciously overeating, and DEPRESSION occur insome diabetics, and compound their stress levels.These situations can be successfully handled withthe support of health care professionals, parents,spouses, or significant others.

The personal role in the treatment of diabetes isimportant. For example, diabetic individuals needto devote more time to personal care than mayhave been done before, particularly giving specificattention to skin, feet, and teeth, and promptlytreating minor injuries such as burns, cuts, andbruises. Keeping diabetes under control can helpdiabetics avoid later stresses such as difficulties inthe vascular system and eye and kidney disease.

Individuals afflicted with diabetes face not onlya shortened life span but also the probability of

incurring acute and chronic complications. Peoplewho have diabetes are two and a half times morelikely to suffer from strokes than those withoutdiabetes; people with diabetes are two to four timesmore likely to develop cardiovascular disease. Dia-betes is the leading cause of new cases of blindnessin adults from 20 to 74 years of age and is the lead-ing cause of end-stage kidney disease.

Prevalence, Causes, and Types of Diabetes

In the United States, about two persons per 1,000have insulin-dependent diabetes by the age of 20;the insulin-dependent form (type 1) affects about150 to 200 persons per 100,000. Non-insulin-dependent (type 2) diabetes is more common;approximately 2,000 persons per 100,000 areaffected. With age, the risk for developing diabetesincreases. People of middle or older age are morelikely to develop diabetes than younger people, andwomen are more likely to have diabetes than men.

Heredity, obesity, and stresses such as emotionalshocks, family disturbances, or surgery can lead todiabetes. Researchers have emphasized the power ofdisruptive and stressful life events as influencing thecourse of the disease. Pregnancy also places extrastresses on the body, and diabetes is often diagnosedin pregnant women or women who have repeatedmiscarriages. People who have diabetes, especiallytype 2, often have high blood pressure too.

Type 1, insulin-dependent diabetes, can occur atany age, though it most commonly occurs duringyouth. Type 1 diabetes used to be called juvenile-onset diabetes and is still called that by some healthcare professionals. About one of every 2,500 chil-dren has this disease. Because the pancreas pro-duces little or no insulin, such patients becomedependent on outside sources of insulin. The dis-ease can be controlled with insulin, proper diet,exercise, and careful monitoring.

Type 2 is non-insulin-dependent diabetes. Esti-mates are that between 60 percent and 90 percentof those with non-insulin-dependent diabetes inWestern societies are obese. Thus it is important forobese individuals to lose weight. This type of dia-betes used to be called maturity-onset diabetes andmay still be called that by some health care profes-sionals. Type 2 is much more common than type 1;more than 5 million Americans have the disease.This type is less severe than insulin-dependent dia-

122 diabetes

betes and starts more slowly. Often it can be con-trolled by diet alone or by a combination of diet,exercise and oral medication.

See also IMMUNE SYSTEM; OBESITY; SUPPORT GROUPS.

FOR FURTHER INFORMATION:American Diabetes AssociationNational Service Center1660 Duke StreetAlexandria, VA 22314(703) 549-1500(800) 232-3472 (toll-free)

National Diabetes Information ClearinghouseBox NDICBethesda, MD 20892(301) 468-2162

SOURCES:Eastman, Richard. “Prevalence of Diabetes Increasing in

U.S.” Journal of the American Medical Association, Novem-ber 2, 1995.

Kahn, Ada P. Diabetes. Chicago: Contemporary Books,1983.

Schade, David S. “The Stress Factor.” Diabetes Forecast,March–April 1982.

Diagnostic and Statistical Manual (DSM IV-R)A categorical guide for classification of mental dis-orders, first published by the American PsychiatricAssociation in 1994. DSM diagnoses can be used bycourts or schools; and although the book is usefulfor many purposes, sometimes being “labeled”according to DSM can cause extreme stress for indi-viduals and their families.

Mental disorders are grouped into 16 majordiagnostic classes, for example, anxiety disordersand mood disorders. The book is used for clinical,research, and educational purposes by psychiatristsand other physicians, psychologists, social workers,nurses, occupational and rehabilitation therapists,counselors, and other health professionals whowish to base a diagnosis of mental disorders, includ-ing anxieties and phobias, on standardized criteria.It was planned to be useful across settings includinginpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care,and with community populations.

The first DSM was published in 1952 so that allmental health-related terms would have the samemeaning across the United States. However, many

of the terms that appear as diagnostic criteria in theDSM are sometimes signs of a disorder and some-times signs of normal behavior. Thus the DSMincludes a cautionary statement saying it takesclinical training to tell the difference between dis-orderly and normal behavior.

About 350 listings range from “mild mentalretardation” to “personality disorders.” In 2005,the DSM-IV was being reviewed and revised by theAmerican Psychiatric Association. A fifth edition,the DSM-V, is slated to be published around 2010.The APA will host conferences, review literature,and conduct studies to determine if proposedchanges will be useful in intended settings.

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Washington,D.C.: American Psychiatric Association, 1994.

Cloud, John. “How We Get Labeled.” Time, 161, no. 3(January 20, 2003): 102–105.

Kahn, Ada P., and Ronald M. Doctor. Facing Fears: TheSourcebook of Phobias, Fears, and Anxieties. New York:Checkmark Books, 2000.

diaphragmatic breathing See BREATHING.

diarrhea Refers to fluidity, frequency, or volumeof bowel movements when compared with theusual pattern for a particular person. It is not a dis-order, but a symptom of a problem. In some indi-viduals, stress and ANXIETY bring on diarrhea.Individuals who have IRRITABLE BOWEL SYNDROME

may suffer bouts of diarrhea.While diarrhea may be the result of anxiety, it

also causes stress and anxious moments. The trav-eler who has a sudden attack must quickly find apublic restroom. The speaker or performer about togo onstage must take time to deal with the per-sonal emergency.

Acute diarrhea affects almost everyone at sometime, often as a result of eating contaminated foodor drinking contaminated water. Usually attacksclear up within a day or two with or without treat-ment; many effective treatments are available asover-the-counter medications. Chronic diarrheamay be symptomatic of more serious conditionsrequiring medical attention.

diarrhea 123

FOR FURTHER INFORMATION:American Gastroenterological Association4930 Del Ray AvenueBethesda, MD 20814(301) 654-2055

dieting Generally refers to following a special ormodified diet for the purpose of losing weight.Motivation to be as thin as models unrealisticallymotivates many people, particularly women, tobegin dieting. Dieting is stressful because losingweight is not easy; it means setting realistic goals.It requires time—often a year for positive results—for some people; it means hard work, both losingthe weight and keeping it off. It is also stressfulbecause many people perceive themselves as over-weight, whether this is the case or not.

Some dieting approaches involve extensivebehavior modification. These programs offer SUP-PORT GROUPS and education about good NUTRITION

and exercise. Most important, they offer help inaltering the individual’s behavior in order to limitfood intake, increase physical activity, and reducethe stress of the current social pressures to be thin.

Individuals who believe they are overweightshould have a physical examination from theirfamily physician to determine whether they areactually overweight or are weight-, shape- or food-obsessed. If overweight, further assessment is nec-essary; if not overweight, they need supportivestrategies to help them feel better about themselvesand referral to community resources to help themwith their concern.

See also BODY IMAGE; EATING DISORDERS; OBESITY.

FOR FURTHER INFORMATION:American Dietetic Association120 South Riverside Plaza, Suite 2000Chicago, IL 60606-6995(800) 877-1600 (toll-free)

Food and Nutrition Information CenterNational Agricultural Library Building, Room 304Beltsville, MD 20705(301) 504-5414

SOURCES:Ciliska, Donna. “Women and Obesity.” Canadian Family

Physician, January 1993.

Hamilton, Michael, et al. The Duke University Medical Cen-ter Book of Diet and Fitness. New York: FawcettColumbine, 1991.

Thomas, Patricia, ed. “Dieting May Be a Losing Proposi-tion.” Harvard Health Letter 19, no. 10 (August 1994).

disabilities A disability refers to a temporary orpermanent loss of faculty. It may refer to physical dis-abilities, such as loss of a leg or of hearing, or mentalcapabilities, such as retardation or autism. COPING

with a disability causes stress for the one who has thedisability and also for parents, siblings, and childrenwho face caring for the disabled person.

Persons who become disabled often strugglewith the anxiety of trying to be like everyone else.Because of their disability they may feel a loss ofSELF-ESTEEM compounded, in many cases, by thelimitations of the living situations they encounter.According to Reverend John A. Carr of theYale–New Haven Medical Center, who was bornwith the congenital absence of both hands and onefoot, “Coping with a handicap will depend on howhuman interactions occur, to allow more or lessprogress toward meaningful life.” In the book, Cop-ing with Crisis and Handicap, Reverend Carr recom-mends that open dialogue between those who aredisabled and those who are not is essentialbecause, “In denying our efforts to fight for a worldmore open to the handicapped, whether we referto architectural or attitudinal barriers, we may bedenying ourselves accessible avenues we will needlater.”

Coping with a Disability in the Family

Mary S. Challela, director of nursing and trainingat the Eunice Kennedy Shriver Center definesparental coping as “managing the day-to-day activi-ties of meeting the disabled child’s needs, the par-ents’ needs, and those of other children in thefamily, in a realistic manner. Before parents can beexpected to assume any of these tasks effectively,they must be allowed and encouraged to respondemotionally to the crisis of disability.” How parentsreact, she explains, is influenced by how and whenthey are told of the abnormality, their degree ofsocial isolation, the type and severity of the disabil-ity, social class and education, attitudes of familiesand friends, and information received from andattitudes of professionals. Parents need emotional

124 dieting

support and counseling in dealing with the initialand subsequent crises, education in learning howto care for the child’s special needs, guidance indealing with other family members, and continuedinterest and encouragement.

According to Allen C. Crocker, Children’s Hospi-tal Medical Center, Boston, there are many emo-tions generated in the sister or brother of a disabledchild, including “concern, curiosity, protectiveness,frustration, sorrow, grief, anxiety, longing, unhap-piness, jealousy, and resentment. The elements ofstress assuredly exist and are troubling to consider.”

Many professionals urge special support for sib-lings, and value the role of self-help groups for par-ents, siblings, and other family members. Suchgroups can help resolve problems and feelings,serve as a socializing agency for all concerned, andprovide a way to reach out to others in similar sit-uations. Also, these SUPPORT GROUPS provide animportant exchange of resources and often becomean important force for obtaining services throughlegislation and social pressure.

In some cases, it may be an ELDERLY PARENT whobecomes disabled. Coping mechanisms for reliev-ing the stresses of the situation include obtainingprofessional guidance and social support.

See also GENERAL ADAPTATION SYNDROME; PAR-ENTING.

FOR FURTHER INFORMATION:Architectural and Transportation Barriers

Compliance Board1331 F Street, NW, Suite 1000Washington, DC 20004-1111(202) 272-5434; (800) 872-2253;

(800) USA-ABLE (toll-free)

Mobility International, U.S.A.P.O. Box 10767Eugene, OR 97440(541) 343-1284

National Information Center for Children and Youth with Disabilities

P.O. Box 1492Washington, DC 20013(800) 695-0285

SOURCE:Milunsky, Aubrey, ed. Coping with Crisis and Handicap.

New York: Plenum Press, 1981.

dis-stress HANS SELYE (1907–82), an Austrian-born Canadian endocrinologist, differentiatedbetween the unpleasant or harmful variety ofSTRESS called dis-stress (from the Latin dis = bad, asin dissonance, disagreement) and eustress (from theGreek eu = good, as in euphonia, euphoria). Dur-ing both distress and EUSTRESS the body undergoesvirtually the same nonspecific responses to variousstimuli acting upon it. However, certain emotionalfactors, such as frustration and hostility are partic-ularly likely to turn stress into dis-stress.

See also COPING; GENERAL ADAPTATION SYNDROME.

SOURCES:Selye, Hans. The Stress of Life, rev. ed. New York: McGraw-

Hill, 1978.———. Stress without Distress. Philadelphia: Lippincott,

1974.

diversity Relates to any group of people that ismixed in terms of race, religion, ethnicity, or gen-der. Because diversity may be perceived as anapproach to quotas in schools or in the WORKPLACE,the concept can be a source of stress for thoseinvolved. Stress can also arise between individualsfrom diverse backgrounds because of cultural dif-ferences. Respect for, and understanding of, thesedifferences can make diversity a successful conceptin business, religious, or community activities.

Conducting diversity awareness workshops isone way in which companies have introduced theidea of valuing personal differences. However,these workshops are only a first step in creating anenvironment in which previous prejudices, amajor source of stress, will be erased and a truesensitivity to diverse employee needs will prevail.

See also ACCULTURATION; COMMUNICATION.

divorce The legal ending of a MARRIAGE and a sit-uation in which all involved experience stress.Husband, wife, children, and even grandparentsare affected by the dissolution of a marriage in thefamily. During the 1990s, about half of all mar-riages ended in divorce.

Women and men who seek divorce do sobecause they have any one or more of many stres-sors in their marriage, such as a poor sexual rela-tionship, difficulties in communicating with eachother, differences in goals, or financial problems.

divorce 125

Feelings of failure are common when a marriagebreaks up; lack of success in a marriage should notreflect on a sense of SELF-ESTEEM, but it does. Whilemany divorced individuals learn from their experi-ences and bring new insights to new relationships,some of these will end in second or third divorces.

Divorced people are commonly angry with eachother, feel that perhaps they have been exploited ortreated badly, and suspect infidelities. Dependingon what triggered the anger, it may not be easy toforget. However, if appropriately contained, one’sanger will not interfere with adjusting to a new life.

According to Ada P. Kahn, in “Divorce: For Bet-ter Not For Worse,” published by the Mental HealthAssociation of Greater Chicago, studies show thatwhen parents are unhappy, children do not feelthat keeping the marriage together on their behalfis a gift. There is no advantage for children whenparents stay in a marriage in which they are con-stantly stressed and cannot resolve basic issues.

Kahn advises telling children why you are get-ting a divorce, that it was a rational decision byboth parties, deliberately and carefully undertakenwith reluctance and with full recognition of howstressful it would be. Children have the right toknow why, with an explanation suited to their ageand level of understanding. Parents should try tocommunicate what divorce will mean for the chil-dren, specifically, how it will affect their visitingand living arrangements. They should be assuredthat they have parental support, permission to loveboth parents, and that both parents will continueto love them. Assurance that the children are notresponsible for the rupture and that they are notresponsible to heal the rupture should come fromboth parents. More complex explanations are inorder in case of desertion or abuse.

As a consequence of divorce, many children feela diminished sense of being parented, becausetheir parents are less available, emotionally, physi-cally, or both. Children may feel that they are los-ing both parents. This is an expected part of thedivorce experience. In most instances, it is tempo-rary, but in a significant number of families, unfor-tunately, it is a feeling that lasts a long time.

The most serious long-range effect is that chil-dren feel less protected in their growing-up yearsand become concerned that they will repeat theirparents’ mistakes of a failed man-woman relation-

ship. To address this issue, parents should talkabout it or be ready to talk when children askquestions. They should not continue to fight thebattles after their divorce, and should never criti-cize former mates in front of the children. Parentsshould realize that they are role models after thedivorce just as they were in the marriage.

Divorced individuals do marry again. However,according to the Center for the Family, CorteMadera, California, 60 percent of second marriagesfail, particularly if one or more of the mates bringchildren into the marriage.

DATING and meeting new people after divorcebrings stress and anxieties about acquiring a sexu-ally transmitted disease, because of the prevalenceof AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME)and STDs (SEXUALLY TRANSMITTED DISEASES).

Rebuilding life after divorce may be stressful,complicated, and difficult. The best advice is to takeone step at a time and start by choosing one stepyou really need or would like to take. Newlydivorced people can seek out resources for theirparticular needs in their community where thereare churches, synagogues, and community mentalhealth agencies that may be able to help.

Divorce differs from annulment, in which acourt declares that a marriage has been invalidfrom its beginning; reasons for annulment varyamong states and countries.

See also COMMUNICATION; COPING; SEXUALLY

TRANSMITTED DISEASES.

FOR FURTHER INFORMATION:Center for the Family5725 Paradise Drive, #300BCorte Madera, CA 94976(415) 924-5750

SOURCES:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House Publications,1992.

Wallerstein, Judith S. Second Chances: Men, Women, andChildren a Decade after Divorce. New York: Ticknor &Fields, 1989.

dizziness A feeling of being unsteady, light-headed, or faint and a sensation of spinning, turn-ing, falling in space, or of standing still while objectsaround are moving. Some individuals experience

126 dizziness

dizziness in extremely stressful situations or as aphobic reaction. People who come into contactwith an object that they fear may react with dizzi-ness, weak knees, and sweaty palms; they also mayfear fainting, falling, having a HEART ATTACK, orotherwise embarrassing themselves. Dizziness, as aresult of a PHOBIA, usually disappears when thephobic object is removed or when the person getsto a place of safety.

During a phobic reaction or a panic attack, anindividual may hyperventilate (breathe more thanthey need to). This results in a drop in the carbondioxide in the blood, causing constriction of bloodvessels in the brain, leading to dizziness or fainting.HYPERVENTILATION is sometimes caused by a physi-cal condition, but is often the result of stress, anx-iety, worry, or panic attacks.

Dizziness also may accompany seasickness.Some sailors advise keeping one’s eyes on the hori-zon to give one a steady spot to watch. In mostcases, dizziness disappears when the individual setsfoot on land. Dizziness as a result of intoxicationwith alcohol usually subsides after a period of sleep.

There are prescription drugs as well as someover-the-counter remedies available to help controldizziness. When dizziness occurs often, a physicianshould be consulted, as it may be a symptom of acondition in need of medical treatment.

See also AGORAPHOBIA; PANIC ATTACKS AND PANIC

DISORDER.

doctors See PHYSICIANS.

domestic violence Abuse of spouses, children, orparents in the home. This may take the form ofwife-battering, child abuse, INCEST, or abusing eld-ers. All of these situations are extremely stressful tothe victims as well as others in the family. Theabuser may behave violently as a response to par-ticular stressors in his or her life.

Domestic violence happens in all strata of soci-ety, and there are many more cases than officialrecords indicate because it is a subject often coveredup out of fear and shame. Characteristics of personswho are victims of family violence include ANXIETY,powerlessness, GUILT, and lack of SELF-ESTEEM.

Professionals who treat victims of family vio-lence are concerned with getting the victims, usu-

ally women or children, away from the abuser andinto therapy before the abuse becomes too severeand additional stressors arise. Some perpetrators aswell as victims of family violence compound theirdifficulties with use of alcohol or drugs.

Battered Women

Battered women are victims of physical assault byhusbands, boyfriends, or lovers. Battering mayinclude physical abuse, sometimes for purposes ofsexual gratification, such as breaking bones, burn-ing, whipping, mutilation, and other sadistic acts.Generally, however, battering is considered part ofa syndrome of abusive behavior that has very littleto do with sexual issues. Drug and alcohol-relatedproblems are more common among families withbattering behaviors. Women who select andchoose to remain in abusive relationships werealso often abused as children. Many women stay insuch relationships without reporting the abuse andwithout seeking counseling. Batterers often wereabused themselves as children.

Women who are abused by their husbands orboyfriends not only sustain injuries from physicalbeatings but also suffer from many mental andemotional scars, including POSTTRAUMATIC STRESS

DISORDER, DEPRESSION, and anxiety.Help for battered women is available. First,

physical protection, often provided by women’sshelters within the community, must be assuredfor the woman and her children. Second, socialsupport services must provide economic protec-tion, since women often stay in abusive relation-ships due to lack of practical economic alternatives.Finally, psychotherapeutic intervention should beaimed at both batterer and victim to traceantecedents of the violent behavior, correct sub-stance abuse problems, and substitute positive COP-ING mechanisms for violent behavior patterns.

Most abused women do not seek help untilbeatings become severe and have occurred over aperiod of time, often two to three years. Somewomen are too embarrassed or believe that if theyreport the beating to police they will not be takenseriously. The majority of women who seek helpbecause of family violence are between ages 20and 60. In 75 percent of households in whichabuse takes place, the husband or boyfriend is analcoholic or on drugs.

domestic violence 127

A study at the University of California, San Fran-cisco, during 1992 indicated many details about liv-ing conditions and circumstances surroundingbattered women. According to the study, the bat-tered women who were interviewed did notdepend on their violent partner for most of theirfinancial support; almost 30 percent had jobs andmany had income from families, welfare, socialsecurity, and other sources.

Among other findings, 40 percent of the womenhad to be hospitalized for injuries. One in three ofthe women had been attacked with a weapon,most often a knife or a club; four had been shot.One in 10 was pregnant when beaten; 30 percentof the group said they had been abused before theywere pregnant. In about half the cases, the hus-bands or boyfriends drank heavily or abused drugs;86 percent of the women had been beaten at leastonce before.

According to Kevin J. Fullin, M.D., St. Cather-ine’s Hospital, Kenosha, Wisconsin, as many as onein two women has suffered from an episode ofdomestic violence sometime in her life. Due tosuch a high rate, physicians and health care work-ers are developing new approaches to domesticviolence in order to increase its detection. The goalis to properly identify anyone who comes to a hos-pital with a domestic abuse situation. The woman,child, or adult who is suspected of being abused isquestioned in a nonthreatening, nonjudgmentalmanner without any other family members pres-ent. The goal of this confidential questioning is tofind the real cause of the problem and do some-thing to stop the abuse.

Battered Child Syndrome

Battered child syndrome includes rough physicalhandling by caregivers resulting in injuries to thebaby or child. This can result in failure to grow, adisability, and sometimes death of the baby orchild. Studies have shown that parents whorepeatedly injure or beat their babies and childrenhave poor CONTROL of their own feelings ofAGGRESSION, or may have been abused or psycho-logically rejected as children.

The syndrome is found among people with sta-ble social and financial backgrounds as well as inparents who are mentally unstable, alcoholic, ordrug-dependent. In most states, laws require physi-

cians to report instances of suspected, willfullyinflicted injury among young patients. When itappears that the child will continue to be battered,steps are taken to remove the child from the home.

Legal Rights of Domestic Violence Victims

Until the late 20th century, police and the legal sys-tem often viewed domestic violence as a privatematter and not a crime. Now, in many states, thepolice may arrest a batterer if there is evidence ofabuse. Civil actions might include legal separation,child custody, child support, and divorce. Onecommon civil action in cases of domestic violenceis the temporary restraining order, which involvesmaking a complaint and going to a hearing toobtain a legal document that limits how close aperson may come to a woman and her children.

A criminal complaint can be filed in addition toor instead of civil actions. A criminal complaintinvolves a police investigation, and if enough evi-dence is found, may lead to an arrest and involve-ment of the judicial system.

See also ADDICTION; ALCOHOLISM; CODEPENDENCY.

FOR FURTHER INFORMATION:Batterers Anonymous1269 North East StreetSan Bernardino, CA 92405(714) 355-1100

128 domestic violence

WHAT BATTERED WOMEN CAN DO

• Leave the scene of the abuse; stay with a friendor family member who will be supportive emo-tionally and provide a safe haven.

• To eliminate confrontation, leave the homewhen the abuser is absent.

• Take bank records, children’s birth certificates,cash, and other important documents along withclothing and personal items.

• If possible, photograph or videotape any conse-quences of abuse, such as injuries to yourself ordamage to the home. These could be importantfor possible later court proceedings.

• Call the police and file a police report. Obtainan order of protection as soon as possible.

• Seek counseling for yourself and your children;join a SUPPORT GROUP along with others whohave been victims of family violence.

National Coalition Against Domestic ViolenceP.O. Box 34103Washington, DC 20043-4103(212) 638-6388

National Council on Child Abuse and FamilyViolence

1155 Connecticut Avenue NWWashington, DC 20036(202) 429-6695

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Shannon, Kari. “Domestic Violence Detection at St.

Catherine’s.” Chicago HealthCare, December 1991.

Dossey, Larry (1940– ) Dallas, Texas, physician,lecturer, and author of Healing Words (The Power ofPrayer and the Practice of Medicine), Meaning and Med-icine (Lessons from a Doctor’s Tales of Breakthrough andHealing), and other books. Much of his writing isdirected toward helping readers relieve stress intheir lives.

He believes that American society is in the gripof a “time sickness” epidemic. He defines this as adisorder in which we feel so overloaded andstressed by schedules that our bodies rebel and werespond to all ringing bells—alarm clocks, tele-phones—as signals to get ready for action. Our bod-ies pump stress hormones, which in turn suppressimmune response. Cholesterol and stomach acidityis increased. “The end result,” he says, “is fre-quently some form of ‘hurry’ sickness, expressed asheart disease, high blood pressure, insomnia, irri-table bowel syndrome.”

About Dossey’s best selling books, a reviewer inWhole Earth Review (fall 1993) said: “Modern medi-cine is based on standardization, the assumption thatthe criteria for symptoms, prognoses and curativepractices can be measured and objectified. Individu-als with a set of symptoms are expected to be helpedby the same course of treatment, and the percentagewho will recover can be predicted. Dossey brings usquite a different perspective, one which taken to itsextreme would create a totally different and ulti-mately individualized medicine.”

Dossey emphasizes that meaning, or the signifi-cance that one attaches to an interpretation of an

event, has been overlooked in modern medicalpractice. Significant life events that are highlystressful and are known to contribute to suscepti-bility to disease, such as death of a spouse or loss ofa job, can have a very different subjective meaning.Each interpretation of a similar event will bringabout stress in different ways.

In his writings, Dossey suggests many possibleavenues toward stress reduction and relief, includ-ing PRAYER and MEDITATION. He believes that thera-pies should be judged according to their effects andunder conditions in which they work. For exam-ple, experiments with people have shown thatprayer and meditation positively affected HIGH

BLOOD PRESSURE, wounds, heart attacks, HEADACHES,and anxiety. He believes in utilizing our powers ofintuition and telepathy as well as meditation todeepen RELAXATION. Also, he encourages becomingaware of the unconscious part of ourselves in orderto summon all the healing powers within ourselvesand others, when we need them to overcomestressful situations.

Dossey suggests that prayer and standard med-ical approaches can be used together; he does notsuggest that prayer be relied on instead of othertherapies. He insists that science and religion standside by side, respecting the domain of each otherand preserving the highest aims of each.

His view of the mind is that it is not localized orconfined to the body, but extends outside it. Thissuggests that mind is capable of affecting not onlyone’s own body but also other bodies that may befar away; this lends an explanation to Dossey’sconcept of the effectiveness of distant prayer.

He has co-chaired a panel on MIND-BODY CONNEC-TIONS at the National Institutes of Health’s OFFICE OF

ALTERNATIVE MEDICINE. When referring to severaleras of medical practice, he says Era I was andremains based on the materialist theory of diseaseand its treatment. Era II discovered the mind/bodylink; it conceives mind as implicated in healing,though it understands mind as local, existing withinthe body and limited by the body’s position in timeand space. Era III medicine, he continues, expandsthis understanding by focusing on how the powersof the mind work between people.

See also ALTERNATIVE MEDICINE; FAITH; PLACEBO

EFFECT.

Dossey, Larry 129

SOURCES:Dossey, Larry. Healing Words: The Power of Prayer and the

Practice of Medicine. San Francisco: Harper, 1993.———. Meaning and Medicine: Lessons from a Doctor’s Tales

of Breakthrough and Healing. New York: Bantam/Dou-bleday, 1991.

———. Prayer Is Good Medicine. San Francisco: Harper,1996.

downsizing Refers to employee cutbacks (LAY-OFFS) and not rehiring for jobs that employeeshave vacated. Downsizing is stressful for the man-agers who make the decision as to who will go andwho will stay and for the employees who are askedto leave.

In many cases, the stress involved in downsizingleaves workers with ANGER and is a possible triggerfor DEPRESSION. To help workers avoid and/or han-dle anger, such issues as job category, seniority, andperformance must be addressed. Equally importantissues include treatment of dismissed employees,positive employee recommendations, and dealingwith surviving employees.

Most companies now consider downsizing oremployee cutbacks as a routine part of business. Asthey become more and more an everyday occur-rence, the very idea of downsizing brings stress tomany workers. In 1994, an American ManagementAssociation (AMA) survey of 713 companies showedthat 30 percent of companies reporting a downsizingplanned to repeat the exercise. Respondees gavebusiness downturn, improved staff utilization, trans-fer of production or work, automation or other newtechnology, merger or acquisition, and plant or officeobsolescence as reasons for downsizing.

With downsizing, workers at all levels areaffected, no matter how long they may haveworked for the organization, no matter how wellthey perform their jobs or how effectively theyhave managed their budgets and staffs. Of the430,000 identified jobs eliminated by AMA respon-dents since July 1988, half belonged to hourlyworkers and half belonged to salaried workers.

Signs of impending downsizing include a hiringfreeze, pessimistic budget projections, closed-doormeetings, decreasing sales, and consolidation ofoperations. Middle managers should be particu-larly alert to requests for department justificationand work plans based on budget reductions.

See also CHANGING NATURE OF WORK; JOB CHANGE;WORKPLACE.

SOURCE:Meyer, G. J. Executive Blues: Down and Out in Corporate

America. New York: Franklin Square Press, 1995.

dreams Mental activity that occurs when one isasleep. Some people enjoy their dreams while oth-ers find them stressful, particularly if they are scaryor otherwise unpleasant.

Dreaming usually involves many vivid sensoryimages, such as sight, sound, motion, touch, andeven smell or taste. For many people, dreaming atnight is a continuation of mental impressions,ideas, and thoughts from that day, and there are nodeeply hidden meanings. They may be sorting outevents from the day in a distorted way because themind is not conscious and awake. For others,images in dreams may be symbols of unconsciousthoughts that may mean nothing, or may refer tomany things. For example, for some people, watermay symbolize birth. There are individuals whobelieve that through interpretations of symbols ina dream, people can have a better understanding ofhow best to cope with life’s stresses. However,symbols are highly individual matters.

Dreaming occurs during periods of rapid eyemovement (REM) sleep, which last for about 20minutes and occur four or five times a night. SLEEP

deprivation, stress, DEPRESSION, and drug abuseoften interfere with REM time. Necessary biochem-ical changes occur at REM and non-REM times thatare essential for normal daytime functioning. Peo-ple who are awakened during periods of REM sleepusually can report their dreams clearly. Those whoawaken normally may not remember dreams at all,or only in a fragmentary way.

People have tried to give meanings to dreamsfor thousands of years. Many interpretations ofdreams have come forth, from Joseph in Egypt toSigmund Freud in Vienna. Much folklore hasdeveloped around the subject of dreams, some ofwhich may add to or relieve the dreamer’s stress.

See also JOURNALING.

FOR FURTHER INFORMATION:Association for the Study of DreamsP.O. Box 1600Vienna, VA 22183(703) 242-8888

130 downsizing

Community Dream Sharing NetworkP.O. Box 8032Hicksville, NY 11802(516) 735-1969; (516) 796-9455

SOURCES:Delaney, Gayle. Living Your Dreams. San Francisco:

Harper & Row, 1988.Faraday, Ann. The Dream Game. New York: HarperCollins,

1990.

driving See also AUTOMOBILES; RANDOM NUISANCES.

drug therapy See also DEPRESSION; PHARMACO-LOGICAL APPROACH.

durable power of attorney See DEATH.

dysfunctional family This term indicates that thedevelopmental and emotional needs of one ormore members of a FAMILY are not being met, lead-ing to STRESS for all concerned.

Research has shown that people raised in dys-functional families—where alcohol or drug abuse,emotional or physical abuse, neglect, incest, maritalconflict, or severe workaholism were present—carryvarying vestiges of these problems well into adult-hood. These issues generally surface in intimateRELATIONSHIPS and on the job. Since these are placeswhere other kinds of stress can be found, unre-solved family issues can compound the stressors.

People from dysfunctional families usually areexcellent employees. They are hard workers,dependable, resourceful, loyal, kind—attributesthat have helped them survive their earlier experi-ences. However, because people from dysfunc-tional families have often not learned to feel goodabout themselves, they may have poor SELF-ESTEEM, compensate by working longer hours thanothers, try for PERFECTION, and take on more thanthey can handle. This leads to even more stress,which impacts their job performance and physicalhealth.

Causes of Dysfunctional Relationships

Often, the basic problem is lack of COMMUNICATION

or poor communications between family members,even though they live in the same household. Anexample of a dysfunctional family is one in which

there is marital conflict between the parents thatresults in their young son showing signs of aggres-sive behavior in school. The family may come tothe attention of a school nurse because of thebehavior problems of the child, which may be asymptom of the dysfunction of the family at home.The parents may be unaware that their behavior iscausing a great deal of stress for the child.

In a dysfunctional family, there is little emphasison encouraging each child to develop AUTONOMY.An example is a family that expects its adolescentchild to obey curfew rules appropriate for ayounger child.

Dysfunctional families usually do not communi-cate constructively when they are having difficulttimes. For example, when a child becomes seri-ously ill, there may be little communication aboutthe illness between family members, and this leadsto unexpressed feelings of guilt. ALCOHOLISM andsubstance abuse tends to be a characteristic of dys-functional families, as the substance abuser cannotbe depended on to fulfill expectations.

Family therapy is helpful in improving life situ-ations for members of dysfunctional families. Intherapy, family members learn to improve theircommunication skills and learn new coping skillsto deal with everyday problems as well as majorlife events.

See also AGGRESSION; COPING; INTIMACY; PSYCHO-THERAPIES.

dysmenorrhea See also MENSTRUATION.

dyspareunia Sexual intercourse that is painful forthe woman. It causes extreme stress for both part-ners and may lead to avoidance of sexual inter-course and ultimately to the breakup of arelationship. The first step in reducing the stress ofpain during sexual intercourse for a woman is todiscuss it with her partner. For some women, psy-chological factors play a part; once the pain hasbeen experienced, the woman may fear recurrenceof the pain. This happens to some women whohave been abused as children or raped. Some ofthese women may fear pregnancy or acquiring aSEXUALLY TRANSMITTED DISEASE (STD) and are notable to relax during intercourse. Tension and anxi-ety, or a lack of adequate stimulation before actual

dyspareunia 131

penetration, may also contribute to pain duringintercourse.

SOURCE:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.

dysthymia A chronic and persistent mood distur-bance that has been present for at least two yearsand is characterized by relatively mild symptoms ofDEPRESSION, such as low SELF-ESTEEM, difficulty inconcentrating, feelings of hopelessness, loss ofappetite, and difficulty in sleeping. This distur-bance is a source of stress for the individuals and

their families, employers, and coworkers because itlimits participation and productivity.

Individuals who have dysthymia are usuallychronically unhappy. Some develop major depres-sion, improve, and then return to the milder stateof dysthymia. The coexistence of these mild andsevere forms of depression is referred to as doubledepression. This condition is treatable; help isavailable from trained social workers, psycholo-gists, and psychiatrists. In some cases, medicationsmay be prescribed.

See also AFFECTIVE DISORDERS; MOODS; PHARMA-COLOGICAL APPROACH.

132 dysthymia

Eeating disorders Eating disorders involve com-pulsive misuse of food to achieve some desiredphysical and/or mental state. They are character-ized by an intense fear of being fat and severeweight loss and may result in ill health and psy-chological impairments.

People with eating disorders may be experienc-ing stress in some aspect of their lives, which theythink will be improved by dieting in excess. Theyhave low SELF-ESTEEM and a fear of fatness. Whensufferers acknowledge their compulsive behavior,their stress is often expressed in feelings of DEPRES-SION and a wish to commit SUICIDE. Sufferers typi-cally hide their illness; when family, friends, orcoworkers discover their illness, they try to help.Typically, people with eating disorders feel theydon’t deserve to be helped, and this creates a greatdeal of stress for all concerned.

Eating disorders share common addictive fea-tures with alcohol and drug abuse, but unlike alco-hol and drugs, food is essential to human life andproper use of food is a central element of recovery.

Estimates indicate that there are 8 millionreported victims of eating disorders in the UnitedStates—7 million of them women (although thenumber of males is increasing) between the ages of15 and 30. Eating disorders can be cured when thesufferer accepts treatment; an estimated 6 percentof all reported patients die.

Anorexia Nervosa

Anorexia nervosa is a syndrome of self-starvationin which people willfully restrict intake of food outof fear of becoming fat, resulting in life-threateningweight loss. Anorexics (people who suffer fromanorexia nervosa) “feel fat” even when they are atnormal weight or when emaciated, deny their ill-ness, and develop an active disgust for food. Deaths

from anorexia nervosa are higher than from anyother psychiatric illness.

Causes of anorexia vary widely. Many anorexicsare part of a close family and have special relation-ships with their parents. They are highly conform-ing, anxious to please, and may be obsessional intheir habits. There is speculation that girls whorefrain from eating wish to remain “thin as a boy”in an effort to escape the burdens of growing upand assuming a female sexual and marital role.Another contribution to the increase in anorexia iscontemporary society’s emphasis on slimness as itrelates to beauty. This is particularly prevalent inthe fashion industry with its overly thin models.Most women diet at some time, particularly ath-letes and dancers, who seem more prone to thedisorder than other women. In some cases,anorexia nervosa is a symptom of depression, per-sonality disorder, or even schizophrenia.

Symptoms include severe weight loss, wasting(cachexia), food preoccupation and rituals, amen-orrhea (cessation of the menstrual period), andhyperactivity (constant exercising to lose weight).The anorexic may suffer from tiredness and fatigue,sensitivity to cold, and complain of hair loss.

Eating disorders sometimes result in other men-tal health disorders as well as depression. Individu-als may suffer from withdrawal, mood swings, andfeelings of shame and guilt. Both anorexics andbulimics develop rituals regarding eating and exer-cise. They often are perfectionists in habits, such asclothes and personal appearance, and have an “allor nothing” attitude about life.

Bulimia

Bulimia is characterized by recurrent episodes ofbinge eating followed by self-induced vomiting,vigorous exercise, and/or laxative and diuretic

133

abuse to prevent weight gain. Most people viewvomiting as a disagreeable experience, but to abulimic, it is a means toward a desired goal.

Another eating disorder is bulimarexia, which ischaracterized by features of both anorexia nervosaand bulimia. Some individuals vacillate betweenanorexic and bulimic behaviors. After months andperhaps years of eating sparsely, the anorexic maycrave food and begin to binge, but the fear ofbecoming overly fat leads her/him to vomit.

Bulimics may be of normal weight, slightly under-weight, or extremely thin. Binging and vomitingmay occur as much as several times a day. Insevere cases, it may lead to dehydration and potas-sium loss, causing weakness and cramps.

A Cycle of Addiction

Behaviors of anorexics and bulimics are driven bythe cycle of addiction. There is an emotional empti-ness that in turn leads to the psychological pain oflow self-esteem. The individual looks for a way todull the pain by using addictive agents (starvation orbingeing), which usually results in the need to purgeor medical problems. Finally, suffering from guilt,shame, and self-hate, the individual goes back to aroutine of starvation and/or bingeing and purging.

Treatment

Medical problems caused by the disorder should bediagnosed and managed first. When the medicalcomplications are severe, an individual may behospitalized to stabilize physical functions andmonitor nutritional intake. Often, small feedingsare carefully spaced because the patient cannothandle very much food at one time. In some cases,antidepressant medications are begun during thehospital stay.

In 2005, treatment of eating disorders can costan excess of $30,000 a month, according to theNational Association of Anorexia Nervosa andAssociated Disorders (ANAD). Many patients needrepeated hospitalizations and can require treat-ment extending two years or more. Some thera-pists believe that anorexia/bulimia is never curedbut merely arrested. However, some behavioristsbelieve that weight gain indicates a cure. There areseveral therapies used in treating the eating disor-ders; these should be discussed with the individ-ual’s therapist. A major part of therapy for eating

disorders involves helping the individual rethinkher/his perception of BODY IMAGE, because often itis perceived flaws that led to the eating disorder inthe first place.

Many people with eating disorders are treatedon an outpatient basis. There may be weekly coun-seling that includes individual and group sessionsfor outpatients and family, marital therapy, andspecialized support for eating disorders.

See also OBESITY.

FOR FURTHER INFORMATION:National Association of Anorexia Nervosa and

Associated DisordersBox 7Highland Park, IL 60035(847) 831-3438(847) 433-4632 (fax)http://www.anad.org

National Eating Disorders Association603 Stewart Street, Suite 803Seattle, WA 98101(800) 931-2237 (toll-free)(206) 382-3587(206) 829-8501 (fax)http://www.nationaleatingdisorders.org

ejaculation The emission of semen from thepenis at orgasm, usually during intercourse or mas-turbation. Ejaculation disorders are conditions inwhich ejaculation occurs before or very soon afterpenetration, does not occur at all, or in which theejaculate is forced back into the bladder. Becauseejaculation disorders interfere with the completionand enjoyment of sexual intercourse, they are verystressful for men as well as for their partners, whodo not always know how to help and may feelsome blame.

Early ejaculation is ejaculation occurring within10 to 60 seconds after penile penetration of thevagina and is also known as premature ejaculation.It is the most common sexual problem in men,often because of overstimulation or anxiety andstress about sexual performance.

Inhibited ejaculation is a rare condition inwhich erection is normal but ejaculation does notoccur. It may be psychological or it may be a resultof a complication of other disorders or drug use.

134 ejaculation

Retrograde ejaculation occurs when the valve atthe base of the bladder fails to close during an ejac-ulation. This forces the ejaculate backward into thebladder. Retrograde ejaculation may be the resultof a neurological disease or can occur from pelvicsurgery, surgery on the neck of the bladder, or aftera prostatectomy.

Treatment for ejaculation difficulties maybegin with a visit to a physician, a urologist, or asex therapist.

See also SEX THERAPY; SEXUAL DIFFICULTIES.

elderly parents By the year 2050, estimates indi-cate that the elderly population age 85 and overwill be 18.9 million, equaling those at present age65 to 69. While people are living longer, healthierlives, care for the very elderly has become a com-mon and stressful issue for society at large and forfamilies. The decision to take a more active role intheir parents’ lives is one of stress for many mid-dle-aged children.

Role Reversal

Adult children should be attentive to changes intheir parents’ judgment and ability to take care ofthemselves and their affairs. To overcome the awk-wardness of the role reversal, children should talkto their parents, find out how they perceive theircircumstances, and discuss mutual concerns. Theycan agree to explore the situation further and worktogether toward a mutually agreeable approach. Ifthe parents do not acknowledge problems, theadult children can keep the dialogue going by ask-ing how they would advise a friend in similar cir-cumstances. This technique may help everyonefocus more clearly on immediate needs and solu-tions as well as longer-range solutions.

The more elderly the parent becomes, the moredependent he or she becomes. Adult children mayface a range of other more stressful emotions, andpossibly the reappearance of long-forgotten feel-ings. In some families, they may have always feltgrateful to their parents and welcome the opportu-nity to repay them. In other families, they mayfind their parents’ dependency too stressful toaccept and feel overburdened, resentful, or guiltyabout their inability or unwillingness to help.

Taking on more responsibility for one’s parentsis an evolving process. Sometimes it may be one or

another sibling who does not want to accept thefact that the parent is becoming dependent or dif-fers with the way problems are approached. Intime, children and parents will become more com-fortable with the role reversal and move towardnew patterns of meeting everyday situations.

Physical Care

As people age, they are more susceptible to a vari-ety of physical disorders. Some conditions such asanemia often result from a poor diet or an under-active thyroid gland; both conditions can be diag-nosed and treated. Failing vision and hearing, alsothought to be attributable to old age, may be recti-fied by removing a cataract or using a hearing aid.It is necessary, but stressful, that CAREGIVERS

remain alert to signs of illness and find the time totake their elderly parent in for regular checkupsand visits to the doctor when symptoms appear.

Emotional Care

In general, the elderly as a group are as mentallyhealthy as the general population. Still, there aresome illnesses specific to this age group that canaffect their behavior, judgment, and memory. Forexample, elderly parents may be overly fearful oflosing CONTROL of what is going on around them.Symptoms may be mild, such as sadness, loneliness,irritability, or confusion, or they may be severe, suchas DEPRESSION, agitation, or delusions. Commoncauses of depression in the elderly are isolation andfeelings of not being wanted or needed. They areafraid of being a nuisance and at the same time fearbeing put away in a nursing home even more.

Elderly parents, feeling the stress of losing theirindependence, may direct their HOSTILITY towardthe adult child. Making them a part of family plansand activities, and encouraging them to attend asenior citizen or day-care centers, can provide thesocialization they need and, at the same time,make them feel like useful members of society.

Adult children should watch for mental healthsymptoms such as forgetfulness and paranoia intheir elderly parent and get appropriate help. Thereare specialists in geriatric mental health who canbe consulted.

Living Arrangements

As parents age, they may decide that it is in theirown best interest to discuss and review their living

elderly parents 135

options. Most older people, despite increased phys-ical or mental frailty, want to live independently aslong as possible. They may want to live near fam-ily members so that help with daily activities andpersonal care is at hand. While this type ofarrangement may be ideal for the elderly person, itplaces a great deal of stress and strain on the fam-ily. Others may want to live with their families,ideally in a separate part of the house where theycan maintain their independence. Two or three(maybe four) generations living under one roofcan prove to be very stressful for most families.

Today, there are many other living arrange-ments for the elderly, ranging from independentresidential living in adult communities, assisted liv-ing in apartments where some meals and healthand social programs are provided, shared housingin the elderly person’s own home or in a commu-nal living arrangement, plus skilled nursing andrehabilitation centers. Social workers usuallyadvise not rushing changes in living, unless needsare immediate and obvious.

When difficult questions such as choosing livingarrangements arise, all people, the elderlyincluded, may not be ready to make decisions.They may want more time before talking about theproblem again. Adult children should considerinvolving others, such as grandchildren, trustedfriends, or their doctor in discussions.

Advance Directives

As parents age, they may begin to think aboutDEATH and whether doctors should use life-pro-longing interventions when they are ill. Advancedirectives are arrangements that can help ease theethical dilemma of decision making when facing aparent’s major illness or prolonged disability.Advance directives are legal documents signed bythe parent that direct adult children to do what theparents desire in the matter of using life-prolong-ing medical technology.

Reducing Stress as a Caregiver

Many adult children find that they cannot copewith their elderly parents alone. They may havefew or no other family members with whom toshare the caregiving responsibilities. If there aresiblings, they may live too far away or have heavydemands on their time.

The idea of sharing responsibilities can be impor-tant for the major caregiver. It also increases thenumber of people to whom parents continue torelate. To get some ideas about available services inthe community, such as day care, meals, recreation,living arrangements, and respite help, consult thelocal Office on Aging. Many such programs featuresliding-scale fees. Additionally, community mentalhealth programs have specialists in the care of olderadults who can provide counsel and references toSUPPORT GROUPS to help share concerns and practicalapproaches.

For adult children whose parents live awayfrom them, local social workers are affiliated withnetworks that can help them arrange for long-dis-tance care.

See also AGING; DEATH.

SOURCE:Kahn, Ada P. “Becoming a Parent to Your Parents.”

Chicago: Mental Health Association of GreaterChicago, 1988.

electricity Electric current as a source of power,while necessary in modern civilization, can be asource of stress for home owners and many work-ers. Safety concerns make the presence of electricpower lines stressful for workers in construction,telecommunications, painting, pest exterminating,utilities, and many other areas of employment.

Safety procedures must be followed whileworking on or around electrical systems. Circuitsand conductors must be tested before touching

136 electricity

PREVENT FUTURE STRESS: TIPS FOR TALKING WITH AN ELDERLY PARENT

• Be patient in starting your discussion.• Set goals for each discussion. Be realistic.• Discuss his/her wishes; permit parents to main-

tain their dignity and keep a sense of control.• Use specific examples: “I’ve been concerned

about your safety at home since your neighbor,Maggie, broke her hip.”

• Suggest some options; explain advantages anddisadvantages.

• Make some specific short-term as well as long-term plans to give both of you peace of mind.

them. Wearing personal protective equipment isessential. The right tools must be used for each job.Equipment must be isolated from energy sourcesand hazards identified.

Regulations concerning electrical safety require-ments are set forth by the Occupational Safety andHealth Administration (OSHA). When these rulesare followed properly, working with electricitybecomes less stressful and less dangerous. Guide-lines by OSHA as well as many industry groups(such as the National Fire Protection Association)cover electrical standards for many industries.

Safe work practices include being sure thatoperating procedures are up to date and appropri-ate for the working conditions, evaluating circuitinformation drawings, and determining the degreeand extent of hazards. Physical barriers aroundenergy sources such as fences and insulators onconductors must be watched. Work areas shouldbe clean and dry; cluttered work areas and benchesinvite accidents and injuries.

Lightning Strikes Are a Source of Stress

Lightning causes fear and stress for many peoplebecause it is dangerous. Approximately 93 people

die each year in the United States as a result ofbeing struck by lightning. Outdoor workers face ahigh risk of suffering a fatal lightning strike. Alightning strike can injure or kill one or more peo-ple. Of those struck by lightning, 30 percent dieand 74 percent are left with permanent disabilities.Death from a lightning strike usually occurs withinone hour of injury. Most lightning strikes occuroutdoors between May and September.

Several steps can be taken to reduce the fearand stress caused by lightning. Weather forecastscan be monitored during the thunderstorm season,because lightning is present in all thunderstorms.Know that lightning often precedes rain and canstrike as far as 10 miles away from the rain of athunderstorm. Seek shelter immediately whenthunder is heard. Avoid trees or tall objects, highground, water, open spaces, and metal objects suchas fences, umbrellas, tools, and metal overhangs onbuildings and recreational areas. Remain inside avehicle; it is safe because rubber tires are noncon-ductive. When indoors, shut off appliances andelectronic devices and avoid using the telephone.Use surge protection to prevent line surges fromtraveling to equipment such as computers.

See also LADDERS.

FOR FURTHER INFORMATION:National Electrical Safety Foundation1300 North 17th Street, Suite 1847Rosslyn, VA 22209(703) 841-3229http://www.nesf.org

Centers for Disease Control1600 Clifton Road NEAtlanta, GA 33033(800) 311-3435 (toll-free)(404) 639-3311http://www.cdc.gov

electroconvulsive therapy (ECT) Also known aselectroshock therapy; a treatment that produces aconvulsion by passing an electrical current throughthe brain. It may be stressful for family members aswell as the patient. ECT is given only to carefullyselected patients (such as those who have depres-sion that is unresponsive to medications or are sui-cidal) under close medical monitoring. Individuals

electroconvulsive therapy 137

WORKING WITH ELECTRICITYWITH LESS STRESS

• Never operate an electric saw while wearingloose clothing such as long, floppy sleeves.

• Read and follow all equipment operatinginstructions. All equipment repairs and adjust-ments should be done by authorized personnel.

• Inspect work areas daily for hazards such asflickering lights, warm switches or receptacles,burning odors, loose connections, and frayed,cracked or broken wires.

• Choose proper cords and connectors, makingsure any portable cord used to power any typeof light and/or heavy-duty industrial equipmentis suitable for the equipment.

• The extension cord thickness should be at leastas big as the electrical cord for the tool.

• Calibrate all testing equipment properly.• Repair sticking switches on electrical saws right

away.• Turn off equipment when finished with each job;

disconnect energy sources.

with severe depression may be referred for thistreatment after a course of therapy with a mentalhealth professional.

Historically, ECT has been used for serioussymptoms of mental illness. ECT affects many neu-rotransmitters in the brain, including norepineph-rine, serotonin, and dopamine. It is also sometimesused to treat acute mania and acute schizophreniawhen other treatments have failed. The number ofECT treatments needed for each person is deter-mined according to the therapeutic response. Aftera course of ECT treatments, such patients usuallyare maintained on an antidepressant drug orlithium to reduce the risk of relapse. In people whoare too medically ill to tolerate medication or whoare not eating or drinking (catatonic) the treat-ment can be lifesaving. Side effects, includingmemory loss, are not uncommon. Patients mustgive informed consent to ECT.

See also DEPRESSION; PSYCHIATRIST.

electronic devices In the early 2000s, many newelectronic devices were developed and in frequentuse by consumers. While many devices are con-venient time savers, they also can cause stressbecause of misunderstanding and malfunction.

Commonly used electronic devices includeremote control devices for television sets and radios,garage door openers, cell phones, handheld personaldigital assistants, calendars and messaging systemsthat connect with computers, beepers, camera tele-phones, security cameras, fax machines, and manyothers.

See also CHANGING NATURE OF WORK; COMPUTERS;IDENTITY THEFT.

elevators Elevators are sources of stress for manypeople. Fear of riding in an elevator may influencewhere an individual works or conducts business.Severe fear can be disabling because it limits one’sactivities. Therapists treat elevator PHOBIA withmany techniques, of which the exposure therapiesare the most effective. EMPLOYEE ASSISTANCE PRO-GRAMS (EAPs) may refer an individual afraid to takeelevators for appropriate mental health counseling.

Elevators are a necessary mode of transporta-tion in multifloor workplaces. Elevator safety pro-cedures are a constant concern in all workplaces

and businesses; inspections by local authoritiestake place regularly. When electricity in a buildingis shut off for any reason, elevators are usuallyunavailable for workers, and another evacuationroute must be designated. Usually during fires ele-vators are not used, and other routes of egressmust be found.

For maintenance workers as well as passengers,there is the hazard of working or riding in a con-fined space, often with electrical and other mechan-ical equipment. For workers outside the elevatorcab, there is a risk of falling or being crushedbetween moving parts of the mechanism. There isa need for adequate lighting when working in theelevator shaft and also for wearing PERSONAL PRO-TECTION EQUIPMENT (PPE).

See also BEHAVIOR THERAPY; CLAUSTROPHOBIA;CONFINED SPACES; ELECTRICITY; EMERGENCY RESPONSE.

ELISA test (enzyme-linked immunosorbent assay)Laboratory test commonly used in the diagnosis ofinfectious diseases; a highly sensitive screening testfor evidence of the presence of HIV antibodies,considered a causative agent of AIDS (ACQUIRED

IMMUNODEFICIENCY SYNDROME.) Tests found positiveby this procedure are usually subsequently testedwith another confirmatory assay (after the late1980s, the Western blot confirmatory assay). Wait-ing for test results is a stressful time. Learning abouta positive test result causes considerable stress andincreasing dilemmas for many individuals. There-fore, appropriate counseling and expert interpreta-tion should be done before and after test results areknown.

See also CHRONIC ILLNESS; HUMAN IMMUNODEFI-CIENCY VIRUS.

FOR FURTHER INFORMATION:CAIN (Computerized AIDS Information Network)San Francisco AIDS Foundation54 Tenth StreetSan Francisco, CA 94103(415) 864-4376

SIECUS (Sex Information and Education Council of the U.S.)

130 West 42nd Street, Suite 2500New York, NY 10036(212) 819-9770

138 electronic devices

National AIDS Information ClearinghouseCenters for Disease Control and PreventionP.O. Box 6003Rockville, MD 20850(800) 458-5231

emergency response A coordinated effort to pro-vide help in reaction to an emergency or disaster inhomes, workplaces, or wherever hazard strikes.Those who respond to emergencies face the stressof floods, hurricanes, tornadoes, gas releases, chem-ical or biological attacks, chemical spills, explosions,or civil disturbances. Each year, more than 20,000emergencies involving the release or threatenedrelease of oil and hazardous substances are reportedin the United States, affecting both large and smallcommunities and the surrounding environment.Emergency response teams support local officials atwork on the front lines. Response may be to sendan ambulance or fire truck, or a team speciallytrained to confront large-scale disasters.

Often people are forced to evacuate, causingstress and anxiety for a community or a worksite.Relocation is a stressful procedure for all involvedbecause of uncertainty and disruption of routines.

See also CHEMICAL HAZARDS; ELECTRICITY; HAZ-ARDOUS AND TOXIC SUBSTANCES; TERRORISM; VIOLENCE.

emotions A range of feelings that humans expe-rience. These may include joy, happiness, sadness,gladness, despair, loving, disgust, fear, surprise, ormany others. These feelings are unique to eachindividual, and in periods of stress, many emotionsmay become evident.

Researchers say that emotional feelings beginbefore the age of two months (when the baby firstsmiles) and continue to develop as the infantadvances into childhood. Developing emotionalfeelings is an important factor in having good men-tal health in later life. Researchers have found thatlack of loving attention and a trusting relationshipduring infancy may result in emotional depriva-tion. Children who are emotionally deprived oftencrave attention and experience a great deal ofstress in COPING with their frustration.

As individuals grow older, their emotional reac-tions are influenced by past experiences. Forexample, before a job interview, there may be feel-

ings of stress and nervousness; before a happyoccasion there may be feelings of joy or gladnessmixed with the stress of not knowing what liesahead. Sweaty palms, red face, nervous tic, weakknees, or rapid heartbeat are some of the indica-tions that individuals are under stress from theiremotions.

The term “emotional problem” or “emotional dis-order” is applied to many mental health concerns;how people express their emotions is an importantaspect of mental health. For example, many emo-tional responses such as nervousness, LAUGHTER,CRYING, and elation are considered within the rangeof normal. However, when responses are out of therange of normal, such as pervasive sadness inDEPRESSION, mental health is threatened.

The term “emotional charge” refers to a stressfulbuild-up of feelings stored in the body and mind.An emotionally charged discussion is one in whichone or more of the participants have a built-upstore of emotions and “let loose” those feelings;often the feelings have nothing to do with the dis-cussion at hand.

Self-Help for Emotional Problems

Emotional Health Anonymous is a national self-help program that provides support to men andwomen who experience emotional problems andillnesses. The self-help groups of EHA use a modi-fied version of the 12 steps to recovery of Alco-holics Anonymous to help participants during andafter their crisis periods. Founded in 1970, thereare SUPPORT GROUPS throughout the United Statesas well as in other countries.

FOR FURTHER INFORMATION:Emotional Health AnonymousGeneral Service Office2430 San Gabriel BoulevardSan Gabriel, CA 91779(818) 573-5482

SOURCE:Padus, Emrika, ed. The Complete Guide to Your Emotions and

Your Health. Emmaus, Pa.: Rodale Press, 1992.

emphysema A chronic, obstructive lung diseasethat causes its victims to struggle for every breaththey take. Because their lungs have lost much oftheir natural elasticity, people suffering from this

emphysema 139

disease cannot completely exhale the carbon diox-ide that is trapped in their lungs. They experienceextreme stress as they fight to replace the stale airwith fresh oxygen. Family members who wish tobe helpful feel useless and frustrated.

Emphysema develops over time. A chroniccough, often called a “smoker’s cough,” and a gen-eral shortness of breath are warning signs ofemphysema. Sufferers do not realize they have ituntil the first signs of breathlessness appear, and bythen delicate lung tissue may have been damagedexcessively. Emphysema is a CHRONIC ILLNESS; thereis no cure.

Some people who have emphysema require useof a portable oxygen tank, making traveling com-plicated and stressful because of the need to makearrangements to replenish their supplies periodi-cally. For these individuals, because of the constantuse of oxygen, eating out in restaurants or going tomovies or concerts is also a stressful experience forthem as well as their companions.

There is no known cause for emphysema, butmost cases are related to cigarette SMOKING. Othercontributing factors are air pollution and certaindusts and fumes. The disease is not caused by agerm or a virus and it is not an infectious or conta-gious disease.

Easing the Stress of Emphysema

Physicians can prescribe medications to relieve thefeeling of breathlessness that accompanies this dis-ease. There are also medicines that help clearmucus from the lungs and that can ward off chestinfections. Also, emphysema patients can be taughtby physical therapists to use their abdominal,chest, and diaphragmatic muscles to help thembreathe more easily.

See also BREATHING.

FOR FURTHER INFORMATION:Chicago Lung Association1440 West Washington, BoulevardChicago, IL 60607(312) 243-2000

Employee Assistance Programs (EAPs) EAPs aredesigned to provide employees with help for stressfulproblems they face on or off the job; having an EAPin one’s company is an important employee benefit.

From the employer’s point of view, whatever EAPscan do to help reduce stress for the employee, helpswith the stress of running a business.

Employee Assistance Programs (EAPs) havebeen in existence for the past 50 years. Mostauthors trace their origin to the founding of Alco-holics Anonymous in 1935. In the 1960s and1970s the scope of EAPs began to include help foremployee problems such as DEPRESSION and othermental health concerns, drug abuse, DIVORCE, andother family difficulties. Since then, these pro-grams expanded to include issues such as environ-mental stress, corporate culture, managing rapidtechnological change, and retraining.

According to the Employee Assistance Profes-sionals Association (EAPA), in mid-2005, 90 per-cent of Fortune 500 companies had an EAP. In theservice industry, 68.4 percent of companies hadthem, and 100 percent of transportation and utilitycompanies had EAPs. The demand for services fromEAPs continues to increase, according to the EAPA.

How EAPs Work

While the programs are geared to identifyingemployees whose personal problems may adverselyaffect their job performance, they also take a proac-tive stance in helping employees avoid problemsbefore they occur. For example, companies are offer-ing their employees seminars on stress reduction,PARENTING, adolescents and drugs, exercise, health,and diet.

EAPs provide referrals to appropriate profes-sional services for employees and their immediatefamilies. Confidentiality is assured; most employ-ees would not use an EAP if they thought theirproblems would be revealed.

Employers implement EAPs for a variety of rea-sons. One is the skyrocketing costs related to pro-viding a medical benefits program; another is thehuge cost attributed to downtime due to employeealcohol addiction and mental illness.

See also ADDICTIONS; JOB CHANGE; JOB SECURITY;WORKPLACE.

FOR FURTHER INFORMATION:Employee Assistance Professionals Association4350 North Fairfax DriveSuite 410Arlington, VA 22203

140 Employee Assistance Programs

(703) 387-1000(703) 522-4585 (fax)http://www.eapaassn.org

empty nest syndrome Situation in which childrenhave grown up and left home; a source of stressexperienced by many middle-aged parents. Typi-cally, the syndrome seems to affect women morethan men, and particularly women whose lives havefocused on their children at the expense of engagingin activities for themselves. For these women, theempty nest syndrome can be a mild form of DEPRES-SION that occurs after the children have left. Suchwomen (and men, too, to some extent) no longerfeel needed and feel a void in their life.

On the other hand, there are many middle-agedcouples who view their children leaving homewith a sense of relief and fulfillment at havingaccomplished a major life task. Many emptynesters, particularly women, return to work, takeon volunteer activities in their community, enrollin classes, or engage in new HOBBIES for which theypreviously had no time.

See also MENOPAUSE.

enabler See CODEPENDENCY.

end-of-life care There is need for discussion andphysician education in the area of health care atthe end of life, according to a report of a study bythe Robert Wood Johnson Foundation released in1995. Persons near DEATH and their family mem-bers often experience extreme stress because of useor nonuse of medical procedures and lack of com-munication with their health care practitioners.

Also in 1995, the American Medical Associationestablished the Task Force on Quality of Care at theEnd of Life, “to aid physicians in identifying whenin the caregiving process, a transition in care needsmay occur, and to identify actions that can betaken to improve the quality of life for those facingthe end of life.”

Ethical Considerations

In a background paper, the American MedicalAssociation’s Task Force reported that end-of-lifeissues have always been fraught with problemsthat society as a whole has not yet addressed.

Through their close relationships with theirpatients, physicians continue to hold a significantrole in how people address these issues. Assumingpatients do not misunderstand the prognosis andtreatment options and they are not suffering froma treatable form of DEPRESSION, physicians in virtu-ally all cases are morally obligated to abide by thecompetent patient’s directions in the provision orstoppage of life-sustaining treatment. Physicianshave an obligation to relieve pain and sufferingand to promote dignity and AUTONOMY of dyingpatients in their care. This includes providing effec-tive palliative treatment, even though it may fore-seeably hasten death.

The AMA also is developing a working defini-tion of “futile treatment” that physicians will beable to use in consultation with patients and theirfamilies when intensive care is requested and thephysician does not believe such treatment has areasonable chance of benefiting the patient.

Euthanasia and Physician-Assisted Suicide

While competent patients generally retain autonomyin end of life decisions, this does not extend torequests for euthanasia or physician-assisted SUICIDE.Dire social implications are inherent in these issues,and they pose a serious risk of abuse that is virtuallyuncontrollable, according to the AMA backgroundpaper. Such practices are ethically prohibited. Theyare fundamentally inconsistent with the physician’srole as healer, and they could contribute to erosionof the patient/physician relationship.

Importance of End-of-Life Issues

Patients deserve full information about their clini-cal status, honest assessment of prognosis, andeducation about potential treatment options,including palliative and hospice care. Physiciansshould encourage patients to consider their atti-tudes and beliefs about health care and quality oflife prior to a crisis. They should advocate comple-tion of advance directives, a signed paper thatstates the patient’s wishes as to prolonging life. Atthe same time, medicine recognizes its responsibil-ity to take actions to enhance the decision-makingability of the medical/health care team that is eth-ically, morally, and professionally trained and canbe entrusted to provide care for patients at the endof life.

end-of-life care 141

To increase understanding and use of advancedirectives, in late 1995 the AMA took action tofamiliarize physicians with the patient guide jointlyreleased in October 1995 by the AMA, the Ameri-can Association of Retired Persons (AARP) and theAmerican Bar Association (ABA): Shape YourHealth Care Future and Health Care Advance Directives.

See also DEATH; ELDERLY PARENTS.

SOURCE:Background paper, American Medical Association,

November 21, 1995.

endogenous depression See DEPRESSION; EXOGE-NOUS DEPRESSION.

endorphins Group of substances formed withinthe body that relieve PAIN and STRESS. Endorphinshave a chemical structure similar to morphine.Since the early 1970s, researchers have understoodthat morphine acts at specific sites called opiatereceptors in the brain, spinal cord, and at othernerve endings. From this knowledge, they identi-fied small peptide molecules produced by cells inthe body that also act at opiate receptors. Thesemorphine-like substances were named endor-phins, short for endogenous morphines.

Effects of endorphins are noted, for example, inaccident victims, who feel no initial pain after atraumatic injury, or in marathon runners, who donot feel muscle soreness until they complete theirrace. In addition to their effect on pain, endorphinsare considered involved in controlling the body’sresponse to stress, regulating contractions of theintestinal wall, and in determining mood.

Addiction and tolerance to narcotic analgesics,such as morphine, are thought to be due to or tocause suppression of the body’s production ofendorphins. Withdrawal symptoms that occur wheneffects of morphine wear off may be caused by a lackof these natural analgesics. Conversely, ACUPUNC-TURE is thought to produce pain relief partly by stim-ulating release of endorphins. LAUGHTER andEXERCISE are also said to promote endorphins.

See also MEDITATION; RUNNER’S HIGH.

enuresis See BED-WETTING.

environment The stresses caused by the environ-ment are a reality of life today. In cities throughout

the United States, there is a rising number of dayswhen the Pollution Standard Index (PSI), which isa combined reading of five major pollutants—par-ticulate matter, sulfur dioxide, carbon monoxide,ozone, and nitrogen dioxide—goes beyond accept-able standards. In fact, PSI can fluctuate from as fewas three to a high well over 200 in any given year.Difficulties in breathing, runny eyes, and light-headedness, all sources of STRESS for the sufferer,are just some of the symptoms caused by bad air.

Inside the home or WORKPLACE, environmentalhazards continue to prevail. It is estimated that upto 15 percent of the population is sensitive toindoor pollutants, which may be 10 times moreconcentrated than in nearby outdoor air. Somechemicals found in and around the household andworkplace are pesticides, permanent press fabrics,gas stove fumes, car exhaust, and particleboard.Even water causes environmental illnesses; symp-toms range from mild to disabling and are oftennonspecific. Every part of the body can be affectedby flu-like headaches, muscle aches, and fatigue,or more debilitating food intolerance and centralnervous system problems such as memory loss,confusion, and DEPRESSION.

See also CLIMATE: RANDOM NUISANCES; SICK

BUILDING SYNDROME.

FOR FURTHER INFORMATION:National Safety Council1121 Spring Lake DriveItasca, IL 60143-3201(800) 621-7619 (toll-free)(630) 285-1121(630) 285-1315 (fax)http://www.nsc/org

Environmental Protection Agency (EPA) A U.S.government agency whose mission is to protecthuman health and the natural environment. Sincethe 1970s, EPA has provided leadership in envi-ronmental science, research, and education efforts.Through its many activities, the EPA reduces stressamong the public caused by potential environmen-tal toxins and AIR POLLUTION. The EPA works withother federal and state agencies, local govern-ments, and Indian tribes to develop and enforceregulations and environmental laws.

The EPA is responsible for setting national stan-dards for many environmental programs. Where

142 endogenous depression

national standards are not met, the EPA issues sanc-tions and takes steps to assist in improving environ-mental quality. The EPA also works with industriesand all levels of energy conservation efforts andvoluntary pollution prevention programs.

envy At one time or another, most people expe-rience envy, a sense that something that othershave is lacking in their lives. It is a stressful emo-tion and people usually are unwilling to admit tothis feeling.

Envy can spring from many types of RELATION-SHIPS. However, it is the situations close at hand,involving FRIENDS, relatives, neighbors, or col-leagues, that are generally more intense and gener-ate envy. An ability to imagine or identify with anadmired person’s strengths is an intellectual asset,which may enable individuals to progress and bet-ter themselves. However, it becomes negative whenthe envious person remains fixated on another per-son’s life and does not try to better his own life in aconstructive way. Low SELF-ESTEEM produces envy,which often does not improve by the attainment ofmaterial things, status symbols, or fame. Healthyself-esteem makes envy unlikely and allows for cre-ative identification with admired traits in others.

Modern American life is full of elements that cre-ate envy. For example, the mobile quality of societydeemphasizes social class and creates the feeling thatall things are possible for all people. This can createstressful feelings of FRUSTRATION, failure, and envywhen expectations are thwarted. Mass media, espe-cially TELEVISION, allows Americans to view“lifestyles of the rich and famous.” ADVERTISING playson feelings of envy with situations of “keeping upwith the Joneses.” The “Me Decade” of the 1980s,with its narcissism and “yuppie” lifestyle, created aclimate in which envy flourished. Faced with a widearray of consumer products made available by hightechnology, it is always possible for individuals tofeel that someone else has more than they do.

Because feelings of envy imply that someone isin a superior position and because most religionsregard envy as sinful, people develop various waysof masking or suppressing it. To avoid expressingenvy, some people develop superior and snobbishattitudes and gossip, criticize, or imply that the per-son to be envied is really the envious one.

See also HOSTILITY; JEALOUSY.

epinephrine Hormone secreted by the adrenalgland; also called ADRENALINE. It is a powerful stim-ulant and is sometimes referred to as the “emer-gency” hormone, as it effects the entire body.Epinephrine is responsible for reactions to FEAR

and ANGER during stressful times, such as rapidheartbeat and the feeling of nervousness and agita-tion. Release of epinephrine throughout the bodyis part of the human body’s FIGHT OR FLIGHT readi-ness response to danger or threat of danger.

As a last resort in cases of cardiac arrest, epi-nephrine is injected into the heart to start it beat-ing again.

See also NEUROTRANSMITTERS; STRESS.

ergonomics Ergonomics issues arise from partic-ular jobs and include the repetitiveness of choresand the use of body force or posture to performtasks, plus the environment in which the job isbeing done, such as poor lighting and ventilation,chair and desk heights, and level of noise. Theseissues can be viewed as stress carriers in the WORK-PLACE and may be a cause of illness and injuryresulting from job tasks.

The science of designing the job, workplace, ortask to fit the individual, rather than to force theindividual to fit the job. Many jobs and tasks involverepetitive motion and the use of body force or pos-ture to perform the tasks. These issues are carriers ofstress and may cause illness and injury resultingfrom the effort, whether at home or at work.

The field of ergonomics gained national atten-tion during the 1990s when OSHA noted that themeatpacking industry had a very high rate of“repeated trauma disorders (RTD),” approximately75 times that of all other national industries.

In 2001, Labor Secretary Elaine Chao reportedthat work-related repetitive strain injuries andsimilar muscular disorders account for more than athird of all job injuries. Most occupational injuriesand illnesses are often diagnosed as muscu-lokskeletal disorders. Cumulative trauma disorders(CTD) are reported as the single fastest growingoccupational issue among the U.S. working popu-lation, according to NIOSH.

In the workplace, the objective of an ergonom-ics program is to focus on identifying individualsand their jobs, implementing medical and work

ergonomics 143

interventions to prevent stress, and then evaluatethe effectiveness of those interventions.

See also CARPAL TUNNEL SYNDROME; REPETITIVE

STRESS INJURIES.

SOURCES:Brown, Stephanie. The HandBook: Preventing Computer

Injury. New York: Ergonomne, 1993.Donkin, Scott W. Sitting on the Job: How to Survive the

Stresses of Sitting Down to Work—A Practical Handbook.Boston: Houghton Mifflin, 1986.

Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnessesand Health Issues. New York: Facts On File, 2004.

estrogen replacement therapy See MENOPAUSE.

eustress HANS SELYE (1907–82), pioneer researcherin the field of STRESS, coined the term eustress torefer to “good stress.” During eustress and DIS-STRESS (bad stress), the body undergoes virtuallythe same nonspecific responses to the various pos-itive or negative stimuli acting upon it. However,he explained, the fact that eustress causes much

less damage than dis-stress demonstrates that“how you take it” determines whether one canadapt successfully to change.

Examples of “good stress” include starting a newromance, getting married, having a baby, buying ahouse, getting a new job, or getting a raise at work.All these situations, as well as others, demandadaptations on the part of the individual. Botheustress and dis-stress are part of the GENERAL ADAP-TATION SYNDROME (G.A.S.), which Selye describedas being the controlling factor in how people copewith stresses in their lives.

Later researchers (Holmes and Rahe) includedseveral “good stress” situations in their SocialReadjustment Rating Scale, which was designed tobe a predictor of ill health. Sources of good stressincluded marriage, marital reconciliation, retire-ment, pregnancy, buying a house, and outstandingpersonal achievement.

See also COPING; HOMEOSTASIS; LIFE CHANGE SELF-RATING SCALE.

SOURCES:Selye Hans. The Stress of Life, rev. ed. New York: McGraw-

Hill, 1978.———. Stress without Distress. Philadelphia: Lippincott,

1974.

euthanasia See END-OF-LIFE CARE.

exercise When individuals exercise to reducetheir STRESS, they are usually participating in suchcardiovascular activities as walking, jogging,weight lifting, using aerobic machines, and engag-ing in aerobic programs or sports such as skiing,swimming, cycling, or rowing. They participate indaily workouts and in weekends devoted to sportsto combat the stress-related, physical tension intheir lives at work or at home.

In addition to relieving stress and muscle ten-sion, exercise helps boost energy levels, improvesposture, lowers blood pressure, and helps controlBREATHING. All of these things have a calming effecton individuals because they raise their pulse rate,increase the supply of blood and oxygen to musclesand vital organs, raise ENDORPHIN and metabolismlevels, and rev up the immune system.

Exercise can have positive benefits that serve asa way to raise SELF-ESTEEM and increase CREATIVITY.

144 estrogen replacement therapy

APPLYING ERGONOMICS CONCEPTS CANMINIMIZE STRESS

• Participatory ergonomics programs require strongdirection, support, and significant expertise.

• Training programs must develop both teamworkand ergonomic skills among participants.

• In workplaces, team size should be kept mini-mal, but should include production workersengaged in the jobs studied, area supervisors,and maintenance and engineering staff who caneffect proposed job improvements.

• Effective team problem-solving requires accessto injury and illness information. In addition,reports on the team’s objectives, progress, andaccomplishments need to be circulated to keepall parties informed about the program.

• Evaluation of results is an important componentof a participatory ergonomic program. Such datawill enable teams to appraise their progress, pro-vide feedback to affected or interested parties,and make suitable corrections where necessaryto improve the overall effort.

SOURCE: DHHHS (NIOSH) Publication No. 95–102

According to Jeff Zwiefel, M.S., director of theNational Exercise for Life Institute, physicalstrength and stamina and a confident attitude arethe main by-products of exercise. A study atBaruch College, New York, found that people whoare stronger and more muscularly fit have a signif-icantly better self-image than their peers. Psycho-logical tests have indicated that those who exerciseare more confident and emotionally stable, andoutlive those who are sedentary.

The same positive effects of exercise on creativ-ity were found by Joan C. Gondola at Baruch Col-lege, when she administered a test on femalecollege students. One group had exercised 20 min-utes before the test and the other group had not;the exercise group had more imaginative responsesthan those who had not. The boost in creativitymay be attributed to the release of ADRENALINE andENDORPHINS during exercise. The right side of thebrain is stimulated by these chemicals, which con-trol creative and intuitive processes.

See also BODY IMAGE.

FOR FURTHER INFORMATION:Aerobics and Fitness Association of America15250 Ventura Boulevard, Suite 310Sherman Oaks, CA 91403(800) 445-5950 (toll-free)

National Fitness Foundation2250 East Imperial Highway, Suite 412El Segundo, CA 90245(213) 640-0145

exogenous depression Exogenous (reactive)DEPRESSION is a type of depression that originates

outside the body. It is often caused by emotionalfactors, such as BURNOUT, GRIEF, or STRESS. Exoge-nous depression is contrasted with endogenousdepression, which researchers believe may becaused by a chemical imbalance in the body.

expatriate workers See CHANGING NATURE OF

WORK.

exposure therapy See BEHAVIOR THERAPY.

extramarital affairs See ADULTERY.

extroversion See INTROVERSION.

Eye Movement Desensitization and Reprocessing(EMDR) A technique for treating a stress-produc-ing traumatic experience that combines a repre-sentation of the trauma and self-evaluation ofemotions and bodily sensations while experiencingbilateral stimulation (eye movement, tappingsounds, etc.). This procedure has empirical supportas a trauma treatment.

EMDR was developed in the early 1990s byFrancine Shapiro, Ph.D., a northern Californiapsychologist.

FOR FURTHER INFORMATION:Matthew J. Friedman, M.D. Ph.D., DirectorNational Center for Post-Traumatic Stress DisorderVA Medical CenterWhite River Junction, VT 05001(802) 296-5132ncptsd@ncptsd.orghttp://www.ncptsd.org

Eye Movement Desensitization and Reprocessing 145

Ffaith See PRAYER; RELIGION.

faith healing The essence of faith healing, forthose who believe in it, is the strong conviction of“mind over matter.” For some people, belief infaith healing contributes to relief of stress.

Historically, some faith healing takes place withthe assistance of a “healer” who places hands onthe individual who is then healed. For example,faith healing was and still is an accepted phenom-enon of Roman Catholicism, where certain saintshave been thought to have healing powers. TheCatholic shrine at Lourdes has gained the reputa-tion for causing miraculous recoveries. NativeAmerican religious practice includes ritualsintended to promote healing of mental and physi-cal ills. Faith healing is a central doctrine of Chris-tian Scientists, who actively discourage reliance ondoctors and conventional medicine. Today, there isa renewed interest in faith healing brought aboutby the resurgence of the fundamental and Pente-costal religious movements. Some of the move-ments’ ministers seem able to cure their congregants’afflictions by arousing in them a religious fervor orhysterical response.

Psychosomatic illnesses are thought to lendthemselves best to the faith healing process. Tocounter the claim that faith healing has succeededwhere conventional medical treatments havefailed, some skeptics take the position that patientsresort to faith healing only when desperate. Feel-ing that something must work, a person gets into astate of mind in which psychosomatic symptomsdisappear, or if the problem is genuinely physical,patients at least feel better.

Research methods are difficult to apply to faithhealing, in part because of the questionable psy-

chosomatic aspects of many diseases. Also, manyspontaneous remissions or recoveries from seriousor hopeless conditions without benefit of the faithhealing process have been recorded. A psychologi-cal study of individuals who had a physical stresscondition relieved by faith healing showed that,while there was little indication of mental illness,they had strong DENIAL mechanisms. These denialmechanisms could have kept them from recogniz-ing continuing symptoms of their stress.

See also ALTERNATIVE MEDICINE; IMMUNE SYSTEM;MIND-BODY CONNECTIONS; PLACEBO EFFECT; PRAYER;RELIGION.

SOURCES:Oxman, T. E., et al. “Lack of Social Participation or Reli-

gious Strength and Comfort as Risk Factors for Deathafter Cardiac Surgery in the Elderly.” PsychosomaticMedicine 57 (1995): 681–689.

Rose, Louis. “Faith Health,” in Cavendish, Richard, ed.,Man, Myth and Magic, vol. 4. New York: MarshallCavendish, 1983.

Sobel, David, and Robert Ornstein, eds. “Faith Heals.”Mental Medicine Update 4, no. 2 (1995).

falling merchandise Workers as well as customersmay be injured by items that fall from store shelves.As stores become larger, stress from falling mer-chandise increases. Such accidents are often referredto as “big box” injuries, as many occur in ware-house-style retail establishments that sell items inlarge containers or quantities. Since 1990, thou-sands of people have been injured and some killedby falling merchandise in retail warehouses. Itemsthat fall range from toys to doors to housewares totelevision sets and other electronic equipment.

Falling merchandise incidents often occurbecause of high stacking, which means storage ofmerchandise on the sales floor about eye level. To

146

handle merchandise, a salesclerk must climb onshelves, stretch, or use a ladder or step stool.

Typically, stores do not use restraining safetydevices such as security bars, fencing, safety ties,and shelf extenders on high shelves because of theexpense involved and the employee time it mighttake to use them. Merchandise can be made to fallby moving merchandise that has been stacked inan unstable manner; moving merchandise on oneshelf in such as way that merchandise on an adja-cent shelf falls, referred to as “push through”;stacking different size boxes on top of one another,and stacking heavy merchandise on top of lightermerchandise. A problem can be caused by vibra-tions in and out of a store, merchandise too largefor a shelf, or goods left hanging over the lip of ashelf.

These incidents are particularly stressful becausemerchandise usually falls without any warning onan unsuspecting worker or customer. Even thoughmerchants know about the risk of falling merchan-dise and the potential for serious injury to workersor customers, most do not give warnings of therisks with signs, banners, or placards. Many stress-ful incidents could be prevented if merchantswould train employees in procedures for recogniz-ing hazards and safely stacking items.

See also LADDERS; SLIPS, TRIPS, AND FALLS.

SOURCE:Kahn, Ada P. The Encyclopedia of Work-Related Injuries, Ill-

nesses, and Injuries. New York: Facts On File, 2004.

family Family and other RELATIONSHIPS sometimesbuffer the stresses faced by individuals during theirlifetime. However, for many people, families canalso be a source of stress. As an example, men andwomen going through marital problems are espe-cially vulnerable to the effects of relationship con-flict. They may suffer from emotional consequencessuch as DEPRESSION and can have a compromisedimmune function leading to an increased rate ofphysical illness. CAREGIVERS who provide supportfor family members who are ill are another exam-ple of a highly stressed group. A decreased immunefunction has been observed in spouses caring formates with ALZHEIMER’S DISEASE.

George R. Parkerson, M.D., and colleagues atDuke University Medical Center reported in the

Archives of Family Medicine (March 1995) that indi-viduals who see themselves as enduring high fam-ily stress are likely to have greater health problemsthan those reporting low family stress. Patientscompleted several different surveys that looked atSELF-ESTEEM, life events and changes, DEPRESSION,and family-induced stress. In addition, informationon the number of physician visits, referrals to otherphysicians, hospitalizations, severity of illness, andcost of treatment incurred by these patients wastabulated. Results showed that family stress oftenhad a stronger impact on health outcomes thanother types of stress such as social or financialstress. Those with high family stress scores hadmore frequent follow-up visits to the clinic, morereferrals to specialists, more hospitalizations, ahigher severity of illness, and incurred highercharges for clinical health care than did those withlow family stress. They also had fewer social sup-port systems.

The Duke University researchers recommendedthat family physicians identify patients with highfamily stress and give them the special care theymay require to prevent unfavorable outcomes.They suggested that questionnaires such as thoseused in the study can help identify patients whoare at high risk of adverse health-related outcomesand who may not be recognized as such throughstandard medical history reports, physical exams,and medical tests.

Having patients bring family stress issues out inthe open with their physicians can be useful. Theresearchers said that one randomized, controlledtrial showed that when family physicians discusseddetails about stressful and supportive family mem-bers with their patients after reviewing question-naire results, patients said they felt generally betterand the process helped them to improve relation-ships with their families.

See also COMMUNICATION; DYSFUNCTIONAL FAMILY;INTIMACY.

SOURCES:Burg, M. M., and T. E. Seeman. “Families and Health:

The Negative Side of Social Ties.” Annals of BehavioralMedicine 16 (1994): 109–115.

Parkerson, George R., et al. “Perceived Family Stress as aPredictor of Health-Related Outcomes.” Archives ofFamily Medicine 4 (March 1995).

family 147

Family and Medical Leave Act of 1993 (FMLA) Afederal law, applying to businesses of 50 or moreemployees, that became effective in 1993 that helpsto relieve stress from many family situations thatrequire a worker to be off the job. It provides certainemployees with up to 12 workweeks of unpaid, job-protected leave a year and requires employers tomaintain the group health benefit during the leave.The law mandates the unpaid leave for qualifiedemployees for the birth or adoption of a child andwhen they or a family member have a serioushealth condition during a 12-month period.

FMLA has a positive effect on retention of qual-ified employees. The U.S. Department of Labor’sEmployment Standards Administration, Wage andHour Division, administers and enforces the FMLAfor all private, state and local government employ-ees, and some federal employees.

When employees and their families understandthe provisions of the law, stressful situations can beimproved. For example, “serious health condition”means an illness, injury, impairment, or physical ormental condition that involves either (1) anyperiod of incapacity or treatment connected withinpatient care in a hospital, hospice, or residentialmedical care facilities or (2) continuing treatmentby a health care provider, including any period ofincapacity, such as inability to work, attend school,or perform regular daily activities due to:

1. A health condition (treatment or recovery) last-ing more than three consecutive days, and anysubsequent treatment or period of incapacityrelating to the same condition that also includestreatment two or more times by or under thesupervision of a health care provider, or onetreatment by a health care provider with con-tinuing regimen of treatment; or

2. Pregnancy or prenatal care. A visit to the healthcare provider is not necessary for each absence; or

3. A chronic serious health condition that contin-ues over an extended period of time, requiresperiodic visits to a health care provider, andmay involve occasional episodes of incapacity(e.g., asthma, diabetes). A visit to a health careprovider is not necessary for each absence; or

4. A permanent long-term condition for whichtreatment may not be effective (e.g., Alzheimer’s,

a severe stroke, terminal cancer). Only supervi-sion by a health care provider is required, ratherthan active treatment, or

5. Any absence to receive multiple treatmentsfor restorative surgery or for a conditionwhich would likely result in a period of inca-pacity of more than three days if not treated(e.g., chemotherapy or radiation treatmentsfor cancer).

An employer may require workers to provide acertification issued by their health care provider orthat of a son, daughter, spouse, or parent to sup-port the request. The employer must allow theemployee at least 15 calendar days to obtain certi-fication.

Some states have their own family leave laws. Ifthe state law provides family and medical leaverights better than the federal law, the state lawapplies. If the FMLA is better, it applies.

FOR FURTHER INFORMATION:U.S. Department of LaborEmployment Standards AdministrationWage and Hour DivisionFrances Perkins Building200 Constitution Avenue NWWashington, DC 20210(866) 4-USWAGE(877) 889-5627 (TTY)http://www.dol.gov/esa

family therapy See PSYCHOTHERAPIES.

family violence See DOMESTIC VIOLENCE.

farming Stressful occupation because farmershave little CONTROL over their lives; weather affectstheir yield, international trade dictates their prices,and government subsidies affect their income. Formany families, farming is a way of life and comeswith a whole set of values, standards, mores, andcharacteristics.

Currently, farming as a vocation is also threat-ened by a lack of respect from the public becausemany farmers have to rely on government subsi-dies to make their livelihood. This lack of respect,added to the farmer’s stress, pressure, and frustra-

148 Family and Medical Leave Act of 1993

tion, can result in physical violence, first focusedon the spouse and then on the children. This is amajor social problem, but one that cannot be eas-ily addressed because of the private, independentnature of farmers, who live in relative isolation andhave few options on how to change their lot.

Musculoskeletal injuries, such as sprains,strains, and traumatic injuries are the greatestworking hazard for farmers. These sources of stressare present in farming because of the repetitivenature of much labor-intensive farmwork. Farmersbend or stoop to reach crops. Sometimes they mustbalance on a ladder, or, when harvesting, mayhave to carry or lift heavy bags full of the harvestedcommodity.

Motor vehicle accidents are one of the mostserious causes of fatal injuries to farmworkers.These often occur when workers are driving orbeing driven to or from fields early or late in theday on unsafe rural roads; collisions may also occurwith slow-moving farm equipment.

Tractors of all sizes are used on many farms: Trac-tor attachments include tillers, snow blowers, andtrimmers. These tractors all have engines, use fuel,have moving parts, carry an operator, and are oftenused with towed or mounted equipment. Sometractors can be overturned and cause serious injury.The fuel used on these tractors may also pose a firehazard. Children riding with adults have fallen fromtractors and been crushed under the wheels orchopped by mower blades. Mowers pose two typesof hazards: potential contact with rotating bladesand being struck by objects thrown from the blades.Both front-end loaders and blades are operatedhydraulically; they are a hazard because they canfall on anyone standing under the attachment.

Among farmworkers, skin diseases are a com-mon source of stress, as are trauma from usinghand equipment such as clippers, irritants andallergens in agrochemicals, allergenic plant andanimal materials (including poison ivy and poisonoak), nettles and other irritating plants, skin infec-tions caused or worsened by heat or prolongedwater contact, and sun exposure (which can causeskin cancer).

Farmworkers experience the stress of respira-tory symptoms and disease from exposure to dustand chemicals. In dry climate farming, inorganic-

dust exposure may result in dust-borne lung dis-eases and chronic bronchitis.

See also CHILD LABOR; CONTROL; FRUSTRATION;LADDERS; POISON IVY; STRESS; WHEEZING.

See also DOMESTIC VIOLENCE.

SOURCE:Haverstock, Linda. “Stress in Farming.” Canadian Family

Physician 38 (1992): 405–406.

fathering, older Fathering later in life is lessstressful than fathering at an earlier age, accordingto economist Martin Carnoy, a Stanford Universityprofessor of education. In his book, Fathers of a Cer-tain Age, Carnoy and his coauthor, and son Davidargue that men in their late 40s, 50s, and even 60s,secure in their careers and ready to make time forfamilies, are more nurturing and willing to share inchild care responsibilities than their younger coun-terparts. As a result, they find fatherhood lessstressful at their age.

The Carnoys reviewed literature comparingfathering experiences at different ages and inter-viewed many older fathers, exploring how theyfeel about PARENTING small children late in middleage. “These older fathers are more stable finan-cially and better able to provide for a child,” theelder Carnoy said. “But more important, they areusually willing to spend a great deal of time on theFAMILY. They have fought the workplace wars andare much less sanguine about the rewards of longwork days. Almost everyone we interviewed whowas raising second families was spending moretime with their children than they did as 30-year-old fathers trying to climb career ladders. Familyplays a much more important everyday role inolder fathers’ lives.”

Fathers of a Certain Age suggests that middle-agefathering is on the increase after many years ofdecline, and that this is no accident. As college-edu-cated women seek to build their professional careersand postpone child-bearing to their early 30s andbeyond, they are much more likely to end up mar-rying a man who is in his mid-40s or older. This hasresulted in “fathers at a certain age,” and census dataindicate that more than 350,000 men in the UnitedStates over age 45 fall into this category.

Although the Carnoys found that older fathersare intensively involved with their children, the

fathering, older 149

book discusses some of the major pitfalls of laterfatherhood. Not only do many middle-aged fathershave to deal with their disapproving older childrenfrom a previous marriage, they also face the sheerenergy requirements of raising a young child, thepossibility of paternal death early in a child’s life,and the financial difficulties of facing RETIREMENT

and paying for a college education.

SOURCE:Carnoy, Martin, and David Carnoy. Fathers of a Certain

Age. Boston: Faber and Faber, 1995.

fatigue See CHRONIC FATIGUE SYNDROME.

fax machines See ELECTRONIC DEVICES.

fear An emotion that results in an intense andunpleasant stress that comes about because of areal threat. In fear, there may be intense feelings ofwanting to escape, together with physiologicalreactions including weakness, DIZZINESS, rapidbreathing, rapid heartbeat, nausea, muscle tension,and weakness in the knees. Different individualshave different physiological responses to fear.

The terms fear and phobia are often misused andare improperly interchanged. Fear is a real andknowable danger, and usually can be recognizedby others. Phobia on the other hand, is an inap-propriately fearful response to a situation and isout of proportion to the real danger, if there is dan-ger at all. Real fear is normal. Chronic PHOBIAS thatcause avoidance behavior are considered ANXIETY

DISORDERS.At times, fear can be a helpful emotion. For

example, the fear reaction enables people to getout of the way when they hear the whistle of atrain. It signals the hypothalamus, which triggers arelease of ADRENALINE into the body. Adrenalineacts immediately to prepare the body for FIGHT OR

FLIGHT. Breathing deepens, perspiration increasesto cool the body, pupils dilate to sharpen vision,the face may turn pale, and the heart beats notice-ably faster.

See also AGORAPHOBIA; ANXIETY; SOCIAL PHOBIA.

feedback Involves objective information givenby a therapist, teacher, or parent, or by others in a

SUPPORT GROUP, to an individual who is seekingcomments about his feelings or actions. It is a shar-ing of feelings or thoughts and ideally should begiven without evaluating consequences to the indi-vidual or demanding that he make a change. Neg-ative feedback, even when given with completeobjectivity, can be stressful and generally arousesdefensiveness in the individual. Positive feedback,on the other hand, enhances SELF-ESTEEM andmakes the individual feel good.

See also COMMUNICATION; LISTENING.

Feldenkrais method See BODY THERAPIES.

feng shui One way to reduce chances for stress isto practice a philosophy that ensures harmony andgood fortune. Such is the Chinese art of geomancy,or feng shui, which involves the proper alignmentof objects with geographical features. In Hemi-spheres magazine (November 1993), John Gofftranslates feng shui as “wind and water” anddefines it as “a product of a culture that honors thespirits of mountains and rivers and views the land-scape as a living thing with cosmic currents.”

Practiced first in Hong Kong, where it influ-enced the design of many corporate buildings,including Citicorp International and MotorolaSemiconductors Hong Kong, Ltd., feng shui hasspread to other parts of the world as well. In addi-tion to corporate offices, there are factors that canremove stress from a household (see below).

150 fatigue

USE FENG SHUI TO REMOVE STRESS WHEN BUILDING OR FURNISHING A HOUSE

• Entryways and windows should be wide enoughto allow light, which symbolizes the Sun andallows good energy to come in.

• Mirrors are particularly used in cramped spacesand over furniture that does not face windows ordoors because they reflect positive energy anddeflect negative forces.

• Buildings near water are good because water isan element of wealth, insight, and motivation.Avoid building near tall buildings because theyblock positive energy and on cul de sacsbecause negative energy has no place to escape.

fertility See INFERTILITY.

fibromyalgia Form of soft tissue or muscularrheumatism that causes PAIN in the muscles andfibrous connective tissues (ligaments and tendons).It is an accepted clinical syndrome that causesstress for the sufferer, not only because of the painand discomfort, but also because of the difficulty inhaving it diagnosed properly.

According to Barry M. Schimmer, M.D., chief ofthe section on rheumatology at Pennsylvania Hos-pital, “For a long time we thought that their prob-lems were psychosomatic and these patients werereferred for psychiatric help. Today we know thatthis condition is very real and needs to be dealtwith and treated like any other chronic illness.”

The exact cause of fibromyalgia is unknown, andthere is no known cure. Many different factors trig-ger the pain, including an illness, such as the flu,hormonal changes, or physical or emotional trauma.

Symptoms

The ailment, which affects 3 million to 6 millionAmericans, primarily Caucasian middle-classwomen between the ages of 45 and 55, results inmuscles becoming tight and tense, and the personfeeling emotionally drained. Other symptoms ofthe disease in addition to pain and constant fatigueare feeling “down” and anxious; numbness andtingling in the hands, feet, and legs; sleep distur-bance, tension headaches, subjective swelling,bladder spasms, and irritable bowel. Cold weather,extremes of activity, fluctuation of barometric pres-sure, and stress often aggravate the symptoms offibromyalgia.

Diagnosis and Treatment

Since diagnosis of fibromyalgia is so difficult, arheumatologist does extensive detective work insorting out the patient’s medical history and per-forming a thorough examination. Said Dr. Schim-mer, “When we examine the patient we will findtender ‘trigger points’ in certain patterns over theneck, shoulders, chest, lower back, and hips andthis helps to separate fibromyalgia from otherconditions.”

Nonsteroidal anti-inflammatory agents areused, as are corticosteroids, but they often do nothelp. Efforts are made to improve sleep. Nonphar-

macologic treatment emphasizes aerobic exercise,particularly water aerobics. Light sports, such asswimming, bicycling, and walking, are encour-aged. Some people find BIOFEEDBACK, hypnother-apy, massage, and SUPPORT GROUPS helpful. Manypatients, in an acute stage of their disease, worryabout having bone cancer or other ominous disor-ders; some become very anxious. Psychotherapycan help certain individuals overcome the atten-dant stresses of this disorder.

See also MASSAGE THERAPY; PSYCHOTHERAPIES.

SOURCES:McIlwain, Harris H., and Debra Fulghum. The Fibromyal-

gia Handbook. New York: Henry Holt, 1996.Starlanyl, Devin. Fibromyalgia and Chronic Myofascial Pain

Syndrome: A Survival Manual. Oakland: New HarbingerPublications, 1996.

Williamson, Miryam Ehrlich. Fibromyalgia: A Comprehen-sive Approach: What You Can Do about Chronic Pain andFatigue. New York: Walker and Company, 1996.

fight or flight response This is an innate reactionpresent in humans as well as animals to a stressfulor threatening situation in which the SYMPATHETIC

NERVOUS SYSTEM (SNS) mobilizes the body for max-imum output and use of energy. When facing astressful situation, the SNS causes many physiolog-ical reactions, including a rapid heartbeat, deepbreathing, slowing down of digestion, and anincrease in blood pressure. These physical func-tions enable the person (or animal) to quickly fleethe dangerous situation or fight back against anaggressor.

An example of the fight or flight response iswhen an individual realizes that he is on a railroadcrossing and the train is coming closer than hethought. Fast flight ensues. Also, when a motheranimal’s cubs are threatened by a predator animal,her instincts take over and the fight or flightresponse follows.

See also ANXIETY DISORDERS; FEAR; PANIC ATTACKS

AND PANIC DISORDER; STRESS.

financial stressors See MONEY.

firefighters and rescue workers The stressfuland dangerous work of these occupations involvesbuildings collapsing, deadly smoke, and heart

firefighters and rescue workers 151

attacks. The workers are often the first emergencyresponders at the scene of a vehicle crash, fire,flood, earthquake, or act of terrorism. About 2 mil-lion fires are reported each year in the UnitedStates; every 18 seconds, fire departments respondto emergency situations.

Firefighters perform many duties to protect livesand minimize property destruction. Duties mayinclude rescuing victims, administering medicalaid, salvaging contents of buildings, connectinghose lines to hydrants, operating pumps, or posi-tioning ladders. Each year, on average, about 50firefighters die from injuries on the job, accountingfor about 1 percent of all fatal work injuries. In theperiod 1992–97, the total number of fatalities forfirefighters was about 17 firefighters per 100,000employed. This compares to five fatalities per100,000 employed for all workers. Firefighters areabout three times as likely to be fatally injured onthe job as the average worker, causing stress for theworkers’ families as well as the injured workers.

Despite efforts to reduce firefighter mortalitywith better protective equipment, breathingmachines, and a buddy system that sends two fire-fighters into a burning building together, deathscontinue to rise. Fire and smoke are responsible forthe largest proportion of deaths and for a high per-centage of injuries, according to Kristin Klober-danz, M.D., director of the Occupational MedicineService at the University of Medicine and Dentistryof New Jersey.

According to Kloberdanz, the attack on theWorld Trade Center in 2001 saw the single highestcount of firefighter deaths in U.S. history.

Other Stressful Hazards: Heart Disease and Cancer

The work is stressful because sites are uncontrolledand sometimes extremely hot environments. Fire-fighters and rescue workers wear protective cloth-ing, which is heavier than most winter clothes, andcarry 75 to 90 pounds of equipment, includingbreathing apparatus. Additionally, rescue workersmay find themselves in agonizing life-or-death sit-uations, which can lead to depression or post-trau-matic stress disorder (PTSD).

Firefighters and rescue workers also suffer ahigher than normal risk of certain types of cancer,including bladder cancer and lymphoma, which

experts attribute in part to the toxins that firefight-ers are exposed to inside burning buildings. Respi-rators and air tanks are mandatory, but thesesafeguards do not prevent all toxic substances,such as benzene, ASBESTOS, and polycyclic aromatichydrocarbons from entering the system.

In addition to fighting building fires, firefightersare called on to control and extinguish forest fires.Some pilot aircraft to locate forest fires or use chainsaws and axes to create fire trails, among otherduties. Forest fires are particularly stressful becausethey may increase rapidly and can surround thefirefighters who are trying to put them out.

Rescue workers also risk coming into contact withbody fluids from victims, sprains and strains, cuts,and hearing loss, often caused by wailing sirens.

See also ELECTRICITY; EMERGENCY RESPONSE;HEART ATTACK; HEALTH CARE WORKERS; LADDERS;NOISE; SLIPS, TRIPS AND FALLS.

SOURCES:NIOSH. Preventing Injuries and Deaths of Fire Fighters Due to

Structural Collapse. Publication No. 99-146, August1999.

NIOSH ALERT. Preventing Injuries and Deaths of Fire Fight-ers. DHHS (NIOSH) Publication No. 94-125, Septem-ber 1994.

fires Fires are a major source of fear and stressfor home owners, workers, and businesses. Fires

152 fires

TIPS FOR AVOIDING THE STRESS OF FIRE HAZARDS

Eliminate fire hazardsKeep all spaces free of waste paper and other com-bustibles, replace damaged electrical cords, andavoid overloaded circuits.

Prepare for emergenciesMake sure all smoke detectors work, know who tocall in an emergency, and participate in fire drills.

Report fires and emergencies promptlySound the fire alarm and call the fire department.

Evacuate safelyLeave the area quickly in an emergency. Use stairsinstead of elevators, and help other members ofyour household or coworkers.

put people out of their homes or places of workand severely affect their livelihoods.

According to former U.S. labor secretary RobertReich, “There is a long and tragic history of work-place fires in this country. One of the most notablewas the 1911 fire at the Triangle Shirtwaist Factoryin New York City, in which nearly 150 women andyoung girls died because of locked fire exits andinadequate fire extinguishing systems. Thattragedy helped put basic workplace safety andhealth considerations on the national agenda.”

FOR FURTHER INFORMATION:National Fire Protection Association1 Batterymarch ParkP.O. Box 9101Quincy, MA 02269-9101(800) 344-3555 (toll-free)(617) 770-0700 (Fax)www.nfpa.org

fireworks Explosive devices used for celebrationsare a source of stress for many bystanders because ofthe possibility of injury. All fireworks are dangerous,especially to children. In 2003, 9,300 people weretreated in U.S. hospital emergency departments forfireworks-related injuries. Injuries from fireworksmost often affect the hands and fingers, eyes, head,and face. Children 14 years and younger sustainedabout 45 percent of injuries related to fireworks,and boys represented 72 percent of all those injured.According to the U.S. Centers for Disease Controland Prevention (CDC), two-thirds of injuries fromfireworks in the United States occur in the days sur-rounding the July 4th holiday.

Under the Federal Hazardous Substances Act, thefederal government banned the sale of the largestand most dangerous fireworks to consumers. Somestates have banned the general public’s use of fire-works altogether. The U.S. National Fire ProtectionAssociation and CDC strongly recommend that fire-works be used only by professionals.

FOR FURTHER INFORMATION:National Center for Injury Prevention and ControlMailstop K654770 Buford Highway NEAtlanta, GA 30341-3724(770) 388-1506

(770) 488-1667 (fax)http://www.cdc.gov/ncipc/duip/spotlite/

firework_spot.htmE-mail: OHCINFO@cdc.gov

SOURCE:National Center for Injury Prevention and Control

fitness See EXERCISE.

flashbacks See POST-TRAUMATIC STRESS DISORDER.

flatulence The expulsion of air, usually swallowedwhen eating, from the stomach or intestine but canalso be induced by ANXIETY in times of stress. Fear ofpassing wind or gas is a common SOCIAL PHOBIA andcan cause stress or embarrassment.

Certain foods are well known as tending tocause flatulence, including beans, cabbage, onions,peppers, cucumbers, celery, and dairy products.

See also INDIGESTION; IRRITABLE BOWEL SYNDROME.

flexible work hours (flex time) An alternative tothe traditional nine to five, 40-hour workweek. Thepolicy allows employees to arrange their arrival andor departure times to fit their family or personalschedules. For many people, flexible work hoursreduce the stress involved in working, commuting,and managing a family. Flexible work hours varyand may be arranged to suit the convenience ofemployees, such as working parents. Under somepolicies, employees must work a prescribed numberof hours and be present during a daily “core time.”Alternative work arrangements such as flexiblework schedules are a matter of agreement betweenthe employer and the employee.

In a Chicago Tribune column, writer CarolKleiman reported on two studies that found flexiblework hours advantageous. One was conducted byFlexible Resources, Inc., a consulting and staffingfirm in Cos Cob, Connecticut, that specialized inpermanent jobs with flexible hours. The other wasby Catalyst, a nonprofit agency in New York thatworks with businesses to advance women.

According to the research, job assignments withflex time are satisfying even though promotionsare slow. Salaries are surprisingly good. Both stud-ies included only women because they are more

flexible work hours 153

likely to work flexible schedules. Both studiesfocused on high-ranking, well-educated, experi-enced professionals and did not include employeesin support or administrative jobs. Lower-levelemployees are less likely to be allowed flexiblehours and more often are required to be on the jobsite all the time.

Kleiman quoted Linda Coletti, a marketingexecutive at a consumer product company inStamford, Connecticut, as saying, “There’s been atremendous change in employers’ attitudes since Istarted working flexible hours eight years ago.Some companies viewed you as a second-class cit-izen, but now your experience is valued.”

A Bureau of Labor Statistics Monthly LaborReview article stated that from 1991 to 1997, thepercentage of full-time wage and salary workerswith flexible work schedules on their principal jobincreased from 14.1 percent to 27.6 percent.

See also CHANGING NATURE OF WORK; HOURS OF

WORK; WORKING MOTHERS.

SOURCES:Beers, Thomas M. “Flexible Schedules and Shift Work:

Replacing the ‘9 to 5’ Workday?” BLS Monthly LaborReview Online. Available online. URL: http://www.bls.gov/opub/mir/2000/06/art3exc.htm. Downloaded onJune 15, 2005.

Kleiman, Carol. “Price Is Right for Flexible Work Hours.”Chicago Tribune, June 12, 2001, sec. 3.

flooding See BEHAVIOR THERAPY.

flying See AIRPLANES.

folk medicine See ALTERNATIVE THERAPIES; FAITH

HEALING; PRAYER.

forgetting An inability to retrieve stored long- orshort-term memories. It is a common occurrenceand a source of stress to many people. Most peopleforget short-term as well as long-term memories,particularly the elderly who experience MEMORY

loss as they grow older. But forgetting is a sign notjust of old age. Many people consciously block outstressful memories and many are simply forgetful.They may forget recently made appointments, for-get what their boss told them earlier in the day, orforget occurrences that happened in childhood.

See also ALZHEIMER’S DISEASE; POST-TRAUMATIC

STRESS DISORDER.

Framingham Type A See TYPE A PERSONALITY.

friends Friends are unique among human RELA-TIONSHIPS. While individuals have little or nochoice in family or neighbors, they can choosetheir friends. Some friendships evolve from sharedinterests or values, some simply from a shared his-tory, and some from compatible personalities.Qualities most appreciated in friends include loy-alty, trust, and an ability to keep a confidence. Peo-ple want to feel that they can rely on their friendsand can have an open and honest friendship dur-ing good as well as stressful times.

When friends are supportive, they help relievethe stress during periods of turmoil or crisis. Indi-viduals who experience DEPRESSION often report alack of friends, although having a wide circle offriends is not a preventive factor for depression.Some reports have indicated that individuals whohave many friends may be healthier and actuallylive longer than those who do not.

Friends can also be a source of stress becausethey may challenge or be challenged by other rela-tionships in the individual’s life. For example, afriendship may be broken or changed when onefriend marries. A friend of the opposite sex fre-quently is unsettling to a spouse or lover. Friendswho do not meet with parents’ approval can be asource of family conflict. Friends who decide toshare housing or enter into a business partnershipsometimes discover undesirable facets of the otherperson’s personality that could be ignored whenthe relationship was less formal. In the WORKPLACE,a friendship may dissolve when two people arevying for the same promotion.

A 1990 Gallup poll reported that the typicalAmerican places much importance on friendship.It also indicated some frustrations about the timeand flexibility needed to form friendships. The sur-vey showed that women and men approachfriendship quite differently. Women tended toform more intimate relationships with otherwomen than men with men. One-on-one activitiesthat promote conversation are more popular withwomen, whereas men are more likely to gettogether in groups for sports, cards, or other such

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activities. Men rely on their wives for emotionalsupport, but many women, even those who aremarried, often rely on women friends. Women aremore likely than men to have a best friend of thesame sex, but a third of the men surveyed said awoman was their best friend.

People make friends in many ways. In the Gallupreport, 51 percent of the 18- to 29-year-olds mademost of their friends at school. Of the 30- to 49-year-olds, 51 percent said they made most of their friendsthrough work. From the age of 50 up, friends camefrom a greater variety of sources, including church,work, clubs, or other organizations.

When participants were asked about argumentswith friends, those under age 30 reported moredisagreements. Friendship evidently becomes moretranquil with age, possibly because friends settletheir differences and learn to recognize sore spots,or possibly because age enables people to recognizeand discard difficult and stressful relationships.

See also INTIMACY.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

frigidity An old term that refers to the inability ofa woman to obtain satisfaction (usually orgasm)during sexual intercourse. Sex researchers Mastersand Johnson coined the term “female orgasmicdysfunction” to replace this term. Regardless of thelabel, the situation may be a cause of stress for thewoman as well as her partner.

Lack of satisfaction during sexual intercoursemay result from a combination of many factors,including the desirability of one’s partner, poorCOMMUNICATION between the partners concerningsexual behaviors and desires, and cultural rejectionof certain sexual practices. Other factors necessaryto the woman’s arousal—stimulation and satisfac-tion—vary widely between individuals. Also, thefear of desertion, acquiring a SEXUALLY TRANSMITTED

DISEASE (STD), or pregnancy may interfere withsatisfaction for some women.

See also ANORGASMIA; DYSPAREUNIA; SEX THERAPY;SEXUAL DIFFICULTIES.

frustration Interference with an individual’simpulses or desired actions of internal or external

forces. Internal forces are inhibitions and mentalconflict, and external forces can come from a par-ent, teachers, and friends, as well as the rules ofthe society. There are deep feelings of discontentand tension because of unresolved problems,unfulfilled needs, or roadblocks to personal goals.Regardless of the cause, frustration causes stress formost people.

Modern life is filled with frustrations from birthto old age. Crying babies may be frustrated becauseof hunger, school-age children may be frustratedby high expectations of their parents, parents maybe frustrated by their jobs, and the elderly may befrustrated by their increasing lack of independence.

People who are repeatedly and constantlystressed by frustrations respond in many ways. Aperson who is mentally healthy usually deals withfrustration in an acceptable way, sometimes withHUMOR. Others react with ANGER, HOSTILITY, AGGRES-SION, or DEPRESSION, while still others become with-drawn and passive. Many children and adults whoare constantly frustrated show regressive behav-ior—going back to childlike behavior, particularlyaggression or depression—and may become unableto cope with problems on their own.

See also CONTROL; COPING; GENERAL ADAPTATION

SYNDROME; STRESS MANAGEMENT.

funeral arrangements See DEATH.

fungi Organisms in indoor air in homes andworkplaces that can cause stressful problems suchas ALLERGIES, ASTHMA, lung diseases, and other res-piratory problems and contribute to SICK BUILDING

SYNDROME.The kind of fungi found in indoor air normally

reflect those in outdoor air when windows are keptopen. To grow and proliferate indoors, however,fungi require a suitable substrate such as wood,paper, gypsum board, or other materials that havea high cellulose content and water. Homes orbuildings where there is chronic water damage orwhere humidity levels are high are particularly atrisk of contamination with fungi.

Fungal growths have potentially stressful injuri-ous effects on health. For example, certain speciesof fungi produce mycotoxins, natural organic com-pounds that initiate a toxic response in humans,

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including mucosal and skin irritation, immunosup-pression, and systemic effects. Humans areexposed to these toxic chemicals primarily byinhalation of spores or of material that has beencontaminated by MOLD. Some people develop aller-gies such as rhinitis and asthma when exposed tomolds. Repeated and heavy exposure to small fun-gal particles can also cause hypersensitivity pneu-monitis in certain people.

Symptoms caused by exposure to mold shoulddisappear once exposure ceases. Systemic effects,such as headache, fever, excessive fatigue, cogni-tive and neuropsychological effects, gastrointesti-nal symptoms, and joint pain, have been observedin some people exposed to molds. Certain speciesof fungi can cause infectious diseases, but this israre, unless the exposed person is severelyimmunosuppressed.

156 fungi

Ggagging, hypersensitive The feeling that one willgag or choke is often associated with stress andanxiety. A fear of gagging is related to the feeling ofa lump in the throat that one cannot seem to swal-low. Those who are hypersensitive gaggers cannottolerate foreign objects in their mouths, such asobjects used during dental treatment. In somecases, individuals may gag, retch, or vomit if theyhear or think about dentistry or smell an odorassociated with dental procedures.

It can relieve stress to understand that gagging isa normal protective reflex for the oropharynx.Also, the sensitivity and trigger area is greater insome individuals than others. In mild cases, gag-ging can be triggered just by touching near theback of the mouth with the tongue or beingtouched by a dental instrument. In more severecases, the trigger can be touching the front of themouth, the face, and the front of the neck; certainsmells or signs associated with unpleasant oralexperiences such as dentistry; or becoming ill dueto certain foods.

Some hypersensitive gaggers swallow with theirteeth clenched and thus have difficulty duringdental procedures. Such individuals have particu-lar difficulty in swallowing with their teeth apart.

Individuals who are hypersensitive gaggers canlearn to relieve their stress and modify their swal-lowing pattern, for example, swallowing with theteeth slightly apart and the tongue further back inthe mouth. If sharp teeth make the tongue overlysensitive, the teeth can be smoothed down some-what by a dentist.

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Facing Fears: The

Sourcebook for Phobias, Fears, and Anxieties. New York:Checkmark Books, 2000.

galvanic skin response (GSR) Use of an elec-tronic device attached to an individual’s fingertipsthat measures minute amounts of perspiration inthe skin in response to emotional or psychologicalstressors. The more tense the individual is, themore perspiration is on his skin; as the individualbecomes calmer, there is less perspiration.

The device converts its electrical information to aneasily observable form, such as light or a buzzingsound, and can be used in conjunction with BIOFEED-BACK or as a test after an individual has learned thebiofeedback technique to reduce effects of stress.

See also RELAXATION.

gambling Playing a game (such as cards or slotmachines and roulette) for money or other stakesor betting on an uncertain outcome (such as ahorse race or football game). The fascination withgambling and the prospect of winning can reducestress for certain individuals by helping them forgettheir problems. This is particularly true when theyare able to control their gambling by setting a dol-lar limit on their losses and stopping their gamblingat that point. However, for many people, gamblingbecomes an ADDICTION and a compulsion, and theyplay on and on.

People gamble for many reasons. Some simplyenjoy the sociability of the event while others findthe risk and unpredictability of the game excitingand stimulating. Some derive a sense of power andimportance from winning; others may gamble outof rebellion. To gamble is still illegal in some situa-tions or considered sinful or immoral by some reli-gious groups.

A Compulsion or an Addiction

Gambling may be considered a compulsion oraddiction when the gambling activity becomes the

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most important aspect of a person’s life. Such indi-viduals will direct all of their efforts toward obtain-ing money to gamble. Seeking funds to enablegambling can become a stressor. For family andfriends of the addicted gamblers who may not beable to pay household bills and provide a living, itbecomes a source of stress as well.

Although gambling does not involve ingestingsubstances, compulsive gambling has many charac-teristics in common with alcoholism. Both theNational Council on Compulsive Gambling andGamblers Anonymous have estimated that there are6 million compulsive gamblers in the United States.Typically, the compulsive gambler is a married manin his early to mid-30s, employed in a field involvingmoney and high risks, such as investment, business,or the law. Usually, compulsive gamblers are outgo-ing, generous, and gregarious, but are prone to sud-den negative mood swings. Even in serious stages ofcompulsive gambling, gamblers will express concernabout their health, but not about their addiction togambling and the stress caused by it.

National attention was focused on the problemof compulsive gambling in the late 1980s with thewell-publicized problems of baseball star Pete Rose.Shortly afterward, a Gallup poll showed a some-what ambivalent public attitude toward gambling.Survey results indicated that gambling as an activ-ity, both legal and illegal, is on the upsurge andextremely popular. Public sentiment ran towardincreasing legalized gambling, although 61 percentof those surveyed said they thought legal gamblingencouraged excessive gambling.

Historically, there have been underworld aspectssurrounding gambling. Films frequently depictexpensively dressed, glamorous men and womengambling in casinos in exotic locations all over theworld, or seedy, down-on-their-luck charactersplaying cards or shooting craps and about to getraided by the police. Today, when more and morestates are passing laws that allow gambling and lot-teries have become an American way of life, gam-bling has become completely accessible to peoplein all walks of life.

Gamblers Anonymous offers a recovery programsimilar to Alcoholics Anonymous. The Council onCompulsive Gambling offers a crisis interventionhotline for compulsive gamblers and their families.

See also ADDICTIONS; SELF-HELP GROUPS.

FOR FURTHER INFORMATION:Gamblers Anonymous3255 Wilshire Boulevard, Suite 610Los Angeles, CA 90010(211) 386-8789

National Council on Compulsive GamblingJohn Jay College of Criminal Justice445 West 59th StreetNew York, NY 10019(212) 765-3833

SOURCES:Hugick, Larry. “Gambling on the Rise; Lotteries Lead the

Way.” The Gallup Poll, June 1989.Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

gay marriage See MARRIAGE; REMARRIAGE.

gender role A collection of attitudes and behav-iors that are culturally and socially associated withmaleness or femaleness. Along with many societalchanges, gender roles have also changed signifi-cantly, particularly during the last half of the 20thcentury. The gender role for many women in West-ern cultures was historically passive and submis-sive, until the women’s liberation movement andsexual revolution. Child care is no longer exclu-sively the woman’s role, and earning the largerpart of the family income is no longer exclusivelythe man’s role. These changes have not occurredwithout stress. Some women try to handle moth-erhood and a career at the same time or sacrificeone for the other, while some men fear that wiveswill advance more rapidly in their career than theywill, and others have mixed emotions about theirrole as fathers.

Stressors from gender roles also occur whenindividuals have persistent feelings of discomfortabout their sexual identity. Transsexualism is themost common example of this situation. Whenpeople have internal conflicts regarding genderidentity and do not accept their biological designa-tion, stressful anxieties may develop, leading theminto practices such as cross-dressing and adoptingthe role of the other sex. Many individuals whobelieve that they are men or women in the body ofthe other sex experience stressful anxieties to the

158 gay marriage

extent that some of them seek surgical sex changeoperations.

See also HAVING IT ALL; SEXUAL DIFFICULTIES.

general adaptation syndrome (G.A.S.) Refers toa term we now know as STRESS; it was coined byHANS SELYE (1907–82), an Austrian-born Canadianendocrinologist and psychologist, in his landmarkbook, The Stress of Life (1956). The G.A.S. is themanifestation of stress in the whole body as itdevelops over time. It is through the G.A.S. thatvarious internal organs, especially the endocrineglands and the nervous system, help individualsadjust to constant changes occurring in and aroundthem and to “navigate a steady course towardwhatever they consider a worthwhile goal.”

Dr. Selye was a pioneer in an area that has con-tinued to look at stress as a threat to wellness. Thesecret of health, he contended, was in successfuladjustment to ever-changing conditions. Life, hesaid, is largely a process of adaptation to the circum-stances in which we exist. He viewed many nervousand emotional disturbances, such as high bloodpressure and some cardiovascular problems, gastricand duodenal ulcers, and certain types of allergicproblems, as essentially diseases of adaptation.

Selye called his concept the general adaptationsyndrome because it is produced only by agentsthat have a general effect on large portions of thebody. He called it adaptive because it stimulatesDEFENSE MECHANISMS. He used the term syndromebecause individual manifestations are coordinatedand interdependent on each other.

There are three stages in the G.A.S., Selye said.Individuals go through the stages many times eachday as well as throughout life. Whatever demandsare made on us, we progress through the sequence.The first is an alarm reaction, or the bodily expres-sion of a generalized call for our defensive forces.We experience surprise and anxiety because of ourinexperience in dealing with a new situation. Thesecond stage is resistance, when we have learnedto cope with the new situation efficiently. The thirdstage is exhaustion, or a depletion of our energyreserves, which leads to fatigue. Adaptability, Selyecontinued, was a finite amount of vitality (thoughtof as capital) with which we are born. We can

withdraw from it throughout life, but cannot addto it.

See also COPING; DIS-STRESS; EUSTRESS; HARDI-NESS; HOMEOSTASIS; PSYCHONEUROIMMUNOLOGY.

SOURCES:Selye, Hans. The Stress of Life. New York: McGraw-Hill,

1956.———. Stress without Distress. Philadelphia: J. B. Lippin-

cott, 1974.

generalized anxiety disorders (GADs) SeeANXIETY.

generation gap See BABY BOOMERS; COMMUNICA-TION; INTERGENERATIONAL CONFLICTS; LISTENING.

genetically modified foods (GM foods) or geneti-cally modified organisms (GMOs) Plants cre-ated for human or animal consumption usingmolecular biology techniques to improve nutri-tional content or increase resistance to herbicides.Many people experience STRESS and disagreementconcerning the controversy regarding such foods.

Traditionally, desired traits have been developedthrough breeding, but this can be very time con-suming and may not yield accurate results. Geneticengineering, on the other hand, can create plantswith the exact desired trait rapidly and accurately.An example is creating a drought-resistant corncrop or a crop that can resist unexpected frost.

Proponents say that genetic engineering canhelp increase the nutritional value and shelf life ofsome foods. Crops modified to resist attack by pestsor disease could result in greater yields, more eco-nomical production, and ultimately lower cost.This could be advantageous for feeding rapidlygrowing populations in developing countries.

Opponents say that GMOs are an unknownquantity and that it is impossible to know thepotential effects on human health and the envi-ronment. New allergens could be created inadver-tently and known allergens transferred fromtraditional foods into genetically modified variants.Research needs to be conducted on the risks ofconsuming genetically modified foods.

Environmental concerns include the possibilitythat GM crops could accidentally cross-pollinatenon-GM crops, leading to contamination and

genetically modified foods or genetically modified organisms 159

increasing the spread of GM crops. Growing GMcrops on a large scale may have implications forbiodiversity.

Labeling of GM foods and food products is also acontentious issue. Generally, agribusiness industriesbelieve that labeling should be voluntary and influ-enced by the demands of the free market. Othersbelieve labeling should be government mandated.

According to the U.S. Food and Drug Adminis-tration, more than 40 plant varieties have com-pleted federal requirements for commercialization.Some examples of these plants include tomatoes,cantaloupes, soybeans, sugar beets, corn, and cot-tons. Not all of these products are yet available insupermarkets. However, the ubiquity of soybeanderivatives as food additives in the contemporaryAmerican diet assures that most U.S. consumershave been exposed to GM food products.

In 2000, 13 countries grew genetically engi-neered crops commercially; U.S. farmers grew 68percent of all GM crops. Soybeans and corn, thetop two most widely grown crops, made up 82 per-cent of all GM crops harvested in 2000.

FOR FURTHER INFORMATION:Economic Research ServiceU.S. Department of Agriculture1800 M Street NWWashington, DC 20036(202) 694-5050http://www.ers.usda.gov/briefing.biotechnologyE-mail: service@ers.usda.gov

geriatric depression See DEPRESSION.

geropsychiatry See PSYCHOTHERAPIES.

gestalt therapy A type of psychotherapy and oneof many therapies useful in treating individuals whoexperience debilitating stress, anxieties, or phobias.It emphasizes treatment of the person as a whole,including biological aspects and organic functioning,perceptions, and interrelationships with the outsideworld, and focuses on the sensory awareness of theindividual’s here-and-now experiences rather thanon past recollections or future expectations.

Gestalt therapy can be used in individual orgroup therapy settings because it uses role-playing,

acting out anger or fright, reliving traumatic expe-riences, and other techniques, such as the “emptychair,” to elicit spontaneous feelings and self-awareness, promote personality growth and helpthe individual develop his or her full potential.Gestalt therapy was developed by Frederick S. Perls,a German-born U.S. psychotherapist (1893–1970).

See also PSYCHOTHERAPIES.

glass ceiling An invisible barrier that keeps manyworking women from rising to the top of their fielddespite good qualifications, experience, and hardwork. This frustration leads to stress and anxietyand, for many individuals, DEPRESSION.

There are many variations of the effects of theglass ceiling. For example, men in high-level postsmay be brought from outside the organization toprovide a fresh outlook while qualified womenalready in the organization are passed over. Also,in discussions involving teamwork and negotia-tions, women are often kept on the periphery ofthe decision making process.

Teasing and harassment may discourage womenfrom seeking a promotion. Women in lower-levelpositions are sometimes given responsible,demanding work that is not reflected in title orsalary. As women attempt to progress in an organ-ization, they may find that performance standardsare higher for them than for men. Women mayalso be inhibited by assumptions that a femininemanagement style is more passive and nurturingtoward fellow workers and less goal oriented anddriven than the masculine management style.

Women who do make it past the glass ceilingfrequently credit the influence of a mentor, spouse,or parent. Some women avoid the glass ceiling bystriking out on their own. In the late 1980s, thenumber of self-employed women was growingfaster than the number of men.

See also SEXUAL HARASSMENT; WOMEN’S MOVEMENT.

glaucoma A group of eye diseases in which aspecific pattern of damage to the nerve located inthe back of eye (optic nerve) results in loss of eye-sight. People who are diagnosed with glaucomaexperience stress as vision loss worsens, leading tototal blindness over time if glaucoma is not treated.

160 geriatric depression

After diagnosis of glaucoma, people need to bechecked regularly by an eye specialist.

The most common form of glaucoma in theUnited States is open-angle glaucoma. In open-angle glaucoma, the optic nerve is slowly damaged,usually causing gradual loss of vision. Both eyescan be affected at the same time, although onemay be affected more than the other. In somecases, much of the person’s eyesight can be affectedbefore he or she notices a change.

Closed-angle glaucoma is less common, account-ing for about 10 percent of all glaucoma cases in theUnited States. It may cause sudden blurred visionwith pain and redness, usually in one eye first.

Causes of Glaucoma

The damage to the optic nerve in glaucoma isthought to be caused partly by increased pressurein the eye (intraocular pressure or IOP) that resultsfrom the buildup of fluid inside the eye. However,damage often occurs without increased IOP. Manydoctors believe that glaucoma should be consid-ered as a neurodegenerative disease, caused bydamage to and loss of nerve cells, rather than justa disease of high intraocular pressure.

Symptoms of Glaucoma

Many people who have open-angle glaucoma haveno symptoms until they begin to notice loss ofvision. Peripheral (side) vision is usually lost beforecentral vision, which is necessary to see detailssharply. A person usually does not notice side visionloss until it becomes severe because the less affectedeye makes up for the loss. Also, the person does notnotice loss of sharpness of vision until late in the dis-ease. By that time, significant vision loss may haveoccurred. Some people with closed-angle glaucomado not have any apparent symptoms or have onlymild symptoms. Others may have several symptomsthat require immediate medical attention.

Symptoms of closed-angle glaucoma usuallyaffect only one eye at a time and often includesudden severe blurring vision, severe pain in theeye itself or in areas immediately around the eye,colored halos around lights, redness of the eye,nausea, and vomiting.

Testing for Glaucoma and Treatment

During routine visits to eye health professionals,patients are usually tested for glaucoma. When a

person is diagnosed with glaucoma, a target typepressure for each eye is established. The target isbased on the amount of damage to the optic nerveand the pressure at which the damage occurred.The target eye pressure is approximately 20 per-cent less than the prior eye pressure. During treat-ment, the target eye pressure is adjusted as neededto prevent damage to the optic nerve.

Treatment is centered on preserving eyesight byslowing damage to the optic nerve. In adults, treat-ment cannot restore eyesight that has already beenlost as a result of glaucoma. Most treatment focuseson lowering the pressure in the eyes. Optic nervedamage can occur at any level of eye pressure,even within the normal range. Lowering the pres-sure in the eyes often can help protect the opticnerve from further damage.

Treatment usually begins with medications;when medications do not successfully lower pres-sure in the eyes, laser or surgical treatments maybe considered. However, in moderate to severecases, it may be appropriate to use laser or surgicaltreatments first.

Treatment with medication or surgery are botheffective; however the risks and benefits may differdepending on the type of glaucoma, age, race, andother factors.

global warming The idea that human activitiescan rapidly change Earth’s climate is a cause forconcern and stress for people all over the world.

Global warming is not a new concept. JeanFourier, a French physicist, was the first to under-stand the “greenhouse” effect. In 1824 he suggestedthat Earth stays warm at night because its atmos-phere traps sun-warmed gases in the same way agreenhouse holds heated air. In 1892, SvanteArrhenius, a Swedish physical chemist, predictedthat, if levels of carbon dioxide in the atmospheredoubled, the average temperature of Earth wouldrise between 1.5 and four degrees Celsius, close tothe prediction most climatologists share today.

Stresses arise for many people who become con-cerned about the increased incidence of moreintense cold during winter and more intense heatduring summer, as well as flooding, landslides, tor-nadoes, and hurricanes. Additionally, some peopleare concerned about the use of products such as

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aerosol sprays and chemical pollutants, which maycontribute to global warming.

globus hystericus See LUMP IN THE THROAT.

goals See HARDINESS.

gonorrhea See SEXUALLY TRANSMITTED DISEASES.

gout A disease caused by the deposit of uric acidcrystals in the joints of the body. It is a source ofstress for many people because they experiencepain, swelling, redness, and heat as well as stiffnessin one or more joints. Gout can flare up withoutspecific causes, or can be brought on by a variety offactors, including a high-protein diet (foods rich inpurines, such as organ meats, anchovies, or sar-dines), moderate to heavy alcohol intake, obesity,or very-low-calorie diets.

Gout is a form of ARTHRITIS (inflammation of thejoints) and affects 2.1 million Americans; it is mostcommon in men aged 40–50. Gout is caused by toomuch uric acid in the blood (hyperuricemia).Hyperuricemia usually is not harmful, and mostpeople who have high levels of uric acid in theirblood never develop gout. Why people developgout is largely unknown, although inherited fac-tors seem to play a large role. When uric acid lev-els in the blood are too high, uric acid maycrystallize and accumulate in the connective tissue,joint spaces, or both.

Symptoms of Gout

A gout attack typically involves pain, swelling, ten-derness, redness, and inflammation in a singlejoint, most often the big toe. Other joints of thefeet and joints of the ankles, knees, wrists, fingers,and elbows may also be involved. Often symptomsdisappear. Mild attacks may stop after severalhours or last for one to two days. Severe attacksmay last up to several weeks, with soreness lastingfor up to a month. Some people only experienceone attack with no recurrence. However, mostpeople have a second attack of gout within sixmonths to two years after their first attack, butthere may also be intervals of many years betweenattacks. If gout is untreated, the frequency ofattacks usually increases with time.

Diagnosing and Treating Gout

Physicians use tests to measure the amount of uricacid in the blood or urine. The only certain way todiagnose gout is to have a joint fluid aspiration(arthrocentesis) test to see whether uric acid crys-tals are present. Usually, gout can be successfullytreated by taking medication and monitoring diet-ing carefully. However, physicians usually wait twoto four weeks after a gout attack is over to begin amedication to lower the high uric acid levels. Foran acute gout attack, a patient may be advised touse heat on the affected joints, rest the joint, andthen take one of several possible prescription med-ications, such as nonsteroidal antiflammatorydrugs (NSAIDs), colcicine, or prednisone. Aspirinshould be avoided because it elevates serum uricacid levels and may worsen symptoms. To preventrecurrent attacks, many patients are advised totake a medication that lowers serum uric acid lev-els, such as allopurinal. Allopurinal blocks uric acidproduction and is the drug most often used inlong-term treatment for older patients and thosewith high levels of excreted uric acid.

See also PAIN.

FOR INFORMATION CONTACT:American College of Rheumatology/Association of

Rheumatology Health Professionals1800 Century Place, Suite 250Atlanta, GA 30345-4300(404) 633-3777(404) 633-1870 (fax)http://www.rheumatology.org

Arthritis Foundation1330 West Peachtree StreetAtlanta, GA 30309(800) 283-7800 (toll-free)(404) 872-7100http://www.arthritis.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

National Institutes of Health1 AMS CircleBethesda, MD 20892-3675(877) 226-4267(301) 495-4484TTY: (301) 565-2966Fax: (301) 718-6366

162 globus hystericus

http://www.niams.nih.govE-mail: NIAMSInfo@mail.nih.gov

greenhouse effect See AIR POLLUTION.

grief An intensely powerful, painful, and stress-ful emotional reaction caused by the loss of a lovedone or of something with very important personalsignificance in an individual’s life. While theexpression of grief is unique to each individual,there are recognized stages of grief (bereavement),which include some common characteristics aswell as sources of STRESS for most people.

Many individuals call into play their ownDEFENSE MECHANISMS. These mechanisms may helpan individual cope with the pain of the loss.

Numbness is a pervasive feeling that enables themourner to get through the first few days follow-ing the DEATH of the loved one; it may last from afew days to a few months. HALLUCINATIONS are alsocommon among the recently bereaved; in somecases, they believe that the dead person walks intothe room or they see him/her in a crowd. In thecase of a deceased infant or child, a parent mayhear his/her cry or voice.

As the initial feeling of numbness begins to wearoff, the individual may feel anger and despair andfeel overwhelmed by the circumstances; these feel-ings can lead to DEPRESSION. In some cases, such asdeath or divorce, people may feel angry that theperson deserted them.

Physical symptoms are fairly common, includingHEADACHES, INSOMNIA, or gastrointestinal com-plaints. Attempted SUICIDE is an abnormal expres-sion of grief, but is not uncommon. There may bean increase in use of tranquilizer drugs and alcoholat this time.

The individual may experience intense feelingsof helplessness. Questions arise: “Could I have pre-vented this from happening? Why wasn’t I power-ful enough to do something more?” Such thoughtsare part of the human condition. People like to feelthat they are in CONTROL at all times, and with griefthey feel the loss of that control.

Many people who have experienced loss saythat it can take up to two years to adjust and get onwith life. However, overwhelming feelings of lossdo recur. In the long run, a positive attitude can

help overcome depressed feelings and the stressesof adjustment.

A support system often influences how well anindividual adjusts after a period of grief. The recov-ery process may be accelerated with friends andfamily nearby. Widowed persons with no relativesand few friends seem to have the most stressorsand the most difficult time adjusting to the deathof a loved one. Some parents who have lost aninfant try to have another baby within a few years;however, the feeling of loss of the first one neverreally goes away. Many divorced people remarrybut others do not.

Overcoming the Stresses of Grief

Individuals who continue to suffer from thestresses of grief for a long period of time may findmental health counseling helpful. Getting helpwhen it is needed is a sign of strength and wisdom;appropriate referrals for mental health help can beobtained from a social worker or a physician. SUP-PORT GROUPS for widows and widowers, parentsand divorcees are effective for many people.Knowing that others had the same emotional reac-tions can help participants cope better with theirgrief stressors. Those grieving for the loss of a childmay also find help in appropriate support groups.

The Bereavement of Loss Center in New York isan organization that provides professional counsel-ing services for individuals who have suffered lossor who anticipate a loss, such as loss of a spouse,child, relative, or friend. The center is nonsectarianand provides psychiatric social workers and psychi-atrists with an advisory staff, including other med-ical specialists, financial advisers, and attorneys.Other sources of help can be found through manyorganizations that offer telephone information andreferral services. Crisis telephone lines and centersand hospital social service departments are some-times a fast way of getting help; these numbersshould be listed in a special section of local tele-phone books.

Another’s Grief as a Stressor

One person’s grief is often a source of stress foranother. Some individuals are at a loss for what tosay or what to do. Despite these feelings, there aresome supportive activities that might be helpful.For example, offering a quiet supportive presence;

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encouraging the bereaved person to talk and sharehappy as well as sad memories; avoiding beingjudgmental of any comments the bereaved personmight make; encouraging him or her to remainconnected to former support systems, such associal or church groups; and being available in aproactive way to get the person back into the cycleof a mentally healthy lifestyle.

See also DEATH; PREGNANCY; SUDDEN INFANT

DEATH SYNDROME.

FOR FURTHER INFORMATION:Bereavement and Loss Center of New York170 East 83rd StreetNew York, 10028(212) 879-5655

Elisabeth Kübler-Ross CenterSouth Route 616Head Waters, VA 24442(703) 396-3441

Mental Health Association of Greater Chicago104 South Michigan AvenueChicago, IL 60603-5901(312) 781-7780

Parents of Murdered Children100 East Eighth Street, Suite B41Cincinnati, OH 45202(513) 721-LOVE

Pregnancy and Infant Loss Center1415 Wayzata Boulevard, Suite 105Wayzata, MN 55391(612) 473-9372

Theos1301 Clark Building717 Liberty AvenuePittsburgh, PA 15222(412) 471-7779

SOURCES:Kahn, Ada P. “Living with the Death of a Loved One,”

(brochure). Chicago: Mental Health Association ofGreater Chicago, 1989.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Kübler-Ross, Elisabeth. On Death and Dying. New York:Macmillan, 1971.

Ramsay, R. W., and R. Noorbergen. Living with Loss. NewYork: William Morrow, 1981.

group therapy See PSYCHOTHERAPIES.

grudges See HOSTILITY.

GSR See GALVANIC SKIN RESPONSE.

guided imagery A technique to help the individualgenerate vivid mental images that help reduceSTRESS. It creates positive mental pictures and pro-motes the relaxation necessary for a healing process.The individual pictures an image, such as a calm,serene lake with sailboats slowly moving along,breathes in a relaxed manner, and becomes morerelaxed. The individual gradually learns to noticeevery detail of the imagined scene and how the senseof RELAXATION deepens with this self-talk. He learns,too, that this sense of calm can be created at any timeby BREATHING and imagining the positive vision.

Some case studies and clinical reports suggestthat the guided imagery technique may be helpfulin the treatment of chronic PAIN, ALLERGIES, hyper-tension, autoimmune diseases, and stress-relatedgastrointestinal, reproductive, and urinary symp-toms. In addition to direct effects, imagery mayaugment the effectiveness of medical treatmentsand help people tolerate discomforts and sideeffects of some medications or invasive procedures.

Imagery has qualities that make it valuable inmind/body medicine and healing; it can bringabout physiological changes, provide psychologicalinsights, and enhance emotional awareness. Use ofimagery, in some cases, changes the need for med-ication. Depending on an individual’s medical con-dition, imagery is best used under the supervision ofa physician in conjunction with holistic medicine.

Guided imagery can be used alone or togetherwith other relaxation techniques. It is often used inconjunction with HYPNOSIS, although the two tech-niques are distinct. While hypnosis serves toinduce a special state of mind, imagery consists ofa focused, intentional mental activity.

See also ALTERNATIVE MEDICINE; IMMUNE SYSTEM;IRRITABLE BOWEL SYNDROME.

FOR FURTHER INFORMATION:The Academy for Guided ImageryP.O. Box 2070Mill Valley, CA 94942(800) 726-2070 (toll-free)

164 group therapy

SOURCES:Goleman, Daniel, and Joel Gurin, eds. Mind Body Medi-

cine: How to Use Your Mind for Better Health. Yonkers,N.Y.: Consumer Reports Books, 1993.

Kerns, Lawrence. Chicago Medicine 97, no. 22 (November21, 1994).

guilt Emotional response to a perceived or actualfailure to meet expectations of the self or others.Guilt is a stressor for many people because guiltfeelings can be destructive if carried to an extreme.It can destroy people’s sense of SELF-ESTEEM andfeeling of capability. However, these feelings canalso be constructive when people begin to under-stand their sources of guilt and learn to cope withthis very common aspect of the human condition.

Some individuals, depending on differences inconscience, can steal or commit crimes against oth-ers and not feel any guilt, while others will sufferfrom stressful guilt feelings over incidents that occurall their lives. Many individuals may experienceguilt feelings for not remembering the birthday of aparent or spouse. Middle-aged adults may experi-ence guilt feelings when dealing with their agingparents. Some individuals who are bereaved over adeath of a loved one may feel some guilt about nothaving done enough for the person when they werealive. Parents of infants who die of SUDDEN INFANT

DEATH SYNDROME (SIDS) suffer stress because of feel-ings of guilt over not preventing the death of theirchild. Spouses and relatives of people who commitSUICIDE may have guilt feelings for years, wonderingif they could have prevented the death.

For some individuals, mental health counselingor participation in an appropriate support groupcan help relieve some of these uncomfortable feel-ings of guilt.

See also COPING; DEPRESSION.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

Gulf War Illness Symptoms reported by manywho served in the armed forces in the Persian GulfWar in 1991. The illness has been a major source ofstress for more than 100,000 American veterans,who, within six to 12 months after exposure,reported a wide variety of symptoms including skinrashes, headaches, disabling fatigue, intermittentfevers, joint and muscle pains, and short-termmemory impairment. The sufferers of Gulf War Ill-ness may have been exposed to depleted uranium,used in artillery shells; fallout from destroyednuclear reactors; biological contaminants, such asbacteria and viruses; or chemical mixtures, possiblyanti-nerve and nerve agents.

In the late 1990s, the United States launched ahealth care outreach effort to evaluate their healthconcerns of those with Gulf War Illness symptoms.The Department of Defense allocated up to $12million for general research on possible causes ofGulf War Illness. In 2004, after studying more than2.5 million veterans for nearly four years, theDepartment of Defense and Veterans Affairsannounced that veterans of the conflict are nearlytwice as likely as other soldiers to suffer from amy-otrophic lateral sclerosis (Lou Gehrig’s disease).Officials said they will offer disability and survivorbenefits to affected patients and families. Researchon the health of these veterans is still under way.

FOR FURTHER INFORMATION:Environmental Agents ServiceVeterans Health AdministrationDepartment of Veterans Affairs810 Vermont Avenue NWWashington, DC 20402(202) 273-8580(202) 273-9080 (fax)http://www1.va.gov/environagents

VA Gulf War Information Helpline(800) 749-8387http://www.va.gov/gulfwar

Gulf War Illness 165

Hhabits Learned responses that one performs auto-matically and frequently. They may include usefulprocedures, such as knowing how to use a computerkeyboard, taking a shower in the morning, or alwaysleaving a key in a certain place. Habits can also beresponses to stressful situations, such as scratchingthe head, NAIL BITING, HAIR PULLING, or reaching for acigarette. These unwanted or undesirable habits, ifcontinued, can contribute to people’s stress levels.

Habits can include certain repetitive and ritualbehaviors such as those practiced by sufferers ofOBSESSIVE-COMPULSIVE DISORDER. These habits thatusually cause the individual stress can be changedby BEHAVIOR THERAPY, psychotherapy, and the sub-stitution of more constructive habits. RELAXATION

therapy, GUIDED IMAGERY, HYPNOSIS, and BIOFEED-BACK may also be helpful techniques in overcom-ing these habits.

See also ANXIETY DISORDERS.

hair loss Hair falling out, extremely thinninghair, and baldness. Hair loss is stressful for peoplebecause they associate their “crowning glory” withSELF-ESTEEM and BODY IMAGE. For many, hair loss isalso symbolic of aging. Sufferers of hair loss mayresort to so-called magic potions, megavitamins,and scalp massage and treatments to encouragenew hair to grow.

More recently, several hair loss products havebeen developed and are selling as over-the-counterproducts. They have proved successful for somepeople but must be used on a continuous basis tobe effective.

Hair loss is common; nearly two out of threemen develop some form of balding. An evenhigher percentage of men and women combinedhave some form of hair loss during their lives.

With appropriate diagnosis, many people suffer-ing from hair loss can be helped. Diagnosis is thefirst step. Hair loss can be due to many differentcauses, such as pregnancy, high fever, severe infec-tion, or severe flu. It may also be due to thyroid dis-ease, inadequate protein in the diet, certainprescription drugs and cancer treatment drugs,birth control pills, low serum iron, major surgery,chronic illness, or ringworm of the scalp. Aftersome forms of hair loss, hair will regrow. Individu-als undergoing chemotherapy experience hair loss;expectations are that hair will grow back some timeafter completion of chemotherapy. Other forms canbe treated successfully by dermatologists.

About 90 percent of a person’s scalp hair is con-tinually growing. Shedding 50 to 100 hairs a day isconsidered normal. When a hair is shed, it isreplaced by a new hair from the same folliclelocated just below the skin surface. Scalp hairgrows about a half-inch a month. As people age,their rate of hair growth slows down, and thinninghair may be noticeable.

See also AGING.

FOR FURTHER INFORMATION:American Academy of DermatologyP.O. Box 4014Schaumburg, IL 60168-4014(708) 330-0230

American Hair Loss Council125 Seventh Street, Suite 625Pittsburgh, PA 15222(214) 581-8717

National Alopecia Areata FoundationP.O. Box 150760San Rafael, CA 94915-0760(415) 472-3780

166

hair pulling A habit that involves pulling outscalp hair and sometimes hair on eyebrows, eye-lashes, and body; men may pull out beard andmustache hairs. For many people, hair pulling is amechanism for COPING with STRESS. They do itwhen they are feeling nervous or tense; or it is acompulsion, known as trichotillomania.

Some individuals pull hair in front of others, butmost often the activity is pursued in secret. Thehairs are carefully hidden or disposed of. The hair-less areas have distinctive features and help distin-guish trichotillomania from other forms of hair lossand disease. The patches are irregular in outline,not sharply defined, and the hair loss is never com-plete. Many of the hairs will break off rather thanbe completely pulled out, so that variable amountsof stubble remain. There are usually no signs ofinflammation, and the scalp elsewhere is normal.

The habit can be treated with BEHAVIOR THERAPY

or other forms of PSYCHOTHERAPIES.See also ANXIETY DISORDERS; HAIR LOSS; HYPNOSIS;

OBSESSIVE-COMPULSIVE DISORDER.

FOR FURTHER INFORMATION:The Obsessive Compulsive Disorder FoundationP.O. Box 9573New Haven, CT 06535(203) 772-0565

Hakomi Form of body-centered psychotherapybased on principles that show individuals ways tolive in harmony with themselves and others. Itteaches individuals to enter a state of awareness inwhich spontaneous and often nonverbal informa-tion becomes available and from which basic andunconscious beliefs stem and direct their lives.Many people use Hakomi as a way of preventingthe harmful effects of stress.

The body stores and expresses what the mindand heart believe. Trained to look at nuances ofvoice and body language, posture and gesture,Hakomi therapists help individuals study theseavenues to unexpressed feelings and past trauma,and gain release from the past. Hakomi teacheshow to observe oneself from a step away (witness-ing) as well as from inside one’s present experi-ence. Individuals learn to have a choice ofresponses. Through the use of witnessing,

unwanted defenses can be studied and willinglyyielded.

Hakomi is a blend of many philosophies andideologies, including Eastern philosophy, Westernpsychology, Taoism, Feldenkrais, Reichian, Rolf-ing, and other structural bodywork therapies,Ericksonian hypnosis, focusing, and neurolinguis-tic programming.

See also ALTERNATIVE MEDICINE; BODY THERAPIES.

hallucinations Seeing, hearing, smelling, tasting,or feeling something that is really not there. Theyare sources of stress because these perceptions can-not be reinforced by anyone else. Hallucinationsmay be disturbing to sufferers as well as those whoare trying to understand what they are feeling.

Hallucinations sometimes occur as a reaction tocertain medications, to high fevers, and serious ill-nesses. They also occur in some severe mental dis-orders, such as schizophrenia.

Reactions to Hallucinogens

Hallucinogens are drugs and agents that produceprofound distortions to one’s senses of sight, sound,smell, and touch, as well as the senses of direction,time, and distance. Although some individuals mayresort to hallucinogens for relief from stress, thereare no acceptable medical uses for hallucinogens.

People may experience a “high” associated withuse of hallucinogens that may last as long as eighthours. However, there are aftereffects, includingacute ANXIETY, restlessness, and sleeplessness. Longafter the hallucinogen is eliminated from the body,the user may experience “flashbacks,” which arefragmentary recurrences of hallucinogenic effects.

Hallucinogens occur naturally but are primarilycreated synthetically. The most common hallucino-gens are LSD (lysergic acid diethylamide), mescaline,peyote, psilocybin mushrooms, 3,4-methylene-dioxymethamphetamine MDMA, and phencyclidine(PCP).

See also ADDICTION.

FOR FURTHER INFORMATION:American Society on Addiction Medicine5225 Wisconsin Avenue NW, Suite 409Washington, DC 20015(212) 244-8948

hallucinations 167

handedness See LEFT-HANDEDNESS.

handicap See DISABILITIES.

hangover A disagreeable physical effect thatoccurs after consuming too much alcohol, or dis-agreeable aftereffects from the use of drugs. Some-times sleeping medications cause hangover-likesymptoms. A hangover is a source of stress as itproduces physical as well as emotional symptomsthat differ between individuals. Some may experi-ence nausea, vomiting, or DIZZINESS, while othersmay have HEADACHES, sleepiness, unsteadiness,blurred vision, depression, or self-pity. For manyindividuals, symptoms do not occur until severalhours after drinking the alcohol, when theyawaken from sleep. They may blame the mixing ofdrinks, but drinking any one alcoholic beveragealone can cause a hangover.

The distinctive headache experienced as part ofa hangover may be due to toxic substances that arereleased into the bloodstream and cause irritationof the brain membranes. Headaches may also comefrom the pressure of swollen blood vessels, whichis an effect of alcohol. When alcohol promotesexcessive urination, the resulting loss of fluid mayreduce spinal fluid pressure, which has beenknown to bring on a headache.

Usually individuals recover from hangoverswithout medical assistance. Recommendationsfrom physicians generally include aspirin (unlessone is aspirin intolerant), bed rest, and solid foodas soon as possible. A cup of coffee and a mealhelps most people feel better.

See also ALCOHOLISM AND ALCOHOL DEPENDENCE.

harassment See SEXUAL HARASSMENT.

hardiness Term adopted by Salvatore Maddi, Ph.D.(a University of Chicago psychologist), to describestress-buffering characteristics of people who stayhealthy. People with hardiness are able to withstandsignificant levels of STRESS without becoming ill;those who are more helpless than hardy developmore illnesses, both mental and physical.

In working with executives at a major Americanemployer, Dr. Maddi and colleagues determined

three techniques that can augment hardiness aswell as happiness and health.

Focusing is a technique developed by EugeneGendlin, an American psychologist. It is a way of rec-ognizing signals from one’s body that something iswrong, such as tension in the neck or a mildheadache. With stress, these conditions worsen.Maddi suggests mentally reviewing where things arenot feeling just right and reviewing situations thatmight be stressful. Focusing increases one’s sense ofCONTROL over stress and enables one to make changes.

Reconstructing stressful situations. This is a techniquein which you think about a recent stressful episodeand write down three ways in which it might havegone better and three ways in which it might havegone worse. If you can’t think of what you couldhave done differently, focus on a person you knowwho deals with stress well and what he or shewould have done. Realize that things did not go asbadly as they could have. Also, realize that you canthink of ways to cope better with the same situation.

Self-improvement. In this technique, you knowthere are some situations you cannot control; youcannot avoid some situations, such as a serious ill-ness or illness of a member of your family. To regainyour sense of control and achieve more effectiveCOPING, choose a new task to master, such as learn-ing how to swim, dance, or develop a new hobby.

Suzanne Kobasa, a City University of New Yorkpsychologist, also used the term hardiness to iden-tify and measure a style of psychological coping.Some of the characteristics people with hardinessexhibited included viewing life’s demands as chal-lenges rather than threats, responding with excite-ment and energy to change, and having acommitment to something they felt was meaning-ful, such as their work, community, and family. Athird trait was a sense of being in control. Havingthe right information and being able to make deci-sions can make an important difference in copingwith stress.

Issue of Control in Hardiness

A study reported in the Journal of Personal and SocialPsychology (April 1995) detailed how 276 Israelirecruits completed questionnaires on hardiness,mental health, and ways of coping at the beginningand end of a demanding, four-month combattraining period. Two components of hardiness,

168 handedness

commitment and control, measured at the begin-ning of the training, predicted mental health at theend of the training. Commitment improved mentalhealth by reducing the appraisal of threat. Controlimproved mental health by reducing appraisal ofthreat and by increasing the use of problem-solv-ing and support-seeking strategies.

See also GENERAL ADAPTATION SYNDROME; LEARNED

HELPLESSNESS.

SOURCES:Floria, V., et al. “Does Hardiness Contribute to Mental

Health during a Stressful Real-life Situation? TheRoles of Appraisal and Coping.” Journal of Personal andSocial Psychology 68 (April 1995): 687–695.

Goleman, Daniel, and Joel Gurin, eds. Mind Body Medi-cine. How to Use Your Mind for Better Health. Yonkers,N.Y.: Consumer Reports Books, 1993.

Padus, Emrika, ed. The Complete Guide to Your Emotions andYour Health. Emmaus, Pa.: Rodale Press, 1992.

“having it all” Expression that became popularduring the 1980s; refers to career WOMEN who fol-low their chosen business or profession, get mar-ried, and raise a family. For many, this has becomea satisfying way of life, but others have experi-enced many stressors, such as frustrations and anx-ieties. Some women feel that they are not givingadequate attention to their MARRIAGE and children,are constantly tired, and feel some guilt over hav-ing their children in DAY CARE centers.

Nevertheless, an increasing number of womendo opt to enter business and professions. Thosewho are most successful say it is due to the help-fulness and understanding of their spouses as wellas an adequate day-care situation.

See also WOMEN’S MOVEMENT; WORKING MOTHERS.

hay fever Allergic rhinitis, which is commonlycalled hay fever, is an inflammation of the nasalpassages caused by an allergic reaction. It is a typeof respiratory allergy that may affect the nose(allergic rhinitis), sinuses (allergic sinusitis), orbronchial tubes (asthma). Allergic rhinitis causessymptoms primarily but not exclusively in thenose. The most stressful symptoms of allergic rhini-tis include sneezing repeatedly, particularly whenwaking in the morning; a runny nose and post-nasal drip; watery and itchy eyes; and itchy ears,

nose, and throat. For some people, symptomsoccur almost immediately, or as in as little as fiveminutes after they have been exposed to an aller-gen such as air pollution, diesel fumes, cigarette orwood smoke, insecticides, strong odors, perfume,and other irritating substances in the air.

In addition to the nose, the eyes, ears, throat,and mouth may be affected. People who developallergic rhinitis may have the allergy for manyyears but may lose some of their sensitivity as theygrow older.

What Causes Hay Fever?

Allergic rhinitis is caused by an allergic reaction thatoccurs when the immune system overreacts to asubstance called an allergen. It is not known whypeople develop allergic rhinitis or other types ofallergies. Most people who have allergies have fam-ily members who also have some kind of allergies.

Some studies suggest that viral or bacterial infec-tions of the nose, throat, and bronchial tubes (alsocalled upper respiratory infections [URIs]), mayplay a role in whether a person develops allergies.

Coping with Hay Fever

Avoidance of the factors (allergens) that may causesymptoms is a good first step. Knowing the aller-gens to which one is sensitive is important. If aller-gic avoidance does not relieve symptoms, or if thesymptoms are severe, a physician will considerother treatment methods. Some medications onlyrelieve symptoms, but other medications mayimprove the underlying condition as well. Some-times allergy shots are recommended.

See also ALLERGIES; ASTHMA.

hazard communication (HazCom) Identifyingand alerting workers or others about dangers orhazards at their location. The goals of a hazardcommunication program are to reduce stress,assure that workers and others are aware of dan-gers and how to protect themselves, and reducethe incidence of illness and injuries.

Generally, hazard communications programscover chemical injuries. Chemicals pose a widerange of health hazards such as irritation, sensitiza-tion, carcinogenicity, and physical hazards such asflammability, corrosion, and reactivity. The HealthCommunication Standard of the Occupational

hazard communication 169

Safety and Health Administration is designed toensure that information about these hazards andassociated protective measures is disseminated toworkers and employers. This is accomplished byrequiring chemical manufacturers and importers toevaluate the hazards of the chemicals they produceor import, and to provide information about themthrough labels on shipping containers and moredetailed information sheets known as materialsafety data sheets (MSDSs). All employers with haz-ardous chemicals in their workplaces must prepareand implement a written hazard communicationprogram, and must ensure that all containers arelabeled, tagged, or marked with an appropriate haz-ard warning. Employees must be provided access toMSDSs and receive an effective training program forall potential exposures to reduce the stress associ-ated with disasters.

The Hazardous Chemicals Standard providedworkers with the right to know the hazards andidentities of the chemicals to which they areexposed in their workplace. A list of the chemicalscan serve as an inventory of all items for which anMSDS must be maintained. When workers havethis information, they can effectively participate intheir employers’ protective programs and take stepsto protect themselves. In addition, the standardgives employers the information they need to designand implement an effective protective program foremployees potentially exposure to hazardous chem-icals. These actions can result in a reduction ofchemical sources of illnesses and injuries.

See also HAZARDOUS AND TOXIC SUBSTANCES;NEEDLESTICK INJURIES.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.

hazardous and toxic substances According tothe Occupational Safety and Health Administration(OSHA), U.S. Department of Labor, hazardous andtoxic substances are chemicals that are capable ofcausing harm. In this definition, the term chemicalsincludes dusts, mixtures, and common materialssuch as paints, fuels, and solvents. People whowork or live in environments where these sub-stances may be present may experience stress ifthey are aware of dangers associated with them.

OSHA currently regulates exposure to approxi-mately 400 substances. The OSHA Chemical Sam-pling Information file contains listings forapproximately 1,500 substances; the ChemicalSubstances Inventory of the Environmental Pro-tection Agency lists information on more than62,000 chemicals or chemical substances. Somelibraries maintain files of material safety datasheets for more than 100,000 substances.

OSHA provides guidelines related to chemicalsfor employers as well as for physicians, industrialhygienists, and other occupational safety andhealth professionals who may need such informa-tion to conduct effective occupational safety andhealth programs with as little stress as possible.

See also CHEMICAL HAZARDS.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.

headaches Headaches include pains in the head,from the outer linings of the brain and from thescalp and its blood vessels and muscles; headachesoccur due to tension in or stretching of these struc-tures. They are a source of stress because of theirdiscomfort and unpredictability. They may becaused by a reaction to stressful situations as wellas to overindulgence in alcohol, extreme fatigue,and certain infections. Headaches are fairly com-mon in DEPRESSION, sleep disorders, and in individ-uals who have many anxieties, as well as thosesuffering from BOREDOM. The National HeadacheFoundation estimates that more than 80 millionAmericans develop headaches each year that areserious enough to warrant treatment by a physi-cian. They are the most frequent complaint thatphysicians treat and may indicate a more seriouscondition.

Types of Headaches

Tension or muscle contraction headaches, caused bytightening in the muscles of the face, neck, andscalp, may result from stress or poor posture; theymay last for days or weeks and can cause variabledegrees of discomfort. About 90 percent of allheadaches are classified as tension headaches.

Cluster headaches. The term refers to a character-istic grouping in a series of attacks. The pain is gen-

170 hazardous and toxic substances

erally very intense and severe and is almost alwaysone-sided; during a series, the pain remains on thesame side. In a new series, it can occur on theopposite side. Cluster headaches are not associatedwith the gastrointestinal disturbances or sensitivityto light that typically accompany other vascularheadaches, such as migraine.

Temporomandibular joint (TMJ) headaches cause adull ache in and around the ear that gets worsewhen one chews, talks, or yawns. Sufferers mayhear a clicking sound on opening the mouth andfeel soreness in the jaw muscles. Stress, a poor bite,or grinding of the teeth may bring on the headache.

Caffeine headaches occur in some individuals whodrink too much CAFFEINE in coffee, tea, and softdrinks. Some people can relieve their symptoms byeliminating drinks containing caffeine from theirdiet. Others, however, who drink large quantities ofsuch liquids and stop abruptly, may suffer caffeinewithdrawal symptoms, including headaches, irri-tability, depression, and sometimes nausea; reliefmay occur with ingestion of a caffeinated beverage.

Migraine Headaches

Migraine or vascular headaches are characterized bythe throbbing sensation that occurs when blood ves-sels in the head dilate or swell. Migraine is an oftendebilitating disease that occurs in periodic attacks,with each attack lasting from four to 72 hours.Symptoms may include intense pain, often associ-ated with nausea, vomiting, appetite loss, and anunusual sensitivity to light and/or sound. Migrainesgenerally start on either side of the head and usuallyremain one-sided. Of the 23 million Americanmigraine sufferers, 60 percent are women. Men andwomen between the ages of 35 and 45 years suffermost from migraine headaches, according to a studyreported in the Journal of the American Medical Associ-ation (December 31, 1991). More than three-fourthsof migraine sufferers come from families in whichother members have the same disorder. The JAMAresearchers reported that 8.7 million females and2.6 million males suffer from migraine headachewith moderate to severe disability. Of these, 3.4 mil-lion females and 1.1 million males experience oneor more attacks per month.

Common migraine headaches start unexpectedly,while classic migraine is usually preceded by awarning symptom known as an aura, which occurs

five to 30 minutes prior to the headache. Typically,the aura includes HALLUCINATIONS of jagged light orcolor, speech impairment, perception of strangeodors, confusion, and tingling or numbness in theface or limbs.

Why Migraine Headaches Are So Stressful

Because migraine headaches usually recur, suffer-ers become concerned that an attack will happen atan unfortuitous time, such as on the day of a grad-uation, a wedding, or important appointment.Migraine headaches often begin during a period oftime filled with anxieties, such as during adoles-cence or MENOPAUSE, or around the time of aDIVORCE or death of a mate. When a physiciandiagnoses headaches, the individual’s anxieties andCOPING styles will be considered.

Migraine headaches, which often occur inmembers of the same family, may result from apredisposing genetic biochemical abnormality.Also, personality traits may play a role in deter-mining who gets migraines. Although there is notypical personality associated with these headaches,some migraine sufferers have characteristics ofcompulsivity and PERFECTION.

Emotional tension and stress may lead tomigraine attacks, because under extreme stress,the arteries of the head and those reaching thebrain draw tightly together and restrict the flow ofblood. This in turn may result in a shortage of oxy-gen to the brain. When blood vessels dilate orstretch, a greater amount of blood passes through,

headaches 171

COMMON MIGRAINE TRIGGERS

• Dietary habits (see detailed listing following)• Environmental factors, such as weather, bright

lights, glare, or noise• Emotional factors such as depression, anxiety,

resentment, or fatigue• Activity, such as motion from riding in a car or

airplane, lack of sleep, too much sleep, eye-strain, and a fall or head injury

• Hormonal, such as menstrual cycle or use oforal contraceptives or estrogen supplements

• Medications, such as overuse of over-the-counter pain relievers and some prescriptionmedications

putting more pressure on the pain-sensitive nervesin and close to the walls of the arteries.

Common Migraine Triggers

In a susceptible person, the migraine trigger mightbe something seen, smelled, heard, eaten, or expe-rienced; it may be one particular trigger or a com-bination of factors.

Approximately 20 percent of all migraine suffer-ers have a sensitivity to a specific food or foods.Knowing that certain foods may trigger migraines isan additional source of stress. Many individuals findthat certain foods (such as cheese, chocolate, andred wine) containing a substance known as tyra-

mine trigger migraine attacks. Sodium nitrite, a pre-servative used in ham, hot dogs, and many othersausages, is a trigger for some people. Althoughsome migraine researchers have recommended thatall migraine sufferers avoid these foods, only about30 percent of people who have migraine headachesexperience this reaction to some foods. Not eating ormissing meals can cause low blood sugar levels,which are also a migraine trigger.

Identifying and avoiding the triggers that causeheadaches is one of the most significant manage-ment techniques for controlling headache fre-quency and stress.

Migraine Headaches, Hormones, and Pregnancy

Although migraine headaches are more commonon young boys than in young girls, the number ofgirls affected increases sharply after the onset ofMENSTRUATION. Certain hormonal changes thatoccur during PUBERTY in girls and remain through-out adulthood may be implicated in the triggeringand frequency of migraine attacks in women.

The link between female endocrine changes andmigraine headaches is reinforced by the findingthat 60 percent of women sufferers involved in aclinical study related attacks to their menstrualcycle. Individual differences exist: attacks mayoccur several days before, during, or immediatelyafter the woman’s menses.

In females with migraine, about 77 percent findthat their attacks disappear completely, occur lessoften, or are milder during pregnancy. In others,attacks either worsened or remained unchanged.

Oral contraceptives also affect the incidence ofmigraine attacks. Some migraine sufferers find theirattacks are worsened while they are on the Pill.Others find that they are not affected, and a smallpercent report improvement. Yet some women,even without any predisposition to migraine,develop it while on the Pill, and nearly three-quar-ters find their headaches disappearing after theystop taking the Pill.

Diagnosis and Therapies

When a headache does not respond to RELAXATION,rest, sleeping, simple self-medication such asaspirin or nonsteroidal anti-inflammatory drugsavailable over the counter, cold compresses on thehead, or relaxation in a dark room, medical assis-

172 headaches

DIETARY FACTORS: POSSIBLE MIGRAINE ATTACK TRIGGERS

• Caffeinated foods and drinks; coffee, tea, choco-late, cocoa, colas/soft drinks

• Alcohol: especially red wine, vermouth, cham-pagne, beer

• Dairy products: aged cheeses, sour cream,whole milk, buttermilk, yogurt, ice cream

• Breads: sourdough, fresh yeast, and some typesof cereals

• Vegetables: some types of beans (broad, Italian,lima, lentil, fava, soy), sauerkraut, onions, peas

• Snacks: nuts, peanuts, peanut butter, pickles,seeds, sesame

• Meats: organ meats, salted meats, dried meats,cured meats, smoked fish, meats with nitrites(such as hot dogs, sausages, lunch meat)

• Fruits: most citrus fruits, bananas, avocados, figs,raisins, papaya, passion fruit, red plums, raspber-ries, plantains, pineapples

• Monosodium glutamate (MSG): a flavorenhancer often used in restaurants and also inseasoned salt, instant foods, canned soup, frozendinners, pizza, potato chips

• Soups: particularly those containing MSG; soupsmade from bouillon cubes

• Desserts: chocolate, licorice, molasses,cakes/cookies made with yeast

• Seasonings and flavorings such as soy sauce,some spices, garlic powder, onion powder, salt,meat tenderizers, marinades

• Hunger: missing meals, fasting, dieting

tance should be sought. During a complete physi-cal and neurological examination, the physicianwill ask about the history of the headaches, theperiod in time in which they have been occurring,when they occur, the circumstances at the time,and how long they last.

Diagnostic techniques may include use of com-puterized tomography scanning (CT scanning) ormagnetic resonance imaging (MRI).

Diagnosis is necessary before an individual takesany medication for headaches. Medications thathelp tension headaches will not help severemigraine headaches, and drugs targeted to relievemigraine headaches may not help any other type.Also, it is important that one does not overmed-icate for headaches and bring on other side effectsfrom medications.

Treatments for headaches include nonpharmaco-logical treatments, such as BIOFEEDBACK, MEDITATION,and relaxation techniques, as well as prescriptionmedications. In the mid-1990s, a medication becameavailable in tablet form (sumatriptan succinate) thatis a highly selective serotonin receptor-agonist forthe treatment of migraine with or without aura. It isnot indicated for cluster headache.

Alternative Therapies

A wide variety of ALTERNATIVE MEDICINE may behelpful for headache sufferers. Some individualsexperience relief with their use and without med-ication while others use them in conjunction withmedication. When individuals consider alternativetherapies, they should be discussed with the attend-ing physician. Although some people can relievetheir headache pain with alternative therapies, forothers these therapies act as an adjunct or comple-ment to the PHARMACOLOGICAL APPROACH, makingthe sufferer more receptive to medical treatment.

Biofeedback involves teaching a person to controlcertain body functions through thought andwillpower, with feedback from an electronic device.

Meditation is a technique of inward contempla-tion that helps some people relieve anxieties and inturn relieve some headaches, by relaxation. Duringmeditation, the mind, as well as other organs inthe body, slows down; heart rate decreases, breath-ing becomes slower, and muscle tensions diminish.

ACUPUNCTURE has been successfully used to treatsome headache sufferers. Acupuncture probably

works because the needle insertions somehowstimulate the body to secrete ENDORPHINS, naturallyoccurring hormonelike substances that kill pain.ACUPRESSURE involves pressing acupuncture pointswith the hands, and can be done by a professionalas well as by a trained layperson.

See also ANXIETY; GUIDED IMAGERY; HANGOVER;HYPNOSIS; TEMPOROMANDIBULAR JOINT SYNDROME.

FOR FURTHER INFORMATION:American Association for the Study of the

HeadacheP.O. Box 5136San Clemente, CA 92672(714) 498-1846(800) 255-ACHE

National Headache Foundation5252 North Western AvenueChicago, IL 60625(773) 878-7715

SOURCES:Diamond, Seymour. The Hormone Headache: New Ways to

Prevent, Manage, and Treat Migraines and OtherHeadaches. New York: Macmillan, 1995.

Inlander, Charles B., and Porter Shimer. Headaches: 47Ways to Stop the Pain. New York: Walker, 1995.

Maas, Paula, and Deborah Mitchell. The Natural HealthGuide to Headache Relief: The Definitive Handbook of Nat-ural Remedies for Treating Every Kind of Headache Pain.New York: Pocket Books, 1997.

healing touch See THERAPEUTIC TOUCH.

health care workers Approximately 6 millionpersons work in more than 6,000 U.S. hospitalsand health care settings, such as nursing homesand laboratories. Nearly 1 million workers providecare in a variety of community health settings,including patient homes, where available controlmeasures are more limited than in the hospital set-ting. Individuals working in health care face manystresses.

Assaults in the workplace and work organiza-tion issues such as inadequate staff, poor indoor airquality, and exposure to infectious agents anddrug-resistant infections like tuberculosis (TB)pose challenges to many health care workers andtheir employers. Female nurse’s aides and licensedpractical nurses are approximately two and a half

health care workers 173

times more likely to experience a work-relatedlower back disorder than all other female workers.Health care workers are at a higher risk of occupa-tional exposure to a number of airborne andbloodborne infectious disease relative to the gen-eral population. For example, urban health careworkers have a rate of seropositivity on tuberculinskin tests approximately eight times that of theU.S. population. There are hospital-based out-breaks of multi-drug-resistant TB; 17 cases havebeen documented among workers. In prevaccinesurveys, the annual incidence of HBV (hepatitis Bvirus) among physicians and dentists was five to 10times higher than among blood donors. The Cen-ters for Disease Control and Prevention (CDC) esti-mated that in 1994 there were approximately1,100 occupationally acquired HBV infections inhealth care workers in the United States, causing250 to 1,000 cases of clinical acute hepatitis and 50hospitalizations.

“Occupational exposure” accounts for approxi-mately 2 percent of all cases of hepatitis C.Although the incidence of occupational hepatitis Cvirus infection among health care workers isunknown, dentists, in particular oral surgeons,have been found to have a significantly higherseropositivity rate than blood donors.

At the end of 1996, the CDC reported 163 U.S.health care workers with documented or possibleoccupational transmission of human immunodefi-ciency virus (HIV) as a consequence of the approx-imately 800,000 needlestick injuries that occureach year. The first case of occupational transmis-sion of HIV infection to a health care worker wasdocumented in 1984, and it raised fear amonghealth care workers and their families. As a conse-quence, advances in occupational health and infec-tion control practices occurred.

Health care workers in nursing and occupa-tional medicine have always faced many sources ofstress. National professional societies in occupa-tional medicine and nursing were established in1916 and 1942, respectively. As recently as the1950s, there was no consensus regarding the occu-pational risk of TB exposure. A number of factorsmay have caused this lack of consensus, includingfear that young people would avoid nursingcareers if they knew the risks involved. When TB

declined significantly in the general public butremained elevated in the medical profession, TBwas recognized as an occupational hazard.

Stress Reduction for Health Care Workers

Stressful factors can be reduced for health careworkers. For example, nonhazardous substancescan be substituted for hazardous ones, workers canbe isolated from hazardous exposure, engineeringcontrols such as better ventilation can be estab-lished, and there can be more administrative con-trols covering work practices, and personalprotective equipment.

Psychosocial and organizational factors may cor-relate with hazards, such as risk-taking personalityprofiles or perceived conflict of interest betweenproviding optimal patient care and protecting one-self from exposure. Adequate and appropriate staffmix to meet the increasing acuity of hospitalizedpatients may have a relationship with work-relatedinjuries among nurses, according to a study by theInstitute of Safety and Health Research.

Priorities to reduce sources of stress includeinfectious diseases, allergic and irritant dermatitis,asthma and chronic obstructive pulmonary dis-ease, lower back disorders, indoor exposures, andorganization of work.

See also CONFINED SPACES; FUNGI; HUMAN IMMUN-ODEFICIENCY VIRUS; NOISE; NURSING HOMES; SHIFT

WORK; SLIPS, TRIPS, AND FALLS; REPETITIVE STRESS

INJURIES; STRESS; VIOLENCE.

health insurance Coverage for costs of specifiedillnesses, injuries, or treatments. Health insuranceis a particular source of stress for those who do nothave it. Many people who are self-employed, workpart time, or are unemployed do not have healthinsurance. Rising health care costs, a soft labormarket in which employers are passing morehealth care costs to workers, and reductions instate safety net programs have resulted in substan-tial increases in the numbers of uninsured.

Specific benefits may include short- and long-term disability, dental, medical, and vision care,and in some cases, accidental death coverage aswell as other benefits.

There are now several forms of health insur-ance. Although health insurance began as indem-nity insurance, with programs in which the

174 health insurance

insured person was reimbursed or the providerwas paid for covered expenses after services wererendered, today health insurance may mean cov-erage by one of many forms of managed care,including HEALTH MAINTENANCE ORGANIZATIONS,preferred provider organizations, or other types ofprepaid plans.

See also LONG-TERM CARE INSURANCE.

health maintenance organizations (HMOs) Pre-paid comprehensive health coverage to an enrolledpopulation for both outpatient physician servicesand hospital charges. HMOs are offered to manyemployed people as an alternative to more tradi-tional indemnity insurance. Controversies haveexisted over whether HMOs use “gatekeepers” toreduce the number of health care services used byits enrolled members.

Unlike traditional health insurance, in whichpatients seek out and choose their own health careproviders, the HMO arranges for as well as pro-vides designated health services needed by planmembers for a fixed, prepaid premium. The HMOis paid monthly premiums or capitated rates by thepayers, who may be employers, insurance compa-nies, government agencies, and other groups.

HMOs contract with health care providers, suchas physicians, hospitals, and other health profes-sionals. HMO members must use participating orapproved providers for all health services, and gen-erally all services must be approved by the HMOthrough a program of utilization review.

In most HMOs, a primary care physician assistsin finding specialists and coordinating needed care.Members enroll for a specified period of time, usu-ally one year and, in most instances, have anoption to move in or out of an HMO annually iftheir employer offers more than one option ofhealth insurance. In some states, HMOs also coverpersons covered by Medicare.

The federal HMO Act of 1973 specifies that eachHMO meet certain regulations; there are also stateregulations that each HMO must follow. Under thefederal HMO Act, an entity must have three char-acteristics to be designated as an HMO: It must bean organized system for providing health care orotherwise assuring health care delivery in a geo-graphic area, it must have an agreed-upon set of

basic and supplemental health maintenance andtreatment services, and it must serve a group ofpeople who have voluntarily enrolled. The fourmost prevalent models of HMOs are the groupmodel, individual practice association, networkmodel, and staff model. Many HMOs are hybrids oftwo or more of these types.

See also HEALTH INSURANCE; MANAGED CARE.

health promotion Stress reduction and stress man-agement are part of many promotion programs inworkplaces and communities. According to theAmerican Journal of Health Promotion, health promo-tion is the science and art of helping people changetheir lifestyle to move toward a state of optimalhealth. Optimal health is defined as a balance ofphysical, emotional, social, spiritual, and intellectualhealth. A combination of efforts can help peopleenhance awareness, change behavior, and createenvironments that support good health practices.

Nearly half of all premature deaths in theUnited States and other developed countries aredue to lifestyle-related conditions. Many of thesedeaths are preventable, and quality of life can beenhanced if people exercise regularly, eat morenutritious foods, avoid smoking and excessive use ofalcohol, build social networks, and have a senseof gratification from intellectual pursuits. Because ofthis understanding, an increasing number of com-munities and employers are taking steps to imple-ment health promotion activities.

The American Journal of Health Promotion was thefirst peer-reviewed journal devoted to health pro-motion and it remains the largest, with subscribersin all 50 United States and about 40 other countries.The publication provides a forum for the many dis-ciplines that contribute to health promotion.

See also EMPLOYEE ASSISTANCE PROGRAMS; STRESS

MANAGEMENT; WORKSITE WELLNESS PROGRAMS.

FOR FURTHER INFORMATION:American Journal of Health Promotion4301 Orchard Lake Road, #160-201W. Bloomfield, MI 48323(248) 682-0707http://www.healthpromotionjournal.com

hearing loss See DEAFNESS.

hearing loss 175

heart attack Known medically as myocardialinfarction; the sudden death of a part of the heartmuscle, characterized, in most cases, by severe,unremitting chest pain. Contributory factors to aheart attack include STRESS, HIGH BLOOD PRESSURE,and TYPE A PERSONALITY.

The onset of a heart attack is extremely stressfulfor the sufferer as well as onlookers. The individualmay be short of breath, restless, feel nauseated orvomit, or lose consciousness. It is crucial to respondimmediately to a suspected heart attack. In mild cases,pain and other symptoms are very slight or do notdevelop at all, in which case the attack is known asa “silent heart attack.” Such an episode may be dis-covered only by subsequent tests.

Fear of having a heart attack is a commonsources of stress, because many symptoms of anxi-eties and PHOBIAS (including HYPERVENTILATION, PAL-PITATIONS, and faintness) mimic some of thesymptoms of a heart attack. Such fears are notunfounded; heart attack is the leading cause ofdeath for both men and women in the UnitedStates. Every year, 1.5 million Americans have aheart attack; one-third of them die as a result. How-ever, from 1981 to 1991, death rates from heartattack decreased more than 30 percent, due partly tobetter diagnosis and advancements in prevention,treatment, surgery, and medication. Treatment ofheart attacks with clot-dissolving drugs, for exam-ple, has helped reduce the death rate dramatically.

Once the coronary artery gets blocked by a clot, aheart attack can occur quite suddenly. Within min-utes of a heart attack, the heart muscle begins tochange. Deprived of oxygen, the affected portion ofthe heart muscle deteriorates and dies; surroundingtissue may also be damaged. The longer the arteryremains blocked, the greater the damage and possi-bility of death. According to the American HeartAssociation, about 60 percent of all heart attackdeaths occur within the first hour. Fear, unfamiliar-ity with the symptoms, and DENIAL are some of thereasons why individuals and their families delay get-ting help. Many deaths from heart attack can be pre-vented with proper and prompt treatment.

Symptoms of a Heart Attack

If the warning signs listed in the box occur, indi-viduals should get help immediately.

Symptoms may be mild, or severe, or even com-pletely absent. Often, older individuals have thefewest or mildest symptoms of heart attack. Fewpeople have all the classic signs. The sooner a per-son receives appropriate medical treatment, thegreater the chances of surviving a heart attack andavoiding permanent damage to the heart. Somepotent new drugs that can prevent the death of the

176 heart attack

WHAT TO DO IF A HEART ATTACK IS SUSPECTED

Seventy percent of heart attacks occur in thehome; family members can assist immensely ifthey know what to do in response to the emer-gency, including cardiopulmonary resuscitation(CPR) procedures. Also:

• Do not spend time trying to reach your physi-cian. Have someone call your local emergencynumber (911 in many urban areas) or an ambu-lance service. Tell the dispatcher that heartattack is suspected. Chew one regular tablet ofaspirin if you are not allergic.

• If getting to a hospital is faster by car, havesomeone drive you there instead of waiting foran ambulance.

• Ask to be taken to an area hospital equippedwith 24-hour emergency cardiac care.

• Try to stay calm. Lie down, propped up with pil-lows. Agitation can increase the likelihood ofabnormal, life-threatening heart rhythms.

• Have someone call your personal physician.

HEART ATTACK WARNING SYMPTOMS

• A crushing chest pressure or pain in the centerof the chest that lasts more than a few minutesor goes away and comes back. The discomfortmay be felt as a burning sensation that can bemistaken for severe heartburn.

• Chest pain that spreads to the shoulders andarms or the left or both sides, as well as to theneck or back

• Accompanying nausea, vomiting, sweating, coldsweats, shortness of breath, palpitations, light-headedness, or faintness

• A sensation of impending doom

heart muscle, for example, work only if they aregiven within the first few hours after the heartattack.

Diagnosis and treatment for heart attack in anemergency room may be stressful for the sufferer.One may be fearful and anxious about the sur-roundings, expectations for life, and hopes forrecovery.

Stresses after a Heart Attack

Individuals who have suffered a heart attack havean increased risk of suffering another one in thefollowing few years. They live with the stress ofANXIETY about this probability. Many such individ-uals benefit from psychological counseling. Thechances of surviving for many years can beimproved by attention to lifestyle changes, includ-ing more RELAXATION, increased exercise, betterdiet, reduction of OBESITY, and cessation of SMOK-ING. An individual who has had a heart attackshould have regular check-ups by a physician.Support and exercise groups can be helpful.

See also ATHEROSCLEROSIS; BIOFEEDBACK; CHOLES-TEROL; HEARTBURN; MEDITATION.

FOR FURTHER INFORMATION:American Heart Association7320 Greenville AvenueDallas, TX 75231(800) 242-USA1(214) 373-6300(214) 987-4334 (fax)www.americanheart.com

National Heart, Lung and Blood Institute9000 Rockville PikeBethesda, MD 20892(301) 496-5166(301) 402-0818 (fax)http://www.nhbli.nih.gov

heartburn Burning sensation in the upper part ofthe abdomen or under the breast bone. It is a causeof STRESS for many people who may fear that it isrelated to heart disease. Heartburn is also a symp-tom of stress, because it can be brought on bynervousness or overeating. The burning sensationis actually associated with the esophagus, a muscu-lar tube that connects the throat with the stomach.

The tube passes behind the breastbone alongsidethe heart, which is why irritation or inflammationhere is known as heartburn.

Heartburn and distress in the digestive tract isfrequently a response to emotional stress. Tense,nervous people who worry about their jobs andfamily problems often complain of acid INDIGESTION

and heartburn. The list of foods that disagree withheartburn sufferers includes just about anything aperson would want to eat. When things gosmoothly for these people, everything agrees withthem. When they are upset or frustrated, nothingdoes. Heartburn usually starts slowly, about anhour or so after they have eaten a heavy or spicymeal. The pain can sometimes be quite intense andmay last a few hours.

Coping with Heartburn

In some cases, the pain is due to irritation(esophagitis) from hydrochloric acid in the stom-ach juice that has backed up into the esophagus;relaxation of the valve between the stomach andthe esophagus is one cause of esophagitis. Hiatushernia, in which part of the stomach slips up intothe chest, is another. This type of heartburn isoften brought on by lying down, especially afterovereating. It may be helped by raising the head ofthe bed, by avoiding certain foods, especiallysweets, and by a low-fat, low-calorie diet.

heartburn 177

TIPS FOR RELIEVING THE STRESS OF HEARTBURN

• Avoid certain foods that are spicy, acidic,tomato-based or fatty, such as sausages, choco-late, tomatoes, and citrus fruits.

• Avoid alcohol, tea, colas, and coffee, evendecaffeinated.

• Eat modern amounts of food to avoid overfillingyour stomach.

• Stop or at least cut back on smoking.• Don’t try to exercise immediately after eating or

before lying down.• Elevate the head of your bed or use extra pillows

to raise the level of your head above your feet.• Avoid tight belts and other restrictive clothing.• Learn relaxation techniques.• If none of these help, see your doctor.

See also ALTERNATIVE MEDICINE; MEDITATION; PEP-TIC ULCER.

heights (acrophobia, altophobia, hyposophobia,hypsiphobia) Fear of heights is a very commonsource of stress, particularly for people in largecities or in mountainous areas. For those who fearheights, visual space is important. They will not beable to go down a flight of stairs if they can see theopen stairwell. They may be frightened looking outof a high window that stretches from floor to ceil-ing but not if the window’s bottom is at waist levelor higher. They may have difficulty crossingbridges on foot because they are near the edge butmay be able to do so in a car.

Sometimes fear of heights is related to an acutefear of falling (which is innate). Babies usually beginto be wary of heights some time after starting tocrawl. The person who experiences extreme stressfrom heights may experience symptoms associatedwith panic attacks and phobias, such as palpitations,sweating, dizziness, and difficulty breathing. A per-son who fears heights may also fear the idea ofheights.

Fear of heights is sometimes associated with afear of airplanes and flying, although height is onlyone element in the complex reaction that leads tofear of flying. Fear of heights is sometimes involvedin other related fears, such as bicycles, skiing,amusement park rides, tall buildings, stairs, bridges,and freeways.

See also PHOBIA.

helplessness A stressful feeling that one cannotdo anything for oneself or influence the outsideworld in any way. In some instances, helplessnesscan be a symptom of DEPRESSION.

Sigmund Freud (1856–1939) used the term psy-chic helplessness to describe the experience duringthe birth process when respiratory and other phys-iological changes occur; he believed that this psy-chic helplessness state led to later anxieties. Freudalso believed that the baby’s helplessness anddependence on the mother created frustration,which in turn led to an inability to cope with latersources of stress.

During the 1970s, psychologist Martin Seligman(b. 1942) developed a concept he called learned

helplessness to describe an individual’s dependenceon others. Many people who feel very stressedhave characteristics of learned helplessness, partic-ularly agoraphobics, who cannot go away fromhome without someone accompanying them.

See also LEARNED OPTIMISM.

help lines See HOT LINES; SELF-HELP GROUPS; SUP-PORT GROUPS.

hemophilia The oldest-known bleeding disorder.Low levels or complete absence of a blood proteinessential for clotting causes hemophilia. The sever-ity of hemophilia is related to the amount of theclotting factor in the blood. There are 20,000hemophilia patients in the United States. Each year400 babies are born with this disorder. The mostsignificant stresses facing the hemophilia patient,health care provider, and research communitytoday are safety of products used for treatment,management of the disease (including inhibitorformation), irreversible joint damage, life-threat-ening hemorrhage, and progress toward a cure.

Sufferers of hemophilia have their own fearsthat may produce stress in those who are aware oftheir condition and who may witness bleedingepisodes. Hemophiliacs are rarely female. Becausethe disease is hereditary and recessive in females, amother may fear and/or feel guilty about passingthe disease to her child. Parents of hemophiliacsmay be excessively protective toward their hemo-philiac child. The child may react by being fearfulof all physical activity or by rebelling against rea-sonable limitations and putting himself or herselfin danger. Siblings of hemophiliacs may be over-protective or jealous of the extra attention given totheir brother or sister. Teachers or other adultsresponsible for the hemophiliac child may fearsmall cuts, which in actual fact are not particularlydangerous. Internal bleeding, particularly aroundthe joints, is the greatest danger to hemophiliacs.In recent years, the AIDS (acquired immunodefi-ciency syndrome) epidemic has produced a newfear for hemophiliacs because some early cases ofAIDS resulted from infected blood transfusions.After the late 1980s, however, new testing proce-dures were developed to assure a safe blood supply.

See also ACQUIRED IMMUNODEFICIENCY SYNDROME.

178 heights

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Facing Fears: The

Sourcebook for Phobias, Fears, and Anxieties. New York:Checkmark Books, 2000.

FOR INFORMATION:National Hemophilia Foundation116 West 32nd Street, 11th FloorNew York, NY 10001(800) 42-HANDI (toll-free)(212) 328-3700(212) 328-3777E-mail: info@hemophilia.orghttp://www.hemophila.org

hemorrhoids Enlarged veins at the lowest part ofthe intestine. Hemorrhoids may be painful orbleed, causing stress for the sufferer. The word lit-erally means a blood (hemo) flow (rhoid), describ-ing one of the characteristics of the disease,bleeding from the anus. “Piles” is a layman’s termfor hemorrhoids.

Hemorrhoids are also stressful because in manycases their cause cannot be determined. CONSTIPA-TION, straining while defecating, sitting for long peri-ods, and infections can aggravate the condition onceit starts. The disorder usually is mild, but if neglected,may result in annoying or painful complications suchas itching, protrusion outside the anus, or fissures inthe anus, and possibly secondary infection.

Treatment consists of warm sitz baths, soothingointments, antibiotics for infection, measures suchas laxatives or stool softeners to relieve constipation,and a diet of digestible foods. Any bleeding from theanus should be investigated by a physician.

See also IRRITABLE BOWEL SYNDROME.

hepatitis B See SEXUALLY TRANSMITTED DISEASES.

herbal medicine Use of a plant or portion of aplant valued for its medicinal, savory, or aromaticqualities. Herbalism gained popularity in the UnitedStates toward the end of the 20th century. Estimatesare that Americans spend more than $1 billion peryear on herbal remedies in a year; many people seekthese alternative remedies to relieve stress.

Herbal medications are deeply rooted in mostfolk medicine traditions and have played an impor-tant role in the evolution of modern medicine and

pharmacology. For example, when the Pilgrimslanded in Plymouth in 1630, they set up herb gar-dens that contained the medicinal varietiesbrought from the Old World. The settlers soon dis-covered that the Native Americans had their ownhealing plants, including cascara sagrada andgolden seal. According to the World Health Orga-nization, 80 percent of Earth’s population usessome form of herbal therapy.

Many contemporary medications are based onspecific herbs but are manufactured from syntheticsubstances believed to be more effective than thenatural herbs. Still, herbal therapies remain amajor component of Ayurvedic, homeopathic, andother alternative approaches.

Herbal products are marketed in the UnitedStates as foods, and are permitted by the Food andDrug Administration provided that the products donot make any therapeutic claims. Herbal productsare sold over the counter and are not subject to thesame safety and efficacy standards that apply toover-the-counter medications. Herbal packaginglabels rarely contain guidelines regarding indicationsfor proper use. As with any medication, herbalremedies are best used under the guidance of aknowledgeable individual, in this case, an herbalist.

See also ALTERNATIVE MEDICINE; AYURVEDA;HOMEOPATHY.

FOR FURTHER INFORMATION:The Herb Research Foundation1007 Pearl Street, Suite 200Boulder, CO 80302(303) 449-2265

herbal medicine 179

HERBAL REMEDIES FOR STRESS RELIEF

• See a physician first for serious conditions. Donot attempt to self-medicate.

• Consider the sources of your products; selectreputable brands.

• Choose reliable forms such as tinctures orfreeze-dried, as powdered forms may losepotency upon exposure to air.

• Overdosing can have harmful effects. Take rec-ommended dosages at suggested intervals.

• Watch for reactions; if unwanted reactionsoccur, stop the medication.

SOURCES:Chevallier, Andrew. The Encyclopedia of Medicinal Plants.

Boston: Houghton Mifflin, 1996.National Women’s Health Report. “Alternative Therapies

and Women’s Health,” Washington, D.C.: NationalWomen’s Health Resource Center, May/June 1995.

herpes simplex virus HSV can cause blisterlikesores almost anywhere on a person’s skin. It usu-ally occurs around the mouth and nose or the but-tocks and genitals. Herpes is a name used for some50 related viruses. Herpes simplex is related to therisk for infectious mononucleosis, chicken pox,and shingles (varicella zoster virus). HSV infectionscan be very stressful because they can reappearwithout any predictability; also, the sores may bepainful and embarrassing.

Two Types of HSV

Type 1. Studies show that most people get Type 1,which affects the lips, mouth, nose, chin, or cheeksduring infancy or childhood. It is transmitted byclose contact with family members or friends whocarry the virus. It can be transmitted by kissing, orby using the same eating utensils and towels. Arash or cold sores on the mouth and gums appearshortly after exposure. Symptoms may be barelynoticeable or may need medical attention for reliefof pain.

Type 2. Type 2, which includes genital herpes,one of the many diseases caused by the herpesvirus, most often appears following sexual contactwith an infected person. It has reached epidemicnumbers, affecting from 5 million to 20 millionpersons in the United States, or up to 20 percent ofall sexually active adults. Genital herpes, althoughrelatively uncommon in the United States until thelate 1960s, may have been the most common sex-ually transmitted disease in the late 1990s. Thechronicity of the disease and the fact that no cureexists is a source of significant stress in the lives ofits sufferers. Stress and anxiety associated withhaving this SEXUALLY TRANSMITTED DISEASE can bereduced with education, counseling, and support-ive physical care.

Herpes is particularly stressful because once thevirus invades the body, it remains for life, although itmay be dormant most of the time. In different indi-viduals, episodes recur with more or less frequency.

Although genital herpes is not usually a med-ically serious disease, it can lead to DEPRESSION andother emotional conditions. Many victims tend toresent the sex partner from whom they contractedthe disease, often leading to divorce or the break-ing up of a relationship. Others consider them-selves damaged for life, fearing that they are unfitfor marriage or a lasting relationship.

The disease is most commonly spread by directcontact, meaning that to get herpes, uninfectedskin must come in contact with an active herpessore. However, the virus may be shed withoutnoticeable symptoms and may thus be transmitted.As herpes sores may be hidden in the internal partsof the female genitalia or may not be painful, onevictim may unwittingly infect another.

Once the herpes virus has entered the skin, itmultiplies rapidly. First symptoms are usually itch-ing or a tingling sensation, followed by the erup-tion of unusually painful sores or blisters. Typically,in the first attack the sores appear two days to twoweeks after exposure and last two to three weeks.Subsequent attacks, which may occur in a fewweeks or not for years, generally last about fivedays. When an attack subsides, the virus lies dor-mant and travels along the nerve fibers until itreaches a resting place.

Complications

In rare cases, the herpes virus may travel to thebrain and cause a serious, often fatal, form ofencephalitis. More commonly, herpes may infectthe cornea of the eye; if untreated, the infectioncan lead to visual damage and even blindness.None of these complications, however, is as com-mon as periodic recurrences at the original site ofinfection.

A serious complication of genital herpes affectsinfants born to women who have active infectionsat the time of birth. Some infants who contract dis-seminated herpes infections die, and half of thosewho survive may suffer brain damage or blindness.Many doctors recommend that the baby be deliv-ered by Cesarean section if the mother has anactive infection near the time of delivery.

Prevention

The most effective way of preventing genital her-pes is avoiding all sexual contact with an infected

180 herpes simplex virus

person. Use of a condom and spermicidal agent willreduce the risk, but this is not absolutely foolproof,particularly when the lesions are on the skin of theperineum and not on the penis or in the vagina.

Treatment and Self-help

There is no way to rid the body of the herpes virus.However, antiviral agents developed during the1990s shorten the duration of an active infection,relieve discomfort, and speed healing. By haltingthe virus from reproducing itself and spreading toother cells, these agents stop the formation of newherpes blisters and help existing sores heal faster.

Many herpes sufferers learn to recognize pat-terns of recurrence and factors that trigger subse-quent episodes. RELAXATION techniques to reducestress are indicated if stress is a factor in recurrentdisease. There are a number of herpes counselingcenters and groups throughout the country to lendsupport and help to victims of the disease. TheAmerican Social Health Association maintains aNational Herpes Information Hotline number:(919) 361-8488. The toll-free number to requestfree literature is (800) 230-6039.

FOR FURTHER INFORMATION:The Herpes Resource Center260 Sheridan Avenue, Suite 307Palo Alto, CA 94306(800) 227-8922 (toll-free)(415) 328-7710

American Academy of Dermatology930 North Meacham RoadP.O. Box 4014Schaumburg, IL 60168-4014(847) 330-0230

SOURCES:Nourse, Alan Edward. Herpes. New York: Franklin Watts,

1985.Sacks, Stephen L. The Truth about Herpes, 3rd ed. Seattle:

G. Soules Book Publishers, 1988.

hierarchy of needs Some theorists believe thathuman behavior is motivated by a series of needsthan can be arranged in hierarchical order, begin-ning with basic physiological needs such as foodand water and progressing to safety needs such asprotection against danger, social or love needs,esteem or ego needs, and self-actualization. Stress

can result from incomplete attainment of theselevels.

The theory was originated by Abraham HaroldMaslow (1908–70), a U.S. psychologist who wasknown as a leader of the human potential move-ment because of his emphasis on self-fulfillment.

high blood pressure The term blood pressure, asused in medicine, refers to the force of blood againstthe walls of the arteries, created by the heart asit pumps blood through the body. As the heartpumps or beats, the pressure increases; as theheart relaxes between beats, the pressure decreases.High blood pressure (hypertension) is the condi-tion in which blood pressure rises too high andstays there.

High blood pressure is an important individualas well as public health issue because it affects asmuch as 25 percent of the adult population in theUnited States. High blood pressure has been associ-ated with the stresses resulting from certain nega-tive emotions or aggressive and hostile behaviors.Although the degree of stress is difficult to assessobjectively, acute and probably chronically stress-ful situations can result in an elevation of the bloodpressure. Certain individuals are overreactive tostress and may suffer more than others when con-fronting certain situations. Individuals with highblood pressure have higher irritability levels, moreGUILT feelings, and more psychic distress.

There are many studies of the effects of psycho-logical factors such as stress, psychological or PER-SONALITY characteristics, and life events on bloodpressure. A problem with these studies has beenthe difficulty of assessing psychosocial factors anddetermining whether they are causes or conse-quences of high blood pressure. It is possible thatthe process of labeling or treating a person withblood pressure elevation can induce a stressful psy-chological change.

Diagnosing High Blood Pressure

According to the National Heart, Lung and BloodInstitute, high blood pressure is more likely todevelop in people with a family history of highblood pressure, those who are overweight, eat ahigh-salt diet, drink excessively, and/or are physi-cally inactive.

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In its early stages, high blood pressure does notusually produce any symptoms; thus it is sometimescalled “the silent killer.” Many people who havehigh blood pressure feel just fine. Regular check-upsare the only way to detect high blood pressure.

High blood pressure is usually diagnosed duringan office visit to a physician. The physician uses astethoscope and a sphygmomanometer, an inflat-able cuff attached to a device that measures bloodpressure. With each heartbeat, blood is pumpedthrough the arteries and veins. The force withwhich blood pushes against the artery walls createsblood pressure, which is represented by two num-bers. The top number, systolic pressure, indicatesthe maximum pressure with which blood pushesagainst the arteries during a heartbeat. The lowernumber, diastolic pressure, indicates pressureagainst the arteries when the heart is at rest. Nor-mal or healthy blood pressure is in the 120/90range. If the reading regularly hits 140/90, one issaid to have high blood pressure.

High blood pressure usually starts when arteriesbecome too narrowed or constricted, impeding theflow of blood. High pressure in these damagedarteries makes them susceptible to a buildup offatty, cholesterol-containing deposits, a conditionknown as ATHEROSCLEROSIS. If blood vessels feedingthe heart become blocked and/or hardened, a per-son may suffer chest pain (known as angina) ormay have a HEART ATTACK. When the blood supplyto the brain is disrupted, STROKE may occur. Othereffects may be kidney failure and eye damage.

“White Coat Hypertension”

Some individuals actually show elevations in theirblood pressure when visiting a physician’s office.Their blood pressure is generally normal butincreases in the presence of physicians and otherhealth care professionals. This is because theseindividuals feel stressed and fearful of doctors orthe surroundings, such as laboratories, where theymight encounter needles or blood testing devices.They may be diagnosed with high blood pressure.

Physicians who understand this phenomenonusually take the patient’s blood pressure at the endof the visit as well as the beginning, and take acareful history to determine the effects of thepatient’s phobias on the blood pressure.

Treating High Blood Pressure

Nondrug measures can help many people controltheir high blood pressure. In many cases, however,these measures may be recommended along withmedication because they are beneficial for overallgood health. Helpful techniques include BIOFEED-BACK; BREATHING; GUIDED IMAGERY; HYPNOSIS; RELAX-ATION; T’AI CHI.

Role of Exercise in Reducing High Blood Pressure

Many activities that reduce stress, including aerobicexercise, running, biking, walking, and swimming,also reduce both systolic and diastolic blood pres-sure. The American College of Sports Medicine(ACSM) recommends aerobic activities three to fivedays a week for 20 to 60 minutes per workout atintensities 40 percent to 80 percent of maximumeffort.

However, the ACSM advises people with highblood pressure to avoid high-intensity strengthtraining, or weight training, because it temporarilyelevates blood pressure whether one has high bloodpressure or not.

182 high blood pressure

SELF-HELP FOR TREATING HIGH BLOOD PRESSURE

• Stress control. Training in relaxation techniquesand use of biofeedback help some patients han-dle stressful life situations in more constructiveways.

• Weight reduction. Some overweight people canreduce their blood pressure by losing excessweight.

• Salt restriction. In combination with medication,salt restriction is often helpful.

• Restriction of dietary cholesterol. High bloodlevels of cholesterol, coupled with high bloodpressure, can damage arteries.

• Restriction of alcohol consumption. Drinkingshould not exceed two ounces of 100-proof,which equals eight ounces of wine or 24 ouncesof beer a day.

• No smoking. Nicotine directly affects the heartand blood vessels producing acute increases inblood pressure. Independent of high blood pres-sure, smoking can damage arteries.

Role of Nutrition

Maintaining a proper diet can be beneficial intreating high blood pressure.

Weight reduction, sodium chloride restriction,and avoidance of excessive alcohol consumptionappear to be the best nutritional approaches to thetreatment of high blood pressure. The role of dietaryalterations of fiber, calcium, magnesium, potassium,dietary fats, carbohydrates, and protein is less con-vincing. Unfortunately, much of the available dataare insufficient to make a final recommendationregarding a potential role for these alterations in theprevention and treatment of high blood pressure.

Weight control is important because the preva-lence of high blood pressure is 50 percent higheramong overweight adults than among adults ofnormal weight; 33 percent of people who havehigh blood pressure are overweight. Overweightindividuals have a twofold to sixfold increased riskfor developing high blood pressure. Modest weightloss can favorably affect high blood pressure.

Recommendations for a prudent diet for highblood pressure prevention and treatment, based onthe current review of the literature, include mod-est weight loss (10 percent of present weight), lim-iting sodium intake to 100 millimoles (six grams ofsodium chloride) and limiting alcohol consump-tion to no more than two drinks per day (30 milli-liters of ethanol).

Drug Treatment for High Blood Pressure

Taking medication for high blood pressure is stress-ful for some individuals because many medicationscause side effects or other problems that compli-cate treatment. These effects may include fatigue,sexual IMPOTENCE, and DIZZINESS.

In some cases, one drug will maintain pressurecontrol over time. More often, one drug controls itfor a time; then a second or third may be needed.High blood pressure can be controlled, as long asappropriate medicines are taken:

• Diuretics act on the kidneys, causing them toflush out salt and water. As fluid in the bloodvessels goes down, pressure goes down.

• Beta blockers act on the heart, reducing the rate atwhich it beats and the amount of blood itpumps; with less output, pressure drops.

• Vasodilators relax the small arteries, reducingtheir resistance to blood flow, causing bloodpressure to go down.

• Sympathetic inhibitors act on the sympatheticnervous system and also relax the arteries, keep-ing pressure down.

• Calcium channel blockers lower the levels of cal-cium in the blood vessel muscle cells. Thisrelaxes the vessels, and pressure drops.

• ACE inhibitors work in a unique way in the body,and have been shown to be effective in control-ling high blood pressure, usually without causingsome of the troublesome side effects caused byolder drugs. ACE inhibitors interrupt a chemicalchain reaction in the body that causes blood pres-sure to rise. The kidney triggers the process byreleasing an enzyme called renin into the blood-stream. As part of the chain reaction, the lungsproduce an enzyme called ACE (angiotensin-converting enzyme). The presence of ACE leadsto production of another chemical that raisespressure. ACE inhibitors bind up ACE, interrupt-ing the chemical chain and maintaining morenormal pressure.

• Alpha blockers and central alpha agonists keepblood vessels open by blocking the action of cer-tain nerves.

See also ALTERNATIVE MEDICINE; EXERCISE; NUTRI-TION; PETS; TYPE A PERSONALITY.

FOR FURTHER INFORMATION:American Heart Association7320 Greenville AvenueDallas, TX 75231(800) 242 USA (toll-free)(214) 373-6300(214) 987-4334 (fax)http://www.americanheart.org

SOURCES:Kerman, D. Ariel. H.A.R.T. Program: Lower Your Blood Pres-

sure without Drugs. New York: HarperCollins, 1992.Lardinois, Claude K. “Role of Nutrition in Treating

Hypertension.” Archives of Family Medicine, August 14,1995.

Pickering, Thomas G., et al. “How Common Is WhiteCoat Hypertension?” The Journal of the American Med-ical Association, January 8, 1988, 225–228.

high blood pressure 183

hives Pink swellings sometimes called wheals thatoccur in groups on any part of the skin. They arestressful to the sufferer because, as they are form-ing, they usually are very itchy and may also burnor sting. Until they are diagnosed, the sufferer maybe bewildered about the cause and possibilities forrelief. Hives usually go away within a few days toa few weeks. Occasionally, a person will continueto have hives for many years. About 10 percent to20 percent of the population will have at least oneepisode in their lifetime.

When hives form around the eyes, lips, or gen-itals, the tissue may swell excessively. Althoughfrightening in appearance, the swelling usuallygoes away in less than 24 hours. Dermatologistsmay use the term angioedema to describe this typeof swelling, which is also used to describe verydeep large hives on other areas of the body.

In the commonest kind of hives, each individualwheal lasts a few hours before fading away, leavingno trace. New hives may continue to develop asold areas fade. They can vary in size from as smallas a pencil eraser to as large as a dinner plate andmay join together to form larger swellings.

Causes of Hives

Hives are produced by blood plasma leakingthrough tiny gaps between the cells lining smallblood vessels in the skin. Histamine, a natural chem-ical, is released from cells called “mast cells,” whichlie along the blood vessels in the skin. Many differ-ent things, including allergic reactions, chemicalsin food, or medications, can cause a histaminerelease. Sometimes it is impossible to find out whyhistamine is being released and hives are forming.

The most common foods that cause hives arenuts, chocolate, fish, tomatoes, eggs, fresh berries,and milk. Fresh foods cause hives more often thancooked foods; food additives and preservatives mayalso be responsible. Hives may appear within min-utes or up to two hours after eating, depending onwhere the food is absorbed in the digestive tract.

Almost any prescription or over-the-countermedication can cause hives. Some of these drugsinclude antibiotics (especially penicillin), painmedications, sedatives, tranquilizers, and diuretics.Antacids, vitamins, eye and ear drops, laxatives,vaginal douches, or any other nonprescriptionitem can be a potential cause of hives.

Many infections can cause hives. Viral upperrespiratory tract infections are a common cause inchildren. Other viruses (including hepatitis B) mayalso be a cause, as well as a number of bacterial andfungal infections.

Some people develop hives from sunlight, cold,pressure, vibration, or EXERCISE. Hives due to sun-light are called solar urticaria. This is a rare disor-der in which hives come up within minutes of sunexposure on exposed areas and fade within one totwo hours. Reaction to the cold is more common.Hives appear when the skin is warmed after expo-sure to cold. If the exposure to cold is over largeareas of the body, large amounts of histamine maybe released, which can produce sneezing, flushing,generalized hives, and fainting. A simple test forthis type of hives can be done by applying an icecube to the skin.

Diagnosis and Treatment of Hives

Diagnosis depends on each individual’s medicalhistory and a thorough examination by a derma-tologist. The best treatment for hives is to find thecause and then eliminate it, which is not always aneasy task. While investigating the cause of hives, orwhen a cause cannot be found, dermatologistsoften prescribe antihistamines to provide somerelief to the sufferer. Antihistamines work best iftaken on a regular schedule to prevent hives fromforming.

In cases of severe hives, an injection of epi-nephrine (adrenaline) or a cortisone preparation,may bring relief.

See also ALLERGIES.

FOR FURTHER INFORMATION:American Academy of Dermatology930 North Meacham RoadSchaumburg, IL 60172-4965(847) 330-0230

HIV positive See ACQUIRED IMMUNODEFICIENCY

SYNDROME; HUMAN IMMUNODEFICIENCY VIRUS.

hobbies Activities people engage in because theywant to, not because they must for economic rea-sons. They are sources of satisfaction, RELAXATION,and relief from the stresses of everyday life formany people. People who look forward to RETIRE-

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MENT do so because they will have more time forhobbies. Choosing hobbies is up to each individual,although in many cases they bring people withcommon interests together. For many people, col-lecting antiques or other collectibles is a hobby.

According to Allen Elkin, Ph.D., director, StressManagement and Counseling Center, New YorkCity, “people who derive most of their identityfrom their profession are going to need othersources of SELF-ESTEEM when they leave that pro-fession behind.” People who have hobbies usuallyhave a consuming interest in their chosen activity.Many former workaholics find satisfaction in ahobby that forces them to concentrate and bepatient, such as building a model train, bird watch-ing, or producing clay sculptures.

See also VOLUNTEERISM.

SOURCES:Godbey, Geoffrey, and John Robinson. Time for Life: The

Surprising Ways Americans Use Their Time. UniversityPark: Pennsylvania State University Press, 1997.

holiday depression Many individuals experienceDEPRESSION as a low mood swing during periods ofthe year in which holidays occur or on holidaysthemselves. They can be stressful times, particu-larly for some single and widowed individuals whomay feel alone and lonely, and see the rest of theirworld in a celebratory mood surrounded by fami-lies. The anticipation of holidays induces somepeople to drink, eat, or smoke more.

The stresses of holiday depression often occurwhen individuals have been uprooted from theirfamilies and moved elsewhere for employment orother reasons. The stresses of moving and reloca-tion are compounded by their being alone. Someindividuals in family settings experience moodshifts out of nostalgia for lost loved ones or for cir-cumstances that existed earlier in their lives.

Avoiding Holiday Depression

People who know that they will be alone on holi-days and will feel stressed should avoid their holi-day depressive episodes by planning ahead. Theycan take a trip to an interesting place, engage insome enjoyable activity with a group, or inviteother people without families to share holidayactivities together. Other individuals who know

they will be alone on holidays may volunteer theirservices to hospitals or shelters for the homeless.Feeling that they will be helpful to others is a wayof combating the stressful feelings associated withthese times.

Usually the depressed mood brought about byholidays under such circumstances goes away afterthe holiday season. However, when the depressivemood does not improve as the calendar rolls on,individuals should seek professional help.

See also AFFECTIVE DISORDERS; SEASONAL AFFEC-TIVE DISORDER.

holistic medicine Holistic medicine involves ashift in belief systems from the dualistic mind/bodysplit toward a view of mind, body, and spirit asbeing closely connected. It has come to mean aspecific way of thinking and practicing the art andscience of medicine and for dealing with illness aswell as relieving stress. Practitioners of holisticmedicine view the individual as a totality, ratherthan as a headache to be relieved or a backache tobe cured.

See also ALTERNATIVE MEDICINE; AYURVEDA;HERBAL MEDICINE; HOMEOPATHY; MIND-BODY CONNEC-TIONS; PSYCHONEUROIMMUNOLOGY.

Holmes, Thomas H., M.D. (1918– ) Neu-ropsychiatrist who researched effects of stressfullife change events on health status. He is knownfor devising a social adjustment rating scale alongwith Richard H. Rahe, M.D., another researcher inthe area of life changes, as a predictor of illness.

See also LIFE CHANGE SELF-RATING SCALE.

Holmes, Thomas H., M.D. 185

COPING WITH HOLIDAY STRESS

• Have a realistic expectations so that you will notplace too many demands on yourself. Beassertive and learn to say no.

• Consider your support system. If you don’t haveone, devote some time and energy to developinga support system by reaching out to others.

• Identify your major annoyances at this time ofyear. Be aware of when they happen and plan tohave alternative responses if you usually becomedepressed.

home care As the population ages, many peoplemake use of home care, which brings on stressesfor themselves as well as the professionals whowork with them. Physicians, nurses, case man-agers, health care aides, therapy specialists, socialworkers, laboratory technicians, nutritionists, andtransportation providers are among workers in thehome care industry.

Demand for health care services continues toincrease as there are more early discharges fromhospitals, more outpatient surgeries, and technicaladvances and pharmaceutical developments thatlengthen the survival of chronically ill patients.Some home care patients have AIDS, are on dialysisor ventilators, receive chemotherapy, or have men-tal illnesses or physical disabilities. Health careworkers manage intravenous therapy, tracheostomycare, and wound irrigations, in addition to manag-ing the risks inherent in home environments.

Potential stressful hazards to home care workersinclude potential violence from clients or others,exposure to communicable diseases, ergonomicissues such as lifting the patient, physical condi-tions (poor lighting, broken stairs), hazardouschemicals, environmental tobacco smoke, andoxygen equipment.

Some hazards can be controlled, reduced, oreliminated through use of lifting devices, havingspecific training in certain work practices, goodhygiene practices such as hand washing and properbody mechanics, and personal protective equip-ment such as gloves and eye protection.

See also ERGONOMICS; HEALTH CARE WORKERS;SLIPS, TRIPS, AND FALLS.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.

homelessness Stresses of homeless people rangefrom solving everyday practical problems such asfinding shelter and enough food, to serious disor-ders such as substance abuse, DEPRESSION, andschizophrenia. The stresses of physical as well asmental health problems are intensified by home-lessness and, conversely, homelessness precipitateshealth problems. Because of the nature of the pop-ulation, it is difficult to assess the numbers ofhomeless people and their characteristic stressors.

The difficulties in providing medical and mentalhealth care for the homeless are related in part tothe reluctance of some of the people to presentthemselves for care, as well as insufficiencies ofcommunity health centers. Many of the psychiatri-cally impaired homeless avoid contract with thehealth care system. Community mobile outreachservices are an important way to help these indi-viduals obtain food, clothing, and medical andmental health care.

For many of the poor and homeless popula-tions, emergency department physicians are theirsource of primary care. These physicians often pro-vide care for families that are in dire financialshape, the elderly, victims of rape and domesticviolence, and drug abusers.

A survey of homeless adults living in beachareas near Los Angeles revealed a high rate of priorpsychiatric hospitalization. The survey covered 529people who had spent the previous night outdoors,in a shelter, in a hotel, or in the home of a relativewith whom they did not expect to stay very long.Sixty-four percent of the people interviewed werewhite; 73 percent were men. They had beenhomeless for an average of two years. Altogether,44 percent had been in hospitals for psychiatricreasons, including ALCOHOLISM and drug depend-ence. Twenty-one percent had made an outpatientvisit for a mental or emotional problem within thepast year. Forty-one percent had never used men-tal health services.

The worst symptoms were noted in the hospi-talized group. There were more SUICIDE attempts,more daily drinking and delirium tremens. Sev-enty-six percent of the hospitalized group and 48percent of the others had been arrested. Peoplewho had been hospitalized were more likely to beliving in shelters. The 41 percent who had neverused mental health services had been homelessabout half as long as the rest and were least likelyto be sleeping outdoors. Surprisingly, they scoredat the same level as the general population on aquestionnaire estimating well-being.

According to mental health professionals, toaddress the complex needs of those categorized ashomeless persons requires a multidisciplinaryapproach. Social services are needed for short-termand long-term food, housing, and entitlementservices. Networks should be developed to enable

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access for those people to specialty medical serv-ices, emergency food pantries, transportation,overnight shelter, and respite care for childrenwhile the parent negotiates the systems. Churchesoften provide for emergency needs and long-termsupport. Legal services are needed to advocate fortheir rights and entitlements. Children who arehomeless require interaction with school systems,health care providers, day care centers, and, often,child protective services to promote health andprevent further illness or trauma.

SOURCE:Kahn, Ada P., and Jan Fawcett. Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.

homeopathy A system to promote healing basedon a philosophy of not bombarding the body withmedications, but stimulating and assisting the bodyto heal itself, using the smallest amount of medica-tion possible. Many people use homeopathic reme-dies to prevent, reduce, and alleviate stress.Homeopathy is considered an alternative therapy.

Homeopathy uses medicines made from plants,minerals, animals, animal substances, and chemi-cals. Whereas some conventional medications sup-press symptoms and the body’s immune response,and occasionally unfortunate reactions to drugs ordrug interactions occur, homeopathic practitionersprescribe only one medication at a time and claimthat there are rarely, if ever, unwanted side effects.Homeopathic medicines are produced in accor-dance with processes described in the HomeopathicPharmacopoeia of the United States.

In this person-oriented instead of disease-ori-ented system, homeopathic practitioners treatpatients based on their symptoms rather than rely-ing solely on diagnostic techniques. Homeopathicpractitioners seek to find causes as well as treatsymptoms; this is often done in a holistic way bytalking extensively with the patient to obtain acomplete health and psychosocial history. In thisregard, homeopathy has a characteristic in com-mon with the Chinese belief that the best doctorsdo not use medicine; they heal by giving guidancefor healthful living.

Homeopathy is used for a wide variety ofchronic and acute problems. These include (but arenot limited to) anxieties, ALLERGIES, digestive prob-

lems, gynecological conditions, and skin diseases.Many homeopathic remedies can be self-pre-scribed and purchased over the counter. However,as with any medication, it is prudent to consult apractitioner who is knowledgeable about the sub-ject. Such individuals can be located through rep-utable local homeopathic pharmacies or theNational Center of Homeopathy, Alexandria, Vir-ginia, or the International Foundation for Home-opathy, Seattle.

Historical Background of Homeopathy

The history of homeopathy goes back about 250years. Samuel Hahnemann, M.D., a German physi-cian, noted that Peruvian bark cured malaria. To testhis theory that the bark might cause as well as curemalaria, he ingested small amounts of the bark anddeveloped symptoms of malaria. He termed thiseffect a “proving” of symptoms. Another example ofa “proving” of symptoms is that poisons in largedoses are fatal; moderate doses can cause symptoms,but small doses can stimulate the body towardreduction of symptoms. Homeopathy is based onthe law of similars, or “let like cure like.” What hasthe power to cause also has the power to cure.

There is a parallel in western medicine, wherevaccines and allergy shots are used that containtiny amounts of killed virus, or allergens, to stimu-late the body’s immune system and prepare it foractual challenge.

The practice of homeopathy came to the UnitedStates in the early 1800s. By the mid-1800s, severalmedical colleges taught homeopathy. Around 1900,there were 22 homeopathic medical colleges andone out of five doctors used homeopathy. However,by 1920, only 15 colleges remained. The decline inthe use of homeopathy in the United States coin-cided with medical science’s increasing view of thebody as a mechanistic device, the advent of medicalspecialization, development of other prescriptiondrugs and medicinal technology, and opposition bythe American Medical Association.

The American Foundation for Homeopathybegan teaching homeopathy as a postgraduatecourse for doctors in 1922. Today, courses areoffered by the National Center for Homeopathy.

In recent years, interest in homeopathy hasincreased along with a widening interest in HOLIS-TIC MEDICINE and ALTERNATIVE MEDICINE. Homeopa-

homeopathy 187

thy may appeal to many people because only nat-ural substances are used as medications. Remediesinclude substances that can be dissolved in a liquidmedium; metals and salts are not dissolvable.According to Hahnemann’s original description,remedies are ground together 10 times for 10 min-utes. Subatomic energy is released. For an inexpli-cable reason, once diluted beyond the 12th dilution,nothing is found under a microscope. Also, becausemedications are so diluted, possibilities of sideeffects are reduced.

Some homeopathic practitioners in the UnitedStates also use other adjunctive therapies, such asspinal manipulation and nutritional counseling.

The largest use of homeopathic medications is inIndia. It is also popular in France and England andbecoming popular in Australia and Germany. InSwitzerland and Germany, homeopathic practi-tioners work under direction of doctors of medi-cine. According to Dr. Sujatha Pillai, a practitionerat Ehrhart & Karl, Chicago, 32 percent of familyphysicians in France prescribe homeopathic medi-cines. A survey in the British Medical Journal (June7, 1986, 1498–1500) indicated that 42 percent ofBritish physicians refer patients to homeopathicphysicians. According to Everybody’s Guide to Home-opathic Medicines (1991), members of the Englishroyal family are homeopathic medicine users andthe queen of England is the patron of the RoyalLondon Homeopathic Hospital and the BritishHomeopathic Association.

Another Homeopathic Technique: Bach Flower Remedies

Bach flower remedies are named after EdwardBach (1886–1936), a British bacteriologist andhomeopath. Flower remedies are a branch ofhomeopathic medicine, and said to be useful inacute situations. He developed a system of 38flower remedies for 38 different emotional states,based only on a person’s psychological symptoms.Distinct from homeopathy, more than one Bachremedy is prescribed at a time. Homeopathic prac-titioners believe in their efficacy.

SOURCES:Cummings, Stephen, and Dana Ullman. Everybody’s Guide

to Homeopathic Medicines. New York: Jeremy Tarcher/Perigree Books, 1991.

Merz, Beverly, ed. “Complementary Therapies: Home-opathy.” Harvard Women’s Health Watch 4, no. 5 (Jan-uary 1997).

homeostasis The body’s tendency to maintain asteady state, despite stressful external changes. Thephysical properties and chemical composition ofbody fluids and tissues tend to remain remarkablyconstant. However, when our self-regulating pow-ers fail, often because of repeated STRESS, the indi-vidual’s health is threatened.

In the late 19th century, Claude Bernard, aFrench physiologist at the Collège de France inParis, taught that one of the most characteristicfeatures of all living beings is their ability to main-tain the constancy of their internal milieu, despitechanges in the surroundings. Subsequently, WalterB. Cannon, a Harvard physiologist, named thispower to maintain constancy homeostasis, whichcan be translated as physiological “staying poweror self-preservation.”

Coping with stress and disease involves a fightto maintain the homeostatic balance of our tissues,despite damage. HANS SELYE, the Austrian-bornCanadian pioneer in stress research, discussed theconcept of homeostasis in his landmark works, TheStress of Life (1956) and Stress without Distress (1978).He said that the nervous system and the endocrinesystem play particularly important parts in main-taining resistance during stress. They help to keepthe structure and function of the body steady,despite exposure to stress-producing or stressoragents, such as nervous tension, wounds, infec-tions, or poisons. He explained this steady state ashomeostasis.

See also COPING; GENERAL ADAPTATION SYNDROME;MIND-BODY CONNECTIONS; STRESS MANAGEMENT.

SOURCES:Selye, Hans. The Stress of Life, rev. ed. New York: McGraw-

Hill, 1978.———. Stress without Distress. Philadelphia: Lippincott,

1974.

homesickness Not really a sickness; it happenswhen people are away from familiar surroundingsand family to whom they feel close. Many peoplehave experienced the stresses of homesickness aschildren while away at camp or visiting friends or

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relatives; soldiers may experience it while sta-tioned in distant lands. Homesickness may involvefeelings of loneliness and confusion with the unfa-miliar. How individuals adapt to such situationsdepends on their personal COPING skills and abilityto adapt. If homesickness persists, it may lead tosymptoms of mild DEPRESSION. However, in mostcases of homesickness, relief occurs when individ-uals return to the familiar or when they adapt tothe new situation.

See also ACCULTURATION; GENERAL ADAPTATION

SYNDROME; INTIMACY; MIGRATION; NOSTALGIA;RELATIONSHIPS.

homosexuality Sexual activity between membersof the same sex, ranging from sexual fantasies andfeelings through kissing and mutual masturbation, togenital, oral, or anal contact. The individual whopractices homosexuality, if a man, is termed a homo-sexual; a female homosexual is referred to as a les-bian. Both men and women homosexuals aresometimes referred to as “gay.” Fear of or prejudiceagainst homosexuals is known as homophobia and isa source of stress to many in the general community.

The term “homosexuality” was popularized dur-ing the 1960s. During the 19th century, other termswere proposed, including “homoerotic” (arousedby the same sex) and “homophile” (lover of thesame sex). Cunnilingus between two women wascalled sapphism after the ancient Greek poet Sap-pho, and lesbianism was named for the Greekisland of Lesbos where she lived.

Homosexual Panic

Homosexual panic (Kempf’s disease) is a panicattack that develops from a fear or delusion thatone will be sexually assaulted by an individual ofthe same sex. The term, coined by Edward Kempf,an American psychiatrist (1885–1971), in 1920,also applies to the fear that one is thought to behomosexual. This feeling occurs more often inmales than in females.

There may be DEPRESSION, conscious GUILT overhomosexual activity, agitation, HALLUCINATIONS,and ideas of SUICIDE. This type of panic attack maydevelop after many varied life circumstances, suchas a loss or separation from an individual of thesame sex to whom one is emotionally attached, or

after failures in sexual performance, illness, orextreme fatigue.

See also GENDER ROLE; LESBIANISM; PANIC ATTACKS

AND PANIC DISORDER; SEXUAL DIFFICULTIES; SEXUAL

PREFERENCES.

SOURCES:Marcus, Eric. Is There a Choice? Answers to 300 of the Most

Frequently Asked Questions about Gays and Lesbians. SanFrancisco: Harper, 1993.

National Museum and Archive of Lesbian and Gay History.The Gay Almanac. New York: Berkley Books, 1996.

hopelessness State of mind in which individualsfeel that it is impossible to deal with the stresses oflife and that situations they face have no possiblesolutions. They may see limited or no availabledesirable alternatives and may experience thestresses of emptiness, pessimism, and being over-whelmed. Nothing matters, and they give up.

Hopelessness is a characteristic of DEPRESSION. Ahopeless person is passive and lacks initiative. Suchan individual may not be able to reach a desiredgoal, accepts the futility of planning to meet goals,has negative expectations of the future, perceives apersonal loss of CONTROL, and sees no way out.Successful treatment of depression with medica-tion and certain types of psychotherapy can reversethis profound state of hopelessness.

The stress of extreme feelings of hopelessness maylead to ADDICTION or SUICIDE. Hopelessness some-times results from false or unrealistic expectations.For example, hopeless people may feel that theyshould be able to accomplish anything and every-thing, and then descend into despair upon failure.Some individuals with depression feel that nothingthey do will work out and that they are powerless.

Some people who are stressed may tend to mag-nify events to the extent that everything appears asan insurmountable obstacle in relation to them-selves. Still another type of magnification results indespair, when they idealize other people andevents. For example, a new friend may be thoughtto be perfect, or an upcoming vacation is plannedto run a smooth course. When the friend proves tohave perceived personality flaws and bad weatherspoils the vacation, the individual who is the mostunrealistic and idealistic may begin to lose hopeabout any friends or any vacation.

hopelessness 189

The stress of hopelessness may also result froma sense of being trapped in a negative set of cir-cumstances from which there is no escape. Whenpresented with a task that must be performed, butseems to be impossible, a sense of FRUSTRATION andfutility leads to hopelessness.

The stress of confusion also leads to a sense ofhopelessness, as confusion contributes to people’sfeelings of loss of control. It is important to under-stand that hopelessness is a subjective state, relatedto the way in which people perceive their prospectsas potentially reversible.

See also COPING; PERFECTION.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.

hormone replacement therapy See MENOPAUSE.

hospitalization The stress of illness is often inten-sified by the threat of being in a hospital, whichmost people find fraught with ANXIETY from begin-ning to end.

Stress starts with the need for a second medicalopinion, which, unless there is an emergency, isoften a requirement of medical insurers beforecommitment to a hospital can be made. Stress thenfollows patients to the hospital registration deskwhere the approach of many admissions personnelto gathering patient information does little to makethem feel comfortable.

Loss of privacy, another key stressor, begins atthe very moment patients exchange their clothesfor hospital gowns and settle down in roomsshared with at least one or more strangers whomay be a great deal more or less sick than they. Itis further compounded by the number of visitorsthey or their roommates may have—people whotalk loudly as they spill into all corners and all sidesof what can be a too small hospital room. In teach-ing hospitals, the stress continues to prevail whendoctors and interns gather around patients’ beds todiscuss clinical aspects of their illnesses, sometimesas if the patients did not exist or at least were notright there in the bed.

Stress escalates when loss of privacy combineswith the loss of CONTROL patients experience asthey are thrown into the uneven rhythm of the

hospital routine—being aroused at early hours formedication before a change in shifts occurs, mov-ing on stretchers or in wheelchairs from one end ofthe hospital to another, waiting in drafty corridorsfor countless tests and X-rays, buzzing for nursingassistance that never comes, having unappealingmeals served at hours when they are often leasthungry, and facing constantly changing caretakersand variations in the delivery of care. The mostserious sources of hospitalization stress are being inPAIN and having to rely on others for help in con-trolling that pain. A device that allows patients tocontrol the intake of pain medication when theyneed it has alleviated this problem for some.

Today, patients waiting to receive various trans-plants—heart, lungs, kidney, and liver—experiencean additional aspect of stress regarding when orwhether the transplant will come. The lists of thoseneeding transplants far exceed availability, and forsome there is little likelihood of a match. Questionsalso arise concerning the criteria for the lists and forthose who are given priority. An example of thatarose in 1995, when baseball star Mickey Mantle

190 hormone replacement therapy

HOSPITAL UTILIZATION*

Hospital Inpatient Care

Number of discharges: 34.7 millionDischarges per 10,000 population: 1,199.7Average length of stay in days: 4.8Number of procedures performed: 43.8 million

Hospital Outpatient Department Care

Number of outpatient department visits: 83.3 millionOutpatient visits per 100 persons: 29

Hospital Emergency Department Care

Number of emergency department visits: 113.9 millionEmergency department visits per 100 persons: 38.9Number of emergency department visits resulting in

hospital admission: 15.8 millionNumber of emergency department visits resulting in

admission to an intensive care unit or coronary careunit: 1.5

*In nonfederal short-stay hospitals, 2003 U.S. data

Source: National Center for Health Statistics

Available at: http://www.cdc.gov/nchs/fastats/hospital.htm.Last downloaded: October 3, 2005.

received a transplant a short time after a diagnosiswas made.

The shortened hospital stays of the later 1990shave increased the anxiety of most patients. Muchof the time needed for rehabilitation and recoverynow is spent outside of the hospital, which puts agood deal of the burden of care on patients’ fami-lies. For those without families, other means ofhome care must be found and questions ariseabout the costs of this care.

Lastly, there is the stress on family and friendsrelated to hospitalization of the dying—ethicalquestions relating to withdrawal of nourishmentand treatment, particularly when there are nodirections from the patient.

See also ACCESS TO CARE; AUTONOMY; DEATH; END-OF-LIFE CARE; PERSONAL SPACE.

Stresses Facing Hospital Workers

Workers in hospitals face stresses of diverse poten-tial hazards that include biological, chemical, psy-chological, physical, environmental, mechanical,and biomechanical challenges.

Biological stresses include infectious/biologicalagents, such as bacteria, viruses, fungi, or parasites,that may be transmitted by contact with infectedpatients or contaminated body secretions/fluids.Examples of these include: human immunodefi-ciency virus (HIV), vancomycin-resistant entero-coccus (VRE), methicillin-resistant staphylococcusaureus (MRSA), hepatitis B virus, hepatitis C virus,and tuberculosis.

Chemical stresses include various forms of chem-icals that are potentially irritating to the body ortoxic, including medications, solutions, and gases.

Psychological factors and situations encoun-tered or associated with one’s job or environmentcan create emotional strain and/or other interper-sonal problems. Inadequate staffing, heavy work-load, and high rates of severe or acute illnessamong patients can create stress.

Physical stress can occur within the hospitalwork environment, such as trauma to one’s bodyor exposure to radiation, lasers, noise, electricity,extreme temperatures, and violence. Environmen-tal, mechanical, and biomedical factors in dailyactivities of hospital workers can cause accidents,injuries, strains, or discomfort. There may be trip-

ping hazards, unsafe/unguarded equipment, poorair quality, slippery floors, confined spaces, clut-tered or obstructed work areas/passageways, force-ful exertions, awkward postures, vibration, andrepetitive and/or prolonged motions or activities.

See also HEALTH CARE WORKERS; FUNGI; HUMAN

IMMUNODEFICIENCY VIRUS; NOISE; NURSING HOMES;SHIFT WORK; SLIPS, TRIPS, AND FALLS; STRESS; VIOLENCE.

hostages Victims who are subjected to theextreme stresses of isolation, confinement, andsometimes mental and physical torture. Captorsfrequently keep hostages in a state of uncertaintyabout their fate. Hostages may be individuals in aforeign country or held locally by criminals for anyone of many purposes.

Hostages may be blindfolded, kept in darkness,and have their ears covered. The sensory depriva-tion experience may produce HALLUCINATIONS.Some hostages have become paranoid, depressed,and think that their country and families have for-gotten them.

Readjustment to normal life after release,though welcome, is sometimes stressful for ex-hostages. Many experience nightmares, insomnia,bouts with abnormal fears, DEPRESSION, and feelingsof rage and helplessness for some time. Mentalhealth professionals are gaining an understandingof the state of mind of former hostages throughexperience. Current thinking is that a regulated“decompression period” helps former hostagesadjust to normal life and to being back with theirfamilies.

Following the Persian Gulf war during 1991,several hostages were released after long years ofcaptivity. Richard Rahe, M.D., director of theNevada Stress Center at the University of NevadaSchool of Medicine, and a former Navy psychiatristwith extensive experience working with hostagesand disaster victims, in an interview with Psychi-atric News, said that how the individuals behavedbefore, during, and after the hostage experiencecan aid in predicting who might have difficultiesupon reentry.

“People who do well have done well in the pastwith stress. They have had adequate-to-goodchildhoods. They did well in captivity. They passedthrough depression, and found themselves

hostages 191

through helping others. They turned the experi-ence into a positive one, by reviewing their lives,making positive changes.”

Rahe also said that survivor GUILT is common, asare recriminations about the way they might havebehaved in captivity, and many are angry towardtheir families or the government for not doingenough to help them. At greatest risk of develop-ing full-blown POST-TRAUMATIC STRESS DISORDER

(PTSD) are those people who already had symp-toms before being taken hostage and those withouta good support system.

Elmore Rigamer, M.D., chief psychiatrist, U.S.State Department, quoted in Psychiatric News (Jan-uary 4, 1991) regarding the “keys to staving offdeterioration” in a hostage situation, commentedthat “mastery” and “connectedness” are the keys toovercoming psychological hurdles associated withhaving been a hostage. Mastery (a sense of CON-TROL) and connectedness (feeling accuratelyinformed) are both important for hostages andtheir families. “The ones who were able to takecontrol of themselves will do wonderfully. Themore feeling of loss of control, the worse.”

Dr. Rigamer emphasized the psychological valueof relaying information to hostages and familiesduring and after the crisis. During the crisis hespent as much time as he could on the telephonewith State Department hostages in Baghdad andKuwait and their families back home, clearing uprumors and giving out information.

In Psychiatric News (January 4, 1991), ThomasM. Haizlip, M.D., University of North Carolina,outlined seven stages of mastery applicable to boththe hostages and their families:

1. Discriminating between good and bad forces

2. Coping by knowing what to do if it ever happensagain

3. Putting your life back in order

4. Dealing with survivor guilt (having left somepeople and worldly goods behind)

5. Realizing that healthy people are willing to takeadvantage of a two-to-three-week “window”after the experience, when willingness to talk isgreatest

6. Hooking up any symptoms with the event,rather than further repressing them

7. Recognizing that many people do not want helpbecause they feel they themselves are impor-tant dispensers of help

Many of these stages are also applicable afterother life traumas, such as domestic violence, wit-nessing, or being a victim of a crime.

See also AUTONOMY; BRAINWASHING.

SOURCES:Haizlip, Thomas M. “Hostages.” Psychiatric News, January

4, 1991, p. 18.Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

hostility A persistent attitude of deep resentmentand intense ANGER. It may be the result of stressfulsituations or may also cause stress for the individ-ual. The hostile person may have an urge to retal-iate against a person or situation. During somesituations of intense FRUSTRATION, deprivation, ordiscrimination, feelings of hostility may be a nor-mal reaction. However, hostile attitudes also mayoccur during ANXIETY attacks, in OBSESSIVE-COMPUL-SIVE DISORDER, or DEPRESSION. Some people whohave antisocial personalities frequently have hos-tile attitudes.

At best, hostile people are simply grouchy. Atworst, they are consumed by hatred. A hostile per-son may have a tense-looking face and body. Theyare easily excitable. They seem to have chips ontheir shoulders and a bitterness toward the world.They may be sarcastic and moody and respondaggressively when challenged.

For many individuals, the stresses of hostilitiescan be worked out through EXERCISE, better COM-MUNICATION skills, BEHAVIOR THERAPY, use of MEDI-TATION and RELAXATION, and psychotherapy.

See also AGGRESSION; ALTERNATIVE MEDICINE; PER-SONALITY; PSYCHOTHERAPIES; TYPE A PERSONALITY.

hot flashes A sudden feeling of warmth occur-ring on the face, chest, or entire body. They are amajor symptom of MENOPAUSE experienced bymany midlife WOMEN. Hot flashes are sources ofstress because they come on unexpectedly, and canbe embarrassing as well as uncomfortable. Thewoman’s body may become flushed, and patchesof redness may appear on her chest, back, shoul-

192 hostility

ders, and upper arms. She may perspire profusely;episodes may last from seconds to minutes. Assweat evaporates, the body temperature decreases,causing chills and a cold, clammy sensation.Women experience the symptoms of hot flashes ina variety of ways. Some have only a few, otherscontinue to have them for years; some womenhave hot flashes several times a day, once a week,or less frequently. For most women, however, hotflashes are self-limiting symptoms and disappearwithout any treatment.

Effects of Hot Flashes

Because hot flashes may occur during the night anddisrupt sleep, women experiencing hot flashes maybecome irritable, tired, and depressed. In a 1986survey (Holt and Kahn), typical complaints abouthot flashes included waking up at night drenchedin sweat, ruining clothes from perspiration, feelingembarrassed at flushing and shivering with no con-trol, and being intolerant of heat or cold. Manywomen find their bodies unable to deal comfortablywith even slight temperature variations.

Some women say that the most stressful aspect ofa hot flash is that it makes them feel out of CONTROL

and interferes with their sense of well-being. Whilehot flashes are not a threat to health, they can makea woman uncomfortable and even anxious abouthaving one in social or professional situations.

Previous generations of women were sometimestold that hot flashes were “all in their head,” andthat menopause was expected to be a time filledwith bizarre behavior and delusions. Such com-ments from medical professionals no doubt addedto the stress level of those women. Fortunately, thisis no longer the case as medical practitioners under-stand the triggers for hot flashes, and supplementsand medications are available to treat them.

Why Hot Flashes Happen

Hot flashes occur because of hormonal changes. Ahormone known as luteinizing hormone (LH) risesafter menopause. Before menopause, it is the sub-stance that helps trigger ovulation. LH “surges”seem to set off hot flashes by dilating surface bloodvessels. Hormonal changes associated with the hotflash may also be due to nerve activity in the hypo-thalamic area that controls temperature and ante-rior pituitary function.

Medical and Self-Help

When hot flashes occur so often that a womanfeels stressed by them, or if she cannot get a goodnight’s sleep, if they interfere with sexual activityor work, or if they make her chronically exhaustedand depressed, medical assistance should besought. Hot flashes are often treated with hormonereplacement therapy and alternative medicationsincluding sedatives and anticholinergic agents(substances that block or interfere with transmis-sion of certain impulses in the parasympatheticnervous system).

A woman’s diet may play a role in whether shesuffers from hot flashes. Refined sugars, caffeine,alcohol, and spicy foods may trigger hot flashes insome women. Recognizing the potential role of dietin reducing or eliminating hot flashes, many alter-native therapists recommend that women ingestfoods or herbs containing phytoestrogens. Phytoe-strogens are natural-occurring sources of estrogen.Sources of phytoestrogens include soybeans, alfalfa,and rice. In addition to certain foods, nutritionalsupplements are frequently recommended by alter-

hot flashes 193

TIPS FOR RELIEVING THE STRESS OF HOT FLASHES

• Air stuffy rooms; keep a window open if one istoo warm.

• Layer clothing. A suit with a lightweight blousegives the wearer more flexibility than a wooldress.

• Wear a cotton (or other absorbent material)blouse under a sweater. Avoid wearing a sweaternext to the skin.

• For desk-workers, use a small, desk-top fan.• During a hot flash, do not overreact. Keep calm;

others will not pay attention.• Learn RELAXATION techniques to feel in control of

the situation.• Regular exercise will tone the vascular system

and may help a woman feel better.• Keep weight down. Slender women seem to

have less erratic estrogen production, and hencefewer erratic experiences with hot flashes.

• Seek homeopathic or alternative remedies; addsoy products to your diet.

native health providers as a means of reducing theincidence of hot flashes. Vitamin E and bioflavi-noids have shown some promise in this area.Herbal remedies for hot flashes include ginseng,vitex, garden sage, sarsaparilla, and dong quai.

See also ALTERNATIVE MEDICINE; BIOFEEDBACK;HERBAL MEDICINE; HOMEOPATHY.

SOURCES:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.———. 50 Ways to Cope with Menopause. Lincolnwood, Ill.:

Publications International, 1994.National Women’s Health Report. “Alternative Therapies

and Women’s Health.” Washington, D.C.: NationalWomen’s Health Resource Center, May/June 1995.

hotlines Telephone lines maintained by trainedpersonnel to provide crisis intervention service orinformation on a given topic. Throughout theUnited States, hotlines cover many concernsrelated to stress and mental health. In many cases,the numbers for information and help are toll freeand usually operate on a 24-hour basis.

Most city telephone directories list some of theavailable hotlines.

See also SELF-HELP GROUPS; SUPPORT GROUPS.

human immunodeficiency virus (HIV) The HIVvirus is considered responsible for causing the infec-tion that leads to Acquired Immunodeficiency Syndrome(AIDS), which continues in epidemic proportions inthe United States and elsewhere in the world in theearly 2000s. According to Avert.org, an interna-tional AIDS charity, during 2004 about 4.9 millionpeople became infected with the human immunod-eficiency virus. In 2004, there were 3.1 milliondeaths worldwide from AIDS.

Many people experience stress because of con-cern about this virus; those who have it are anx-ious about their health and those who do not haveit are fearful of contracting it. Many people have amisunderstanding about how it is transmitted,which adds to their stress level.

How the Virus Is Transmitted

The virus is usually transmitted by direct exchangeof body fluids, such as blood or semen, or by usingcontaminated needles for illicit drug use. Many

individuals experience stress about contracting thevirus by eating in restaurants in which infectedindividuals may work or by sending their childrento a school that an infected child is known toattend. In most cases, these anxieties are unfounded,as the virus does not survive outside the body,according to research reports.

Individuals who suspect their partners of high-risk sexual contacts, such as homosexual men orprostitutes, should seek medical advice aboutscreening for and preventing transmission of theHIV virus. Use of condoms during sexual intercourseis promoted as a way to prevent the transmission.

HIV and AIDS in Pregnancy

According to the March of Dimes, an estimated120,000 to 160,000 women in the United Statesare living with the virus; many do not know theyare infected. Approximately 15,000 children in theUnited States have contracted HIV; about 3,000have died. About 90 percent contracted the virusfrom their mothers during pregnancy or birth.

Since 1994, when a government study showedthat drug treatment during pregnancy greatlyreduced the risk that an HIV-infected mother willpass the virus to her baby, the number of babieswho contract the virus from their mothers hasdropped. Between 1992 and 1999, the number ofchildren reported by the Centers for Disease Con-trol and Prevention (CDC) with HIV infection con-tracted from their mothers declined 83 percent.However, according to the CDC, between 280 and370 infants per year in the United States still con-tract HIV from their mothers. In 2002, the CDCrecommended that all pregnant women be offeredvoluntary testing for HIV as a routine part of pre-natal care. Women who know they carry the viruscan get treatment to help protect their babies.

About 600,000 babies worldwide contract HIVeach year. About 90 percent of cases occur indeveloping countries where new treatments arenot generally available.

According to the March of Dimes, HIV-infectedbabies do not show signs of HIV infection at birth,but about 15 percent develop symptoms or die inthe first year of life. Nearly half die by age 10.However, new drugs are improving the prognosisfor infected children and many are free of serioussymptoms much of the time.

194 hotlines

Concerns about Getting HIV from a Health Care Professional

Some people experience stress when having blooddrawn or dental and medical procedures donebecause they fear contracting the HIV virus.According to an article in Health (September 1992)the person who draws the blood presents virtuallyno risk. To infect a person, a health professionalwho is HIV positive would have to get stuck withthe needle, and in turn stick that person with thecontaminated needle. There is little likelihood ofthis happening. In the case of dental hygienists whomanipulate sharp instruments inside a person’smouth, they would have to injure themselves andbleed into exposed tissue in that person’s mouth.

According to an article in Health (September1992), one can reduce one’s stress level about thissituation by being sure that one’s health care pro-fessional is taking universal precautions. Look overthe doctor or dentist’s office. Equipment andinstruments should look clean. Personnel shouldwash their hands before and after procedures, andshould wear gloves, masks, and eye guards (duringprocedures where body fluids might splatter). Pro-tective gear should be changed or discardedbetween patients. Needles and other sharp objectsshould be disposed of in secure containers. Any-thing that goes in your mouth or inside your bodyshould arrive in sterile packaging, be disinfected, orbe sterilized by autoclave or dry heat.

See also HIV/AIDS TREATMENT INFORMATION SERV-ICE; SEXUALLY TRANSMITTED DISEASES.

FOR FURTHER INFORMATION:CAIN (Computerized AIDS Information Network)San Francisco AIDS Foundation54 Tenth StreetSan Francisco, CA 94103(415) 864-4368

AIDS-Hotlines National AZT Hotline(800) 843-9388 (toll-free)

National AIDS Information ClearinghouseCenters for Disease Control and PreventionBox 6003Rockville, MD 20850(800) 458-5231 (toll-free)

March of Dimes1275 Mamaroneck Avenue

White Plains, NY 10605http://www.marchofdimes.com

Avert.org4 Brighton RoadWest Horsham SussexRH13 58AEnglandhttp://www.avert.org

humanistic psychology This approach to psy-chology and treating stress centers on the personand his or her own experiences. Humanistic psy-chology opposes Freudian psychology, whichholds that sexual drive is the sole motivatingforce, and behavioral psychology, which explainshuman behavior as the produce of a multiplicityof organismic and environmental relationships,each of which in turn dominates the others at cer-tain times.

In humanistic psychology, emphasis is onhuman qualities such as choice, creativity, valua-tion, and self-realization; meaningfulness is thekey to selection of problems for study. The ultimateconcern of humanistic psychology is the develop-ment of each person’s inherent potential.

According to humanistic psychologists, a personhas a hierarchy of many needs, beginning withphysiological needs, safety, love and “belonging-ness,” needs for esteem, esthetic needs, the need toknow and understand, and ending in the essentialneeds for self-actualization. In contemporary soci-ety, many of these needs are not met, causingstress for the individual.

Humanistic psychology is a value orientationthat holds a hopeful, constructive view of humanbeings and of their substantial capacity to be self-determining.

The Association for Humanistic Psychology

The Association for Humanistic Psychology (AHP)was founded in 1962 by Abraham Maslow, KurtGoldstein, Rollo May, Carl Rogers, and others. It isa worldwide community of diverse people promot-ing personal integrity, creative learning, and activeresponsibility in embracing the challenges of beinghuman. AHP attracts therapists, teachers, consult-ants, body workers, lawyers, social workers, corpo-rate managers, futurists, and politicians because

humanistic psychology 195

personal encounter and social responsibility is atthe heart of the organization’s tenets.

See also HIERARCHY OF NEEDS.

FOR INFORMATION:Association for Humanistic Psychology1516 Oak Street, #320AAlameda, CA 94501-2947(510) 769-6495http://ahpoffice@aol.com

humming Humming is a voiced sound thatsounds like “hmmm.” Humming gently can helprelieve stress. Sound moves though the body asvibration. Sound moves by compressing andexpanding the material it is moving through,whether air, water, or the wood of a door. Thatwave of compression and expansion is what hap-pens when you make a sound that moves throughyour body. Through your body, this pulse of open-ing and closing presses and releases many levels oftissue, from fluid to bone. Muscle, fluid, nerves,vital organs, bone—all are touched and massagedby the pulsation of sound.

• Let the sound move up into your brain, out intoyour arms and hands, down through your torsoand legs and feet. The more relaxed you are asyou make the sound, the further it will travel.

• People around you may not hear the sound, butyou will feel it as it moves throughout yourbody.

• Hum a while, rest and feel the sound movethrough you.

SOURCE:Henderson, Julie. Embodying Well-Being: How to Feel as

Good as You Can. Napa, Calif.: Zapchen Resources,2003.

humor A positive emotion that usually providesa helpful release of stress and anxieties for manypeople. Humor may actually ease PAIN and mayhelp the respiratory system by exercising the lungs.LAUGHTER, the expression of humor, may influencethe immune system, by stimulating production ofcertain hormones that help to ease pain and liftone’s mood.

Humor is a universal language and has univer-sal appeal. The basis for much humor is that we areprepared for one thing and something else hap-pens. Although we are startled, we know there isno danger, and we release our surprise in laughter.Thus a story with an unexpected ending, or a gameof peek-a-boo for an infant, can seem humorousand bring about a laughter response.

Shared humor relieves anxiety in stressfulgroup situations, such as when airplanes or trainsare delayed. It also relieves stresses that result fromBOREDOM. At times when it seems that nothing isleft to talk about, familiar topics can be renewed byemploying humor.

In work situations, a humorous approach canhelp one face sources of stress an daily disap-pointments. Blumenfeld and Alpern, in theirbook Humor at Work, outline some characteristicsof stress-reducing humor, which can be used inthe workplace as well as in other settings. How-

196 humming

USE OF HUMOR TO RELIEVE STRESSFUL SITUATIONS

• Reduce tension by joking about universal humanfrustrations and faults.

• Encourage people to relax and laugh.• Delight in poking fun at oneself.• Unite people by building rapport.• Create a supportive atmosphere of fun and

caring.• Note the positive aspects of human

relationships.

PREVENT STRESS: AVOID THESE USES OF HUMOR

• Poking fun at other people’s individual shortcomings

• Reflecting anger• Offending with inappropriate use of sexual refer-

ences or profanity• Dividing a group by put-downs• Using a stereotype to denigrate a person or

group• Creating a cruel, abusive, and offensive

atmosphere

ever, the authors warned against using humor thatcan be misused and actually lead to stress.

Some therapists employ humor to momentarilyrelieve DEPRESSION during therapy sessions. Onetechnique is known as paradoxical therapy, inwhich the therapist gives the individual new per-spectives on his or her problems by exaggeratingthem to the point of making them seem funny. Thetherapist might assign the individual to bedepressed or anxious at a certain time of day. Some-times the silliness of such situations helps alleviatethe individual’s depressed or anxious feelings.

Historical Overview of Humor

Ancient scholars understood the role of humor ingood health. The Book of Proverbs says: “A merryheart doeth good like a medicine.” Conversely,many individuals who suffer from depression losetheir sense of humor and few things make themsmile or laugh. Studies in the late 20th century sug-gested that an ability to enjoy humor and to laughhave effects on mental as well as physical health.NORMAN COUSINS’s book Anatomy of an Illness (1977)stimulated interest in the use of humor in recoveryfrom both mental and physical illness. While fight-ing ankylosing spondylitis, he checked out of thehospital and spent weeks watching Marx brothersmovies and other comedies. He believed that thepositive feelings aroused by humor and laughterhelped him recover. Increasingly, hospitals andhealth care practitioners are bringing humor pro-grams into their compendia of therapies.

SOURCES:Blumenfeld, Esther, and Lynne Alpern. Humor at Work.

Atlanta: Peachtree Publishers, 1994.Ziv, Avner. Personality and Sense of Humor. New York:

Springer Publishing Co., 1984.

hypersensitivity pneumonitis (HP) Repeatedinhalation of a foreign substance, such as an organicdust, a fungus, or a mold, causes an inflammation ofthe lungs and stress for the sufferer. The immunesystem of the body reacts to these substances, calledantigens, by forming antibodies, molecules thatattack the invading antigen and try to destroy it. Theacute inflammation, or pneumonitis (a hypersensi-tivity reaction), is produced by the combination ofantigen and antibody, which later can develop intochronic lung disease. The ability of the lungs to take

in oxygen from the air and to eliminate carbon diox-ide is impaired.

The condition is also known as allergic alveoli-tis. Allergic refers to the antigen-antibody reaction,and alveolitis means an inflammation of the alveoli,tiny air sacs in the lungs where the exchange ofoxygen and carbon dioxide takes place.

Certain changes occur in the lungs of personswho have HP. In the acute stage, there are largenumbers of inflammatory cells throughout thelungs and the air sacs may be filled by a thick fluidmixed with these cells. In the subacute stage, dis-ease extends into the small breathing tubes, orbronchioles, and the inflammatory cells collect intotiny granules called granulomas. Finally, in thechronic stage of HP, the previously inflamed parts ofthe lungs become scarred and unable to function.

Stressful occupational factors cause severaltypes of hypersensitivity pneumonitis. For exam-ple, farmer’s lung is a type of HP caused by anti-gens from tiny microorganisms on moldy hay.After a time, very little of the allergenic material isneeded to set off a reaction in the lungs. Birdfancier’s lung is a form of external allergic alveoli-tis caused by the inhalation of avian proteins pres-ent in droppings and feathers of certain birds,particularly pigeons and caged birds. As in farmer’slung, there is an acute and a chronic form. Maltworkers’ lung is caused by inhalation of malt dust.

SOURCE:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.

hypertension See HIGH BLOOD PRESSURE.

hyperventilation Deep and fast BREATHING; it issometimes referred to as overbreathing. Someindividuals who feel very stressed and those whohave panic attacks and PHOBIAS may react withhyperventilation, which in turn makes them fearthat they are dying or having a HEART ATTACK.

Hyperventilation can result in rapid heartbeat,sweating, and numbness or tingling in the handsand feet, light-headedness, DIZZINESS, fainting.These symptoms in turn exacerbate the individ-ual’s stress and anxiety level.

Individuals who are hyperventilating typicallyfeel short of breath, and when they breathe deeply

hyperventilation 197

and faster to get more air into their lungs, they arereally taking in too much air. This breathing patternmakes them feel even more stressed, as it removestoo much carbon dioxide from the blood, where itis needed for the body to perform efficiently.

When an individual has a dizzy spell or feels theeffects of hyperventilation, breathing into a paperbag for a few minutes can help restore the balanceof oxygen and carbon dioxide in the blood. Whensome of the exhaled carbon dioxide from the bagreturns to the lungs, the individual will begin tobreathe more normally again.

RELAXATION therapy, including breathinginstruction, helps some individuals relieve thestressful symptoms of hyperventilation.

See also COPING; MEDITATION.

hypnosis (hypnotherapy) A type of attentive,receptive and focused concentration accompaniedby an altered state of consciousness and a dimin-ished awareness of environmental stimuli. It isconsidered an alternative therapy and is sometimesused to help relieve symptoms of stress, such asANXIETY, PHOBIAS, and PAIN, and insomnia and tocontrol habits such as SMOKING, overeating, or NAIL

BITING, often in conjunction with other therapies.Hypnosis is sometimes used for memory

enhancement. While hypnosis does not help a per-son remember better, it relieves some of the stressand tension that may be inhibiting memory. Thegreater the stress the individual feels, the less likelyhe is to remember clearly and accurately.

Hypnotherapy utilizes the hypnotic “trance,” astate of deep RELAXATION, to produce a state of highsuggestibility. While in this state, suggestions areoffered either by a therapist or the individual him-self; such suggestions are aimed at improving someaspect of physical or mental health, or stress reduc-tion. Often the suggestion takes the form of imag-ining a desired result in detail.

In that state some people gain the ability tochange their perceptions of stress, anxiety, pain,memories, and feelings. “This opens up a tremen-dous use of hypnosis in pain control,” says Peter B.Bloom, M.D., past president of the InternationalSociety for Hypnosis.

Hypnotherapy has been used as a complement tomedical therapy in a number of conditions and as aprimary treatment modality in others. In the man-

agement of pain, for example, hypnosis has beenused not only to reduce the stress and anxiety thataccompany painful medical procedures, but also toreduce the discomfort and need for analgesics asso-ciated with labor and delivery, hysterectomy, coro-nary bypass surgery, and abdominal surgery.

Benefits of hypnotherapy include decreasednausea and pain, shorter hospital stays, and morerapid healing. Hypnotherapy has been used todecrease bleeding in hemophiliacs, to help stabilizeblood sugar in diabetics, and to reduce the severityof asthmatic attacks.

Self-Hypnosis

Treatment with hypnosis involves teaching self-hyp-nosis techniques so participants can induce a trance-like state in themselves and use suggestions to helpthem restructure their thinking regarding the condi-tion for which they are seeking help. Some individ-uals undergo hypnotic induction by listening to avoice giving them instructions to become increas-ingly relaxed and focused. Many people are thentaught to enter the hypnotic state on their own andto give themselves suggestions aimed at achievingtheir goals. For example, in management of pain,hypnosis helps to block the perception of pain bydrawing the individual’s attention away from it.Self-hypnosis has been shown to be effective for thecontrol of chronic headaches.

Self-hypnosis is sometimes used to promoterelaxation on cue in stressful situations. In general,autohypnosis by itself will not significantly relievestress responses. It can, however, be used as a sup-plement to BEHAVIOR THERAPY to make images morevivid and to heighten one’s ability to concentrate.

Contrary to popular belief, the power of hypno-sis lies within the individual and not the hypnotist.In a therapy situation utilizing hypnosis, the indi-vidual cooperates with the therapist to utilize thisform of intense concentration to facilitate andaccelerate reaching particular therapeutic goals.Individuals cannot be hypnotized against their will,but some individuals are more or less capable ofachieving a hypnotic trance.

See also HEADACHES.

FOR FURTHER INFORMATION:American Society of Clinical Hypnosis140 N. Bloomingdale RoadBloomingdale, IL 60108-1017

198 hypnosis

(630) 980-4740http://www.asch.net

SOURCES:Callahan, Jean. “Hypnosis: Trick or Treatment?” Health,

May–June 1997.Kerns, Lawrence L. “A Clinician’s Guide to Mind-body

Treatments.” Chicago Medicine, November 21, 1994.Lehrer, Paul M., and Robert L. Woolfolk, eds. Principles

and Practice of Stress Management, 2nd ed. New York:Guilford Press, 1993.

hypochondriasis Preoccupation with the beliefthat one has a serious disease is based on the indi-vidual’s own interpretation of physical symptomsor sensations. This situation is a source of stress forthe individual as well as health care professionals. Athorough physical examination does not supportthe diagnosis of the supposed physical disorder orthe individual’s unwarranted interpretation ofthem, although a coexisting physical disorder maybe present. The unwarranted belief of having a dis-ease persists despite medical reassurance. However,the belief is not delusional, as the hypochondriaccan acknowledge the possibility that he or she maybe exaggerating the extent of the feared disease orthat there may be no disease at all.

The preoccupation may be with bodily func-tions, such as heartbeat, sweating, or digestion, orwith minor physical abnormalities, such as a smallsore or an occasional cough. The individual inter-prets these sensations as evidence of a serious dis-

ease. The feared disease or diseases may involveseveral body systems at different times or simulta-neously. Alternatively, there may be preoccupationwith a specific organ or a single disease, for exam-ple, in which the individual fears or believes thathe or she has heart disease.

Hypochondriasis often causes people to showsigns of ANXIETY, depressed mood, and obsessive-compulsive personality traits. The most commonage of onset is between 20 and 30 years. It isequally common in males and females.

See also DEPRESSION; OBSESSIVE-COMPULSIVE

DISORDER.

hypothalamus The coordinating center of thebrain; plays an important part in reacting to stress-ful situations. It is a small area located above thepituitary gland, with nerve connections to mostother areas of the nervous system; it controls theSYMPATHETIC NERVOUS SYSTEM (controls the innerbody organs). During STRESS, FEAR, or excitement,the brain sends signals to the hypothalamus, whichinitiates a chain of activity, including faster heart-beat, faster BREATHING rate, and increased bloodflow to the muscles (the FIGHT OR FLIGHT RESPONSE).

The hypothalamus also controls reactions thatcause sweating or shivering, stimulates appetiteand thirst, regulates sleep, motivates sexual behav-ior, and determines EMOTIONS and MOODS; it indi-rectly controls many of the endocrine organs thatsecrete hormones.

hypothalamus 199

Iidentity theft Identity theft has reached epidemicproportions in the United States, causing manypeople concern and stress. Most people do notknow that they have been victimized until it is toolate. According to Betsy Broder, an identity theftexpert with the Federal Trade Commission, “Iden-tity thieves are able to get the equity out of yourhouse, buy luxury cars in your name, and theyhave evaded law enforcement by using some else’sname when they are arrested. They are resourcefuland creative.”

According to the Federal Trade Commission’sfirst national survey of the problem in 2004, 3.3million Americans found within the past year thattheir names had been used to open fraudulentbank or credit card accounts or to commit othercrimes. An additional 6.6 million people reportedunauthorized purchases on their existing accounts.According to Carole Fleck, in her article “StealingYour Life,” experts say the number has been dou-bling every year since 2000.

A factor that increases the stress involved in iden-tity theft is that the crime can take many forms;however, it always involves misappropriation ofnames, Social Security numbers, credit card num-bers, or other pieces of personal information forfraudulent purposes.

In December 2004 Congress passed the Fair andAccurate Credit Transaction Act to slow the risingtide of identity theft. The law gives people access totheir credit reports and requires that financial insti-tutions be alert to the patterns of identity theft.

The Federal Trade Commission estimates thatidentity thieves in 2003 cost consumers $5 billionin out-of pocket expenses and cost businesses $48billion.

If you suspect identity theft, close the accountyou think has been fraudulently used, file a policereport, contact the credit reporting agencies, placea fraud alert on your accounts, and contact theFederal Trade Commission.

FOR FURTHER INFORMATION:Equifax(888) 766-0008 (toll-free)http://www.equifax.com

Experian(888) 397-3732 (toll-free)http://www.experian.com

Federal Bureau of InvestigationInternet Fraud Complaint Centerhttp://www.idtheftcenter.org

Federal Trade Commissionhttp://www.consumer.gov/idtheft

TransUnion(800) 680-7289 (toll-free)http://www.transunion.com

SOURCE:Fleck, Carol. “Stealing Your Life.” AARP Bulletin 45, no. 2

(February, 2004): 3–4.

illiteracy The inability to read or write. It is a per-sonal stressor for many people, contributing to their

200

PROTECT YOURSELF AGAINST IDENTITY THEFT

• Shred your mail. Shred preapproved credit cardsolicitations. If bills for credit cards you alreadyhold are late, call your issuer.

• Guard your Social Security number as it is thekey to an identity thief’s attack.

• Watch your credit. Place an alert on your creditreports if you suspect any fraudulent activity.

poor self-image and affecting their ability to obtainemployment with which to support their families.People who are unable to read or write or who doone or both poorly may develop techniques to hideor compensate for their lack. Embarrassment maykeep them from seeking help. For children, the illit-eracy of a parent can also be a source of embarrass-ment and cause them a great deal of stress.

Illiteracy is a fairly common problem in theUnited States estimates are that 75 percent ofunemployed Americans are illiterate. In the early1990s, the New York Telephone Company had togive 60,000 people an entry-level exam in order tohire 3,000 employees. Some major corporationshave had to use graphics on assembly lines to com-pensate for workers’ inability to read simplephrases. As jobs have become increasingly techni-cal and the economy has shifted from an industrialto a service base, more jobs will require skills thatinclude reading and writing ability.

LEARNING DISABILITIES account for some illiteracy;however, there is not always agreement amongeducators as to what extent. There is a growingmovement in American education to reduce illiter-acy by treating reading and writing problems aslearning disabilities at an early stage in schooling.

At the end of the 20th century, many commu-nity organizations have taken on illiteracy as aproject. Volunteers work with people who needhelp reading and writing.

See also SELF-ESTEEM; VOLUNTEERISM.

imagery See GUIDED IMAGERY.

immigration See ACCULTURATION; MIGRATION.

immune system A collection of cells and proteinsthat protect the individual against possibly harmfulmicroorganisms such as viruses, bacteria, and fungi.It is involved in problems of ALLERGIES and hyper-sensitivity, rejection of tissues after grafts and trans-plants, and probably CANCER. Suppression of theimmune system can occur as an inherited disorderor after infection with certain viruses, includingHIV (the virus that causes AIDS), resulting in low-ered resistance to infections and to the develop-ment of malignancies. There is evidence that severeSTRESS and DEPRESSION may inhibit normal immunefunction, although this has not been proven.

Relationship of Stress and the Immune System

There are possible physiological and behavioralexplanations for changes in the immune systemdue to stress and negative emotional states. Stressis associated with activation of several systems,including the hypothalamicpituitary-adrenal axisand the SYMPATHETIC NERVOUS SYSTEM.

Certain lifestyle factors influence the immuneresponse. For example, lack of SLEEP or EXERCISE

and use of alcohol and drugs affect the immunesystem in adverse ways. The best ways for a per-son to maintain immune system health are tohave a balance of exercise, rest, RELAXATION,recreation, fun, and LAUGHTER, a nutritionallyhealthy diet, and positive connections with fam-ily and/or friends.

Writing in World Health (March–April 1994), Dr.Tracy B. Herbert, Carnegie-Mellon University,reported on studies relating stress and the immunesystem. Factors such as bereavement, DIVORCE,UNEMPLOYMENT, and caring for a relative withALZHEIMER’S DISEASE were investigated. Generally,studies found that there is a large decrease in bothlymphocyte proliferation and natural killer cell activ-ities in individuals who have experienced stress.

The duration of stress also affects the amount ofimmune change; the longer the stress, the greaterthe decrease in the number of specific types ofwhite blood cells. Dr. Herbert also reported thatinterpersonal stress seems to produce differentimmune outcomes when compared with the stressdue to unemployment or exams.

Researchers have also looked at relationshipsbetween ANXIETY and depression and the immunesystem. Results suggest that depression and anxi-ety are associated with decreases in lymphocyteproliferation and natural killer cell activity,changes in the numbers of white blood cells, andthe quantity of antibodies circulating in the blood.It seems that the ability of the body to produceantibodies to a specific substance is related to thelevel of anxiety. More anxiety results in less anti-body production after exposure to a potentiallyharmful substance.

See also AUTOIMMUNE DISORDERS; ALTERNATIVE

MEDICINE; GUIDED IMAGERY; HUMAN IMMUNODEFI-CIENCY VIRUS; MEDITATION; MIND-BODY CONNECTIONS;PSYCHONEUROIMMUNOLOGY.

immune system 201

SOURCES:Herbert, Tracy B. “Stress and the Immune System.” World

Health, March–April 1994.Locke, Steven, and Douglas Colligan. The Healer Within.

New York: New American Library, 1986.Sapolsky, Robert M. Why Zebras Don’t Get Ulcers: A Guide

to Stress, Stress-Related Diseases, and Coping. New York:W. H. Freeman, 1994.

implosive therapy See BEHAVIOR THERAPY.

impotence The inability of a male to completesexual intercourse due to partial or incompleteachievement of, or maintaining, an erection. Esti-mates indicate that 10 million American men haveerectile impotence and consequently the stress ofFRUSTRATION, embarrassment, and irritability.Impotence may take the form of low interest insexual activity, premature ejaculation, coitus with-out ejaculation, or erectile capacity only with pros-titutes. It is a stressor for men as well as theirpartners.

Diagnosing Impotence

Diagnosing the causes of impotence involves manyphysical and psychological tests conducted withthe impotent man, and, in some cases, his partner.The physical examination includes blood, hor-mone and circulation tests, neurological studies,and tests on penile blood pressure and tempera-ture, among others.

An important test to distinguish organic frompsychological impotence is the Nocturnal PenileTumescence Test (NPT), in which erections thatoccur during sleep are measured. Most men havebetween two and five erections while asleep, eachlasting from five minutes to half an hour. In thetest, which can be conducted in sleep laboratoriesor in the home, an electronic device is used torecord changes in penile size. An insufficent num-ber of nocturnal erections may indicate a physicalproblem for which further medical attention isnecessary.

Treatment

Emotional factors, such as marital stress or depres-sion, also affect impotence. It was once thoughtthat psychological factors caused most impotence,but with increasing medical knowledge, the pro-

portion that can be explained on physiologicalgrounds is increasing. It is important for men suf-fering from impotence to have a thorough check-up for physical as well as emotional causes by aknowledgeable physician and/or sex therapist.Treatment may be as simple as treating the diseaseor eliminating the drug causing it, or as compli-cated as surgical implantation of a prosthesis. SEX

THERAPY is helpful to many men. In 1998 the FDAapproved Viagra (sildenafil citrate), the first oralpill to treat impotence. Other medications havebecome available since then.

See also PROSTATE CANCER; SEXUAL DIFFICULTIES;SEXUAL RESPONSE CYCLE.

FOR FURTHER INFORMATION:American Urological Association1000 Corporate Blvd.Lithicum, MD 21090(866) RING-AVA (toll-free)http://www.auanet.org

Impotence Institute of America, Impotents Anonymous

10400 Little Patuxent Parkway, Suite 485Columbia, MD 21044-3501(800) 669-1603 (toll-free)

National Kidney and Urologic DiseasesInformation Clearinghouse3 Information WayBethesda, MD 20892-3580(800) 891-5390 (toll-free)(703) 738-4929 (fax)http://kidney.niddk.nihigov

SOURCES:Church, Paul, and Peta Gillyatt. “Impotence: No Need to

Suffer in Secret.” Harvard Health Letter 21, no. 7 (May1996).

Frye, Christopher C., ed. “Impotence.” Mayo Clinic HealthLetter, August 1997.

incest Generally defined as sexual intercoursebetween persons so closely related that they areforbidden by law to marry. When these sexualrelations occur, many family members, includingthe victims, do not report them out of fear ofreprisal or fear of being abandoned by the perpe-trator. Stress and family tensions are ongoing insuch situations.

202 implosive therapy

In Western society, sexual intercourse betweenfather and daughter or mother and son, betweencousins, or between uncles and nieces, aunts andnephews, is prohibited.

See also DOMESTIC VIOLENCE.

SOURCES:Spies, Karen Bornemann. Everything You Need to Know

about Incest. New York: Rosen Publishing Group, 1992.Tritchell, James B. Forbidden Partners: The Incest Taboo in

Modern Culture. New York: Columbia University Press,1987.

incontinence, urinary See URINARY INCONTINENCE.

indecision See DECISION MAKING.

indigestion Refers to a variety of symptomsbrought on by eating, including FLATULENCE,HEARTBURN, abdominal pain, and NAUSEA. It causesa burning discomfort in the stomach because theindividual has eaten too much, too fast, or too-rich, spicy, or fatty foods. Nervous indigestion is acommon cause of stress. This stress generallyresults from anything that causes ANGER, ANXIETY,PAIN, and FEAR. STAGE FRIGHT, going for a job inter-view, or going on a first date are sometimes stress-ful situations that can cause indigestion.

To keep stress levels in line, eat a balanced diet;do not overdo. Allow plenty of time for eating.Limit foods that cause indigestion; eat small mealsfour times a day instead of three larger ones. Getadequate sleep and practice deep breathing, visual-ization, and other stress-reducing techniques.

Belching

Belching, or common burping, comes from the swal-lowing of air or from gas in the stomach caused bythe chemical reactions of food and digestive juices.Many individuals feel stressed by the embarrassmentthat results from belching in a social situation or pub-lic place. To overcome the embarrassment, as well asthe source of the problem, careful attention to dietmay make a difference. Also, taking more time toselect foods carefully and eat slowly may reduce theincidence of this annoying reaction.

Belching may occur more frequently when anindividual feels stressed because he or she eithereats too fast or selects foods that contribute to

heartburn, bloating, and belching. In addition todiet, RELAXATION techniques may be useful.

Bloating

The term bloating applies to the full, distended feel-ing in the abdomen, which occurs after overeating.Many people react to stressful situations by overeat-ing, eating too fast, or eating spicy, greasy foods, allof which contribute to bloating. The discomfortcauses further stress, as bloating leads to belching orburping, which can be socially embarrassing.

See also IRRITABLE BOWEL SYNDROME; NUTRITION.

industrial hygiene A profession concerned withmany stressful factors regarding safety and healthin workplaces, the community, and the environ-ment. Professionals in this field include scientistsand engineers who work to protect the health andsafety of workers and the community. Their jobsinvolve assuring that local, state, and federal lawsand regulations are followed.

Industrial hygienists face the challenges of plan-ning emergency response and coordinating teams,assessing risks, and making recommendations forimproving the safety of workers and those in thecommunity. They also advise government officialsand participate in developing regulations regardinghealth and safety of workers and their families. Indoing so, they encounter stresses of trying to satisfyauthorities as well as employers and communityresidents.

According to the American Industrial HygieneAssociation, workers also advise on ergonomics,noise hazards, and respiratory protection.

industrial hygiene 203

TIPS TO RELIEVE STRESS DUE TO BLOATING

• Relax before eating; eat and drink slowly.• Limit foods/beverages that contain air, such as

carbonated drinks, baked goods, whippedcream, and souffles. Do not smoke, chew gum,suck on hard candy, or drink through straws ornarrow-mouthed bottles.

• Correct loose dentures.• Eat fewer rich foods, such as fatty meats, fried

foods, cream sauces, gravies, and pastries.• Do not lie down immediately after eating.• Do not try to force yourself to belch.

See also AIR POLLUTION; CLEAN AIR ACT OF 1990;EMERGENCY RESPONSE; ERGONOMICS; NOISE.

inferiority complex An individual’s feeling ofvery low SELF-ESTEEM. He or she feels that otherpeople are better-looking, better achievers, ormore successful. Some children develop an inferi-ority complex because they are the victims of bul-lies while they are growing up. Other children doso because their parents have not encouragedthem or belittle or overly criticize all their efforts.In some families one child may be compared unfa-vorably with another; this can lead to an inferior-ity complex. Inferiority complexes can hauntindividuals throughout their lives and cause themstress in business and social situations. It can leadto mental and physical disorders such as sleepless-ness, DEPRESSION, loss of appetite, and HEADACHES.

Some people have inferiority complexes becauseof their BODY IMAGE. Contemporary advertising maycontribute to the negative image many people, par-ticularly women, have of their bodies. Female mod-els are often anorexic and compulsive aboutremaining thin, some to the point of interferingwith their good health. They set examples that areimpossible, and unhealthy, for the average personto attain.

The term inferiority complex was first used by CarlJung (1875–1961), a Swiss psychiatrist and philoso-pher. A complex includes ideas linked together andrelated to feelings that affect an individual’s behav-ior and PERSONALITY. People with serious inferioritycomplexes can learn to raise their self-image dur-ing psychotherapy.

See also EATING DISORDERS; PSYCHOTHERAPIES.

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: A

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

infertility An inability of a couple to conceive.Usually the diagnosis of infertility is made after atleast one year of sexual intercourse without con-traception. Infertility is often a cause of STRESS andANXIETY for many couples, particularly those whohave delayed marriage and childbearing until theirlate 30s or early 40s. This frustrating and oftenanguishing problem affects about 15 percent of all

couples of childbearing age, and only about one-half the couples professionally treated for infertilityachieve pregnancy.

Female Infertility

Failure to ovulate is a common cause of femaleinfertility. It may be caused by a hormonal imbal-ance, stress, or a disorder of the ovary, such as atumor or a cyst. Disorders of the uterus andblocked Fallopian tubes are other reasons for infer-tility. It is rarely caused by a chromosomal abnor-mality or allergy to her partner’s sperm.

Reasons why subfertility increases with time arelargely based on changes that take place in awoman’s body as she ages. For example, olderovaries in middle-aged women produce less fertil-ity-enhancing hormones. Additionally, these ovaare not as receptive to sperm penetration and theytend to be spontaneously aborted once fertilized.

Male Infertility

According to Dana Ohl, M.D., assistant professor ofsurgery, University of Michigan Medical Center,anabolic steroids, which can lower sperm countdrastically and sometimes irreversibly, will alsoleave an indelible mark on infertility statistics inthe years to come; young men in high school whouse steroids will find difficulty in impregnatingtheir wives five to 10 years from now.

Some men perceive their condition as a stressfulthreat to their masculine identity, which they mayassociate with their sexual prowess. One of the bestways to get men to accept infertility is to encour-age them to talk about their condition, both withtheir partners and in support groups.

Assisted Reproduction Techniques

Assisted reproduction techniques, which weredeveloped during the 1980s and 1990s, offer hopeto conceive a child, even for couples stressed bycomplex forms of infertility. These techniques orig-inated in England with the birth of the first IVF (invitro fertilization) baby, Louise Brown, in 1978.Since then, assisted reproduction procedures havebeen successfully performed worldwide, enablingthousands of couples with otherwise untreatableinfertility to produce their own healthy babies.

Couples most suited for IVF are those in whichthe wife has a normal uterus and ovaries, but her

204 inferiority complex

Fallopian tubes are damaged, blocked, or absent.Many patients in IVF programs have previouslybeen treated for tubal disease that required surgery,which proved unsuccessful, or which required com-plete removal of the Fallopian tubes. Women suffer-ing from endometriosis, or adhesions affectingreproductive organs, may be candidates for IVF orGIFT (gamete intra-fallopian transfer). Couples inwhom the husband has an infertility problem mayalso be suitable for IVF, TET (tubal embryo transfer),or ICSI (direct sperm injection into an egg cell).

Options with Technology

Understanding the options with assisted reproduc-tion techniques helps relieve the stress of infertilityfor many couples. IVF is essentially a tubal bypassprocedure. Mature eggs are retrieved from theovary with ultrasound guidance. The eggs are fer-tilized by the husband’s sperm in the laboratory. Inspecial circumstances, IVF procedures may be per-formed using donated egg cells, sperm, or embryos.The resulting embryos are transferred into thewoman’s uterus or into her tubes via laparoscopy.

Tubal embryo transfer (TET) is performedthrough laparoscopy in an operating room. GIFT(gamete intra-fallopian transfer) is similar to IVF,but the eggs and sperm, instead of being incubatedin vitro, are placed together in the Fallopian tubes ofthe wife. GIFT can be performed if at least one ofthe tubes is healthy but an egg is unable to reach it.

Couples interested in exploring how medicaltechnology can help them conceive should contactlocal medical centers and thoroughly check thecredentials of the physicians who specialize ininfertility or reproductive endocrinology, as well asthe laboratories and facilities they are considering.Knowing that they are in the hands of experts willhelp relieve some of the stresses of undergoing theassisted reproduction procedures, which may beemotionally and financially costly.

A support group started by infertile couples isRESOLVE.

See also BIOLOGICAL CLOCK; IMPOTENCE.

FOR FURTHER INFORMATION:American Fertility Society2140 11th Avenue South, Suite 200Birmingham, AL 35205-2800(205) 933-8494

Fertility Research Foundation1430 Second Avenue, Suite 103New York, NY 10021(212) 744-5500

RESOLVE, Inc.P.O. Box 474Belmont, MA 02178(617) 484-2424

SOURCES:Berger, Gary S., Mark Goldstein, and Mark Fuerst. The

Couple’s Guide to Fertility, rev. ed. New York: Double-day, 1994.

“Costly Choices, No Guarantees: The Maze of FertilityServices.” Women’s Health Center Management 5, no. 7(July 1997).

information explosion Today, all types of profes-sionals are caught in the volume of informationthey need to do their jobs. This is occurring at thesame time that career and family commitments aretaking up more and more of their time. The factthat there is more to read and less time available toread it is in itself stressful.

It is not only the growing stacks of magazinesand newspapers in homes and memos and reportsin offices that causes the concern described byRichard Wurman in his book, Information Anxiety. Itis also the information forced on us through COM-PUTERS with their on-line programming, faxmachines, electronic mail, cellular phones, voicemail, answering machines, VCRs, audio and video-tapes, and through the increasing number of regu-lar and cable TV channels.

The problem is, Wurman says, that while printand computer information envelops us, what wereally need is knowledge. However, the solutionfor something that sifts through and synthesizes allof the data to make it usable is still a long way off.In the meantime, it is necessary to be creative inthe approach to information gathering.

See also RANDOM NUISANCES.

inhibition The inner restraints within individualsthat prevent them from carrying out mental orphysical activities. As a psychoanalytic term, inhi-bition means unconsciously restraining instinctualimpulses. Inhibitions cause stress for many peoplebecause they feel blocked from doing many things

inhibition 205

they might like to do. Some people who havemany inhibitions are shy and withdrawn. Some,who are extremely inhibited about certain areas oftheir lives and activities, may develop SOCIAL PHO-BIAS. They may feel inhibitions about speaking infront of a crowd, about walking into a room filledwith strangers, or calling a new acquaintance toarrange a social engagement. Others have inhibi-tions related to sexual activity; SEX THERAPY may behelpful with these concerns.

The stresses associated with many inhibitionscan be overcome with a variety of therapies,including BEHAVIOR THERAPY.

See also PHOBIAS; PSYCHOTHERAPIES.

insomnia The inability to SLEEP or stay asleep;often a stressful situation and may be a symptom ofother disorders. Among the most prevalent causesof insomnia are a history of STRESS, recent GRIEF,ANXIETY, or DEPRESSION. According to a studyreported in Canadian Family Physician (February1992), insomnia occurs in up to 35 percent ofpatients who have depression, anxiety, or mania.Certain prescription drugs (antihypertensives, anti-asthmatics) along with CAFFEINE, nicotine, and alco-hol are believed to account for another 12 percentof cases of insomnia. While alcohol helps some peo-ple fall asleep more easily, they often awaken inabout four hours with rebound insomnia. Othercauses of insomnia include tolerance to, or with-drawal from, sedative-hypnotics, restless leg syn-drome (aching, burning, pricking sensations in legmuscles during the night in bed), and sleep apnea.

See also ALCOHOLISM AND ALCOHOL DEPENDENCE.

FOR FURTHER INFORMATION:American Academy of Sleep MedicineOne Westbrook Corporate Center, Suite 920Westchester, IL 60154(708) 492-0930(708) 492-0943 (fax)http://www.aasmnet.org

insurance See HEALTH INSURANCE; HEALTH MAINTE-NANCE ORGANIZATIONS; LONG-TERM CARE INSURANCE.

intense illness concern See HYPOCHONDRIASIS.

intergenerational conflicts Intergenerationalconflicts resulting in stress have particular meaning

within the family. Because people live longer, it isnot unusual to have family members representingas many as three or four generations. Having morethan two of those generations living under oneroof is less likely to occur today than in earliertimes, but it is generally agreed that generationalconflicts are often due to living together in one res-idence. However, no matter how close or far apartthe generations live, as long as they continue tomeet and share holiday and other family celebra-tions, some areas of generational conflict, oftenlabeled as a generation gap, will persist.

Generation gap refers to the inability to commu-nicate, viewing the same phenomenon with oppo-site conclusions, insensitivity to the feelings ofothers, and criticism of one’s feelings and beliefs.While generation gaps have always existed, thegap, which usually extended between parents andchildren, has broadened to include grandparents aswell. In these three-generational families, issuesthat most often involve all three generations inareas of disagreement include behavior.

Some young people often carry a stereotype ofolder adults as “living in the past,” overly conser-vative and unable to understand the young andhow much things have changed since they wereyoung. While many young people admire and loveolder people, and in specific instances (parents, rel-atives, friends, teachers) even use them as rolemodels, the stress-filled intergenerational conflictspersist.

A good deal of stress emanating from middle-aged and older adults toward the young, in fact,due to the overpowering youth culture of this gen-eration. In addition, older people’s view of theyounger generation may be colored by their ownfeelings of self-achievement and life satisfaction.When they feel good about themselves, they aremore likely to have higher expectations of theyounger generation.

See also AGE DISCRIMINATION; BABY BOOMERS;COMMUNICATION; ELDERLY PARENTS; LISTENING; PAR-ENTING; PUBERTY.

Internet dating See DATING.

intimacy Intimacy is marked by very close asso-ciation and friendship between individuals. Emo-

206 insomnia

tional intimacy can exist between lovers, friends,siblings, or children and parents. There is evidencethat intimacy can be linked to good health, butwhen a relationship turns sour, it can be a sourceof stress for many people.

Close Relationships and Good Health

There is evidence that suggests that when individ-uals have happy relationships, the likelihood ofdisease and complications from disease is far less,according to Len Sperry, M.D., Duke University. Afive-year study found that unmarried heartpatients who did not have a confidante were threetimes more likely to die from cardiac disease thanthose who were married or had a close friend. Sim-ilar findings were presented in a Canadian study of224 women with breast cancer. Seven years afterthey had been diagnosed, 76 percent of the womenwith at least one intimate relationship survived.The explanation for this, Sperry says, is that feelingcared about and important helps maintain a per-son’s optimism in times of stress. These emotionalboosts translate into a strong immunity that helpsfight disease.

The Stress and Fear of Intimacy

Author of the book, Too Close for Comfort: Exploringthe Risks of Intimacy, Geraldine Piorkowski, Ph.D.,explored the theory that the fears and stress of inti-macy can be healthy when they are realistic andprotective of the self. To do this, Piorkowski sug-gests that individuals reflect and learn from pastexperiences, schedule enough time to develop

these relationships, be willing to share feelingswith others, work at relationships but allow forfailures, and be on intimate terms with more thanone person.

Dr. Piorkowski comments, “There is a level ofimperfect intimacy that is good enough to live andgrow on. In good-enough intimacy, painfulencounters occasionally occur, but they are bal-anced by the strengths and pleasures of the rela-tionship. There are enough positives to balance thenegatives. People who do well in intimate relation-ships don’t have the perfect relationship, but it isgood enough.”

Developing Intimacy in Cyberspace

More and more people are developing relation-ships online. They meet in chat rooms, and, formore intimacy, carry on their affair using e-mailand exchange photos via the Internet. There’s alsoan addictive quality to conversing online, andsome people, particularly those who have not beenhonest, may have been wasting the other’s per-son’s time. But the real danger is that online rela-tionships are not limited to consenting adults.Sexual predators use the information highway as aroute to meet children and lure them to meetingplaces and abuse them.

Because not all Internet users are benign, par-ents should warn their children about the dangersof online predators.

See also DATING.

SOURCE:Piorkowski, Geraldine K. Too Close for Comfort: Exploring

the Risks of Intimacy. New York: Plenum Press, 1994.

introversion A PERSONALITY characteristic markedby self-reliance and more of an interest in workingalone or doing recreational activities alone thanwith others. The opposite personality type is char-acterized by extroversion, which involves more out-going tendencies. Introverts may be stressedbecause they are preoccupied with their own innerthoughts and feelings rather than with other peo-ple. Introverts tend to be rather contemplative andsensitive people, and may seem aloof to others.

See also PERSONALITY; SELF-ESTEEM.

Iraq See NUCLEAR WEAPONS; VIOLENCE.

Iraq 207

TAKING THE STRESS OUT OF INTIMATE RELATIONSHIPS

• Do not plunge in. Relationships should developslowly.

• Autonomy is important, do not lose control ofyour own needs.

• Do not expect perfection in yourself or the otherperson.

• Set boundaries and recharge, using periods ofdistance to strengthen your sense of self.

• Accept criticism, rejection, and disappointmentas a fact of life.

• Maintain a life away from the relationship.

irradiated mail To make mail safe from biohaz-ards following ANTHRAX attacks in fall 2001, U.S.Postal Service and government officials began irra-diating mail destined for government offices inspecified zip codes in the Washington, D.C., area.Postal workers as well as mail recipients experi-enced anxiety and stress when several federalworkers began reporting health symptoms theybelieved were related to handling irradiated mail.Irradiation destroys bacteria and viruses that couldbe present in the mail.

The National Institute for Occupational Safetyand Health (NIOSH) conducted health hazard eval-uations on the handling of irradiated mail by postalemployees, federal workers, and congressionalemployees. NIOSH sent teams of investigators,including industrial hygienists and occupationalmedical physicians, to survey employees abouttheir symptoms and to monitor the air for chemi-cal by-products that could be released from themail. NIOSH did not detect airborne contaminantsabove occupational exposure limits. Employeesreported skin irritation, eye, nose, and throat irri-tation, headaches, and nausea. These symptomsmay have resulted from a combination of variousfactors, including suboptimal environmentalhumidity, drying effects on the skin of handlingirradiated paper, odors, and stress.

See also ANTHRAX; STRESS; TERRORISM.

irritable bowel syndrome (IBS) Applies to a pat-tern of symptoms in the digestive tract that affectabout twice as many women as men. Only rarelydoes IBS begin in people over the age of 50; it is adisease of young adulthood and sometimes adoles-cence. For many, the attacks are brought on by cer-tain stressful life situations.

IBS is one of the most common gastrointestinalconditions seen by physicians today. The symptomsmost commonly experienced include abdominalpain, CONSTIPATION or diarrhea, and gaseousness.Symptoms may vary in severity and may last for aday or even months, if not treated. Irritable bowelsyndrome in the past was referred to as mucouscolitis, spastic colitis, nervous diarrhea, and irritablecolon; these terms have generally been discarded.

IBS often has been considered to be caused byemotional conflict or STRESS because doctors have

been unable to pinpoint its organic cause. How-ever, many individuals who suffer from ANXIETY

DISORDERS, panic attacks, or panic disorder also suf-fer from IBS. While stress is a link, there are alsoother contributing factors. For example, eatingcauses contractions of the colon. Normally, thisresponse may cause an urge to have a bowelmovement within 30 to 60 minutes after a meal. Inpeople with IBS, the exaggerated reflex can lead tocramps. Sometimes the spasm delays the passage ofstool, leading to constipation. At other times, thespasm leads to more rapid passage of feces or diar-rhea. While some symptoms, such as abdominalpain, may be triggered by emotional stress, thesymptoms are real and not imaginary. Symptomsoccur because the intestinal tract does not functionproperly, although no organic disease is present.

IBS can cause a great deal of discomfort, but isnot serious. However, for some people it can be asource of stress and disabling. Some people may beafraid to go to dinner parties, seek employment, ortravel on public transportation. However, withattention to stress management, proper diet, andsometimes medication prescribed by a physician,most people with IBS can control their symptomseffectively.

Self-Help for IBS

Individuals who have been diagnosed with IBSmay be advised to engage in more tension-reliev-ing activities, such as sports or HOBBIES, and physi-cal EXERCISE. They may be advised to concentrateon RELAXATION techniques and possibly counselingby a psychologist who can provide guidance inrelaxation techniques. Also, they may be advisedto eat meals at regular times and with good eatingpractices, such as chewing slowly, and with meas-ures designed to keep them from swallowing air.Large meals may also cause cramping and diarrheain some people, so that eating smaller meals morefrequently, or eating smaller portions of foods maybe recommended. Foods that are low in fat andrich in carbohydrates and protein may also helpalleviate symptoms. Dietary fiber, present in wholegrain breads and cereals and in fruits and vegeta-bles, has also been shown to be helpful in lessen-ing IBS symptoms. High-fiber diets keep the colonmildly distended, which helps to prevent spasmsfrom developing. Some forms of fiber also keep

208 irradiated mail

water in the stools, thereby preventing hard, diffi-cult-to-pass stools from forming. Although high-fiber diets may cause gas and bloating, over time,these symptoms may dissipate as the digestive tractbecomes used to the increased fiber intake. Chew-ing gum, drinking carbonated beverages, caffeine,and alcohol, and smoking should be avoided.

Getting Medical Help

Periodic flare-ups of IBS symptoms are fairly com-mon. When IBS becomes the body’s habitual wayof reacting against undue stress—and since mostpeople experience some physical symptoms ofstress at least occasionally—the goal should be tocontrol these symptoms.

Individuals who have IBS may be advised totake a combination of antispasmodic drugs andtranquilizers, which may relieve symptoms. Anti-spasmodic medications are sometimes called anti-cholinergics; as painful spasms may be the primarysymptom of IBS, treatment with these medica-

tions is often useful. However, in an effort to reg-ulate colonic activity or minimize stress, someindividuals become dependent on laxatives ortranquilizers. When this occurs, the physician maytry to withdraw the drug slowly and work withthe individual to control specific symptoms ofstress, as well as the irritable bowel symptoms,with life-style changes.

See also ANXIETY; GUIDED IMAGERY; INDIGESTION;MEDITATION; PANIC ATTACKS AND PANIC DISORDER.

SOURCES:Cunningham, Chet. The Irritable Bowel Syndrome (I.B.S.) &

Gastrointestinal Solutions Handbook. Leucadia, Calif.:United Research Publishers, 1995.

Tannenhaus, Norra. Learning to Live with Chronic IBS. NewYork: Dell, 1990.

isolation See LONELINESS.

itching See ALLERGIES; LICE.

itching 209

J

210

Japan, stress in See KAROSHI.

jealousy An attitude or EMOTION that encom-passes a continuum of ENVY, distrust, hostility, andrivalry with another person. It sometimes leads tosuspicion of unfaithfulness or apprehension of aloved one’s exclusive devotion. When an individ-ual experiences jealousy, he or she has feelings oflow SELF-ESTEEM and self-imposed stress.

Examples of jealousy include the feeling thatsome children experience when a new siblingarrives, or when one’s spouse has an intimate RELA-TIONSHIP with another. An individual may be jeal-ous about another’s ability to afford the luxuries oflife, such as elegant housing, country club member-ships, expensive clothes, and fur coats. Jealousiesalso occur when one individual perceives anotheras smarter, or at work when one individual ispassed over for another who gets a promotion.

Stress caused by jealousy can be relieved by arealistic look at oneself and one’s capabilities,whether academic, financial, or professional. Anassessment of one’s own good points can overridefeelings of envy of others. If not dealt with, jeal-ousy can lead to inappropriate behavior such asstalking, sexual abuse, and criminal action.

See also RELAXATION.

jet lag Term given to the disruption of one’s bodyrhythms (CIRCADIAN RHYTHMS) resulting from trav-eling through several time zones within a shortspan of time. It takes many individuals several daysor longer to recover from the stress of this type oftravel. The sleep schedule, appetite, and ability toconcentrate well while recovering from jet lag varyfrom individual to individual.

See also AIRPLANES.

SOURCE:Wingler, Sharon. Travel Alone & Love It: A Flight Attendant’s

Guide to Solo Travel. Willowbrook: Chicago SpectrumPress, 1996.

job change Making the transition into a newposition, whether continuing to work for the samecompany or for a new one, can be stressful. Bothsituations have pros and cons. Coming from theoutside means the individual does not have toworry about managing coworkers or friends. How-ever, when the individual does not have a mentoror friend in a new company, he has no one to relyon, to show him the ropes and to introduce him tocorporate policies and politics. Starting out freshalso means not knowing what employees are goodat, who are the hard workers, and who sloughs off.

Promotion, whether from within or without,can also significantly raise stress levels because itraises fear of incompetence and fear of failure.Usually these fears and stresses will go away oncethe new position is mastered and evidence of SUC-CESS becomes visible.

See also CHANGING NATURE OF WORK; DOWNSIZ-ING; JOB SECURITY; LAYOFFS; NETWORKING; OCCUPA-TIONAL STRESS; WORKPLACE.

SOURCE:Snyder, Don J. The Cliff Walk: A Memoir of a Job Lost and a

Life Found. Boston: Little, Brown, 1997.

job loss See OCCUPATIONAL STRESS.

job security Lack of job security is a major causeof instability and stress for workers throughout theworld. This was not so 30 to 40 years ago. Then,many employers had implicit or explicit long-termemployment contracts with their workers, contractsthat emphasized management’s commitment and

pledge to minimize the need for LAYOFFS. Wagesand job benefits increased over the years, and it wasnot unusual for the company to pay the total costof employees’ health care and charge minimally forfamily coverage. This job security led workers toexpect to remain in their jobs for many years, andit was not unusual for workers to devote theirentire working lives to one company, retiring withthe traditional gold watch and company pension.

During the later 1990s and early 2000s, DOWN-SIZING, layoffs, MERGERS, and other organizationalchanges have greatly altered the job security pic-ture. Employers are no longer sharing their wealth;raises and employee benefits have been scaledback. Full-time jobs are harder to find.

Suggestions for improving one’s job securityinclude learning to operate one’s own business,becoming a free agent or “gun for hire,” settingnew professional goals, looking for new jobs whilestill employed, considering new fields, buildingportable skills; setting up a network of trusted col-leagues, clients, former bosses, and other profes-sionals who know the worker’s track record andopportunities available in his/her field; creating anescape hatch (options, lateral moves, further edu-cation); and being ready to accept change.

See also JOB CHANGE; NETWORKING; OCCUPA-TIONAL STRESS; WORKPLACE.

SOURCE:Alderman, Lesley, and Karen Cheney. “Here’s the Good

News about Jobs.” Money, May 1996, pp. 111–121.

job stress See OCCUPATIONAL STRESS.

journaling Writing down thoughts and experi-ences in a daily or weekly journal is a way for theindividual to relieve stress, sort out confusion, anddeal with problems. Writing, and reading what hasbeen written, sometimes exposes suppressed, sub-conscious feelings that can be dealt with more con-structively when they are recognized. In this sense,a diarist may get closer to his/her feelings and bet-ter understand self-motivations.

The cathartic effect of writing involves a dis-tancing from negative feelings and experiences.Once the feelings or experiences are described onpaper, the writer frequently has a sense of being ridof them, of being able to go on to something else.

Writing may also help to bring repressed thoughtsand attitudes out into the open and eliminate someof the restrictions that sap energy and limit pro-ductivity. Simply the act of writing may grant asense of CONTROL, a way of giving some order andmanageability to problems.

Symptoms such as ANXIETY, DEPRESSION, andapathy may be masks for envy, JEALOUSY, and rageturned inward at the self. Some diarists have foundit useful to write a portrait of a person whom theyenvy or who has angered them. The portrait some-times reveals qualities of their own that they wishto either develop or change.

Making lists in a diary can be a good way of set-ting goals and giving order to what may seem to bean enormous or chaotic task. Journaling also canbe useful for the person who is attempting to con-trol addictive or obsessive behavior.

Journaling is used by many SUPPORT GROUPS forovereaters, as well as those who wish to stopSMOKING or drinking. The diary not only improvesself-understanding and serves as a way to recordprogress, but also gives the individual something todo over which he/she has complete control whenhe wants a drink, cigarette, or is about to give in toa desire to overeat.

See also EATING DISORDERS; SELF-ESTEEM.

SOURCE:Adams, Kathleen. Journal to the Self. New York: Warner

Books, 1990.

judicial proceedings Stresses endured by indi-viduals serving on juries range from being awayfrom their families in the event of a sequesteredjury, to the agonizing DECISION-MAKING processes inwhich they will have to engage.

First there is the stress of the selection process,during which an individual faces the feeling ofbeing out of CONTROL of his destiny for the next dayor, perhaps, for weeks. Then here is the concernabout being sequestered or a period of time with agroup of strangers. Some stress surrounds howwell the individual will get along with fellow jurymembers. There is also the stress of making theright decision, particularly in a life or death matter,and having one’s own judgment swayed by othersin making a decision.

judicial proceedings 211

Stresses for Lawyers

LAWYERS are the first to attest to the extreme stressthat arises during a jury trial. This stress often isexhibited by a loss of temper on both sides of theissue. That is why stress management is a populartopic of seminars offered to lawyers nationwide.These seminars encourage lawyers to recognize thestressors such as physical separation from their fam-ilies and disruption of normal routines that mayoccur, particularly when a trial goes on for a longperiod of time, and to strategize ways to handle thestress. The seminars emphasize the need for lawyersto maintain themselves physically and emotionallyand to try to talk out feelings, something that can bealien to those involved in legal work.

When asked about effective ways to handlestress, many lawyers highly rate building a wall ofseparation between their professional and privatelives. Others value a healthy regimen that includesno SMOKING or drinking, staying in shape by exer-cising, and establishing healthy lifestyle habits.

SOURCE:Kahn, Ada P. “Win the Case against Stress.” Record

(Chicago Bar Association), May 1994.

junk food See COMFORT FOODS; WEIGHT GAIN AND

LOSS.

junk mail See SPAM.

212 junk food

KKabat-Zinn, Jon, Ph.D. Founder and director ofthe Stress Reduction Clinic, University of Massa-chusetts Medical Center, Worcester, where he isalso an associate professor of medicine. He is theauthor of popular books about coping with STRESS

including Mindfulness Meditation in Everyday Life,Meditation for Daily Living, and Full Catastrophe Liv-ing: Using the Wisdom of Your Body and Mind to FaceStress, Pain and Illness.

Dr. Kabat-Zinn is a proponent of mindfulnessMEDITATION, a more than 2,000-year-old Buddhistmethod of meditation, and living fully in the pres-ent. This approach offers a unique way to copewith stress and illness. Mindfulness meditation canhelp induce deep states of RELAXATION and, attimes, directly improve physical symptoms.

Other forms of meditation involve focusing on asound or the sensation of breath leaving and enter-ing the body. Anything else that interferes in themind during these types of meditation is seen as adistraction to be disregarded. Mindfulness, on theother hand, is insight meditation and encouragesthe meditator to note any thoughts as they occurand observe them intentionally but non-judgmen-tally, moment by moment. This practice of observ-ing thoughts, feelings, and sensations can help themeditator to become calmer and have a broaderperspective regarding life. Kabat-Zinn teachesreaders to reflect on the beauty of the present andemotional and spiritual applications of meditation.

See also ALTERNATIVE MEDICINE; GUIDED IMAGERY;MIND-BODY CONNECTIONS.

FOR FURTHER INFORMATION:Stress Reduction ClinicUniversity of Massachusetts Medical CenterWorcester, MA 01655(508) 856-1616

SOURCES:Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdom

of Your Body and Mind to Face Stress, Pain and Illness.New York: Delacorte, 1991.

———. Wherever You Go, There You Are: Mindfulness Medi-tation in Everyday Life. New York: Hyperion, 1993.

karoshi “Death from overwork”—synonymouswith stress in Japan. An article by C. Frank Lawlisin Alternative Therapies (July 1995) reports that“People (in Japan) are literally dying at their work-stations. It appears that their entire physiologicalsystem collapses or shuts down.”

Lawlis draws from a 1989 study by Chiyoda Fireand Marine Insurance, Ltd., one of the top insur-ance carriers in Japan. Chiyoda, which covers over100,000 Japanese corporations, conducted a majorstudy on health problems Japanese people arelikely to encounter. One important conclusion ofthe study was that in 40 percent of the healthproblems, stress played a major role.

As a result, Chiyoda established N.C. Wellness, acompany that developed programs integrating Ori-ental medicine into health promotion for employ-ees. Buildings housing the programs wereconstructed to focus on tranquil space and functionin a similar fashion to that of a “cocoon.” At thesame time, they were designed as places for nonor-dinary pleasure where “interference from every-day affairs is barred” and where the environmentto practice the mind-body and awareness elementsof balance is enjoyable and protective.

The first prototype center was opened inKichjoji, Musashino-shi, Tokyo, in June 1994. Thecore program offered at this site incorporated six“directions”: self-management, self-promotion,self-discovery/purpose of life, fun and pleasure,interpersonal skills, and community.

213

See also ACCULTURATION; ALTERNATIVE MEDICINE;MIND-BODY CONNECTIONS.

kinesics The study of COMMUNICATION as expressedthrough facial expression and other body move-ments. Theories and techniques of studying thistype of nonverbal communication were developedby Ray L. Birdwhistell (1918– ), who found thatcertain gestures and expressions were specificallymale or female and also related to regional andnational groups. BODY LANGUAGE changes with age,health, mood, and the degree of STRESS or RELAX-ATION experienced by the individual. Birdwhistell

developed his theories with the use of photographyand a notation system of symbols called kinegraphsto describe gestures and expressions.

SOURCE:Birdwhistell, Ray L. Kinesics and Context. Philadelphia:

University of Pennsylvania Press, 1970.

kleptomania See SHOPAHOLISM.

Kohut, Heinz See SELF-PSYCHOLOGY.

kundalini See YOGA.

214 kinesics

Llabyrinth Originally an ancient spiritual tool, thelabyrinth is now experiencing a worldwide come-back as a form of stress relief and self-healing. Alabyrinth is a geometric design made on theground or on the floor. It consists of a single pathleading from the entrance to the center and backout again. The defined space, usually in spiralform, has a number of circuits.

The labyrinth is not attached to any particularreligion and has a wider and more spiritual qualitythan do symbols of specific religions. It is used as awalking meditation and for ceremony and rituals.“We in the West especially need to learn how toquiet our minds. The labyrinth is a safe place toorder chaos and to calm the frightened heart,”according to Rev. Lauren Artress, author of Walkinga Sacred Path, Rediscovering the Labyrinth as a SacredTool. People walking labyrinths frequently relatefeelings of peace that come over them as they fol-low the path. Others report suddenly seeing solu-tions to problems they have been facing.

A labyrinth is not a maze. Mazes have dead endsand serve to challenge the mind. The labyrinth, how-ever, is a single path which invites quiet introspec-tion without the dead ends of a maze. Labyrinthsdate back thousands of years and have been found inArizona, Peru, Iceland, Egypt, India, and Sumatra,according to the Labyrinth Resource Center based inEngland. In the United States, about 1,100 labyrinthsare listed on an international labyrinth locator Website. They are in shopping centers, hospitals, col-leges, parks, prisons, churches, and backyards. Morethan 100 hospitals nationwide have built labyrinthsthat are used by patients, their families, hospitalstaff, and community groups.

Labyrinths typically range in size from 24 to 166feet or even longer in diameter and are made ofstones, grass, flowerbeds, portable canvas, concrete,

wood, or brick. They may be inside or outdoors,temporary or permanent.

SOURCES:Artress, Lauren. Walking a Sacred Path: Rediscovering the

Labyrinth as a Sacred Tool. New York: Riverhead Books,1995.

DuBois, Elise. “Labyrinths Can Be Paths to Inner Peace.”Life-Times 20, no. 1 (January 2005): 4.

ladders Use of ladders is a source of stress formany people at home and at work. Falls from lad-ders are a common cause of injuries. According to

215

REMOVE STRESS FROM LADDER USE: CHOOSE THE RIGHT LADDER

• Ladder style: Step or extension. Both may beneeded. A stepladder can be used indoors andoutdoors but has height limitations. Use an exten-sion ladder primarily outdoors where extra heightis needed. An extension ladder can be usedindoors where high ceilings are hard to reach.

• Size of ladder: For stepladders, the height of theladder plus four feet equals the total reach. Forexample, a four-foot ladder can be used to reachan eight-foot ceiling. Use a six-foot ladder toreach a 10-foot ceiling, etc.

• For an extension ladder, the base and upper sec-tions must overlap. Thus a 20-foot extension lad-der is only good for about 17 feet. The laddermust travel above the roofline two to three feetso that it can be used for balance as one climbsonto the roof.

• Duty rating: Ladders are sold by duty rating,which means how much weight a ladder is ratedto carry. The more weight it will hold, thestronger it must be.

(continues)

the American Academy of Orthopedics, more than500,000 people a year in the United States aretreated for ladder-related injuries. About 300 peopledie from ladder-related injuries annually. Occupa-tions involving use of ladders include construction,plumbing, heating and air conditioning, electricalwork, and roofing.

See also CONFINED SPACES; ELECTRICITY; SLIPS,TRIPS, AND FALLS.

lasers Laser remote pointing devices used at pre-sentations by computer projection can be a sourceof stress if used improperly. Care must be takenwith laser pointers that produce an intense, highlydirectional beam of light of a single wavelength.The penlike laser pointer produces a fine beam thatcan be hazardous to unprotected eyes if one looksat the laser from within the direct beam. Repeatedexposure to relatively low-powered lasers, or froma single exposure to medium-powered lasers, maycause long-term damage to sight or minor damageto the skin. Exposure to high-level lasers maycause severe burns and depigmentation.

There is a wide range of applications of lasers inscientific use and for cutting and welding. Medicallasers are used on eyes and for microsurgery, neu-rosurgery, and dermatology. Protective eyewearspecifically designed for protection against non-ionizing radiation lasers and laser systems may beused to reduce stressful effects of laser use. Suchequipment includes goggles, face shields, specta-

cles, or prescription eyewear using special filtermaterials or reflective coatings. At all times, usersshould avoid looking into a laser beam or a laserreflection. Lasers should be used in a controlledarea with emphasis on controlling the path of thelaser beam.

laughter An individual’s response, a smile,chuckle, or explosive sound, to something thatinspires joy or scorn. The ability to laugh, and itscompanion, a sense of HUMOR, can provide psycho-logical relief from stress, tension, ANXIETY, HOSTIL-ITY, and emotional pain. Laughter helps individualsdeal with stressful situations, whether at work, insocial situations or in health care settings.

Laughter may be a defense against personalfeelings of self-consciousness or embarrassment.An ability to laugh at oneself can be an importantCOPING mechanism against these stresses. However,many people find it difficult to poke fun at them-selves and to acknowledge that they have made amistake. Individuals suffering from DEPRESSION

often lose their ability to laugh and see no humorin their lives or in the world around them.

The Curative Powers of Laughter

Maintaining a sense of humor can help most peo-ple stay healthy. It causes the body to have a phys-iological response, and the IMMUNE SYSTEM gets thebenefit. For example, when one laughs, variousmuscles tense, then relax, which can result in ton-ing. BREATHING gets faster, allowing the body totake in more oxygen and to get rid of more carbondioxide. Heart and pulse rate and blood pressurealso increase to promote more vigorous circulation,and an increase in the brain’s chemical transmittersaids mental alertness.

Research shows that laughter, like exercise, canstimulate the brain to produce secretions known asENDORPHINS. Endorphins increase one’s sense ofphysical and mental well-being and, to some extent,relieve pain.

The curative power of laughter is not a 20th-century discovery. In the Book of Proverbs, it says:“A merry heart doeth good like a medicine.” Nor-man Cousins (1915–90), former editor of the Sat-urday Review and later a member of the faculty ofthe medical school at the University of California atLos Angeles, used the curative power of laughter to

216 lasers

• Construction material: Choices are wood, alu-minum, and fiberglass.

• Wood ladders are solid and sturdy. However,they are heavy and thus cumbersome and some-what difficult to transport. Wood must be main-tained to prevent cracking, splitting, and rotting.Wood is economical and does not conduct elec-tricity when clean and dry. When doing electri-cal work, choose a fiberglass ladder.

• Ladders made from high-strength aluminum arelightweight, but salt air or chemicals can cor-rode and weaken an aluminum ladder.

• Fiberglass ladders are lighter than wood butheavier than aluminum. They are not subject torot, and do not bend easily.

help himself recover from a degenerative disease ofthe body’s connective tissue. Following are a fewexcerpts from Cousins’ Anatomy of an Illness, inwhich he described the benefits of laughter:

I made the joyous discovery that ten minutes ofgenuine belly laughter had an anesthetic effectand would give me at least two hours of pain-freesleep . . . Exactly what happens inside the humanmind and body as the result of humor is difficult tosay. But the evidence that it works has stimulatedthe speculations not just of physicians but ofphilosophers and scholars over the centuries.

Cousins checked out of the hospital and spentweeks watching Marx brothers’ movies and othercomedies. He attributed his recovery to the positivefeelings that laughter aroused in him.

Research in Laughter

In an article titled “Laughter” in American Scientist(January–February 1996), University of Marylandpsychologist Robert R. Provine attempted to shedsome light on laughter as a stereotyped, species-spe-cific form of COMMUNICATION. Among other things,Provine’s research provides a novel approach to themechanisms and evolution of vocal production,speech perception, and social behavior.

The laugh tracks of television situation come-dies—attempts to stimulate contagious laughter inviewers—and the difficulty of extinguishing “laughjags” or fits of nearly uncontrollable laughter arefamiliar phenomena. “Rather than dismissing con-tagious laughter as a behavioral curiosity,” Provinesuggests, “we should recognize it and other laugh-related phenomena as clues to broader and deeperissues. Clearly, laughter is a powerful and perva-sive part of our lives.”

Provine and his assistants observed humanlaughter in various natural habitats, such as shop-ping malls, classrooms, sidewalks, offices, andcocktail parties. Among other things, they foundthat, contrary to their expectations, most conversa-tional laughter is not a response to structuredattempts at humor, such as jokes or stories. Spon-taneity, mutual playfulness, in-group feelings, pos-itive emotional tone, and not comedy, mark thesocial settings of most naturally occurring laughter.They also found that the average speaker laughs

about 46 percent more often than the audience,and that females, whether they are speakers oraudiences, laugh more often than males. “In somerespects laughter may be a signal of dominance/submission or acceptance/rejection,” Provine con-cluded. “In some situations, laughter may modifythe behavior of others by shaping the emotionaltone of a conversation.”

See also PSYCHONEUROIMMUNOLOGY.

SOURCES:Peter, Laurence J. The Laughter Prescription. The Tools of

Humor and How to Use Them. New York: BallantineBooks, 1982.

Provine, Robert R. “Laughter.” American Scientist 84, no. 1(January–February 1996).

Roach, Mary. “Can You Laugh Your Stress Away?”Health, September 1996.

lavatories, public Many people are fearful ofusing public lavatories and experience stress whenthey want to urinate or have a bowel movement ina place where another person might be aware ofwhat they are doing. Others experience stressbecause they fear contracting a disease from a toi-let seat or from a towel or sink in a public lavatory.Some people fear producing odors and others fearencountering odors in public lavatories. Some indi-viduals are unable to pass urine or move theirbowels in a place other than their own bathroomat home.

Because of the incidence of AIDS (acquiredimmunodeficiency syndrome), stress regardingpublic lavatories has increased, despite educationalcampaigns.

Young children who are being toilet-trainedmay use the toilet appropriately at home but notuse public lavatories until they are more accus-tomed to using facilities outside of their home. Thisis a source of stress for both child and parent.

See also ACQUIRED IMMUNODEFICIENCY SYN-DROME; PHOBIA; TOILET TRAINING.

lawyers Individuals whose profession is to con-duct lawsuits and provide advice regarding legalobligations for clients. Under constant pressure towin, there are extremely high levels of STRESS asso-ciated with practicing law. Lawyers are frequentlyin adversarial situations and face deadlines and

lawyers 217

pressures from many people, including clients,partners, and opposing lawyers.

Litigators, lawyers who represent clients inJUDICIAL PROCEEDINGS, must have a tough exteriorto dominate the situations that they encounterand to win. In private life, some find it difficult toswitch to a more equal role with personal partnersor family, resulting in still another level of stressand tension.

Lawyers as individuals tend to be high achievers.Usually they have high expectations of themselvesand others; often these expectations are unreason-able, causing a disparity. “Most lawyers are bynature compulsive people,” said Nancy Weisman,general counsel, Rush North Shore Medical Center,Skokie, Illinois, in an article in the Chicago BarAssociation’s journal, Record (May 1994). “Lawyersare often the bringers of news, both good and bad.We bear the burden of delivering answers fromother lawyers or the courts. It’s easy to explain awin. Explaining a lost motion or case is a stressorlawyers face at times,” said Weisman.

Additionally, lawyers must be good listeners andwatch for BODY LANGUAGE and unspoken signals totry to anticipate the opposing lawyer’s responses.Body language plays an equally important role inanticipating feelings of the judge or jury. At thesame time, lawyers usually make efforts to hidesigns of their vulnerability, which in itself is astressful posture to take.

Different Stressors at Different Career Stages

Lawyers face different stresses that may threatentheir mental and physical health at various careerstages. Just out of law school, in midcareer, andwhen nearing RETIREMENT they face particular ten-sion-producing factors. Personal stressors compoundthe tension levels they face throughout their lives.

Most young lawyers begin careers as associatesand are single. Hoping to meet a mate, they try tomaintain an active social life, but find it difficultwhile working 80 hours a week or more. Theadded pressure of a new social relationship whenthey do enter into one, while meeting the demandsof their bosses and clients, can be overwhelminglystressful.

Married lawyers, particularly those who havechildren, are often torn between wanting to dotheir jobs well and enjoying family life. They may

have experienced feelings of resentment aboutbeing absent from family events because of clients’needs. They want to have time and energy for theirchildren’s needs and for their partners. They haveto factor these stressors into already stressful days.

As careers advance, there is the COMPETITION tobecome a partner as well as comparison with thecareers of former classmates. Some law firms’ newfamily leave policies have great appeal for younglawyers; still they worry that they will be on aslower track than their peers.

Lawyers who are solo practitioners or in verysmall firms face the constant challenge of bringingin enough business to stay afloat. Lawyers whosefirms have reorganized or merged with anotherfirm may find the prospect of being downsized outof the firm a serious stressor. Those who do stayfind that they have a new boss to report to, a newinternal structure to adjust to, and new or addi-tional responsibilities beyond their full workload.

As they near retirement, some lawyers feelthreatened by younger partners in their firms.Others may regret not reaching the top echelon oftheir firm. They become concerned about whatthey will do after they retire from their positions,which have centered on their practice and theirclients. Some face the stressful situation of havinghad too little time to develop outside interests orHOBBIES, which are usually the key to making asmooth transition from career to retirement.

See also CHANGING NATURE OF WORK; DOWNSIZ-ING; JOB SECURITY; LAYOFFS; MERGERS.

SOURCE:Kahn, Ada P. “Win the Case against Stress.” Record (Chicago

Bar Association), May 1994.

layoffs Layoffs or reductions in force (RIFs) havebecome everyday occurrences for companies. Thepotential for this occurrence affects everyone andis a cause for stress. Today, more than ever, there isno JOB SECURITY, and the big organization that tookcare of its workers is a thing of the past.

During the recession years of the 1980s, jobreduction was blamed on national or internationalbusiness conditions. Today more and more compa-nies are reducing their workforces in order to savemoney (after merger or acquisition) or realize pro-ductivity gains.

218 layoffs

Layoffs also are due to plant closings, workslowdowns, corporate DOWNSIZINGS or MERGERS,and acquisitions. Being laid off is different frombeing fired, though the individual will probablyfeel the same stress. When workers are fired, it isbecause their performance is lacking; when layoffsoccur, performance is rarely cited.

Typically, there are five emotional stages thatfollow a termination, and they are not unlike thosefelt at the time of any major loss:

Stage One: Denial. It must be some mistake, this can’tbe happening to me.

Stage Two: Self-Blame. I must have done somethingwrong. How did I screw up?

Stage Three: Anger. Why did management do this tome?

Stage Four: Depression. It’s not worth getting out ofbed in the morning.

Stage Five: Acceptance. What happened may be all forthe best.

On virtually every indicator of mental and physi-cal health, job loss due to layoffs has a negativeimpact. People who lose their jobs are often anxious,depressed, unhappy and, in general, dissatisfied withtheir lives. They have lowered SELF-ESTEEM, areshort-tempered, and are fatalistic and pessimisticabout the future. Thus, job loss is clearly hard onone’s health, and it is important to get CONTROL overone’s life and one’s stress after a job loss.

See also WORKPLACE.

learned helplessness According to Martin E. P.Seligman, an American psychologist (1942– ),learned helplessness refers to a feeling of helplessnessand stifling of motivation brought about by expo-sure to aversive events over which people have noCONTROL. Such stressful situations lead to feelingsof powerlessness, BOREDOM, and DEPRESSION, andthe individual becomes passive and nonassertive.

In experiments, Seligman and Steven Maier,another psychologist, exposed animals to patho-logic amounts of psychological stressors. Thosestressors included loss of control and predictabilitywithin certain contexts, a loss of outlets for FRUS-TRATION, a loss of sources of support, and a percep-tion of life worsening. The animals had troubleCOPING with many varied tasks, such as competing

with other animals for food or avoiding socialAGGRESSION. Such animals have a motivationalproblem; they are helpless because they do noteven attempt to cope with a new situation.

The condition that the animals experienced wasa condition very similar to depression in humans.Later, Seligman coined the term LEARNED OPTIMISM

to refer to the opposite behavior, in which an indi-vidual does not give up but persists toward a goal.

See GENERAL ADAPTATION SYNDROME.

SOURCE:Seligman, Martin E. P. Learned Optimism. New York:

Alfred A. Knopf, 1991.

learned optimism A term coined by Martin E. P.Seligman in his book Learned Optimism (1991),describing attitudes and behaviors people exhibitwhen they face the stress of failures and disap-pointments that inevitably are a part of life’s expe-rience. According to Seligman, in childhood,individuals learn to explain setbacks to themselves.Some are able to say and believe: “It was just cir-cumstances; it’s going away quickly, and there ismuch more in life.” Scientific evidence has shownthat this optimism is vitally important in overcom-ing defeat, promoting achievement, and maintain-ing or improving health. He documents the effectsof optimism on the quality of life.

In his book, Seligman shows how to stop auto-matically assuming GUILT, how to get out of thehabit of seeing the direct possible implications inevery setback, and how to be optimistic.

The opposite is LEARNED HELPLESSNESS, a term hecoined earlier, which relates to an attitude of hope-lessness about the future and future activities.

See also COPING; GENERAL ADAPTATION SYNDROME.

SOURCE:Seligman, Martin E. P. Learned Optimism. New York:

Alfred A. Knopf, 1991.

learning disabilities A group of physical and psy-chological disorders that interfere with learning.Because they may be taunted by their peers, youngpeople who have such disabilities may also sufferstress from a loss of SELF-ESTEEM and motivation.Learning disabilities are also a source of stress toparents who have high expectations for their chil-dren. Even when the disabilities are diagnosed,

learning disabilities 219

they may wonder why their children are not doingwell in school and urge them to do better.

Learning disabilities include problems in learningcaused by defects in speech, hearing, and memory;they do not include disabilities due to emotional orenvironmental deprivation or to poor teaching.

Children with minimal or borderline MENTAL

RETARDATION generally have difficulty learning.Other children suffer from hyperactivity, which low-ers the attention span; dyslexia, which is difficultyin reading; dyscalculia, an inability to performmathematical problems; and dysgraphia, referringto writing disorders. Specific learning difficulties inchildren of normal intelligence may be caused byforms of minimal brain dysfunction, which may beinherited and untreatable.

Generally difficult to diagnose, children withlearning disabilities should be observed and taughtby teachers who have a degree in special educa-tion. Stresses of learning difficulties faced by chil-dren, parents, or adults can best be handled byobtaining help from social workers or psychologistsspecializing in learning disabilities. In addition todiagnostic testing, these professionals can providenecessary psychological support.

See also ATTENTION-DEFICIT HYPERACTIVITY DISOR-DER; PARENTING.

SOURCES:Grey House Publishing. The Complete Learning Disabilities

Directory. Lakeville, Conn.: Grey House Publishing,1994.

Hall, David. Living with Learning Disabilities: A Guide forStudents. Minneapolis: Lerner Publications, 1993.

left-handedness In religious symbolism and folk-lore, the left side is associated with the devil, andthis attitude has permeated outlooks held by manypeople for centuries. Left-handers often deal withsubtle attitudes reflected in such phrases as a “left-handed compliment” that imply that something iswrong with being left-handed. Left-handed peopleare a minority in the United States, comprisingabout 13 percent of the population.

In earlier generations, children were encour-aged to use their right hands instead of their left,creating stressful situations for both parents andchildren. Studies of left-handedness in the popula-tion by age group show proportionally more young

left-handers, probably an indication that parentsand teachers are no longer trying to switch thesechildren into using their right hands.

Probably the biggest stress factor facing individ-uals who are left-handed is that handwriting tech-niques, scissors, and other kitchen and householdtools are not designed with them in mind. How-ever, catalogs with special products made for left-handers abound.

SOURCES:Coren, Stanley. The Left-Hander Syndrome: The Causes and

Consequences of Left-Handedness. New York: Free Press,1992.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

leisure See HOBBIES; RECREATION; VACATIONS.

lesbianism Female HOMOSEXUALITY. Lesbianism isa term derived from the Greek poet Sappho, wholived on the island of Lesbos. Women who practicelesbianism (lesbians) prefer women as sexual part-ners, although some lesbians have or have hadheterosexual partners. Lesbians are part of the gaycommunity along with homosexual men. Today,lesbians still face some stresses of nonacceptanceby their families, childhood friends, coworkers andbosses, and members of their community at large.

More and more lesbian couples have becomeparents (co-mothers) through artificial insemina-tion and ADOPTION. While facing all the concernsand stresses of parenthood, they may encounterparticular stressors because of their choice of livingsituation.

The gay liberation movement during the 1970sand 1980s encouraged homosexuals to meet anddiscuss their important issues and provided a polit-ical organization to work toward legal change andfight job discrimination. The National Gay and Les-bian Task Force is a clearinghouse for these groupsand provides information on local organizations.

FOR FURTHER INFORMATION:The National Gay and Lesbian Task Force90 William Street, Suite 1201New York, NY 10038(212) 604-9830(212) 604-9831http://www.thetaskforce.org

220 left-handedness

SOURCES:Jay, Karla, ed. Dyke Life. From Growing up to Growing Old,

a Celebration of the Lesbian Experience. New York: BasicBooks, 1995.

McDaniel, Judith. The Lesbian Couples Guide: Finding theRight Woman and Creating a Life Together. New York:HarperPerennial, 1995.

Slater, Suzanne. The Lesbian Family Life Cycle. New York:Free Press, 1995.

lice Small insects that live on humans and sur-vive by feeding on blood. They are a source ofstress, particularly to children in day care or ele-mentary school and their parents/caregivers. Licespread from one person to another through closebodily contact or through shared clothing or per-sonal items such as hats, hairbrushes, helmets, ear-phones, or bedding. Lice cannot fly or jump. Headlice are particularly common in school-age chil-dren; however, adults can be affected too, particu-larly if they live in a household with children.

Body lice are most often spread by contact withpersonal items, especially clothing and hats. Theylive and lay eggs in the seams of clothing and arepresent on the body only when they feed. Undercertain conditions, such as during natural disastersor wartime, lice may transmit life-threatening dis-eases such as typhus, relapsing fever, and trenchfever.

Symptoms and Treatment

Symptoms may vary depending on which type oflice is present. Itching is the most common symp-tom of all types of infestation. Itching usuallybegins a week or more after lice infest the person.The eggs (called nits) of head lice may be seen onshafts of hair; one may need a magnifying glass tosee them. Nits are brown before they hatch andwhite to light brown after hatching. They aretightly attached to the hair shaft and do not slideup and down on the hair.

Lice will not go away without appropriate treat-ment. The most common treatment for lice isapplying a cream, lotion, or shampoo that containsan ingredient that kills lice. Treatment should usu-ally begin when symptoms of lice are present orwhen live lice and nits have been found on theperson’s body or in clothing. Usually, children mayreturn to school or day care after their first treat-

ment. However, some schools have a “no nits” pol-icy, which means that the child can only return toschool or day care after nits have been removed.

Pubic Lice (Crab Lice)

Pubic lice live in pubic hair or, more rarely, inarmpits, body hair, or beards. They are usuallypassed from one person to another during sexualcontact; sexual partners of an infected personshould also be treated. They are called crab licebecause of their crablike claws, which they use tograsp hair. Their bites can cause itching. In chil-dren, crab lice may attach to the eyelids.

Persons who believe they or their children areinfested with lice of any type should seek adviceregarding treatment from their physician or phar-macist.

life change events See GENERAL ADAPTATION SYN-DROME; LIFE CHANGE SELF-RATING SCALE; SELYE, HANS.

life change self-rating scale The original lifechange rating scale was developed as a predictor ofillness based on stressful life events by authorsHolmes and Rahe and presented at the Royal Soci-ety of Medicine in 1968. In many variations, thistype of rating scale has been used to help individ-uals determine their composite stress level withinthe last year.

To take this test, mark any of the changes listedbelow that have occurred in your life in the past 12months. Your total score indicates the amount ofstress you have been subjected to in the one-yearperiod. Your score may be useful in predicting yourchanges of suffering illness in the next two yearsdue to physiological effects of serious stressors.

What Your Score Means

A total score less than 150 may mean you haveonly a 27 percent chance of becoming ill in thenext year. If your score is between 150 and 300,you have a 51 percent chance of encounteringpoor health. If your score is more than 300, youare facing odds of 80 percent that you will becomeill; and as the score increases, so do the odds thatthe problem will be serious. To avoid these conse-quences, attention to RELAXATION and STRESS reliefcan help.

life change self-rating scale 221

SOURCE:Adapted from Holmes, Thomas, and Richard Rahe. “The

Social Readjustment Rating Scale.” Journal of Psychoso-matic Research 11 (1967): 213–218.

lightning Many people find lightning such asource of stress that they will not go outdoors on

days when lightning is predicted. When rain isforecast, they might call the weather bureau tocheck for the possibility of lightning. During astorm that includes lightning, frightened peoplemight take refuge in a closet or in bed, feeling saferin an enclosed place.

Some people acquire the fear of lightning fromobserving their parents or others, while many peo-ple have experienced traumatic incidents in con-nection with lightning or thunderstorms. Somepeople overcome fears of natural phenomena suchas lightning with exposure therapy.

See also ELECTRICITY; PHOBIA.

light therapy See PSORIASIS; SEASONAL AFFECTIVE

DISORDERS.

listening Hearing with thoughtful attention; askill necessary for good COMMUNICATION betweenindividuals. It is an active process in which onegives complete attention to what others are sayingand how they are saying it. According to DeborahTannen, author of Talking from 9 to 5: How Women’sand Men’s Conversational Styles Affect Who Gets Heard,Who Get Credit and What Gets Done at Work, “Listen-ing taps two important areas, gathering informa-tion and developing relationships.” Active listeningcan reduce the stress of communication not only inbusiness but in personal life as well.

By using nonverbal gestures such as a nod ofthe head or a smile, active listeners can conveyconcern and reinforce or encourage the other’sverbalizations. Listeners contribute by asking goodquestions, providing FEEDBACK on what they hear,

222 lightning

LIFE CHANGE SELF-RATING SCALE

Event Value

Death of spouse 100Divorce 73Marital separation 65Death of close family member 63Personal injury or illness 53Marriage 50Fired from work 47Marital reconciliation 45Retirement 45Change in family member’s health 44Pregnancy 40Sex difficulties 39Addition to family 39Business readjustment 39Change in financial status 38Death of close friend 37Change to different line of work 36Foreclosure of mortgage or loan 30Change in work responsibilities 29Son or daughter leaving home 29Trouble with in-laws 29Outstanding personal achievement 28Spouse begins or stops work 26Starting or finishing school 26Change in living conditions 25Trouble with boss 23Change in residence or school 20Change in recreational habits 19Change in church or social activities 19Change in sleeping habits 16Change in eating habits 15Vacation 13Christmas season 12Minor violation of the law 11Your total score:

Adapted from Holmes, Thomas, and Richard Rahe. “TheSocial Readjustment Rating Scale.” Journal of PsychosomaticResearch 11 (1967): 213–218.

REDUCE STRESS WITH BETTER LISTENING SKILLS

• Focus on the speaker; use eye contact. Keepinterruptions, such as phone calls and other con-versations, down to a minimum.

• It helps to question the speaker. You can gentlyguide a conversation, show that you are inter-ested in what he/she is saying, and what youmight want to learn.

• Do not judge the person speaking; concentrateon the information he/she is presenting.

and seeking consensus or pointing out differencesof opinion within a group. On the other hand, peo-ple feel listened to when more than just their ideasget heard; they feel valued, and they will con-tribute a lot more to the conversation.

See also BODY LANGUAGE.

SOURCES:Nichols, Michael P. The Lost Art of Listening. New York:

Doubleday, 1995.Tannen, Deborah. Talking from 9 to 5: How Women’s and

Men’s Conversational Styles Affect Who Gets Heard, WhoGets Credit and What Gets Done at Work. New York:William Morrow, 1994.

lithium See MANIC-DEPRESSIVE DISORDER; PHAR-MACOLOGICAL APPROACH.

live-in Common term for members of the oppo-site sex who share a domicile without the benefitof marriage. In many cases, stresses arise when oneindividual decides he or she wants to get marriedand the other does not. Additionally, stresses ariseif the couple decides to break up. Besides the hurtfeelings and blows to the ego, there may be mutu-ally owned property or equipment, and live-insmay face the same dilemmas as a couple goingthrough a DIVORCE.

Live-in is a term that evolved during the last twodecades of the 20th century when this practicebecame fairly common in the United States amongmen and women of all ages. The demographic termfor this situation, used by the United States CensusDepartment, is POSSLQ (person of the opposite sexsharing living quarters).

See also FRIENDS; INTIMACY; RELATIONSHIPS.

living will See END-OF-LIFE CARE.

loneliness State of mind relating to lack of com-panionship or separation from others. It is differentfrom being alone, which is a question of choice. It isthis lack of choice that make loneliness so stressful.

When people feel lonely, they are most likely toreact in one of two ways. The first is a sadnessresponse indicated by too much time spent eating,sleeping, and crying. The other response is “cre-ative solitude” where a person finds a way to dealwith loneliness such as reading a good book or

watching a movie, listening to or playing music,using artistic talents to paint, crochet, quilt, weave,or do ceramics, spending time in the garden, orpursuing other interests and HOBBIES. When peopledeal with loneliness creatively, they are in factfighting BOREDOM and, in that process, theybecome happier, calmer, and less stressed.

Some lonely people fit the shy, retiring stereo-type; others compensate for their feelings by tryingto become the center of attraction whether it be inthe classroom or at a party. Individuals who havespouses and families can be lonely even thoughthey are surrounded by people. Adolescents andteenagers may become lonely when they long tobe part of their peer group and are not. Many wid-owed or divorced people in their later yearsbecome lonely as their friends die and they find itincreasingly difficult to make new friends.

Conditions such as mental and physical DISABIL-ITIES or language or ethnic barriers, sometimes pro-duces isolation that results in loneliness.

Research on Loneliness

In some cases, loneliness results from a sense ofloss, a feeling that the past was better than thepresent. A 1990 Gallup poll showed that lonelinessis most common among the widowed, separated,and divorced. Over half of this group felt lonely“frequently” or “sometimes” compared with 29percent of the married participants. Adults whohad never married fell in between. According tothe survey, women are more likely to be lonelythan men, possibly, not because they genuinelyhave less companionship but because they placemore importance on friendship and are more will-ing to confess to being lonely.

Loneliness is often a factor in DEPRESSION, drugADDICTION, and alcoholism. In recent years, manystudies have shown that the more connected to lifeindividuals are, the healthier—mentally and phys-ically—they will be.

According to The Complete Guide to Your Emotionsand to Your Health, results of a survey conducted bysocial researchers Rubenstein and Shaver indicatethat loneliness has little to do with the number ofpeople in a given living situation, but is more aptto be defined by people’s expectations of life andreactions to their environment. Rubenstein andShaver’s questionnaire drew 22,000 respondents

loneliness 223

over the age of 18. The survey confirms that “feel-ing lonely”—regardless of living arrangement—isassociated with greater health risks, includingsome psychological symptoms such as ANXIETY,depression, CRYING spells, and feeling worthless.Nearly one-quarter of the people who lived alonefell into the “least lonely” category. They had moreFRIENDS on the average than people who lived withother people and were less troubled by symptomsof stress such as HEADACHES, ANGER, and irritability.

By comparison, young people who continued tolive with parents after college appeared to be theloneliest of all respondents. Rubenstein explains,“A young person in this situation has differentexpectations. If there’s no girlfriend or boyfriend inthe picture, they face a social-psychological con-flict. For young adults, in particular being alone—especially on Saturday night—can be a stigma. Thismakes them feel rejected and lonely.”

Key to combating loneliness is maintaining afeeling of self-worth and the ability to care notonly for yourself but also for other people andother things. Altruistic people lose themselves inothers. The process can block out depression, makeus less aware of our own inadequacies, and help ussurmount our personal problems. When youmaintain a pattern of caring, whether for a house,a garden, pets, or other people, you are protectingyourself against despair. And in the process, you’lllive a more happy and healthy existence—whetheralone or in the company of others.

See also ALCOHOLISM AND ALCOHOL DEPEND-ENCE; COPING; GENERAL ADAPTATION SYNDROME;VOLUNTEERISM.

SOURCES:Padus, Emrika. The Complete Guide to Your Emotions and

Your Health: Hundreds of Proven Techniques to HarmonizeMind and Body for Happy, Healthy Living. Emmaus, Pa.:Rodale Press, 1992.

Wilson, Marlene. You Can Make a Difference! Boulder: Vol-unteer Management Associates, 1990.

long-term care insurance Insurance to care foroneself or another on an ongoing basis due to dis-ability or age. The decision to purchase long-termcare insurance can be a stressful one. Manyspouses vow to care for each other, and middle-aged children assure parents that their needs will

be cared for. However, the reality is that when theelder needs care, younger family members may beworking, and spouses may need care themselves.Some people decide to save the yearly premium forthis kind of insurance and use it for the care whenneeded. However, escalating costs may make thissituation unworkable, because as of 2004, theannual cost of care averages $58,000 a year, accord-ing to the American Council of Life Insurers.

Unlike health insurance policies, which are gen-erally standardized, long-term care policies offermany options affecting the cost. One can select thedaily or monthly dollar amount for care, the num-ber of years of payments, the type of care, such asfacility-based, home- and community-based, orboth, and other details.

People age 18 to more than 84 may purchaselong-term care insurance when they are fully inde-pendent mentally and physically. A medical screen-ing may be required before obtaining a policy, andcertain conditions may be uninsurable. It is advan-tageous from a price standpoint to purchase thistype of insurance at a younger age. Premiums arebased on age when the policy is taken out as well asthe specific health risks of the individual.

See also AGING; ELDERLY PARENTS; HEALTH INSUR-ANCE.

loss See GRIEF.

lost work days According to the Bureau of LaborStatistics, U.S. Department of Labor, in 2003, 1.3million injuries and illnesses in private industryrequired recuperation away from work beyond theday of the incident. Days away from work arestressful for the employer, who must find areplacement to do necessary work, and stressful forthe employee, who may lose income. There mayalso be stress for a caregiver who is responsible forthe injured or ill worker.

The National Safety Council defines lost workdays as days away from work on which theemployee would have worked but could not. Daysof restricted activity are days on which the workerwas assigned to a temporary job, or worked at apermanent job less than full time, or worked at apermanent job but could not perform all dutiesnormally involved with that job.

224 long-term care insurance

low back pain See BACK PAIN.

lump in the throat Many individuals experiencea “lump in the throat,” which is the feeling of aneed to swallow but, upon swallowing, the sensa-tion does not go away. The medical term for thisunpleasant situation is globus hystericus. Some indi-viduals have this feeling before a stressful event,such as a court appearance, a public speakingengagement, a role in a play, or a singing solo, andthey are concerned that they will not be able tospeak or sing. Dryness and muscular contractionplay a causative role.

RELAXATION and BREATHING techniques can helpovercome this feeling. For some, MEDITATION andGUIDED IMAGERY is also helpful.

See also ANXIETY; STRESS.

lying Many individuals experience stress whenlying because they fear being caught and punished.Lying, making false statements with consciousintent to deceive, may be considered nonpatholog-ical or pathological. When adults or children seek toavoid punishment or to save others from distress,these nonpathological lies are sometimes referredto as “white lies.” Pathological lying is a major char-acteristic of an antisocial personality and may be asymptom of many psychophysiological disordersdue to guilt and fear reactions. The lie detector(polygraph) is based on physiological reactions.

See also GUILT.

Lyme disease A disease caused by a bacterial infec-tion spread by ticks; it is a source of stress to thosewho hike, camp, or spend a lot of time outdoors, par-ticularly in wooded areas. Lyme disease is the mostcommon disease transmitted by insects in the UnitedStates. There are about 17,000 cases of Lyme diseaseeach year. Lyme disease occurs in North America,Europe, and Asia. Deer ticks spread Lyme disease inthe northeastern and upper midwestern UnitedStates. Western blacklegged ticks spread the diseaseon the Pacific coast (mostly in northern Californiaand Oregon). Lyme disease is named after Lyme,Connecticut, where it was first recognized.

Anyone can develop Lyme disease, and the riskof Lyme disease is highest during the spring, sum-mer, and early fall months when young ticks are

most active and people spend more time outdoors.Infected ticks can travel from one state to anotheron birds, deer, and other animals. These animalsand the ticks they carry find their way into localforest preserves, parks, golf courses, and backyards.

Symptoms, Treatment, and Prevention of Lyme Disease

Early signs and symptoms can include an expand-ing skin rash and flulike symptoms such as bodyaches and mild fever. Tick bites can go undetectedbecause not all people infected with Lyme diseasedevelop a rash.

Lyme disease may be diagnosed based on thesymptoms, medical history, and whether or notone has been exposed to infected ticks. A blood testmay be used to confirm diagnosis. It is reassuringto know that most people who get bitten by ticksdo not develop Lyme disease, especially if exposureto the ticks occurred outside the high-risk areas.

If Lyme disease is diagnosed early, antibiotictreatment usually gets rid of the infection so that nofurther complications develop. If Lyme disease goesundetected or untreated, problems involving theskin, joints, nervous system, and heart may developweeks, months, or even years later. Antibiotic treat-ment can be used at that time, and in rare cases thedisease may cause permanent damage.

Prevention is the only way to avoid Lyme dis-ease. Use insect repellents specific for ticks, wearlight-colored clothing, and check yourself and fam-ily members for attached ticks after being in grassyor wooded areas.

The Lyme Disease Foundation

The Lyme Disease Foundation (LDF) is dedicatedto finding solutions for tick-borne disorders. LDFincludes businesses, patients, government, and themedical community working together to find solu-tions to tick-borne disorders. The LDF has strongties to the international scientific community.

FOR FURTHER INFORMATION:The Lyme Disease FoundationBox 332Tolland, CT 06084-0332(860) 870-0070(860) 870-0080 (fax)http://www.lyme.orgE-mail: Lymefnd@aol.com

Lyme disease 225

M“mad cow” disease (bovine spongiform encepha-lopathy) A progressive neurological disorder of cat-tle. Because there is evidence that mad cow disease,formally known as bovine spongiform encephalopa-thy (BSE), has been transmitted to humans, prima-rily in the United Kingdom, many people in theUnited States became concerned about eating meatand using products that contain meat by-products.

The disease was first diagnosed in cattle in En-gland in 1996. The first confirmed case among U.S.cattle occurred in December 2003. Canada’s first caseemerged in May 2003, prompting the U.S. to stopCanadian beef imports. In January 2005 the thirdcase of mad cow disease was confirmed in Canada.

In the United Kingdom, the disease that occurredin humans was a variant form of Creutzfeldt-Jakobdisease (vCJD). More than 1 million cattle may havebeen infected with BSE. Although a substantialspecies barrier appears to protect humans fromwidespread illness, as of November 2004 more than150 cases of vCJD had been reported worldwide,primarily in Britain. The one case of vCJD in theUnited States was in a young woman who likelycontracted the disease while living in Britain.

Determining Causes, Eliminating Risks

According to the National Center for InfectiousDiseases, the nature of the transmissible agent isunknown. Currently, the most accepted theory isthat the agent is a modified or misshapen form ofa normal cell surface component known as prionprotein. The pathogenic form of the protein is bothless soluble and more resistant to enzyme degrada-tion than the normal form.

People who eat meat containing the prions face apossible risk of contracting the rare but fatal humancondition, variant Creutzfeldt-Jakob (vCJD) disease,according to the Food and Drug Administration(FDA).

In some pharmaceuticals regulated by the FDA,including human vaccines and animal drugs usedon farms, cow products are used routinely duringmanufacture. Cow remnants left over from slaugh-ter have long been used to manufacture vaccines.Serum is drawn from cow’s blood and sugars fromcow’s milk. Amino acids from cow bones are addedto growth media to encourage viral vaccines grownin living cells.

In summer 2004 the FDA strengthened safetymeasures to reduce the chance of mad-cow-taintedcow parts being used in consumer goods such as lip-stick and hair spray. In 2000 the FDA told manufac-turers to replace products in their vaccines derivedfrom cows born, raised, and slaughtered in countrieswith confirmed mad cow cases. Manufacturers hur-ried to find replacement materials from countrieswhose cows were free of the fatal brain malady.

The FDA banned brains and other cattle parts thatcould carry the disease’s infectious agent from use indietary supplements and cosmetics. The ban affectsproducts made from animals at least 30 months old,the age at which the brain-wasting disease can befound, according to the FDA. The restrictions pro-hibit the use of the brain and spinal cord, where themisshapen proteins blamed for mad cow disease areconsidered most likely to be found. Other bannedparts from older animals include skulls, eyes, andnervous system tissue close to the spinal cord.

In December 2003 the Organic ConsumersAssociation recommended universal mad cow test-ing to assure safe meat supply.

FOR INFORMATION:Centers for Disease Control and Prevention200 Independence Avenue SWWashington, DC 20201(202) 401-6997(202) 260-4462 (fax)http://www.cdc.gov

226

Organic Consumers Association6101 Cliff Estate RoadLittle Marais, MN 55614(218) 226-4164(218) 353-7652 (fax)http://www.organicconsumers.org

mammography A specific type of imaging usinga low-dose X-ray system for examination of thebreasts. The images of the breasts can be viewed onfilm at a view box or on a digital mammographyworkstation. The subject of mammography causesstress for many women. Concerned about possiblefindings and fear of cancer, many women postponehaving this screening examination. Some fear dis-comfort from the procedure. However, medicalexperts agree that successful treatment of breastcancer often is linked to early diagnosis.

Mammography plays a central part in earlydetection of breast cancers because it can showchanges in the breast up to two years before apatient or physician can feel them. Current guide-lines from the U.S. Department of Health andHuman Services (HHS), the American Cancer Soci-ety (ACS), the American Medical Association(AMA), and the American College of Radiology(ACR) recommend mammography screeningsevery year for women beginning at age 40.

The National Cancer Institute adds that womenwho have had breast cancer and those who are atincreased risk due to a genetic history of breastcancer should seek expert medical advice aboutwhether they should begin screening before age 40and about the frequency of screening.

Fear of Possible Risks Causes Stress

Some women postpone having mammogramsbecause they fear possible risks of radiation fromthe procedure. However, the reality is that theeffective radiation dose from a mammogram isabout 0.7 mSv, which is about the same as theaverage person receives from background radiationin three months. The federal mammographyguidelines require that each unit be checked by amedical physicist each year to insure that the unitoperates correctly.

Five to 10 percent of screening mammogramresults are abnormal and require more testing(more mammograms, fine needle aspiration, ultra-

sound, or biopsy) and most of the follow-up testsconfirm that no cancer was present. According tothe Radiological Society of North America, esti-mates are that a woman who has a yearly mam-mogram between ages 40 and 49 would haveabout a 30 percent chance of having a false-posi-tive mammogram at some point in that decade,and about a 7 to 8 percent chance of having abreast biopsy within the 10-year period. The esti-mate for false-positive mammograms is about 25percent for women age 50 and older.

Limitations of Mammography

Interpretations of mammograms can be difficultbecause a normal breast can appear different ineach woman. Also, the appearance of an image canbe compromised if there is powder or salve on thebreasts, or if the woman has undergone breast sur-gery. Because some breast cancers are hard to visu-alize, a radiologist may want to compare the imageto views from previous examinations. Not all can-cers of the breast can be seen on mammography.

Breast implants can also impede accurate mam-mogram readings because both silicone and salineimplants are not transparent on X-rays and canblock a clear view of the tissues behind them, par-ticularly if the implant has been placed in front of,rather than beneath, the chest muscles. However,the National Cancer Institute says that experiencedtechnologists and radiologists know how to carefullycompress the breasts to improve the view withoutrupturing the implant. When making an appoint-ment for a mammogram, women with implantsshould ask if the facility uses special techniquesdesigned to accommodate them. Before the mam-mogram is taken, they should make sure the tech-nologist is experienced in performing the exam onpatients with breast implants.

A study at Massachusetts General Hospitalreported in 2004 indicated that only 6 percent ofwomen who received a mammogram in 1992received mammograms yearly for the next 10years, according to the study of more than 72,000women of all ages.

Most of the women received only five exams dur-ing the 10-year time period. “I think it’s very likelythis is a widespread phenomenon in America, thefailure of women to return promptly to get mammo-grams,” said James Michaelson, study author and

mammography 227

assistant professor of pathology at the hospital andHarvard Medical School. “Prompt annual return isreally important to get the maximum life-sparingbenefit of screening mammography.”

Women who are screened annually and arediagnosed with breast cancer die from the diseaseat a rate half that of those who do not get annualexams, Michaelson said. Poor women, those with-out insurance, and those from nonwhite racialgroups had particularly low rates of receivingmammograms, he said.

See also CANCER.

SOURCE:Radiological Society of North America, Inc.820 Jorie BoulevardOak Brook, IL 60523-2251(630) 571-2670(620) 571-7837 (fax)

managed care A variety of types of health insur-ance, including health maintenance organizations(HMOs) and preferred provider organizations(PPOs). HMOs permit specified services for a pre-paid fee to an enrolled population that uses serv-ices in specified places or from specified providers.Some people find this limitation in their choice ofphysicians a stressful factor. Sometimes employersand employees share costs of coverage for employ-ees and their families. Those who object to HMOsbelieve that care may be withheld to save the planmoney.

HMOs have been touted for bringing affordablehealth coverage to a wide range of consumers, aswell as criticized for cutting costs by limiting treat-ment options and patient choice. In the early2000s, doctors and patients continue to seek newways to regulate the managed care industry by giv-ing patients new rights, including the ability to suetheir health plans. Controversy continues overhow to protect patients without further driving upalready expensive health care costs.

Enrollment in managed care plans rose signifi-cantly after 1973 when a federal law paved theway for insurance companies to finance anddeliver health care. The increase was due in largepart to employers shifting their workers away fromthe traditional, and considerably more expensive,“fee-for-service” health insurance plans.

Although critics of HMOs claim limitation ofchoices regarding doctors, proponents claim higherquality of care and closer monitoring of care. Somemanaged care plans have physicians as their employ-ees, while other plans compensate physicians on a“capitation” basis (number of patients they served).

As health care costs spiraled upward, healthplans became the subject of popular criticism and asource of stress by enacting limits on what man-aged care would cover. For example, in most cases,managed care plans limit the number of mentalhealth visits for which a patient may be covered.

HMOs and other forms of managed care are alsoavailable to retirees as a supplement to Medicare.However, in the early 2000s, some HMOs acrossthe United States stopped covering the localMedicare population, and those individuals wereforced to find other health insurance providers.

manic-depressive disorder Disorder character-ized by mood disturbances and changes. It is amental health disorder that puts stress on the indi-vidual as well as those around him or her becausethere may be moods of mania as well as DEPRESSION

or a swing between the two states (bipolar disor-der). In the manic state, the individual is exces-sively elated, agitated, hyperactive, and hasaccelerated thinking and speaking patterns; in thedepressed state, the individual feels extremely sad,helpless, and hopeless.

An individual in a manic state will show anabnormal increase in activity and believe that he orshe is capable of achieving any goal. There may bea grandiose sense of knowing more than others,extravagant spending of money, little need forsleep, increased appetite for food, alcohol, and sex,or inappropriate bursts of LAUGHTER or ANGER.Severe mania may result in violence and hospitaladmission is often required.

Relatively mild symptoms of the manic state areknown as hypomania. First appearance of manicattacks is usually before age 30, and they may lastfor a few days or several months. When attacksbegin after age 40, they may be more prolonged.Mania often runs in families and may be geneti-cally transmitted.

Depression is more common than mania.Depression affects about one in 10 men and one in

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five women at some time in their lives. Mania(unipolar or bipolar) affects only about eight per1,000 people, men and women equally. The recov-ery rate from manic-depressive disorder is about 80percent.

Severe manic-depressive illness often requireshospitalization. Antidepressant medications and, insome cases, electroconvulsive therapy are used intreating depression. Antipsychotic drugs are pre-scribed to control the symptoms of mania. To pre-vent relapse, lithium is often used. Many peoplewho have manic-depressive illness lead healthy,well-balanced lives when taking lithium under theguidance of their physician.

See also AFFECTIVE DISORDERS; PHARMACOLOGICAL

APPROACH.

manic episode See MANIC-DEPRESSIVE DISORDER.

marijuana A drug derived from the plantCannabis sativa, is used as a stress reliever by somepeople because it is said to intensify sensory expe-riences, including seeing, hearing, tasting, andtouching. It may make the user feel relaxed, but insome cases it creates feelings of ANXIETY and dis-trustfulness.

There is no accepted medical use for smokingmarijuana, although THC (delta-9 tetrahydro-

marijuana 229

cannabinol) in capsule form is prescribed in certaincarefully selected medical cases. The only marijuanacurrently approved for medical use is the syntheticform of its most active component, tetrahydro-cannabinol, available as Marinol. It was developedas an antiemetic for chemotherapy patients.

Advocates of medicinal marijuana continue theirefforts for easier access to the illicit drug. Propo-nents cite anecdotal evidence that smoked mari-juana restores appetite in patients with AIDSwasting syndrome, controls chemotherapy-inducednausea and vomiting, reduces interocular pressurein glaucoma patients, and alleviates painful spastic-ity in multiple sclerosis. Most of mainstream medi-cine disagrees, however, and insists that the healthrisks far outweigh the potential benefits.

Marijuana, in the later 1990s, was federally des-ignated as a Schedule I drug, like LSD and heroin,with high potential for abuse and no medical appli-cation. Advocates want marijuana downgraded toSchedule II, where it would be classified likecocaine and morphine as having a proven thera-peutic value.

There were an estimated 2.6 million new mari-juana users in 2002. This means that each day anaverage of 7,000 Americans tried marijuana for thefirst time. About two-third (69 percent) of thesenew marijuana users were under age 18, andabout half (53 percent) were female.

A report by the U.S. Department of Health andHuman Services Substance Abuse and MentalHealth Services Administration, Office of AppliedStatistics, indicated that the annual number ofmarijuana initiates generally increased from 1965until about l973. From l973 to l978, the annualnumber of marijuana initiates remained level atmore than 3 million per year. After that, the num-ber of initiates declined, reaching a low point in1990, then rose again until 1995. From 1995 to2002, there was no consistent trend, with esti-mates varying between 2.4 million and 2.9 millionper year. The proportion of marijuana initiatesunder age 18 (69 percent in 2002) has generallyincreased since the 1960s, when less than half ofinitiates were under age 18. The average age ofmarijuana initiates was around 19 in the late 1960sand 17.2 in 2002, the most recent year for whichstatistics are available. (See chart on page 229.)

See also ADDICTIONS.

marital therapy Many individuals who arestressed by a difficult or troubled MARRIAGE chooseto engage in marital therapy. This may involve cou-ples in therapy, or therapy for each individual alone.The therapy may be directed toward overcomingspecific problems, such as COPING with the other’sDEPRESSION, helping one partner manage MONEY bet-ter, helping one partner overcome an unwantedcompulsion, such as GAMBLING, or toward saving amarriage that might end in DIVORCE. Psychologicalcounseling or sexual therapy, or a combination ofboth, may be involved in marital therapy.

In some cases, just the suggestion of marital ther-apy is a source of stress to one or the other partners.For the therapy to have a chance at succeeding, it isessential that both partners participate.

See also BEHAVIOR THERAPY; INTIMACY; MARRIAGE;PSYCHOTHERAPIES; RELATIONSHIPS; REMARRIAGE; SEX

THERAPY.

marriage The marriage of one man to onewoman, or monogamy, is the most common form ofmarriage in the Western world. As a personalarrangement, marriage means a lifelong emotionaland legal commitment to another individual. Forpeople unwilling to make a commitment, thethought of marriage is extremely stressful. In the1990s, many young people avoided marriage untiltheir late thirties. Marriage later in life may bringwith it the stress of the BIOLOGICAL CLOCK for womenand increased anxieties about becoming parentsbefore both the woman and the man are too old.

Stresses Involved in the Marriage Ceremony

Planning for the marriage ceremony may be stress-ful for one or both partners or for parents of thecouple. Some weddings in the United Statesinvolve hundreds of guests, while other cere-monies take place in a judge’s chambers or thestudy of a clergyperson. Plans for large weddingsmay result in stress for members of the weddingparty. Ceremonies for marriage may be lengthyand complex or very simple, and ceremonies fre-quently contain elements of religious observance.In interfaith marriages, particularly, decisions mustbe made about who will perform the ceremonyand in which tradition the wedding will be con-ducted. Good COMMUNICATION and mutual agree-ment between bride and groom are essential to

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avoid ongoing stress. Most marriage ceremoniesare followed by the consumption of food, andplanning this event can also be stressful for thoseinvolved who seek PERFECTION in the special day.

Commuter Marriages

A study by Barbara Bunker, State University ofNew York, noted that nearly 1 million Americancouples who work in different cities and see eachother only on weekends feel no more stress thandual-career couples who live in the same place.From previous research, Bunker knew that long-distance “commuter couples” experience specificstrains different from those felt by dual-career cou-ples living together full time. Not surprisingly, thecommuters were less pleased with their relation-ships, but more satisfied with their work lives andthe time they had for themselves.

The researchers were surprised that the stay-at-home couples reported feeling just as much stressin their lives as did the commuters, and, in fact, feltmore overloaded. Bunker and her colleagues spec-ulated that people who see their spouses only onweekends are better able to focus fully on theirwork during the week and on their domestic liveswhen they are at home. This separation of workand family might make it easier to handle multipleroles, while stay-at-home couples must learn tomanage all aspects of their lives simultaneously.

Alternative Forms of Marriage

Because so many traditional monogamous mar-riages have resulted in stress and divorce, manyindividuals have experimented with alternativemarital or sexual relationships. While some of thestresses in traditional marriages are overcome bythese alternative unions, many stressful situationsalso arise in them. At the latter part of the 20thcentury, the possibility of marriages betweenhomosexual couples has become an issue for manyindividuals.

Gay marriage. During the early 2000s, there wasincreasing interest in as well as controversy overthe issue of marriage between two persons of thesame sex. Advocates of “same-sex marriage”believe that lawful marriage and the benefitsthereof should be available to same-sex couplesand that denial of lawful marriage denies one ormore of their rights as American citizens. Advo-

cates of traditional marriage oppose this positionand hold that lawful marriage should be defined asbetween one man and one woman. This contro-versy induces stress on both sides of the issue, par-ticularly for some individuals who wish to marry.

Legal recognition of same-sex partners has fourforms; marriages, civil unions, reciprocal benefits,and domestic partnerships. Forty states have lawsor constitutional amendments forbidding mar-riages between those of the same sex.

Many national organizations have advocated forthe legal rights of persons in same-sex unions. Theserights include health insurance, hospital visitation,and Social Security survivor benefits. Since the early2000s, many national organizations have spokenout in favor of legal rights for same-sex partners;these include the American Civil Liberties Union,American Psychiatric Association, Human RightsCampaign, National Association for the Advance-ment of Colored People, National Organization forWomen, and United Farm Workers Union.

As of October 2005 in the United States, onlythe state of Massachusetts recognized same-sexmarriage, while an increasing number of otherstates offered persons in same-sex relationshipslegal status similar to those in civil marriages, byway of domestic partnerships, civil unions, orreciprocal beneficiary laws.

Proponents of equal marriage rights in theUnited States say there are more than 1,050 federallaws, as well as state and private benefits, such asdiscounts and family memberships, in which mar-ital status is a factor, thereby excluding same-sexcouples.

In 2004, a poll by the Columbia BroadcastingSystem found that only 22 percent of the Americanpublic favored legal recognition of same-sex mar-riages, while 73 percent opposed legal recognition ofthese marriages. Many people distinguish betweensame-sex marriage and civil unions, which providesame-sex couples some legal rights. Although fewerthan one-fourth of Americans thought gay and les-bian people should be allowed to marry, there waslarger support for civil unions. More than half ofAmericans supported some type of legal status forsame-sex couples wishing to make a long-termcommitment. Forty percent thought that relation-ships of same-sex couples should have no legal

marriage 231

recognition. Opposition correlated with level of reli-gious service attendance, age, political affiliation,and residence in southern states. Support was high-est among residents of western and New Englandstates as well as among young, nonchurchgoers.

Open marriage. The concept of open marriagewas espoused by Nena and George O’Neil in theirbook, Open Marriage (1972). Disadvantages of thissystem include possibilities for JEALOUSY and fear oflosing one’s spouse. Open marriage emphasizesequality and flexibility for both the male andfemale roles in the marriage and includes an agree-ment not to be emotionally, socially, or sexuallyexclusive. While this system attracted attention, itwas largely discarded as generally unworkable formost couples.

Swinging. Sharing sexual activities between cou-ples has been termed swinging. A couple may switchpartners with another married couple, or a marriedcouple may engage in sexual activities with a singlefemale, single male, or an unmarried couple. Recre-ational swingers are primarily interested in sexualactivities without close friendships or involvementwith their sexual partners. Swinging first gainedpublic attention during the 1950s (then known as“wife swapping”). Clubs and magazines devoted toswinging exist. Major reasons for dropping out ofthe swinging scene include the stress of jealousy,the threat to marriage, and the threat of sexuallytransmitted diseases and the HIV virus.

See also COHABITATION; FATHERING, OLDER; LIVE-IN; MARITAL THERAPY; MOTHERS; REMARRIAGE; STEP-FAMILIES.

FOR FURTHER INFORMATION:American Association of Marriage and Family

Therapy112 South Alfred StreetAlexandria, VA 22314-3061(703) 838-9808(703) 838-9805 (fax)http://www.aamft.org

SOURCES:Bunker, Barbara, et al. “Quality of Life in Dual-Career

Families: Commuting Versus Single-Residence Cou-ples.” Journal of Marriage and the Family, May 1992.

Gottman, John Mordechai. Why Marriages Succeed or Fail:What You Can Learn from the Breakthrough Research to

Make Your Marriage Last. New York: Simon & Schuster,1994.

Roloff, Tamara L., and Mary E. Williams, eds. Marriageand Divorce. San Diego: Greenhaven Press, 1997.

Simpson, Eileen B. Late Love. A Celebration of Marriage afterFifty. Boston: Houghton Mifflin, 1994.

Steinem, Gloria. Outrageous Acts and Everyday Rebellions.New York: New American Library, 1983.

masked depression Some people appear to bewell but work hard at hiding DEPRESSION. For them,the hiding is a heavy source of stress. They out-wardly do what they think is expected of themwhile inwardly they feel hopeless and even suici-dal. They may have little facial animation, appearto have a fixed expression, and show little emo-tion. The terms depressive equivalents, affective equiva-lents, hidden depression, and missed depression are alsoused for this situation. Some mental health profes-sionals use the term borderline depression for suchindividuals.

See also AFFECTIVE DISORDERS; MANIC-DEPRESSIVE

DISORDER; PHARMACOLOGICAL APPROACH.

massage therapy A form of body therapy inwhich the practitioner applies manual techniquessuch as kneading, stroking, and manipulation of thesoft tissues of the body, the skin, muscles, tendons,and ligaments with the intention of positivelyaffecting the health and well-being of the client.Massage therapy helps many people relieve STRESS

and body aches caused by tension and anxieties.A professional massage increases blood flow and

relaxes muscles. Massage therapy can provide any-thing from soothing RELAXATION to deeper therapyfor specific physical problems. It can aid in recov-ery from pulled muscles or sprained ligaments.Massage therapy can also ease many of the uncom-fortable stresses of child bearing, the discomforts ofBACK PAIN and exhaustion, as well as the pains ofcertain REPETITIVE STRESS INJURIES related to on-the-job activities.

According to the American Massage TherapyAssociation, once the massage is under way, manybeneficial reactions are set in motion. Massagetherapy can hasten the elimination of waste andtoxic debris that are stored in muscles, increase theinterchange of substances between the blood andtissue cells, and stimulate the relaxation response

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within the nervous system. Responses to massagetherapy can help to strengthen the immune sys-tem, improve posture, increase joint flexibility andrange of motion, and reduce blood pressure.

Types of Massage

The most universally understood Western form ofmassage is Swedish, also called Esalen. It consists ofmany types of strokes: gliding the hand across theskin, kneading, lifting, squeezing and grasping themuscles, gentle pushing, friction, vibration, jostlingand rocking, and percussion (hacking, chopping,and rapid pounding).

Oriental massage, sometimes referred to as SHI-ATSU or ACUPRESSURE, involves pressing at certainpoints along invisible energy meridians that runthrough the body; the practitioner looks for tightspots, knots, or anything that interferes with theflow of energy.

Deep tissue massage uses slow strokes anddeep finger pressure to combat aching muscles,such as a stiff neck or bad back. Sports massage isa combination of stretching and Swedish or deep-tissue massage performed before or after strenu-ous exercise.

REFLEXOLOGY, the massage of the hands, feet,and ears, is based on the belief that specific areasgovern all parts of the body. For example, the tipsof the toes correspond to the head, while the insidearch of the foot reflects the spine. The theory isthat by stimulating the nerve endings of the differ-ent organs in the body, changes can be effected.

Choosing a Massage Therapist

According to the American Massage Therapy Asso-ciation (AMTA), a qualified massage therapistshould have a solid foundation in physiology andbe knowledgeable about the inner workings of thebody. Therapists from an accredited school haveusually completed 500 hours of training, includingclasses in anatomy, first aid, and cardiopulmonaryresuscitation.

The American Massage Therapy Association,founded in 1943, is the largest and oldest nationalorganization representing the profession. Member-ship in the AMTA is limited to those who havedemonstrated a level of skill and expertise throughtesting and/or education. All AMTA therapistsmust agree to abide by the AMTA Code of Ethics.

According to the AMTA, their number of mem-bers increased from under 5,000 in 1986 to over20,000 in 1994.

Experiencing a Massage

Most massage therapists work in small, semi-dark-ened rooms, where soft music of the client’s choicewill be playing. Some therapists offer a choice ofscented candles. The massage therapist leaves theclient alone to undress and lie down on a paddedmassage table. During the massage, the entire bodyis draped in a sheet; only the portion that is cur-rently being worked on is exposed. Quiet is anessential feature of the massage experience. Whileconversation with the therapist may be limited, aperson should speak up if experiencing discomfort,feeling hot or cold, or desiring more or less pres-sure, or wanting more attention paid to a certainarea of the body, such as an aching back.

Massage is “productive down time.” During themassage, the body feels very heavy and sinks intothe table. As the therapist’s hands locate areas oftension, the individual consciously tries to let goand relax these areas. He or she lets go of a desireto control movement and allows the therapist tomove limbs into whatever position is required.

Patricia Deer, a certified massage therapist andowner of Energy Breaks, Chicago, says that a goodneck and shoulder massage may contribute towardbetter mental performance as well as relief ofstress. One study reported that people whoreceived 15-minute seated massages during theirworkday showed brain-wave patterns consistentwith greater alertness. Those people were also ableto complete arithmetic problems twice as fast andwith half the errors, as they did before the mas-sage. “Employers are increasingly recognizing thebenefits of “mini-tune-ups” for people who sit atdesks or computers much of the day,” says Deer.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MIND-BODY CONNECTIONS; ROLFING.

FOR FURTHER INFORMATION:American Massage Therapy Association800 Davis Street, Suite 100Evanston, IL 6001(888) 843-2682 (toll-free)(847) 864-0123(847) 864-1178 (fax)http://www.amamassage.org

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masturbation Usually refers to sexual self-stimu-lation for gratification and pleasure and usually toan experience of orgasm. The method is to massagethe penis or clitoris with the hand. The subject ofmasturbation is stressful for many people becausein previous generations, parents warned youngpeople against masturbation, suggesting that doingso would lead to dire consequences such as acne,impotence, insanity, or worse. Thus many peoplewho believed that they were going against culturalmores developed anxieties and GUILT about thepractice. Now masturbation is considered normalbehavior, particularly among teenagers and adultswithout sexual partners.

Sex therapists during the latter part of the 20thcentury use masturbation as a technique toinstruct clients in learning to know what pleasesthem so that they can later instruct a partner.

Compulsive masturbation is an obsessive urgeto masturbate without sexual feeling or satisfac-tion. Such an individual may substitute masturba-tion for a lack of social satisfaction that arises fromshyness, or an inability to establish relationshipswith the opposite sex, or to relieve anxieties.

See also SAFE SEX; SEX THERAPY.

SOURCE:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.

mathematics anxiety Experiencing stress relatedto practical applications of mathematics in every-day life, such as counting small change or readingtimetables. Additionally, math ANXIETY resultsbecause mathematics is an abstract science andmany people have difficulties understandingabstractions.

As simple a chore as balancing a checkbookcauses many individuals to perspire and experi-ence a more rapid heartbeat. Many students whoare good in all subjects experience feelings of dis-comfort in math classes. Why this happens isn’t aclearcut issue. There are many factors involved inwhy this happens; the individual may be unsure ofhis or her abilities regarding adding and subtractingor there may be a fear of making a mistake. In aschool setting, making a mistake when called uponwould be embarrassing.

meditation A learned technique to relieve STRESS

and involves deep RELAXATION brought on byfocusing attention on a particular sound or imageand breathing deeply. One directs thoughts awayfrom work, family, relationships, and the environ-ment. During meditation, the heart rate, bloodpressure, and oxygen-consumption rate decrease,temperature of the extremities rises and musclesrelax.

Meditation also has been shown to reduce anumber of medical symptoms and improve health-related attitudes and behaviors. For example, peo-ple with chronic obstructive pulmonary disease(COPD) who practiced meditation reduced the fre-quency and severity of episodes of shortness ofbreath and the number of visits to emergencyrooms. People with heart disease, hypertension,CANCER, DIABETES, and chronic PAIN have reportedfeeling more self-confident, more in CONTROL oftheir lives and better able to manage stress aftermastering the meditation technique. Meditationhas been used successfully by individuals whohave PANIC ATTACKS AND PANIC DISORDER.

Meditation may bring out increased efficiencyby eliminating unnecessary expenditures ofenergy. Individuals who practice meditation some-times report a beneficial surge of energy marked byincreased physical stamina, increased productivityon the job, the end of writer or artist’s “block,” orthe release of previously unsuspected creativepotential.

Learning to Meditate

Meditation is a very self-disciplined routine and away to learn more about one’s own thoughts andfeelings. Simple procedures can be learned easily.The basics include sitting in a quiet room with eyesclosed, breathing deeply and rhythmically withattention focused on the breath. Also, there maybe a focus on either a special word, or mantra, suchas “peace,” which one repeats over and over again,or on steadily watching an object, such as a candleflame, for a 20-minute period once or more daily.

Meditation relies on the close links betweenmind and body. When one meditates, the alphabrainwaves indicate that the body is relaxed andfree from physical tension and mental strain.BIOFEEDBACK monitoring has indicated that medi-tation encourages the brain to produce an evenly

234 masturbation

balanced pattern of alpha and theta brain waverhythms. This means that the body is relaxed andthe mind calm, yet alert. The “relaxation response”sets in, which is the opposite of the physical ten-sion that results from stress.

Types of Meditation Vary

Modern meditation techniques are derived fromspiritual practices in Eastern cultures dating backmore than 2,000 years. Traditionally, the benefitsof the techniques have been defined as spiritual innature, and meditation has constituted a part ofmany religious practices. In the latter part of the20th century, however, simple forms of meditationhave been used for stress management with excel-lent results. Contributing to the rising interest isthe fact that these meditation techniques arerelated to biofeedback (which also emphasizes adelicately attuned awareness of inner processes)and to muscle relaxation and visualization tech-niques used in BEHAVIOR THERAPY.

There are two basic types of meditation. One isconcentration and the other, insight. Concentrationtypes, such as TRANSCENDENTAL MEDITATION, oftenuse a special sound or silently repeated phrase tofocus attention and screen out extraneous thoughtsor stimuli. Insight-oriented meditations, such as mind-fulness meditation, accept thoughts and feelings thatarise from moment to moment as objects of atten-tion and acceptance. The goal of mindfulness is anincreased awareness of what is happening in one’smind and body right now. Recognition and accept-ance of present reality provide the basis for changesof attitudes and conditions.

See also ALTERNATIVE MEDICINE; BENSON, HER-BERT; GUIDED IMAGERY; KABAT-ZINN, JON.

SOURCES:Benson, Herbert. The Relaxation Response. New York: Mor-

row, 1975.Chopra, Deepak. Creating Affluence: Wealth Consciousness in

the Field of All Possibilities. San Rafael, Calif.: NewWorld Library, 1993.

———. Creating Health: How to Wake up the Body’s Intelli-gence. Boston: Houghton Mifflin, 1991.

Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdomof Your Body and Mind to Face Stress, Pain and Illness.New York: Delacorte, 1991.

———. Wherever You Go, There You Are: Mindfulness Medi-tation in Everyday Life. New York: Hyperion, 1993.

Kerman, D. Ariel. The H.A.R.T. Program: Lower Your BloodPressure without Drugs. New York: HarperCollins, 1992.

Mahesh Yogi, Maharishi. Science of Being and Art of Living:Transcendental Meditation. New York: Meridian, 1995.

memory An ability to learn by observation andto retain, remember, and call up information pre-sented through the senses. Many people feelstressed and anxious because of their poor memo-ries and inability to recall things at will. Some peo-ple fear they are developing ALZHEIMER’S DISEASE

when their memory fails them. During periods ofextreme stress, many people experience memorydifficulties.

The exact amount of retention depends on fac-tors such as the thoroughness of the learning, onrepetition, and on the nature of the content. Themore thoroughly the person learns, the greater theduration and amount of retention. Many peopleretain visual images of what they have learned, suchas people, objects, pictures, or the printed page.Children have superior visual imagery, but this abil-ity usually declines after about the age of 15.

Individuals have recall in various steps. Imme-diate recall involves remembering from a few sec-onds to a few minutes; an example is rememberinga phone number long enough to write it down.Short-term recall involves memory from a fewminutes to a few days. Long-term memory refersto memory from a few days to a few years.

Verbalizing the memory involves finding theright words, which then calls into play the entireleft side of the brain where words are stored. All

memory 235

SITUATIONS IN WHICH MEDITATION MAY REDUCE STRESS

• Tension or anxiety• Chronic fatigue• Insomnia and hypersomnia• Abuse of alcohol or tobacco• Excessive self-blame• Chronic subacute depression• Irritability, low tolerance for frustration• Strong tendencies to submissiveness• Difficulties with self-assertion• Prolonged bereavement reactions

parts of the brain are required for comprehensionand storage of memory.

A poor memory may be due to poor learning,but sometimes there are psychological reasons forFORGETTING a fact, an event, or a person. This maybe called motivated forgetting, as the person sub-consciously tries to forget. Many people have atendency to forget unpleasant things, but whenforgetting becomes extreme it is called repression.When thoughts associated with GUILT, shame, orFEAR are pushed into the unconscious mind, ten-sion and ANXIETY may result.

How Memory Works

There is ongoing research to determine just howthe memory works. However, researchers agreethat certain events occur in the central nervous sys-tem. It has been suggested that there are chemicaland/or physical changes in brain cells and nervepathways. Another theory is that memory is estab-lished in the cerebral cortex through a scanningprocess comparable to that of a computer. Memoryis a cell-to-cell transmission of information across asynapse that has both electrical and chemical prop-erties. This interaction and transmitting across cellwalls takes place in a split second. Memories ofsmell, touch, and taste are placed in several placesin the brain, awaiting a similar stimulus, such as thesmell of a familiar food, to reactive the memory.

Age-Related Memory Impairment

Many individuals are less able to remember certaintypes of information as they get older. The term“age-associated memory impairment” (AAMI) isused to describe minor memory difficulties thatcome with age. AAMI is often most noticeable whenthe individual is under severe stress. When the per-son is relaxed, he or she will be able to rememberthe forgotten material with no difficulty. There is notreatment for AAMI, but written reminders, lists,the use of association to remember names, andallowing more time to remember may be helpful.

Amnesia and Other Forms of Memory Loss

Amnesia may be produced by physical or chemicalchanges in the brain. If the cause is psychological,the loss of memory is a defense against experiencesthat have been extremely painful and intolerable.Amnesia may be total or only for certain events or

periods of time. Paramnesia is a false or distortedmemory and serves as a protection against unbear-able anxiety. The individual fills in the gaps in hismemory by statements that are not true, althoughhe believes they are. This condition occasionallyoccurs in senility and in alcoholic psychoses.Hypermnesia is an extreme degree of retentivenessand recall. There is unusual clarity of memoryimages. It occasionally occurs in individuals facedwith death and also in mental prodigies, but ismore common in individuals during hypnosis andin a drug intoxication induced by amphetaminesand hallucinogens. Impressions arising from emo-tionally colored events are registered with morethan usual intensity and the result is that one hasa vivid recollection of details.

Getting Help

Individuals should seek professional help for mem-ory difficulties if they feel extremely stressed, anx-ious, or fearful because of the loss; if they feel outof touch with reality because they cannot remem-ber what day of the week it is or where they are;or if they feel that forgetting things is upsettingtheir work or home life. Local hospitals that havegeriatric centers may be a helpful resource; addi-tionally, local departments of health may be able tomake referrals to centers that have facilities formemory evaluation.

SOURCES:Kra, Siegfried J. Aging Myths; Reversible Causes of Mind and

Memory Loss. New York: McGraw-Hill, 1985.Mark, Vernon H. Reversing Memory Loss: Proven Methods for

Regaining, Strengthening, and Preserving Your Memory.Boston: Hougthon Mifflin, 1992.

menopause Cessation of menses (menstrualperiods). Menopause occurs at midlife (average age50–51), when a woman’s ovaries stop producingeggs (ovulating) and monthly bleeding from theuterus ceases. During the climacteric (a period oftime when gradual hormonal changes occur beforeand after menopause itself), the ovaries graduallyproduce less estrogen and progesterone.

Stress during Menopause

Menopause occurs at a time in women’s liveswhen they have many psychosocial concerns aswell as concerns about their changing bodies.

236 menopause

Many women experience particular stresses, con-flicts, and challenges at this time. In generationspast, the “change of life” was considered to be atime when women would be naturally irritableand even irrational. Many of women’s complaintsaround the time of menopause were written off bydoctors as being “all in your head.” Now, however,it is recognized that other issues in a woman’s lifeat midlife contribute to her stress level in additionto changes in hormonal levels.

However, differences of opinion regarding hor-mone replacement therapy by experts leave manywomen feeling stressed, confused, and in search ofadditional opinions.

Many women are affected by a variety of stres-sors around the time of menopause. One is a feelingthat they are no longer attractive to men; another isa feeling of loss because they are no longer able tobear children. They may be divorced or widowedand facing a husband’s retirement or their own.They may be dealing with grown children who havereturned home, or may be anticipating financial dif-ficulties due to an inflationary economy.

Hormone Replacement Therapy Controversy

For more than 40 years, women who experiencedhot flashes before, during, and after menopausewere advised by physicians to take hormonereplacement therapy, which consisted of a combi-nation of estrogen and progestin drugs. Womenwith an intact uterus were advised to take thecombination because of the possibility that estro-gen alone might contribute to development ofuterine or other cancers. Those without a uteruswere advised to take estrogen alone. Estimates arethat as of 2002 about 6 million women in theUnited States were taking estrogen and progestinfor various reasons, including relief of menopausalsymptoms and for the prevention of heart diseaseand brittle bones (long-term use).

In summer 2002, the U.S. government stopped amajor study of hormone replacement therapy onthe risks and benefits of combined estrogen andprogestin in healthy menopausal women, citing anincreased risk of invasive breast cancer. Researchersfrom the National Heart, Lung, and Blood Instituteof the National Institutes of Health also foundincreases in coronary heart disease, stroke, andpulmonary embolism.

The study, known as the Women’s Health Initia-tive (WHI), was stopped after participants weretracked for an average of 5.2 years and found thatthe risks of the therapy exceeded the benefits.

Many women stopped taking estrogen and prog-estin. Some women were advised to take the lowesteffective dose for a short term to combat serious hotflashes and vaginal dryness. Physicians also coun-seled all women to consider their own situations,intensity of symptoms, and risk factors for disease.Physicians advised women to improve health habitsand have yearly mammograms and physical exami-nations with checks of blood pressure and choles-terol levels. Women who stopped taking thehormones were advised to have a bone density test,with a follow-up about year later, to determine ifthey needed another bone preserving drug.

Many women turned to ALTERNATIVE MEDICINE

for relief of symptoms. Other aids to relieve somediscomforts are layering clothing, avoiding woolfabrics close to the skin, and using a portable fan.When vaginal dryness occurs along with diminish-ing estrogen levels, these factors may contribute toDYSPAREUNIA and sexual difficulties. What a hus-band or lover may interpret as lack of interest mayactually be fear of painful intercourse or seriousdiscomfort during intercourse. A thorough physi-cal examination by a gynecologist should besought, with sex therapy useful in some cases.

See also HOT FLASHES.

SOURCES:Holt, Linda Hughey, and Ada P. Kahn. 50 Ways to Cope

with Menopause. Lincolnwood, Ill.: Publications Inter-national, 1994.

Kahn, Ada P., and Linda Hughey Holt. Midlife Health: AWoman’s Practical Guide to Feeling Good. New York:Avon Books, 1989.

Wright, Karen. “Menopause Naturally.” Health, Janu-ary–February 1996.

menstruation Term for the uterine bleeding thatcommonly occurs in WOMEN approximately once amonth between PUBERTY and MENOPAUSE. Someyoung women in the United States begin menstru-ating as early as age nine and as late as age 16.Many have an irregular pattern of menstruationvarying from one- to three-month intervals. Peri-odic flow varies from extremely light to moderate

menstruation 237

or very heavy. Blood loss during each period aver-ages about one ounce but can vary from a third ofan ounce to almost two ounces. Although themenstrual period usually lasts about four to fivedays, it can last fewer or more days and still be con-sidered within the range of normal. The fact thatthere are so many individual differences betweenwomen’s menstrual patterns is often a source ofstress for women.

Historically, for many women, the onset ofmenstruation (menarche) has been filled withwonder, awe, and sometimes fear. Menstruationmarks the beginning of physical adulthood forwomen, as bearing children becomes possible aftermenarche. Young women can become pregnantshortly after the onset of menstruation, and thiscan lead to unwanted children and the stresses ofchildraising.

Understanding Menstruation

Menstruation is the removal of the lining of theuterus that is prepared each month to provide for apotential PREGNANCY. At the same time, the ovaryripens an egg (ovum) each month and releases it(ovulation) so that it can be fertilized and implantedin the uterus. When fertilization does not occur, theuterus empties and these cyclical preparations beginagain. Menstruation usually begins two weeks afterovulation if the egg is not fertilized.

Menstruation is caused by cyclic fluctuation ofthe hormones estrogen and progesterone. During a“typical” menstrual cycle, ovarian estrogen is pro-duced in response to stimulation from the pituitaryhormones known as follicle stimulating hormone(FSH) and luteinizing hormone (LH). At midcycle,ovulation occurs in response to an “LH surge” andthe ovary forms a small cyst (a corpus luteum) inthe follicle that has surrounded the egg or ovum.Progesterone is produced, which causes structuralchanges in the uterine lining. If the ovum is fertil-ized and implants in the uterine lining, menstrua-tion does NOT occur; hence a late menstrual periodmay be a signal of pregnancy or of some menstrualirregularity.

Stressful Aspects Surrounding Menstruation

Premenstrual syndrome (PMS). Many women experi-ence higher levels of stress or are more irritable ordepressed just before and during their menstrual

periods. Some notice annoying bloating, fluidretention, breast tenderness, and HEADACHES. Somewomen who have migraine headaches find thatthe onset is associated with their menstrual peri-ods. Most women cope successfully with theirsymptoms by getting a little extra rest, limiting ordecreasing salt intake, and recognizing the tempo-rary nature of the annoyances. Women who haveexcessive premenstrual symptoms should bringthem to the attention of a physician.

Sexual intercourse during menstruation. In somecultures, menstruating women have been excludedfrom society during their periods. Over centuries,concerns regarding menstruation have included thenotion that sexual intercourse during menstruationis harmful to both men and women’s health andthat deformed children may result from intercourseduring this time. Historically, some men haveavoided contact with menstruating women out offear of castration, or that menstrual blood wasmeant to form the body of a child and therefore isfilled with potent and dangerous energy.

Menstrual cessation. When periods stop for anunexplained reason, great feelings of stress ensueas a woman may fear pregnancy or disease.Absence of menstruation is called amenorrhea.Amenorrhea is normal prior to puberty or aftermenopause; it occurs frequently as a response toextreme stress, weight loss, or to a wide range ofhormonal, physical, or emotional causes. Anorexianervosa, an EATING DISORDER, usually results inamenorrhea. Runner’s or athlete’s amenorrhea is acommonly observed syndrome in which womenundergoing rigorous physical training temporarilycease having periods.

Pain. Painful menstruation is known as dysmen-orrhea, and is a source of stress for the suffererbecause the discomfort often leads to lost daysfrom work, school, or social activities. Cramplikepain (cramps) may be associated with the passageof uterine clots and may start just before or duringmenstruation and may last only while the mass ispassing out of the uterus, or may continue forhours or days. Many women feel cramps in theirlower abdomen, lower back, and thighs. Medica-tions may relieve discomfort.

Personal protection. Protecting clothing and hid-ing the fact that a woman is having her menstrual

238 menstruation

period has been a concern for generations. Themost common ways of disposing of menstrual fluidare use of externally worn sanitary napkins (inBritain, known as sanitary towels) or internallyworn tampons.

Internally worn tampons can be used by youngwomen from the start of menstruation. Physicianssay that virginity is intact until one’s first act of sex-ual intercourse. The hymeneal ring, a tissuebetween the internal and external genital organs,is usually large enough to admit a tampon, whichhas been slightly lubricated for easier insertion.Many women of all ages find tampons a neaterway to deal with menstruation, and a way to avoidexternal irritation of the genital area with a sani-tary napkin.

During the 1980s, concern about a conditioncalled toxic shock syndrome, a serious infectiousdisease linked to tampon usage, caused manywomen to stop using tampons. However, withproper attention to hygiene and frequent replace-ment of tampons, women need not fear toxicshock syndrome. Also, some of the materials usedin tampons have been changed by the manufac-turers, making them safer to use.

SOURCES:Holt, Linda Hughey, and Melva Weber. Guide to Woman-

Care. New York: Random House, 1984.Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1989.

mental retardation Impaired intellectual func-tion that results in an inability to cope with thenormal responsibilities of life. To be classified asmentally retarded, a person must have an IQ below70 and impairment must be present before the ageof 18. For families, stress results from COPING withthe responsibilities of raising a retarded child. Earlydiagnosis is extremely important so that specialeducation and training programs can be startedand the child given every opportunity to learn.

It is crucial that families then seek professionalhelp to define the retardation problem honestlyand clearly. Next, they must gather information oncommunity resources in order to make informeddecisions about their child’s future. While everystate and most urban areas now have special gov-ernmental departments concerned with retarda-

tion where advice and consultation are available,accessing these agencies is not always easy andthey are often bureaucratic.

Faced with the sadness and difficult problems ofraising a retarded child, one of the first decisionsfamilies must make concerns institutionalization.Unless the child has debilitating physical problemsas well as severe retardation, most families will optto keep the child at home.

While the mentally retarded child remains achild all his or her life, they can experience feelings,concerns, emotions, fears, wonder, discovery, love,and laughter, as do all children. A retarded childdoes learn when given good training and support. Ifthey are well cared for in a responsible and lovinghome, they will thrive and some may become rea-sonably independent and self-supporting.

FOR FURTHER INFORMATION:American Association on Mental Retardation444 North Capitol Street NW, Suite 846Washington, DC 20001-1512(800) 424-3688 (toll-free)(202) 387-1968(202) 387-2193 (fax)www.aamr.org

National Down’s Syndrome Society141 5th AvenueNew York, NY 10010(800) 221-4602 (toll-free)(212) 460-9330

SOURCES:Dolce, Laura. Mental Retardation. New York: Chelsea

House, 1994.Dunbar, Robert E. Mental Retardation. New York: Franklin

Watts, 1991.Grossman, Herbert J., et al., eds. AMA Handbook on Men-

tal Retardation. Chicago: American Medical Associa-tion, 1987.

McNey, Martha. Leslie’s Story: A Book about a Girl with Men-tal Retardation. Minneapolis: Lerner Publications, 1996.

mergers The transformation of two or more cor-porations into one organizational structure for rea-sons of growth, economy of scale, diversification orvertical integration. They are becoming increas-ingly common in the late 1990s.

In their book The Human Side of Mergers and Acqui-sitions, Buono and Bowditch state, “mergers and

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acquisitions can sufficiently transform the organiza-tional structures, systems, processes; in one or bothof the firms involved people often feel stressed, dis-oriented, frustrated, confused, and even frightened.”

Emotions felt by employees during mergers mayarise in stages and can be conflicting. These emo-tions range from shock, disbelief, ANGER, and hope-lessness to excitement and high expectations forthe future. When the merger is completed,employees move slowly toward acceptance, oftenexperiencing a period of mourning and GRIEF.When a proposed merger does not go through, itusually means that one of the companies is seekingchange and sometime down the road the changewill occur. This outlook compounds the stress foremployees, particularly at the management levelwhere there is bound to be job redundancy.

An analysis of LAYOFF announcements in thesummer months of 1995 by the outplacement firmof Challenger, Gray & Christmas showed that oneout of three jobs cut was a result of mergers. Suchjob cuts could be attributed to corporate restruc-turing and plant and office closings.

Staff reductions that occur due to mergers cre-ate less dissatisfaction and bitterness when they arehandled with sensitivity and concern. Where pos-sible, staff redundancies can be managed throughattrition, early RETIREMENT, and attractive sever-ance packages. When involuntary termination isnecessary, decisions should be made objectivelyand supported by outplacement assistance andrelated job search services.

Most of those who lose their jobs through merg-ers may have little financial loss, as they are usu-ally white-collar employees who are givengenerous severance packages. However, they oftenexperience the stress of having to rethink theircareers and relocate to obtain new employment.

See also CHANGING NATURE OF WORK; DOWNSIZ-ING; WORKPLACE.

SOURCE:Buono, Anthony F., and James L. Bowditch. The Human

Side of Mergers and Acquisitions: Managing Collisionsbetween People Cultures and Organizations. San Fran-cisco: Jossey-Bass, 1989.

midlife crisis Certain stressful situations thatoccur at or around middle age are often referred to

as “midlife crisis.” Men and women both experi-ence these stressors. For some, stresses occur asindividuals realize that they have reached theprime of their lives and so begin to questionwhether or not they have achieved their goals.Others reset goals and, in some cases, turn theirlives in new directions.

Specific stressors that occur at midlife includechildren growing up and leaving home, job loss,forced RETIREMENT, DIVORCE, widowhood, loss of asex life because of lack of a partner, seeking a newpartner, REMARRIAGE, stepchildren, and care of ELD-ERLY PARENTS.

Men and women at midlife realize that they nolonger have the physical strength and stamina thatthey had when they were younger. For women,MENOPAUSE marks the end of their fear of havingunwanted children. Many men and women beginto fear that they are losing their attractiveness andsex appeal and so turn to COSMETIC SURGERY forsuch procedures as relieving age lines or removingexcess body fat. They may embark on strenuouscourses of exercise at health clubs and gyms in aneffort to retard effects of aging. Some resort to pur-chasing of sports cars to make themselves feelyounger. Divorces occur as one of the spousesbecomes involved with another younger partner.

See also EMPTY NEST SYNDROME; MENOPAUSE;SELF-ESTEEM; STRESS.

SOURCE:Kahn, Ada P., and Linda Hughey Holt. Midlife Health. A

Woman’s Practical Guide to Feeling Good. New York:Avon Books, 1989.

migraine See BIOFEEDBACK; GENERAL ADAPTATION

SYNDROME; HEADACHES; MENSTRUATION; PAIN.

migration Leaving one’s country to settle inanother. Doing so can set in motion a stressfulmourning process similar to that which occursafter losing a loved one. The country one is leavingappears as an object, a nonhuman object, withwhich one develops a relationship.

At first, loss of country might appear morestressful for the involuntary emigrant; however, itis no less difficult for the voluntary one. Some rel-atives and friends might feel abandoned and resentthe person leaving. Although the emigrant adjusts

240 midlife crisis

to a new life in the new country, at the same timehe or she may long for the old country.

Some may prolong their stress by holding on toa fantasy of transience in the new country for aslong as 30 years. For example, by not learning thelanguage of the new country or, more subtly, bynot becoming a citizen.

Culture Shock

Another stressful aspect of migration is cultureshock, which is the result of a sudden change froma known environment to a strange, unknown one.The impact can be violent and, combined with themourning process set in motion by the loss of thatwhich is familiar, can cause a threat to the new-comer’s identity. The sense of the continuity of theself and the sense of self-sameness, is threatened.At the same time, the consistency of one’s owninterpersonal interactions is disrupted. No longer isthere the same confirmation of one’s identity ininteraction with the environment. As an example,an American living in a hostile country would beacutely aware of his nationality. Whether in a hos-tile country or not, environmental clues that nor-mally confirm the emigrant’s identity are absentand are replaced by unfamiliar phenomena,including language, architecture, housing, mannerof dress, food, music, and smells.

One means of COPING with the stress of a newenvironment is to try to translate the unfamiliarinto the familiar. For example, an individual froma forested country may look at tall buildings in acity and say that tall buildings look like the forest.There may have been a similar mechanism at workwhen the early American settlers chose an areathat was physically like the one they left, thusreducing the psychologically “unsettling” effect ofbeginning a new life in a strange environment.

See also ACCULTURATION; HOMESICKNESS; MOVING.

SOURCE:De Vryer, Miepje A. “Leaving, Longing, and Loving: A

Developmental Perspective of Migration.” Journal ofAmerican College Health 38 (September 1989).

mind-body connections Health philosophers inthe 21st century emphasize the mind-body con-nections or links between the mind, brain, andother organ systems. Research studies have demon-

strated that psychological as well as physical stresshas effects on health. Increasingly, physicians arerecognizing that BEHAVIOR THERAPY and ALTERNATIVE

MEDICINE such as GUIDED IMAGERY, RELAXATION,BIOFEEDBACK, and HYPNOSIS are useful adjuncts inthe comprehensive care of many patients, many ofwhom have stress-related disorders.

The term mind-body medicine relates to manytreatments and approaches, ranging from MEDITA-TION and relaxation training to social SUPPORT

GROUPS planned to engage the mind in improvingphysical as well as emotional well-being.

According to Herbert Benson, M.D., author ofThe Relaxation Response, “Too often in practice ofmodern medicine, the mind and body are consid-ered to be separate and distinct, which is not in ourbest interests. Because of specialization, patientsare no longer treated as whole persons. Instead, weare separated into groups of organs and specificsymptoms are not considered in context.”

In The Mind/Body Effect, Dr. Benson emphasizedthe need for practicing behavioral medicine, whichincorporates the principles of medicine, physiol-ogy, psychiatry, and psychology. Patients areviewed in their entirety, with the realization thatwhat happens in their mind has direct bearing onthe state of their physical health.

In The Mind/Body Effect, Dr. Benson makes itclear that psychological factors often induce physi-cal ailments. He indicates that, in extreme cases,

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ADVANTAGES OF MIND-BODYCONNECTIONS FOR STRESS RELIEF

• Can be used along with standard medicalpractices

• Financial cost of procedures is low• Physical and emotional risk is minimal; potential

benefit is great• Many can be taught by paraprofessionals.• No high-tech interventions• May improve quality of life by reducing pain

and symptoms for people with chronic diseases• May help control or reverse certain underlying

disease processes• May help prevent disease from developing

fear and a sense of hopelessness can even inducedeath.

Many conditions have been found to respond tosuch techniques when they are used alone or incombination with standard medical and surgicaltreatments. These include HIGH BLOOD PRESSURE,coronary artery disease, CANCER, chronic PAIN, TMJsyndrome, HEADACHES, eczema, PSORIASIS, IRRITA-BLE BOWEL SYNDROME, ARTHRITIS, rheumatic dis-eases, ASTHMA, and DIABETES.

The Mind/Body Group at Boston’s Beth Israel Hospital

The Mind/Body Group is part of a program of theDivision of Behavioral Medicine at Beth IsraelHospital and is headed by Herbert Benson, M.D., acardiologist. It is one of many programs across thecountry to help individuals suffering from a varietyof medical disorders, including cancer, arthritis,and diabetes.

The program uses a variation of the relaxationresponse, the meditation method pioneered by Dr.Benson. Since the early 1980s, the group hastaught people to use the power of their minds tohelp themselves bring about the relaxationresponse, learn how to change their own physiol-ogy, and finally have some sense of CONTROL overthemselves and their lives.

An Example of Mind-Body Connection: Diabetes Control

Dr. Joan Borysenko, one of the group and aninstructor at Harvard Medical School who is trainedin cell biology and psychology and is an innovativeresearcher in PSYCHONEUROIMMUNOLOGY (PNI), hasdeveloped a program for diabetics. These sessionsare attended only by diabetics, creating a therapeu-tic dynamic group identity. Members of the groupgive each other social support in their relaxationprocedures and encourage each other to follow theregimen. Results indicate that in those who prac-ticed the relaxation response and exercised, bloodsugar was lowered. Thus, diabetics had a drug-freetechnique in controlling levels of blood sugar thatcould help minimize damage from the disease andhelp them live longer and with better quality of life.

See also KABAT-ZINN, JON; PRAYER; RELIGION;SIEGEL, BERNIE; SOCIAL SUPPORT SYSTEM; WEIL,ANDREW.

SOURCES:Benson, Herbert. Beyond the Relaxation Response. New

York: Berkeley Press, 1985.———. The Mind/Body Effect: How Behavioral Medicine Can

Show You the Way to Better Health. New York: Simon &Schuster, 1979.

———. The Relaxation Response. New York: Avon Books,1975.

Borysenko, Joan. Minding the Body, Mending the Mind.New York: Bantam, 1988.

Goleman, Daniel, and Joel Gurin, eds. Mind Body Medi-cine: How to Use Your Mind for Better Health. Yonkers,N.Y.: Consumer Reports Books, 1993.

Kerns, Lawrence L. “A clinician’s guide to mind-bodytreatments.” Chicago Medicine 97, no. 22 (November21, 1994).

Locke, Steven, and Douglas Colligan. The Healer Within.New York: New American Library, 1984.

mindfulness meditation See also ALTERNATIVE

MEDICINE; KABAT-ZINN, JON; MEDITATION; MIND-BODY

CONNECTIONS.

mining workers According to the National Insti-tute for Occupational Safety and Health (NIOSH)these workers have one of the most stressful aswell as dangerous jobs in the United States: miningthe earth, underground and on the surface, forcoal, ore, and stone. In mining settings, confinedworkspaces, poor visibility, and the use of large,powerful equipment are sources of stress as well ashazards. Coal and metal miners who suffer injuriestend to lose twice as many days of work as work-ers in other industries.

Mining techniques and stressful conditions arediverse and differ substantially between the coalsector and metal and nonmetal mining. The latterincludes production of metals such as gold andcopper, nonmetals such as salt and phosphate, andproduction of stone, sand, and gravel.

In the United States approximately 400,000miners are employed in more than 11,000 surfaceand underground mines. An estimated 2,000 min-ers die from lung diseases caused by exposure tocoal mine dust every year.

According to NIOSH, mining has the highestrate of fatal injuries of all U.S. industries. Morethan 80 miners die from fatal work injuries eachyear. However, the Mine Safety and Health

242 mindfulness meditation

Administration reports that total mining fatalitiesreached the lowest level in history in 2001. Forevery fatality, there is often a family facing thestress of grief and handling family affairs.

Preventing Stress and Illness among Miners

Inhaling fine particles of silica causes silocosis, anoften fatal lung disease. This is a stressful disease forminers because each year thousands of coal workersare afflicted with it. To reduce silicosis among min-ers, NIOSH disseminates information to inspectors,miners, and employers throughout the surface-min-ing industry describing steps to prevent silicosis.

NIOSH promotes methods of monitoring work-ers’ exposures, procedures for medical screeningand surveillance of miners, and the use of personalprotective equipment to reduce the health risks ofunderground and surface coal miners and to pre-vent pneumoconiosis. Further, to protect minersfrom respiratory diseases, NIOSH recommends anexposure limit for respirable coal mine dust.

As long as people have worked in mines, theoccupation has been a stressful one. In 1891 Con-gress passed the first federal statute governingmine safety, a modest law that applied only tomines in U.S. territories. Among other things, itestablished minimum ventilation requirements atunderground coal mines and prohibited operatorsfrom employing children under 12 years of age.

In 1910, following a decade during which thenumber of coal mine fatalities exceeded 2,000,Congress established the Bureau of Mines as a newagency in the Department of the Interior. Thebureau was responsible for conducting researchabout reducing accidents in the coal mining indus-try, but was given no inspection authority until1941, when Congress empowered federal inspec-tors to enter mines. In 1947, Congress authorizedthe formation of the first code of federal minesafety regulations.

The Federal Coal Mine Safety Act of 1952 pro-vided for annual inspections in certain undergroundcoal mines and gave the bureau limited enforce-ment authority, including power to issue violationnotices and imminent danger withdrawal orders.

The first federal statute directly regulating non-coal mines did not appear until the passage of theFederal Metal and Nonmetallic Mine Safety Act of1966, which provided for the promulgation of

standards, many of which were advisory, and forinspections and investigations; however, itsenforcement authority was minimal.

The Federal Coal Mine Health and Safety Act of1969, generally referred to as the Coal Act, wasmore comprehensive and more stringent than anyprevious federal legislation governing the miningindustry. The Coal Act included surface as well asunderground coal mines within its scope, requiredtwo annual inspections of every surface coal mineand four at every underground coal mine, and dra-matically increased federal enforcement powers incoal mines. The Coal Act also required monetarypenalties for all violations and established criminalpenalties for knowing and willful violations. Thesafety standards for all coal mines were strength-ened, and health standards were adopted. The CoalAct included specific procedures for the develop-ment of improved mandatory health and safetystandards and provided compensation for minerswho were totally and permanently disabled bypneumoconiosis, or black lung disease, the pro-gressive respiratory disease caused by the inhala-tion of fine coal dust.

In 1973, the Mining Enforcement and SafetyAdministration (MESA) was created as a newdepartmental agency separate from the Bureau ofMines.

In 1977, Congress passed the Federal MineSafety and Health Act (Mine Act), the legislationthat currently governs MSHA’s activities. The MineAct amended the 1969 Coal Act in many ways andconsolidated all federal health and safety regula-tions of the mining industry, coal as well as non-coal mining, under a single statutory system. TheMine Act strengthened and expanded the rights ofminers and removed one source of stress byenhancing protection of miners from retaliation forexercising such rights.

The Mine Act transferred responsibility for carry-ing out its mandates from the Department of theInterior to the Department of Labor and named thenew agency the Mine Safety and Health Adminis-tration (MSHA). Mining fatalities dropped sharplyunder the Mine Act from 272 in 1977 to 86 in 2000.

Stresses that mining workers face have beenreduced significantly because of provisions of theFederal Mine Safety and Health Act of 1977 (MineAct). Compliance and enforcement of mandatory

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safety and health standards has eliminated somefatal accidents and reduced the frequency andseverity of nonfatal accidents.

Uranium Miners

Uranium mining is an occupation in which there isa higher incidence of lung cancer and other lungdiseases than in most other areas of work. There isalso an increased incidence of skin cancer, stomachcancer, and kidney disease among uranium min-ers. Because of the risks and the diseases, uraniummining may be one of the most stressful occupa-tions in a dangerous industry.

Increased rates of lung cancer have been notedin studies of hard rock miners exposed to radon inthe United States, Canada, and Europe. Higherexposure correlates with higher numbers of cancerdeaths. Increases in lung cancer due to radiationhave been noted in both smokers and nonsmokers.

See also CANCER; CONFINED SPACES; NUCLEAR

WEAPONS; RADON.

Minnesota Multiphasic Personality Inventory(MMPI) A self-rating questionnaire to determinepersonality types. The MMPI may be of some useto therapists in helping people with stress concernsor phobias. It is also a source of stress for individu-als who must take the test before employment orfor purposes of promotion.

The MMPI was developed by Starke RosecransHathaway (1903–84), a U.S. psychologist and JohnCharnley McKinley (1891–1950), a U.S. psychia-trist, in 1942. Results of the questionnaire pointtoward nine personality scales: hypochondria,depression, hysteria, psychopathic deviate, mascu-line-feminine interest, paranoia, psychasthenia,schizophrenia, and hypomania. The taker of thetest indicates agreement or disagreement with 550statements. Results are scored by an examiner or bycomputer to determine the individual’s personalityprofile as well as any tendency to fake responses.The MMPI is widely used in clinical research.

miscarriage The spontaneous loss of a PREG-NANCY before the fetus is capable of surviving out-side the uterus. Many women who experiencemiscarriage also experience symptoms of extremeSTRESS, GRIEF, and DEPRESSION for a period of time

after the event. They feel the loss, even though thechild was never born and they never saw the child.

Family and friends sometimes may seem lesssympathetic toward women who have sufferedmiscarriages than toward those whose babies arestillborn or die in early infancy. Many are encour-aged to try to achieve another pregnancy verysoon. Those who do try often overcome theirdepressed feelings, but for those who have diffi-culty in achieving another pregnancy, mourningover the lost pregnancy may continue.

Miscarriage: What Is It?

Understanding the physiology involved in theprocess may help women who experience miscar-riage to mentally adjust to the situation. Early mis-carriages are usually the result of defects in thefetus. Later miscarriages, which occur in the mid-dle trimester, are more likely to be caused by anincompetent cervix, uterine abnormalities, tox-emias, or preexisting chronic disease.

Women who miscarry after some strenuousactivity may feel GUILTY and some even believe thatthey induced the miscarriage. Usually this is notthe case. Normal exercise does not usually inducemiscarriage. Most women who have been tennisplayers, hikers, or swimmers usually are advised bytheir obstetricians to continue exercising through-out their pregnancy (or until the last two months).

The first sign of the possibility of miscarriage isvaginal bleeding, with or without cramping; how-ever, not all vaginal bleeding indicates miscarriage.Some bleeding may be associated with implanta-tion, or it may come from the vagina, vulva, orcervix. If bleeding occurs from the uterus withoutany dilation of the cervix, and usually withoutpain, the situation is termed threatened abortion.With appropriate medical care, cases of threatenedabortion can be salvaged, and many women havehealthy babies who were in the “threatened” stageduring pregnancy. Treatment includes rest.

Late miscarriage may be the most stressful anddifficult for a woman (and the infant’s father) toaccept. If she has had good medical care and fol-lowed her obstetrician’s advice, she should not feelthat anything she did or did not do induced themiscarriage. In a later miscarriage, when the pla-centa and embryo are totally evacuated, the termused is complete abortion. When placental tissue

244 Minnesota Multiphasic Personality Inventory

remains in the uterus, the term is incomplete abor-tion, and the tissue must be removed by curettage.

Miscarriage is also known as spontaneous abortion;the term miscarriage is more commonly used becauseit is more socially acceptable. Both terms refer to theloss of an embryo or fetus before maturity.

See also POSTPARTUM DEPRESSION.

mitral valve prolapse See PANIC ATTACKS AND

PANIC DISORDER.

modeling A BEHAVIOR THERAPY technique inwhich a person learns by observation without rein-forcement from a therapist. The troubled individ-ual watches someone else perform a particularaction such as giving a speech in public (in the caseof one who is fearful about speaking in front ofothers) and then gradually becomes able to per-form the action without fear. In a traditional learn-ing sense, modeling is a form of social learning;children learn appropriate culturally acceptablebehaviors in this way from parents and elders.

See also PUBLIC SPEAKING.

mold Organisms in indoor air and elsewhere thatare sources of stress because they can cause ALLER-GIES, ASTHMA, lung diseases, and other respiratoryproblems and contribute to SICK BUILDING SYN-DROME. The molds or FUNGI that affect indoor airquality are multicellular organisms formed ofmicroscopic branched filaments called hyphae. Avisible colony of interwoven hyphae forms amycelium, and the myceloid fungi most commonlyfound indoors are called molds; the terms mold andfungus are used interchangeably in this entry.

When windows can be kept open, the kind offungi in indoor air normally reflect those in out-door air. To grow and proliferate indoors, however,fungi require a suitable substrate such as wood,paper, gypsum board, or other materials that havea high cellulose content and water. Buildings orhomes where there is chronic water damage orwhere humidity levels are high are particularly atrisk of fungal contamination.

Various aspects of fungal growth and structurehave potential stressful and injurious effects onhealth. Certain species of fungi produce mycotox-ins, natural organic compounds that initiate a toxic

response in humans, including mucosal and skinirritation, immunosuppression, and systemiceffects. The primary mode of human exposure tothese toxic chemicals is by inhalation of spores orof material that has been contaminated by mold.Some people develop stressful allergies, such asrhinitis and asthma, when exposed to molds.Heavy and repeated exposure to small fungal par-ticles can also cause hypersensitivity pneumonitisin certain people.

Molds also produce various volatile organic com-pounds such as alcohols and ketones. These com-pounds, which are responsible for the musty odorassociated with the presence of molds, are irritants.

Other Stressful Health Concerns

Systemic effects, such as headache, fever, excessivefatigue, cognitive and neuropsychological effects,gastrointestinal symptoms, and joint pain, havealso been observed in some people exposed tomolds. Symptoms caused by exposure to moldshould disappear once exposure ceases. Whetherthere is a threshold for exposure below which nohealth effects occur is unknown.

A 281-page study by the National Academy ofSciences released in May 2004 is the most defini-tive look to date at the national controversy overmold, which has prompted hundreds of lawsuits,millions of dollars in cleanup costs, and claims thatthe fungi breed many illnesses.

The scientific review found no proof that moldcauses memory loss, fatigue, seizures, inhalationfevers, skin outbreaks, or other conditions thatmany people said they have experienced. “Theconsequences of being exposed to toxic mold havelargely been overstated,” said Dr. Karin Pacheco,assistant professor of occupational and allergic dis-ease at National Jewish Medical Research Center inDenver. The National Academies’ report did, how-ever, confirm well-documented and generallyaccepted claims that symptoms in people withasthma can be exacerbated by mold.

See also CHEMICAL HAZARD.

SOURCES:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Injuries. New York: Facts On File, 2004.King, Norman, and Pierre Auger. “Indoor Air Quality,

Fungi, and Health.” Canadian Family Physician 48(February 2002): 298–302.

mold 245

money A cause of stress in one way or anotherfor most people. Lack of money is stressful, andhaving money to invest or spend, wisely orunwisely, is also a source of stress. Money isinvolved in every aspect of life, from housing toeducation to social life.

For some, money arouses stressful feelings ofENVY—possibly one reason that those who have itmay be reluctant to discuss it and those who lack itmay pretend that they are well off. Parents may bereluctant to reveal their financial matters to theirchildren, which may lead them to fantasize thatthey are quite well off, in serious financial straits,or simply lead them to think that money is a TABOO

subject.For practical purposes, many households have

no disposable assets to respond to emergenciesand absorb shocks. There are more stresses onthose in this situation. There are effects on one’ssense of CONTROL, optimism, happiness, security,and SELF-ESTEEM.

Western tradition offers two conflicting mes-sages regarding money: that of self-denial, gen-erosity, and spirituality, and that of capitalism andmaterialism. The most practical attitude seems tobe that it is good to have money, but not to flauntit or even discuss it.

As a group, the very rich are a minority and mayexperience the same stressful feelings of isolationand alienation that other minorities experience.Middle- and upper-middle-class children sense thatboth rich and poor children are different and mayreject them for that reason. Marriage among thewealthy is often riddled with divorce and extramar-ital affairs, possibly because the marriages are fre-quently entered into for financial or social ratherthan emotional reasons. If both spouses are well-to-do, each may go his or her own way and neverhave to form the cooperative couple of the middleclass. When wealthy men or women “marry down”they may acquire a more attractive and personablespouse than they deserve. However, day-to-day liv-ing may make some of the stresses of this type ofrelationship difficult.

Children of the wealthy may experience a stress-ful type of upbringing in which one or both parentsmay be traveling or preoccupied with social or busi-ness events much of the time. The child may have

to live up to the larger-than-life achievements andreputation of his family. At the same time, he maybe indulged in ways that reduce the possibilities ofhis ever developing the characteristics and talentsto meet his family’s expectations.

See also PERFECTION; SHOPAHOLISM.

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.Krueger, David, ed. The Last Taboo. New York: Brun-

ner/Mazel, 1986.

monoamine oxidase inhibitors (MAOIs) SeePHARMACOLOGICAL APPROACH.

moods A mood is an emotion that determineshow a person feels and often relates to his or herstress level. Examples of moods include sad or gladand angry or happy. According to the AmericanPsychiatric Association (in Diagnostic and StatisticalManual of Mental Disorders, 4th ed.), for diagnosticpurposes, moods are characterized as follows:

Dysphoric: An unhappy or sad mood, such asdepressed, anxious or irritable.

Elevated: A more cheerful than usual mood.Euphoric. A feeling of extreme well-being; also

occurs in MANIC-DEPRESSIVE DISORDER. This typeof mood is beyond what most people rate assimply “feeling good.”

Euthymic: Feeling good; absence of depressed orelated mood, and feeling able to cope with life.

Irritable: A feeling of internal tension and beingeasily annoyed and provoked to anger.

See also AFFECTIVE DISORDERS; DEPRESSION.

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Washington,D.C.: American Psychiatric Association, 1994.

Justice, Blair. Who Gets Sick: How Beliefs, Moods andThoughts Affect Your Health. Los Angeles: J. P. Tarcher,1988.

Kals, W. S. Your Health, Your Moods and the Weather. Gar-den City, N.Y.: Doubleday, 1982.

Moon Many people attribute their stress to theMoon. The effect of the Moon on human behavior,particularly as causing insanity, has been a topic of

246 money

speculation for centuries. The word lunatic, coinedby the physician Paracelsus in the Middle Ages,derives from the Latin word for “moon.”

In some cultures there is a fear that the “man inthe Moon” is the biblical Cain, accounting for theobservation that as the Moon becomes fuller andstronger, human behavior becomes more violentand erratic. People who are mentally unstable arethought to be particularly affected by the cycles ofthe Moon. Although scientific proof is lacking, pro-fessionals such as nurses, police, and firefighterswho deal with large numbers of people in emer-gency situations report an upsurge in activity andmore extreme behavior at the time of the full Moon.

Many stress-inducing superstitions are con-nected with the Moon. For example, a full Moonon Christmas prophesies a poor harvest; on Sun-day, bad luck. A red Moon foretells murder or war.Sleeping in the moonlight is thought to produce atwisted face. Ancient Greeks and other culturesbelieved that the rays of the Moon contained dam-aging power that could be collected by witches andmagicians and used for evil purposes.

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Facing Fears: The

Sourcebook for Phobias, Fears, and Anxieties. New York:Checkmark Books, 2000.

mothers Traditionally, they protect and nurtureoffspring. They give their infants and childrenemotional warmth as well as sensory stimulation,both of which are necessary for them to develop asense of self-worth and an ability to deal effectivelywith stresses of the environment.

For many women, motherhood may serve pur-poses other than the simple desire for a child. Forexample, children may seem to be the solution fora stressful or troubled MARRIAGE. Women mayexpect their children to succeed where they havefailed and may live vicariously through their off-spring. Faced with her older children maturing andthe threat of no longer being needed, some womenwill have another child rather than explore thenext phase of life.

Changing Images of Mothers

The media at the end of the 20th century reflectthe fact that mothers have changed, or possibly theaudience has grown more realistic and tolerant,

even admiring, of different types of mothers. Forexample, in the 1950s and early 1960s televisionmothers were always homemakers, dispensingwisdom and charm, while dressed appropriately.Title roles in the later 1990s include unmarriedmothers and WORKING MOTHERS.

Today, many mothers undertake the double roleof having a career and family, sometimes out ofeconomic necessity. However, even thoughwomen work they still tend to be saddled withhome, family, and social responsibilities. Whilemen may be willing to stay home with a sick childor leave work punctually because of a family obli-gation, they may not be met with the understand-ing they need from their employers.

Working mothers’ responsibilities include get-ting themselves to work and quite often gettingtheir child to a DAY CARE facility. Some mothers ofschool-age children may have to deal with theworries of having “latch key” children. Careersmay have to be adapted to eliminate travel or situ-ations where the mothers are inaccessible to a tele-phone. HOBBIES, interests, or just having time foroneself are almost nonexistent on such a mother’sschedule. Faced with these pressures, morewomen are expressing an interest in limiting theirfamily to one child or staying home with their chil-dren and/or trying to work from their home. Manywomen who completed their education in the late1970s, began careers, married, and had children,tried HAVING IT ALL—meaning marriage, family, andcareer—and feel constantly stressed by all factors.Since the 1990s, some women who work outsidethe house are opting for less aggressive careertracks so that they can spend more time with theirfamilies and have less stress in their lives.

See also ADOPTION; MOTHERS-IN-LAW; REMAR-RIAGE; STEPFAMILIES; UNWED MOTHERS.

SOURCES:Jetter, Alexis, Annelise Orleck, and Diana Taylor, eds. The

Politics of Motherhood: Activist Voices from Left to Right.Hanover, N.Y.: University Press of New England,1997.

mothers-in-law The butt of many jokes, whichcomedians find good for a laugh. While jokes mayreflect some underlying social truths, in practice,

mothers-in-law 247

many spouses have excellent RELATIONSHIPS withtheir in-laws; many don’t.

Sometimes stresses and conflicts arise between adaughter-in-law and her husband’s mother or thehusband and the wife’s mother. The source ofthese conflicts may be the children’s repressedresentments of their own parents being projectedtoward in-laws; ethnic, social, and religious differ-ences; or the mother-in-law’s own stress in adjust-ing to the departure of her children and the agingprocess. Open lines of COMMUNICATION mayimprove the situation.

See also LISTENING; MOTHERS; PARENTING.

SOURCE:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.

motion sickness Uncomfortable feeling of queasi-ness, NAUSEA, and DIZZINESS. It occurs because ofconstant motion, along with conflicting signalsfrom the eyes, inner ears, and sensors in musclesand joints. Anticipating motion sickness is a sourceof stress for many people, and some even avoidcertain situations because of their fears.

Motion sickness occurs when in a moving vehi-cle, such as a car, boat, or airplane. Many peopledevelop motion sickness during a car trip on abumpy road. Other people require more unstableconditions, such as a ride aboard a pitching boat tobecome upset. Still others do not experience motionsickness, and their doubts about a sufferer’s discom-fort lead to further stress for the unfortunate ones.

Understanding Motion Sickness and Using Self-Help Techniques

Understanding how motion sickness occurs mayhelp relieve its attendant stress. On a ship, forexample, the eyes record movement, the innerears detect rolling motion, yet the body is station-ary. One technique that helps many people isfocusing on the horizon or on a fixed, distantobject instead of looking at swirling waves or road-side trees that seem to be moving. Preventivemeasures and natural remedies also may prevent,or at least relieve, the dizziness, nausea, vomiting,and clamminess symptomatic of motion sickness.Over-the-counter medications work by depressingsignals from the inner ear and by quieting the gas-

trointestinal tract and decreasing nausea. Most ofthese preparations should be taken an hour or sobefore departure.

In an airplane, motion is less pronounced in anaisle seat over a wing, preferably on the right sidewhere there is less swaying, because most flightpatterns call for left turns. In a car, ride in the frontseat and, unless driving, lean back against a stableheadrest to minimize inner-ear reaction to move-ment. Looking down or reading while riding canproduce motion sickness because of the apparentmovement outside the windows. Being the driveralso helps as drivers seldom suffer from motionsickness. At sea, reserve a midship cabin near thewaterline where motion is minimal and, as muchas possible, stay topside in the middle of the deck.

Eat lightly before a trip and eat small amounts atfrequent intervals while traveling. It is easier tobecome queasy on an empty stomach. Sucking on alemon or eating olives at the first sign of nausea arefolk remedies that work for some people. They maywork because motion sickness creates superfluoussaliva, which trickles down to the stomach and con-tributes to nausea. Lemons and olives containmouth-drying agents that diminish the queasiness.

Fortunately, most sufferers from motion sick-ness find relief as soon as they get off the airplane,out of the car, or off the ship. Symptoms and theirstress usually disappear quickly.

mourning See DEATH; GRIEF.

moving Moving involves relocating to anotherplace of residence, or possibly to another place ofwork or business. Moving is a source of stress formany people because it removes them and theirfamilies from familiar surroundings, families,friends, neighbors, schools, and sports and otheractivities. Moving may be the third most stressfulevent, after the death of a loved one and divorce.The length of the distance moved may increase thelevel of stress, as visiting the old familiar territorybecomes more difficult.

The U.S. Census Bureau reports that accordingto Census 2000, more than 22 million people weredomestic migrants who changed their state of resi-dence between 1995 and 2000. Of these, approxi-mately half relocated to a state in a different region.

248 motion sickness

Younger people seem to move more often thanolder people. The U.S. Census Bureau reported thatAmericans age 20–29 were the likeliest to moveduring 1998–99. In that age group, 32.4 percentmoved, more than double the national average of15.9 percent. Of 30–34-year-olds, 22.8 percentmoved. Of 35–44-year-olds, 14 percent moved;25–54-year-olds, 9.5 percent, 55–64-year-olds, 6.7percent, and those 65 and older, 4.5 percent.

One of the stressors people find in moving is“sticker shock.” Home prices in the new locationcould be a pleasant surprise, and they find they canbuy more house than they had before for lessmoney. Unfortunately, that is not always the case,and some couples are faced with “downsizing”their living accommodations in the new morecostly setting.

Many companies turn to specialized providers ofrelocation services who range from small, oftengeographically specialized concerns, to real estateconglomerates that handle thousands of reloca-tions each year and are responsible for orchestrat-ing all details of a move. When a company decidesto transfer an employee to another city, sometimeson short notice, it should do so with as little stressas possible for the employee and the employee’sfamily. From the employee’s viewpoint, the keyquestion concerns what level of support theemployer will provide in the move. According toStephen C. Roney, president of Coldwell BankerRelocation Services in Mission Viejo, California,“from the employer’s viewpoint, the key issue isultimately one of productivity.”

Migration from one country to another carrieswith it all the stresses of moving as well as adapt-ing to new culture.

See also ACCULTURATION; MIGRATION.

mugging A realistic contemporary source ofstress that many people experience because victimsare confronted unexpectedly and may suffer phys-ical harm as well as losing possessions. The concernabout the possibility of being mugged leads manypeople to avoid wearing expensive, attention-get-ting clothes or jewelry on the streets. The concernabout mugging is related to the overall fear of vio-lence in our society.

See also VIOLENCE.

Multiple Chemical Sensitivity syndrome A vari-ety of stressful symptoms that some people experi-ence as a result of exposure to agents in theenvironment. These agents may include many nat-ural and artificial substances, some of which haveseveral chemical constituents. For many sufferers,symptoms interfere with daily activities. Somepeople report that they were symptom-free beforea single large exposure. Later they find that theysuffer more in response to previously toleratedlow-level exposures. There are controversiesregarding this syndrome among regulatory agen-cies, legislators, clinicians, researchers, patients,lawyers, and others.

Symptoms may occur in the central nervoussystem, with respiratory and mucosal irritation, orgastrointestinal problems. There may be difficultyconcentrating, depressed mood, memory loss,weakness, dizziness, headaches, heat intolerance,and arthralgias.

Substances that may induce symptoms includeinsecticide sprays, paint thinner, fumes from var-nish, shellac, or lacquer, aerosol air fresheners, cig-arette smoke, gasoline and diesel exhaust, drycleaning fluid, floor cleaner, furniture polish, andfumes from certain indelible marking pens.

To reduce stress induced by these symptoms,health professionals aim to control (not cure)symptoms and treat concomitant psychologicalsymptoms. Sufferers are encouraged to engage inactivities they can tolerate, learn relaxation exer-cises, and avoid isolation and social withdrawal aswell as unproved therapies.

See also AIR POLLUTION; RELAXATION; SICK BUILD-ING SYNDROME; STRESS.

muscle relaxants Pharmacological agents thatact on the central nervous system or its associatedstructures to reduce muscle tone and spontaneousactivity. Many people experience tense, tight, orstrained muscles as a result of stress or injury andsome resort to these prescription medicationsinstead of or in addition to using mind-body tech-niques for RELAXATION. Many skeletal muscle relax-ants also function as minor tranquilizers.

See also MIND-BODY CONNECTIONS; PHARMACO-LOGICAL APPROACH.

muscle relaxants 249

music A basic social and cultural activity ofmankind, involving sounds produced by the voiceor by instruments. Music is often used a therapy toreduce stress and help people relax. It is a way toconnect with people and a way of getting throughto people who are otherwise unreachable. Somesongs embody life experiences and may bring backmemories of courtship, a wedding or even wartime.For example, in many nursing homes, individualswho have been very untalkative and unresponsivemay start to tap their feet to music, particularly livemusic that they watch as it is performed, or willbegin to hum or even sing.

According to Oliver Sacks, American neurolo-gist, author of The Man Who Mistook His Wife for aHat and a pioneer in developing therapies, musicorganizes motor functions, thus smoothing out, forexample, the uncontrolled movements that afflictpatients with Parkinson’s disease and enablingpeople with speech losses to sing the words tofamiliar melodies.

Historical Background: Music and Healing

Using music as a relief of stress and as a healer isnot a new concept. In Greek mythology, Apollowas god of both music and medicine. His son Aes-culapius became god of medicine and cured men-tal diseases with song and music. Plato, a Greekphilosopher, believed that music influenced a per-son’s EMOTIONS and character. According to theBible, David’s harp-playing relieved King Saul’smelancholy (DEPRESSION).

In his plays, Shakespeare referred to the healingpowers of music. The first English-language bookon music as therapy, Medicina Musica, was writtenin the early 1700s by Richard Browne, an apothe-cary. Browne said music could “soothe turbulentaffections” and calm “maniacal patients who didnot respond to other remedies.”

Music therapy was used in the early part of the19th century in the form of brass bands for patientswith the then-identified mental disorders, includ-ing ANXIETY. In the 20th century, particularly dur-ing World War II, many American psychiatrichospitals began active music therapy programs. In1950, the National Association for Music Therapy(NAMT) was organized; in 1954, NAMT recom-mended a curriculum for preparation of music

therapists. Subsequent organizations of musictherapists were formed in England, Europe, SouthAmerica, and Australia. Since the 1980s there hasbeen a growing focus on medical/physiologicalapplications of music therapy.

Music and Stress Management

Music therapy may be effective in reducing stressbecause it addresses the whole person concurrentlyand simultaneously on physical, affective, cogni-tive, and social levels. Music is a noninvasive tech-nique with few if any side effects, with relative easeof administration and with increasing therapeuticpromise as indicated by studies in many fields.

Researchers have looked at the influences ofmusic in managing stress in many anxiety-provok-ing situations. One example is test taking: Anxietylevels appear to rise in the absence of music, while

250 music

STRESS-RELIEVING RESPONSES TO MUSIC

• Heart rate acceleration is correlated with loud-ness, tempo, and musical complexity; heart ratedeceleration is correlated with resolution ofmusical conflict, decreasing loudness, and slow-ing tempo.

• Stimulative music increases heart rate; sedativemusic decreases heart rate.

• Rock music leads to heart deceleration.• Tachycardia (fast heartbeat) is associated with

driving rhythms and increasing dynamics; brady-cardia (slow heartbeat) is associated withchanges in rhythm, texture, and dynamics.

• Sedative music significantly increases fingertemperature.

• Blood pressure is affected by music listening, butthe type of music that affects these changes isunknown; music is effective in reducing bloodpressure in essential hypertensives.

• Music that is enjoyed increases respiration.• Music decreases stomach acid production.• Popular music produces more electroencephalo-

graph (EEG) changes than classical music, partic-ularly in middle-aged subjects. Popular musiccauses a decrease in blood flow to the brain inyoung adults; classical music promotes brainblood flow enhancement in middle-agedsubjects.

they are held constant with music. Music mayhave more effect on highly anxious subjects. Stim-ulative music may increase worry and emotional-ity; more sedative music decreases these feelings.

The effects of music in reducing stress and anx-iety associated with various medical procedureshas been studied. For example, music appears toimprove mood and to comfort adult patients ingeneral hospitals and to reduce anxiety signifi-cantly in chronically ill patients. Several studieshave reported successful applications of music toreduce anxiety during PREGNANCY. Additionally,music is reported to decrease PAIN responses duringlabor and to elicit positive psychological responses.

A number of studies have examined the effectsof music in dental procedures. Listening to musiccauses significant reductions in heart rate, bloodpressure, and stress hormones, and significantlydecreases the need for pain relieving medications.There is also an improvement in the patient’s feel-ing of CONTROL, as he/she has a choice of music.The pain threshold and tolerance during dentalprocedures increase with music.

In a study of chronic pain, patients playing self-selected tape-recorded music reported not only areduction in the emotional experience of sufferingbut also a reduction in the actual sensation of pain.In addition to reducing pain, particularly in painclinics, music has been offered during chemother-apy as a form of relaxation and distraction to bringoverall relief and to reduce nausea and vomiting.

Music and Worker Productivity

According to a report by Greg Oldham, professor oforganizational behavior at the University of Illinois

at Urbana-Champaign, allowing employees to lis-ten to personal stereo headsets can improve pro-ductivity. Among 75 employees who woreheadsets an average of 20 hours during the work-week, productivity increased by 10 percent over afour-week period. Among 181 employees who didnot wear headsets during the same period, therewas no change in productivity. According to Old-ham, the headset wearers were less nervous, lessfatigued, more enthusiastic and more relaxed atwork than were the employees in the controlgroup. The most popular types of music wereoldies and country music.

See also ALTERNATIVE MEDICINE; ARTHRITIS; STRESS

MANAGEMENT.

SOURCES:Aldridge, David. “The Music of the Body: Music Therapy

in Medical Settings.” ADVANCES, The Journal of Mind-Body Health 9, no. 1 (winter 1993).

Allen, K., and J. Blascovich. “Effects of Music on Car-diovascular Reactivity among Surgeons.” Journal ofthe American Medical Association 272 (1994):882–884.

Crowley, Susan L. “The Amazing Power of Music,” Bul-letin (American Association of Retired Persons), Feb-ruary 1992.

Lehrer, Paul M., and Robert L. Woolfolk. Principles andPractice of Stress Management. New York: Guilford Press,1993.

music therapy See MUSIC.

myocardial infarction See HEART ATTACK.

myocardial infarction 251

Nnail biting A difficult habit to break. In spite ofthe stereotype of the nervous nail biter, nail bitingdoes not correlate with specific personality quali-ties. However, many children as well as adults bitetheir nails when affected by stress. Situations thatcause ANXIETY, FEAR, BOREDOM, PAIN, or tensionrelate to nail biting.

With some people, nail biting continues becauseit is a routine and unconscious HABIT without anobvious underlying cause. Many people areembarrassed and bite their nails only when no oneis around to see them. A somewhat universalhabit, nail biting has no relationship to sex, race, orintelligence. It is estimated that over 50 percent ofthe population has had the nail biting habit atsome point in life. Nail biting usually starts inchildhood after the age of three and frequentlyends in adolescence when peer pressure and per-sonal grooming become important. About 20 to 25percent of adults remain nail biters. More womenthan men seek help to break the habit.

There seems to be a slight hereditary tendencyto nail biting, but, because family members areprone to mimic each others’ habits, this is hard toestablish. It seems, however, that a nail-biting par-ent is likely to have trouble correcting a nail-bitingchild.

See also NERVOUS HABITS; OBSESSIVE-COMPULSIVE

DISORDER.

SOURCE:Smith, Frederick Henry. Nail Biting: The Beatable Habit.

Provo, Utah: Brigham Young University Press, 1980.

National Center for Complementary and Alterna-tive Medicine An increasing number of people inthe United States are turning to ALTERNATIVE MEDI-CINE for stress reduction and improvement of well-ness. This trend encouraged the United States

medical establishment not only to take notice butalso to establish the Office of Alternative Medicine(OAM) within the National Institutes of Health in1992. In 1999, the name of the OAM was changedto the National Center for Complementary andAlternative Medicine (NCCAM). As such, it wasthe 25th independent component of the NationalInstitutes of Health.

One of NCCAM’s primary mandates from Con-gress is to award research grants to scientists study-ing the effects of alternative therapies on stress aswell as various illnesses. The NCCAM strives tofund research projects and to establish an informa-tion clearinghouse on alternative medicine so thatthe public, policy makers, and public healthexperts can make informed decisions about healthcare options.

Many of the grants awarded by the NCCAMfocus on strategies to reduce stress and related dis-orders. For example, research grants awarded by theNCCAM have included studies on ACUPUNCTURE forunipolar depression, MASSAGE THERAPY for HIV, HYP-NOSIS for chronic lower back pain, massage therapyfor post-surgical outcomes, MUSIC therapy for psy-chosocial adjustment after brain injury, classicalHOMEOPATHY for health status, T’AI CHI for mild bal-ance disorders, GUIDED IMAGERY for ASTHMA, imageryand RELAXATION for breast cancer, Ayurvedic herbalsfor Parkinson’s disease, BIOFEEDBACK and relaxationfor DIABETES, and YOGA for OBSESSIVE-COMPULSIVE

DISORDER.Since its inception, hundreds of awards have

been granted. The grants provide a proving groundto determine if it is the alternative therapy thatworks or if it is the patients’ belief in the therapythat helps them get better. Alternative practitionersare encouraged about the potential for scientificevidence confirming the value of therapies that do

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not involve drugs, surgery, or other invasive pro-cedures. Such evidence may prove to physiciansthat alternative therapy has credibility.

The NCCAM provides a directory of alternativehealth care associations relating to holistic healthcare, diet/nutrition/lifestyle changes, MIND-BODY

CONNECTIONS, art, music, dance and humor ther-apy, traditional and ethnomedicine, structural andenergetic therapies, pharmacological and biologicaltreatments, bioelectro-magnetic applications, andmore.

See also AYURVEDA; CHIROPRACTIC MEDICINE; MED-ITATION; NATUROPATHY.

FOR FURTHER INFORMATION:National Center for Complementary and

Alternative MedicineNational Institutes of HealthBethesda, MD 20892(888) 644-6226 (toll-free)(886) 464-3615 (TTY)(866) 464-3616http://www.nccam.nih.govE-mail: info@nccam.nih.gov

naturopathy A form of alternative medicine. It isbased on two principles: the accumulation of wasteproducts and toxins in the body causes disease;symptoms of disease are the body’s way of trying toget rid of these substances. Proponents believe thatnature heals itself by strengthening the healingpowers within, and that individuals can do thesame by dealing with factors that potentially hin-der wellness. In addition to the accumulation ofwaste products and toxins, these hindrancesinclude bodily structural imbalances, emotionalstressors, and detrimental lifestyles.

The goal of naturopathy therapy is to free thebody to heal itself by enhancing its self-healingpower. Practitioners agree that it is the ultimategoal of any type of wellness practitioner to encour-age the body’s own life force to operate more effi-ciently within the individual. He/she mayencourage the individual to use many techniquesfor controlling STRESS and promoting wellness,including nutritional and herbal supplements,BREATHING and EXERCISE programs, and MEDITATION.

See also ALTERNATIVE MEDICINE; HERBAL MEDI-CINE; NUTRITION.

FOR FURTHER INFORMATION:American Association of Naturopathic Physicians3201 New Mexico Avenue NW, Suite 350Washington, DC 20016(866) 538-2267 (toll-free)(202) 895-1392(202) 274-1992 (fax)http://www.naturopathic.org

nausea A feeling of sickness in the stomach thatcauses a loathing for food and an urge to vomit.Some people experience nausea when under stressor recalling an anxiety-producing experience fromthe past. Others experience stress from DIZZINESS,light-headedness, or sweating that accompaniesnausea.

When individuals become nauseated before cer-tain events, such as a public speaking appearanceor a dramatic performance, playing in a sportsevent or taking an examination, BEHAVIOR THERAPY

techniques can help. However, in all cases ofrepeated nausea, physical causes should be ruledout before undergoing psychotherapy for the con-dition. Some medications may produce nausea as aside effect in susceptible individuals.

See also PERFORMANCE ANXIETY; SOCIAL PHOBIA.

needlestick injuries Approximately 5.6 millionworkers in the health care industry and relatedoccupations face the stress of possible needlestickinjuries (NSIs). These workers risk being exposedto blood-borne pathogens, including humanimmunodeficiency virus, hepatitis B virus, hepati-tis C virus, and others.

An estimated 600,000 to 800,000 needlestickinjuries and other percutaneous (though the skin)injuries occur annually among health care work-ers, according to a report by the OccupationalSafety and Health Administration (OSHA) inMarch 1999. Nurses sustain the majority of theseinjuries. As many as one-third of all NSIs may berelated to the disposal process. The Centers for Dis-ease Control estimates that 62 to 88 percent ofsharps injuries can potentially be prevented byusing safer medical devices and better disposaltechniques.

In November 2000, Congress passed the Needle-stick Safety and Prevention Act, directing OSHA to

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revise its blood-borne pathogen standards and todescribe in more detail requirements for employersto identify and make use of effective and safer med-ical devices. Since then, OSHA has educatedemployers, health care workers, and the generalpublic on its revised standards. New provisionsrequire employers to maintain NSI logs and involvenonmanagerial employees in selecting safer med-ical devices. Enforcement of these new provisionsbegan in July 2001. Safer handling of medical sharpdevices will help reduce the stress of possible NSIs.

See also HEALTH CARE WORKERS; HUMAN IMMUN-ODEFICIENCY VIRUS.

nerve agents See SARIN.

nervous habits Habits that include involuntarytwitches and facial tics and voluntary behaviorssuch as nose picking, thumb sucking, and nail bit-ing. These habits may be a reaction to STRESS or ameans of relieving stress and anxieties for somepeople. If the individual has a strong desire to over-come these nervous HABITS, in some cases BEHAV-IORAL THERAPY techniques will help.

See also ANXIETY; IRRITABLE BOWEL SYNDROME;NAIL BITING; OBSESSIVE-COMPULSIVE DISORDER.

networking Using one’s contacts in business andin personal life to acquire information, to achievesome professional advantage, or to expand one’scircle of friends. It is a useful technique in findingout about marketing and industry trends and isunsurpassed for generating job leads and inter-views. The stress involved in networking is that theindividual may be bothering his friends, casualacquaintances, or complete strangers; the individ-ual may fear rejection in these efforts. Despite thestress, networking has become an important partof finding work.

One of the important rules of networking is thatpeople should never call anyone with whom theydon’t have a connection or referral. According toMarilyn Moats Kennedy, managing partner ofCareer Strategies, Chicago, the goal in networkingis to amass a list of 400 people with similar inter-ests and skills in your target industry who willremember your name and answer your calls. Togain that network, Kennedy recommends forming

concentric circles starting with coworkers, pastemployers, friends, relatives, and other peoplewith whom you have contact within your commu-nity and personal life. Not to be overlooked is animmediate former boss. A survey by Lee HechtHarrison, an outplacement firm based in NewYork, indicated that as many as one in three jobseekers get help in their networking efforts fromtheir former boss.

Kennedy calls the people in the first concentriccircle the individual’s inner sanctum. Having askedeach inner sanctum person for contacts, these con-tacts become a second concentric circle. The thirdconcentric circle consists of people referred by thethe second circle.

Keeping a log of the networking calls you makeeach day is an important part of the process.Through contacts, certain employers or jobdescriptions are identified for follow up. Otherinformation coming from referrals should be col-lected and filed for future use.

See also JOB CHANGE; JOB SECURITY.

SOURCE:Burg, Bob. Endless Referrals. Networking Your Everyday Con-

tacts into Sales. New York: McGraw-Hill, 1994.

neurotransmitters Chemicals that carry mes-sages from one nerve cell to another or to musclecells; these messages are transmitted within a frac-tion of a second.

Norepinephrine (a neurotransmitter) is releasedby the adrenal gland in response to signals trig-gered by STRESS, exercise, or by an emotion such asfear. Norepinephrine helps maintain a constantblood pressure by stimulating certain blood vesselsto constrict when the blood pressure falls belownormal. Serotonin (a neurotransmitter) is thoughtto be involved in controlling states of conscious-ness and MOOD.

See also ANXIETY; DEPRESSION; PHARMACOLOGICAL

APPROACH.

nightmare A frightening DREAM characterized bya sense of oppression or suffocation that usuallywakes people up during sleep. It occurs, most fre-quently, during REM (rapid eye movement) sleepand during the later part of the nighttime sleepperiod. Immediately after a nightmare, people feel

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very stressed. They have a clear recollection of thedream accompanied by intense uneasiness.

Children often have nightmares after a dayfilled with great excitement, such as a first day ofschool or seeing a frightening movie or TV show.When they grow older and can distinguish a dreamfrom reality, they are less frightened when night-mares occur.

Some individuals suffer nightmares as part ofPOST-TRAUMATIC STRESS DISORDER (PTSD), particu-larly those who have witnessed a crime, been a vic-tim of a crime, or served in a battle. They mayrelive their experience in the nightmare and wakeup just as frightened as they felt when the eventfirst happened.

See also BEHAVIOR THERAPY.

SOURCE:Krakow, Barry. Conquering Bad Dreams & Nightmares: A

Guide to Understanding, Interpretation and Cure. NewYork: Berkeley, 1992.

night shift See SHIFT WORK.

nitrous oxide (N2O) Commonly called laughinggas, nitrous oxide is an anesthetic agent used inoperating rooms and during dental procedures.Workers are exposed to N2O while administeringthe anesthetic gas to patients. The threat of expo-sure is a source of stress for them because devicesto reduce exposure have created a false sense ofsecurity in many health care workers. “Employersmust ensure that these systems provide theexpected level of protection,” according to NationalInstitute of Occupational Safety and Health(NIOSH) past director D. Linda Rosentock. “Healthcare workers should not have to risk their health toimprove the health of others,” she emphasized.

Several studies have shown that occupationalexposure to N2O may cause reduced fertility, spon-taneous abortions, and neurological, renal, andliver disease as well as documented decrease inmental performance, audiovisual ability, and man-ual dexterity. Animal studies have shown thatexposure to N2O during gestation can produceadverse health effects in offspring.

Operating rooms are often equipped with scav-enging systems that vent unused and exhaled gasaway from the work area. Research shows that

appropriate systems can significantly reduce therisk of impaired fertility among female dental assis-tants exposed to N2O.

However, a report by NIOSH indicated that evenwith scavenging systems in place, measurementshave been reported as 12 times higher than rec-ommended limits in hospital operating rooms andmore than 40 times the NIOSH recommended limitin dental operating rooms. These systems must becontinuously monitored and maintained to effec-tively reduce exposure to N2O.

Many people who fear dental work receive N2Oto help them relax and undergo dental procedures.

See also DENTISTS.

FOR FURTHER INFORMATION:National Institute for Occupational Safety and

Health200 Independence Avenue SWWashington, DC 20201(202) 401-6997(202) 260-4464 (fax)http:/www.cdc.gov/niosh

noise A stress issue because of its psychological aswell as physiological characteristics. Noise can bewanted or unwanted or distracting. The volume orfrequency of the noise can be physically debilitating.

Certain forms of noise, such as loud music, maysimply annoy some people while others feel moreproductive with certain types of music.

As chronic noise levels approach 85 decibels,significant potential for permanent hearing lossincreases. Usually, hearing loss occurs only on spe-cific frequency levels, depending on the amount ofthe exposure. It may be difficult for an individualto become aware of a hearing loss until it evolvessignificantly.

The federal government mandates that workersexposed to high levels of noise wear protective earequipment. Certain workers are more prone toinjuries from noise than others. These include rockmusicians, machine shop workers, and lumber millemployees.

SOURCE:Girdano, Daniel A., George S. Everly, Jr., and Dorothy E.

Dusek. Controlling Stress and Tension: A HolisticApproach. Englewood Cliffs, N.J.: Prentice Hall, 1990.

noise 255

norepinephrine A hormone secreted by nerveendings in the sympathetic nervous system and bythe adrenal glands. Its primary function is to helpmaintain a constant blood pressure by stimulatingcertain blood vessels to constrict when the bloodpressure falls below normal.

In some cases, an injection of the hormone maybe given in the emergency treatment of shock orsevere bleeding. Excessive levels of norepinephrinein the brain have been associated with manic states.

Norepinephrine is also sometimes called nora-drenaline.

nostalgia A longing to return to a place whereone may have emotional ties or a yearning toreturn to some past period or irrecoverable condi-tion.

When nostalgia is characterized by excessive orabnormal sentimentality, it becomes stressfulbecause it is related to feelings of isolation. Accord-ing to Miepje DeVryer, in the Journal of AmericanCollege Health, nostalgia should be distinguishedfrom the stress of experiencing HOMESICKNESS,which tends to be resolved by returning “home.”

In contrast, when the individual longs or yearnsfor a lost past, and does so without desire to actu-ally return, he is merely experiencing a normalresponse to nostalgia. His memories are usually ofexperiences with places and things rather thanpeople. He is encompassed by a bittersweet feeling,painful and stressful on the one hand, pleasurableand soothing on the other.

See also ACCULTURATION; LONELINESS; MIGRATION;MOVING.

SOURCE:DeVryer, Miepje A. “Leaving, Longing and Loving: A

Developmental Perspective of Migration.” Journal ofAmerican College Health 38 (September 1989).

nuclear weapons A source of stress that beganduring the later 20th century and continues. Theconcern is related to the development of atomicand nuclear power. The fear is based on a feelingby individuals that they have no control over thefate of the world and that nuclear weapons can killoff all of human life and civilization. This fear isalso related to a fear of death and a fear of theapocalypse, or the end of the world.

Although nations have worked out treaties gov-erning manufacture and storing of nuclear weapons,many people around the world still fear that suchweapons may be used for mass destruction.

In 2002, U.S. troops went to Iraq to disarm Sad-dam Hussein following reports that weapons ofmass destruction existed there. An internationalsurveillance team spent two years looking forthem. In early 2005 the group charged with hunt-ing banned weapons said the ongoing violence inIraq, coupled with lack of new information, ledthem to abandon the effort. The report concludedthat Iraq had no stockpiles of biological and chem-ical weapons and its nuclear program had decayedbefore the U.S.-led invasion, in findings contrary toprewar assertions by the Bush administration.

However, in 2005, many issues surroundingnuclear weapons continue to be ongoing sources ofstress. There are concerns about nuclear weaponsin North Korea and Iran, missing nuclear materialsthat can become bombs, and threats of so-calleddirty bombs that can cause mass destruction. Thelack of security concerning nuclear materials is alsoa source of stress.

See also TERRORISM; VIOLENCE; WAR.

nursing homes Homes that provide care at vari-ous levels for individuals who cannot care forthemselves. Older persons today are faced withstressful choices in determining how they willspend their final years. Adult children, as well, feelthe tremendous stress of helping their parentsmake the right choice. In some cases, they mustmake the choice for the parents when the parentsare unable to do it themselves.

For some older adults, the preference will be toremain in their own home; others may choose tomove in with their children. However, the latteroption may not be as viable as it was in years past.Space could be at a premium in their children’shomes, and both husband and wife may be tieddown to a job. Even more likely, these adult chil-dren may be at the beginning of their RETIREMENT

years, having only recently shed the responsibilityof their own sons and daughters.

Some older adults will find comfort and safetyin housing complexes built specifically to meet theneeds of senior citizens. In these complexes, they

256 norepinephrine

will have all the conveniences of independent liv-ing combined with meal service and plannedsocial, cultural, and recreational activities.

Any of these options work as long as the olderpersons involved remain independent and healthy.However, when illness and physical limitationsrelated to living longer occur, the need for full-timecare becomes a priority. It is that priority that oftenis best met in a nursing home environment.

Stress for Nursing Home Workers

Coping with the idiosyncracies of residents can bestressful for workers. Many nursing home workersface similar sources of stress as those in hospitalsand in the home care industry.

Major sources of stress for nursing home work-ers include injuries while handling patients, such asslips, trips, and falls, contact with objects and equip-ment, assaults and violent acts by patients, andexposure to harmful substances in the air such asair “fresheners” and insecticides. According to theU.S. Department of Labor, Bureau of Labor Statis-tics, nursing aides, orderlies, and attendants suffer70 percent of nursing home injuries that result indays away from work. More lost workdays arereported for female workers than male workers.

Workers in nursing homes include nurses,licensed practical nurses, health aides, maids,cooks, janitors, and laundry staff.

See also HEALTH CARE WORKERS; NEEDLESTICK

INJURIES; SLIPS, TRIPS, AND FALLS; TUBERCULOSIS;VIOLENCE.

SOURCE:Yeh, Elizabeth, How to Achieve Quality of Life and Care in a

Nursing Home. Houston: Rosenwasser Publishing,1996.

nursing mothers Many nursing mothers feelinsecure about starting to breast-feed. Their con-cerns may include the ability to produce milk andpossible nipple discomfort. Nursing an infant bringsboth physical and emotional sources of stress.

Working women have particular stresses, asthey may become concerned about being able tocontinue to feed their infant when they return towork. However, some of the stress associated withbreast-feeding and working have been reducedbecause as of 2000, at least 20 states had legislation

protecting mothers who breast-feed. The numberof states with legislation addressing nursing moth-ers in the workplace nearly doubled that year. Anexample is the state of Illinois, which in 2001 reg-ulated that employers must accommodate nursingmothers. Under the Illinois Nursing Mothers in theWorkplace Act, an employer must provide unpaidbreak time for nursing mothers. The law applies toemployers who have more than five workers otherthan immediate family. The break time must, ifpossible, run concurrently with break time alreadyprovided to the employee. An employer is notrequired to do so, however, if it would unduly dis-rupt an employer’s operations.

Additionally, employers must make reasonableefforts to provide a room or location near the workarea (other than a toilet stall) to allow the motherprivacy either to feed her infant or to pump milk.

Representing another advance, in 2002, theHawaii legislature passed an amendment to its fairemployment practices law providing that noemployer can prohibit a worker from expressingbreast milk during any meal period or other breakperiod required to be provided by the employer bylaw or by a collective bargaining agreement.

In 1998, other states, among them California,Florida, and Texas, enacted similar laws. A Califor-nia law simply urges all employers to support andencourage working mothers who want to continuebreast-feeding. Both the Texas Breast FeedingRights and Policies Law and the Florida PublicHealth Law encourage breast-feeding in the work-place by allowing businesses that develop a policysupporting worksite breast-feeding to use the des-ignation “mother-friendly” or “baby-friendly” intheir promotional materials.

President Clinton signed a law making breast-feeding legal on all federal property where awoman and her child have a right to be. Under thelaw, it is illegal to ask a woman who is nursing herinfant child to move from federal property.

Many major corporations have already includedmother-friendly programs in their employee bene-fits packages. These companies have beenprompted by studies citing decreased rate of absen-teeism of mothers who continue to breast-feedafter returning to the job and the lower medicalbills of nursing mothers and their children. Some

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companies report that accommodating mothershas been excellent for their bottom line.

Women can find support, education, and somerelief from some of the stresses they face from theLa Leche League, an international organizationdevoted to assisting women with breast-feeding.

See also WORKING MOTHERS.

FOR FURTHER INFORMATION:La Leche LeagueP.O. Box 4079Schaumburg, IL 60168-4079(847) 519-7730 or (800) LA-LECHE (toll-free)(847) 519-0035 (fax)http://www.lalecheleague.org

nutrition The study and science of the food peo-ple eat and drink and the way food and drink aredigested and assimilated in the body. STRESS playsan important role in nutritional aspects of life. Attimes of certain mental or physical illnesses, anindividual’s nutrition may be less than optimal. Forexample, a severely depressed person may have lit-tle interest in eating, and lose weight, or a patientwith a chronic illness, such as cancer, may have lit-tle appetite because of chemotherapy. ALCOHOLISM

and substance abuse can suppress the appetite,leading to a decrease in food intake.

In Western societies today, many people feelstressed over the relationship between diet andhealth. The focus is on the danger of too much fatin the diet, and on the effects of food additives, col-oring, and preservatives. Inadequate intake of pro-tein and calories may occur in people who restricttheir diet and try to lose weight. This can lead toEATING DISORDERS such as anorexia nervosa. It canalso occur because of mistaken beliefs about diet

and health. Emphasis on thinness in our society hasled many to poor nutritional habits in an effort tolose weight. Hence one’s perception of BODY IMAGE

may interfere with proper nutritional intake.Psychotropic medications can contribute to

inadequate nutrition for some individuals. Forexample, dry mouth, a side effect of some medica-tions, may make eating less pleasurable than usual.Other side effects that interfere with one’s ability tomaintain good nutrition include glossitis, nausea,abdominal pain, vomiting, and diarrhea.

See also OBESITY; WEIGHT GAIN AND LOSS.

SOURCES:Bland, Jeffrey S. “Psychoneuro-Nutritional Medicine: An

Advancing Paradigm.” Alternative Therapies 1, no. 2(May 1995).

Napier, Kristine. “Nutrition: Fat Is Everyone’s Issue.”Harvard Health Letter 21, no. 3 (June 1996).

Thomas, Patricia, ed. “Nutrition: High-Protein Diets:Where’s the Beef?” Harvard Health Letter 22, no. 3(January 1997).

258 nutrition

TAKE THE STRESS OUT OF CHOOSING ANURSING HOME

• Tour the facility for cleanliness, safety andsecurity.

• Check the activity calendar.• Ask to see its annual report/financial statement.• Observe and talk with residents or drop in

unannounced.• Look for conveniences such as handrails, call

buttons, and other devices designed specificallyto assist older people.

• Observe how personal privacy is respected.• Determine what help is available in making the

transition.

Oobesity Obesity is body weight in excess of biolog-ical need. In the early 2000s, obesity was declaredan epidemic in the United States by the Centers forDisease Control and Prevention. In early 2005,between 44 and 64 percent of U.S. adults were con-sidered overweight or obese. Estimates are that 34percent of adult women are obese, compared with28 percent of men. In children and adolescents, therate of obesity has climbed sharply in recent years.Now it is understood that halting and reversing theupward trend of the obesity epidemic will require acommitment to action by individuals as well aseffective collaboration among government, volun-tary, and private sectors. Obesity is now a private aswell as public source of stress.

Obesity is defined as having a body mass index(BMI) of 25 or more. Current obesity numbersreflect an increase of up to 74 percent since 1991.During the same time frame, diabetes increased by61 percent, reflecting the strong correlationbetween obesity and development of diabetes. Anestimated 17 million people have diabetes in theUnited States.

Obesity can affect a person’s SELF-ESTEEM, feel-ing of attractiveness, and mental well-being. It can

lead to social withdrawal and have debilitatingeffects on the body. Commercial diet programshave attracted millions of overweight individuals.Estimates indicate that Americans spend about $40billion each year on weight loss products and serv-ices. Many resort to radical surgery or drugs toreduce obesity.

Overweight and Lean Muscle Mass

Overweight may or not be due to increase in bodyfat. It may also be due to an increase in lean mus-cle. For example, professional athletes may be verylean and muscular, with very little body fat, yetthey may weigh more than others of the sameheight. While they may qualify as “overweight”due to their large muscle mass, they are not neces-sarily overly fat, regardless of BMI.

Waist Circumference

Waist circumference is a common measure used toassess abdominal fat content. The presence of excessbody fat in the abdomen, when out of proportion tototal body fat, is considered an independent predic-tor of risk factors and ailments associated with obe-sity. According to the U.S. Centers for DiseaseControl and Prevention, in general, men are consid-ered at risk who have a waist measurement greaterthan 40 inches, and women are at risk who have awaist measurement greater than 35 inches.

New Dietary Guidelines for Better Food Choices

The sixth edition of Dietary Guidelines for Americans,released in early 2005 by the U.S. Departments ofHealth and Human Services and Agriculture, givesaction steps to reach achievable goals in weight con-trol, stronger muscles and bones, and balanced nutri-tion to help prevent chronic diseases such as heartdisease, diabetes, and some cancers. Promoting gooddietary habits is key to reducing the problems of

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The BMI is a single number that evaluates an indi-vidual’s weight status in relation to height. BMI is amathematical formula in which a person’s bodyweight in kilograms is divided by the square of hisor her height in meters (wt/[ht]2). BMI is highlycorrelated with body fat. The criteria for obesity arethe same for men and women. Someone who isfive feet, seven inches tall is obese at 192 poundsand a person who is five feet, 11 inches is obese at215 pounds.

obesity and physical inactivity. The guidelinesfocus on helping individuals to maintain bodyweight in a healthy range and balance caloriesfrom foods and beverages with calories expended.They also aim to prevent gradual weight gain overtime, make small decreases in food and beveragecalories, and increase physical activity.

Surgery to Reduce Obesity

For some people for whom diets have failed, sur-gery is their last resort in the battle to lose weight.An increasing number of persons take this route.In 2004, the number of weight-loss surgical proce-dures rose 36 percent to 141,000, five times the1999 level, according to the American Society forBariatric Surgery. In the conventional gastricbypass and a minigastric bypass, the stomach isradically reduced in size using surgical stapling andthe intestines are shortened. People lose weightafterward because their stomachs hold less foodand the shorter intestinal tract gives the food lesschance of being absorbed into the body. Before thistype of surgery, patients usually receive psycholog-ical counseling; after surgery, there is close follow-up by nutritionists.

In sum, nothing is more effective than psycho-logical motivation to help obese people to loseweight by dieting and exercise and to keep it off.

See also BODY IMAGE; DIETING; EATING DISORDERS;WEIGHT GAIN AND LOSS.

FOR FURTHER INFORMATION:American Society of Bariatric Physicians5600 South Quebec, Suite 1600Englewood, CO 80111Phone: (303) 7794833

National Association to Aid Fat AmericansP.O. Box 188620Sacramento, CA 95818Phone: (916) 443-0303

U.S. Department of Health and Human Services200 Independence Avenue SWWashington, DC 20201http://www.hhs.gov/news

SOURCES:Krueger, Anne. “How Did I Get So Fat?” American Associ-

ation of Retired Persons Magazine. Available online.URL: http://www.aarpmagazine.org/health/articles/

a2004-11-18-mag-sofat.html. Downloaded on June22, 2005.

National Institutes of Health. Clinical Guidelines on the Iden-tification, Evaluation, and Treatment of Overweight andObesity in Adults. Bethesda, Md.: Department of Healthand Human Services, National Institutes of Health,National Heart, Lung and Blood Institute, 1998.

Stunkard A. J., and T. A. Wadden (eds.) Obesity: Theoryand Therapy. 2nd ed. New York: Raven Press, 1993.

obsessive-compulsive disorder (OCD) An ANXI-ETY DISORDER characterized by a person’s obses-sions, which are repeated intrusive, unwantedthoughts that may lead to carrying out ritualized,compulsive acts. This disorder affects 2.4 millionAmericans and is a cause for stress for the suffereras well as family members, coworkers, and friends.

OCD may come on suddenly, often beginning inearly childhood, around age eight to 10. The disor-der is twice as prevalent in the general populationas panic disorder or schizophrenia. OCD is partlyinherited and partly the result of environmentalfactors. Personality traits of orderliness and cleanli-ness are said to be related to OCD and certain braindisorders can result in compulsive behavior.

Obsessions

Obsessions come into the mind involuntarily andrecur. Sufferers are not able to ignore them; theyconsider these thoughts, such as fear of beinginfected by germs or dirt and constant doubt aboutsuch things as turning the coffeepot off or lockingthe front door, senseless and somewhat unpleas-ant, but unrelenting.

Compulsions

A normal lifestyle routine is impossible for manyOCD sufferers because they constantly repeat ritu-als that take up considerable time. People whohave OCD are aware that their compulsions andrituals are irrational, but they cannot help them-selves. Some are ashamed of their actions and hidethem from family and friends, often delaying treat-ment for years.

Hand washing, checking, and counting are themost common compulsions among people withthis disorder. Other types of rituals relate to fastid-iousness and PERFECTION, such as cleaning thehouse, showering, repeating names or phrases,

260 obsessive-compulsive disorder

hoarding, avoiding objects, and performing tasksextremely slowly and repeatedly.

OCD and Links with Depression

Researchers speculate that OCD may be closelyassociated with DEPRESSION. Some individualsexperience only OCD while others suffer from bothOCD and depression. The link between OCD anddepression is borne out by laboratory tests onpatients who have the two illnesses. For example,obsessive-compulsives, like some people who havedepression, do not stop producing dexamethasone,a steroid naturally produced in the body, during adexamethasone suppression test. When the steroidis injected into the body, the body should stop pro-ducing dexamethasone on its own. OCD patientscontinue to make the steroid. Also, obsessive-com-pulsives, like depressed people, show an abnormallapse in the time it takes between first falling asleepand the first dream, normally from one to twohours. When researchers looked at the immediatefamily members of people suffering from OCD,they found a high percentage had depression ormanic-depressive disorder. Many OCD sufferershave symptoms associated with depression, such asGUILT, indecisiveness, low self-esteem, ANXIETY, andexhaustion.

Pharmacological and Behavior Therapies

PHARMACOLOGICAL APPROACHES include use ofprescription medications for some individuals.Researchers have learned that medications thataffect the serotonergic system (such as clomipramine

and fluoxetine) can be useful in relieving symptomsin some patients.

BEHAVIOR THERAPY is one of the most effectivetreatments for OCD. During therapy sessions, theperson is exposed to situations that cause extremestress and anxiety and provoke compulsive behav-iors. The individual is not allowed to go throughthe usually performed rituals, such as excessivehand washing after handling money. This tech-nique works well for people whose compulsionsfocus on situations that can be easily recreated. Forthose who follow compulsive rituals because theyfear catastrophic events that cannot be recreated,individuals must rely more on imagination.

FOR FURTHER INFORMATION:Anxiety Disorders Association of America11900 Parklawn Drive, Suite 100Rockville, MD 20852Phone: (301) 231-9350

Obsessive-Compulsive Disorder FoundationP.O. Box 70Milford, CT 06460-0070(800) 639-7462 (toll-free)

SOURCES:American Psychiatric Association. Obsessive-Compulsive

Disorder. Washington, D.C.: American PsychiatricAssociation, 1988.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Reyes, Karen. “Obsessive-Compulsive Disorder: There IsHelp.” Modern Maturity, November–December 1995, 78.

obsessive-compulsive disorder 261

BEHAVIOR THERAPY FOR OCD

Technique Action experienced Anticipated effect

Prevention of response Individual gradually delays performing Helps reduce compulsion.ritual for longer intervals.

Thought stopping Individual tries to voluntarily interrupt Helps decrease obsessions.obsessive thoughts.

Imagery Individual is encouraged to imagine being Help decrease obsessions and anxiety.exposed to feared situation and prevent an unwanted response.

Modeling Therapist actively models response. Alters patient’s unwanted behaviors to more acceptable ones.

Exposure Individual is gradually exposed to the feared Reduces anxiety; decreases obsessions thought or object. and compulsions.

occupational health psychology (OHP) A newfield of psychology that takes an active role inresearch and practice to prevent OCCUPATIONAL

STRESS, illness, and injury. Although research andpractice in OHP covers a wide range of topics, theNational Institute for Occupational Safety andHealth (NIOSH) has urged that the field give spe-cial attention to primary prevention of organiza-tional risk factors for stress, illness, and injury atwork. This viewpoint is expressed in the NIOSH-proposed definition of OHP: “OHP concerns theapplication of psychology to improving the qualityof work life, and to protecting and promoting thesafety, health and well-being of workers.”

The notion of health “protection” in the NIOSHdefinition refers to intervention in the work envi-ronment to reduce worker exposures to workplacehazards, while health “promotion” refers to individ-ual level interventions to equip workers withknowledge and resources to improve their healthand thereby resist hazards in the work environment.

OHP is particularly concerned with the dramatictransformation of work and employment that hasbeen under way in industrial economies since the1980s and how changing organizational structuresand processes influence the health and well-beingof workers and their families.

Graduate Training Programs in OHP

During the 1990s, NIOSH and the American Psy-chological Association launched a series of initiativesto promote the field of OHP. A program has beenimplemented to support both postdoctoral and grad-uate level training in OHP at major universities.These programs have strong interdepartmental link-ages that expose psychology students to topics andmethods in occupational safety and health and pro-vide opportunities for workplace internships. Corecurricula in these training programs usually includecourse work addressing job stress theory, organiza-tional risk factors for occupational stress, injury, andillness, health implications of stressful work, organi-zational interventions (e.g., work design), and pro-grams (e.g., employee assistance programs) forreduction of occupational stress, illness, and injury.

Journal of Occupational Health Psychology

Journal of Occupational Health Psychology waslaunched in 1996 and publishes research, theory,

and public policy articles in occupational healthpsychology, representing a broad range of healthpsychology concerns.

It focuses on the work environment, the indi-vidual and the work-family interface. The journalpublishes articles by researchers and practitioners,concerning psychological factors in relationship toall aspects of occupational health, including stress.

See also NOISE; OCCUPATIONAL STRESS; STRESS

MANAGEMENT.

FOR FURTHER INFORMATION:American Psychological Association750 First Street NEWashington, DC 20002-4242(800) 374-3120 (toll-free)(202) 386-5700(202) 336- 5568 (fax)http://www.apa.orgwebmaster@apa.org

EditorJournal of Occupational Health PsychologySchool of BusinessQueen’s UniversityKingston, ON K7L 3N6Canada

occupational stress The Bureau of Labor Statis-tics (BLS) Survey of Occupational Injuries and Ill-nesses classifies occupational stress as “neuroticreaction to stress.” Many employees undergo stressas a normal part of their job, but some experienceit more severely than others, to the point that theyneed time away from work.

According to the BLS, there were 3,418 such ill-ness cases in 1997. The median absence from workfor these cases was 23 days, more than four timesthe level of all nonfatal occupational injuries andillnesses. More than two-fifths of the cases resultedin 31 or more lost workdays, compared to one-fifthfor all injury and illness cases.

The 1997 estimate of 3,418 cases of occupa-tional stress is the lowest since 1992, when BLSbegan collecting these data. The decline is consis-tent with the trend for all nonfatal occupationalinjuries and illnesses involving days away fromwork. Occupational stress cases declined by 15 per-cent over the 1992–97 period, whereas all injuriesand illnesses declined by 21 percent.

262 occupational health psychology

White-Collar Occupational Stress

White-collar occupations had a higher proportion ofstress cases than both blue-collar and service occu-pations combined. Managerial and professionaloccupations, with 16 percent of the cases, and tech-nical, sales, and administrative support occupations,with 48 percent, had higher proportions of occupa-tional stress cases than they did of all occupationalinjury and illness cases involving days away fromwork, 5 percent and 15 percent, respectively. Threeoccupations accounted for almost 80 percent of allcases of occupational stress; the two white-collaroccupations just mentioned and operators, fabrica-tors, and laborers. Occupations most often leading tooccupational stress disorders include bookkeepers,accounting, and auditing clerks—5 percent; supervi-sors and proprietors, sales occupations—4 percent;investigators and adjusters, excluding insurance—4percent; cooks—4 percent; and production occupa-tional supervisors—4 percent.

Industries with High Occupational Stress

According to the BLS, finance, insurance, and realestate, with 12 percent of the cases, and services,with 35 percent, had higher proportions of occu-pational stress cases than they did of all occupa-tional injury and illness cases involving days awayfrom work, 2 percent and 23 percent, respectively.The proportion of occupational stress disorders waslower in all other industries than comparable pro-portion of all injuries and illnesses. Four industriesaccounted for the bulk of occupational stress cases:services (35 percent), manufacturing (21 percent),retail trade (14 percent), and finance, insurance,and real estate (12 percent).

Incidence Rates of Stress by Industry and Occupation

The nonfatal occupational injury and illness inci-dence rate for occupational stress cases was lessthan one case per 10,000 full-time workers in each

occupational stress 263

of the major industry divisions in 1997, the lowestsince BLS began collecting such data in 1992. Theincidence rate for occupational stress in finance,insurance, and real estate (FIRE) in 1997 was thelowest in six years, and for the first time since1992, did not significantly exceed the rates for allother industry divisions. In contrast, for all injuriesand illnesses, the rate of 67.4 in FIRE was the low-est among the major industry divisions, and lessthan one-third of the total private industry rate.

Relative Risk of Stress by Occupation

The risk of injury or illness faced by employees’individual occupational groups compared to therisk faced by all occupations combined is called rel-ative risk. When constructing an index for such arisk faced by all occupations combined, the index isequal to one. In 1997, the index for occupationalstress ranged from 0.6 for managerial and profes-sional occupations to 1.6 for technical, sales, andadministrative support occupations.

The relative risk for occupational stressexceeded the relative risk for all injuries and ill-nesses for white-collar jobs. Among blue-collar andservice jobs the reverse was true: Relative risk foroccupational stress was lower than the risk for allinjuries and illnesses.

FOR FURTHER INFORMATION:U.S. Department of LaborBureau of Labor StatisticsPostal Square Building, Room 28502 Massachusetts Avenue NEWashington, DC 20212-0001(202)606-6179http://www.bls.gov

Ohashiatsu Based on the same system of Orien-tal medicine as ACUPUNCTURE; a form of therapyuseful for relief of stress in some people.Ohashiatsu addresses the body’s energy meridiansand points along those meridians called tsubos.Instead of using needles, however, the practitionerof Ohashiatsu use hands, elbows, and sometimeseven knees as tools. The goal is to achieve a feelingof deep RELAXATION, harmony, and peace.

Ohashiatsu adds psychological and spiritualdimensions to traditional SHIATSU by incorporatingZen philosophy, movement, and MEDITATION to bal-ance the energy of body, mind, and spirit.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MIND-BODY CONNECTIONS; ZEN.

operant conditioning See CONDITIONING.

orgasm See SEXUAL RESPONSE.

outsourcing See CHANGING NATURE OF WORK.

overeating See OBESITY; NUTRITION; WEIGHT GAIN

AND LOSS.

overtime Hours worked beyond the usual work-day or workweek. According to Paul Landsbergis,Ph.D., of Mount Sinai School of Medicine, longwork hours are related to work-related injuries,fatigue, less SLEEP, blood pressure elevation, andcardiovascular disease. Recent research on over-time and health effects suggest that overtime mayact directly as a stressor, may act to increase expo-sure to other workplace hazards, or may promoteunhealthy behaviors.

The average number of hours worked annuallyby workers in the United States increased steadilyfrom 1970 through the 1990s and currently sur-passes that of Japan and most of western Europe.The influence of overtime and extended work shiftson worker health and safety, as well as on workererrors, is gaining increased attention from the scien-tific community, labor representatives, and industry.

Extended work hours have been associated withwork accidents and injuries, and with muscu-loskeletal disorders and pain. Some studies havefound links between long work hours and per-ceived STRESS, other psychological symptoms,excessive alcohol use, and smoking (usually above50 hours per week).

In a study of overtime and performance,researchers investigated United Auto Workersworking day and evening shifts. They reportedpoorer performance on tests of cognitive functionand executive function, such as the ability to pri-oritize and plan tasks, for individuals who workedovertime as compared with those who did not. Inanother study, as work hours increased amonghealth care workers, automobile crashes and on-the-job accidents increased.

264 Ohashiatsu

Overtime has been associated with fatigue andshorter sleep hours. Insufficient sleep can increasethe activity of the sympathetic nervous system,heart rate, and blood pressure, and may be animportant pathway connecting long work hoursand illnesses, according to Landsbergis.

“Dual-job families in the United States work farlonger hours than in most other industrialized coun-tries. Parents face an economy that offers fast-trackjobs with many extra hours a week, or dead-endjobs, at 20 to 25 hours, with little in between,”according to Natalie Gahrmann, author of Succeedingas a Super Busy Parent. Parents have choices. They canremain in a “good” job that keeps them away fromhome 10 to 12 hours a day, they can take a part-timejob with lower wages, fewer benefits, and noadvancement, or they can quit. Extra hours at theoffice may mean more opportunities for advance-ment, or opportunities for BURNOUT. It can also meanmissing out on important family milestones.

Gender, Age, and Overtime

Studies have given more attention to male workersthan to female workers and less is known about

how overtime and extended work shifts influencehealth and safety in women. However, one Cana-dian report indicated that women tend to spendmore of their time away from work on child careand domestic responsibilities, which may reducethe time available for sleep and recovery fromstress at work. Another study provided some sup-port for increased risk for musculoskeletal disor-ders when long hours worked combined withadditional domestic workload.

One study examined the influence of age onextended work shifts and reported that younger par-ticipants maintained better performance with longerwork shifts when compared with older participants.

SOURCE:Caruso, Claire C., et al. “Overtime and Extended Work

Shifts: Recent Findings on Illnesses, Injuries, andHealth Behaviors,” Available online. URL: http://www.cdc/gov/niosh/docs/2004-143/pdfs/2004-143.pdf. Accessed on June 22, 2005.

overtime 265

Ppain A feeling that can range from mild distressto unbearable, acute suffering. It occurs followinginjury or as a result of disease when the body’s sen-sory nerve endings are stimulated.

Pain is not restricted to a specific type of stimu-lus; it can be aroused by extreme stimulation ofany sense. Loud noise and bright lights can bepainful, as can be HEADACHES, toothaches, cancer,inflammation of tissue and muscles, and bonebreakage.

In his book Painstoppers, author Norman D. Fordidentifies stress as the genesis of pain. Ford says,“Stress occurs only when we perceive life througha filter of fear-based, negative beliefs. Stress is theunderlying cause of some 70 percent of all chronicpain. Virtually all pain in the neck, upper and lowerback, and shoulders is stress-related and so are mostheadaches. Such pain-provoking diseases as ulcers,irritable bowels, rheumatoid ARTHRITIS, cancer, andheart disease are also stress related. Overeatingbecause of emotional stress also leads to OBESITY,which worsens the pain of osteoarthritis.”

Treatment

Course of treatment at the Texas pain clinic isbased on how patients are categorized: somatic,those whose pain is primarily of physical origin,with some psychological issues possible; psy-chogenic, those who experience pain but havenothing physically wrong; malingering, those whoare either faking or greatly exaggerating their pain.Treatments include RELAXATION training, HYPNOSIS,BIOFEEDBACK, behavior modification, and family,marital, and sexual counseling.

In Mental Medicine Update, Robert Ornstein,Ph.D., and David S. Sobel, M.D. stated that 10 per-cent to 30 percent of Americans suffer fromchronic or recurrent pain, which extracts a heavytoll on health, ability to work, and sense of well-

being. While feelings of anxiety, frustration, andloss of control and confidence can amplify theexperience of pain, it does not mean that the painis not “real.” It just means that emotions make it

266

REDUCE STRESS: PARTICIPATE IN PAIN CONTROL

• Identify small steps toward independence frompain, such as accepting the pain and not blam-ing others for your problems.

• Track pain levels and activities with awarenessof the difference between physical pain sensa-tions and emotional pain distress.

• Check the “costs/benefits” in relation to partici-pation in family activities, work and play, andrelationships with people.

• Express feelings and anxieties; learn ways todecrease anger responses.

• Block negative thoughts; use relaxation tech-niques to fight the chronic stress of sleep distur-bance, fatigue, poor concentration, increasedmuscle tension, anxiety, depression, and loss ofself-control—all of which amplify pain.

• Distract yourself by focusing on the environ-ment, singing or using imagery to concentrateon pleasant, dramatic, and healing thoughts.

• Indulge in healthy pleasures and fun.• Focus on the pain and the thoughts and feelings

that accompany the pain.• Reclaim an active life by setting short- and long-

term goals.• Exercise on a regular basis; increase the amount

gradually. Modify how you use your body, suchas during lifting, bending, and sitting, and whatyou use for physical support—chairs, desks andcounters, wrist bands, and other methods.

• Prepare for flareups by knowing the specificpain relievers that work best for you.

worse. In addition to physical treatment of pain,the authors suggest behavioral self-managementthat includes mind-body strategies such as relax-ation techniques, SUPPORT GROUP therapy, andbiofeedback training. To those suffering chronicpain, Ornstein and Sobel suggest that when theybecome partners in pain treatment, they becomepart of the solution.

See also ALTERNATIVE MEDICINE; CHRONIC ILLNESS;GUIDED IMAGERY.

FOR FURTHER INFORMATION:American Academy of Pain Medicine4700 W. LakeGlenview, IL 60025(847) 375-4731(877) 734-8750 (fax)http://www.painmed.org

SOURCES:Ford, Norman D. Painstoppers: The Magic of All-Natural

Pain Relief. West Nyack, N.Y.: Parker Publishing, 1994.Ornstein, Robert, and David Sobel. “RX: Managing

Chronic Pain.” Mental Medicine Update 4, no. 1 (1995).

paintball A fast-paced action sport usuallyplayed on an open field, although there are someindoor arenas. Parents and spouses may worrywhen they know their loved ones are playing,because the sport involves paintball guns and maycause injuries. Usually, the game is a variation ofthe childhood game capture the flag. Some peoplefind the activity exhilarating while others find itterrifying.

There are two teams and each player gets an airgun. Team members wear colorful armbands foridentification. The object of the game is to capturethe other team’s flag, bring it back to base, andtouch it to one’s own flag without being elimi-nated. Getting eliminated means being hit with apaintball. Referees remove players once they areeliminated. The paintballs are marble-sized andhave a hard shell to enable it to sail long distances.

Typically, paintball guns have a barrel to launchthe paintball, a trigger to activate the launch pro-cedure, a reservoir to hold extra paintballs, andsome type of pressurized gas to provide propulsion.Players usually receive several hits in the course ofa game; the hits may leave a little redness at the

point of contact but most players say they usuallydo not hurt.

Protection, Safety, and Following Rules

The Paintball Times recommends a face protec-tion/goggle system to protect the eyes. Players areadvised to never take off the mask, except in des-ignated areas. Dark clothing, in layers, is recom-mended. The magazine advises;

• Be sure you understand your gun and its limi-tations

• Wear comfortable hiking/running shoes or foot-ball or soccer cleats to provide traction in grassand mud

• Obey the orders from the captain of your team

Traveling to paintball tournaments by air withpaintball equipment can be a stressful experience.Players must be prepared to carry goggles inchecked luggage or as carry on, but paintguns mayonly be transported in checked luggage and com-pressed gas (CO2 or HPA) tanks may be carried inchecked luggage only if the valve or regulatorassembly is completely removed from the tank,allowing inspectors to see inside the open tankneck. However, as of the end of 2005, most tanksare not yet designed this way.

Players traveling with equipment should checkwith their airline’s policies for prohibited items.Some airlines may not accept compressed air andCO2 tanks for transport under any conditions.

SOURCE:Khan, Sami. “What Is Paintball?” The Paintball Times.

Available online. URL: http://www.PaintballTimes.com. Downloaded on November 26, 2004.

palpitations A conscious sensation of the heart’sbeating harder and faster than normal or skippingbeats. Whereas normally people are not aware ofhow their hearts beat, many of them experiencepalpitations when they participate in strenuousexercise or have stress-producing experiences.

Thumping or fluttering feelings in the chest donot normally indicate heart disease and may be aresult of heavy use of caffeine, alcohol, or smoking.An arrhythmia (irregular beat) may cause a palpi-tation. Individuals may feel faint and breathless

palpitations 267

and their pulse may be as high as 200 beats perminute but remain regular. Hyperthyroidism,overactive thyroid glands, may also cause palpita-tion by speeding up the heartbeat.

Many individuals experience palpitations dur-ing panic attacks or as a phobic reaction to a stim-ulus they fear. For example, a person who isphobic about dogs may experience palpitations justat the sight of a dog walking on the sidewalk.Although the dog is on a leash and does not poseany threat, the phobic individual may experiencepalpitations along with sweaty palms, weak knees,and DIZZINESS.

Those who experience palpitations may fear thatthey are having a heart attack or that they are goingto die. For many people, just thinking these thoughtsand becoming afraid of imagined consequences cancause palpitations to increase. Symptoms of ANXIETY,such as palpitations, are treated with BEHAVIOUR

THERAPY and, in some cases, drug therapy.If an individual experiences palpitations for sev-

eral hours or the feeling recurs over several days,or if they cause chest pain, breathlessness, or dizzi-ness, a family physician, general internist, or spe-cialist in cardiology should be consulted as soon aspossible. If palpitation episodes are brief, they areprobably within the range of normal. Some med-ications may produce palpitations in individuals.

See also ANXIETY DISORDERS; PANIC ATTACKS AND

PANIC DISORDER; PHARMACOLOGICAL APPROACH;PHOBIAS.

panic attacks and panic disorder A panic attackis a short period (five to 10 minutes) of suddenlyoccurring, intense fear or discomfort, usually forno apparent reason. The feeling may be caused bystress but it also causes extreme stress in theaffected individual because it is usually accompa-nied by a fear of dying, a sense of imminent dan-ger or impending doom, and an urge to escape.

Panic attacks are considered one of severalANXIETY DISORDERS. They can occur in a variety ofanxiety disorders, such as panic disorder, AGORA-PHOBIA, SOCIAL PHOBIAS, and POST-TRAUMATIC

STRESS DISORDER.The word panic is derived from the name Pan,

whom Greeks worshiped as their god of flocks,herds, pastures, and fields. Pan loved to scare peo-

ple and make eerie noises to frighten passersby.The fright he aroused was known as “panic.”

Criteria for Diagnosis

To be diagnosed as a panic attack, organic factorshave to be ruled out as the cause of the distur-bance. The panic incident must include at leastfour or more of the characteristic symptoms, whichare a sense of breathing difficulty, PALPITATIONS orrapid heartbeat, sweating, trembling, shaking, feel-ings of smothering or choking, chest pains, nauseaor abdominal distress, DIZZINESS or light-headed-ness, paresthesia, and chills or hot flushes.

HYPERVENTILATION (fast, shallow breathing)worsens the symptoms and leads to a pins and nee-dles sensation and to a feeling of derealization ordepersonalization. These symptoms are usually theresult of underlying emotional conflicts such asfear of being trapped or loss of emotional support.

According to the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition. (DSM-IV), typi-cally the first attack occurs in individuals in the lateteens. Initially, attacks are unexpected and do notoccur immediately before or on exposure to astressful situation, such as a simple phobia or socialPHOBIAS. Subsequently, certain situations may beidentified with having a panic attack, such as cross-ing a bridge or being on an escalator. Once a panicattack has occurred in a particular setting, the indi-vidual may become fearful that it will happenagain and tend to avoid that situation.

The Context of Panic Attacks

When a health professional assesses the signifi-cance of the problem, it is important to determinethe context in which it occurs. According to DSM-IV, three characteristic types of panic attack relatein different ways to the onset of the attack and thepresence or absence of situational triggers:

Unexpected panic attack: The onset of the attack isnot associated with any situational trigger.

Situationally bound attack: The attack almostinvariably occurs immediately on exposure to, orin anticipation of, the stressful situational trigger.

Situationally predisposed panic attack: More likelyto occur on exposure to the situational cue or trig-ger, but is not invariably associated with the cueand does not necessarily occur immediately afterexposure to the stressful factor.

268 panic attacks and panic disorder

Panic Disorder

When panic attacks recur frequently and disrupt anindividual’s life, the condition is known as panic dis-order. Sufferers (1 percent to 2 percent of the popu-lation) may have attacks ranging from two or threea day to two to four times a week. This type of dis-order tends to run a fluctuating course and becomesworse when the individual comes under stress.Panic disorder usually begins during periods ofchoices, transitions, separation, and added responsi-bilities. There is often a family history of panic dis-order. For example, first-degree relatives of patientswith panic disorder are at a markedly higher risk ofdeveloping the disorder (15 percent to 20 percentcompared to 1 percent in the general population).

In diagnosing panic disorder, the essential fea-ture is the presence of recurrent, unexpected panicattacks followed by at least one month of persistentconcern about having another panic attack, worryabout the possible implications or consequence ofthe attacks, or a significant behavioral changedrelated to the attacks.

Personality Characteristics

Personality characteristics of those who have panicdisorder vary considerably. However, H. MichaelZal, a clinical professor of psychiatry at thePhiladelphia College of Osteopathic Medicine, hasobserved some common factors. Additionally,cross-sectional studies of persons with panic disor-der or agoraphobia have demonstrated personalitytraits of dependency, avoidance, low SELF-ESTEEM,and interpersonal sensitivity. One common attrib-ute shared by panic-prone people may includeplacing a great value on CONTROL. Any loss orthreatened loss of control, particularly changes intheir lifestyles, causes them to feel anxious andstressed. According to Dr. Zal, panic-prone peopleovervalue their independence and feel great dis-comfort in acknowledging their dependency needs.They are often reluctant to accept help and preferhelping others. Known to repress feelings, they feelanxious when their EMOTIONS surface. As perfec-tionists and compulsive individuals, they have highexpectations of themselves and others.

It is difficult to estimate how many men sufferfrom panic disorder because men may attempt tomask their symptoms by drinking alcohol or byother means. This type of self-medication can

develop into a secondary problem. Many men goto family physicians, see multiple specialists, or endup in emergency rooms, thinking they have phys-ical disorders. They complain of lower gastroin-testinal problems, which are sometimes a symptomof panic disorder. When the panic disorder istreated, these gastrointestinal symptoms disappear.

Treatment for Panic DisorderTreatment for the stresses that come with panicdisorder may involve COGNITIVE THERAPY, BEHAVIOR

THERAPY, or medical therapy. Often a combinationof treatments is specifically chosen for each patient.Treatment begins with education about the illnessand encouragement to reenter situations the per-son has come to avoid. Help for some individuals isin cognitive therapy (changing how they think anddealing with their feeling of anxiety). For others,behavior therapy (changing how they act inresponse to certain situations and using desensiti-zation techniques to gradually expose sufferers tothe situations they have avoided) is useful.

In the late 1990s, ALPRAZOLAM (trade name,Xanax) was the first and only medication approvedin the United States for panic disorder. Previously,various studies indicated that tricyclic antidepres-sant drugs (such as imipramine) provided an effec-tive, safe treatment for panic disorder. However,these medications typically take three to six weeksfor noticeable improvement, and side effectsincluding anxiety symptoms occur in up to one-third of the patients.

Help for Panic Disorder SufferersFamily members can help in recognizing panic dis-orders by being alert to the individual’s level ofanxiety. Because symptoms can be hidden,repeated avoidance of situations is often the bestclue. Family members can give the sufferer sup-port, be good listeners, and talk openly and con-structively among each other. Instead of enablingthe person to avoid a situation, family memberscan help him or her make a small step forward byfinding something positive in that effort.

See also PHARMACOLOGICAL APPROACH; TACHY-CARDIA.

FOR FURTHER INFORMATION:Anxiety Disorders Association of America8700 Georgia AvenueSilver Spring, MD 20910

panic attacks and panic disorder 269

(240) 487-0120http://www.adaa.org

National Mental Health Association1021 Prince StreetAlexandria, VA 22314-2971(800) 969-6642 (toll-free)(703) 684-7722(703) 684-5968 (fax)http://www.nmha.org

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual, Fourth Edition. Washington, D.C.: AmericanPsychiatric Association, 1994.

Kahn, Ada P. “Panic Attacks” and “Family Members CanHelp Sufferers Cope with Attacks.” Chicago Tribune,June 23, 1991.

Zal, H. Michael. Panic Disorder: The Great Pretender. NewYork: Insight Books, Plenum Press, 1990.

parental afterschool stress (PASS) Working par-ents worry about their children during the lateafternoon hours. More than 37 percent of the laborforce consists of parents of minor children; most ofthose children are school age. However, most ofthese parents have work schedules that preventthem from being home when their children get outof school. The gap between the end of the schoolday and the time most parents get home fromwork is estimated at about 20–25 hours each week.There are significant health, academic, and socialrisks associated with leaving school-age childrenunsupervised. Children’s well-being as well asparental work performance is affected.

A study by the Community, Families and WorkProgram at Brandeis University and funded by theAlfred P. Sloan Foundation of 243 parents, mostlymothers, employed at JPMorgan Chase, revealedthe impact of reliable after-school options on par-ents’ productivity at work and their psychologicalwell-being.

In 2004 researchers Rosaline Barnett and KarenGareis reported that parents with high parentalafter-school stress are much more frequently inter-rupted, distracted, and drained of energy at workby nonwork issues; they much more frequentlymake errors, turn down requests to work extrahours, and miss meetings and deadlines at work.The quality of their work is significantly lower thanthat of their low-PASS counterparts.

Parental concerns about children’s afterschoolarrangements have a bottom line cost in lost pro-ductivity. This cost may be reflected in up to fiveextra days of missed work per year per employee.On average, not including vacation days, employedparents with high PASS miss about eight days ofwork per year, while their counterparts with low-PASS miss about three days of work per year.

Employed parents who were at the highest riskfor parental afterschool stress were those whosejobs were less flexible and whose children spentmore time unsupervised after school. Other factorscontributing to parental stress included a longcommute time.

See also FLEXIBLE WORK HOURS; SHIFT WORK;WORKING MOTHERS.

parenting Caring for and nurturing children. Theterm may also apply to the situation when grand-parents take over the care of their grandchildrenbecause their sons or daughters are no longer ableto fulfill their responsibilities.

Of all the roles in life, parenting is one of themost important; it is one for which there is theleast preparation and which therefore brings withit a great deal of STRESS. For those with littleinstruction and no experience, the stress of parent-ing begins with the basics of feeding, bathing, andcaring for the baby. As role models, parents providemoral and ethical values; as disciplinarians, theyreward good conduct and withhold reward whenconduct is bad. They deal with family disputesincluding sibling rivalry and, at the same time, tryto avoid playing favorites, recognizing the needs ofall their children. Keeping children safe through-out their lifetime is a constant concern.

Parenting involves responding to problems andconcerns of children, both physical and mental. Aschildren grow, parents watchfully wait to step inwhen there is trouble while recognizing their owncapacities and respecting their children’s need todo things for themselves.

Parenting Adult Children

When children become adults, the parenting roleoften becomes one of friend and companion. Manyadult children and their parents enjoy the samesports activities, traveling together, and sharinghobbies. Characteristics of a good relationship while

270 parental afterschool stress

the children were growing up, such as open andhonest communications, carry over into later life.

Eventually the young people leave home andsome parents are faced with the EMPTY NEST SYN-DROME and no longer feel needed. While this maybe a time of stress and loneliness, it is a time whenparents can explore their own interests and enjoythe intimacy they shared as newlyweds.

DIVORCE carries with it special stresses for theparents as well as children. Another stressfuldimension of parenting is when grandparents takeover the role of parents. A growing numbernationwide have assumed the financial, physical,and emotional responsibility for their grandchil-dren. Grandparents Raising Grandchildren wasfounded in 1988 to provide the information andresources needed for those facing this stressfulchallenge. Current census figures indicate 4.7 mil-lion children living with grandparents and 1.1. mil-lion being raised by grandparents alone; however,this may be an understatement because the figuresdo not cover informal living arrangements.

See also BIRTH ORDER; ELDERLY PARENTS; SIBLING

RELATIONSHIPS; STEPFAMILIES; WORKING MOTHERS;UNWED MOTHERS.

SOURCES:Leach, Penelope. The Child Care Encyclopedia. New York:

Alfred A. Knopf, 1984.Rogers, Fred. “Parenting: A Lifelong Commitment.” The

Rotarian (September 1995): 12–14.

passive aggression See AGGRESSION.

passwords See COMPUTERS; IDENTITY THEFT.

PDA (personal digital assistant) See ELECTRONIC

DEVICES.

Peck, M(organ) Scott (1936– ) American psy-chiatrist, author and lecturer and author of severalbest-selling books, including The Road Less Traveled:A New Psychology of Love, Traditional Values and Spir-itual Growth and The Road Less Traveled and Beyond.Peck postulates that when an individual acceptsthe inherent stresses in life, he can transfer weak-ness into strength through self-discipline and love.This “real love” is “an act of the will to extend one-

self for the purpose of nurturing one’s own oranother’s spiritual growth.”

For many years, Peck has had an interest in thegrowing interface between RELIGION and science.He received his M.D. from Case Western ReserveUniversity and his A.B. from Harvard University.

See also GENERAL ADAPTATION SYNDROME; HARDI-NESS; PRAYER.

SOURCE:Peck, M. Scott. The Road Less Traveled and Beyond. New

York: Simon and Schuster, 1997.

peer group A group whose members are of equalstanding with each other. This refers to people whoare of the same age, educational level, or have thesame job or profession. A peer group can causestress for the individual because it can influencefeelings of self-concept, SELF-ESTEEM, attitudes, andbehaviors.

Peer group relationships are important to chil-dren as well as adults. While children look to eachother for acceptance and approval, so do adultswho are seeking new friends and acceptance in agroup.

Peers are crucial to psychological developmentof the individual throughout life. Children learn tocooperate, work together, handle aggressiveimpulses in non-destructive ways, and explore dif-ferences between themselves and their friends.Throughout the school years, children rely on theirpeers as important sources of information and mayuse peers as standards by which to measure them-selves. Many look to their peers as models ofbehavior and for social reinforcement as often asthey look to their own families.

Some children who do not learn to combatLONELINESS by fitting into a peer group maydevelop emotional problems later in life. Thesechildren who feel different from their peers mayendure particular stresses as they work toward fit-ting in. Such children may be those who are inrecently divorced families, recently merged fami-lies with two sets of parents, or adopted children ofsingle parents. However, there are children, whenthere are no extenuating circumstances, who areborn loners and shun the values of their peers.

For adults, the increasing mobility that oftencuts them off from family and longtime friends has

peer group 271

made the development of peer relationships atwork and in other social and community activitiesextremely important.

Peer Pressure

Peer pressure is the influence of the peer group onthe individual. It begins in adolescence, becauseteenagers want to belong to a group. Teenagersreact to the physical changes they are goingthrough, as well as their changing responsibilitiesand experiences by close bonding with those intheir own age group. Music, language, and cloth-ing are held extremely important by the peergroup. The rallying cry of teenagers often is “every-body’s doing it.” Parents frequently becomestressed by this peer pressure on their youngsters.They may also fear that the influence of friendsmay lead their children to genuinely damagingactivities such as experimenting with drugs, irre-sponsible sexual activity, criminal behavior, ordropping out of school.

Peer pressure doesn’t end with the teens butbecomes more subtle in the ways it affects adults.It may be caused by ADVERTISING that brings the“keeping up with the Jones” philosophy thateveryone else on the block has one; it may arisefrom the COMPETITION generated by the BABY

BOOMERS who influenced their generation by plac-ing a high value on possessions, or it may behuman nature that among peers there will alwaysbe leaders who have the power to influence.

See also PARENTING; PUBERTY.

peptic ulcer Ulcers in the part of the digestivetract where gastric (stomach) secretions are presentare known as peptic ulcers. They may occur in theesophagus, stomach, or duodenum. STRESS maycreate an opportunity for peptic ulcers to developbecause it can cause people’s stomachs to churn outexcess gastric acid. However, doctors now believethat infection by the bacterium Helicobacter pylori isthe primary cause of many ulcers.

The symptoms of peptic ulcers sometime disap-pear for periods of days, weeks, or months, only toreappear, often after a person has become emotion-ally tense or nervous, or has picked up an infectionthat disturbs the chemical balance of the system.Other symptoms are loss of appetite, belching, feel-ing bloated, weight loss, nausea, and vomiting.

Every day, an estimated 4,000 Americansdevelop a peptic ulcer. Heredity can be a factor. If aperson’s blood relatives have had ulcers, his or herchance of getting one is increased two or threetimes. Two additional risk factors are involved ingetting ulcers: smoking and overuse of aspirin.Smoking cessation improves the odds against get-ting an ulcer. Aspirin can adversely affect the pro-tective lining of the stomach and duodenum.

Types of Ulcers

There are two common types, duodenal and gastric.A duodenal ulcer is a sore that occurs in the duo-denum, the first part of the intestine into whichthe stomach empties. More than 80 percent of allpeptic ulcers are found in this area in young ormiddle-aged people. A sharp, gnawing pain mayoccur one to three hours after meals and will usu-ally go away when a little food is eaten. Pain mayalso occur in the middle of the night when foodhas left the stomach and the ulcer is being bathedin acid. Individuals may often feel extremely hun-gry, but eating sweets and foods that stimulate thesecretion of the acid will probably start or intensifythe pain.

Gastric ulcers are sores in the lining of stomach.Increasingly, they have become a disease of olderpeople, most often occurring between the ages of55 and 65; men and women are equally affected.The pain may begin with a meal or soon after andfeels relatively constant. It is not likely to berelieved by eating food and may even be madeworse with eating. Antacids may not provide anyrelief.

Advice About Diet and Medication

Bland diets were once recommended for ulcerpatients, but that is rarely the case anymore. Aphysician may suggest that the sufferer avoid anyfoods that irritate the stomach, but will probablywrite a prescription for an ulcer medication. Sev-eral pharmaceutical products now are availablethat are quite successful at eliminating ulcer painand healing the ulcer itself. Doctors often prescribeantibiotics to kill the H. pylori bacteria.

Even when symptoms vanish, taking medicationas prescribed is necessary. This is extremely impor-tant since the ulcer may not quite be healed, evenif the pain has been relieved. Most ulcers generally

272 peptic ulcer

heal within four to six weeks of treatment, but theycan rapidly recur if the medication is stopped toosoon. Duodenal ulcer can be a chronic conditionand there is a good chance that the ulcer will recur.Some physicians recommend that certain peopletake, on an ongoing basis, a reduced dosage of ulcermedication to prevent recurrence.

See also RELAXATION.

FOR FURTHER INFORMATION:Digestive Disease National Coalition507 Capitol Court NE, Suite 200Washington, DC 20002(202) 544-7497(202) 546-7105 (fax)http://www.ddnc.org

perfection The state of being expert, proficient,flawless, without fault or defect. It is an unrealisticgoal, a drive toward the impossible and unattain-able and is a source of stress for many people. Per-fectionists are very achievement-oriented. Theyare unable to select what is important and have thefaulty idea that perfectionism equals quality.

The perfectionist faces stress and frustrationwith failure of any kind, imagined, real, large, orsmall. The obsession with perfection ultimatelyresults in fragmentation of self, loss of efficiency,sleep deprivation, less time for exercise, rest andquiet meals, increased use of alcohol and drugsand, ultimately, exhaustion. The perfectionist idealleaves out the important fact that people are onlyhuman, and have limitations of body, mind, andspirit.

Overcoming Perfectionism

People who are plagued by the need to be perfectand the stresses that are incurred should realizetheir own limitations and reevaluate personal pri-orities. They must decide what is important andwhat is not and set realistic deadlines and short-and long-term goals, and choose values that matter.

See also OBSESSIVE-COMPULSIVE DISORDER; SELF-ESTEEM.

performance anxiety Many people experienceextreme stress over any kind of performancebecause they fear failure, CRITICISM, or not measur-ing up to real or imaginary standards. Issues ofSELF-ESTEEM are involved. Time and energy spentin thinking about their fears may interfere withconcentration on preparation and on the perform-ance.

For some individuals, performance anxiety maycause loss of sleep, indigestion, DIZZINESS, or evenfaintness. However, if properly directed, the nerv-ous energy generated by stress before a perform-ance can become an advantage. When focused onthe best possible outcome, for example, that therewill be a standing ovation, the individual will bechallenged to do a good job.

Performance anxiety is a common stressor topeople who speak publicly before large or smallaudiences, as well as musicians, actors, and otheron- and off-stage performers. Anyone who is thecentral focus of other people’s attention can expe-rience performance anxiety.

performance anxiety 273

TIPS TO AVOID THE STRESS OF LIVING WITH AN ULCER

• Avoid foods that cause you to experience ulcerpain.

• Avoid alcohol, juice, and caffeinated drinks suchas coffee, tea, and cola beverages.

• Eat three nutritionally balanced meals each day.• Milk may relieve some pain at first but actually

causes the stomach to produce even more acid.Ask your doctor if you should avoid milk.

• Take medication exactly as your doctor pre-scribes it.

CONQUER PERFECTIONISM: AVOID STRESS

• Look for sources of satisfaction in simplepleasures.

• Pursue special interests such as painting, music,gardening, reading, or handicrafts.

• Take better care of the personal self withimproved diet, rest, and exercise.

• Concentrate on the process of achieving a goalinstead of the goal itself.

• Establish friendship outside work and family.• Set personal priorities and stay with them.• Find time to be alone and become better

acquainted with yourself.

Coping with Performance Anxiety

Many individuals use MEDITATION and deep BREATH-ING exercises to reduce stress before performances.Others carry a good luck charm, which provides theiranxieties with a placebo-like effect. Some follow cer-tain rituals before every performance: establishing aroutine way of getting dressed, avoiding certainfoods or beverages (caffeine and alcohol particularly)or taking a walk. For severe cases of performanceanxiety, physicians may prescribe medication; how-ever, medications may have side effects.

See also PUBLIC SPEAKING; SOCIAL PHOBIA; STAGE

FRIGHT.

performance review Reviews that are held sepa-rately from salary reviews and are annual (some-times biannual) management evaluations of howwell employees are doing their jobs. The evalua-tions, held face-to-face, are a source of stress forboth the managers and the employees. Accordingto Dr. Susan E. Brodt, assistant professor of businessadministration, Duke University, “The process ofjob evaluations often is so stressful because mostcompanies do not do them correctly.” Brodtresearched how some 100 firms do employeereviews and concluded that they may be a waste oftime because the important topics were often notdiscussed. Brodt added that appraisals “generallyare conducted too late to change performance,often long after problems occur. They’re anxiety-filled and people tend to avoid sensitive subjects.”Finally and tragically, Brodt continues, they canlead to misunderstandings in which talentedemployees are fired or forced to leave the company.

Chris B. Bardwell, a Chicago-based humanresource consultant, argues in favor of perform-ance reviews “because employees need to knowareas in which they should improve and also areaswhere they are having success.”

However, it has been reported that when layoffsoccur, employees often feel that performance eval-uations are either not used at all or are purposelydowngraded to justify terminations. One study ontermination showed that 75 percent of the surveyrespondents had received “excellent” or “outstand-ing” in their last reviews and were still let go. As amanagement tool, performance reviews are oftenseen as political devices—inflated to assure maxi-

mum merit raises and deflated to speed up the ter-mination procedure—according to which way thewind is blowing.

See also JOB SECURITY; LAYOFFS; MERGERS; WORK-PLACE.

Perls, Frederick See GESTALT THERAPY.

personality The sum of all of an individual’sbehavioral and emotional tendencies. Personalitydevelops from the interaction of many complexfactors, including heredity and environment.Many theorists hold that genetics is more impor-tant than environment, while others take theopposite view.

Personality characteristics may be predictors ofhow well an individual copes with the stresses oflife. According to studies by psychologist SuzanneO. Kobasa and associates at the University ofChicago, survivors, or people with “HARDINESS,”share three specific personality traits that appear toafford them a high degree of stress resistance: theyare committed to what they do, they feel in CON-TROL of their lives, and they see change as a chal-lenge rather than a threat.

Personality Disorders

For some individuals, personality traits and pat-terns are severe enough to cause them extremestress and interfere with normal functioning. Suchindividuals are said to have a personality disorder.Personality disorders usually are recognizable byadolescence or earlier, continue through adult-hood, and become less obvious in middle or oldage. They involve behaviors or traits that affectrecent and long-term functioning. Individuals mayhave more than one personality disorder at a time.Their patterns of perceiving and thinking are usu-ally not limited to isolated episodes, but are deeplyingrained, inflexible, maladaptive, and severeenough to cause mental stress or anxieties, orinterfere with interpersonal relationships and nor-mal functioning.

Personality Tests

Personality tests are questionnaires designed todetermine various traits, assist in psychologicalresearch and, at time, determine the suitability of

274 performance review

an individual for a particular field of work or jobassignment. Personality tests measure many aspectsof an individual’s being, such as how easily she isdisturbed by stressors, how she relates to peopleand her degree of extroversion or INTROVERSION.

See also HOSTILITY; TYPE A PERSONALITY; TYPE BPERSONALITY; TYPE C PERSONALITY.

personal protective equipment (PPE) Acces-sories and clothing designed to provide a barrieragainst hazards while people work certain jobs.PPE can reduce stress for workers because theyfeel safer with the devices. Examples of PPEinclude hard hats, work boots, safety goggles, eyeand face protectors, hearing protectors, gloves,and respirators.

Many PPE regulations are set by the U.S. Occu-pational Safety and Health Administration (OSHA),including some to reduce hazards for those whowork with chemicals. For example, important OSHAPPE regulations for chemical workers includerequirements that employers perform a writtenhazard assessment, select appropriate PPE to pro-tect workers, and maintain a written record indi-cating that employees have been properly trainedbefore performing any job task. The training mustinclude understanding when PPE is essential, whatPPE is necessary, how to properly put on, remove,adjust and wear PPE, limitations of the PPE, andthe proper care, maintenance, and disposal of thePPE. While people may feel safer following theseregulations, many employers as well as employeesfind complying with these regulations an addi-tional source of stress because of necessary paper-work and reports.

Despite the protection from PPE, there areongoing sources of stress involved in their use.Appropriate PPE does not provide a 100 percentguarantee of safety, leaving workers in hazardousareas with varying degrees of stress on their jobs.In addition to using PPE appropriately, workersknow that every piece of PPE has limitations. Forexample, gloves may develop small holes and res-pirator cartridges may not indicate when they needreplacement.

personal space The invisible zone of privacy thatindividuals unconsciously put between themselves

and other people. Although personal space is some-thing rarely noticed, when it is invaded by someoneapproaching too closely, people may feel stressedand become anxious, irritated, and even hostile.

According to Lisa Davis, in In Health, “We inviteothers in to our personal space by how closely weapproach them, the angle at which we face them,and the speed with which we break a gaze. It’s asubtle code but one we use and interpret easily andautomatically, having absorbed the vocabularysince infancy.”

Anthropologists have reported that people fol-low fairly established rules regarding how far apartthey stand, depending largely on their relationshipto each other. For example, friends, spouses,lovers, parents, and children tend to stand inside a“zone of intimacy,” or within arm’s reach, while apersonal zone (about four feet) is comfortable forconversation with strangers and acquaintances.

The size needed for personal space depends onmany variables, including the individual’s culturalbackground, gender, and the nature of the occa-sion. Individuals from North European or Britishancestry usually want about a square yard of spacefor conversation in uncrowded situations. How-ever, people from more tropical climates choose asmaller personal area and are more likely to reachout and touch the occupant of another space. InMediterranean and South American societies,social conversations include much eye contact,touching, and smiling, typically while standing at adistance of about a foot. In the United States, how-ever, people usually stand about 18 inches apartfor a social conversation; while they will shakehands, they tend to talk at arm’s length.

Understanding cultural and gender differencesin interpretations of personal space is becomingmore important as intercultural trade and businesstransactions escalate. The interpretation of per-sonal space leaves much room for misinterpreta-tion. Consultants have developed businessesinterpreting for people of all nationalities themeaning and use of personal space to relieve thepossibilities for occurrences of stressful situations.

See also ACCULTURATION; CROWDING; MIGRATION.

SOURCES:Davis, Lisa. “Where Do We Stand?” In Health, September/

October 1990.

personal space 275

Padus, Emrika, ed. The Complete Guide to Your Emotions &Your Health. Emmaus, Pa.: Rodale Press, 1994.

pets Pets reduce the stress of LONELINESS, providecompanionship, and give owners a sense of orderin their lives. No matter what, the routine of caringfor pets provides a distraction from life’s stressfulproblems and draws the owners out of themselves.According to Health (November–December 1994),60 percent of American households have a pet.

Researchers have found that pets can be impor-tant factors in reducing stress and providing posi-tive effects on human health. James Serpell, azoologist at the University of Pennsylvania says:“People who acquire pets report fewer minorhealth problems such as colds, flus, and backaches.They tend to think less about their problems andare happier with their lives.”

According to a University of Pennsylvania study,blood pressure drops sharply when people simplystroke a cat or dog. A study of 5,741 Australiansreported that those who owned pets had choles-terol and triglyceride levels markedly lower thanthose who did not. Some nursing homes and otherinstitutions may have pets in residence or programsthrough which pets visit residents or patients.

A UCLA study reported that older adults whohad pets made fewer visits to doctors than thosewithout. Caring for an animal seemed to makethem feel less anxious about their own health.Many dentists keep aquariums in their officesbecause it seems that dental patients suffer lessanxiety if they watch fish in an aquarium beforeoral surgery.

In an effort to learn more about the symbioticrelationship between humans and pets, the Amer-ican Animal Hospital Association asked pet ownersquestions about day-to-day interactions with theirpet in a pet owner survey. Results from the surveyshow that: 75 percent of dog owners and 69 per-cent of cat owners spend 45 to 60-plus minuteseach day engaged in activities with their pets; 69percent of dog owners and 60 percent of cat own-ers said they give their pets as much attention asthey would to their children; 59 percent of the dogowners and 57 percent of the cat owners admittedto having their pet sleep with them or next to orunder the bed; and 54 percent of survey respon-

dents claimed that they feel an emotional depend-ence on their pets. The survey was conducted byAAHA drawn from its membership. Respondentswere pet owners from 39 states, the provinces ofCanada, and the District of Columbia, who taketheir pets to AAHA veterinarians.

Choosing the Right Pet

It is said that the world is divided into “dog people”and “cat people.” Cat owners admire their pets’independence, graceful shape and movements,and wild instincts. Since cats tend to require lesshuman companionship than dogs, they are idealfor busy people who must be away from home forlong periods of time. Dogs, on the other hand,have been called the “yes men of the animalworld.” They have an affectionate, emotionalnature and an appetite for food, regardless ofwhether they are really hungry or if it is good forthem. Most important, dogs offer unconditionallove and act out human behavior, which theirmore inhibited masters can enjoy vicariously.

Stress of Pet Loss

The death of a pet can be a devastating and stress-ful experience. The child who has lost a pet isinconsolable for a time; however, this brush withgenuine loss may lead to maturity. Adults who losepets often are reluctant to express themselvesfreely about their sorrow because they fear thatothers will think their behavior is childlike andself-indulgent. The fact that veterinary hospitalsnow send a sympathy card or letter of condolenceon the death of a pet shows the awareness of thestressful effect of a pet owner’s loss.

See also GRIEF.

SOURCES:American Veterinary Medical Association. Animal Health

News and Feature Tips. Summer 1995.Dossey, Larry. “The Healing Power of Pets: A Look at

Animal-Assisted Therapy.” Alternative Therapies 3, no.4 (July 1977).

Laskas, Jeanne Marie. “When the Nine Lives Are Over.”Health, March 1997.

pharmacological approach Therapy for disorderscaused or worsened by stress are often treated witha pharmacological approach. In many cases, pre-scription medications are used in combination with

276 pets

psychotherapy, BEHAVIOR THERAPY, or some of manyALTERNATIVE MEDICINE approaches. Prescriptionmedication is often helpful for individuals who haveANXIETY DISORDERS, DEPRESSION, AGORAPHOBIA, PANIC

ATTACK AND PANIC DISORDER, OBSESSIVE-COMPULSIVE

DISORDER, POST-TRAUMATIC STRESS DISORDER, as wellas other disorders. In many cases, use of MEDITATION,BIOFEEDBACK, GUIDED IMAGERY, and RELAXATION

therapy continue to be helpful after prescriptionmedication is stopped.

While there are many effective techniques formanaging stress without medications, the pharma-cological approach may be helpful, sometimes justfor the short term. Anxiety disorders, like somemedical conditions, can be controlled but notcured; chronic conditions require long-term man-agement, often with a combination of alternativetherapies as well as pharmacological therapies.

The best principle with pharmacological therapyis to use the lowest effective dose for the shortestpossible period of time. However, before any med-ication is taken, an individual should have a thor-ough medical and psychiatric examination.

Categories of Medications

There are three major classes of medications usedfor the disorders discussed in this book: benzodi-azepines (BZDs), cyclic antidepressants, and noncyclicantidepressants. Additionally, a number of pharma-cological agents are categorized as “other antianxi-ety medications.”

Alcohol is the oldest antistress drug and remainsthe most frequently used (and misused) nonspe-cific tranquilizer. BARBITURATE DRUGS have beenavailable since 1903; they are respiratory depres-sants and are contraindicated in people with respi-ratory insufficiency. In the 1930s, a series ofnonbarbiturate, non-BZD hypnotic drugs weredeveloped. Many of them carried the same prob-lems as the barbiturates and most are no longeravailable. In 1957 the first BZD, chlordiazepoxide(Librium) was introduced for the safe managementof anxiety.

Benzodiazepine Drugs

BZDs are popular choices in the early 2000s for thepharmacological management of anxiety. Otherindications for BZDs include insomnia, seizures,muscles spasms, and the induction of anesthesia.

All BZDs have similar anxiolytic, sedative, andanticonvulsant properties.

The length of BZD treatment varies betweenindividuals. Some individuals continue medica-tions for several years. Generally, long-term anxi-olytic treatment should continue for at least twoweeks after complete remission of symptoms. Thedose should then be tapered off, and, if possible,the medication should be discontinued. Should thesymptoms return, the medication can be usedagain but, upon remission, tapered off.

Antidepressant Medications

Antidepressants usually are not recommended fortreating episodic anxiety or even excessive anxiety.However, in cases of depression for which they areprescribed, doses will vary between individuals.

Most drugs used to treat depression either mimiccertain NEUROTRANSMITTERS (biochemicals thatallow brain cells to communicate with each other)or alter their activity. Antidepressants are thoughtto decrease the activity or concentration of theseneurotransmitters, which occurs during expres-sion. The major neurotransmitters involved appearto be NOREPINEPHINE, SEROTONIN, and dopamine.The precise pharmacologic mechanisms of antide-pressant drugs, as well as the balances of neuro-transmitters in individuals who have depression,still are not entirely understood. As newer, more

pharmacological approach 277

SOME COMMONLY USED BENZODIAZEPINE DRUGS

Trade name Generic name

Long ActingLibrium chlordiazepoxideKlonopin clonazepamTranxene clorazepateValium diazepamDalmane flurazepamPaxipam halazepamCentrax prazepamDoral quazepam

Short ActingXanax alprazolamAtivan lorazepamSerax oxazepamRestoril temazepamHalcion triazolam

specific antidepressants are developed, under-standing of antidepressants and depression evolvesand improves.

Historical Development of Antidepressants

Antidepressant medications were developed dur-ing the 1950s after physicians noted that tubercu-losis patients treated with iproniazid sometimesbecame extremely cheerful. The notion that thiselevated mood might be a side effect of the drugled to the development of a class of antidepressantsknown as monoamine oxidase inhibitors (MAOIs).They were followed by the tricyclic antidepressantsand lithium.

The three major categories of antidepressantsare tricyclic antidepressants (TCAs), monoamine oxi-dase inhibitors (MAOIs), and lithium. There are also“novel” antidepressants.

Commonly, antidepressant medications take upto two to three weeks before having a full effect(although side effects may begin immediately). Thetime elapsing before the drug becomes therapeuticvaries with the drug. Antidepressants may have tobe taken regularly for months, even years, if theirgains are to continue. For some individuals, relapseoften occurs upon stopping the drug.

Tricyclic Antidepressants

Tricyclic antidepressants are so called because thechemical diagrams for these drugs resemble threerings connected together. An example of a tricyclicantidepressant is imipramine, which has been usedsince the late 1950s. Tricyclics elevate mood, alert-ness, and mental and physical activity, andimprove appetite and sleep patterns in depressedindividuals. When given to a non-depressed per-son, tricyclics do not elevate mood or stimulate theperson; instead, the effects are likely to increaseanxiety and arouse feelings of unhappiness.

Tricyclic antidepressants are generally well toler-ated, relatively safe, and cause minimal side effects.Their antidepressant effects, however, often takeseveral weeks to appear; because of this lag, tri-cyclics are not prescribed on an “as-needed” basis.

Some depressed individuals may respond wellto one tricyclic, but not at all to another. Due to thetime lag of several weeks before any beneficialeffects show up, a physician will try first one drugfor the time needed, and then, if results are not

noticeable, prescribe another tricyclic, and give itseveral weeks. Such trials, with their waiting anduncertainty, may lead to some anxiety and stressfor both the individual and physician.

Some of the more well-known tricyclic antide-pressants (and their trade names) are shown in theaccompanying chart.

Side effects of tricyclic antidepressants. Side effects oftricyclic antidepressants include excessive drymouth, sweating, blurred vision, HEADACHE, uri-nary hesitation, and constipation. Drowsiness andDIZZINESS, as well as vertigo, weakness, rapid heartrate, and reduced blood pressure upon standingupright are likely to occur early on, but usually dis-appear within the first several weeks. Tricyclicsshould be used cautiously in persons with heartproblems.

Drug interactions and cautions. Tricyclic antidepres-sants and MAO inhibitors are not recommended tobe combined except under unusual circumstances.A common drug interaction involves the combina-tion of tricyclics and alcohol, and possibly other

278 pharmacological approach

ANTIDEPRESSANT MEDICATIONS

Trade name Generic name

Cyclic antidepressantsAnafranil clomipramineAsendin amoxapineAventyl, Pamelor nortriptylineElavil, Endep amitriptylineLudiomil maprotilineNorpramine, Pertofrane desipramineSinequan, Adapin doxepinSurmontil trimipramineTofranil, Janimine imipramineVivactil protriptyline

Monoamine oxidase inhibitors (MAOIs)Eldepryl selegiline/deprenylEutonyl pargylineMarplan isocarboxazidNardil phenelzineParnate tranylcypromine

Examples of “Novel” antidepressantsDesyrel trazodoneProzac fluoxetineWellbutrin bupropion

sedatives, as tricyclics enhance effects of these sub-stances. In large doses, use of other anticholinergicdrugs (those that block effects of acetylcholine, achemical released from nerve endings in theparasympathetic division of the autonomic nerv-ous system) may interfere with actions of hista-mine, serotonin, and norepinephrine. Side effectsmay include slurred speech, confusion, hallucina-tions, and memory deficits, particularly short-termmemory impairment.

Monoamine Oxidase Inhibitors (MAOIs)

MAO inhibitors (MAOIs) are primarily used forindividuals who have not responded adequately totricyclic antidepressants. These drugs are generallyconsidered somewhat less effective than the tri-cyclics, and, due to a wider range of potential andoften unpredictable complications, use is limited.However, MAOIs may be prescribed for certaintypes of depressions and generalized anxiety disor-ders and are used to help individuals who havepanic attacks.

When a tricyclic antidepressant is tried and dis-continued because of ineffectiveness, a gap of sev-eral days is recommended before the monoamineoxidase inhibitor is tried. In the reverse case, where

the MAOI is ineffective and is to be replaced by atricyclic, a much longer period of two weeksbetween medications is recommended.

Interactive effects. A drawback of the MAOIs, as agroup, is that they may lead to unpredictable andoccasionally serious interactions with some foodsand drugs. For example, combining MAOIs with aclass of drugs called sympathomimetic drugs maylead to serious complications; common nasal decon-gestant sprays often include phenylpropanolamineor phenylephrine, both sympathomimetics. Also,cough and cold preparations or any preparationnot specifically recommended by a physicianshould be avoided. The pain drug Demerol shouldnot be given with MAOIs, but other pain relievingdrugs, for example, morphine, can safely be used.

Individuals taking MAOIs must avoid the aminoacid tyramine or they may experience a dangerousrise in blood pressure. Tyramine is present in manyfoods, including alcoholic beverages, cheese, liver,lima beans, and beverages containing caffeine andchocolate.

A side effect of MAOIs is that they lower bloodpressure, an effect not well understood byresearchers; one MAOI, pargyline, is used to treathypertension.

Lithium

Lithium is effective in individuals who have bothdepression and mania and in preventing futureepisodes. It acts without causing sedation, but, likethe tricyclics and MAO inhibitors, requires a periodof use before its actions take effect. Side effects oflithium may rule it out for use as an antidepres-sant; there may be nausea and vomiting, muscularweakness, and confusion.

Other Treatments for Depression

ALPRAZOLAM (Xanax) may lift depression, althoughit is primarily a drug used to treat anxiety andpanic disorder. In some individuals, alprazolam hasshortened or interfered with panic attacks and alsoinduced sleep. In depressed individuals with a highlevel of anxiety, alprazolam may be added to tri-cyclic antidepressants.

Development of “Novel” Antidepressant Medications

In the past several decades, while conventionalantidepressants have been helpful for many indi-

pharmacological approach 279

COMMONLY USED TRICYCLIC ANTIDEPRESSANTS

Trade name* Generic name

Anafranil climipramineAsendin amoxapineAventyl nortriptylineElavil amitriptylineEmitripEndepEnovilJanimine imipramineNorfranilNorpramin desipraminePamelorSinequan doxepinSurmontil trimipramineTipramineTofranilTofranil-PMVivactil protriptyline

*Trade names as used in the United States.

viduals, limitations of these antidepressants havebeen noted, namely their lack of specificity ofaction, delayed onset of action, side-effect profile,and potential for lethality in overdose. Approxi-mately 20 percent to 30 percent of depressed per-sons do not respond to traditional antidepressants.

During the late 1980s and 1990s, the emergenceof newer antidepressants, such as fluoxetine andbupropion, offered the advantages of antidepres-sants with fewer side effects and less potential forlethality in overdose. However, research has shownthat both of these agents have unique side effects.Their overall efficacy appears to be no greater thanconventional antidepressant treatments, and theyalso have a delayed onset of action.

The goal of recently developed antidepressants isto act faster and more powerfully than previouslyused antidepressants, with less frequent and lesssevere side effects and with more ability to target anindividual’s specific type of depression. Newer anti-depressants are unicyclic, bicyclic, or of other molecu-lar configurations. Where tricyclics and MAOIs areunderstood to influence chemicals known as neu-rotransmitters, the newer antidepressants are tech-nically classified by their preferential influenceover individual neurotransmitters—norepinephrine,serotonin, or dopamine.

Fluoxetine. Fluoxetine (Prozac), one of the“novel” antidepressants, was introduced in theUnited States in 1988. Fluoxetine is part of a classof selective serotonin reuptake inhibitors (SSRIs)with low toxicity and free of many side effectsattributed to tricyclic antidepressants. Fluoxetine isnot sedative, has no anticholinergic side effects,and does not promote weight gain. Another SSRI,Sertaline, has similar advantages.

Like other antidepressant drugs, fluoxetine doesnot help everyone with depression. It has its ownunique side effects, including possible nausea andweight loss, both usually time limited, insomnia,and anxious agitation that occurs rarely and is dose-related. Most people adjust to these side effects.

Other Antianxiety Medications

Beta-blockers. Beta-blockers (beta-adrenergic recep-tor antagonists) are frequently used in treatinghypertension, angina, and migraine headaches.They are occasionally used to help individuals withsymptoms of anxiety such as rapid heartbeat,

tremor, tingling, perspiration, blushing, and chestconstriction. A number of beta blockers are effec-tive in treating both generalized anxiety and situa-tionally produced anxiety, such as SOCIAL PHOBIA

and PERFORMANCE ANXIETY.Buspirone. Buspirone (trade name: BuSpar), is

considered a “novelty” antianxiety agent and ispharmacologically unrelated to BZDs or other anx-iolytics. It is popular because it causes less sedationand has less potential for dependence than otheranxiolytics. However, there is a four-week lag inefficacy; with BZDs individuals notice a rapid onsetof improvement.

See also AFFECTIVE DISORDERS; BENZODIAZEPINE

DRUGS; EXOGENOUS DEPRESSION; HERBAL MEDICINE;IMMUNE SYSTEM; MANIC-DEPRESSIVE DISORDER; MIND-BODY CONNECTIONS; PSYCHOTHERAPIES; VALIUM.

SOURCES:Appleton, William S. Prozac and the New Antidepressants:

What You Need to Know about Prozac, Zoloft, Paxil, Luvox,Wellbutrin, Effexor, Serzone, and More. New York: Plume,1997.

Carlin, Peter. “Treat the Body, Heal the Mind.” Health.January/February 1997.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth, 2nd ed. New York: Facts On File, 2001.

Sachs, Judith. Nature’s Prozac: Natural Therapies and Tech-niques to Rid Yourself of Anxiety, Depression, Panic Attacksand Stress. Englewood Cliffs, N.J.: Prentice Hall, 1997.

Turkington, Carol. Making the Prozac Decisions: A Guide toAntidepressants. Los Angeles: Lowell House, 1994.

Wilkinson, Beth. Drugs and Depression. New York: RosenPublishing Group, 1994.

phobia An irrational, intense fear of an object orsituation and a strong desire to avoid the fearedobject or situation. Most people have minor fears,for example, experiencing some ANXIETY whenunable to avoid contact with bugs, bees, and otherundesirable encounters. However, when a fearinterferes with normal social function, causes sig-nificant distress, and is out of proportion to anyreal or apparent danger, it is considered a phobia.

Phobia sufferers are subject to a great deal ofstress because they cannot explain or understandtheir fear. Nor can they voluntarily control theiranxiety response and their need to avoid thedreaded stimulus or situation.

Phobic reactions that occur when the phobicstimulus appears include: persistent and irrational

280 phobia

panic, dread, horror or terror; rapid heartbeat,shortness of breath, trembling and overwhelmingdesire to flee the situation; and avoidance of thesituation.

Phobias are classified by the American Psychi-atric Association (Diagnostic and Statistical Manual ofMental Disorders, 4th ed.) as the most common formof ANXIETY DISORDER. People of all ages, at allincome levels, and in all geographic locations suf-fer from phobias. Between 5.1 percent and 12.5percent of Americans suffer from phobias. Brokendown by age and gender, phobias are the mostcommon mental health concern among women inall age groups and the second most common illnessamong men over age 25.

Categorizing Phobias

Phobias cannot be neatly classified because fear ofalmost any situation can occur and may be associ-ated with any other psychological symptoms. How-ever, in a general way, phobias can be classified as:

Specific phobias, also known as simple phobias.Specific phobias are characterized by a persistent,irrational fear of, and compelling desire to avoid,specific situations or objects. The category of specificphobias contains an endless list of fears, as almostany object or situation can be phobic for any givenindividual.

Commonly recognized specific phobias relate toparticular animals (dogs, rats, mice, birds, spiders,and snakes); enclosed spaces (claustrophobia),such as being in an elevator or sitting in the mid-dle of a theater row; darkness; heights; or thunder-storms. Some specific phobias have to do withtransportation, such as driving across bridges, rid-ing in trains, or flying in airplanes.

Phobias related to the sight of blood or injuryare unique types of specific phobias. Unlike otherspecific phobias, which cause increased pulse andother physiological signs of arousal, blood andinjury phobias produce lower pulse and bloodpressure, and bring on fainting spells.

A person who has a specific phobia experiencesstressful physiological symptoms and behavior typ-ical of many phobic disorders. However, becausethese fears are so specific, the individual can usu-ally manage to avoid contact with the object oftheir phobia. On the other hand, individuals whofear common situations, such as riding in elevators

or going over bridges, may not easily avoid thesestressful stimuli.

How simple phobias start is not well under-stood. Researchers differ in their explanations;some report that direct conditioning—for example,a traumatic event—is an important factor, whileothers say that indirect learning experiences orexposure to negative instructions and vicariousexperiences are also influential. Opinions varyregarding effects of family influences on specificfears. While some experts say that the majority ofsimple phobics come from families in which noother member of the family shares the same fear,some studies have found relatively strong associa-tions between the fears of mothers and children.Many simple phobics are dependent or anxiousindividuals, and their family backgrounds mayhave contributed to these characteristics. Individu-als who have simple phobias may not recall theorigin of their fear. Treatment of the phobic symp-tom, however, does not have to wait until the ori-gin is uncovered.

Specific phobias can begin at any age. However,certain phobias are more common among certainage groups. For example, infants often fear loudnoises and strangers. Fear of animals, which isprevalent in children between the ages of nine to11, stays with many girls after age 11 but disap-pears in most boys. Fear of aging occurs most com-monly in people over age 50.

Social phobia involves fear of being scrutinizedby others. People with SOCIAL PHOBIAs may fearmaking mistakes, being criticized, and makingfools of themselves. They also may fear eating ormaking a speech in public, using public toilets,writing in public, and making complaints. Becauseof the fear of interacting with the opposite sex,strangers, or aggressive individuals, social phobicsare stressed when they are in social or business sit-uations such as parties, meetings, and interviews.Some individuals will participate in a particularactivity only when they cannot be seen—for exam-ple, swimming in the dark. Social phobias developover many months or years, but sometimes a pre-cipitating event can be determined.

Social phobics have ongoing problems withexcessive stress, generalized anxiety, dependence,and DEPRESSION. Sweating, fainting, blushing, andvomiting may all be symptoms of social phobia.

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Usually social phobias begin in a range from 15to 30 years of age. They tend to persist throughoutadulthood, unlike specific or simple phobias, whichtend to diminish as the individual enters youngadulthood. Many such individuals have traits thatinterfere with social and marital adjustment.

Some social phobics attribute their fears todirect conditioning, some to vicarious factors, andsome to instructional and informational factors;direct negative learning experience may play animportant role. Development of social phobias maybe influenced somewhat by parental behavior. Forexample, parents who have few friends and aresocially anxious in the presence of others mayinfluence their children to react in similar ways.Also, the presence of anxiety in children is oftenassociated with criticism and verbal punishment.

Agoraphobia. Possibly the most stressful and seri-ous of the phobias. Agoraphobics are afraid toleave a safe place such as their home or be apartfrom a safe person such as a spouse or close rela-tive. Such separations cause intense anxiety andpanic. A small percentage of agoraphobics remainhousebound, sometimes for many years.

Symptoms of AGORAPHOBIA include a wide rangeof avoidance behaviors, including a fear of enteringpublic places or open spaces, traveling, social inter-action, and even being alone. Agoraphobics oftenhave physiological symptoms such as palpitations,lightness in the head, weakness, atypical chestpain, and difficulty in breathing. Some agorapho-bics have panic attacks. Agoraphobics express fearsof losing CONTROL, going insane, embarrassingthemselves, and dying.

Phobias of internal stimuli. These are fears thatdevelop within the individual without reason. Asan example, fear of dying from an illness, such ascancer, heart disease, or venereal disease, forwhich there are no physical symptoms. Some ofthese fears, which occur in both sexes, may beregarded as an extreme form of hypochondria.Often characteristic of depressive illnesses, thesephobias improve when the depression improves.

Obsessive phobias. Examples of obsessive phobiasare fear of harming people or babies, fear of swear-ing, or a fear of contamination that leads to obses-sive hand washing and cleaning. Such phobiasusually occur along with other obsessive-compul-sive symptoms.

Treatment of Phobias

Many forms of therapy, ranging from BEHAVIOR

THERAPY to psychoanalysis, are used by qualifiedpsychiatrists, psychologists, social workers, andother mental health professional to treat phobias.

In behavior therapy, the therapist focuses on thesymptoms and attempts to change the physiologi-cal reactions. There are phobic people who havegood results with exposure therapy. They are ableto face their feared object or situation and, as aresult, are desensitized. Many others are helpedwith BIOFEEDBACK, RELAXATION, GUIDED IMAGERY,and MEDITATION therapies.

Sometimes antianxiety drugs and a variety ofother medications can help people face their pho-bic situations and overcome them. Pharmacologi-cal treatment for phobias varies with individualsand should be used only with supervision by aphysician or mental health professional.

See also ALTERNATIVE MEDICINE; OBSESSIVE-COM-PULSIVE DISORDER; PANIC ATTACKS AND PANIC DISOR-DER; PERFORMANCE ANXIETY; PHARMACOLOGICAL

APPROACH; PSYCHOTHERAPIES; PUBLIC SPEAKING.

FOR FURTHER INFORMATION:American Psychiatric Association1400 K Street NWWashington, DC 20005(202) 692-6850http://www.psych.org

Anxiety Disorders Association of AmericaNational Mental Health Association1021 Prince StreetAlexandria, VA 22314-2971(800) 969-6642 (toll-free)(703) 684-7722(703) 684-5968 (fax)http://www.nmha.org

SOURCES:American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, 4th ed. Washington, D.C.:American Psychiatric Association, 1994.

Bourne, Edmund J. The Anxiety & Phobia Workbook. Oak-land: New Harbinger Publications, 1995.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Monroe, Judy. Phobias: Everything You Wanted to Know, ButWere Afraid to Ask. Springfield, N.J.: Enslow Publish-ers, 1996.

282 phobia

Nardo, Don. Anxieties and Phobias. New York: ChelseaHouse, 1992.

physician-assisted suicide See END-OF-LIFE CARE.

physicians Stress affects physicians, just as itdoes members of any other occupational group. Anincreasing number of American physicians arebecoming employees in managed care systems, andthis possibly means that they will have less AUTON-OMY and less CONTROL over their time management.Some physicians will change their professionentirely or will find other work in the health carefield, such as medical administrators, governmentanalysts, or health journal editors.

According to Peter Orton, in Canadian FamilyPhysician, among family physicians, stressors pre-dicting job dissatisfaction and lack of mental well-being have included the demands of the job andpatient expectations, interference with family life,constant interruptions at work and home, practiceadministration, and greater external managementof the profession.

Stress has effects on physicians, staff, family,and patients. Among physicians, stress is a leadingcause for SUICIDE, accidental poisoning, alcoholism,liver disease, substance abuse, and ANXIETY andDEPRESSION; marital problems and accidentsincrease because of these factors.

The effect on physicians’ families often goesunnoticed until it is too late. While spouses believetheir partners are emotionally drained, physiciansdeny it. Spouses often comment on physicians’inability to discuss emotional problems and com-plain that they are essentially left to bring up theirchildren as single parents. This has an effect onmarital relationships, particularly when it is a rela-tionship between two doctors.

Staff and patients also suffer from physicians’stress. Staff may be blamed for the physicians’ mis-takes and be the butt of their short tempers. Patientscomplain of being kept waiting for doctors’ appoint-ments and hurried through their examinations.

Still, there are many benefits in being a physi-cian, particularly a family physician. Historically,they have had autonomy, job security, and careeropportunities. Their work allows for a regular shar-ing of experiences with colleagues.

Preventing Stress

Once a stress-related problem is recognized byphysicians, they can try to reduce demands ontheir time. Stressors should be identified at an earlystage and practical steps taken to reduce them. Insome cases, physicians need to improve their orga-nizational skills, become proactive, and take con-trol. This involves using tools of human resourcemanagement, time management, delegation, COM-MUNICATION, and teamwork.

COPING mechanisms can be improved by seekingsupport in the WORKPLACE and at home. Time shouldbe allocated for family, exercise, and relaxation.

SOURCES:Chambers, R. “Health and Lifestyle of General Practition-

ers and Teachers.” Occupational Medicine 42, no. 2(1992): 69–78.

Orton, Peter. “Stress and Family Physicians.” CanadianFamily Physician 41 (February 1995).

placebo effect The therapeutic benefit of achemically inactive substance that has no medici-nal effect but that superficially resembles an activepharmacological effect or therapy. The wordplacebo is Latin and means “I shall please.” Patientsbelieve that taking a placebo will have positiveeffects on their health, and this can be an impor-tant factor in relieving the stresses involved inmany illnesses and conditions.

Usually the word placebo refers to a pill or cap-sule that has no pharmacologically active sub-stance; however, the term placebo effect is notrestricted to therapy with an inert pill. It appliesalso to therapeutic results, both psychological andphysiological, that occur by any method that hasno demonstrable specific action on the disorderbeing treated.

Sometimes placebos induce reactions because ofthe power of suggestion. For example, individualsenrolled in a “double-blind” study do not know ifthey are taking a placebo or the real drug, andmany improve because they think they are takingan active substance. The placebo effect wasdescribed in The Healing Mind, by Irving Oyle.“Whatever you put your trust in can be the precip-itating agent for your cure.”

See also ALTERNATIVE MEDICINE; MIND-BODY CON-NECTIONS; PRAYER.

placebo effect 283

plant closings See CORPORATE BUYOUT; COST-CUT-TING; DOWNSIZING; LAYOFFS; MERGERS.

plastic surgery Any operation carried out torepair or reconstruct skin and underlying tissuesthat have been damaged or lost by injury or dis-ease, malformed since birth, or changed withaging. Plastic surgery techniques enable an injuredor diseased person to regain some sense of SELF-ESTEEM and remove the stress of coping with thedeformity. Operations performed mainly to improveappearance in a healthy person are known as COS-METIC SURGERY.

The scope of plastic surgery improved dramati-cally during the 1990s by the use of microsurgicaltechniques to join blood vessels, allowing transferof blocks of skin and muscle from one part of thebody to another.

See also BODY IMAGE.

play therapy Used in psychotherapy as a treat-ment for stress-related problems in children. It isbased on the theory that all play in children hassome symbolic significance.

Children choose from toys, such as dolls andpuppets, and drawing and art materials, such asclay and finger paint, and games. These activitiesmirror children’s emotional life and fantasies,enabling them to act out feelings and thoughts thatcause anxiety and stress. Observing them at playhelps the therapist diagnose the source of thechild’s stresses. Play therapy is also referred to asanalytical play therapy and ludotherapy.

See also PSYCHOTHERAPIES.

plumbing A stressful occupation because itinvolves mending burst pipes, cutting openings inwalls and floors, and often using hand and powertools. Working hazards including falling from lad-ders, scaffolds and roofs, and slipping and falling onwet and slippery surfaces. Plumbers experience stressbecause of cuts, stabs, bruises, and finger crushingfrom hand tools and machinery, and being hit on thehead with pipes, particularly in CONFINED SPACES or inlow-ceiling basements and passageways.

Plumbers are also exposed to the stresses of bio-logical hazards, such as many microorganisms andparasites in sewage, stagnant water, and unsani-

tary installations. Additionally, they work in exces-sively damp, cold, or hot places and may experiencewrist problems due to overexertion during thread-ing and cutting work, and calluses on the knees(plumber’s knee) because of prolonged work whilekneeling.

They may have burns from hot or corrosive liq-uids from burst pipes, and burns from portableblowtorches used for soldering. Additional hazardscome from electric shock and electrocution fromportable lamps and electric tools, and fires andexplosions as a result of using mobile electric lampsor tools in confined spaces.

Plumbers may experience stress from chemicalhazards such as contact dermatitis from exposureto various components of draining and sewage liq-uids, from exposure to solvents and other compo-nents of cleaning fluids, and irritation of therespiratory system and eyes from exposure toacids, alkalis, and various corrosive liquids used tounclog pipes. They might also face oxygen defi-ciency or exposure to gases when working in con-fined spaces, irritation to the respiratory tract, andpossible damage to lungs from exposure toASBESTOS, mineral fibers and other fibers whenapplying or dismantling piping insulation or pipes.

See also CHEMICAL HAZARDS; ELECTRICITY; SLIPS,TRIPS, AND FALLS.

poison ivy Poison ivy (including sumac and oak)can cause severe skin rashes and is the most com-mon cause of allergic reactions in the UnitedStates. It affects 10 million to 50 million Americanevery year and can be a very stressful experience.

Itching, burning, and blistering cause stress forpoison ivy sufferers; they also experience stressfrom knowing that they can get poison ivy withoutcoming in contact with the plant. The colorless orslightly yellow oil (urushiol) that oozes from anycut or crushed part of the plant, including the stemand the leaves, is easily spread. Sticky, and virtu-ally invisible, it can be carried on the fur of ani-mals, on garden tools and sports equipment, or onany objects that have come into contact with acrushed or broken plant. The effect on the skin canbe neutralized to an inactive state by water.

Once the urushiol touches the skin, it pene-trates in a few minutes. In those who are sensitive,a reaction appears in the form of a line or streak of

284 plant closings

rash, sometimes resembling insect bites, within 12to 48 hours. Redness and swelling will be followedby blisters and severe itching. It is additionallystressful because the rash can affect almost anypart of the body, especially areas where the skin isthin; the soles of the feet and palms of the handsare thicker and less susceptible.

First-aid treatment includes thorough cleansingof the infected area, sponging with alcohol, andapplying calamine lotion. Severe reactions should bereported to a physician, who may prescribe corticos-teroids drugs to be taken by mouth or injection.

Prevention is the best cure. One should bewatchful for the plants whenever out of doors. Ifgoing to areas where poison oak or ivy is likely togrow, wear protective clothing.

See also ALLERGIES.

FOR FURTHER INFORMATION:American Academy of Dermatology930 MeachamSchaumburg, IL 60172-4965(708) 330-0230

police Police and other law enforcement person-nel have jobs that are inherently stressful and dan-gerous; they face unique hazards and are morelikely than workers in other fields to die violently,for example, suffering a fatal incident while purs-ing criminals or in highway chases.

Law enforcement officers perform a range ofduties from apprehending criminals to issuing traf-fic citations. Detectives may work as plainclothesinvestigators, collect evidence for criminal cases,and participate in raids and arrests. Special agentsemployed by federal government agencies conductcomplex criminal investigations, do surveillance ofcriminals, and sometimes infiltrate illicit drugorganizations using undercover techniques.

Law enforcement personnel can reduce theirsources of stress by some degree through goodtraining, teamwork, and special equipment such asbullet-resistant helmets and vests.

See also VIOLENCE.

politically correct Term coined in the early 1990sthat refers to a sensitivity about many causes,including the needs and problems of minorities anddisabled people, avoidance of sexist and racist terms

and attitudes, and respect for animals and the envi-ronment. In an effort to be “politically correct,”politicians, government officials, and organizationalleaders are adding an additional stressor to theirown activities as well as those of their constituentswho must use an additional caution in theiractions.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health, 2nd ed. New York: Facts On File, 2001.

postpartum depression DEPRESSION immediatelyfollowing the delivery of a baby. It is probablycaused by hormonal changes after the birth as wellas stressful psychological factors. Postpartumdepression ranges from extremely common andshort-lived “maternity blues” or “baby blues” to astate of serious depression in which the mothermay have to be hospitalized.

Some women become depressed after CHILD-BIRTH because they fear being a parent or being afailure as a parent. They feel less loving toward thebaby than they think they should and feel sexuallyunattractive to their mates because their bodieshave not regained normal shape. Women may beoverwhelmed with chores of a new baby, and sleepdeprivation, caused by the baby’s frequent wakingduring the night, can lead to additional stresses ofirritability and chronic fatigue. If women go fromcareers outside the home into full-time mother-hood, they may also suffer a loss of SELF-ESTEEM.With reassurance and support from family andfriends, this type of “blues” lasts only two or threedays. However, in about 10 percent to 15 percentof women the depression is more marked and lastsfor weeks. There is a constant feeling of tiredness,difficulty sleeping, restlessness and loss of appetite.These symptoms are more likely to happen whenthere is a strained relationship with the father,financial or other concerns, no family support or apersonality disorder. First-time mothers, singlemothers, or women who suffered from depressionduring PREGNANCY are likely sufferers. The condi-tion may clear up on its own or may be treatedwith antidepressant drugs.

Persistent, severe depressions may becomemajor depressions or bipolar (manic-depressivedisorders) and require psychiatric treatment.

postpartum depression 285

post-traumatic stress disorder (PTSD) ANXIETY

DISORDER produced by an unusual and extremelystressful event, such as assault, an act of violence,rape, natural disaster, or physical injury. PTSD hasbeen referred to as battle fatigue or shell shockwhen it occurred from military combat.

Often PTSD surfaces several months or evenyears later, although its symptoms can occur soonafter the event. Sufferers characteristically reexpe-rience the trauma in painful recollections or recur-rent DREAMS or nightmares. Some have diminishedemotional responsiveness (“numbing”), feelings ofestrangement from others, insomnia, disturbedsleep, difficulty in concentrating or remembering,GUILT about surviving when others did not, avoid-ance of activities that cause recollection of thetraumatic event, and intensive thoughts related tothe event. Avoidance behavior also affects suffer-ers’ relationships with others because they oftenavoid close emotional ties with family, colleagues,and friends.

Sometimes the re-experience comes as a sud-den, painful rush of EMOTIONS that seem to have nocause. These emotions may be anger or intensefear. Some PTSD sufferers endure anxiety andpanic attacks as a result. During panic attacks, theirthroats tighten, BREATHING and heart rate increase,and they may feel dizzy and nauseated.

Overcoming PTSD

Individuals who have PTSD can learn to workthrough the trauma and pain and resolve theiranxieties. Individual psychotherapy is one of manyuseful therapies. PTSD results, in part, from the dif-ference between the individual’s personal valuesand the reality of what he/she witnessed or expe-rienced during the traumatic event. Psychotherapyhelps the individual examine his/her values andbehavior with the goal of resolving the consciousand unconscious conflicts that were created. Addi-tionally, the individual works to build SELF-ESTEEM

and self-control, develops a reasonable sense ofpersonal accountability, and renews a sense ofintegrity and personal pride.

In many cases, family therapy is recommendedbecause members of the family may affect and beaffected by the PTSD sufferer. Some spouses andchildren report that their loved one does not com-

municate, show affection, or share in family life.The therapist can help members of the family rec-ognize and cope with the range of emotions theyfeel and, when needed, help them improve theircommunication skills and learn techniques for par-enting and stress management.

A newer technique for PTSD involves “rap”groups, in which survivors of similar traumaticevents are encouraged to share their experiencesand reactions. Group members help each otherrealize that many people have gone through thesame thing and experienced the same emotions.Over time, the members will experience animproved self-image and self esteem. Antidepres-sant medications have also been reported toreverse symptoms of PTSD.

National Center for Post-Traumatic Stress Disorder

The National Center for Post-Traumatic Stress Dis-order was established in 1989 within the U.S.Department of Veterans Affairs to carry out multi-disciplinary activities in research, education, andtraining. The center focuses on PTSD and otherpsychological and medical consequences of trau-matic stress.

The Executive Division in White River Junction,Vermont, directs the overall operations of the cen-ter. This division also houses the PTSD ResourceCenter, the largest collection of PTSD materials inthe world, and manages the Web site. In WestHaven, Connecticut, the Clinical NeurosciencesDivision specializes in pharmacotherapy, neurobi-ology, brain imaging, and genetic epidemiology. InMenlo Park, California, the Education and ClinicalLaboratory specializes in education and dual diag-nosis treatment, and houses a sleep laboratory. TheWomen’s Health Sciences Division in Boston,Massachusetts, emphasizes women veterans’issues, including physical health, sexual assault,and Gulf War syndrome. In Honolulu, Hawaii, thePacific Island Division has special expertise in eth-nocultural issues.

Although the center was created in response toa congressional mandate to address the needs ofveterans with military-related post-traumatic stressdisorder, the needs of others are also considered.PTSD is no longer considered a problem limited to

286 post-traumatic stress disorder

Vietnam War veterans; it is recognized as a majorpublic behavioral health problem for military vet-erans and active duty personnel subject to thetraumatic stress of war, dangerous peacekeepingoperations, and interpersonal violence. Also,because of the prevalence of assault, rape, childabuse, disasters, and severe accidental and violenttrauma among civilians, PTSD is also a publichealth problem in the general population. Esti-mates are that PTSD affects more than 10 millionAmerican children and adults at some point intheir lives.

While the center does not provide direct clinicalcare, the center’s research, educational, and con-sultation initiatives have positively affected theclinical treatment of veterans with PTSD. Also, thecenter’s efforts have contributed to the world’smost comprehensive body of literature on the sub-ject. Since its inception, the center has made sig-nificant progress in furthering the understandingand treatment of PTSD both within the VeteransAdministration and in the general population. As aleading authority on PTSD, the center serves andcollaborates with many agencies and constituen-cies, including veterans and their families, govern-ment policy makers, scientists, researchers,doctors, journalists, and the lay public.

See also COMMUNICATION; CONTROL; COPING; LIS-TENING; PSYCHOTHERAPIES.

FOR FURTHER INFORMATION:Anxiety Disorders Association of AmericaNational Center for Post Traumatic Stress DisorderVA Medical CenterWhite River Junction, VT 05001(802) 296-5132E-mail: ncptsd@ncptsd.orghttp://www.ncptsd.org

National Institutes of Mental Health5600 Fishers LaneRockville, MD 20857(301) 443-2403

U.S. Veterans AdministrationMental Health and Behavioral Sciences Services810 Vermont Avenue NW, Room 915Washington, DC 20410(202) 389-3416

SOURCES:Catherall, Donald Roy. Back from the Brink: A Family Guide

to Overcoming Traumatic Stress. New York: BantamBooks, 1992.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth, 2nd ed. New York: Facts On File, 2001.

Porterfield, Kay Marie. Straight Talk about Post-TraumaticStress Disorder: Coping with the Aftermath of Trauma. NewYork: Facts On File, 1996.

powerlessness Lacking the authority or capacityto act. It is a stressful situation for most peoplebecause they feel that they lack CONTROL and knowthat they cannot significantly affect the outcome ofa situation.

For some people, feelings of powerlessnessunderlie DEPRESSION, suspiciousness, and aggres-sive behavior. Powerlessness is also associated withwithdrawal, passivity, submissiveness, apathy,increased frustration, agitation, ANXIETY, AGGRES-SION, acting-out behavior, and even violence.

A person who feels powerless may be unable toset goals or follow through on activities relating toschool, work, or family life. This feeling can beinduced by illness and hospitalization, becausesuch events compromise a sense of self. Strategiesto help people who feel powerless include teachingthem to gain control of a situation and helpingthem to develop better means of COPING with thestressors in life.

See also AUTONOMY; SELF-ESTEEM.

SOURCE:McFarland, Gertrude K., and Mary Durand Thomas. Psy-

chiatric Mental Health Nursing. Philadelphia: J. B. Lip-pincott, 1991.

prayer Act of the individual speaking to God inadoration, confession, supplication, or thanksgiv-ing. According to researchers, repeating a prayercan help reduce stress and improve physical ail-ments by lowering the heart rate, breathing rate,and brain wave activity.

At a national conference on faith in Boston in1995, experts said that the idea of prayer is gainingsupport among cost-conscious health organizations.“The supposed gulf between science and spiritualityin healing does not always exist,” said HERBERT

BENSON, M.D., a Harvard Medical School professor.Benson explained that scientific studies have

prayer 287

demonstrated that, by repeating prayers, words, orsounds and passively disregarding other thoughts,many people are able to trigger a specific set of ben-eficial physiological changes. Studies show that thisRELAXATION response decreased visits to healthmaintenance organizations by 36 percent.

Another internationally known authority in thefield of mind-body medicine, LARRY DOSSEY, M.D.,said that the power of prayer to heal should nolonger be regarded as just a matter of faith. Dosseyis a physician who has practiced medicine for morethan 20 years. He has become a believer, not inRELIGION, but in a growing body of research sug-gesting that prayer is an important scientificallyverifiable factor in healing. “I have come to regardit as one of the best-kept secrets in medical sci-ence,” he says in his book, Healing Words: The Powerand the Practice of Medicine.

See also ALTERNATIVE MEDICINE.

SOURCES:Dossey, Larry. Healing Words (The Power of Prayer and the

Practice of Medicine), San Francisco: Harper, 1993.———. Meaning and Medicine (Lessons from a Doctor’s Tales

of Breakthrough and Healing). New York: Bantam/Dou-bleday, 1991.

pregnancy The period while a woman is carryingan embryo/fetus from conception to birth; it ismarked by a cessation of menses. Many womenmay find that their MOODS are more changeableand that they are subject to mental, emotional, andphysiological stresses at this time. They may expe-rience bouts of DEPRESSION, become easily annoyedor angered, feel more lethargic than usual, and besubject to periods of CRYING. Emotional changes aredue to hormonal as well as emotional adjustmentsinvolved in pregnancy.

An important influence in reducing the naturalstressors of pregnancy is a supportive emotionalenvironment during and after the pregnancy. Whilemost couples have a positive attitude, others havechildren to please the grandparents or because“everybody’s doing it.” In some cases, conceptionoccurs in an attempt to save a marriage that is dys-functional or to deal with anxiety about sterility.There are also anxieties relating to such questionsas: Was the child wanted, was an abortionattempted or considered, or are there hereditary

disorders in the family. However, these anxietiesusually are replaced by positive feelings as signs oflife are experienced and the pregnancy progresses.

For many women, an early symptom of preg-nancy is morning sickness, which is sometimes con-sidered “imaginary” but is a very real problem forsufferers. Nausea during the first months of preg-nancy may be due to a low level of vitamin B6, ormay occur because of the natural slowing down of apregnant woman’s digestive process. When foodremains undigested in the stomach for longer peri-ods than normal, nausea and the urge to vomitoccurs. Morning sickness usually diminishes or dis-appears by the time the pregnancy is in the fourthmonth. Other symptoms of pregnancy that can betroublesome are CONSTIPATION, HEMORRHOIDS, HEART-BURN, urinary tract infections, swollen ankles, BACK

PAINS, varicose veins, leg cramps, and breathlessness.Women may cope with the psychological

stresses of pregnancy better when they begin par-ticipating in “prepared CHILDBIRTH” classes, offeredby many hospitals, which teach prospective par-ents about the physiological changes that occurduring pregnancy and labor. These classes provideexercises to help the prospective mothers learn torelax and reduce tension. An example is the popu-lar Lamaze method, named for a French obstetri-cian, which involves breathing and relaxingmethods and massage routines for the expectantmother and her coaching partner right through thebirth itself.

Men and Pregnancy

Couvade (the French word for “hatching”) is theterm applied to the range of sympathetic physicalchanges men go through during their wives’ preg-nancy. Some men actually experience such symp-toms as nausea, fatigue, back pain, and weight gainas a result of the stresses of anticipated fatherhood.In Western cultures, however, men have a role inpregnancy and often participate in prenatal educa-tion classes and the birth event itself.

Baby Blues

Endocrine changes after childbirth as well asfatigue from being awakened during the night tofeed the newborn often lead to POST-PARTUM

DEPRESSION, or “baby blues.” Some women becomeweepy a few days after giving birth. Some who

288 pregnancy

experience clinical depressive symptoms may par-tially reject the infant and feel withdrawn. Thisresponse becomes evident in difficulties in feedingand patterns of mother-child interaction. In mostcases, postpartum depression does not last morethan two weeks. However, if it persists longer or ifa woman develops irrational fears, despair, hope-lessness, and violent anger toward the new baby,professional help should be sought.

Fears Lead to Stress in Pregnancy

Fears of pregnancy stem from both psychologicaland physical sources. For example, unmarriedwomen fear conceiving and bearing a child out ofwedlock, while some married women do not want achild; some fear the pain of childbirth, while othersare frightened of dying during childbirth; some fearthat their pregnancy makes them unattractive totheir husbands, while others are concerned aboutreturning to their original physical appearance.

Many women become anxious and embarrassedby the physical symptoms associated with preg-nancy. Morning sickness, food cravings, frequenturination, water retention, bloating, and swollenbreasts are some of their complaints. First-timemothers may not understand the movements ofthe fetus and fear that their baby is abnormal ordead. Recent findings about effects on the fetus ofthe mother’s smoking and alcohol consumptionhave caused many pregnant women to abstain outof fear that they will have an unhealthy baby.

Pregnancy and Sexual Intercourse

Marital stress arises for many couples during preg-nancy when they become concerned about theadvisability of continuing sexual intercourse duringpregnancy. In many relationships, partners may fearhurting the fetus or the man may fear hurting thewoman. Depending on the course of the pregnancy,gynecologists usually allow women who have nounusual vaginal discharges, pain, or other symp-toms, to continue sexual relations until the seventhmonth. In later months, modifications of coital posi-tion are suggested to assure that intercourse will notharm the baby or cause a miscarriage.

The United States has the highest rates of teenpregnancy and births in the western industrializedworld. According to the National Campaign to Pre-vent Teen Pregnancy (NCPTP), teen pregnancy

costs the United States at least $7 billion annually.Thirty-four percent of young women become preg-nant at least once before they reach the age of 20,about 820,000 a year. Eight in 10 of these preg-nancies are unintended and 79 percent are tounmarried teens.

Teenage pregnancy may be a source of stress forthe young woman, her family, and the community.Teen mothers are less likely to complete high schooland only 1.5 percent have a college degree by age30. Teen mothers are more likely to end up on wel-fare (nearly 80 percent of unmarried teen mothersend up on welfare), according to the NCPTP.

Contraceptive use among sexually active teenshas increased but remains inconsistent. Three-quarters of teens use some method of contracep-tion (usually a condom) the first time they havesex. A sexually active teen who does not use con-traception has a 90 percent chance of pregnancywithin one year.

Pregnancy Loss

Experts say that 20 percent to 30 percent of expec-tant couples will face the emotional pain and stressof prenatal loss. When a miscarriage occurs veryearly in a pregnancy, some people think it’s“nature’s way,” and that the couple should put themiscarriage behind them and go on with theirlives. Jane Summers, M.D., director, Women’sMental Health Program, Pennsylvania Hospital,disagrees. “You cannot predict the level of attach-ment based on the length of pregnancy.” Accordingto Dr. Summers, parents-to-be develop a fantasy oftheir baby. When pregnancy loss occurs, they losetheir fantasy baby: Even though they never got tosee their baby smile or hear the baby coo, the childis real to them in many ways.

Dr. Summers added: “Pregnancy loss has muchin common with other losses and, in some ways,can be more painful. When an adult dies, mournershave memories of the deceased that can be shared.The parents of an unborn infant have only theirprivate hopes and dreams. There are no tangiblememories to laugh and cry about with others.”

While women may have a harder time dealingwith the loss, some men have a particularly hardtime, too. Says Martin Rosenzweig, M.D., director,Mood Disorder Programs, Pennsylvania Hospital,“People extend sympathy to a woman in a way

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that may not be extended to a man.” Although notas obvious, men also may have dreams for theirunborn child. Often his spousal role may prevent aman from sharing his feelings, because he must bestrong for his wife. At the same time, the wife mayinterpret his silence as not caring. That’s why it isso important for couples to talk to each other abouthow they feel about the loss.

Typically, reaction of couples to the initial lossfollows a continuum. First, couples feel numb,empty, and shocked and are often in a state of dis-belief. Denial, which may turn to anger or rage,can follow. Next comes a series of “what ifs.” Whatif the wife hadn’t gone dancing; what if the hus-band hadn’t taken the wife camping? Would thebaby be alive? Though these reactions are unreal-istic, they are typical feelings of self-blame.

Emotions can be accompanied by physical reac-tions as well. Couples may notice changes in sleep-ing and eating habits, or feel anxious or tired. Withtime most people come to terms with their loss.However, if symptoms continue for too long, pro-fessional support can help. A therapist can help

people to come to terms with guilt and anger, andseparate reality from perception.

Assisted Reproduction Techniques

Pregnancy and motherhood without marriage hasbecome more culturally acceptable in some West-ern countries. Today, couples who cannot conceivecan become parents with use of “assisted repro-duction” techniques including in vitro fertilizationand artificial insemination. Surrogate motherhoodis also gaining some degree of acceptance, despitelegal complications. Women who delay mother-hood into their late thirties or early forties, becauseof their own or their husbands’ careers or becauseof the attraction of the single life, face diminishedfertility and greater anxiety about possibility ofbirth defects, which increase with maternal age.However, amniocentesis (testing the amniotic fluidto detect abnormalities in the fetus) can allay somefears of women who postpone motherhood.

See also INFERTILITY; UNWED MOTHERS.

FOR FURTHER INFORMATION:American College of Nurse-Midwives8403 Colesville Road, Suite 1550Silver Spring, MD 20910(240) 485-1800(240) 485-1818 (fax)http://www.midwife.org

American College of Obstetricians and Gynecologists

409 12th Street SWP.O. Box 96920Washington, D.C. 20090-6920(202) 638-5577http://www.acog.org

National Campaign to Prevent Teen Pregnancy1776 Massachusetts Avenue NW, Suite 200Washington, DC 20036(202) 478-8500(202) 478-8588 (fax)http://www.teenpregnancy.org

Planned Parenthood Federation of America434 West 33rd StreetNew York, NY 10001(800) 798-7092 (toll-free) (210) 541-7800http://www.plannedparenthood.org

290 pregnancy

HELPING OVERCOME THE STRESS OF PREGNANCY LOSS

• For parents who have experienced a loss: Afterseveral weeks have passed, don’t hesitate to seekmedical facts to help clarify misconceptions andfacilitate your grieving process.

• Join a support group and share your experiencewith others.

• Plan how you will spend anniversary dates.• Accept the help and support of family and

friends.• Give yourself time to heal.• For friends and relatives of the grieving parents:

don’t trivialize the parents’ GRIEF with clichéssuch as “Don’t worry, you’ll have another.”

• Don’t turn away from the grieving couple; try toprovide a sympathetic ear and support, exceptwhen the couple doesn’t want to talk.

• Help with tasks such as minding the grievingcouple’s other children, shopping, or preparingmeals.

• If the baby was named, refer to the name andrecognize anniversary dates.

SOURCES:Eisenberg, Arlene, Heidi Eisenberg Murkoff, and Sandee

Hathaway. What to Expect When You’re Expecting. NewYork: Workman Publishing, 1984.

Kahn, Ada P., and Jan Fawcett. The Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Rockwell, Beverly. “Expectant Fathers: Changes andConcerns.” Canadian Family Physician 35 (May 1989):663–665.

premenstrual syndrome (PMS) See MENSTRUATION.

presenteeism Showing up for work even if one istoo stressed, distracted, or ill to work productively.It is the opposite of ABSENTEEISM. Many workershave concerns such as children, elderly parents, orthe health of a loved one, or their own discomfortsdue to poor health. Reasons for working when illvary. Some feel they have a commitment to the jobincluding coworkers and company. Others cannotafford to take sick days or go on disability, and oth-ers are afraid to lose their job. Sometimes it is acombination of reasons. Their minds are occupiedwith many random issues and their time may betaken up with phone calls relevant to these situa-tions and not their jobs. There is a faulty assump-tion that when people are at work they are beingproductive. The problem of presenteeism is thatsuch workers are a drain on productivity.

Peter Schnall, M.D., and Maritza Jauregui,Ph.D., of the University of California, Irvine, char-acterized presenteeism, or “Lost Work ProductiveTime” by 1) time not on task, 2) decreased qualityof work, 3) decreased quantity of work, and 4)unsatisfactory employee interpersonal factors. Theresearchers suggested that presenteeism is a largerproductivity drain than either absenteeism or short-term disability. In 1999, the Employee Health Coali-tion of Tampa, Florida, found that lost productivityform presenteeism was actually 7.5 times greaterthan productivity loss from absenteeism.

A study by the Institute for Health and Produc-tivity Studies at Cornell University, reported inApril 2004, found that up to 60 percent of the totalcost of employee illnesses comes from presen-teeism. The study, supported by the National Phar-maceutical Council, the Cornell Institute, and aprivate firm, Medstat, used an insurance databaseon medical conditions and absences of about

375,000 employees over three years. They com-bined these with published studies on productivityamong workers with certain illnesses. Theresearchers estimated that from 49 percent to 89percent of the total costs caused by HEADACHES

were due to reduced on-the-job productivity,rather than absent employees or health care costs.Workers showing up with ALLERGIES were respon-sible for an estimated 55 to 82 percent of allergycosts to businesses. Estimates of on-the-job arthri-tis costs ranged from 35 to 77 percent.

In addition to not being mentally present on thejob, some employees are afraid of losing their jobsthrough DOWNSIZING, so they work excessive hoursor remain at work in the evenings in order to beseen when there is no work to do. The result ismore stress, unhappiness, and poorer performance.To avoid this situation, many employers insist thatworkers stick to their assigned hours and take vaca-tions at appropriate intervals, and they provideflexible working hours and other destressing tech-niques. Some employers realize that employeesneed not only lunch breaks but also a life outsidethe office. Solving the problem of presenteeismhelps workers to achieve a work-life balance.

British Telecom checks employee time sheets toidentify where long hours are being worked andreminds staff that overtime is not acceptable. TheBritish government is encouraging employers to helpreduce stress by requiring employees to take lunchbreaks and annual holidays and discouraging themfrom working long hours and taking work home.

In 1998, France conducted an experiment con-cerning work-life balance by enforcing a new 35-hour work-week. The aim was to reduceunemployment by redistributing labor between theoverworked and the unemployed. However,employers said the 35-hour week failed to createjobs and was uncompetitive. Unemployment inFrance remained at 10 percent in 2005.

Cary Cooper, professor of organizational psy-chology and health at Manchester University inthe United Kingdom, is credited with coining theterm presenteeism to describe the overwork andfeelings of job insecurity resulting from downsizingand restructuring in the 1990s. According toCooper, “The phenomenon of presenteeism, anoverwhelming need to put in more hours, or at the

presenteeism 291

very least, appear to be working very long hours, isanother dangerous symptom of the explosivedegree of pressure in the workplace.”

See also FLEXIBLE WORK HOURS; OVERTIME.

SOURCES:Andrea, H., et al. “Associations between Fatigue Attribu-

tions and Fatigue, Health and Psychosocial WorkCharacteristics: A Study among Employees Visiting aPhysician with Fatigue.” Occupational EnvironmentalMedicine 60 (2003): 99–104.

Schnall, Peter and Maritza Jauregui. “Work Stressors andTheir Cost to Employers.” In The Changing Nature ofWork and Workforces. Yelin, Ed, ed., Los Angeles, 2004.

presurgical stress Fears about pain, body dam-age, health, limited function, complications, oreven death. When patients understand beforehandwhat will happen and the possible consequences ofany surgery, stress can be reduced to some extent.

According to the Canadian Psychological Asso-ciation, preparing patients for the challenges ofsurgery is an essential component of overall sur-gery care. Preparation is now more important thanever because recent health care reforms emphasizeefficiency and cost-effectiveness, resulting inshorter hospital stays for all surgical procedures;the number of same-day surgeries has increased.

Presurgical preparation is a health care servicein which necessary information is provided to thepatient some time before admission.

Presurgical preparation has been shown to assistpatients in dealing more effectively with surgery.Presurgical preparation has been associated withreduced stress, fewer complications, greater satis-faction, shorter time in hospital, and more positivepsychological well-being. Such programs have alsobeen effective in reducing pain and discomfort, aswell as assuring that the patient follows self-careplans after the procedure.

SOURCE:Canadian Psychological Associationhttp://www.cpa.ca/factsheets/presurgical.htm

privacy protection See IDENTITY THEFT.

pro-choice and pro-life Pro-life is the term used-for those in favor of upholding the right to life forthe developing fetus and who are therefore againstabortion; pro-choice is the term used for those infavor of a woman’s right to choose whether or notto have an ABORTION.

These terms arose in the United States in the1970s and by the early 1980s had become centralto political debate and an important election issue.Pro-life advocates, along with pro-family advocateswho want a return to values based on the familyunit, oppose legalizing abortion. Pro-choice advo-cates believe their position supports the civil rightsof all women. The controversy between thesegroups continued throughout the 1990s, eruptingin shootings and bombings by pro-lifers and caus-ing emotional stress for individuals on both sides ofthe issue.

progressive muscle relaxation Also known asprogressive RELAXATION; a stress management pro-cedure in which individuals learn to make height-ened observations of what goes on under theirskin. They learn to control all of the skeletal mus-cles so that any portion can by systematicallyrelaxed or tensed by choice.

First, there is recognition of subtle states of ten-sion. When a muscle contracts (tenses), waves ofneural impulses are generated and carried to the

292 presurgical stress

REDUCE PRESURGICAL STRESS

Find out:• When to arrive at the hospital and where to

check in• What to bring, particularly if staying overnight• The specific procedure scheduled• Presurgical and postsurgical medications, such

as the anesthetic and pain medication• Expectations of how to feel after surgery• Self-care duties and related postsurgical exercise

programs• How long to stay in hospital before returning

home• How to prepare the home for recovery period

after hospital care• A discharge plan, support when leaving the hos-

pital and arriving at home

brain along neural pathways. This muscle-neuralphenomenon is an observable sign of tension.

Next, having learned to identify the tensionsensation, the individual learns to relax it. Relax-ation is the elongation (lengthening) of skeletalmuscle fibers, which then eliminates the tensionsensation. This general procedure of identifying alocal state of tension, relaxing it away, and makingthe contrast between the tension and ensuingrelaxation is then applied to all of the major mus-cle groups.

As a stress management technique, progressiverelaxation is effective only when individuals havethe ability to selectively elongate their muscle fiberson command. They can then exercise the self-con-trol required for progressive relaxation and morerationally deal with the stressful situation.

See also ALTERNATIVE MEDICINE; BIOFEEDBACK.

SOURCES:Jacobsen, E. “The Origins and Development of Progres-

sive Relaxation.” Journal of Behavior Therapy and Exper-imental Psychiatry 8 (1977): 119–123.

———. Progressive Relaxation, 2nd ed. Chicago: Universityof Chicago Press, 1983.

Lehrer, Paul M., and Robert L. Woolfolk, eds. Principlesand Practice of Stress Management, 2nd ed. New York:Guilford Press, 1993.

prostate cancer The prostate is a walnut-sizedgland located at the base of the bladder in males. Itsurrounds a part of the urethra, the tube that car-ries urine from the bladder through the penis.Prostate cancer is a malignant growth in the outerzone of the prostate gland. It is the second mostcommon CANCER in men; particularly during thelatter part of the 20th century, the threat ofprostate cancer, which seems to be on the rise, hasbecome a stressful issue. However, the increase inincidence may be partially attributed to earlyexaminations for the disease. When prostate can-cer is discovered at an early stage, the outlook forrecovery is very good.

This disease is especially common in African-American men and may run in families. Thefathers and brothers of men who have prostatecancer appear to have three times the risk of dyingfrom the disease.

Symptoms are caused by enlargement of theprostate and include difficulty in starting urination,

poor flow of urine, and increased frequency of uri-nation. Eventually the flow of urine may ceasebecause the urethra is blocked or because cancerhas spread to the bladder and ureters. In advancedcases, pain may be in the nerves of the pelvis or bespread by cancer to anywhere in the body.

Cancer of the prostate is diagnosed when thephysician feels the prostate through the rectumand it is hard and knobby. This is verified by ultra-sound scanning, pyelography, and prostatic biopsy.Also, a simple, painless blood test is available todetect prostate cancer. Treatment may be surgicalremoval of the prostate, radiation, or hormonaltherapy.

SOURCES:Goldfinger, Stephen E. “The Big Chill: Prostate Cancer.”

Harvard Health Letter 20, no. 11 (September 1995).Jacobsen, S. J., et al. “Incidence of Prostatic Cancer Diag-

nosis in the Era before and after Serum Prostate-Spe-cific Antigen Testing.” Journal of the American MedicalAssociation 274, no. 18 (November 8, 1995):1,445–1,449.

Prozac See PHARMACOLOGICAL APPROACH.

psoriasis A common and persistent skin diseasecharacterized by thickened patches of inflamed,red skin covered by silvery scales. It causes physi-cal discomfort as well as social embarrassment. Thediagnosis of psoriasis is a source of stress to affectedindividuals because there is no treatment that per-manently cures the disease.

In the United States, two out of every hundredpeople between the age of 10 and 30, have psoria-sis (4 million to 5 million people). Approximately150,000 new cases occur each year. Psoriasis cannotbe passed from one person to another, although itis more likely to occur in individuals whose familymembers have it. The name of the disease comesfrom the Greek word meaning “itch.”

Causes of Psoriasis

Dermatologists say that specific causes areunknown; however, there may be an abnormalityin the functioning of certain white cells in thebloodstream, which triggers inflammation in theskin, causing the skin to shed itself too rapidly,every three to four days. New spots may be noticed

psoriasis 293

10 to 14 days after the skin is cut, scratched, orseverely sunburned. Psoriasis also can be activatedby infections, such as strep throat, and by certainmedications. Dry skin and lack of sunlight some-times bring about flareups of the disease.

Forms of Psoriasis

Forms of psoriasis differ in the shape and pattern ofthe scales, how long they last, and where they are.The most common form begin with little redbumps, which gradually grow larger and formscales. Although the top scales flake off easily andoften, scales below the surface stick together.When they are removed, the tender, exposed skinbleeds; these small red areas grow, sometimesbecoming quite large. The most common sitesaffected by psoriasis are the elbows, knees, groinand genitals, arms, legs, scalp, and nails. It oftenappears in the same sites on both sides of the body.

Psoriasis affects nails by pitting them, and caus-ing them to loosen, thicken, or crumble. Inversepsoriasis occurs in the armpit, under the breast,and in skin folds around the groin, buttocks, andgenitals. Guttate psoriasis usually affects childrenand young adults. It often shows up after a sorethroat, with many small, red, drop-like, scaly spotsappearing on the skin. It often clears up withouttreatment in a few months or less.

Diagnosis and Treatment of Psoriasis

Dermatologists make a diagnosis of psoriasis byexamining the skin, nails, and scalp, and may takea skin biopsy for microscopic examination. Thegoal of treatment is to reduce inflammation andslow down rapid skin cell division.

Psoriasis outbreaks may improve with moderateexposure to sunlight or an ultraviolet lamp and useof a smoothing, emollient cream. Moderate attacksare treated with an ointment containing coal tar oranthralin. Other methods of treating psoriasisinclude corticosteroid drugs, PUVA (a type of pho-totherapy) and some types of anticancer drugs,such as methotrexate.

Some patients with severe psoriasis are treatedwith the Goeckerman treatment, named for aMayo Clinic dermatologist who first reported thetreatment in 1925. The treatment combines coaltar dressings and ultraviolet light and is performedin specialized centers.

Dermatologists and researchers are continuallytesting new drugs and treatments.

See also PAIN.

SOURCE:Goldfinger, Stephen E. “Scales of Injustice: Psoriasis.”

Harvard Health Letter 20, no. 2 (December 1994).

psychiatrist A physician (medical doctor with anM.D. degree) who specializes in the diagnosis andtreatment of mental, emotional, or behavioralproblems; some psychiatrists do research in thefield of mental health. Many people who cannotcope with the stresses in their lives seek help frompsychiatrists. Psychiatrists trace the patient’s per-sonal and family history to seek possible causes ofa problem. A psychiatrist can prescribe counseling,individually or in groups, and medications and, ifnecessary, can admit patients to hospitals.

Psychiatrists are trained in a variety of diag-nostic techniques and therapies. There is a strongmedical emphasis because of the rapid develop-ment of techniques of psychopharmacology whichrequire a knowledge of pharmacology, physiol-ogy, cardiology, and endocrinology, all subjectstaught in medical training. Recent advances inneuroscience, as it relates to behavior, have pro-vided a strong medical and psychosocial focus forpsychiatry.

In addition to providing direct patient care,many general, child, and adolescent psychiatristsdevote time to other professional activities, such asadministration, medical teaching, and research,and many work in more than one setting. Psychi-atrists today are likely to devote at least part oftheir practice hours to salaried and managed caresettings, including health maintenance organiza-tions, preferred provider organizations, and largehospital systems.

Cooperation and consultation between psychia-trists, primary care physicians, and other healthcare practitioners continues to be important for theprovision of comprehensive care to patients. Espe-cially in rural areas, primary care providers are crit-ical gatekeepers for the diagnosis and treatment ofmental health problems. The detection of mentaldisorders and the treatment of the less severe dis-orders, including the prescription of medications,often take place in a primary medical setting. Pri-

294 psychiatrist

mary care physicians, however, are less likely thanpsychiatrists to treat patients with serious or com-plex mental disorders, such as patients with dualdiagnoses or comorbidity of psychiatric and med-ical illnesses. Primary care physicians are morelikely to prescribe medications for anxiety, whilepsychiatrists are more likely to prescribe drugs forDEPRESSION.

See also PHARMACOLOGICAL APPROACH; PSY-CHOTHERAPIES.

SOURCES:“The Future of Psychiatry.” Journal of the American Medical

Association 264, no. 19 (November 21, 1990).Manderscheid, R. W., and M. A. Sonnenschein, eds. Men-

tal Health, United States, 1990. DHHS Pub. No. (ADM)90-1708. Washington, D.C.: Government PrintingOffice, 1990.

psychoanalysis The mode of treatment for men-tal health disorders developed by Sigmund Freudand his followers at the beginning of the 20th cen-tury. He believed that mental disorders were aresult of the failure of normal emotional develop-ment during childhood.

Some individuals who suffer from extremestresses in their lives, with which they cannotcope, seek psychoanalysis. The therapy aims tohelp the patient understand his or her emotionaldevelopment and to make appropriate adjustmentsin particular situations.

Psychoanalysis is practiced by clinicians whohave undergone specialized training after resi-dency training. Individuals who practice psycho-analysis are usually medical doctors, but notnecessarily so. Those who are not must pass certainexaminations given by an accredited institute ofpsychoanalysis. Psychoanalysts must undergo psy-choanalysis themselves to resolve their own emo-tional problems before they start their practice. TheAmerican Psychoanalytic Association has morethan 3,000 members, and the International Psy-choanalytical Association numbers over 7,500.

Analysts use features of free association, dreamanalysis, and the development and workingthrough of transference or distortions in the indi-vidual’s relationship with the analyst. Sessions areusually held four or five times a week and a com-pleted analysis may take three to five years, but

length of treatment varies considerably with thenature of the problems being treated.

Changes in the Field

The nature of psychoanalysis is changing toinclude multiple theoretical viewpoints that worksynergistically. There is a proliferation of psycho-analytic publications dealing with clinical and the-oretical issues, as well as the application ofpsychoanalytic study to other fields such as history,literature, anthropology, and art.

See also PSYCHOTHERAPIES; SELF-PSYCHOLOGY.

psychodrama An adjunct to psychotherapy inwhich the patient acts out certain roles or inci-dents; this is sometimes useful for individuals try-ing to overcome the serious effects of stresses intheir lives. The roles or incidents may or may notbe related to people closely involved with the indi-vidual or may concern situations that they findparticularly stressful.

The purpose of psychodrama is to bring out hid-den concerns and to allow expression of a person’sdisturbed feelings. Therapeutic value comes fromthe release of pent-up emotions and from insightsinto the way other people feel and behave. Psy-chodrama is often carried out with a partner or ina group. In many cases, use of music, dance, andpantomime may be included.

The technique was developed by J. L. Moreno,a Viennese psychiatrist, in 1921. Psychodrama isconsidered an early form of group therapy orgroup psychotherapy.

See also ALTERNATIVE MEDICINE; DANCE THERAPY;PSYCHOTHERAPIES.

psycho-imagination therapy (PIT) A techniquethat uses waking imagery and imagination to effectpersonality changes and alter the ways in which anindividual copes with stress. The basic propositionof psycho-imagination therapy is recognizing peo-ple’s needs to become aware of how they definethemselves in relation to others and how theythink others define them.

See also ALTERNATIVE MEDICINE; PSYCHOTHERAPIES.

psychologist A nonmedical specialist in diagnos-ing and treating mental health concerns such as

psychologist 295

difficulties in coping with stress. In most states, apsychologist has a Ph.D. degree from a graduateprogram in PSYCHOLOGY. Licensed psychologistsreceive insurance reimbursement, have hospitalprivileges, and act as expert witnesses in courtcases.

Prior to World War II, psychologists were pri-marily involved in academic institutions, with onlya few individuals employed outside universitiesand actively engaged in mental health services.After 1977, with the passage of the Missouri psy-chology licensure act, all 50 states and the Districtof Columbia granted statutory recognition to theprofession.

Along with dramatic growth in the number ofpractitioners, there has been a significant expan-sion in the psychologist’s role as provider of men-tal health care. For example, today psychologistsare involved in almost every type of mental healthsetting, including institutional or communitybased, research or treatment oriented, or generalhealth or mental health focused. Within theseenvironments, psychologists’ roles have alsoexpanded beyond traditional activities of diagnos-tic assessment and psychotherapy to include pri-mary prevention, community-level interventionstrategies, assessment of service delivery systems,and client advocacy.

Psychology has many subspecialties, whichinclude child, developmental, school, clinical,social, and industrial; some psychologists have pri-vate practices, are employed by health care facili-ties, or teach in universities.

Psychologists cannot prescribe medications; theyrefer patients requiring medication to a physician.

See also BEHAVIOR THERAPY; PSYCHIATRIST; PSY-CHOTHERAPIES.

psychology The study of the processes of themind, such as memory, feelings, thought, and per-ception, as well as intelligence, behavior, andlearning. Within this field, there are many differentapproaches. For example, behavioral psychologystudies the way people react to events and adapt tostress; neuropsychology relates human behavior tobrain and body functions; and psychoanalytic psy-chology emphasizes the role of the unconsciousand the experiences of childhood.

Clinical Psychology

Clinical psychology is a branch of psychology spe-cializing in the study, diagnosis, and treatment ofbehavior disorders. This branch of psychologybecame popular in the United States during thelate 1940s and 1950s. Much of the research in clin-ical methods, diagnosis, and therapy has takenplace within departments of clinical psychology.

In most states, clinical psychologists must belicensed to treat clients and, in some states, theymust have a Ph.D. degree. Training for the Ph.D. inclinical psychology includes course work, develop-ment of research skills, and clinical practice.

See also BEHAVIOR THERAPY; PSYCHOTHERAPIES.

SOURCE:Manderscheid, R. W., and M. A. Sonnenschein, eds. Men-

tal Health, United States, 1990. DHHS Pub. No. (ADM)90-1708. Washington, D.C.: Government PrintingOffice, 1990.

psychoneuroimmunology (PNI) Relatively newbranch of science that studies the interrelationshipsamong the mind (psycho), the nervous system(neuro), and the IMMUNE SYSTEM (immunology).The aim of this field is to investigate and documentinterrelationships between psychological factorsand the immune and neuroendocrine systems.Research efforts include looking at effects of emo-tional STRESS on the immune system and health. Ina general way, PNI seeks to understand the scien-tific basis of the MIND-BODY CONNECTION.

Authors Locke and Colligan, in The HealerWithin, explain that a premise of PNI is that theimmune system does not operate in a biologicalvacuum but is sensitive to outside influences. PNIresearchers speculate that there is a line of com-munication between the mind and the cells thatare the immune system. Tendrils of the brain’snerve tissues run through important sectors of theimmune system, including the thymus gland, bonemarrow, lymph nodes, and spleen. Hormones andNEUROTRANSMITTERS secreted by the brain have anaffinity for immune cells. Also, certain states ofmind and feelings can have strong biochemicalresults.

The field began in 1981 with the publication ofa book edited by Robert Ader (Psychoneuroimmunol-ogy). While most of the research presented was pri-

296 psychology

marily based on animal models of stress and illness,the collection paved the way for clinical researchwith humans.

During the later 1980s and 1990s, researchersfrom various backgrounds were drawn to thisnew discipline. Social psychologists, experimentalpsychologists, psychiatrists, immunologists, neu-roendocrinologists, neuroanatomists, biologists,oncologists, and epidemiologists, among other spe-cialists, have all made contributions to PNIresearch. Together, they seek to explain the way inwhich the brain and mind contribute to illness orkeep people healthy.

PNI and Cancer

Considerable research has been done with PNI andcancer patients. Work has progressed beyond lookingat cell activity and now evaluates the role of ALTER-NATIVE MEDICINE, such as group therapy, in inducingimmune response in cancer patients, allowing iden-tification of potentially helpful support modalities,and evaluation of possible mechanisms of action. In1995, a pilot study was conducted to differentiate theeffect of support from that of imagery / RELAXATION

on immune function and to explore the relationshipof emotional well-being and quality-of-life measuresto the immune function.

Arthritis and the PNI Link

A research study evaluating personality traits ofpeople who have rheumatoid arthritis was under-taken by Robert Fathman, Ph.D., a Dublin, Ohio,clinical psychologist, and Norman Rothermich,M.D., professor emeritus, Ohio State University,Columbus. “We found that rheumatoid arthritissufferers have a personality that leads them to tryoverly hard to be nice to other people, not to leanon others for emotional support, and to stow thingsinside, especially anger,” they concluded. Manyrheumatoid arthritis sufferers also had a situationof long-term tension or anger in their lives. “Thesetraits seemed to precede the disease, not resultfrom it. The end result is that repressed anger ‘eatsthem up’.” Rheumatoid arthritis is considered anautoimmune disease, in which the immune systemmutinies against the body.

In a well-known study in the field of psychoneu-roimmunology, psychiatrist George Solomon, M.D.,and Rudolf H. Moos, Ph.D., both then at the Stan-

ford University School of Medicine, discovered thatthe difference between people who developrheumatoid arthritis and those who do not lies intheir psychological profile. People who have therheumatoid factor in their blood but stay in goodpsychological condition will not get arthritis. On theother hand, those who are genetically predisposedand endure long periods of stressful anxiety and/orDEPRESSION or suffer some major emotional upsetare at a higher risk for arthritis.

See also HUMOR; LAUGHTER; PLACEBO EFFECT;STRESS MANAGEMENT.

SOURCES:Locke, Steven, and Douglas Colligan. The Healer Within.

New York: New American Library, 1984.Moye, Lemuel A. “Research Methodology in Psychoneu-

roimmunology: Rationale and Design of the Images-PClinical Trial.” Alternatives Therapies 1, no. 2 (May 1995).

Padus, Emrika, ed. The Complete Guide to Your Emotions andYour Health. Emmaus, Pa.: Rodale Press, 1994.

Psychonomic Society The Psychonomic Societyis an organization of researchers in psychology andallied sciences. Members must hold a Ph.D. degreeor equivalent and must have published significantresearch other than their doctoral dissertations. Atthe end of 2004, the society had a membership ofabout 2,500.

Many issues relating to stress are discussed inthe six journals published by the society: Learning& Behavior (formerly Animal Learning & Behavior);Behavior Research Methods, Instruments, & Computers;Cognitive, Affective & Behavioral Neuroscience; Memory& Cognition; Perception & Psychophysics; PsychonomicBulletin & Review.

More than 700 papers and posters are presentedat the society’s annual conference.

FOR FURTHER INFORMATION:The Psychonomic Society1710 Fortview RoadAustin, TX 78704(512) 462-2442(512) 462-1101 (fax)http://www.psychonomic.org

psychotherapies The treatment of mental andemotional concerns by psychological methods. In apsychotherapy, a therapeutic relationship between

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the patient and a therapist (psychotherapist) isestablished. The relationship is focused on thepatient’s symptoms. Patterns of behavior—moodswings, low SELF-ESTEEM, and not being able to dealwith stress—can benefit from this interactionbetween patient and therapist.

There are many types of psychotherapists whocan be recommended by friends, family physicians,or local community mental health centers. Thereare several rules to follow when choosing a thera-pist. Check out credentials. Know whether thetherapist is a PSYCHIATRIST, PSYCHOLOGIST, or psychi-atric social worker. Determine where the personreceived training, and check with that institution.Also, because there are professional societies formany specialties, check with the appropriateorganization to see that the therapist has appropri-ate accreditation.

Choosing a Psychotherapist

People seeking help may be faced with the ques-tion of who to choose. If they recognize what theirproblems are and there are just occasional periodsof feeling moody, a psychiatrist may not be needed.Guidelines for selecting psychotherapist ratherthan a psychiatrist include:

The end of the stressful problem is in sight, but theindividual just can’t get there by him/herself.

The individual realizes that symptoms are of shortduration and that the stress that brought themon can be identified.

However, a person who has tried going to atherapist and has not found relief, may need a psy-chiatrist because of the following reasons:

M.D.s are the only mental health therapists whocan prescribe medications.

For certain emotional illnesses, medications maybe helpful.

The individual has incapacitating or debilitatingsymptoms.

The individual has other concurrent medical prob-lems for which care and medications are beingreceived.

There is a history of mental illness in the family;other family members have ever been hospital-ized for mental illness; or the individual requireshospitalization for a mental problem.

Group Therapy

Group therapy is treatment of emotional or psy-chological problems in groups of patients or in self-help support groups led by a mental healthprofessional. These groups attract individuals withsimilar concerns. For example, such groups may befor recently widowed persons (GRIEF), divorcedpeople (self-esteem), parents who have lost a childto SUDDEN INFANT DEATH SYNDROME, people sufferingfrom DEPRESSION, or those concerned with OBESITY.

Therapy groups include from three to 40 peoplebut work best with 10 to 12 participants who meetfor an hour or more, once or twice a week. Thereis therapeutic interaction among the individuals inthe group; members find that others share theirfeelings and experiences and this helps them feelless alone and less helpless.

Group therapy is useful for people who havepersonality problems, ALCOHOLISM, drug depend-ency, EATING DISORDERS, and ANXIETY DISORDERS.

Co-therapy

This is a form of psychotherapy in which morethan one therapist works with an individual orgroup. Co-therapy is also known as combinedtherapy, cooperative therapy, dual leadership, mul-tiple therapy, and three-cornered therapy. Co-ther-apists work in various areas. For example, in SEX

THERAPY one therapist is a male and the other isfemale to encourage both viewpoints in sexualityproblems concerning a married couple.

Geropsychiatry

This is a specialized form of mental health care thataddresses the complexities involved between men-tal and physical illness in the elderly. For example,an elderly patient who might appear to have psy-chotic symptoms may be experiencing symptomsof toxicity resulting from taking two or moreincompatible drugs. Many psychosomatic disordersand chronic conditions manifest themselves withsymptoms of depression. Physicians specializing ingeropsychiatry are located in community hospitalswhere they can provide a safe and secure environ-ment and offer psychological evaluation in con-junction with medical testing and liaison servicesfor elderly patients being treated for medical orsurgical conditions.

298 psychotherapies

An increasing number of hospitals are addingthis component to their mental health programs.Some hospitals contract with various managedcare organizations which provide these services.

Family Therapy

Family therapy is a form of psychotherapy thatfocuses on the family unit, or at least the parentand child (in single-parent families), rather thanseparate treatment of one or more family mem-bers. It is based on the theory that an individualwho is troubled or is mentally ill should not beseen in isolation from the family unit. Familymembers become aware of how they deal witheach other and are encouraged to communicatemore openly with each other. The discussions andconfrontations lead to understanding.

Family therapy usually focuses on here-and-now stresses and their practical solutions. It can behelpful when at least one member has a relativelyserious problem, such as recurrent depression, orneeds ongoing assistance in coping with outburstsof anger and emotional withdrawal.

Family therapy has become increasingly popu-lar for dealing with problems of children and ado-lescents. Typically, the therapy group will consist ofboth parents, or a parent and stepparent, two sep-arated parents, or other parental pairings depend-ing on the environment in which the child lives. Inmany cases, the child is brought to a mental healthprofessional because of difficulties in school, suchas exhibiting aggressive behavior or cutting classes.

See also COMMUNICATION; LISTENING; MARITAL

THERAPY; SUPPORT GROUPS.

puberty The developmental stage between child-hood and adulthood. It is the term used for thephysical and emotional changes of adolescence: Itusually occurs between the ages of 10 to 15 in boysand girls. This is a stressful period for many youngpeople, as when they enter puberty they are nolonger children but are not accepted by society asadults. Tensions exist between children’s depend-ence on their parents and their increasing desirefor independence from their parents.

Many young people feel stressed by the emo-tional ups and downs they experience. They maylaugh, cry, or explode in anger without any appar-

ent reason. Parents, teachers, and others need tobe understanding, patient, tolerant, and sympa-thetic to help the adolescents weather this transi-tion successfully.

Sexual and Physical Changes

Puberty, also defined as the period at which matu-ration of the sexual organs occurs, begins at aboutage 11 or 12 for girls and 13 or 14 for boys. How-ever, there are wide variations; some girls begin tomenstruate as early as age eight or nine and othersas late as age 16. In Western cultures, the averageage at which adolescents reach sexual maturity hasbeen steadily decreasing over the last century, pos-sibly as a result of better nutrition and medical care.

Many physical changes occur during puberty. Inboys, this includes an increase in the secretion ofmale hormones and in testicular functions, andenlargement of the external sex organs. Nocturnalemissions or WET DREAMS are a normal, automaticrelease at night for secretions that accumulate inthe boy’s sexual organs. Hair increases on the boy’slegs, pubic area, chest, underarms, and face. Laterhis voice deepens. A spurt of growth in height andgeneral filling-out usually occurs shortly before thestart of this period.

Adolescents, particularly boys, often feel stressedby comparisons with their peers concerning physi-cal development. Early-maturing boys seem tohave advantages on later-maturing boys; they dobetter in athletics, are generally more popular, andhave a positive sense of SELF-ESTEEM.

In girls, female hormone production and ovar-ian activity increase, the uterus matures and nearlydoubles in size, the breasts develop, and mammaryglands mature. The pelvis also widens and rounds,and hair begins to show on the legs, pubic area,and underarms. MENSTRUATION and ovulationbegin, often irregularly at first.

Body weight may double during puberty, due tomuscle growth in boys and increased fat in girls.

Communications between Generations

Adolescents need guidance and reinforcementalong the way; it is important that they and theirparents keep the lines of COMMUNICATION open.They may have questions about the physical, sex-ual, and personality changes that they are experi-encing as well as concerns about making appropriate

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choices and decisions. Today’s teenagers face manyexternal sources of stress, such as peer pressure,drugs and alcohol, and the possibility of teenagepregnancy. For some, internal sources of stress maylead to EATING DISORDERS and SCHOOL problems.

See also INTERGENERATIONAL CONFLICTS; LISTEN-ING; PARENTING; PREGNANCY.

public speaking The art of making speeches toan audience. Individuals can experience stressrelated to public speaking ranging from mildapprehension to true phobic reactions. The antici-pation of giving a speech in public may arouse feel-ings ranging from only a mild form of ANXIETY,which might be considered normal, to feelings ofrapid heartbeat, faintness, DIZZINESS, nausea, orother symptoms of a phobia.

An individual may suffer a mild degree of stressas a common reaction to being asked to give thespeech, preparing it, and, finally, getting up infront of people to give it. There may be apprehen-sion about how one looks or sounds and what peo-ple will think about the speech. All theseapprehensions, however, could spur the individualto making the best possible presentation.

A truly social phobic person who is phobicabout public speaking probably would not acceptsuch an invitation, nor would an individual whohas an extreme fear of failure.

People who manage to give a speech in publicbut are extremely uneasy often exhibit behaviorssuch as shuffling the feet, pacing, no eye contact,facial tics or grimaces, moistening the lips and clear-ing the throat frequently, and noticeably perspiring.

Issues of self-confidence and SELF-ESTEEM areinvolved in the stress of public speaking. Peoplewho have given many speeches and feel confidentabout the subject matter, as well as their appear-ance, will probably experience only a mild degreeof stress.

See also BREATHING; PERFORMANCE ANXIETY;SOCIAL PHOBIA; STAGE FRIGHT.

SOURCE:Moore, Amy Slugg. AMWA Journal 18, no. 1 (2003):

9–12.

public transportation See RANDOM NUISANCES.

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TIPS FOR RELIEVING STRESS IN PUBLIC SPEAKING

• Visualize yourself as the presenter you want tobe. Visualize yourself doing well.

• Practice your speech using a tape recorder or avideotape. Ask family members or friends forcritiques.

• Critique yourself: Consider if you mumble ortalk too fast, if your voice is flat or monotonous.Do you overuse certain words? Do you varypitch, range, tone, and volume?

• Memorize your opening and closing remarks.Memorizing the opening will get you throughthe first nervousness that most presenters feel.Knowing the closing will allow you to end on astrong and positive note.

• Avoid reading your visuals word for word.• Practice responses you may need if you are

interrupted by those who digress. For example,“Let’s talk about that after the speech.”

• Consider doing vocal exercises before the talk.Vary your pitch and tone using a syllable suchas “ahh.” Yawn to relax your voice and to openyour throat.

• Arrive at least 30–60 minutes before your talk.Try out your projection equipment. Becomefamiliar with the space: light switches, rest-rooms, and temperature controls.

• Move chairs around if necessary, to make sureyou can be seen by as many participants as pos-sible, particularly if you are using any projectionequipment.

• Let your audience know your involvement withyour topic. Spend a few minutes explaining yourbackground to establish yourself as the expert.Remind yourself that you know more than youraudience; that is why you were chosen to dothis speech.

• Encourage participation and interaction. React toraised hands. To start questions, pose your own:“This is a question I’m frequently asked.”

• Maintain eye contact with the audience andwith people while they are asking questions.

• Use hand gestures to supplement your speech.Avoid distracting hand gestures.

• Use props when you can.• If your mind goes blank, take time to think.

Have a sip of water. Ask the audience to standand stretch. Relax yourself. Take deep breaths.

Qqi gong A self-healing art combining meditation,visualization, and movement to enchance the mind-body connection. Practitioners say that regular prac-tice can reduce stress; establish balance; integratemind, body, and spirit; bring peace; and prevent andtreat illness. Qi gong comes from two Chinesewords. The word qi (chi) means energy. Gong (kung)means skill, or practice of cultivating energy. Thus,qi gong means the skill of attracting vital energy.

Internal qi gong is similar to meditation, withvisualizations to guide energy. External qi gongincludes movements to accompany meditations.

To find a qi gong teacher, contact local martialarts centers, acupuncture clinics, yoga centers, orthe teacher registry provided by the NationalQigong Association.

FOR INFORMATION:National Qigong (Chi Kung) AssociationP.O. Box 252Lakeland, MN 55043(888) 815-1893

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Rradon Radioactive decay of radium produces acolorless, odorless, tasteless gaseous element calledradon. It is a source of stress for many peoplebecause it has been found in communities andhomes. Some researchers suggest that radon maylead to some cases of cancer, particularly lung can-cer. Some people install devices in their homes todetect the presence of radon. Radon occurs natu-rally in many materials, such as rock, soil, andbuilding materials. The gas is released continuouslyinto the atmosphere. Uranium miners and workerswith uranium are sometimes exposed to radon.

See also CANCER; ENVIRONMENT; MINING WORKERS.

random drug testing A method of identifyingpeople who use illicit drugs. Testing may be donebefore employment, after accidents, or when anemployer believes there are reasonable grounds fortesting. In many cases, drug testing is carried out aspart of the preemployment physical examination.This situation is stressful for both the employers aswell as the candidates, as positive tests may resultin dismissal and false positive results can result innonemployment.

Drug tests may include tests for alcohol,cocaine, heroin, inhalants, LSD (acid), marijuana,MDMA (Ecstasy), methamphetamine, nicotine,and anabolic steroids.

Testing is usually carried out by independenttesting organizations. A variety of tests may beused. For example, Breathalyzers can be used todetect alcohol and urinalysis can detect manydrugs present in the body. Hair, blood, saliva, andbrain waves are also used for testing.

According to authors Tyler D. Hartwell, et al.,the incidence of testing is partially based on thetype of worksite, characteristics of employees, andpolicies of the company. Drug testing has increased

since the mid-1980s. Programs that test for illicitdrugs are more than twice as prevalent as thosethat test for alcohol use. Programs are most preva-lent in large worksites, industries affected by drugtesting legislation, and those employing high-riskor unionized workers. At many locations, drugtesting is part of EMPLOYEE ASSISTANCE PROGRAMS.

Indiscriminate urine testing can be stressful foremployees or athletes. The American Civil Liber-ties Union (ACLU) opposes indiscriminate urinetesting. The ACLU claims that urine tests do notdetermine when a drug was used—they detectonly metabolites, or inactive, leftover traces of pre-viously ingested substances. Also, the ACLU assertsthat drug screens often used are not reliable andmany tests yield false positive results 10 percent to30 percent of the time.

See also ADDICTION; ALCOHOLISM AND ALCOHOL

DEPENDENCE; COCAINE; COPDEPENDENCY; WORKSITE

WELLNESS PROGRAMS.

FOR MORE INFORMATION:American Civil Liberties Union125 Broad Street18th FloorNew York, NY 10004(212) 549-2500(202) 549-2640 (fax)http://www.aclu-org

SOURCE:Hartwell, Tyler D., et al. “Prevalence of Drug Testing in

the Workplace.” Monthly Labor Review 119, no. 11(November 1996): 35–46.

random nuisances Annoying or unpleasant situ-ations with which individuals cope. They mayinclude difficult things such as commuting in traf-fic, finding a parking spot, depending on public

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transportation when the weather is bad; or annoy-ing things like construction noise outside youroffice window, phone calls from telemarketers atdinnertime, last-minute dinner guests, or zippersthat get stuck at a critical moment. Such nuisancesdiffer for each person, but it they are perceived asstressful, they take their toll.

Successful people regard random nuisances as“small stuff.” There is a saying, “Don’t sweat thesmall stuff; it’s all small stuff.” As stressors, randomnuisances may seem small. However, the responseto some of life’s “small stressors” may escalate intophysical responses, such as ANGER and rage, thatare similar to responses to major stressors.

HANS SELYE explained the concept of STRESS withtwo basic ideas: The body has a similar set ofresponses to many of life’s stressors; this he calledthe GENERAL ADAPTATION SYNDROME (G.A.S.). Also,stressors can make an individual ill. To prevent ill-ness induced by stressors, keeping a positive per-spective on life and everyday occurrences isessential. The individual should endeavor to copewith the small stressors and keep them from esca-lating into more serious consequences.

Many individuals find that MEDITATION at theend of a day helps them meet challenges of home,children, and paying bills. Others find that partici-pating in regular EXERCISE helps them forget aboutthe random nuisances of each day.

See also HARDINESS; RELAXATION.

rape Forcible sexual intercourse against the willof the partner. There is some variation amongstates as to the actual definition. In many states,sexual assault need not involve either force, actualpenetration, or ejaculation; in others, genital con-tact under the threat of force or even impliedthreat of force meets the legal definition.

Rape is an extremely stressful situation for thevictim and her/his family members. The psycholog-ical effects of rape are severe. Many victims suffersignificant ANXIETY, DEPRESSION, and post-traumaticstress reactions that last for years and can adverselyaffect their professional, personal, and sexual lives.

While rape has traditionally been an offensebetween a man and woman, there has been anattempt to remove gender identification and toinclude homosexual rape and other offenses, such

as sexual contact between an adult and an under-age child or adolescent and INCEST.

Traditionally, women have feared violent sexualassault by a stranger. However, society now recog-nizes that forced intercourse can occur with perpe-trators known to the victim, even the husband.The incidence of “date rape” (rape by a person withwhom one has had a social engagement) is increas-ingly reported.

Rape is now recognized as more a crime of vio-lence than one of sexuality; rapists often have ahistory of other types of violent crime. As courtsand law enforcement agencies have been moresympathetic toward victims, the number ofreported rapes in the United States has increaseddramatically.

Rape victims may be physically injured at thetime of the assault. They may be shot, knifed, orbeaten, and immediate medical attention is usuallygiven to injuries. The rape itself can cause perinealbruising or lacerations, particularly if the victim isvery young, anal penetration occurs, and/or dan-gerous objects are used in the assault. Cultures aretaken for gonorrhea and other SEXUALLY TRANSMIT-TED DISEASES and appropriate antibiotics may berecommended. If a victim is exposed to HERPES orAIDS, there is, at present, no effective way of pre-venting these diseases.

After reporting a rape and being examined at amedical facility, the rape victim’s body and clothingwill be examined for traces of blood, semen, hair,or clothing of the rapist. Recent development ofDNA “fingerprints” from semen and blood permitaccurate identification of the person responsible.

Women at risk for pregnancy may be offered“morning after” contraception. Unfortunately,many victims fail to press charges either out of fearof having to relive the incident in court or out offear of shame or reprisal.

Date Rape and Date Rape Drugs

Date rape is forced or coerced sex between part-ners, dates, friends, friends of friends, or generalacquaintances. Some experts prefer to use the term“drug facilitated sexual assault” in place of “daterape.” Date rape can be coerced both physicallyand emotionally. If a person has had too muchalcohol to drink or is on drugs he or she cannotconsent to sex, thus having sex with them is legally

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rape. There are certain “date rape” drugs that ren-der the victim unconscious and limit memory;using these drugs on someone constitutes daterape and is a federal crime with a possible 20-yearsentence.

Date rape drugs may be difficult to trace but evi-dence of intercourse is not, and in cases where useof these drugs is suspected, evidence of rape stan-dards are lower.Harrison, Maureen, and Steve Gilbert, eds. The Rape Ref-

erence: A Resource for People at Risk. San Diego: ExcellentBooks, 1996.

Miller, Maryann. Drugs and Date Rape. New York: RosenPublishing Group, 1995.

raves See CLUB DRUGS.

recreation The activities people do as a means ofdiversion or refreshment. For many people, theseactivities restore health and offset the effects ofstress in everyday life.

Recreation comes in many forms. Sports activi-ties such as tennis, golf, bowling, ice skating,

rollerblading, and bike riding are activities manypeople enjoy. Others play cards, sing in choirs, actin plays, keep a journal, or go to movies, plays, andconcerts. Most forms of recreation help individualscope with stressors in their lives because theydivert attention from them.

At times, recreation itself can be stressful.Examples are games in which individuals arehighly competitive or participation in communitytheater, when individuals may experience STAGE

FRIGHT or fear of forgetting their lines. It is impor-tant to choose a balance of recreational activitiesthat meet the need for personal satisfaction andachievement, as well as to bring healing to thespirit, mind, and body.

See also EXERCISE; HOBBIES; MIND-BODY CONNEC-TIONS; PAINTBALL; RELAXATION; VOLUNTEERISM.

recreational therapists Individuals also knownas therapeutic recreation specialists who providerecreation activities and treatment services to peo-ple who have disabilities or illnesses or are elderly.Recreational therapists help their clients reduceSTRESS, DEPRESSION, and ANXIETY and recover basicmotor functioning and reasoning abilities, buildconfidence, and socialize effectively so that theycan enjoy greater independence as well as reduceor eliminate effects of their illness or disability.They use a variety of techniques including arts andcrafts, animals, sports, games, dance and move-ment, drama, music, and community outings.

According to the U.S. Department of Labor,recreational therapists held about 27,000 jobs in2002. About a third of salaried jobs for therapistswere in nursing care facilities and another third inhospitals. Others worked in state or local govern-ment agencies and in community care facilities forthe elderly, including assisted living facilities. Onlya small number of therapists were self-employed,usually contracting with long-term care facilities orcommunity agencies. Some teach, conductresearch, or consult for health or social servicesagencies.

Most employers prefer to hire candidates whoare certified therapeutic recreation specialists. TheNational Council for Therapeutic Recreation Certi-fication is the certificatory agency.

See also DANCE THERAPY; DEPRESSION; STRESS.

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PROTECT YOURSELF AGAINST DATE RAPE

The best defense against date rape is to try to pre-vent it whenever possible.• Avoid visiting secluded places (such as bed-

rooms) with someone until you know the personwell and can trust them.

• Never spend time alone with someone whomakes you feel uneasy or uncomfortable.

• Stay sober. Many date rapes involve drugs oralcohol, and a date might slip drugs such asRohypnol (flunitrazepam), GHB (gamma-hydrox-ybutyrate), or Ketamine (ketamine hydrochlo-ride) into a drink to make you more vulnerable.

• What do these drugs look like? Rohypnol is apill and dissolves in liquids. Ketamine is a whitepowder. GHB has a few forms: a liquid with noodor or color, white powder, or pill.

• Learn to say no in a definite way.• Take self-defense courses. These can build confi-

dence and teach valuable physical techniques thata person can use to get away from an attacker.

Source: http:www.kidshealth.org

FOR INFORMATION:National Council for Therapeutic Recreation

Certification7 Elmwood DriveNew City, NY 10956(845) 639-1439(845) 639-1471 (fax)E-mail: nctrc@nctrc.orghttp://www.nctrc.org

reflexology A form of body therapy based on thetheory that every part of the body has a direct lineof communication to a reference point on the foot,hand, and ear. By massaging these referencepoints, professional reflexologists say they can helpthe corresponding body parts to heal. Throughimproved circulation, elimination of toxic by-prod-ucts, and overall reduction of stress, the bodyresponds and functions better because it is morerelaxed.

See also ALTERNATIVE MEDICINE; BODY THERAPIES.

SOURCE:Feltman, John, ed. Reflexology: Hands on Healing. Emmaus,

Pa.: Rodale Press, 1989.

relationships Relationships are formed betweenindividuals connected by affinity. These relation-ships include the individual’s FAMILY, spouse,lovers, friends, and business or professional associ-ates. Good relationships are healthy and nurturingand act as a buffer against outside stressors. How-ever, even the most meaningful relationships canat times be nonsupportive and sources of stress.

Relationships and Health

Best friends fit this category: He or she is on thesame wave length with you and understands yourpersonal situations, such as dealing with a difficultboss or overbearing parent; appreciates andadmires who you are, even if there isn’t alwaysagreement on what is being done or said; gives youcompliments and makes you feel important in hisor her life.

According to S. Leonard Syme, Ph.D., Univer-sity of California at Berkeley, people who have aclose-knit network of intimate personal ties withother people seem to be able to avoid disease,maintain higher levels of health and, in general,deal more successfully with life’s difficulties. Dr.Syme and his research team found that peoplewith many social contacts had the lowest deathrate, and people with the fewest contacts had thehighest rates. Single, divorced, and widowed peo-ple have higher rates of many diseases. Widows,particularly in the first year after their husbands’deaths, have many more symptoms of physical andmental disease as well as death rates that are fourtimes higher than average. “One can guard againstthe ill effect of being single through a solid net-work of friends and associates,” says Dr. Syme.

Socially isolated people may be more likely toadopt self-destructive health habits and may getdepressed and become suicidal or accident-prone.“All diseases are ‘social diseases,’” says DennisJaffe, author of Healing from Within. “It’s as thougha breakdown in the social support structure precip-itates a breakdown in the body’s immune system.”

This breakdown in the body’s immune systemresembles the body’s stress response. People wholack outlets for stress release are susceptible to a listof stress-related illnesses. Having one or two closefriends with whom they feel free to say anything isinvaluable. When they are overwhelmed, they

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USING REFLEXOLOGY TO REDUCE STRESS

• Choose a quiet place.• Apply a few drops of a light, absorbent,

greaseless lotion to your feet and massage them, continuing until the lotion is totallyabsorbed.

• Grasp the ankle, heel, or toes of one foot firmlyin one hand, place the thumb of your otherhand on the sole of your foot at the heel andapply steady, even pressure with the edge ofyour whole thumb.

• Keep your thumb slightly bent at the joint anduse a forward, caterpillar-like motion. This iscalled thumbwalking; press one spot, move for-ward a little, press again, and so on.

• When you reach the toes, start again at a newspot on the heel. Continue until the entire bot-tom of the foot has been worked. Then finger-walk the top of the foot. Work your entire foottwice this way.

don’t trust their own judgment, and an objectiveview from a friend can help.

Romantic Relationships

Romantic relationships are far riskier and poten-tially more stressful to the individual’s emotionaland physical well-being than people realize. Notonly are feelings likely to be hurt, SELF-ESTEEM

damaged, and trust betrayed, but there can bephysical and mental battery by an outraged spouse.America’s high DIVORCE rate suggests that INTIMACY

has painful consequences.According to Geraldine K. Piorkowski, author of

Too Close for Comfort: Exploring the Risks of Intimacy,romantic relationships can be stressful becausethey are related to the process of getting close toanother person. As we become more intimate(both emotionally and sexually), we reveal ourdeepest secrets, hopes, inadequacies, and even fan-tasies. We become more vulnerable, and thus eas-ily cut to the core by a hostile comment, act ofbetrayal, or moment of rejection.

Further, Piorkowski says, stress arises in rela-tionships when our emotional needs and expecta-tions are unrealistic. Also, we may lose ourAUTONOMY and wind up feeling suffocated by theother’s demands; their neediness may drain energyneeded to pursue our own desires and interests.We may be blamed for all the problems in the rela-tionship and suffer GUILT and loss of self-confidenceas a result.

Relationships and Support Groups

A lack of connections with other people can bedetrimental to health, says Dr. Andrew Weil, author

of Spontaneous Healing. “Surrounding yourself withsupportive people is an important step for any heal-ing you need to do. Whenever I take a family his-tory from a patient, I always ask about people whoare helping or hindering someone’s illness. Forexample, sometimes a friend or family memberwho means well only make matters worse, maybeby not wanting the patient to express sadness aboutbeing sick or show discomfort from pain.”

In terms of building relationships through sup-port groups, Dr. Weil urges patients to find anddevelop relationships with people who have thesame conditions and who have improved ratherthan simply to join a SUPPORT GROUP. “I find thatsome support groups can be counterproductiveand cause more stress for the individual,” he says.“For example, some patients with cancer are horri-fied and extremely stressed when they see anotherperson with a more advanced form of the disease.There is a similar phenomenon with chronic fatiguesyndrome.”

Some people are more fatalistic about their ill-ness while others tend to be positive thinkers. Thisshould be factored into any relationships devel-oped through a support group, and especially withthe regular people in your life, suggests Dr. Weil.

See also COMMUNICATION; DATING; INTERGENERA-TIONAL CONFLICTS; LISTENING; LIVE-IN; MARRIAGE;PARENTING.

SOURCES:Gilbert, Roberta M. Extraordinary Relationships. A New Way

of Thinking about Human Interactions. Minneapolis:Chronimed Publishing, 1992.

Jaffe, Dennis T. Healing from Within. New York: Knopf,1980.

Piorkowski, Geraldine K. Too Close for Comfort: Exploringthe Risks of Intimacy. New York: Insight Books, 1994.

Weil, Andrew. Spontaneous Healing: How to Discover andEnhance Your Body’s Natural Ability to Maintain and HealItself. New York: Knopf, 1995.

relaxation A feeling of freedom from anxiety andtension. Internal conflicts and disturbing feelings ofSTRESS are absent. Relaxation also refers to thereturn of a muscle to its normal state after a periodof contraction.

People who are very tense and anxious canlearn to relax using relaxation training, a form ofBEHAVIOR THERAPY or ALTERNATIVE MEDICINE. Relax-

306 relaxation

COMPONENTS OF A HEALTHY RELATIONSHIP

• Realism: openness and honesty with each other• Trust: allowing the individuals to share their feel-

ings• True friendship: having no hidden motives• Forgiveness: accepting the individual as he or

she is• Security: knowing that individuals can count on

one another• Vulnerability: exposing weaknesses that allow

the relationship to grow

ation techniques are methods used to consciouslyrelease muscular tension and achieve a sense ofmental calm. Historically, relaxation techniqueshave included MEDITATION, T’AI CHI, MASSAGE THER-APY, YOGA, MUSIC, and AROMATHERAPY. More mod-ern developments include AUTOGENIC TRAINING,PROGRESSIVE MUSCLE RELAXATION, HYPNOSIS, BIOFEED-BACK, and aerobic EXERCISE.

Many of these techniques were developed tohelp people cope with stresses brought on by thechallenges of life. They are different approaches torelieving stress by bringing about generalized phys-ical as well as mental relaxation. Relaxation tech-niques have in common the production of therelaxation response as one of their stress-relievingactions. Additionally, relaxation may counter someof the immunosuppressing effects of stress and mayactually enhance the activity of the IMMUNE SYSTEM.

Relaxation training programs are commonlyused in conjunction with more standard forms oftherapy for many chronic diseases. The MIND-BODY

CONNECTION between relaxation and ill health hasbeen demonstrated in many conditions. Some ofthe physiological changes that occur during relax-ation include decreased oxygen consumption,decreased heart and respiratory rates, diminishedmuscle tension, and a shift toward slower brainwave patterns.

The “Relaxation Response”

In the 1970s, HERBERT BENSON, M.D., a cardiologistat Harvard Medical School, studied the relationshipbetween stress and hypertension. In stressful situ-ations, the body undergoes several changes,including rise in blood pressure and pulse andfaster breathing. Dr. Benson reasoned that if stresscould bring about this reaction, another factormight be able to turn it off. He studied practition-ers of TRANSCENDENTAL MEDITATION (TM) andfound that once into their meditative states, someindividuals could willfully reduce their pulse,blood pressure, and breathing rate. Dr. Bensonnamed this “the relaxation response.” He explainedthis procedure in his book (written with Miriam Z.Klipper), The Relaxation Response (1976).

Relaxation Applications

Relaxation training can be particularly useful forindividuals who have “white coat hypertension,”

which means that their blood pressure is high onlywhen facing certain specifically stressful situations,such as having a medical examination or visiting adentist. It can also help reduce hostility and anger,which in turn affect the body and the individual’sphysical responses to stress. Anxieties can lead topanic attacks, nausea, or gastrointestinal problems.

There are many applications of relaxation train-ing to help individuals learn CONTROL over theirmental state and body and in treating conditions asdiverse as high blood pressure, cardiac arrhythmia,chronic pain, insomnia, premenstrual syndrome,and side effects of cancer treatments. Relaxationtraining is an important part of childbirth classes tohelp women cope with the pain of labor.

In a training program, individuals are instructedto move through the muscle groups of the body,making them tense and then completely relaxed.Through repetitions of this procedure, individualslearn how to be in voluntary control of their feelingsof tension and relaxation. Some therapists provideindividuals with instructional audio tapes for useduring practice, while other therapists go throughthe procedure repeatedly with their clients.

To determine the effectiveness of relaxationtraining, some therapists use biofeedback as anindicator of an individual’s degree of relaxationand absence of ANXIETY.

See also GUIDED IMAGERY; HOBBIES; KABAT-ZINN,JON; MEDITATION; RECREATION.

SOURCES:Benson, Herbert. Beyond the Relaxation Response. New

York: Berkeley Press, 1985.———. The Relaxation Response. New York: Avon Books,

1975.Goleman, Daniel, and Joel Gurin, eds. Mind Body Medi-

cine. How to Use Your Mind for Better Health. Yonkers,N.Y.: Consumer Reports Books, 1993.

Lehrer, Paul M., and Robert L. Woolfolk, eds. Principlesand Practice of Stress Management, New York: GuilfordPress, 1993.

religion The service and worship of God. It is acommitment to a personal set or institutionalizedsystem of attitudes, beliefs, and practices. Religionhelps many people cope with stresses of lifebecause it gives them a sense of security, meaning,order, and an ethical pattern for living.

religion 307

Faith in God

Belief and trust in and loyalty to God or belief inthe doctrines of religion historically have been anavenue for relieving stress and increasing an indi-vidual’s physical and mental health. Studiesregarding benefits of religion indicate that religiousbeliefs offer some protection from hypertension,death from heart disease, and cancer. While aphysician cannot recommend a patient participatein religion, asking about such behavior and posi-tively reinforcing it may improve the patient’squality of life. In some cases, it may prove to be auseful piece of evidence that patients will use toalter their survival behaviors.

Involvement with religion very often increases inolder adults, an observation that led researchersheaded by psychiatrist Thomas Oxman at Dart-mouth Medical School to investigate the role reli-gion might play in the health of the elderly. Theyfound that those who derive at least some strengthand comfort from religion are more likely to survivelonger after cardiac surgery than those who do not.Researchers looked at the effect on survival of anumber of biomedical, psychological, and social fac-tors as well as religious feeling and activity. Thosewho said they found at least some strength andcomfort from their religious feelings were threetimes more likely to survive than those who had nocomfort from religious faith. Those who participatedin social and community activities, such as churchsuppers, senior centers, or historical societies, hadthree times the survival rate of those who did notparticipate in any organized activity. Those who hadboth protective factors—religious and social sup-port—showed a tenfold increase in survival.

However, while religion contains elements thatare supportive, it also contains elements that maybe damaging to a person’s management of stress.For example, the promise of reward in the afterlifehas inspired and comforted many, but has alsobeen held responsible for making believers passiveor accepting of hardships and inequalities, whichthey could overcome through their own efforts,because they hope for a better life in the beyond.

Religion in Wartime

A survey of World War II veterans offered interest-ing insights into the religious state of mind of menwho experienced the stresses of warfare. About 26

percent said that the war made them more reli-gious; 19 percent that war made them less reli-gious. Fifty-eight percent of those surveyed saidthat even though their religious conviction mayhave increased, decreased, or remained the same,their war experiences made them more interestedin the subject of religion. The veterans exhibited aneven stronger tendency when describing their reli-gious attitude during battle. Most were of the opin-ion that everyone prays in combat. An interestingvariation was the comment, “There were atheistsin fox holes, but most of them were in love,”implying that the thought of a loved one mightcarry a man through danger almost as well as anappeal to a higher power.

The influence of Religion on Mental Health

Between 1930 and 1960, theologian Paul Tillich(1886–1965), philosopher Martin Buber (1878–1965) and psychoanalyst Rollo May (1909–94)published important works attempting to synthe-size religion, psychology, and modern philosophi-cal movements. An interest in combining themental health disciplines with the influence of reli-gion has encouraged the development of trainingin pastoral counseling in recent years. In the early1970s, priest-sociologist Andrew Greeley (1928– ),in his book Unsecular Man: the Persistence of Religion,described a conservative, religious social trend thatrecently has become more obvious in movementssuch as the creationist opposition to secularhumanism in education and the political influenceof religious leaders and celebrities publicizing their“born again” experiences.

See also ALTERNATIVE MEDICINE; MEDITATION;MIND-BODY CONNECTIONS.

SOURCE:Koenig, Harold George. Is Religion Good for Your Health:

The Effects of Religion on Physical and Mental Health. NewYork: Haworth Pastoral Press, 1997.

relocation The need to transfer to a new companylocation as part of a promotion or lateral careermove. Transfers may also become necessary due toreorganizations and MERGERS. A fact of life and astressor for most workers and their families today,relocation means losing a SUPPORT GROUP (FRIENDS

and/or relatives), finding a new residence and new

308 relocation

community resources (places to worship, schools,doctors, dentists, etc.), handling the move (packingand unpacking), and, in the case of dual careers, theneed for one spouse to find new employment andthe possible financial impact of that.

Children probably suffer the most stress duringrelocations. New schools can mean new methodsof teaching and new textbooks, and, most impor-tant, new friends. Research had shown that adultswho as children moved frequently due to parentjob transfers may find it difficult to form lastingfriendships and have not learned the necessaryskills to form intimate relationships.

Frequent transfers can be hard on all membersof the family. They have been known to trigger agroup of stress reactions called the mobility syn-drome, which can include DEPRESSION, deteriora-tion of health, dependency on one’s own family foremotional satisfaction, reclusiveness, a high rate ofalcoholism and drug dependency, and marital dis-cord that often leads to divorce. There is anincrease of acting out behavior on the part of chil-dren and teenagers. Many of these stress reactionsrequire professional help.

For the first time, many people are assessing theviability of a transfer not only in terms of careersand the financial and housing implications of themove, but also in terms of the quality of life forthemselves and their families. Since relocationoften becomes a primary part of a promotion, it isimportant to see if it matches family values andpriorities as well as the individual’s career plan.Whatever the decision, applying COPING techniquesand strategies is necessary to handle the resultingstress.

See also ACCULTURATION; CHANGING NATURE OF

WORK; GENERAL ADAPTATION SYNDROME; MIGRATION;MOVING; NOSTALGIA.

remarriage Entering into a MARRIAGE contractbetween a couple when one or both of them hasbeen left a widow or widower or when there hasbeen a DIVORCE. Bride and groom bring with themremembrances, some good and some bad, of previ-ous marriages. If there are children, establishingnew family RELATIONSHIPS as well maintaining oldfamily ties are major concerns. Widows or widow-ers who experienced “good marriages” are less

likely to have fears and apprehensions than thosewho are divorced.

Many people do find their second marriage, par-ticularly after a divorce, a source of stress. Forexample, some divorced men and women marry aperson very similar to their first spouse andencounter similar difficulties. Others try very hardto find a quality that was lacking in their firstspouse. As a consequence, they may marry a per-son who has that particular quality but may beblinded to other ways in which they are actuallyincompatible.

Divorced or widowed persons may remarry outof emotional and financial need without under-standing themselves first or resolving their feelingsabout their previous marriage. Ex-mates mayinterfere when one or the other remarries andfamily members may make it obvious that theypreferred the previous spouse. In some cases, menand women are stressed by feelings of GUILT abouthow the second marriage has affected their chil-dren or previous spouse.

Being accepted into the family, a stressor formany, may relate to the circumstances of thecourtship. For example, if a woman was the “otherwoman” while the new husband was still married,his relatives may regard the wife as a “homewrecker.” If a recently widowed woman marriestoo soon, her relatives may think the marriage wasdisrespectful to the deceased.

Statistics on Remarriage

In 1990, 31.3 percent of women who remarriedwere 35 to 44 years old, compared to about 20 per-cent aged 25 to 29 years old and about 22 percentaged 30 to 34 years old. Only 16 percent of womenremarrying in 1990 were 45 to 64 years old, com-pared to 8 percent who were 20 to 24 years old.Only 2.7 percent of remarriages in 1990 were bywomen 65 years old and older.

About one-third of remarrying men in 1990were 35 to 44 years old, compared to about 20 per-cent being 30 to 34 years old. Another 24 percentof remarrying men in 1990 were 45 to 64 yearsold, compared to about 14 percent being 25 to 29years old. Men 65 years old and older were morelikely in 1990 to remarry than men 20 to 24 yearsold (5.1 percent vs. 2.6 percent).

remarriage 309

The rate of divorced women remarryingdecreased from 123.3 per 1,000 women in 1970 to76.2 per 1,000 women in 1990. The rate of divorcedmen remarrying decreased from 204.5 per 1,000men in 1970 to 76.2 percent per 1,000 men in 1990.

Seventy-five percent of divorced women remarrywithin 10 years.

Many older individuals who are past childbear-ing and child-rearing years opt for a LIVE-IN

arrangement instead of remarriage.See also INTIMACY; STEPFAMILIES.

SOURCES:Gender Center. “Marriage, Divorce, and Remarriage in

the United States,” Available online. URL: http://www.gendercenter.org/mdr.htm. Downloaded onApril 21, 2005.

Kahn, Ada P., and Jan Fawcett. Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Statistical Abstract of the United States, 1991. Washington,D.C.: U.S. Department of Commerce, 1991.

Wilson, Barbara Foley. “The Marry-Go-Round.” AmericanDemographics, October 1991, 52–54.

repetitive stress injuries (RSI) Injuries that resultfrom repetitive motions, such as using a computeror certain types of factory work. As people spendmore time at computers, sitting at a desk, lookingat a screen, and typing information, they becomemore and more open to repetitive stress injuries.Human beings are not meant to do repetitivemotions all day in work spaces not set up toaccommodate either the equipment or their bod-ies. The result is damage to muscles in the fingers,wrists, hands, arms, neck, head, and back.

The rate of RSIs is increasing as more Americansturn to computers at work and at home. RSIs areaffected by the individual’s work pacing, work stress,environment conditions and personality traits.

The kinds of problems computer users reportinclude shooting pains in the arms, acute pain orstiffness in the arms, neck, shoulders, and/or back,acute wrist or finger pain, numbness or tingling inthe fingers, hands, arms, or shoulders, and chronicpain in the neck, shoulders, or back.

A specific type of repetitive stress injury relatingto wrist and hand disorders is CARPAL TUNNEL SYN-DROME, and it has been identified as one of thefastest growing occupational illnesses. Carpal tun-

nel syndrome is the result of inflamed tendons inthe wrist.

FOR FURTHER INFORMATION:Association for Repetitive Motion SyndromeP.O. Box 471973Aurora, CO 80047(303) 369-0803http://www.certifiedpst.com/arms

repression See MEMORY.

resolutions Statements of will or intent. Manypeople make resolutions at the beginning of thenew year, and later in the year are stressed by thefact that they cannot live up to their own hopesand expectations. Commonly, people determine tochange their negative behaviors and HABITS intopositive ones, such as losing weight, stoppingSMOKING, exercising more, and working hard toimprove themselves.

Often people are earnestly trying to changetheir habits, but find that doing so becomesincreasingly hard. Other responsibilities get in theway and often the time is used for other tasks.They feel frustrated and finally abandon the reso-

310 repetitive stress injuries

AVOIDING REPETITIVE STRESS OF COMPUTER USE

• Select chairs and desks that can be adjusted formaximum work comfort. The desk should behigh enough and feet should be on the floor.

• Support your back with a pillow to keep posturecorrect and relieve strain.

• Be sure your keyboard and mouse are at a com-fortable level; raise or lower if necessary.

• Avoid flexing wrists; use a contoured wristsup-port device.

• Take work breaks—stretch, roll the neck, anduse hand squeezing exercises; stand up andwalk about.

• Keep monitor at arm’s length (24 inches) fromface.

• If pain persists, see a doctor. Work space orwork habit changes, physical therapy, specialexercises, medication, braces, or surgery may berecommended.

lution with the thought that it might become a res-olution the next year. To avoid the stress and FRUS-TRATION of unkept resolutions, Mark Groder,author of Business Games: How to Recognize the Play-ers and Deal with Them, suggests:

Know your own limits; don’t make resolutionsthat are too ambitious.

Consider the obstacles in keeping your resolu-tion; set your priorities.

Use breaking a resolution as an opportunity forself-understanding; perhaps you were overly opti-mistic in making it.

See also PERFECTION; SELF-ESTEEM; WEIGHT GAIN

AND LOSS.

SOURCE:Groder, Martin. Business Games: How to Recognize the Play-

ers and Deal with Them. Des Moines: Boardroom Clas-sics, 1995.

retirement Retirement usually means that theindividual is withdrawing from the work force ofhis or her own free will. It generally occurs whenpeople are around age 65 or older, but in times ofeconomic problems due to DOWNSIZING, LAYOFFS,and MERGERS, it can occur earlier.

Retirement, highly desired by some, producesstresses including ANXIETIES, BOREDOM, and feelingsof lack of productivity and loss of SELF-ESTEEM forothers. Some retired people feel that they are notcontributing members of society and becomedepressed and withdrawn. Some miss the identityand the prestige they formerly received from theirposition at work.

Those who adjust the best to retirement andexperience the least stress seem to be the peoplewho participate in new activities and make newacquaintances. Most retired people enjoy havingmore time for family and FRIENDS, for travel, for con-tinuing their education, and for pursuing HOBBIES.

People who have planned ahead for their retire-ment generally start an interest or hobby beforestopping work. For example, some individuals startto learn a musical instrument while others pursuea woodworking or sewing hobby. Many do volun-teer work to help others who are in need of assis-tance. In most of the big cities in the United States,there is a “job corps” of senior citizens willing to

donate their time and use their knowledge in busi-ness and industry.

Continuing education classes at local collegesand universities are targeted to retired people whoenjoy learning. A great many of these people par-ticipate in Elderhostel activities, where they travelto college campuses all over the world to study andtour.

Retirement and Second Careers

Retirement is no longer a once-in-a-lifetime hap-pening. Some individuals who retire go back topaid positions in an area in which they alreadyhave an expertise; some go to an entirely differentarea. Researchers at the University of SouthernCalifornia tracked 2,816 American men whoturned 55 between 1966 and 1976. Approximatelyone-third went back to work for an average of twomore years after they retired. Other significantfindings indicated that the average American maleretires between ages 61 and 62, that white-collarworkers stay on the job about two years longerthan blue-collar workers, and that blue-collarworkers spend an average of 10 years in retire-ment; white-collar workers, 12.

Wives of retired men are sometimes affected bytheir mates’ retirement. A study reported in ModernMaturity (December 1991–January 1992) indicatedthat most women polled reported satisfaction withtheir husbands’ retirement. Effects of retirementon 413 upper-middle-class women married to menretired an average of 16 years were examined.More than one-third of the women had no prob-lems with their husbands’ retirement, and two-thirds said they were fully prepared for it. Only 12percent said they felt stressed by some loss of per-sonal freedom, and 5 percent to 6 percent reportedan increase in household chores. Among thosewho said they would have done things differently,the majority mentioned the need to be better pre-pared financially for their later years.

Planning Ahead Relieves Stress

Relieving some of the stresses of retirementdepends largely on pre-retirement planning andthe retirement process itself. A variable in life sat-isfaction during retirement is socioeconomic status.According to the College of Family Physicians ofCanada, those with middle and upper incomes

retirement 311

report a higher degree of adaptation. Householdincome drops drastically (one-half to one-third).Many retirees experience poverty for the first time.Financial problems are the major reasons for stressand dissatisfaction with retirement.

Actual financial hardship may differ from per-ceived financial hardship. Strategies to cope withthe stress of reduced income include expenditurereduction, rearrangement of assets, or continuedactivity in the labor force. Education is the mostinfluential factor related to successful coping withreduced income.

See also AGING; ELDERLY PARENTS; HARDINESS;RECREATION; VOLUNTEERISM.

SOURCES:Dennis, Helen, and John Migliaccio. “Redefining Retire-

ment: The Baby Boomer Challenge.” Generations:Journal of the American Society on Aging 21, no. 2 (sum-mer 1997): 45.

Godin, Seth. If You’re Clueless about Retirement and Want toKnow More. Chicago: Dearborn Financial, 1997.

Manchester, Joyce. “Aging Boomers and Retirement:Who is at Risk?” Generations: Journal of the AmericanSociety on Aging 21, no. 2 (Summer 1997): 19.

ricin A poison that can be made from the wasteleft over from processing castor beans; it can be apowder, a mist, or a pellet, or dissolved in water orweak acid. Ricin is one of many substances thatcause stress to those who fear terrorist attacks. Asign of ricin exposure would be that a large num-ber of people who have been close to each other(such as in a subway or train car) suddenly developfever, cough, or excess fluid in their lungs. There isno widely available reliable test to confirm that aperson has inhaled ricin.

Understanding more about ricin can alleviatefears that cause stress. To be exposed to ricin, itwould take a deliberate act to make ricin and thenuse it to poison people. Accidental exposure toricin is highly unlikely. People can breathe in ricinmist or powder and be poisoned. Ricin can also getinto water or food and then be swallowed.Depending on the route of exposure (injection orinhalation), as little as 500-micrograms of ricincould be enough to kill an adult. A 500-microgramdose of ricin would be about the size of the head ofa pin. A greater amount would likely be needed tokill people if the ricin were swallowed.

According to the Centers for Disease Control,some reports indicated that ricin may have beenused in the Iran-Iraq War during the 1980s, andquantities of ricin were found in al-Qaeda caves inAfghanistan after 2000.

Signs and Symptoms of Ricin Exposure

The major symptoms of ricin poisoning depend onthe route of exposure and the dose received, thoughmany organs may be affected in severe cases.

Initial symptoms of ricin poisoning by inhala-tion may occur within eight hours of exposure.Likely symptoms include difficulty breathing,fever, cough, nausea, and tightness in the chest.Heavy sweating may follow, as well as fluid build-ing up in the lungs. Finally, low blood pressure andrespiratory failure may occur, leading to death.

Following ingestion, initial symptoms typicallyoccur in less than six hours. The victim woulddevelop vomiting and diarrhea that may becomebloody. Severe dehydration may result, followedby low blood pressure. Other signs and symptomsmay include hallucinations, seizures, and blood inthe urine. Within several days, the person’s liver,spleen, and kidneys might stop working, and theperson could die.

With skin and eye exposure, ricin in its powderor mist form can cause skin or eye redness and pain.

Treating Ricin Poisoning

If ricin exposure cannot be avoided, the mostimportant step in treatment is getting the ricin offor out of the body as quickly as possible. Get freshair by leaving the area where the ricin wasreleased. Treatment involves supportive medicalcare depending on the route by which victims werepoisoned. Care might include helping victimsbreathe, giving them intravenous fluids and med-ications to treat conditions such as seizures andlow blood pressure, or washing out their eyes withwater if their eyes are irritated.

If you are near a release of ricin, emergencycoordinators may tell you to either evacuate thearea or to shelter in place inside a building to avoidbeing exposed to the chemical.

See also SARIN; TERRORISM.

FOR INFORMATION:Agency for Toxic Substances and Disease RegistryDivision of Toxicology

312 ricin

1600 Clifton Road, NE, Mailstop E-29Atlanta, GA 30333(888) 422-8737http://www.atsdr.cdc.gov

right sizing See DOWNSIZING; LAYOFFS; MERGERS;WORKPLACE.

risk See DECISION-MAKING.

road rage Stress-producing expression of angerand hostility while driving a car. People are in ahurry and become frustrated because of trafficdelays, being cut off by other drivers, or beinggiven obscene signals by other drivers. Road rage isdangerous because drivers become excited andmay accelerate their speed or make sudden andrisky moves. The term road rage implies that impa-tience and competition have increased in our cul-ture, perhaps due, in part, to increased populationdensity.

Rohypnol See RAPE.

Rolfing One of the many contemporary BODY THER-APIES used to relieve stress and improve emotionaland physical health. It is a form of deep tissue mas-sage and is a combination of the disciplines of Easternphilosophical systems and practices and Westernknowledge of muscular and skeletal structure.

The technique, which is often combined withother body therapy techniques, was developed byIda Rolf (1896–1979), an American biochemist. As ayoung woman, she had an accident and was suc-cessfully treated by both an osteopathic physicianand a yoga instructor. She combined these twotechniques with the medical system of homeopathy,a practice that calls upon the patient’s own healingpowers rather than merely treating symptoms. Thetherapy gained recognition through Rolf’s work atthe Esalen Institute in California during the 1960s.From what had been considered the fringe or one ofmany alternative therapies, Rolfing and other bodytherapies entered the mainstream of mental andphysical treatments in the mid-1900s.

Rolfing focuses on the network of connectivetissue—fascia, tendons, and ligaments—that con-

tains the muscles and links them to the bones.Whenever connective tissue fails to work effec-tively, pain can result. For many, Rolfing helps toheal the body by bringing it into proper alignmentand proper relationship to the forces of gravity. ARolfing practitioner puts pressure on certain areasof the patient’s connective tissue to improve thestructure of the body. Certified Rolfers have hadtraining in human anatomy, physiology, kinesiol-ogy, and various massage techniques.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MASSAGE THERAPY.

FOR FURTHER INFORMATION:The Rolf Institute5055 Chaparral Court, Suite 103Boulder, Colorado 80301(303) 449-5903(303) 449-5978 (fax)http://www.rolf.org

SOURCE:Rolf, Ida P. Rolfing: Reestablishing the Natural Alignment and

Structural Integration of the Human Body for Vitality andWell Being. Rochester, Vt.: Healing Arts Press, 1989.

rotator cuff injuries Injuries to the rotator cuffare stressful because they are painful and debilitat-ing. Such injuries may be caused by overuse or afall. They may result in loss of income from lostworkdays or decreased involvement in personaland family activities.

The rotator cuff is a reinforcing structure aroundthe shoulder joint composed of four muscle ten-dons that merge with the fibrous capsule enclosingthe joint. Falling or breaking a fall with the arm canbruise or tear a rotator cuff’s tendons or muscles.

These injuries are common among professionaland amateur athletes, especially baseball pitchers,tennis players, and swimmers. They also are com-mon in workers whose jobs involve lifting, carry-ing heavy loads, and reaching, which can strain ortear tendons and muscles.

Repeated overhead movement of the arms canstress the rotator cuff muscles and tendons, causinginflammation and eventually tearing. Diagnosis isusually confirmed with imaging techniques or X-rays. Treatments range from physical therapy toanti-inflammatory medications to surgery.

rotator cuff injuries 313

runner’s high A certain feeling of physical andmental well-being and a relief of stress is oftenreported by individuals who run or jog. This mayoccur during or after a period of EXERCISE, whenthe cardiovascular system works harder and longerthan it usually does. For example, about 30 to 40minutes of jogging may produce the feeling of“runner’s high” in many individuals.

There is a common misconception that runner’shigh is caused exclusively by the release of ENDOR-PHINS, brain chemicals that can reduce pain and

elevate mood in a manner similar to opiate drugs.In addition to the release of endorphins, exercisecauses the body to discharge many neurochemicalsthat trigger physiological reactions. For example,stimulation of the sympathetic nervous systemalong with activation of the endocrine system’sadrenal medulla causes an increased heart rate anddelivery of more oxygen to the brain, contributingto the relief of stress.

See also RECREATION.

314 runner’s high

S“safe sex” Avoiding behaviors that may lead toSEXUALLY TRANSMITTED DISEASES, AIDS, or PREG-NANCY. Safe sex involves being in a monogamousrelationship, knowing one’s partner, avoiding sex-ual relationships with known drug users, and usingCONDOMS and spermicidal agents properly. Theneed for practicing safe sex causes stress for manyindividuals who fear contracting a disease or findpreparations and precautions annoying. For somecouples, use of a condom becomes a stressful issue.

See also BIRTH CONTROL; SEXUAL REVOLUTION.

“sandwich” generation A term that describes peo-ple in midlife who have responsibilities for takingcare of ELDERLY PARENTS as well as their own almostadult or adult children. Stresses abound because ofthe multiple and sometimes conflicting roles. Stres-sors include living arrangements, financial con-straints, and time constraints, as in many cases bothindividuals in a midlife couple are still working.

To improve such stressful situations, open COM-MUNICATION between all parties involved is essen-tial. Young people need to realize that theirconcerns must be balanced with the concerns of theelderly, to reduce some of the stress on the middlegeneration. Those caught in the middle need totake time for themselves and their own interests.RELAXATION techniques can also be helpful.

See also INTERGENERATIONAL CONFLICTS; LISTEN-ING; PARENTING.

sarin An artificial chemical warfare agent classi-fied as a nerve agent and originally developed as apesticide. Nerve agents are the most toxic and rap-idly acting of the known chemical warfare agents.The mere mention of sarin is a source of stress formany people concerned about acts of terrorismthroughout the world.

According to the Centers for Disease Control,sarin (also known as GB) and other nerve agentsmay have been used in chemical warfare duringthe Iran-Iraq War in the 1980s. Sarin was used intwo terrorist attacks in Japan in 1994 and 1995.

People can be exposed to sarin through skin oreye contact if it is released into the air, or via inhala-tion of air containing sarin. If sarin is released intowater, people can be exposed by touching or drink-ing water that contains sarin. Following contamina-tion of food with sarin, people can be exposed byeating the contaminated food. A person’s clothingcan release sarin for about 30 minutes after it hascome in contact with sarin vapor, which can resultin exposure of other people.

How Sarin Works

Sarin presents an immediate but short-lived threatbecause it evaporates quickly. Depending on theamount of sarin to which a person was exposed,how the person was exposed, and the duration ofthe exposure, the extent of poisoning may vary.Symptoms will appear within a few seconds afterexposure to the vapor form of sarin and within afew minutes to up to 18 hours after exposure tothe liquid form. Breathing function may beseverely impaired.

Sarin is the most volatile of the nerve agents,which means that it can easily and quickly evapo-rate from a liquid into a vapor and spread into theenvironment. People can be exposed to the vaporeven if they do not come in contact with the liquidform of sarin.

Signs, Symptoms, and Treatment for Sarin Exposure

People may not know that they were exposedbecause sarin has no odor. Mildly or moderatelyexposed people usually recover completely. Severely

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exposed people are not likely to survive. Peopleexposed to a low or moderate dose of sarin bybreathing contaminated air, eating contaminatedfood, drinking contaminated water, or touchingcontaminated surfaces may experience some or allof the following symptoms within seconds to hoursafter exposure: runny nose, watery eyes, eye pain,blurred vision, drooling and excessive sweating,cough, chest tightness, rapid breathing, diarrhea,increased urination, confusion, drowsiness, weak-ness, headache, nausea, vomiting and/or abdomi-nal pain, slow or fast heart rate, low or high bloodpressure. Exposure to large doses may result in lossof consciousness, convulsions, paralysis, and respi-ratory failure. However, showing these signs andsymptoms does not necessarily mean that a personhas been exposed to sarin.

Medical attention should be sought immediatelyafter exposure. Treatment consists of removingsarin from the body as soon as possible and pro-viding supportive medical care in a hospital setting.Antidotes are available. They are most useful ifgiven as soon as possible after exposure.

See also TERRORISM.

FOR FURTHER INFORMATION:Agency for Toxic Substances and Disease RegistryDivision of Toxiciology1600 Clifton Road NE, Mailstop E-29Atlanta, GA 30333(888) 422-8737 (toll-free)(404) 498-0057 (fax)http://www.atsdr.cdc.gov

Bioterrorism Preparedness and Response PlanningCenters for Disease Control and PreventionMailstop C-181600 Clifton RoadAtlanta, GA 30333(404) 639-3311http://www.bt.cdc.gov

SARS (Severe Acute Respiratory Syndrome) Aviral respiratory illness caused by SARS-associatedcoronavirus (SARS-CoV). SARS was first reportedin Asia in February 2003. Over the next fewmonths, the illness spread to more than 24 coun-tries in North America, South America, Europe,and Asia before the SARS global outbreak of 2003was contained. Many people experienced stress

out of fear of sitting next to an ill person on an air-plane or having the virus spread in other ways.Unnecessary travel to many parts of the world wascurtailed because of the epidemic. Changing vaca-tion and business travel plans was a source of stressto many individuals and businesses.

According to the World Health Organization(WHO), 8,098 people worldwide became ill withSARS during the 2003 outbreak; of these, 774 died.In the United States, only eight people had labora-tory evidence of the infection. These people hadtraveled to other parts of the world with SARS.

How SARS Spreads

Close person-to-person contact is the main way thatSARS seems to spread. The virus is thought to betransmitted most readily by respiratory droplets pro-duced when an infected person coughs or sneezes.Droplet spread can happen when droplets from thecough or sneeze of an infected person are propelleda short distance (generally up to three feet) throughthe air and deposited on the mucous membranes ofthe mouth, nose, or eyes of nearby persons. Thevirus also can spread when person touches a surfaceor object contaminated with infectious droplets andthen touches his or her mouth, nose, or eye.

“Close contact” in the context of SARS meanshaving cared for or lived with someone with SARSor having direct contact with respiratory secretionsor body fluids of a patient with SARS. Examples ofclose contact include kissing or hugging, sharingeating or drinking utensils, talking to someonewithin three feet, and touching someone directly.Close contact does not include activities such aswalking by a person or briefly sitting across a wait-ing room or office.

Symptoms of SARS

SARS usually begins with a high fever (greaterthan 100.4°F), headache, overall feeling of discom-fort, and body aches. Some people also have mildrespiratory symptoms at the outset. About 10–20percent of patients have diarrhea. After two toseven days, SARS patients may develop a drycough. Most develop pneumonia.

Centers for Disease Control and Prevention Response

In 2003, the Centers for Disease Control and Pre-vention (CDC) of the U.S. Public Health Service

316 SARS

worked closely with the World Health Organiza-tion and other partners in a global effort to addressthe SARS outbreak of 2003. The CDC activated itsEmergency Operations Center to provide coordina-tion and response, committed more than 800 med-ical experts and support staff to work on the SARSresponse, and deployed medical officers, epidemi-ologists, and other specialists to assist with onsiteinvestigations around the world. Additionally, CDCprovided assistance to state and local healthdepartments in investigating possible cases ofSARS in the United States, conducted extensivelaboratory testing of clinical specimens from SARSpatients to identify the cause of the disease, andinitiated a system for distributing health alertnotices to travelers who may have been exposed tocases of SARS.

CDC continues to work with other federal agen-cies, state and local health departments, and healthcare organizations to plan for rapid recognition andresponse if person to person transmission of thevirus recurs. CDC provides the latest informationon SARS on the SARS Web site: http://www.cdc.gov/ncidod/sars.

FOR FURTHER INFORMATION:Centers for Disease Control and Prevention1600 Clifton RoadAtlanta, GA 30333(800) 311-3435 (toll-free)(404) 639-3534http://www.cdc.gov

SOURCES:Guan Y, Zheng B. J., He Y. Q., et al. “Isolation and Char-

acterization of Viruses Related to the SARS Coron-avirus from Animals in Southern China.” Science 302,no. 5643 (October 10, 2003): 276–278.

Normille, D., and M. Enserink. “Tracking the Roots of aKiller.” Science 301, no. 5631 (August 15, 2003):297–299.

school This term refers to learning institutions,including nursery schools and preschools. Thestress caused by fear of going to school may cause achild to be absent, tardy, or simply refuse to attendschool. Fear of going to school may begin as early askindergarten, but usually develops during elemen-tary or junior high school. In many cases, the childbegins to devise reasons for staying home. Some

develop symptoms, such as nausea, stomachaches,or HEADACHES; others leave home for school, thenreturn without their parents knowing that they areabsent from school, or spend their day elsewhere.Cases of extreme refusal to attend school may beconsidered school PHOBIA. (Fear of school, or schoolphobia, is known as didaskaleinophobia.)

School avoidance (also known as school refusal orschool absenteeism) is one of the most commonANXIETY DISORDERS in children. Avoidance mayresult from many aspects, such as anxiety over sep-aration from the parents or getting along withteachers, a discipline issue, a complication of amood disorder, or a fear of failure.

Overcoming the Stresses of School

Helping a child who feels stressed by school atten-dance should begin with discussions with the childand the teacher or teachers involved, and investi-gating possible causes of the child’s problem withinthe school or school transportation situation.

Reasons may include low SELF-ESTEEM; beingbullied, teased, or criticized; or feeling inferior toothers. Situations surrounding actual school issuesshould be considered, such as riding on the schoolbus, eating in the school lunchroom, using the pub-lic washrooms, and undressing in the gym lockerrooms. Issues of BODY IMAGE may be involved.

With appropriate counseling and conferenceswith teachers or other school officials, all con-cerned can develop a new understanding of thechildren’s stresses regarding school.

Treatment of a child who avoids school shouldbe regarded as crisis intervention. The goal shouldbe to get the child back in school as soon as possi-ble and attending regularly with less fear and moreconfidence to meet the daily challenges.

Stresses on Schoolteachers

In today’s urban societies, teachers face morestresses than just in the classroom. Some neighbor-hoods in inner cities are populated by gang mem-bers, gun carriers, and drug dealers. From the timeteachers leave their car in the parking lot, enterthrough a metal detecting machine, and arrive intheir classrooms, there can be considerable uneasi-ness. Dealing with young people who are concernedonly with getting through school and who nearlydare teachers to teach them something, is stressful

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for even the most dedicated of teachers. Counselingservices within the school can be helpful.

See also COPING; CRITICISM; PARENTING; PERFEC-TION; UNDERACHIEVEMENT.

seasonal affective disorder syndrome (SADS) Aform of mild DEPRESSION resulting from the stress ofnot seeing much sunshine or daylight for monthsat a time. It is characterized by severe mood swingscorresponding to the change of seasons. Depres-sion usually becomes more prevalent during thewinter months, while the mood improves with thecoming of spring.

The incidence of SADS, which an estimated 35million Americans suffer from, rises with geo-graphic latitude, affecting 1.4 percent of Floridiansbut almost 10 percent of the population of NewHampshire.

Role of Genetics

People who eat more, sleep more, and are moredepressed during the winter months may havefamily members experiencing similar changes,according to an article in the Archives of General Psy-chiatry. Researchers from Washington UniversitySchool of Medicine surveyed 4,639 adult twinsfrom Australia to determine if there is a biologicalpredisposition to seasonal rhythms in mood andbehavior (seasonality). Two types of seasonalitywere described: one characterized by a winter pat-tern and a second by a summer pattern of depres-sive mood disturbance. The researchers found thatwinter was much more likely than summer to leadto changes in mood, energy, social activity, sleep,appetite, and weight. They also found a “significantgenetic influence” on those changes; 17 percentreported that they felt worse during the winter and8 percent reported that they experienced a sum-mer pattern of worsening in mood.

The researchers concluded, “There is a tendencyfor seasonality to run in families, and this is largelydue to a biological predisposition. These findingssupport continuing efforts to understand the roleof the stress of seasonality in the development ofmood disorders.”

Role of Light Therapy

Therapy for SADS includes use of specially madebright lights that extend the hours of illumination

during short winter days and help reset the body’sCIRCADIAN RHYTHMS. In some cases, a PHARMACO-LOGICAL APPROACH and PSYCHOTHERAPY are useful.

See also CLIMATE; MOODS.

SOURCES:Anderson, Janis L., and Gabrielle I. Weiner. “Seasonal

Depression.” Harvard Health Letter 21, no. 4 (February1996).

Madden, Pamela A. F. “Seasonal Changes in Mood andBehavior.” Archives of General Psychiatry, January 1996.

Rae, Stephen. “Bright Light, Big Therapy.” Modern Matu-rity, February–March 1994.

secondary depression A DEPRESSION occurring inan individual who has another illness, either men-tal or physical, preceding the depression. Forexample, depression may accompany psychiatricdisorders such as OBSESSIVE-COMPULSIVE DISORDER,ALCOHOLISM AND ALCOHOL DEPENDENCE (most com-mon); depression may occur after or together witha medical illness. Careful evaluation of secondarydepression by a physician is essential to determinethe cause and course of treatment to reduce thestress the individual is experiencing.

See also PHARMACOLOGICAL APPROACH.

secondary gain A secondary gain is an obviousadvantage that an individual gains from his or heranxiety or severe effects of stress. Family andfriends may be more protective and more attentiveand may release the individual from responsibility.For example, an agoraphobic person experiencessecondary gains by having someone willing toaccompany him or her outdoors or do errands andchores.

See also AGORAPHOBIA; ANXIETY; PHOBIAS.

secrets Bits of information people hide or areafraid to tell. Some feel stressed about keepingtheir secrets or learning the secrets of others. Theword secret is derived from the Latin secretus, mean-ing “separate” or “out of the way.” The current def-inition, according to the American Heritage Dictionaryof the English Language, includes: “Something kepthidden from others or known only to oneself or toa few. Concealed from general knowledge or view.Dependably close-mouthed; discreet. Not visiblyexpressed; private; inward.”

318 seasonal affective disorder syndrome

Most people know something that fits the abovedefinition of secrets. However, the definition doesnot include many people who are uncomfortableand stressed. They think that there is somethingwrong in having a secret, don’t know what to doabout it, and feel scared and threatened. Many peo-ple struggle lifelong with the keeping of secrets. Aperson’s own secrets become all-consuming, suchas having committed a crime, attempted suicide,having mental illness in the family, or his or herown sexual orientation. There are women and menwho are secret alcoholics, agoraphobics afraid toventure out of their homes, women who have hadabortions or, after giving birth, gave babies away,and people who know they are adopted and nevertold their spouses. Some people keep prior mar-riages secret; others are or were victims of abuse bytheir husbands or wives. Hiding these secrets, aswell as invisible disabilities, such as vision or hear-ing impairment, diabetes, or cancer, producesstresses that can lead to ANXIETY DISORDERS.

Many people who hide secrets CATASTROPHIZE

(constantly asking “what if”). Catastrophizing is pre-dicting in the imagination the actuality of a negativeevent. They project the “worst case” scenario intothe future and act on it as if it were true. As indi-viduals continue worrying about hiding a secret, orworrying about what might happen if they tell, thestress produced leads to body tension, causing psy-chophysiological illnesses such as HEADACHES andstomachaches, and behavior symptoms such as irri-tability, short temper, difficulty concentrating, anxi-eties, DEPRESSION, and frustration.

Sharing Secrets

Divulging secrets at the wrong time to the wrongpeople can be embarrassing, shameful, and mayinterfere with one’s life and lifestyle. On the otherhand, telling a secret at an appropriate time to anappropriate person, may help one feel freer,unburdened, and able to let go of real or imaginedfears. According to Kahn and Kimmel, authors ofEmpower Yourself, secrets can be divided into thoseto keep, those to let go of and those to share. Manycouples share secrets—the intimacies of their RELA-TIONSHIP. Family members and business associatesshare secrets. For many the sharing of secrets helpsbond their loving and supportive relationships.

See also COMMUNICATION; INTIMACY.

SOURCES:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

Pennebaker, James W. Opening Up: The Healing Power ofConfiding in Others. New York: William Morrow, 1990.

security object A special object, such as afavorite toy or blanket, that gives a child comfortand reassurance. If the object is taken away or lost,even temporarily, the child will experience greatstress and probably cry inconsolably. Loss of achild’s security object also causes stress for parents,as they must find ways to help the child deal withthe loss.

See also GRIEF; PARENTING.

self-confidence See SELF-ESTEEM.

self-efficacy The concept that one can performadequately; it is also called self-confidence. Theconcept as it relates to anxiety disorders wasresearched during the 1970s by Albert Bandura (b.1925), a U.S. psychologist at Stanford University.Self-efficacy (SE) measures how likely one believesone would succeed if one attempted a task. The SErating correlates highly with performance in abehavioral test just after the rating. In people whohad phobias asked to rate SE concerning their pho-bic task, SE is low before treatment and rises afterindividuals improve with exposure treatment.

Improved SE or self-confidence at the end oftreatment may be a major mediator in the reduc-tion of stress regarding a phobia. However, a betterway to increase SE is by exposure, the same proce-dure that can reduce fear. In experiments, SE cor-related highly with low performance of afrightening task, but also with the stress and fearexpected during it. In one experiment with 50snake-phobic students, most refused to try to holdthe snake because they were frightened, notbecause they felt inept. They were certain that theycould hold the snake if they really “had to.” If atask is frightening, SE reflects an individual’s will-ingness rather than ability to do it. When willing-ness rises, there is less anticipated fear and stress.

SE can predict psychological changes achievedby different modes of treatment. Expectations of

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personal efficacy determine whether copingbehavior will begin, how much effort will beexpended, and how long it will be sustained in theface of aversive experiences. Persistence in activi-ties that are subjectively threatening but, in fact,are relatively safe produces, through experiencesof mastery, further enhancement of self-confi-dence, and corresponding reduction in defensivebehavior and reduction of stressful factors.

Individuals derive expectations of self-efficacyor self-confidence from four main sources: per-formance accomplishments, vicarious experience,verbal persuasion, and physiological states. Themore dependable the experiential sources, thegreater the changes in perceived self-efficacy andreduction of stress.

See also ANXIETY DISORDERS; PHOBIA; SELF-ESTEEM;STRESS.

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Facing Fears: The

Sourcebook for Phobias, Fears, and Anxieties. New York:Checkmark Books, 2000.

self-employment See CHANGING NATURE OF WORK.

self-esteem Accepting oneself, liking oneself andappreciating one’s self-worth. A high degree ofself-esteem is a major characteristic of successfulCOPING with stress. Low self-esteem can lead tomental and physical disorders, such as DEPRESSION,poor appetite, HEADACHES, insomnia, and, inextreme cases, SUICIDE.

Many people become stressed when they com-pare themselves with others or use unrealisticstandards set for them by others. Those who thinkthey do not measure up, have low levels of self-esteem and may feel inferior, either intellectuallyor physically. In contrast, individuals with highself-esteem feel confident and capable. People withlow self-esteem often become workaholics anddepend on approval from others.

Lack of self-esteem has been indicated as onepossible causative role for social ills, includingjuvenile delinquency, crime, and substance abuse.Lack of self-esteem can be life threatening, partic-ularly in young people, where it is a major factor indepression and suicide.

Causes of Low Self-Esteem

While causes of low self-esteem vary between indi-viduals, there are many common themes. Somehave low self-esteem because of physical appear-ance, for example, individuals who are overweight.This can be overcome by seeking counselingregarding a diet and exercise program. Some haveprominent facial features, such as a misshapennose or ear; with counseling and possibly cosmeticsurgery, improvements can be made in bothappearance and outlook.

Abuse is another common cause. Having beenabused as a child, either sexually or psychologi-cally, or having been an abused spouse or in acodependent relationship can have a lasting effecton a person’s self-esteem.

Some children lose their self-esteem on the ath-letic field because they do not complete well or donot have the physical ability to keep up or are bul-lied by team members. Other children lose self-esteem in the classroom when they are stressed bydoing subjects they find hard. Simple commentsand CRITICISM by teachers can be stressful to a childand can lower self-esteem. For example, a childtold that he or she cannot sing well and should justmouth the words, may lose his confidence in evertrying to sing again. A high school student criti-cized because of a tendency to stutter may becomeafraid to stand up and speak in front of a crowd. Inmany cases, low self-esteem can lead to the stressesof social fears and phobias.

See also BODY IMAGE; CODEPENDENCY; DATING;DOMESTIC VIOLENCE; INFERIORITY COMPLEX; INTIMACY;OBESITY; RELATIONSHIPS; SCHOOL; SOCIAL PHOBIAS;UNDERACHIEVEMENT.

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

self-help groups The concept behind self-helpgroups is sharing feelings, perceptions, and con-cerns with others who have had or still have thesame experience. According to the American Med-ical Association, self-help groups typically exhibitthe following characteristics and benefits:Common problem: Members immediately identifywith one another.

320 self-employment

Mutual aid/helper therapy: Members benefit as muchfrom giving help as from receiving it.Network for support: Members provide a network ofemotional and social support through regular andspecial gatherings, telephone calls, newsletters, vis-its, and computers.Unconditional acceptance: Members are usuallyencouraged to share their personal situations in anonjudgmental, caring environment.Shared information: Through the group process andwritten material, members capture and share theirsuccessful techniques for COPING.Low cost: Expenses are shared through collections atmeetings, minimal membership dues, or fund-rais-ing projects.

The self-help movement, with growing strengthand visibility, has led to increased openness andunderstanding of many disorders, such as ANXIETY

DISORDERS and CHRONIC ILLNESS. Such groups helpmany people develop better coping skills to meetthe challenges they face.

Self-Help Techniques

Self-help groups utilize group discussions as well asaudio and videotapes. Self-help can work if theindividual is motivated to make it work. In fact,even with psychotherapy under the guidance of aprofessional, much of the improvement in a per-son’s ability to cope with STRESS actually comesfrom self-help.

Many individuals join SUPPORT GROUPS to learnself-help techniques for particular situations. Theseinclude MEDITATION and PROGRESSIVE MUSCLE

RELAXATION. Both are skills that can be learned andapplied to relieve stress, ANXIETY, and PHOBIAS.

See ALTERNATIVE MEDICINE.

FOR FURTHER INFORMATION:National Self-Help Clearinghouse22 West 42nd StreetNew York, NY 10036(212) 642-2944

SOURCE:American Medical Association. Healthcare Resource and

Reference Guide. Chicago: American Medical Associa-tion, 1993.

self-hypnosis See HYPNOSIS.

self-psychology Term for the psychological sys-tem propounded by Heinz Kohut (1913–81), anAustrian-born American psychoanalyst. His theoryholds that all behavior as well as stresses can beinterpreted in reference to the self. He proposedthat even a young child has tendencies towardassertiveness and ambition, idealization of parents,and the beginnings of values. All these tendenciescontribute to strong ties between the infant andparent.

Kohut believed that the real mover of psychicdevelopment is the self, rather than sexual andaggressive drives, as Sigmund Freud suggested.Kohut used the term self-object to describe an objectin an infant’s surrounding that the infant regardsas part of himself or herself. People with narcissis-tic personality disorder cannot separate adequatelyfrom the self-object and thus cannot perceive orrespond to the individuality of others. Kohutbelieved that the lack of emphatic responsebetween parent and infant is the cause of laterstresses and psychological disorders in the growingchild.

Kohut explained his major theories in severalpublications, including The Analysis of the Self(1971), The Restoration of the Self (1977) and TheSearch for the Self (1978).

See also PSYCHOTHERAPIES.

FOR FURTHER INFORMATION:Kohut ArchivesInstitute for Psychoanalysis180 North Michigan AvenueChicago, IL 60601(312) 726-6300

SOURCES:Kohut, Heinz. The Analysis of the Self. New York: Interna-

tional Universities Press, 1971.———. The Psychology of the Self. New York: International

Universities Press, 1978.———. The Restoration of the Self. New York: International

Universities Press, 1977.

self-talk Messages one gives to oneself, oftenstemming from comments heard during childhoodor earlier negative experiences. Negative self-talkmay include such statements as “I can’t do this;this will never work out; I’m no good at this.” Onthe other hand, positive self-talk may include such

self-talk 321

messages as “I’ve done this before; everything willwork out; I’ll find a way.”

Negative self-talk is a source of stress for manypeople because it discourages them from takingany risks or making desired changes in their lives.Positive self-talk can help relieve stress because itreinforces confidence in one’s own abilities.

SOURCE:Kahn, Ada P., and Sheila Kimmel. Empower Yourself: Every

Woman’s Guide to Self-Esteem. New York: Avon Books,1997.

Selye, Hans (1907–82) An Austrian-born Cana-dian endocrinologist and psychologist, well knownfor his work in STRESS research. He introduced theconcept of stress during the early 1940s. He is theauthor of The Stress of Life (1956) and Stress withoutDistress (1974).

He defined stress as “the nonspecific response ofthe body to any demand made upon it. It is morethan merely nervous tension.” He categorized over1,000 physiological occurrences related to stressand adaptation. His theory is a description of whatone may expect with chronic exposure to stressors,and with the body’s attempts to adapt and returnto “normality.”

In 1950, Selye coined the term GENERAL ADAPTA-TION SYNDROME (G.A.S.). Selye borrowed the termstress from physics, and applied it to the mutualactions of forces that take place across any sectionof the body to threaten HOMEOSTASIS. Although notall states of stress were harmful, according to Selye,he held that the more severe, protracted, anduncontrollable situations of psychological andphysical distress led to disease states. His concept ofG.A.S. focused on the reaction of the body to ill-ness or foreign substances as opposed to concen-trating on specific illnesses and their treatment.

Although his work was controversial during histime, mental health disciplines profited from hisground-breaking work in stress research. His con-cept of stress opened new avenues of treatmentthrough the discovery that hormones participate inthe development of many degenerative diseases,including coronary thrombosis, hardening of thearteries, high blood pressure, arthritis, pepticulcers, and even cancer.

Selye received his medical training in Europe;he did most of his innovative research on the

effects of stress in Montreal at McGill Universityand the Institut de Medicine et de Chirurgie Exper-imentales de l’Universite de Montreal, of which hewas director for many years. He received his med-ical degree and his Ph.D. from the German Univer-sity in Prague. Selye earned doctorates in medicine,philosophy, and science, as well as at least 19 hon-orary degrees from universities around the world.He authored more than 32 books and more than1,500 technical articles.

See also DIS-STRESS; EUSTRESS; STRESS MANAGE-MENT.

SOURCES:Selye, Hans. The Stress of Life. New York: McGraw-Hill,

1956.———. Stress without Distress. Philadelphia: J. B. Lippin-

cott, 1974.

sense of humor See LAUGHTER.

sensory integrative dysfunction An inability totake in information through the senses (touch,movement, smell, taste, vision, and hearing) tocombine it with prior information, memories, andknowledge stored in the brain to make a meaning-ful response. Many parents experience stress whentheir young children appear lazy or stubborn, shy,or headstrong. Young children may seem easilydistracted, hyperactive, or uninhibited becausethey do not screen out nonessential sensory orvisual information. They may constantly ask aboutor orient to sensory input that others ignore, suchas fans or distant airplanes. Other children may failto respond to certain stimuli, such as when theirname is called. Children with regulatory disordersmay have difficulty establishing appropriate sleep-ing and eating patterns. Understanding why thisbehavior occurs and taking steps to change thechild’s behavior can help relieve stress betweenparent and child.

Sensory integration occurs in the central nerv-ous system and is generally thought to take placethrough complex interactions of the portions of thebrain responsible for coordination, attention,arousal levels, autonomic functioning, emotions,memory, and higher level cognitive functions.Because there are many variables between chil-dren, personalities, and environment, there is no

322 Selye, Hans

single list of symptoms identified with sensoryintegrative dysfunction.

The syndrome was first researched and describedin Sensory Integration and the Child, by A. Jean Ayres,Ph.D. She says: “Good sensory processing enablesall the impulses to flow easily and reach their des-tination quickly. Sensory integrative dysfunction isa sort of ‘traffic jam’ in the brain. Some bits of sen-sory information get tied up in traffic, and certainparts of the brain do not get the sensory informa-tion they need to do their jobs.”

According to Linda C. Stephens, writing in theAAHBEI News Exchange, parents and professionalsshould look at patterns of behaviors and the over-all situation of how problems interfere with thechild’s function in his or her play, physical andemotional development, and ability to developindependence. A child suspected of having a sen-sory integrative disorder should be evaluated by ahealth care professional who has had additionaltraining in sensory integration evaluation andtreatment.

Identifying Dysfunctions in Young Children

The child may lack purpose in his or her activityand be easily distracted. While young children’sattention span is generally short, a child who hassensory integration dysfunction shows even moredistractibility, and does not play, climb, or swing inan organized way. Other children with this dys-function may be very repetitive in playing withtoys. They may learn one way to play with a toy orplayground equipment without adding variationsor playing creatively. Other children may havepoor balance and trip easily and bump their headsbecause they lack protective responses when theybegin to fall.

Some children have difficulty calming them-selves after exciting physical activity or after becom-ing upset. Tantrums may occur and the child mayseen inconsolable. Other children seek excessiveamounts of vigorous sensory input, such as swing-ing or spinning without experiencing dizziness.

Children may become discouraged or developpoor SELF-ESTEEM, particularly if they are aware ofdifferences in their function and those of theirpeers. A child’s difficulty with motor skills and playactivities may make it hard for him to be part of a

group, cause aggressive behaviors, or cause thechild to be a loner. The child may have difficultywith transitions, such as leaving one place to go toanother.

Parents should look at behavior patterns andhow the problems interfere with the child’s func-tion in his or her play, physical and emotionaldevelopment, interaction with other children andadults, and ability to develop independence. Helpis available from certified professionals (usuallyoccupational or physical therapists). Therapistsmay administer and interpret results of the Sen-sory Integration and Praxis Tests and make recom-mendations to concerned parents.

FOR FURTHER INFORMATION:Klinefelter Syndrome and Associates11 Keats CourtCoto de Caza, CA 92679(888) 999-9428(949) 858-3443 (fax)http://www.genetic.org

American Association for Home-Based EarlyInterventionists6500 Old Main HillLogan, UT 84322-6500(800) 396-6144 (toll-free)(435) 797-5580 (fax)http://www.aahbei.orgE-mail: fpayne@cc.usu.edu

SOURCES:Ayres, A. Jean. Sensory Integration and the Child. Los Ange-

les: Western Psychological Services, 1994.Stephens, Linda C. “Sensory Integrative Dysfunction.”

AAHBEI News Exchange, 2, no. 1 (winter 1997): 1–7.Trott, Maryann Colby, et al. SenseAbilities: Understanding

Sensory Integration. Tucson, Ariz.: Therapy SkillBuilders, 1993.

separation anxiety A stressful feeling one expe-riences when separated from parents or individualswith whom one has an attachment. Infants andtoddlers normally experience stress and anxietywhen separated from parents or caregivers, but theintensity usually diminishes by the time the child isfour to five years old. Children who fear separationcry, cling to the parent, and demand to be held andcuddled.

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Symptoms of separation anxiety in childhoodmay be HEADACHES, stomachaches, and othervague complaints in an effort to keep the parentfrom leaving or to keep the child home fromSCHOOL. School phobia, or school avoidance, issometimes a case of separation anxiety. Whatsome children fear is that something dreadful willhappen to their parent(s) if they are away, or thatthe parent will not be there when the childreturns.

Sometimes the parent (usually the mother) hasa fear of danger when her child is away from her,which is transmitted to the child and augments thechild’s own fears. The mother of a child with sepa-ration anxiety may need supportive psychotherapyto help relieve her own stresses as well as those ofthe child.

See also AGORAPHOBIA; GRIEF; SECURITY OBJECT.

September 11, 2001 (9/11) In a series ofdeliberate and deadly acts, the worst event of ter-rorism in the history of the United Statesoccurred on this date. Two hijacked airlinerscrashed into the World Trade Center towers inNew York City. Thousands were feared deadwhen the towers collapsed more than an hourafter the impacts. A third hijacked airlinercrashed into the Pentagon. A fourth, possiblybound for another target in Washington, D.C.,crashed in Somerset County, Pennsylvania,apparently after passengers attempted to over-power the hijackers. The Federal AviationAdministration suspended all air traffic in theUnited States and diverted international flights toCanada. Federal offices and public buildings inWashington, New York, and other major citieswere closed.

More than 3,000 people died as a result of thetragic acts or remained missing following theattacks.

• Victims came from 80 different nations, frommany different races and religions.

• 343 firefighters and paramedics perished at theWorld Trade Center.

• 23 police officers and 37 Port Authority policeofficers died at the World Trade Center.

• Approximately 2,000 children were left withouta parent and many families were permanentlydisrupted by the events.

• One business alone lost more than 700 employ-ees, leaving at least 50 pregnant widows.

Many survivors and witnesses suffered symp-toms of POST-TRAUMATIC STRESS DISORDER.

President George W. Bush called the attacks“acts of war” and along with many world leaders,began steps to prevent future terrorist attacks.

The event has come to be known as 9/11, andthe event was and continues to be an inestimablesource of stress for all Americans.

As a result of the attacks, the USA PATRIOT Actof 2001 was signed into law in a stated attempt topursue and punish terrorists and also to preventfurther attacks. The USA PATRIOT Act in itself hasbeen a source of stress for some who fear that thefreedoms and liberties formerly enjoyed by Ameri-cans are being limited in the name of preventingterrorist attacks.

September 11 was designated by PresidentGeorge W. Bush as Patriot Day (Public Law 107-89) in December 2001.

See also ANTHRAX; TERRORISM.

serious mental illness (SMI) A diagnosable,mental, behavioral, or emotional disorder experi-enced by an individual in the past year that meetsthe criteria specified in the Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition (DSM-IV)and that results in functional impairment substan-tially interfering with or limiting one or moremajor life activities. A scale of six questions is usedto measure SMI. These questions ask how fre-quently a respondent experienced symptoms ofpsychological distress during the one month in thepast year when he or she was at his or her worstemotionally.

In 2003, according to the Department of Healthand Human Services, Substance Abuse and MentalHealth Services Administration, Office of AppliedStudies, there were an estimated 19.6 millionadults aged 18 or older with SMI. This represents9.2 percent of all adults and is higher than the rateof 8.3 percent in 2002. (See chart.)

324 September 11, 2001

serotonin A NEUROTRANSMITTER found in the cen-tral nervous system, in many tissues, in the liningof digestive tract, and in the brain, serotonin influ-ences SLEEP and emotional arousal and is indirectlyinvolved in the psychobiology of DEPRESSION. Lowlevels of serotonin may contribute to developmentof depression. Some antidepressant medicationsincrease the levels of serotonin and norepineph-rine, another neurotransmitter.

See also PHARMACOLOGICAL APPROACH.

serotonin reuptake inhibitors (SRIs) See DEPRES-SION; PHARMACOLOGICAL APPROACH.

sex appeal Usually refers to personal appeal orphysical attractiveness for members of the oppositesex. A healthy, good-looking face, attractive hair,and an attractive body shape are generally theembodiment of sex appeal in the United Statestoday. Individuals with these characteristics arefeatured in advertisements and in films. Peoplemay find these advertisements a source of stress asthey seem to feel that these models are a threat totheir SELF-ESTEEM.

A person who has sex appeal may be said to be“sexy” based on cultural patterns and personaltastes. For example, men who are muscular andathletic are considered sexy, as are women who are

sex appeal 325

TABLE 6.1A SERIOUS MENTAL ILLNESS IN THE PAST YEAR AMONG PERSONS AGED 18 OR OLDER, BY GENDER AND DETAILED AGE CATEGORIES: NUMBERS IN THOUSANDS, 2002 AND 2003

GENDER

Total Male Female

Age Category 2002 2003 2002 2003 2002 2003

TOTAL 18 OR OLDER 17,483b 19,588 6,041a 6,887 11,442b 12,70218 543 644 216 275 326 36919 514a 619 192 223 322 39520 511 574 214 243 297 33221 571 544 218 199 353 34522 533 508 209 196 324 31123 518 518 193 190 324 32824 426b 545 159 218 268 32725 469 468 160 146 309 32226–29 1,458 1,725 543 635 915 1,09030–34 2,132 1,967 732 589 1,400 1,37835–39 1,995 2,253 846 775 1,150a 1,47840–44 2,236 2,248 643 662 1,593 1,58645–49 1,713a 2,224 559 776 1,154 1,44850–54 1,397 1,718 384 667 1,013 1,05055–59 904 991 305 387 599 60460–64 416 521 158 199 259 32266 or Older 1,148 1,521 313 505 835 1,016

*Low precision; no estimate reported.

NOTE: Serious Mental Illness (SMI) is defined as having a diagnosable mental, behavioral, or emotional disorder that met the cri-teria found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and resulted in functionalimpairment that substantially interfered with or limited one or more major life activities. See Section B.4 of Appendix B of theResults from the 2003 National Survey on Drug Use and Health: National Findings.a Difference between estimate and 2003 estimate is statistically significant at the 0.05 level.b Difference between estimate and 2003 estimate is statistically significant at the 0.01 level.

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003.

relatively slim but have large breasts. At other peri-ods in history, women who were plump were con-sidered attractive, as shown in paintings of PeterPaul Rubens, a Flemish painter (1577–1640)whose nudes gave our vocabulary the term Rube-nesque, to refer to the well-developed and heavierbody shapes.

See also ADVERTISING; BODY IMAGE; EATING DIS-ORDERS.

sex drive A level of desire to have sexual activity.This level varies in strength and is different forwomen and men and at different ages and stages oftheir lives. Differences may be due to stress or toinhibitions influenced by parental, religious, andpeer group attitudes about sex.

People’s expression of sexual desire may differalso, according to whether or not they have a part-ner. For example, sex researchers have found thatsome widowed postmenopausal women who haveno partner believe that their sex drive is not verystrong, while women in the same peer group whodate and have male companions feel a strong sexdrive.

While some researchers believe that sex drivedecreases with age, many older adults will attest tothe fact that sex drive can persist throughout allstages of life. Good health, freedom from chronicdisease, and companionship with others of theopposite sex stimulates the sex drive to continueuntil older age.

See also SEX THERAPY; SEXUAL DIFFICULTIES.

sexism An attitude or belief that one sex is supe-rior to the other in certain situations. The attitudeseems to cause stress for all concerned. The termoften refers to male attitudes about women, suchas “women in public office might cry if they areupset,” or “a woman shouldn’t be trained for ahigh-paying job because she will leave to havechildren.” To a large extent the WOMEN’S MOVE-MENT during the latter half of the 20th centuryfought to overcome sexism.

See also SEXUAL HARASSMENT.

sex therapy Includes counseling and treatmentfor SEXUAL DIFFICULTIES that are not due to medicalor physical causes. People may encounter sexual

difficulties because of stress, while at the same timesexual difficulties are a cause of stress for them.The purpose of sex therapy is to address the anxi-eties that a couple has about sexual activity bylearning what normal sexual behavior is and byincreasing their enjoyment of sex by graduallyengaging in intimate activities. Couples learn tocommunicate better with each other regardingsexual matters and preferences, retrain theirapproaches and response patterns, and thus reducetheir feeling of stress.

Sex Therapy Techniques

Sex therapists use several techniques. One is sen-sate focus therapy, in which the couple explorespleasurable activities in a relaxed manner withoutsexual sensations. The couple might start withmassage of non-erogenous areas of the body. Grad-ually, as anxieties diminish, the couple progressesto stimulation of sexual areas and finally to sexualintercourse.

Other techniques sex therapists use are directedtoward reducing premature EJACULATION, relievingvaginismus (muscle spasm of the vagina), andhelping both partners reach orgasm.

For sexual difficulties related to physical causesor illness, individuals should consult a physician,particularly specialists in gynecology or urology.

See also ANORGASMIA; COMMUNICATION; DYSPARE-UNIA; INTIMACY; LISTENING; SEXUAL PREFERENCES.

SOURCE:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.

sexual difficulties Any conditions that interferewith the process leading to and including enjoy-ment of sexual intercourse (coitus). Sexual diffi-culties are extremely stressful for the individualsinvolved. Indeed, many marriages and relation-ships break up because of sexual stress.

The opposite of sexual difficulties are feelings ofcontentment after a pleasurable and satisfying sex-ual encounter. An individual has a feeling ofintense fulfillment in the orgasmic and resolutionphases of the SEXUAL RESPONSE CYCLE. This isaccompanied by a feeling of extreme RELAXATION,sometimes a “high” feeling and emotional close-ness with the partner.

326 sex drive

There are temporary sexual difficulties andthere are dysfunctions or situations that persistlifelong. Use of some prescription drugs may causesexual dysfunction for some individuals; it may bepossible that other similar drugs can be substitutedby a physician that do not have these unpleasantside effects.

Examples of female sexual difficulties includeANORGASMIA, DYSPAREUNIA (painful sexual inter-course), and VAGINISMUS. Examples of male sexualdysfunctions include IMPOTENCE, difficulty in main-taining erection, premature EJACULATION, andretarded ejaculation.

Sexual Fears

Many people are under stress and that stress tendsto impair or weaken their sexual responses topartners. For example, some women fear experi-encing pain during intercourse or fear that theywill not experience ORGASM. Some men fear thatthey will not be able to achieve or maintain anerection long enough for a satisfying experiencefor their partners.

The stress of CHRONIC ILLNESS can cause peopleto fear that they will not be able to enjoy sexuallyfulfilling experiences. For example, some hus-bands after heart surgery fear the sexual act itself;their wives fear that sexual activity will harm theirhusbands.

The threat of acquiring a SEXUALLY TRANSMITTED

DISEASE (STD) or the HIV virus (known as thecause of AIDS) is a contemporary fear of many peo-ple who are not in monogamous relationships.These fears can largely be overcome by the use ofSAFE SEX practices.

See also BEHAVIOR THERAPY; COMMUNICATION;HUMAN IMMUNODEFICIENCY VIRUS; SEX THERAPY.

sexual harassment Unwelcome and unwantedsexual attention, usually on the job; it is particu-larly stressful for the person experiencing it. Theharassment may involve men toward women,women toward men, or the same-sex individuals;it may include jokes, remarks, and questions aboutthe other’s sexual behavior, “accidental” touching,and repeated and unwanted invitations for a dateor for a sexual relationship. It can be verbal, visual,physical, or written.

Sexual harassment is defined in terms of itseffect on the recipient. This means that behaviormeant to be humorous or well-intentioned is sex-ual harassment if it is offensive to the individual atthe receiving end. It is not the intent of the senderof the behavior that counts because what one per-son may view as harmless can be objectionable toothers.

Of all incidents of sexual harassment reported tothe Equal Employment Opportunities Commissionin fiscal year 1990, 92 percent were reported bywomen. Women in lower positions are far lesslikely to tell a harasser who holds a higher organi-zational position that his/her conduct is unwel-come. However, in a research study of femalemedical students, 61 percent reported having been

sexual harassment 327

EXAMPLES OF SEXUAL HARASSMENT

• Dirty jokes or sexually oriented language• Nude or semi-nude photos, posters, calendars,

or cartoons• Obscene gestures, lewd actions, or leering• Introduction of sexual topics into business con-

versations• Requests for dates or sexual favors that are not

mutually acceptable• Unwelcome hugging, patting, or touching

SEXUAL HARASSMENT: WHAT TO DO

• Tell the offender promptly and clearly that theconduct is unwelcome and unacceptable. Dothis verbally or in writing, or both.

• Document in writing every incident, with spe-cific details of the offensive behavior and yourresponse.

• Do not feel guilty. Sexual harassment is not yourfault. By clearly voicing your expectations, youforce the offender to choose whether to changethe unwelcome behavior or to purposely con-tinue it.

• If the problem continues, tell your supervisor. Ifyour supervisor is the harasser, talk to anotherexecutive or report it to the department ofhuman resources.

sexually harassed by residents or interns and 48percent claimed to be harassed by patients.

A United States Supreme Court decision (Meri-tor v. Vinson) in 1980 declared that sexual harass-ment is a form of sex discrimination and, therefore,a violation of Title VII of the 1964 Civil Rights Act.During the 1980s, American society becameincreasingly aware of sexual harassment. Forexample, in the study by the U.S. Merit SystemsProtection Board reported in 1988, federal workerswere more inclined to define certain types ofbehavior as sexual harassment than in 1980.

In the late 1990s, cases of sexual harassment inthe military services were uncovered. Stressesarose when enlisted men and women felt obligatedto follow requests of their superiors. Disciplinarycharges occurred in many cases and led to dis-charge, which will probably serve as a deterrent toongoing sexual harassment in the military.

sexuality The ability to think and behave as asexual being; also, any aspect of human thought orbehavior that has sexual meaning. It implies a self-concept of oneself as a sexual being as well as hav-ing the capacity to respond to erotic stimuli andsexual activity. Sexuality encompasses being com-fortable with sexual fantasies and erotic zones ofthe body as well as with one’s own gender identity.However, no specific set of behavior or SEXUAL

PREFERENCE is necessary to have a good sense ofone’s own sexuality. Social, psychological, and bio-logical dimensions to human sexuality lead tostress for many people.

See also SEXUAL DIFFICULTIES.

sexually transmitted diseases (STDs) Diseasesthat affect both men and women and are generallytransmitted during sexual intercourse. STDs causeindividuals considerable stress because of physicaldiscomforts, psychological pain, possible INFERTIL-ITY, and the potential that they may be life-threat-ening, as in the case of AIDS.

STDs cause psychological distress for many rea-sons, including a need to communicate the prob-lem to one’s partner and a need to discloseinformation about past sexual activities and part-ners. The term SAFE SEX relates to sexual practicesthat aid in the prevention of STDs as well as AIDS.

The stresses and long-term effects caused by twoSTDs, syphilis and gonorrhea, have been withhuman beings for centuries. Those two diseaseswere commonly referred to as venereal diseaseslong before the term STD was coined. Syphilis andgonorrhea are still prevalent, and on the increasedue to the upswing in other concurrent STDs.These other STDs became notably widespread dur-ing the latter decades of the 20th century. Theyinclude chlamydia, herpes, hepatitis B, as well asgenital warts, and other vaginal infections.

Individuals who are widowed or divorced andwho begin dating and seeking new partners aftertheir loss, as well as never-married individuals, areconcerned about STDs. Fear of acquiring STDs hasled many formerly sexually active people to seekfewer sexual partners. Such concerns have alsoincreased the use of condoms, which, when appro-priately used, are thought to reduce the likelihoodof spreading most STDs (as well as AIDS).

Unlike infections with herpes, chlamydia, andgonorrhea, which can be transmitted at birth, con-genital syphilis is a prenatal infection. Fetal infec-tion may occur at any time during pregnancy. It is

328 sexuality

HOW TO REDUCE RISKS OF ACQUIRING AN STD

• Have sexual contact with only one partner wholimits contact to you only. Have a monogamousrelationship.

• Ask your partner about any suspicious lookingdischarges, sores, or rashes. Look your partnerover.

• Use condoms. Condoms provide some (thoughnot complete) protection against STDs. However,the condom must be put on before sexual activ-ity begins and not removed until the end of theactivity.

• Use foam, a diaphragm with spermicides, orsponge spermicides, which kill many infectiousagents; these should be used in addition to thecondom.

• If another partner has a STD, the other partnermust be informed and treated at the same timeto avoid reinfection. Avoid the “ping-pong”effect of infection.

more likely to occur if the mother has primary, sec-ondary, or early latent syphilis, as many organismsare present in the circulation during these stages.

ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)has become a widely known disease during the lat-ter part of the 20th century. The AIDS virus isknown to be transmitted by direct exchange ofbody fluid, such as semen or blood, and thus isconsidered a sexually transmitted disease.

FOR FURTHER INFORMATION:National VD HotlineAmerican Social Health Association(800) 227-8922; CA: (800) 982-5883

American Social Health AssociationP.O. Box 13827Research Triangle Park, NC 27709(919) 361-2742(919) 361-8425 (fax)http://www.ashastd.org

SIECUS (Sex Information and Educational Council of the U.S.)

130 W. 42nd Street, Suite 350New York, NY 10036-7802(212) 819-9770(212) 819-9776 (fax)http://www.siecus.org

SOURCES:Kahn, Ada P., and Linda Hughey Holt. The A-Z of Women’s

Sexuality. Alameda, Calif.: Hunter House, 1992.Sack, Fleur. Romance to Die For: The Startling Truth about

Women, Sex and AIDS. Deerfield Beach, Fla.: HealthCommunications, 1992.

sexual preferences The choices women and menmake when experiencing attraction to and partici-pating in sexual activities with other men, women,or both genders. These may be influenced by envi-ronment, early childhood experiences, possiblygenetic makeup, and early hormonal exposureeffects on central nervous system development.

HOMOSEXUALITY refers to sexual attraction tomembers of the same sex. Bisexuality refers to sex-ual attraction to members of the opposite sex andmembers of the same sex. Stresses involve perceiv-ing oneself as different from most people and attimes not understanding one’s attractions.

See also LESBIANISM.

sexual response A physiological reaction to sex-ual stimulation and arousal. In women, vaginallubrication is an early sign in the sexual responsecycle. In men, erection of the penis occurs.Responsiveness is a highly individual matter,largely determined by mutual feelings of love andaffection between the partners and a wide varietyof emotional and physical circumstances. Levels ofresponsiveness vary between individuals, and varywithin the same individual at different times.Many people experience stress about theirresponses, not realizing that a wide range of differ-ences are considered normal.

See also SEX THERAPY.

sexual revolution The changes in sexual atti-tudes and behaviors in the United States during the1960s, 1970s, and early 1980s. With the changescame increased stresses for many people as morechoices of lifestyle became socially acceptable.Generally, there were more liberal attitudes towardpremarital sexual activity, changes in the doublestandard in which sexual activity had previouslybeen seen as more acceptable for men than forwomen, and more open discussion of women’ssexual needs. Increases in premarital activityevolved in part as a result of development of betterand easier means of BIRTH CONTROL, including oralcontraceptives during the late 1950s.

For many young people, DATING habits during thesexual revolution included sexual intercourse earlyin the relationship. However, with the increase ofSEXUALLY TRANSMITTED DISEASES and ACQUIRED

IMMUNODEFICIENCY SYNDROME (AIDS) in the hetero-sexual population since the 1980s, people havebecome more cautious and selective about theirsexual partners and monogamy has regained favor.

The sexual revolution was closely tied with theWOMEN’S MOVEMENT. Many college dormitoriesbecame coeducational, and there was wideracceptance of unmarried adults “living together.”While this arrangement was acceptable to many,for others it was a source of stress.

shell shock See POST-TRAUMATIC STRESS DISORDER.

shiatsu Considered an alternative therapy thatmay be useful for some individuals to prevent orrelieve the effects of stress. Shiatsu is a specific

shiatsu 329

method for manipulating tsubos (points along themeridians where the flow of energy may becomeblocked). The manipulation may occur throughpressing with the fingers and hands, or through theuse of elbows, knees, and feet. The points that aremanipulated are known as ACUPRESSURE or ACUPUNC-TURE points. Manipulation of the body’s approxi-mately 360 tsubos is thought to release the flow ofenergy (chi). There are many forms of shiatsu.

See also ALTERNATIVE MEDICINE; BODY THERAPIES.

SOURCE:McCarty, Patrick. A Beginner’s Guide to Shiatsu: Using Fin-

ger Pressure for the Relief of Headaches, Back Pain, andHypertension. Garden City, N.Y.: Avery PublishingGroup, 1995.

shift work Usually refers to working a series ofhours earlier or later in the day than the moreusual 9 to 5 routine. Some work an afternoon shift,from 4 to 11 P.M.; others work the night shift, from11 P.M. to 7 A.M. People who do shift work experi-ence many unique stresses. How well one adapts toshift work depends on how well one handles theinterruption of the body’s CIRCADIAN RHYTHMS. Thebreak in circadian rhythm can affect mental ability,alertness, and temperament. Thus some night shiftworkers experience anxiety and lapses in memoryas a result of SLEEP deprivation.

Individuals who do shift work also suffer socialstresses. For example, many people function on a 9to 5 schedule, with most socialization occurringafter work and on weekends. For night-shift peopleto have a family or social life, they must schedulecreatively. Spouses and children of shift workersalso experience stress because of this schedule.

How Night Shift Workers Can Avoid Stress

“The best strategy is to stay on one shift as long aspossible. You’ll have the best chance of gettingrestful sleep that way; you’ll be more alert andpotentially safer,” says Rebecca Smith-Coggins,M.D., a Stanford University emergency medicinephysician who studies what happens when peo-ple’s sleep habits change.

“People who work random shifts in a 24-hourwork environment suffer in their ability to performspecific physical tasks and to make decisions. Otherstudies have shown that when workers are shiftedforward rather than randomly, they perform better

and have fewer sick days. However, it still takestwo weeks to get used to a night shift after a dayshift,” according to Smith-Coggins.

Workers new to the night shift can help them-selves adjust by knowing that they won’t get a fullsix to eight hours’ sleep in one stretch immediately.To help make the change, Smith-Coggins advisesthat new night workers take a three-hour napbefore starting work, then sleep again after theirshift. “Studies as well as our own experienceamong emergency department workers point tothis double sleep pattern as the easiest way toswitch over,” she says.

Eventually most shift workers will find them-selves sleeping longer after they get home and nap-ping less before they start work. Ultimately, a full“night’s” sleep is possible in the morning, afterworking the night shift.

Changing Work Shifts

For people who must change shifts, the healthiestapproach seems to be to start the new shift later inthe day. For example, it’s easier on sleep and restpatterns to change from an eight-hour shift start-ing at 7 A.M. to one starting at 3 P.M. rather thanthe reverse. Moving forward is better because mosthumans operate on a 25-hour sleep-wake cycle.“Our body temperature and other natural func-tions rotate as if the day were 25 hours long. Youcan see how that works by studies that place peo-ple in a darkened setting with no clues about time.They develop a natural tendency to get up onehour later everyday, a clear indication that we areon a forward rather than back or static cycle,”Smith-Coggins explained.

Other ways for night workers to get more effi-cient rest include darkening the bedroom as muchas possible or using a sleep mask. Ear plugs or so-called white noise, such as a humming sound froma fan or air conditioner, can help. It is also helpfulto maintain the same bedtime rituals, such asrelaxing with a book or television show, particu-larly if the material is not unsettling.

SOURCES:Hurley, Margaret, and Elizabeth A. Neidlinger. “To Shift

or Not to Shift.” Schumpert Medical Quarterly 9, no. 2(October 1991).

Smith-Coggins, Rebecca. “Night Shifts Can Be Easier.”Circulation, December 1, 1995.

330 shift work

shopaholism A compulsion to shop. While somepeople view shopping as recreation and a way toreduce stress, for others, shopping can lead to acompulsive syndrome. Excessive shopping sharessome characteristics with OBSESSIVE-COMPULSIVE

DISORDER, in which people perform certain ritualsto relieve tension. In this way, compulsive shop-ping is similar to the problems of alcoholics orgamblers who exhibit obsessive behavior.

Compulsive shoppers buy things in order to for-get the stresses of their lives and make themselvesfeel good. However, over time it takes more andmore spending and buying to improve their moods.

Many people who are normally good about bal-ancing their budgets overbuy around holidays, sofor individuals who are compulsive shoppers, theproblem will be magnified. Excessive shopping canbe attributed in part to an attempt to promote abetter self-image through buying multiple orexpensive gifts, to change people’s perceptionsabout the giver, to make an economic statement,or to serve as a substitute for weaker aspects of thegiver’s relationship with others.

Support Group for Shopaholics

Debtors Anonymous is a support group for over-spenders based on the 12-step recovery program ofAlcoholics Anonymous. DA members work towardfinancial solvency the way AA members worktoward abstinence. Experienced DA members

review new members’ finances and help them for-mulate an action plan for resolving debts and aspending plan for the future. DA members look toone another for support, hope, and strength indealing with the stresses of indebtedness.

FOR FURTHER INFORMATION:Debtors AnonymousP.O. Box 920888Needham, MA 02492-0009(781) 453-2743(781) 453-2745 (fax)http://www.debtorsanonymous.org

SOURCES:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001O’Connor, Karen. When Spending Takes the Place of Feeling.

Nashville: Thomas Nelson, 1992.

shredding machines See IDENTITY THEFT.

shyness Generally refers to excessive discomfort,embarrassment, and INHIBITION in the presence ofothers, which can lead to avoidance. Shyness is asource of stress for many individuals who recog-nize their shyness.

Shy people generally would like to be moredynamic, outgoing, and outspoken. They may beeager to meet new people and learn new activities,but are often reluctant to do so because of discom-fort and anxiety about what to say or do. Excessiveshyness sometimes becomes a SOCIAL PHOBIA.

Shyness is fairly common in children and ado-lescents. However, as the young person developsan increasing sense of SELF-ESTEEM, shyness oftendisappears.

See also PHOBIAS; PUBERTY.

sibling relationships Relationships betweenbrothers and sisters; stresses include COMPETITION

between siblings who often vie for parental atten-tion. The situation first occurs after the birth of anew baby, when an older sibling feels “displaced.”The feelings of rivalry may persist among siblingsthroughout life. One child may be continuouslycompared with another, and the parents may fur-ther the feeling of rivalry by appointing one childas the better example. Throughout school, brothersand sisters may strive to outdo one another.

sibling relationships 331

COPING WITH THE STRESS OF SHOPAHOLISM

• Shop with a list and buy only what is on the list.• Shop with a partner who will help you resist.• Avoid browsing and avoid sales. The excitement

can trigger a shopping spree.• Develop new social outlets. Cultivate groups of

friends with whom you can share activities as ahealthful alternative to shopping.

• Learn alternatives for COPING with stress. Peoplewith addictive illnesses usually do not cope wellwith stress.

• Physical exercise is a good stress reliever andwill clear your mind for better concentrationlater on.

• Avoid using credit cards. Use them only for busi-ness, if you need to.

PERSONALITY differences may account for siblingrivalry. For example, while one sibling may beextroverted, have an outgoing personality, andmake friends easily, another sibling may be moreintrospective, find it difficult to mingle but excelsin school. The introspective sibling may be jealousof the extroverted sibling’s sociability, while theextrovert may be jealous of the other sibling’s aca-demic achievements.

Sibling rivalry may persist even after the deathof parents, when brothers and sisters become jeal-ous over uneven distribution of their parents’ pos-sessions.

See also BIRTH ORDER; JEALOUSY; RELATIONSHIPS.

sick building syndrome Refers to illnesses causedby working or living in modern buildings. Symp-toms may be caused by air-conditioning systems,fluorescent lighting systems, and not enough venti-lation. Modern buildings are tighter in constructionand depend on air circulators, as opposed to outsideair from windows, for ventilation. A contemporarypersonal and societal source of stress, sick buildingsyndrome was once known as “building-related ill-ness.” Symptoms may include HEADACHES, itchyeyes, nose and throat, dry cough, diminished men-tal acuity, sensitivity to odor, and tiredness.

Additionally, stressful symptoms may be causedby the FRUSTRATION of feeling closed in and notbeing able to control the amount of heat or light inthe immediate ENVIRONMENT. Thus the stress of thesyndrome is also related to feelings of lack of per-sonal CONTROL.

A ripple effect sometimes occurs when oneemployee in such a building begins complaining ofillness. Soon others believe that they too haveheadaches as a result of the WORKPLACE. An out-break of Legionnaires’ disease, a form of pneumo-nia, from bacteria in an air-conditioning systemwas first identified among American Legion con-ventioneers in a Philadelphia hotel during the1970s; outbreaks of Legionnaires’ disease occurredas recently as 1995. Organisms responsible for thedisease as a contaminant of water systems wereresponsible for earlier epidemics of pneumonia,although the cause had not been known.

The influence of sick building syndrome as asource of employee stress was recognized on a

large scale when complaints of sick building syn-drome to the U.S. Department of OccupationalSafety and Health (OSHA) doubled between 1980and 1981. Recognized by the insurance industryunder the name “tight building syndrome,” Fire-man’s Fund Insurance Company established itsown “tight building syndrome” laboratory in late1983, after investigating 48 buildings in the UnitedStates and discovering that about one-third pre-sented health hazards from indoor air pollution.

Relief of Stress Caused by Sick Building Syndrome

Individuals who believe they are being made ill bytheir building should consult their company psy-chologist, if there is one, or department of humanresources. Reports should be filed in a timely wayso that investigations can be made. Removal of thepollutant, if possible, is essential. There may bepossibilities to improve air balance and adjustment,including percentage of outside air being circu-lated. All humidifiers, filters, and drip pans must bechecked. Overall maintenance of the buildingshould be evaluated, and cleaning materials, airfresheners, and moth repellents should be selectedcarefully. New carpeting should be installed on aFriday, allowing ventilation of the building overthe weekend.

Additionally, individuals should determine ifthere are any possible steps they can take to relievetheir personal stress. These may include requestingbeing moved to another part of the building, orbringing a small electric fan or heater to work. Ifnecessary, a short vacation away from the pollu-tants may be helpful.

FOR FURTHER INFORMATION:National Safety Council1121 Spring Lake DriveItasca, IL 60143-3201(800) 621-7619 (toll-free)(630) 285-1121(630) 285-1315 (fax)http://www.nsc.org

SOURCE:Griffin, Katherine. “When Your Office Calls in Sick.”

Health, January–February 1993.

sick role The protected position that an individ-ual who is anxious, phobic, or considered not well

332 sick building syndrome

assumes or is put in by family and friends. The sit-uation can be a source of stress for the individualor the caregivers. The sick role may give thelabeled individual the advantages of attention andsupport, emotional and financial, that he or shemight not otherwise have. However, the individualin the sick role may not be motivated to improvebecause he or she fears removal of attention,which is a powerful reinforcer. Some individualswho have AGORAPHOBIA are encouraged in the sickrole because the families do errands and chores forthem, enabling the phobic individuals to perpetu-ate their agoraphobic tendencies.

The sick role may have positive effects on a fam-ily in that it may cause family members to becomemore cohesive.

See also ANXIETY DISORDERS; SELF-ESTEEM.

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Facing Fears: The

Sourcebook for Phobias, Fears and Anxieties. New York:Checkmark Books, 2000.

SIDS See SUDDEN INFANT DEATH SYNDROME.

Siegel, Bernie S(hepard), M.D. (1921– ) Sur-geon, lecturer, and author of the best-selling book,Love, Medicine and Miracles. Through his leadership ofExceptional CANCER Patients (ECaP), a CaliforniaSUPPORT GROUP that he founded, Dr. Siegel encour-ages members try to help heal themselves. By shar-ing their FEAR and ANGER with each other, ECaPmembers undergo a form of stress reduction andalternative therapy that, according to Siegel, aids inthe healing process. They utilize the concept of“carefrontation,” a loving, safe, therapeutic con-frontation, which facilitates personal change andhealing and helps relieve the stress of chronic illness.

Siegel believes that getting well is not the onlygoal; learning to live without fear and to be atpeace with life and ultimately death is also impor-tant. He utilizes group therapy involving patients’dreams, drawings, and images. Dr. Siegel travelsextensively to speak, facilitate workshops, andshare his techniques and experiences.

Dr. Siegel completed his surgical training at YaleNew Haven Hospital and the Children’s’ Hospital ofPittsburgh. He received his M.D. from Cornell Uni-versity and his B.A. from Colgate University. He

has been a practitioner of pediatric and generalsurgery.

See also SELF-HELP GROUPS; PSYCHOTHERAPIES.

SOURCE:Siegel, Bernie S. Love, Medicine & Miracles. New York:

Harper & Row, 1986.

sighing Taking a deep breath, letting it all out atonce with a light push from the central diaphragm,at the same time emitting a sound like “ahhh.” Thisis a good stress reliever, because when we breathemore, we feel more vital, more responsive, andmore energized.

Sighing pumps the central diaphragm, whichhelps all the other diaphragms to move. The moretoned and resilient our diaphragms are, the moreeasily and appropriately we are able to move thefluids of our body (blood, lymph, cerebrospinalfluid), which means we feel more mobile and gen-erally better. Appropriate fluid movement meansappropriate energy movement and distributionand balanced internal fluid pressure. Appropriateinner pressure of fluid helps keep us easily uprightand increases feelings of capability.

FOR FURTHER INFORMATION:Zapchen ResourcesP.O. Box 6392Napa, CA 94581

SOURCE:Henderson, Julie. Embodying Well-Being: How to Feel as

Good As You Can in Spite of Everything. Napa, Calif.:Zapchen Somatics, 2003.

simple phobia (single or specific phobia) A sim-ple PHOBIA is an intense, irrational fear that persistsand compels a person to avoid one specific situa-tion or object. Almost any situation or object suchas heights, bridges, dogs, or cats can become a spe-cific phobia for an individual. This kind of fear is anintense source of stress for the suffering individual.Help can be obtained with BEHAVIOR THERAPY.

See also ANXIETY DISORDERS.

skin cancer See SUNLIGHT.

sleep The natural state of lowered consciousnessand reduced metabolism. Lack of sleep and inability

sleep 333

to sleep are sources of stress for many people, whilefor others, sleep difficulties are symptoms of stress.Difficulties related to sleep are among the com-monest problems patients complain about whenthey visit physicians.

Age, state of health, medication, and psycholog-ical state affects sleep. DEPRESSION is a major factorthat interferes with sleep, causing some individualsto sleep too much and preventing others from get-ting to sleep or sleeping through the night. Indi-viduals who have a CHRONIC ILLNESS or PAIN oftenexperience interrupted sleep. Sleeping habits affectmost people’s MOODS and their ability to cope withstress. Many feel somewhat irritable and shorttempered without adequate sleep.

Men and women show some differences insleep patterns. For example, as they age, men losetheir ability for deep sleep (delta sleep) sooner thanwomen, even though more women complainabout insomnia and light sleeping. Men begin tolose their deep sleep in their late 40s and 50s, whilewomen continue to have deep sleep later in life.

The old adage “early to bed and early to rise” istoo generalized a plan for most people, says Ros-alind Cartwright, M.D., of Rush-Presbyterian-St.Luke’s Medical Center, Chicago. “There are manyindividual patterns of sleep that work well. Someelderly people don’t go to bed until 4 A.M. Theystay awake until then, reading, knitting, or doingsome creative work. They wake up at 8 A.M. wheneveryone else does and they feel good. Such indi-viduals once went to bed at midnight and worriedabout staying awake for hours; now they turnthose hours into doing something constructive.”

Sleep Disorders

There are two basic categories of sleep disorders.One is known as DIMS, or disorders of initiating ormaintaining sleep. These include getting to sleep,staying asleep, or waking too early.

The other is known as DOES, or disorders of exces-sive sleep. Characteristics may include falling sleepinappropriately and a difficulty in awakening.Such individuals are known as hypersomniacs.

Sleep apnea is another common and more seri-ous disorder of sleep. It involves brief periods ofceasing to breathe. There may be at least 250,000people in the United States who cease breathing sooften or for such long periods of time at night that

they are tired all day and are likely to drift off intosleep at any moment. They must walk aroundoften to fight off sleep and cannot drive safely.

Sleep apnea is marked by loud SNORING, pro-longed periods between breaths (apnea), weightgain, and elevated blood pressure. Diagnosis of sleepapnea can be made from a tape recording at the bed-side of the snorer. If there are repeated pauses ofmore than 10 seconds between snores, it may meanthat the oxygen level in the brain is going down.The person must wake himself/herself to restart thebrain. There is treatment for sleep apnea, and it isimportant that such people be treated because thisdisorder causes a strain on the heart.

Repetitive nocturnal myoclonus involves involun-tary jerky motions of the legs or episodes of twitch-ing that disturb sleep. This is an uncomfortablesensation that occurs just before falling asleep. Theindividual feels an urge to get up and walk around.This sensation may increase with age and fre-quently runs in families; it is more common inindividuals age 50 to 60 than in younger people.

Sleep difficulties of menopausal women. Manymidlife women experience stress because ofchanges in their sleep patterns around MENOPAUSE.Some changes may be due to HOT FLASHES or toother factors involving individual psychosocialstresses. According to Dudley Dinner, M.D., direc-tor, Sleep Disorders Center, Cleveland Clinic Foun-dation, while women may sleep seven to eighthours at age 20, they may decrease to six or six-and-a-half hours between ages 55 and 60. Also,sleep tends to become more “fragmented.” Womenin this age group may awaken oftener and spendmore time awake during the night, although theirtotal time in bed may increase.

Sleep disturbance related to medication. A side effectof medications can be sleepiness; all medicationsshould be taken only under a physician’s supervi-sion. Some medications may make sleep apneaworse.

Medications used for inducing sleep. Individualswho are stressed by an inability to fall asleep orstay asleep sometimes have sleeping medicationsprescribed for them. Often at a time of greatbereavement, such as after the death of a spouse orparent, an individual will have difficulty sleepingand can be helped with the assistance of an appro-priately prescribed medication for short-term use.

334 sleep

Dreaming. Most dreaming takes place during theREM stage. Nightmares of being unable to movehave a real basis during this phase of sleep becauseof the limpness of the muscles. People will proba-bly forget DREAMS unless they awaken during aREM period or within 10 minutes afterward (seebelow).

Sleepwalking (somnambulism) may occur whileasleep during NREM (nonrapid eye movement)sleep; this affects about 5 percent of adults andmany more children. For unknown reasons, boysare more likely to sleepwalk than girls. A child maysleepwalk after awakening from a nightmare ornight terror, and may scream, talk, or even urinatein an inappropriate place. It is difficult to awaken asleepwalker; the best approach is to calmly leadhim or her back to bed. However, in a householdwhere an individual is known to sleepwalk, it isbest to close off stairwells and remove objects inpossible pathways to prevent injury.

Sleep Research

Evaluation of sleep disturbances is carried out inmany sleep laboratories across the United States.Sessions for a troubled sleeper in a sleep laboratorydepend on the diagnosis and how complex theproblem is. For example, some tests for narcolepsy,a disorder of excessive daytime sleepiness, aredone during the day, with a series of five shortnaps. However, most sleep lab evaluations aredone during the night. Patients are monitored formany things, including naso-oral air flow andheart rate. Insomniacs are tested to determine howmuch they really sleep. Typically, many physiolog-ical parameters are measured. There is an intercomfrom the control room, and researchers can talk tothe patient’s room or tape record what is going onin any room.

Stages of Sleep

With use of an electroencephalogram (EEG), agraphic depiction of the brain’s electrical potentialsrecorded by scalp electrodes, sleep is divisible intotwo categories: non-rapid eye movement (NREM)sleep and rapid eye movement (REM) sleep.Dreaming sleep is another term for REM sleep.There are four stages of NREM sleep. Stage I occursimmediately after sleep begins, with a pattern oflow amplitude and fast frequency. Stage II has

sleep 335

HOW TO GET A GOOD NIGHT’S SLEEP

• Avoid stressful situations before bedtime. Post-pone discussions of problems until morning,whenever possible. Avoid lengthy telephone con-versations that may upset you before bedtime.

• If you have an argument or tension-filled discus-sion late at night, don’t go to bed mad.

• If you are alone and feel hostile, call a friendand talk. Venting may help you unload and youwill sleep better.

• Drink a cup of warm milk before bedtime. Eat alight snack. Avoid stimulating beverages contain-ing CAFFEINE, such as coffee, cola beverages, andchocolate.

• Take a warm, relaxing bath before going to bed.• Relax in bed and read something you enjoy.

As your mind becomes engrossed, your mus-cles will relax. When your body is relaxed,you are likelier to become sleepy and readyfor sleep. Watching television may have thesame effect.

• Read something you find very dull. When yourmind cannot handle what you present, yourinternal coping mechanism of falling asleep maytake over. Watching television may have thesame effect.

• Experiment by changing your environment.Make the room warmer or colder. Use differentcombinations of covers. Some people like thefeeling of the “weight” of blankets, while othersdo not. If you like warmth without weight, usean electric blanket. Some have dual controls sothat each bed partner can have individualarrangements.

• Avoid using sleeping pills. People build up a tol-erance to them and some have daytime hypnoticeffects. Some pills induce sleep apnea.

• If you must take a sleeping pill during times ofextreme stress, such as after the death of aloved one, after surgery, or during extreme jetlag, take short-acting sleeping medications (seeabove).

• Nightly use of a sleeping medication may not beeffective after a while. If you have to use them atall, use them only every other night or everythird night.

• Avoid taking naps during the day; go to bed alittle later each night.

characteristic waves of 12–16 cycles per secondknown as sleep spindles. Stages III and IV haveprogressive further slowing of frequency and anincrease in amplitude of the wave forms. After thebeginning of sleep, over a period of 90 minutes, aperson goes through the four stages of NREM sleepand goes from them into the first period of REMsleep. Dreaming usually occurs during REM sleepand short cycles (20–30 minutes) of REM sleeprecur about every 90 minutes throughout thenight. This type of sleep is so named because of thecoordinated rapid eye movements that occur.

FOR FURTHER INFORMATION:American Sleep Disorders Association1610 14th Street NW, Suite 300Rochester, MN 55901(507) 287-6006

SOURCES:Carey, Benedict. “The Slumber Solution.” Health,

July–August 1996.Hales, Dianne. The Complete Book of Sleep. Reading, Mass.:

Addison-Wesley Company, 1981.Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

sleep apnea See SLEEP.

slips of the tongue Saying one thing but meaninganother. Such slips may be stressful for the personwho speaks them as well as a source of embarrass-ment, or even CRITICISM and ridicule by listeners.

Sigmund Freud theorized that these acts have asubconscious basis with some motivation that isnot recognized by the person who commits them.This type of behavior is temporary and correctable.Although undesirable, it tends to fall within nor-mal limits and is not considered a disorder. Slips ofthe tongue are also known as “lapsus lingae.”

SOURCE:Campbell, Robert Jean. Psychiatric Dictionary. New York:

Oxford University Press, 1981.

slips, trips, and falls Falls are a common cause ofstressful injuries in homes and workplaces. Theyare often caused by slipping or tripping. For olderpeople, falling is often associated with disablinginjuries. For working people, falls are associated

with injuries and lost time from work. Workerswho suffer falls also cause stress for employers interms of lost production and the need to rehireworkers to do the jobs.

To avoid falling, looking for slip and trip hazardsaround the home or workplace such as unevenfloors, trailing cables, and areas that are sometimesslippery due to spills. In the food service industry,in food processing plants, and in the meat industry,slippery floors are a common hazard that can leadto falling.

In industry, maintenance includes inspection,testing, adjustment, and cleaning. Lighting shouldenable people to see obstructions and potentiallyslippery areas so they can work safely. Lights shouldbe replaced or repaired before they become too dimfor safe work. Floors should be checked for loosesurfaces, holes and cracks, worn rugs and mats. Besure mats are securely fixed and do not have curl-ing edges.

Footwear can play an important part in pre-venting slips and trips, both at home and work. Inhomes, shoes or slippers should not catch on car-pets and at work should be heavy enough to pre-vent injuries to feet. In homes as well as work, allpassageways, staircases, and means of access shouldbe unobstructed and free from tripping hazards.Cleaning methods and equipment should be suit-able for the type of surface being treated. Careshould be taken not to create additional hazardswhile cleaning and maintenance work is beingdone. Openings in floors, edges of balconies, andplatforms must be adequately fenced to preventpersons from falling. LADDERS and scaffolding mustbe suited to their intended use and must be prop-erly erected, made secure, and checked before theyare used.

smoking The inhaling and exhaling of tobacco byusing cigarettes. A major public health problem inthe United States, smoking is a source of stress fornonsmokers as well as smokers. It was only in thelate 1990s that cigarette companies had reluctantlyadmitted that the nicotine contained in cigarettes ishabit-forming and addictive. Many smokers saythey want to quit but cannot; expressing and fol-lowing through with the desire to quit smokingbecomes a source of stress for them.

336 sleep apnea

Effects of Smoking

Nicotine affects the central nervous systemthrough routes that differ from other drugs, but itproduces very similar results, such as pleasurableeuphoria, dependency, and withdrawal symptomswhen stopped suddenly. Smokers who quit mayexperience genuine physical discomfort and crav-ings. Withdrawal symptoms from nicotine includeHEADACHES, irritability, upset stomach, BREATHING

and circulation problems, trouble sleeping, DIZZI-NESS, and numbness.

The actual physiological effects of smoking aresomewhat at odds with the sensations that smok-ers report. When nicotine enters the bloodstream,it raises the heart rate and blood pressure anddilates the arteries. It also raises the level of glu-cose in the blood. However, smokers report asense of relief from stress despite the stimulatingeffects of nicotine. Smokers claim it improvesshort-term memory, intellectual performance, andconcentration.

Stresses between Smokers and Nonsmokers

While scientists have documented the harmfuleffects of smoking, many smokers still believe thatit is their “right” to smoke when and where theywant to. Since antismoking laws were enacted inthe United States during the 1980s and early1990s, there have been frequent incidents of angerand hostility between smokers and nonsmokers.Nonsmokers maintain the “right” to clean air.Increasingly, workplaces are changing over to non-smoking and setting up outdoor smoking areas forsmokers. In the large cities of America, mostrestaurants have nonsmoking areas. Those thatdon’t will not attract nonsmokers. For asthmaticsand those with other respiratory disorders, smokein the air is more than an annoyance; being forcedto breathe in secondhand smoke can make themfeel physically ill.

Eventually the United States may become asmokeless society. However, in developing coun-tries, the numbers of smokers is unfortunatelyincreasing and cigarette consumption is rising.

smoking 337

Consequences of Smoking

The main harmful components of cigarette smokeare tar, nicotine, and carbon monoxide. The lungsretain 70 percent to 90 percent of these chemicalswhen one inhales. Tarry substances clog the lungsand affect breathing. Carbon monoxide decreasesthe ability of red blood cells to carry oxygenthroughout the body.

Smoking lowers one’s resistance to infectionand ulcerative diseases. It also increases one’s riskfor bad breath, severe gum diseases, tooth loss, andpremature aging of the skin, which many peoplefind sources of stress. Pregnant women who smokehave higher rates of miscarriage, stillbirth, prema-ture birth, low birth weight, and complications ofPREGNANCY. Infants of mothers who smoke duringpregnancy also have more of a chance of SUDDEN

INFANT DEATH SYNDROME (SIDS) than do infantswhose mothers did not smoke. Smoking is creditedas a factor in nearly 500,000 deaths per year, rep-resenting more Americans than die from accidents,infectious diseases, murders, suicides, diabetes, andcirrhosis combined.

The disease most often associated with cigarettesmoking is lung CANCER. This disease, which only50 years ago was almost unheard of, is now theleading cause of cancer deaths in men and women.Lung cancer, once believed to be predominantly adisease of males, in the mid-1980s overtook breastcancer to become the number one cause of cancerdeaths for women. Over 85 percent of the peoplewho die of lung cancer could have avoided the dis-ease completely if they did not smoke. For this rea-son, coping with their deaths is doubly stressful fortheir family members.

Stop Smoking Programs

Almost all health risks decrease when one gives upsmoking. As withdrawal symptoms subside, one islikely to notice good symptoms such as improvedsenses of taste and smell, increased energy, andenhanced SELF-ESTEEM and self-control. Regularexercise will enable one to avoid or minimizeweight gain and keep the body in good physicalshape.

Quitting smoking is not easy. Many stop-smokingprograms exist to help cigarette addicts. However, forprograms to be helpful, the individual must attend

regularly and follow the rules set forth. For many,unfortunately, this is easier said than done. Whenone stops smoking, nicotine dependency may causesome stressful and unpleasant sensations. For exam-ple, one may temporarily experience withdrawalsymptoms such as DEPRESSION, irritability, anxietyrestlessness, trouble concentrating, headache,drowsiness, gastrointestinal disturbances, increasedcoughing, or difficulty sleeping.

Many national organizations can help one affil-iate with a stop-smoking program; check for a localchapter.

See also ADDICTION; EMPHYSEMA; HABITS.

FOR FURTHER INFORMATION:American Cancer Society1599 Clifton Road NEAtlanta, GA 30329(800) 227-2345 (toll-free)(404) 315-9348 (fax)http://www.cancer.org

American Heart Association7320 Greenville AvenueDallas, TX 75231(800) 242-USA1 (toll-free)(214) 373-6300

338 smoking

STRESS RELIEVERS FOR THOSE WHO AREQUITTING SMOKING

• List your reasons for wanting to stop and want-ing to continue smoking.

• Note when and where you smoke the most.• Set a date for quitting; tell your family and friends.• Remove cigarettes, ashtrays, and matches from

your home, car, and office.• Minimize stressful situations and other occasions

when you previously craved a cigarette.• Spend time where smoking is prohibited.• Reach for high-fiber, low-calorie snacks, such as

vegetables or fruits when you have the urge tosmoke.

• Talk to someone who is supportive until the urgeto smoke passes.

• Increase aerobic exercise (walking, biking).• User relaxation techniques (such as meditation,

guided imagery).• Reward yourself for quitting smoking.

(214) 987-4334 (fax)http://www.americanheart.org

American Lung Association61 Broadway, Sixth FloorNew York, NY 10006(800) LUNG USA (toll-free)(212) 315-8700(212) 315-8872 (fax)http://www.lungusa.org

Centers for Disease ControlOffice of Smoking and Health1600 Clifton Road, NEW (Mail Stop K-50)Atlanta, GA 30333(404) 639-3311http://www.cdc.gov/tobacco

National Cancer Institute9000 Rockville PikeBuilding 31, 4A-21Bethesda, MD 20892(800) 4-CANCER (toll-free)(800) 422-6237 (toll-free)(301) 435-3848http://www.nci.nih.gov

SOURCES:Hammond, S. Katharine. “Environmental Tobacco

Smoke Presents Substantial Risk in Workplaces.” TheJournal of the American Medical Association, September26, 1995.

Spitzer, Joel. “Medical Implications of Smoking.” Skokie,Ill.: Good Health Program, Rush North Shore MedicalCenter, 1995.

snoring Noisy BREATHING through the openmouth during SLEEP; produced by vibrations of thesoft palate. Snoring is stressful because it maydeprive both the snorer as well as the bed partnerof necessary sleep, resulting in irritability and ten-sion for both the next day.

Frequently, snoring occurs as people sleep ontheir backs; their tongues slide back into a positionthat partially blocks the nasal passage, forcingmouth breathing, particularly in a deep sleep. It ismore common in overweight people, partlybecause they are more likely to sleep on their backsand also because fatty tissue in their throats maycause blockage. Snoring also may be caused byenlarged tonsils, nasal problems, heavy drinking,smoking, or eating just before sleep.

Measurements of snoring volume have recordeddecibel levels as high as the sound of a jack ham-mer or pneumatic drill. Robert W. Hart, M.D., writ-ing in Chicago Medicine (Dec. 21, 1991), characterizedsnoring as “mild, moderate, severe, or heroic.”According to Hart, the incidence of habitual snor-ing in an unselected population is estimated near20 percent. However, in overweight males betweenthe ages of 30 and 59, that incidence reaches 60percent.

Snoring, Sleep Apnea, and Stress

Many stressed individuals who report chronic fatigueand irritability are victims of sleep apnea, known asobstructive sleep apnea syndrome (OSAS). Ifuntreated, OSAS can have lethal consequenceswhen daytime sleepiness leads to automobile andindustrial accidents, as well as consequences forinterpersonal relationships because of short tem-pers due to tiredness.

OSAS is characterized by repetitive episodes ofcomplete apnea or incomplete obstruction of theupper airways during sleep. OSAS is more com-mon in males and post-menopausal females, withits frequency increasing with age and weight. TheOSAS sufferer may complain of feelings of chokingor suffocating during the night or feel panickybecause of an inability to take in enough air. Allthese feelings are extremely stressful for the suf-ferer as well as his or her sleep partner.

Treatment options for OSAS include generalmeasures, such as weight loss, abstinence fromalcohol, pharmacological approaches for limitedperiods of time, oral and orthodontic devices, andsurgical procedures, such as nasal surgery or uvu-lopalatopharyngoplasty (repair of the uvula, thesmall, fleshy protuberance that hangs from themiddle of the lower edge of the soft palate, whichis part of the mouth).

See also CHRONIC FATIGUE SYNDROME.

FOR FURTHER INFORMATION:American Sleep Disorders Association1610 14th Street NW, Suite 300Rochester, MN 55901(507) 287-6006

SOURCES:Lipman, Derek S. Snoring From A to ZZZZ: Proven Cures for

the Night’s Worst Nuisance. Portland, Ore.: SpencerPress, 1996.

snoring 339

Pascualy, Ralph A. Snoring and Sleep Apnea: Personal andFamily Guide to Diagnosis and Treatment. New York:Demos Vermande, 1996.

social phobia The irrational fear and avoidanceof being in a situation in which one’s activities canbe observed by others. It involves a fear of beingembarrassed, humiliated, criticized, censured, or insome way evaluated in social settings by the reac-tions of others. The most common social phobia isfear of speaking in public, whether in front of alarge audience or in front of a small group such asduring a party. Other common social PHOBIAS

include blushing, eating, drinking, writing, urinat-ing, or vomiting in the presence of others. Somesocial phobics fear that their hands will tremble orshake as they eat or write and tend to avoid restau-rants, banks, and other public places. They oftenavert their eyes when talking to another person.Some social phobics have been known to cross thestreet to avoid greeting people they know, andsocial phobics are fearful of attending parties, par-ticularly with people they do not know.

Usually social phobias begin after puberty andpeak after the age of 30, but social phobics havehad lifelong SHYNESS and introverted habits. Bothmen and women suffer from social phobias andmay have more than one at a time. Also, manyagoraphobics have social phobias, and many socialphobics have some agoraphobic symptoms.

See also AGORAPHOBIA; ANXIETY DISORDERS.

FOR FURTHER INFORMATION:Anxiety Disorders Association of America8700 Georgia AvenueSilver Spring, MD 20910(240) 487-0120http://www.adaa.org

SOURCE:Kahn, Ada P., and Ronald M. Doctor. Encyclopedia of Pho-

bias, Fears, and Anxieties, 2nd ed. New York: Facts OnFile, 2000.

social support system A social support systeminvolves an individual’s relationships with others,including significant others, friends, people on thejob, in the community and religious groups, as wellas material resources. An individual with a stressconcern may have an inadequate social support

system because family members do not understandhis/her circumstances and thus may not offer theassistance or encouragement that could be helpful.

Individuals with good social support systemsseem to have better recoveries from illnesses andsurgeries than those without such support.

See also SELF-HELP GROUPS; SUPPORT GROUPS.

social workers Workers trained to have expertisein counseling people regarding available commu-nity resources for various types of support andtherapy; many of them provide counseling forindividuals with concerns about stress. Socialworkers work in the public and private sector; theymay work in publicly funded health and mentalhealth clinics and in schools, family agencies, clin-ics, hospitals, and private practice. Some work inEMPLOYEE ASSISTANCE PROGRAMS (EAPs), alcoholand chemical dependency programs, and in reli-gious settings.

In the 1960s and 1970s, with the establishmentof comprehensive community mental health cen-ters, clinical social workers provided a major pro-portion of outpatient mental health treatmentservices. In the 1980s, an increasing number ofclinical social workers moved into full- or part-time private practice and these practices continueto grow.

In 2005, there were 153,000 members of theNational Association of Social Workers (NASW),an organization limited to those persons who havea bachelor’s, master’s, or doctoral degree from auniversity program accredited by the Council onSocial Work Education.

See also PSYCHOTHERAPIES.

FOR FURTHER INFORMATION:National Association of Social Workers750 First Street NE, Suite 700Washington, DC 20002-4241(800) 638-8799 (toll-free)(202) 408-8600(202) 336-8310 (fax)http://www.socialworkers.org

SOURCE:Manderscheid, R. W., and M. A. Sonnenschein, eds. Men-

tal Health, United States, 1990. Washington, D.C.: Govt.Printing Office; DHHS Pub. No. (ADM) 90–1708, 1990.

340 social phobia

somatization An individual experiencing physi-cal symptoms as a response to psychological stress,in the absence of disease or out of proportion to agiven ailment. For example, people experiencephysical symptoms such as fatigue, shortness ofbreath, or even pain as a response to stress.

Somatization can be hazardous to healthbecause people who have ongoing complaints mayundergo uncomfortable and invasive proceduresthat are not needed and can cause complications.Individuals who repeatedly report chest painsmight eventually undergo coronary angiographyto rule out serious arterial narrowing. Also, theseindividuals may be taking medications needlessly,some with serious side effects.

Individuals who “somatize” are said to havesomatoform disorders. Treatment of somatization mayinclude use of various PSYCHOTHERAPIES, RELAX-ATION exercises, MEDITATION, MASSAGE THERAPY, tak-ing VACATIONS or dealing more effectively withstresses at home or in the WORKPLACE.

See also COPING; GENERAL ADAPTATION SYNDROME.

SOURCE:Kahn, Ada P., and Jan Fawcett. The Encyclopedia of Mental

Health. 2nd ed. New York: Facts On File, 2001.

spam Irritating and often deceptive junk e-mail;unsolicited commercial e-mail that frustrates con-sumers and costs businesses time and money. It isstressful because it seems to be an invasion of

time and space for most computer users. In 2004,according to the American Association of RetiredPersons (AARP), 60 percent of all e-mail wasspam.

The first national anti-spam bill was signed intolaw in December 2003. The new law requiresspammers to identify adult material and carriessubstantial penalties for those who write spam thatuses phony greetings, fake sender addresses, andfraudulent sales approaches.

Internet legal expert David Sorkin of the JohnMarshall Law School in Chicago says the new lawmay curb the growth of really obnoxious spamsuch as raunchy offers for sex devices, and “low-est” mortgage rates.

See also COMPUTERS; ELECTRONIC DEVICES; RAN-DOM NUISANCES.

SOURCE:Basler, Barbara. “Frazzled by Junk E-Mail?” AARP Bulletin

Available online. URL: http://www.aarp.org/bulletin/yourlife/articles/a2004-02-10-spam.html. Downloadedon April 25, 2005.

spas Businesses that offer many services to coun-teract stress and help patrons relax. Spas mayrange from fairly basic establishments offeringminimal services such as manicure, pedicure, andmassage, to more elaborate places that also includehair styling, facials, steam baths, nutritious meals,exercise classes, personal training, and other serv-ices. Some spas are live-in facilities, while othersare walk-in for the day. Some spas are “destina-tion” spas that attract vacationers in search ofrespite from their daily routine.

A study by Cornell University’s School of Hospi-tality Administration indicated that destination spasmay help people have more energy, less fatigue,and more endurance. According to researcher MaryTabacchi, a visit to a destination spa where thefocus is on healthy living is one of the few traveloptions that leave vacationers feeling rested,refreshed, and energized. The 2004 study sug-gested that increased levels of energy and staminaduring the day may contribute to a greater sense ofself-confidence and body image, which translatespositively into many aspects of life such asincreased job performance, feelings of accomplish-ment, positive well-being, and less fatigue.

spas 341

COPING WITH STRESSFUL SPAM

• Give your primary e-mail address only to per-sons you trust.

• Maintain alternate e-mail addresses if you buyproducts online, register for free offers, or signup for e-mail newsletters.

• Create an e-mail address with numbers as wellas letters. A more complicated address is harderfor spammers to find.

• When you go to a Web site, check their privacypolicy before giving your e-mail address. Optout of receiving e-mail from their partners.

• Don’t open spam. Just delete it. Opening it con-firms to the sender that yours is a workingaddress.

SOURCE:Heart to Heart, newsletter of The Heartland Spa, Decem-

ber, 2004.

FOR FURTHER INFORMATION:The Heartland Spa1237 East 1600 North RoadGilman, IL 60938(800) 545-1853 (toll-free)(800) 683-2144 (fax)http://www.heartlandspa.com

specific phobia See SIMPLE PHOBIA; PHOBIAS.

spirituality Spirituality has been described asexperiencing the presence of a power, a force, anenergy, or of God. This definition is from the writ-ings of HERBERT BENSON, M.D., president, TheMind/Body Medical Institute, and chief, Divisionof Behavioral Medicine, Deaconess Hospital,Boston. Spirituality, for many, is directly connectedto PRAYER, faith, and RELIGION; belief systems helpmany individuals cope with symptoms of STRESS.

Dr. Benson’s work at the Harvard MedicalSchool considered the healing effects of spiritual-ity; research later confirmed that some peopleexperienced increased spirituality as a result ofRELAXATION therapy whether or not they used areligious repetitive focus. This notion came aboutafter Harvard researchers had systematically stud-ied the benefits of mind/body interactions for morethan 25 years. The research confirmed that when aperson engages in a repetitive prayer, word, sound,or phrase and when intrusive thoughts are pas-sively disregarded, a specific set of physiologicalchanges ensues. There is decreased metabolism,heart rate and rate of breathing, and distinctlyslower brain waves.

These changes are the opposite of those inducedby stress and are an effective therapy in a numberof diseases including HIGH BLOOD PRESSURE, cardiacrhythm irregularities, many forms of chronic PAIN,INSOMNIA, symptoms of CANCER and AIDS, premen-strual syndrome, ANXIETY, and mild and moderateDEPRESSION. To the extent that any disease is causedor made worse by stress, increased spiritualitybrought about by relaxation is an effective therapy.

See also ALTERNATIVE MEDICINE.

spouse abuse See DOMESTIC VIOLENCE.

stage fright An intense feeling of nervous antici-pation that many people experience before givinga public speech or making an appearance on astage. For some, the feeling occurs before they goon stage, while others experience it just as theyenter the stage. Those who have been in theatricalproductions, play a musical instrument or singpublicly, or have been videotaped, probably haveexperienced this feeling at some time. People whoexperience a high level of STRESS because of stagefright may view the audience as an adversaryready to judge them personally without regard tothe content or message of their presentation.

Because of the stress caused by intense stagefright, some people go out of their way to avoidPUBLIC SPEAKING and public appearances; and somemay actually develop a phobia. Symptoms of thisphobia have many common characteristics; peoplemay become dizzy and nauseated, have sweatypalms and weak knees, feel a rapid heartbeat, andexperience difficulty breathing. While most peoplefeel these symptoms in a very mild manner, pho-bics momentarily fear that they will die due totheir rapid heartbeat and difficulty in gettingenough air to breathe, even though they may beover-breathing. These symptoms may occur foronly a few moments before going onstage, but assoon as they are onstage their nervousness disap-pears and they focus all of their attention andenergy on their performance.

Many successful public figures have overcomestage fright. Some lose their fear by systematicallybecoming accustomed to appearing in front of peo-ple. BEHAVIOR THERAPY and RELAXATION techniquescan help people overcome stage fright. Physicalrelaxation involves exercises to eliminate nervous-ness and ANXIETY and leads to physical ease andcalmness. Mental and psychological relaxationinvolves exercises to develop objectivity, aware-ness, mental clarity, and a positive mental attitude.

Overcoming the stress of stage fright depends onthe individual’s developing confidence in his or herability to speak or perform. Knowing the materialwell, whether it is a musical performance or a pub-lic speech, helps relieve stress. Confident individu-als learn to convert their stress into positive energy.

342 specific phobia

See also ALTERNATIVE MEDICINE; ANXIETY DISOR-DERS; PERFORMANCE ANXIETY; SOCIAL PHOBIA.

stammering See STUTTERING.

STDs See SEXUALLY TRANSMITTED DISEASES.

stepfamilies Families formed when a divorced orwidowed parent remarries. Stresses in stepfamiliesare more complex than in traditional nuclear fam-ilies, possibly because society has not defined therole of the stepparent as it has of the natural par-ent. As a result, everyone may have different ideasregarding how stepparent and stepchild should getalong. Frequently, stepparents feel that theyshould assume the role of an actual parent. Thismay be very uncomfortable and objectionable totheir stepchildren, specially when the childrencontinue to have a strong relationship with theirown natural parent.

Children who live with a single parent mayhave had some sense of being the center of atten-tion in the household and may have difficulty giv-ing up that role with the arrival of a stepparent.

The living arrangements that are set up whentwo families merge may cause stresses and chal-lenges to all involved. For example, some childrenmay be in residence, some may visit. A child whohad been living with one parent may suddenlydecide he wishes to leave that parent, possiblybecause of a new stepparent in that household. Ifconflicts erupt between stepsiblings, parents mayside with their own child, rather than makingpeace as they would in a traditional family.

Stresses may also arise in the stepparentedhousehold because there may be a highly chargedsexual atmosphere in the home; the couple actu-ally are newlyweds with children present. Thismay arouse real or potential relationships betweenstepsiblings, which are technically, although notbiologically, incestuous. There is also a potential fortechnical incest between stepparent and stepchild,particularly if the stepparent is young, even closeto the age of the child. In an attempt to be warmand friendly, some stepparents may unwittinglyencourage these feelings in children.

In situations involving older couples and adultchildren, children may feel that their inheritance

rights are threatened by the arrival of a stepfatheror mother.

Many people help relieve the stresses broughtabout by the formation of a stepfamily with familycounseling services and SUPPORT GROUPS for step-parents and children.

See also DIVORCE; REMARRIAGE; SELF-HELP GROUPS.

FOR FURTHER INFORMATION:Stepfamily Association of America, Inc.650 J Street, Suite 205Lincoln, NE 68508(800) 735-0329 (toll-free)(402) 477-8317 (fax)http://www.saafamilies.org

SOURCES:Belovitch, Jeanne. Making Re-marriage Work. Lexington,

Mass.: Lexington Books, 1987.Wald, Esther. The Remarried Family. New York: Family

Service Association of America, 1981.

stillbirth The death of a fetus between the 20thweek of gestation and delivery. A stillbirth causes aspecial kind of GRIEF and stress for the parents.Although they have never seen their child, theyhave imagined how he or she would look, whatthey would use for a name, and how the childwould interact with others in the family.

After the stillbirth, there are no “real” memo-ries, such as photographs or items the child actu-ally used or touched. Friends and others in thefamily do not share the loss with the parents in theway that they might in the case of an older infantwho died, making grief even more stressful for theparents.

Even though another child may arrive a year ormore later, many parents of a stillborn never fullyrecover from their loss. Some remember the “duedate” for years, and observe it with sadness, reviv-ing the feeling of loss and sadness.

Major causes of stillbirth appear to be loss ofoxygen to the baby, either because of a problemwith the placenta or an umbilical cord accidentbefore or during labor. However, for more thanhalf of stillbirths, there is no known cause, and thelack of an explanation is also a source of stress forthe grieving parents.

See also MISCARRIAGE; PREGNANCY.

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stress The response of the body and mind tostrains or burdens that demand adaptation; it isany hindrance that disturbs an individual’s mentaland physical well-being. These interferences mayrange from RANDOM NUISANCES to life-threateningsituations. From a scientific perspective, stresscauses an imbalance in an individual’s equilibrium(HOMEOSTASIS). Controlling stress is essential forwellness because continued exposure can lead tosymptoms, such as HEADACHES or more seriousconditions such as HIGH BLOOD PRESSURE andDEPRESSION. Research has shown that stress alsoaffects the IMMUNE SYSTEM and causes it to be lessefficient in fighting off diseases. Coping well withstress also can improve an individual’s chances ofliving with CHRONIC ILLNESS.

Understanding Stress

Stress is an internal response to circumstancesknown as stressors. Stressors may be internal situa-tions, such as feelings of insecurity or frustration,or external events, such as a bad review at work,or cancellation of an airplane flight.

Stressors can also be reactions to happy eventsas well as to bad news and unhappy events; thereare good stressors derived from satisfying personaland professional events as well as unpleasant ones.For example, happy personal stressors may includegetting married, having a baby, or moving to a newhouse; happy work stressors may include landing anew job or getting a promotion at work. Unpleas-ant stressors may include marital difficulties, ill-ness, or being fired. HANS SELYE, pioneer in stressresearch and author of Stress without Distress andThe Stress of Life, termed the good events that causestress as EUSTRESS and those that caused unpleasanteffects as DIS-STRESS. Both types of stress causephysiological responses, including activation of thenervous system and of the FIGHT OR FLIGHT

RESPONSE. That is why during stressful times, peo-ple may notice that they have a faster heartbeatand a sick feeling in their stomach; it is difficult towork or function efficiently at such times.

How individuals accommodate to change influ-ences the extent of stress they experience. Selyeused the term GENERAL ADAPTATION SYNDROME toexplain how individuals cope with stressors. Hesuggested that individuals cope with stressors. Hesuggested that individuals experience events in dif-

ferent ways; what results in emotional strain andANXIETY for one person may not bring about thosereactions in others. Also, in the same individual,adaptations that are tolerated well at one time maynot be handled so well at another.

Chronic stress results in ongoing wear and tearon the body’s organs and systems, making themmore susceptible to illness. When symptoms showup, many individuals begin to seek medical or psy-chological help. According to Herbert BENSON,M.D., Harvard cardiologist and author of The Relax-ation Response, more than 80 percent of visits tophysicians’ offices may result from stress inpatients’ lives. “Physicians are aware of stress as afactor in diagnosing and treating many commonhealth concerns.” For example, many people seekhelp for gastrointestinal symptoms, an inability toSLEEP, headaches, depression, and chronic fatigue.They may have high blood pressure. “The besttreatment is to get at the cause of the stress,” rec-ommends Catherine R. Landers, M.D., a memberof the Department of Medicine at Rush NorthShore Medical Center, Skokie Illinois. “We knowthat physical problems, even if induced by stress,can interfere with the quality of one’s work andability to meet the needs of family members. Med-ications won’t provide any long-lasting results.There are strong MIND-BODY CONNECTIONS. Helpingthe individual change his or her COPING styles usu-ally works better than anything we can prescribe asmedication.”

Research Reveals Effects of Stress on Health

A study reported in Proceedings of the National Acad-emy of Sciences focused on 119 men and womenwho were taking care of spouses with dementia.The health of the caregivers was compared withthat of 106 people of similar ages who were not liv-ing with the stress of constant caregiving.

Blood tests showed that a chemical called inter-leukin-6 (IL-6) sharply increased in the blood of thestressed caregivers compared with blood of the oth-ers in the test. Previous studies associated IL-6 withseveral diseases, including heart disease, arthritis,osteoporosis, type 2 diabetes, and certain cancers.

The study also found that the increase in IL-6 canlinger in caregivers for as long as three years after acaregiver had ceased that role because of thespouse’s death. Of the test group, 78 spouses died

344 stress

during the survey. According to Janice Kiecolt-Glaser, professor of psychology and psychiatry atOhio State University, people under stress tend torespond by doing things that can increase their lev-els of IL-6. For example, they may smoke orovereat; smoking raises IL-6 levels, and IL-6 issecreted by fat cells. Stressed people also may not getenough exercise or sleep. Exercise reduces IL-6 andnormal sleep helps regulate levels of the chemical.

In 2004, other research findings attempted toexplain how stress can lead to premature aging.Chronic psychological stress is associated withaccelerated shortening of telomeres, caps on theends of chromosomes in white blood cells, andhastens their demise, according to a report in Pro-ceedings of the National Academy of Sciences.

Dr. Elissa S. Epel at the University of California,San Francisco, and her colleagues investigated thetheory that psychological stress affects telomereshortening and thereby contributes to acceleratedaging. Their study included 39 healthy pre-menopausal women who were primary caregiversfor a child with a chronic illness, and 19 age-matched mothers of healthy children who servedas a comparison (control) group. Stress was meas-ured with a standardized questionnaire, andtelomere length was measured in participants’blood samples. Within the caregiving group, thelonger that a woman had been a caregiver, theshorter was the length of her telomeres. Thesefindings may have implications for health, astelomere shortening is associated with prematuredeath from cardiovascular disease and infections.

Sources of Stress

Stress can come from an individual’s family, WORK-PLACE or community connections. Stress within afamily causes tension and difficulties in communi-cating effectively. There may be INTERGENERATIONAL

CONFLICTS or situations arising from assisting ELD-ERLY PARENTS. In some cases, interpersonal stressesdevelop when an adolescent has two simultaneousfeelings, such as wanting to be independent duringPUBERTY and yet feeling dependent on parents. In afamily, several people may be trying to cope withtheir own stress as well as the stress of others aboutwhom they care. For example, when a father dies,the son tries to console his mother, even whenstruggling with his own sadness.

Stress that starts within the family can affectone’s work and the reverse is also true. Familyproblems can make a person irritable on the job,distrustful of coworkers, and prone to mistakes andaccidents. Likewise, a difficult day at the office canmake a person short-tempered and hostile athome. Workplace factors that contribute to stressinclude lack of autonomy, lack of satisfaction, andfeeling bored, underpaid, or overworked.

Many people feel stressed by demands madeupon them from their community or religiousactivities. While these activities add to a person’sSOCIAL SUPPORT SYSTEM, they may have taken ontoo many responsibilities, and are asked to take onmore, and feel that there is not enough time tocomplete all of them adequately. Already feelingoverwhelmed, but wishing to maintain their repu-tation as a “doer,” they agree. Learning when tosay no is an important skill to practice.

While stress can be physiologically devastatingto many people, others find that stress actuallyraises their energy level and helps them focus theirmind better on their work, family, or social activi-ties. Some thrive on many kinds of stressors, suchas COMPETITION and comparison with others. Peo-ple who do so are often attracted to high-stressoccupations and professions, or do well at compet-itive games and sports.

Learning to Manage Stress

“Stressors cannot be eliminated, so our goal shouldbe to control and manage stress,” says ElaineShepp, LCSW, a psychotherapist on the staff atRush North Shore Medical Center, Skokie, Illinois.She goes on to say, “It is possible to ‘neutralize’ thetoxic effects of unrelenting stress. People who copewell with stress put their personal and professionallives into perspective. They may experience a con-stantly high level of pressure and unrealisticdemands at work but develop their own ideals ofconduct and test themselves by their own stan-dards. They are able to prioritize their work andenjoy family life as well as their chosen recre-ational activities.”

Relieving Stress: An Individual Matter

Avenues toward relieving stress are personal mat-ters. Many people find that regular physical work-outs involving running, walking, or exercising in a

stress 345

gym or health club, or using equipment at home,helps them overcome their reactions to today’sevents and get ready to effectively face tomorrow’schallenges. Using muscles is a way to use up someof the “fight or flight” readiness in the body.

A healthy diet with three meals a day is a basicfor wellness and can also help prevent and relievestress. Well-balanced meals provide a slow releaseof necessary nutrients throughout the day. Forsome people, too much CAFFEINE causes additionalstress by bringing on symptoms of anxiety. “Crashdiets” or “fad diets” can lead to anxiety, depression,and an inability to maintain an appropriate weight.Acceptance of one’s BODY IMAGE and a good senseof SELF-ESTEEM will encourage people to maintaingood NUTRITION as well as good health.

People use many alternative therapies to relievestress. These include ACUPUNCTURE, GUIDED IMAGERY,MEDITATION, PROGRESSIVE MUSCLE RELAXATION, andYOGA. Some use MASSAGE THERAPY or listen to MUSIC

as stress relievers. However, what allows oneperson to relax may actually cause stress foranother. An example is noise level in the work-place or at home. Each individual should try tocreate an environment in which to work and livethat is the least stressful in order to focus onreaching his or her peak performance and a feel-ing of well-being.

HOBBIES help many people combat stress. Partic-ipating in an activity simply for the enjoyment ofit, makes their stress level go down. Such hobbiesmay include dancing, art and painting, sewing,building model trains or planes, bird watching, orplaying a musical instrument. Choices of hobbiesare as diverse as human nature.

A social support system is important, too. Manypeople find relief from stress in talking with theirsupport groups. When they are able to talk abouttheir issues, problems, and concerns and get FEED-BACK from trusted, objective family and friends,people get an enlightened perspective that oftenhelps them to lighten their stress load.

When Professional Help May Be Necessary

There are times when reactions to stress detractfrom a person’s energy necessary for productivework and effective personal functioning. At thesetimes, when talking to a friend just isn’t enough,professional assistance is available. Those who seek

professional help to overcome effects of extremestress should not consider themselves “weak,” saysShepp. “Seeking help is an intelligent way of usingavailable tools to increase one’s level of function-

346 stress

RECOGNIZE YOUR PERSONAL SIGNALS OF STRESS

Each person has unique sources of stress as well aspersonal signals of stress. Sources of stress comefrom within oneself (personal), from family life,from the workplace, and from community activi-ties. Some common sources of stress and personalsignals are listed below.

SOURCES OF STRESS

Individual stressors• Aging• Feeling unattractive or insecure• Achievement or success problems• Change in habits• Relationship concerns• Inability to pay bills; mortgage worries

Family stressors• Death, illness, or injury of a family member• Divorce; remarriage• Marital difficulties; sexual difficulties• Holidays, vacations• Problems with children• Young adult leaving home or returning home• Lack of privacy• Not enough time

Workplace/community stressors• Difficulties with boss or coworkers• Threatened layoffs• Boredom; not enough work• Overwork; underpayment• Lack of autonomy• Automation in the workplace

Personal Signals of Stress• Irritability or bad temper• Headaches; stomachaches; digestive problems• Inability to sleep• Grinding teeth• High blood pressure• Lethargy; inability to work; finger-tapping• Depression; panic, or anxiety• Fatigue; restlessness; accident proneness• Sexual difficulties

ing. Counseling can help prevent BURNOUT andassist in dealing with life situations requiring theinput of a non-involved, knowledgeable person.”

Death of a close relative or friend, divorce orremarriage, marital difficulties, sexual problems, orillness of one’s own or a family member are com-mon stressful occurrences. Financial problems, suchas facing a large mortgage or accumulated bills, canhappen to anyone. Individuals faced with these andother serious life stressors may feel out of CONTROL

and that their worlds are caving in around them.If you find yourself feeling totally overwhelmed

and decide to seek professional help, how should

you select a psychotherapist and choose from amyriad of PSYCHOTHERAPIES? You may want to talkwith a close relative, colleague, or friend who hasexperienced psychotherapy. However, if the issueof confidentiality is important to you, find a men-tal health professional or social worker in a hospi-tal or community agency who can help direct you.The psychotherapist should be one with whomyou have a sense of comfort, who also understandsyour particular stressors, and who can suggestpractical ways for you to handle your stress. Find atherapist who is multifaceted in his or herapproach to problems and knowledgeable aboutmany options available to treat particular prob-lems. Look for one who is open to consulting withother professionals who have additional expertise.

See also ANGER; ANXIETY DISORDERS; BEHAVIOR

THERAPY; CATASTROPHIZE; CORONARY ARTERY DISEASE;EXERCISE; KABAT-ZINN, JON; POST-TRAUMATIC STRESS

SYNDROME; PSYCHONEUROIMMUNOLOGY; RELATIONSHIPS;SUPPORT GROUPS; VOLUNTEERISM; WEIL, ANDREW.

SOURCES:Benson, Herbert. Beyond the Relaxation Response. New

York: Berkeley Press, 1985.———. The Relaxation Response. New York: Avon Books,

1975.Benson, Herbert, and Eileen M. Stuart. The Wellness Book:

The Comprehensive Guide to Maintaining Health andTreating Stress-Related Illness. New York: Carol, 1992.

Carey, Benedict. “Don’t Face Stress Alone.” Health, April1997.

Field, Tiffany, Olga Quintino, et al. “Job Stress ReductionTherapies.” Alternative Therapies 3, no. 4 (July 1997).

Hornig-Rohan, Mady. “Stress, Immune Mediators andImmune-Mediated Disease.” Advances: The Journal ofMind-Body Health 11, no. 2 (spring 1995).

Kahn, Ada P. “Stress” (pamphlet), Chicago: MentalHealth Association of Greater Chicago, 1989.

———. “Win the Case against Stress.” Chicago Bar Asso-ciation Record, May 1994.

———. “Women and Stress.” Sacramento Medicine, Sep-tember 1995.

Pelletier, Kenneth R. Sound Mind, Sound Body: A Model forLifelong Health. New York: Simon and Schuster, 1994.

Sapolsky, Robert M. Why Zebras Don’t Get Ulcers. NewYork: W. H. Freeman, 1994.

Selye, Hans. The Stress of Life, rev. New York: McGraw-Hill, 1978.

———. Stress without Distress. Philadelphia: J. B. Lippin-cott, 1974.

stress 347

CHECKLIST: COPING WITH STRESS

• Identify external stress-producing factors overwhich you have little or no control, such as onyour job.

• Identify internal factors such as perfectionismand unrealistic self-expectations.

• Recognize your personal signs of stress, such as:Increased irritability with family members orcoworkers Headaches; stomachaches; digestive disorders Overeating; increased alcohol consumption Sleeplessness; chronic fatigue Depression; feelings of hopelessness

• Separate your problems at home from your workconcerns, and vice versa.

• Be realistic in your daily outlook; don’t expecttoo much of yourself or others.

• Prioritize your responsibilities; learn to occasion-ally say no to requests you consider unreason-able or undoable.

• Pay attention to a healthy lifestyle, such as eat-ing a well-balanced diet and exercising.

• Reduce your consumption of caffeinated bever-ages, cut down on coffee, tea, and cola, whichcan increase your heart rate and your irritabilitylevel.

• Develop a regular habit of exercising; a 20-minute walk each day can be effective in fight-ing muscle tension.

• Develop a sense of humor; increase your abilityto see humor in sometimes intolerable situations.

• Learn some RELAXATION techniques that work foryou, such as deep breathing or listening to yourfavorite music.

• Seek professional help if you feel overwhelmed.

Stress and Anxiety Research Society (STAR) Amultidisciplinary international organization ofresearchers who share interest in STRESS, COPING,and ANXIETY. Members from more than 35 coun-tries meet annually to exchange research findingsand clinical applications of a wide range of stressand anxiety-related issues. STAR conferences pro-vide a unique opportunity to learn how psychol-ogy is studied and practiced through the world.

Since 1980, yearly meetings have been held inmany countries and provide a platform for majoraddresses by internationally known scholars, paperposter sessions, and workshops. The conferencesare relatively small, with approximately 150–200participants, meaning that close collegial relation-ships are easily established.

Topics covered in recent years have includedclinical issues, education, work-related stress, com-puters and technology, stress and coping of the eld-erly, test anxiety, disasters and post-traumatic stressdisorder, stress and anxiety in sports, cross-culturalissues, stress and anxiety in music, and migration.

STAR publishes an international journal, AnxietyStress, and Coping.

FOR FURTHER INFORMATION:Anxiety Stress, and CopingKrys Kaniasty, EditorDepartment of PsychologyIndiana University of PennsylvaniaIndiana, PA 15705(724) 357-5579(724) 357-2214

Conference OfficeStress and Anxiety Research SocietyUniversiteit van AmsterdamP.O. Box 192681000 GG Amsterdam+ 31 (0)20 525 4791 (phone)+ 31 (0)20 525 4799 (fax)congres@uva.nl

stress management Refers to an individual’s per-sonal COPING skills for dealing with STRESS. It alsorefers to a multibillion-dollar industry that includesprograms, products, services, and techniques to helppeople reduce stress on an individual or group basis.For example, stress management programs offer

help to people interested in overcoming stress-related disorders ranging from EATING DISORDERS toissues of SELF-ESTEEM. Programs may include use ofmany ALTERNATIVE THERAPIES.

Many stress management programs are offeredin the WORKPLACE and address such problems asALCOHOLISM and other ADDICTIONS, finances, nutri-tion, and other employee concerns.

See also EMPLOYEE ASSISTANCE PROGRAMS; PSY-CHOTHERAPIES.

SOURCE:Murphy, Lawrence R. “Stress Management in Work Set-

tings: A Critical Review of the Health Effects.” Ameri-can Journal of Health Promotion 11, no. 2 (November/December): 112–35.

stressors See STRESS.

stress urinary incontinence (SUI) The tendencyto leak urine when the bladder is stressed by sneez-ing, coughing, running, jumping, or other activities.According to the American Urological Association,about one in five U.S. women over age 50 suffersfrom stress urinary incontinence (SUI). It is a con-cern that causes emotional stress and embarrass-ment and is a psychosocial issue because thecondition may affect or disrupt social activities,work, and relationships. Urge incontinence, thesudden unbearable need to urinate, is less common.

Stress incontinence is caused by an incompetenturinary sphincter and results in involuntary loss ofurine with increased intra-abdominal pressure.Approximately one of three women who have hada vaginal birth, even an uncomplicated one, willdevelop SUI at some point in their life. Giving birthto twins or bearing more than one child does notnecessarily raise the risk because the damage hasusually been done with the first child, according toDr. Linda Brubaker of Loyola University in Chicago.

Young women may experience SUI after child-birth, but the problem becomes more noticeablelater in life, particularly around the time ofMENOPAUSE, when loss of estrogen contributes toweakening of muscle walls.

Help for SUI

Remedies for SUI have improved in recent years.Today 90 percent of women who seek help find

348 Stress and Anxiety Research Society

relief, and new treatments are on the way. Manypatients are advised to make lifestyle changes, loseweight, reduce intake of liquids, and cut back onirritants such as caffeine, alcohol, and cigarettes. Ifthe patient’s pelvic floor is weak, she will need tolearn how to train her muscles with Kegel exer-cises (pelvic contractions commonly taught to pre-vent SUI after childbirth).

Medications used to treat stress incontinenceare aimed at increasing the contraction of the ure-thral sphincter muscle. Treatment with medica-tions tends to be more successful in patients withmild to moderate stress incontinence.

Biofeedback techniques can help women isolateand work the pelvic muscles. Another approachgaining popularity is collagen or fat injections,administered under local anesthesia by a urologist,to plump up tissues around the urethra. The bodytends to absorb collagen, and the injections mustbe repeated every year or so.

Several surgical techniques are in use to helpwomen who have SUI. Approximately 135,000SUI surgeries are performed a year in the UnitedStates with a success rate of 75 to 95 percent.

FOR FURTHER INFORMATION:American Urological Association1000 Corporate BoulevardLinthicum, MD 21090(866) RING AUA(410) 223-4375 (fax)http://www.auanet.og

stroke An interruption to the blood supply of thebrain, or leakage of blood outside vessel walls, thatcauses damage to a part of the brain. Sensation,movement, or function controlled by the damagedarea may be impaired. Paralysis or some speechimpairment may occur. Strokes are fatal in aboutone-third of cases and are a leading cause of death indeveloped countries. A stroke is a very stressful eventin the life of the sufferer as well as the caregiver.

According to the National Stroke Association(NSA), of the 750,000 strokes per year, more than100,000 are recurrent strokes. NSA further esti-mates there is up to a 14 percent increased risk ofrecurrent stroke within one year and up to a 40percent increased risk within five years of the ini-tial stroke.

See also ATHEROSCLEROSIS; CORONARY ARTERY DIS-EASE: HEART ATTACK; HIGH BLOOD PRESSURE.

FOR FURTHER INFORMATION:American Heart AssociationNational Center7272 Greenville AvenueDallas, TX 75231-4596(800) 242-8721 (toll-free)(214) 373-6300(214) 987-4334 (fax)http://www.americanheart.org

National Stroke Association300 East Hampden AvenueEnglewood, CO 80110(800) 787-6537 (toll-free)http://www.stroke.org

stuttering A speech disorder involving repeatedhesitation and delay in saying words or in whichcertain sounds are unusually prolonged. Stutteringis also known as stammering. Stuttering is stressfulbecause it causes the sufferer embarrassment andANXIETY. Some stutterers become socially with-drawn because they fear ridicule from others.

Stuttering usually starts in early childhood andmay be a temporary situation. However, about halfof the children whose stuttering persists after agefive continue to do so throughout adulthood.Causes of stuttering are not understood; theories saythat it may be due to a subtle form of brain damageor may be related to a psychological problem.

When people who have a stammer becomeanxious or fearful, their stuttering becomes worse.For example, some children who are fearful of get-ting up and speaking in the classroom have diffi-culty getting words out. Interestingly, these samechildren feel no particular stress and have no diffi-culty in reading aloud or singing in unison.

Speech therapy helps some individuals improvetheir speech pattern; training may include learningto give equal weight to each syllable.

See also SOCIAL PHOBIA.

FOR FURTHER INFORMATION:National Center for Stuttering200 East 33rd StreetNew York, NY 10016(212) 532-1460(800) 221-2483 (toll-free)

stuttering 349

Stuttering Resource Foundation123 OxfordNew Rochelle, NY 10804Phone (800) 232-4773

substance abuse See ADDICTION.

success A favorable outcome or attainment ofwealth or stature, success can be a source of stresswhen it happens as well as when it does not hap-pen. Some who view success as a source of stress,fear that they will not be able to reach a higherplateau or that they will not be able to fulfill otherpeople’s expectations. Others may fear that byachieving success they will have to move to a bet-ter neighborhood, bigger house, or send childrento a better school. All these expectations may leadto anxieties and stressful feelings about change.

While success can be a source of satisfaction, italso can be stressful because some individuals mayfear that achievement will place them in anothersocial, academic, or social class and they will losefriendships. Some individuals actually avoid suc-cess because they want to continue conforming totheir group.

Expectations for success are stressful becausethey correlate with people’s fear of failure. Aninability to reach what people regard as successmay reflect unfavorably on their self-image andSELF-ESTEEM.

Certain PERSONALITY types are driven toward suc-cess. The TYPE A PERSONALITY, for example, is associ-ated with intense drives for success. Such individualshave competitive feelings, are extremely goal ori-ented, take on multiple commitments, and becomepreoccupied with meeting deadlines. Often, afterserious illness, such individuals learn to relax moreand redirect their drives, placing more value onfamily and friendships.

SOURCE:Van Fleet, James K. Lifetime Guide to Success with People.

Englewood Cliffs, N.J.: Prentice Hall, 1995.

sudden infant death syndrome (SIDS) SIDS, or“crib death,” is the sudden and unexplained deathof an infant. Infants who are victims of SIDS areusually between the ages of two to four months,when they stop breathing during a normal sleeping

period. Ninety percent of all victims die within thefirst four months, but SIDS may strike children asold as one year.

In 2001, 2,236 children died of SIDS in theUnited States, according to the Centers for DiseaseControl and Prevention. The death rate hasdropped by half since 1992, when the governmentand private organizations started a campaign tellingparents to put their babies to sleep on their backs.

Although causes of SIDS are unknown, it is notcaused by childhood vaccines, suffocation, vomit-ing, or choking. Research projects are under way todetermine predictive factors that may preventfuture deaths.

Parents who have lost a child to SIDS may findSUPPORT GROUPS helpful.

See also GRIEF.

FOR FURTHER INFORMATION:American Sudden Infant Death Syndrome

Institute509 Augusta DriveMarietta, GA 30067(800) 232-SIDS; (800) 232-7437 (toll-free)(770) 426-8746(770) 426-1369 (fax)http://www.sid.org

suicide Killing oneself voluntarily and intention-ally. In some cases, suicide is the consequence ofDEPRESSION and stress. It is a subject that is a stress-ful one for many people to talk about, and a ver-dict of suicide certainly is not one that the familywants to hear.

Suicide is the eighth leading cause of DEATH inthe United States and the second most frequentcause of death for young people in the 15–25 agegroup. About 12 percent of those who threaten orattempt suicide actually kill themselves. Currentstatistics may understate the actual occurrence ofsuicide. For example, there may be suicidal inten-tions behind many auto and other accidents. Addi-tionally, because of insurance coverage issues andlegal criteria for classifying cause of death, suicidemay not be recorded as the cause in many cases.

Preventing Suicide

Suicide is a manifestation of depression that can besuccessfully treated. People who show signs of

350 substance abuse

depression and express hopelessness or suicidalimpulses should be encouraged to get immediateprofessional help in order to avoid a crisis. If a sui-cidal crisis does occur, the family should remove allweapons and lethal means from the home, includ-ing prescription drugs, and the individual threat-ening suicide should not be left alone at any time.

One of the most difficult challenges cliniciansface is preventing the suicide of their patients.Such psychiatric clinicians routinely deal withpatients whose diagnoses indicate a high risk forsuicide. The physician, psychotherapist, or mentalhealth worker is sometimes the only person whorecognizes suicidal intent. Studies have shown thatfrom 40 percent to 75 percent of suicidal individu-als see a physician within six months to a year pre-ceding their self-destructive acts. A number ofstudies have pointed out that even while receivingpsychiatric treatment, psychiatric hospitalization,or treatment with psychotherapic drugs, patientsdo commit suicide.

Evidence seems to support the contention thatmost suicides occur in the context of psychiatricillness. However, the absence of psychiatric treat-ment at the time of suicide does not necessarilypreclude the existence of a serious mental distur-bance; severely depressed patients may appearsymptom-free just prior to suicide. This may leadto an erroneous assumption that the individual is“normal” at the time of suicide.

Additionally, the presence of real or perceivedphysical illness may be significant in the assess-ment of suicidal risk. In malignant or incurable ill-ness, two critical suicidal periods seem to be thoseof: a) uncertainty while diagnosis and prognosisare still at issue, and b) shock following the firstrealization of the upheavals and suffering, actual orfantasized, that are to follow.

Depression and Suicide

Individuals who have serious depression are highsuicide risks. Symptoms may include feelings ofhopelessness, helplessness, and emptiness, espe-cially with severe anxiety or panic attacks, sleepdisturbance, weight loss, complete loss of interest,loss of sexual interest, impairment of function,delusional guilt, neglect of personal appearanceand cleanliness, and inability to make decisions.Generally, the risk of suicide appears to be greatest

in the early course of depressive illness (first threeepisodes).

Common instances of increased suicidal risk indepressed individuals are associated with separa-tion or loss. The loss does not necessarily have tobe a death of a loved one, but may be simply atemporary loss such as home or job or temporaryseparation such as from therapist, money, or love.

The “failure situation” ranks high as a precursorof suicide. This situation may occur when one istrying to regain or attain a higher level of function,such as starting a job or returning to college. Also,the failure factor ranks high when individuals try tomeet higher expectations of themselves or others.

Recognizing Suicide Intentions

A characteristic of a chronically suicidal person isrepeated communication of a wish to die or suici-dal thoughts. However, this in itself is not sufficientto distinguish the high- from the low-risk individ-ual, since the majority of the much larger group ofpeople who attempt but do not complete suicidealso convey intent in advance.

Personalities of many suicidal individuals haveshown tendencies toward rigid thinking, whichdoes not allow for alternatives in a crisis; PERFEC-TION in all undertakings is a personality trait that iscarried to a pathological extreme.

A suicidal individual often shows intensedependency as an underlying lifestyle dynamic.This dependency may be notable throughout allspheres of the suicidal individual’s lifestyle whereinordinately excessive demands are made on oth-ers for constant attention, affection, and approval,and where the individual feels unable to cope forhimself, thereby needing continual supervisionand guidance.

Recognizing Youth at Risk

There are some specific clues to predict suicideamong youngsters or adolescents. For example,they are more likely to communicate with those intheir peer group than with their parents. They maygive away a prized possession with the commentthat they will not be needing it anymore. Theymay be more morose and isolated than usual.Although there may be signs of insomnia, worry,and anorexia, the youngster may not have all theclassical signs of depression.

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One study listed symptoms occurring in 25 col-lege-age suicides in order of their frequency: despon-dency, futility, lack of interest in school work,tenseness around people, insomnia, suicidal com-munications, fatigue and malaise without apparentorganic cause, feelings of inadequacy or unworthi-ness, and brooding over the death of a loved one.

Having a gun in the home may increase the riskthat a psychologically troubled teen will commitsuicide, according to David A. Brent, M.D., in theJournal of the American Medical Association (Decem-ber 1991). Dr. Brent and colleagues noted that theodds that potentially suicidal adolescents will killthemselves are raised 75-fold when a gun is kept inthe house. They commented on differencesbetween teen suicides and that of adults. For teens,they said, a suicide attempt may be an attempt tocommunicate that they are in great pain, althoughthey may be ambivalent about wanting to die. Forsuch adolescents, ready access to a firearm mayguarantee that their plea for help will not be heard.

Suicide and the Aging Population

A federal study published during 1991 showed thatfrom 1980 to 1986, suicides by Americans aged 65and older jumped 23 percent for men and 42 per-cent for African-American men. The rate for whitewomen rose 17 percent, while there were too fewsuicides among African-American women to showa meaningful trend. A study in Illinois under a

grant from the American Association of RetiredPeople Andrus Foundation showed that the greatmajority of the elderly who committed suicidewere physically healthy. However, 79 percent hadshown symptom of a major treatable psychiatricillness, usually depression or ALCOHOLISM.

Assisted Suicide

In 1991, Final Exit, a “how-to” book by DerekHumphry, executive director of the Hemlock Soci-ety (a group aimed at promoting death-with-dig-nity), was published. He emphasized that hiscontroversial book for the terminally ill was notmeant for unhappy or depressed people.

Many mental health professionals were con-cerned that this book and others may legitimizesuicide for troubled people with undiagnoseddepression who could be treated if their illnesseswere diagnosed correctly. Many expressed fear thatsuch books could increase suicide rates, particu-larly among the elderly who are not terminally ill.However, according to David Clark, past president,American Society of Suicidology (an organizationdedicated to preventing suicide), many people,when they recover from an attempted suicide, areextraordinarily glad that someone did not helpthem die.

In March 1990, physicians writing in the NewEngland Journal of Medicine about “The Physician’sResponsibility toward Hopelessly Ill Patients” heldthat “it is not immoral for a physician to assist inthe rational suicide of a terminally ill person.” Twoof the 12 authors of the paper dissented from thisstatement.

Dr. Jack Kevorkian (1928– ), an Americanphysician with a specialty in pathology, is famousand controversial for his advocacy of the right todie and his suicide assistance of terminally ill peo-ple. During the 1990s, he helped more than 100people die in this manner. As of late 2005, he is ina Michigan prison, serving a 10–25-year sentence.He will be eligible for parole in 2007.

The first time he assisted a terminally ill personwith suicide was in 1990, and until 1998, hehooked patients up to a machine of his own inven-tion to facilitate death. The patient would push abutton, releasing chemicals or drugs to inducedeath. He was charged with murder in Michiganseveral times but was acquitted or had a mistrial. In

352 suicide

RECOGNIZING CHARACTERISTICS OF SUICIDAL INDIVIDUALS

• Depressed mood; hopeless-helpless• Disturbed sleep patterns and appetite distur-

bances• Anger, hostility• Ambivalence; impaired concentration• Withdrawn, isolative behavior• Constricted thought processes; tunnel vision• Psychomotor agitation or psychomotor

retardation• Anxious; attentive to internal stimuli• Verbalizes suicidal thoughts or plans and refer-

ences to death• Gives away possessions; impulsive behaviors

1997, the U.S. Supreme Court ruled that stateshave the right to outlaw physician-assisted suicide.In March 1999, a jury in Michigan found Dr.Kevorkian guilty of second-degree murder and ofdelivering a controlled substance. He had adminis-tered a lethal injection to an ALS sufferer. In April1999, he was sentenced to prison. On September29, 2005, in a television interview, Dr. Kevorkianindicated that if he is granted parole, he willrestrict himself to campaigning to have the lawchanged and would not resume helping people die.

See also AFFECTIVE DISORDERS.

FOR FURTHER INFORMATION:American Academy of Child and Adolescent

Psychiatry3615 Wisconsin Avenue NWWashington, DC 20016(202) 996-7300

American Association of Suicidology5221 Wisconsin Ave NWWashington, DC 20015(303) 692-0985

American Psychiatric Association1000 Wilson Boulevard, Suite 1825Arlington, VA 22209-3901(703) 907-7300

National Alliance for the Mentally IllColonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22201-3042(703) 524-7600

National Committee on Youth Suicide Prevention666 Fifth Avenue, 13th FloorNew York, NY 10103(212) 677-6666

National Institute of Mental Health5600 Fishers LaneRockville, Maryland 20857(301) 443-4513

National Mental Health Association1021 Prince StreetAlexandria, VA 22314-2932(800) 969-NMHA(703) 684-7722

SOURCES:Brent, David A., et al. “Teens More Likely to Commit

Suicide When Gun Is in Home.” Journal of the Ameri-can Medical Association, December 3, 1991.

Fawcett, Jan, William A. Scheftner, Louis Fogg, et al.“Time-Related Predictors of Suicide in Major AffectiveDisorder.” American Journal of Psychiatry 147, no. 9(September 1990).

Garrison, Jayne. “Rushing Heaven’s Door.” Health,May–June 1997.

Humphry, Derek. Final Exit: The Practicalities of Self-Deliv-erance and Assisted Suicide for the Dying. Secaucus, N.J.:Carol Publishing, 1991.

Kahn, Ada P., and Jan Fawcett. Encyclopedia of MentalHealth. 2nd ed. New York: Facts On File, 2001.

Katz, Marvin. “Critics Fear Misuse of Suicide Books.”Bulletin, American Association of Retired Persons 32, no.11 (December 1991).

“Should the Doctor Ever Help?” Harvard Health Letter 16,no. 10 (August 1991).

sunlight Light from the Sun, which helps plantsgrow and helps elevate people’s moods. Soaking upthe Sun’s rays has been a favorite American pas-time for many years. Lying in the sun was believedto be a great way to relax and escape from thestress of everyday life. The sun not only made peo-ple feel good, it also contributed to a tanned, out-door look. That was before the dangers ofultraviolet rays were understood, said the Ameri-can Academy of Dermatology (AAD) in its pam-phlet The Sun and Your Skin, published in 1994.Now it is known that too much sun can causewrinkles freckles, skin texture changes, dilatedblood vessels, and skin CANCER.

Recommendations to Prevent Skin Damage

It is important to avoid overexposure to the Sunbecause the Sun produces both visible and invisiblerays, known as ultraviolet-A (UVA) and ultravio-let-B (UVB). Both cause suntan, sunburn, and sundamage. There is no “safe” UV light. People shoulduse protection against the sun whenever outdoors.While the harmful UV rays are more intense in thesummer, at higher altitudes, and near the equator,effects of the sun are also increased by wind andreflections from water, sand, and snow. Even oncloudy days, UV radiation reaches Earth.

The AAD recommends avoiding deliberate sun-bathing and wearing a wide-brimmed hat, sun-glasses, and protective clothing if it is necessary to

sunlight 353

be in the sun, and to use a sunscreen, at all times.A sunscreen works by absorbing, reflecting, orscattering the Sun’s rays on the skin. Choosing theright sunscreen can be a source of stress because somany choices are available. All sunscreens,whether they are ointments, gels, creams, lotions,or wax sticks, are labeled with SPF (sun protectionfactor) numbers. The higher the SPF, the greaterthe protection from sunburn caused by most UVBrays. Some sunscreens, called “broad spectrum,”block out both UVA and UVB rays.

Protecting against effects of the sun should startby avoiding the peak hours of the sun—usuallybetween 10 A.M. and 4 P.M. Sunscreens should beapplied about 20 minutes before going outdoorsand should be reapplied about every two hoursafter swimming or strenuous activities.

Skin Cancer

While too much sun can cause painful sunburn,age the skin with wrinkles, freckles, and sunspots,set off allergic reactions such as rashes, hives, andblisters, and cause cataracts, the worst possibleeffect is skin cancer. There are three common typesof skin cancer: basal cell carcinoma, squamous cellcarcinoma, and melanoma.

Estimates indicate that approximately 700,000Americans develop skin cancer every year. Fortu-nately, most skin cancers can be detected andcured if found early. Dermatologists recommendperiodic self-examinations; watching the patternsof moles, freckles, and “beauty marks”; and beingalert to changes in the number, size, color, andshape of pigmented areas. Contact a dermatologistif changes occur.

Effects of Too Little Sunlight

Too little sunlight in the environment, such as innorthern locations during winter months, canresult in a form of depression known as SEASONAL

AFFECTIVE DISORDER. Treatment involves going to aplace with a brighter atmosphere, or using spe-cially designed light treatments.

See also AFFECTIVE DISORDERS; BODY IMAGE;CHRONIC ILLNESS; CLIMATE; DEPRESSION.

FOR FURTHER INFORMATION:American Academy of DermatologyP.O. Box 4014Schaumburg, IL 60168-4014

(847) 330-0230http://www.aad.org

superiority complex An unrealistic and exagger-ated belief of a person that he or she is better thanothers. Such a complex is a source of stress for theindividual as well as others. In some people, this is acompensation mechanism for unconscious feelingsof low SELF-ESTEEM or inadequacy. For example, bul-lies who push other children around may act likethat because, in reality, they have low self-esteem.

Some adults with a superiority complex seem tobe snobbish, but they may be covering up for aninadequacy, such as lack of a college education.

See also INFERIORITY COMPLEX.

superstition Beliefs that have survived sinceancient times regarding the mysteries of nature.Superstitions abound among cultures around theworld; many people who still hold superstitiousbeliefs become stressed when they allow theirsuperstitions to take over their life.

Many odd and amusing notions and customspersist; some are harmless and some are harmful.Scientific thinking supersedes the superstitiousbecause modern science believes that everything innature has a natural cause and that laws of naturecan explain cause and effect.

Superstitious beliefs are more common amongpeople with little education, but even well-edu-cated people have a tendency to cling to supersti-tious beliefs. For example, hotels and othercommercial buildings sometimes avoid numberingthe 13th floor because many persons believe it isunlucky. Fridays that fall on the 13th day of themonth are considered unlucky. If your ears burn, itmeans someone is talking about you. Bad luck fol-lows walking under a ladder, breaking a mirror, orhaving a black cat cross your path. It is supposed tobe good luck if one finds a penny or a four-leafclover. Stressful interactions may arise betweenfamily members or friends when one clings tothese old superstitions and another counters themwith more practical explanations.

See also ACCULTURATION; TABOOS.

support groups Individuals with the same expe-rience about a specific health or social concern

354 superiority complex

who join together to help each other by sharingexperiences and advice and by providing emo-tional support for each other.

Support groups exist for patients as well asspouses and family members in almost every med-ical or social category. For example, individuals withMANIC-DEPRESSIVE DISORDER began an organizationthat now has become nationwide, with chapters inmany cities. Individuals with CHRONIC FATIGUE SYN-DROME (CFS) have done the same, with the resultthat sufferers no longer need feel alone with theirproblems. There are support groups for parents ofchildren with specific diseases, as well as groups forspouses of ALZHEIMER’S DISEASE patients and formiddle-aged people who care for ELDERLY PARENTS.

Many physicians recommend that patients joinsupport groups because the sharing with otherscan be effective and augment any therapies pro-vided by medical means.

An additional benefit of belonging to a supportgroup for a particular concern is that one can stayup to date on progress as researchers work towardbetter treatments or legislators work on the issues.Many groups circulate articles from popular andscientific publications and bring in experts to dis-cuss their latest findings.

According to Karyn Feiden, author of Hope andHelp for Chronic Fatigue Syndrome, benefits of sup-port groups generally fall into three major areas:informing and educating the general public, andparticularly patients, their families, and the med-ical community; counseling and consoling thosewho have been diagnosed with a particular disor-der; and organizing and advocating for the cause atlocal and national levels.

Support Groups for Breast Cancer Patients

David Spiegel, M.D., Stanford University Schoolphysician and faculty member, pioneered workwith support groups for BREAST CANCER patients. In1991, at the national meeting of Y-ME (a breastCANCER advocacy organization), he reported con-clusions of a 15-year study of 86 metastatic breastcancer patients.

While we know that psychosocial support affectsoutcome in terms of length of survival, the mech-anism by which it does so is not clear. However,results of this study strongly suggest that psy-

chosocial support can improve the quality of lifefor cancer patients, is inexpensive and easy toorganize, and should be a standard part of care.

Social support is an important stress buffer andis strongly related to survival. The risk of cancerand cancer mortality is higher if one is not sociallyintegrated. The ratio may be as high as 2:1. Formen, marital status is a protective factor, withmarried men at the lowest risk. For women, thebest protective factor is relationships with womenfriends and relatives . . .

When patients manage STRESS better, it mayallow their bodies to devote more resources to fight-ing illness. This comes not by denying the illnessand wishing it away, but by managing life, relation-ships with family and physicians, one’s own feelingsabout having a terminal illness as fully as possible,and making their lives fuller and richer. Such tech-niques are not a cure for cancer, but there is someevidence that they may prolong survival.

From our support groups as well as other stud-ies, we know that mutual support should beencouraged. There was a tremendous poweramong the women with the same problem. Mostpeople don’t understand DEATH, feel isolated andthat they are already dead. Enhancing mutual sup-port made these women feel more a part ofhumanity.

A bonding develops quickly because women inthe group know what others’ fears are like; thishelps to normalize their reactions and relationshipswith each other. People feel awkward talking aboutcancer because they find it hard to deal with anxi-ety about death. “We found that it was not deathitself, but the process of dying, including losingphysical CONTROL, an inability to do what they didbefore, and PAIN, that were most difficult for thewomen to face. Thus there was a series of problems,not just one problem. However, there are someconstructive things one can do, for example, workout a living will, improve means of pain control,and talk with one’s physician about ongoing care.

“We were concerned that putting women withmetastatic cancer together might demoralize someof them. Instead, direct confrontation with deathled the women to discussions of positive copingstrategies and no decline in mood.”

The criteria for inclusion in the randomizedprospective study was that women agreed toattend weekly support groups for a year. Fiftywomen were randomly assigned to the support

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group situation; 36 were assigned to their routinecancer care. The women had comparable kinds ofinitial surgery, similar initial staging, comparabledegrees of metastatic spread, similar courses ofchemotherapy and disease-free intervals (threeyears for both groups).

Therapy groups included eight to 10 womenand two therapists who met weekly for an hourand a half. Intervention focused on direct con-frontation of fears of dying and death, realisticassessment of prognosis, and development of newcoping strategies for interaction with physicians,family, and friends.

Overall, patients in the treatment group showeda reduction in total mood disturbance while thosein the control group worsened in terms of tension,fears, anxiety, confusion, and fatigue. The treat-ment group coped substantially better, and experi-enced less denial, significant reductions in mooddisturbance, fewer phobic symptoms, and less pain.

Both the treatment and control groups had rou-tine oncologic care. At 10-year follow-up, onlythree of the original 86 patients were still alive, anddeath records were obtained for the other 83. Sur-vival from the time of randomization and onset ofintervention was 36.6 months for the treatmentgroup, compared with 18.9 months for the controlgroup. Four years after randomization, all of thecontrol patients had died and one-third of theintervention sample were still alive. There was adifference in survival from the first metastases, 43months vs. 58 months.

In explaining the survival differences betweenthe two groups, Dr. Spiegel said that women whoare less depressed may eat better, exercise more,take better care of themselves, and may encouragephysicians to be more assiduous in treatment. “Wenow call this supportive-expressive group therapy.The theme is how the women face their futures,not their pasts,” said Dr. Spiegel.

See also BEHAVIOR THERAPY; CHRONIC ILLNESS;DEPRESSION.

SOURCES:Feiden, Karyn. Hope and Help for Chronic Fatigue Syndrome.

New York: Prentice Hall, 1990.Kahn, Ada P. “Psychosocial Support Influences Survival

of Cancer Patients.” Psychiatric News, October 1991.Kreiner, Anna. Everything You Need to Know about Creating

Your Own Support System. New York: Rosen PublishingGroup, 1996.

Locke, Steve, and Douglas Colligan. The Healer Within.New York: New American Library, 1986.

sympathetic nervous system (SNS) One of twodivisions of the autonomic nervous system. Thesystem controls many involuntary activities of theglands, organs, and other parts of the body andreadies it for coping with suddenly occurring situ-ations. The SNS is very involved in stressresponses, as it is responsible for preparing peoplefor fighting, fleeing, action, or sexual climax.

The SNS includes connections from the eyes tothe urogenital organs. Typical sympathetic changestake place during heavy exertion or when facingextremely stressful situations. The pupils widen tofacilitate vision, the arteries constrict to supplymore blood to the muscles and the brain, heartbeatincreases, ADRENALINE is secreted to increasemetabolism, the skin perspires to eliminate wasteproducts, and stomach and intestinal activitiescease so that energy can be directed elsewhere.

See also FIGHT OR FLIGHT RESPONSE.

symptom An indication of an illness or mentaldistress noticed by the sufferer. For example,symptoms of stress may be sleeplessness, fatigue,difficulty concentrating, or irritability. A symptomis different from a sign, which is an indication of adisorder noticed on an objective basis by anotherperson, such as a physician. A group of symptomsas well as signs is sometimes referred to as a SYN-DROME. An example is post-traumatic stress syn-drome, which includes a wide range of symptoms,such as nightmares, feelings of claustrophobia, andan inability to concentrate; the physician maynotice increased heartbeat, rapid breathing, andother signs during examination.

syndrome A group of SYMPTOMS or signs thatoccur together and make up a particular disorder.For example, the syndrome that leads a physicianto diagnose extreme stress in an individual, mayinclude elevated blood pressure, difficulty sleeping,loss of weight, inability to concentrate, lack ofinterest in sexual activity, as well as others.

syphilis See SEXUALLY TRANSMITTED DISEASES.

systematic desensitization See BEHAVIOR THERAPY.

356 sympathetic nervous system

Ttaboos Ideas, concepts, or practices that are notdiscussed or carried out openly by a given cultureare referred to as taboos. Some taboos are so spe-cific to a culture that they are difficult for outsidersto understand. The source or reason for a taboomay be unknown or forgotten; taboos may havegiven groups of people moral and ethical codes bywhich they lived.

Certain taboos that are common to many cul-tures are a source of stress. For example, referencesto the dead and DEATH are frequently avoided,made in hushed tones, or accompanied by a ritualgesture or phrase; SUICIDE is not discussed in manycultures, nor is INCEST, so much so, that referenceto the behavior and to the act itself may have beensuppressed. During the 1990s in the United Statesthere were revelations that incest had a higherincidence than previously thought. As a conse-quence, the taboo to speak out and protest about itwas, to a large extent, lifted.

Some taboos evolve from social hierarchies, suchas the Hindu caste system, which rigidly regulatescontact among the castes. Other taboos are relatedto rulers or persons in authority. For example, on avisit to the United States, Queen Elizabeth IIaccepted a friendly, but highly irregular, hug from awoman who was not familiar with royal protocol.

Other taboos involve sex roles and contactbetween the sexes such as the exclusion of womenfrom male clubs. Cleanliness, especially of food,and bodily functions, such as excretion or MEN-STRUATION, give rise to taboos in many cultures;Native American tribes confined their women to aspecific lodge during their menstrual periods.

The word taboo is derived from the language ofthe Polynesian people, meaning “forbidden” or“dangerous.” It is the term used for behaviorrelated to their king. He was thought to be so full

of power or mana that his shadow, parts of hisbody, and even objects that he touched were con-sidered dangerous.

See also SUPERSTITION.

SOURCES:Douglas, Mary. “Taboo,” in Cavendish, Richard, ed., Man,

Myth and Magic, vol. 10. New York: MarshallCavendish, 1983; 2,767–2,771.

Gregory, W. E. “Taboos,” in Corsini, Raymond J., TheEncyclopedia of Psychology, vol. 3. New York: Wiley,1984; 398.

tachycardia Rapid beating of the heart, over 100beats per minute in an adult. Most people experi-ence 60 to 100 beats a minute, with an average of72 to 78 beats. It is normal for tachycardia to occurunder some conditions, such as vigorous EXERCISE

or sexual activity. However, tachycardia is some-times associated with AGORAPHOBIA, ANXIETY, PANIC

ATTACKS AND PANIC DISORDER. People who alreadyfeel stressed, anxious, or fearful may become evenmore so when they become aware that their heartis beating rapidly. Under such circumstances theymay fear that they are having a HEART ATTACK and,along with the rapid heartbeat, experience symp-toms such as difficulty in BREATHING, PALPITATIONS,and DIZZINESS.

Other reasons for tachycardia at rest are hyper-thyroidism, coronary heart disease, a high intakeof CAFFEINE, and treatment with an anticholinergicand some decongestant drugs.

t’ai chi A physical, mental, and spiritual practicethat uses movement to balance energy, and helpsachieve and maintain harmony within oneself.Those who practice t’ai chi say that it aids them todevelop more mental and spiritual energy, feelmore overall vitality, and obtain relief from stress.

357

T’ai chi is an outgrowth of Chinese martial arts,spirituality, and Chinese medicine, and has beenpracticed for more than 2,000 years. As a martialart and a popular meditative practice, it is oftencalled MEDITATION in motion. According to Chinesephilosophy, to do t’ai chi is to connect the individ-ual with nature through movement. It is consid-ered “great shadow boxing,” which draws on Taoistbeliefs in the interdependence of the body and themind. In the open spaces and parks of China today,millions of young and old people practice t’ai chi,gently swaying, gliding, and stepping.

Benefits of T’ai Chi

Practitioners of t’ai chi usually experience deepand restful sleep. Their nervous system is soothedand calmed. The gentleness of t’ai chi ensures thatthey do not suffer strains and other muscularinjuries, but instead develop greater strength, flex-ibility, and suppleness. Some athletes use t’ai chi asa way of warming up.

People who perform t’ai chi move all their jointsand exert more energy than it appears. Throughthe use of slow BREATHING, individuals can pacesome of the systems of their body. They can stabi-lize their heartbeat, the exchange of oxygen andcarbon dioxide, and the secretion and absorptionof endocrine fluids. The movements also improvehealth by assisting the flow of blood, creating tran-quility for the entire nervous system, and throughdeep concentration, fostering deep peace of mind.

United States researchers have been studyingthe physical and mental benefits of t’ai chi, particu-larly for older people, many of whom suffer from alack of balance and experience falls. In an article inthe Journal of the American Geriatric Society (May1996), an evaluation of a 15-week course taken by72 men and women over age 70 showed that t’aichi not only improved their balance but also helpedthese people abort falls by teaching them to copewith missteps and precarious positions. Anotherstudy, reported in the Harvard Health Letter (July1997), said that older adults who practiced t’ai chihad significantly lower blood pressure readingsafter the exercise and a decreased fear of falling.

T’ai Chi ClassesBooks and videos on t’ai chi are available, but thebest way to learn t’ai chi is in classes held in t’ai chi

studios, adult education courses at high schoolsand colleges, YMCAs and YWCAs, and senior adultcenters. Many people combine t’ai chi with otherforms of exercise.

See also ALTERNATIVE MEDICINE.

tantrums Fits of ANGER usually experienced bychildren, although some adults, particularly thosewho have mental disorders, also experience thesephysical outbursts. Tantrums can happen any-where. Anyone who has ever witnessed childrenthrowing a tantrum in public sympathizes with thestress and FRUSTRATION felt by their parents.Although physical outbursts are a normal part ofchildhood development, they are no less embar-rassing for parents who must manage a child’s lossof CONTROL, and their own loss as well.

Childhood tantrums come in many forms—usu-ally a combination of screaming, stomping around,writhing on the floor, and breaking or wieldinghandy objects. Children may be angered by beingunable to deal with new experiences or frustratedby a perceived obstacle. For example, objects theymight want to handle can be too dangerous, toocomplex, or too delicate for their small fingers.

When children learn that the world does notcenter on them nor does it necessarily revolvearound what they want, a tantrum is the way inwhich they may revolt. They are protesting againstlimitations on their behavior set by their parentsand society. Fortunately for parents, most childrenoutgrow their tantrums and eventually learn howto interact with their environment in a moremature way.

See also HOSTILITY; PARENTING.

TASERs Handheld weapons (also known as stunguns) that deliver a jolt of electricity to immobilizethe target. The jolt may be up to 50,000 volts firedfrom as far away as 21 feet. A TASER shot can pen-etrate thick clothing and stun the target by induc-ing an uncontrollable contraction of muscle tissue.TASERs are a source of stress for many. There iscontroversy concerning use of stun guns becausemore than 50 people in North America have diedsince 2001 after TASER shocks (total population ofthis region is estimated at 490 million). Critics saymore research is needed regarding their safe use.

358 tantrums

Amnesty International Canada has called for sus-pension of the use of TASERs until studies candetermine how they can be safely used. However,100,000 police officers have participated in a study,with no deaths. Also, no autopsy report from adeath after a shot from a TASER by a police personhas concluded that the TASER caused the death.However, persons who have a heart condition orare otherwise weak could be at risk.

Officers from more than 7,000 of the 18,000 lawenforcement agencies in the U.S. are armed withTASERs and many credit the stun guns with curb-ing shootings. Phoenix, Arizona, was the firstmajor metropolitan police force to provide TASERsfor its officers, and some 1,200 other Arizona agen-cies now use the stun guns. (Manufacturer TASERInternational is based in Arizona). Officials say thestun guns have reduced injuries to both officersand suspects. After TASERs were issued to allPhoenix patrol officers, police shootings fell totheir lowest point in 13 years. TASERs, also knownas stun guns, are intended to allow police officersto subdue violent individuals without killing themor injuring bystanders.

Canadian police say TASERs have saved 4,000lives since the police forces began using them inCanada in 1999. “TASERs are a less lethal alterna-tive,” according to Staff Sergeant Peter Sherstein, ofthe Royal Canadian Mounted Polices (RCMP)Emergency Response Team in Edmonton, Alberta,Canada. “There are still risks. There could be a situ-ation where a person hit with a TASER shot couldfall and hit his head. But we have to balance thatout. We have several cases where if TASERs werenot present, guns would have been the alternative.”

Use on Airlines

In 2004, Korean Airlines received approval by theU.S. Homeland Security Department’s Transporta-tion Security Administration (TSA) to carry elec-tronic TASER stun guns on some of its flights in theUnited States to protect against hijacking and otherattacks. Korean Air flights landing or departing theUnited States or crossing U.S. airspace are allowedto carry the weapons, but flights completely con-tained within the United States are not, as of theend of 2004. At least 50 flights a week will carrythe weapons. “They will be used by specially

trained personnel,” said Tom Smith, president ofArizona-based TASER International, manufacturerof the TASERs. Other airlines are expected to fol-low the example in the next few years.

TASER International lobbied the U.S. HomelandSecurity Department for three years to allow theirTASER to be used as a security measure on boardU.S. airlines. According to an article in the Wash-ington Times, Yolanda Clark, a TSA spokeswoman,said an agency working group studied several “not-so-lethal weapons” in 2003, including devices thatshoot beanbags, nets, and chemicals. They con-cluded that only the electric-shock devices couldbe used to enhance commercial security. Accordingto the article, thousands of flights are protected byarmed federal air marshals, and nearly 6,000 pilotshave been trained and carry guns to protect thecockpit against a terrorist attack.

2005 TASER Use Government Report

According to the U.S. Government AcceptabilityOffice, in a report issued in May 2005, law-enforcement agencies have studied policies andtraining requirements to assure safe use of TASERs.Operational protocols require that TASERs be visu-ally inspected daily and, in some cases, tested weeklyor at the beginning of an officer’s shift. Safety pro-cedures specify that TASERs not be used on chil-dren, pregnant suspects, or bystanders.

Some federal, state, and local jurisdictions havelaws that address TASER use, but requirements dif-fer. For example, the army prohibits TASERs frombeing brought into selected military installations inGeorgia. The TSA (Transportation Safety Adminis-tration) may approve use of TASERs on aircraft butmust prescribe training and guidance on appropri-ate circumstances for their use. At state and locallevels, the state of Indiana and the city of Chicago,Illinois, regulate the sale or possession of TASERsby non–law-enforcement persons. TASERs aresubjected to the same restrictions that apply tofirearms. Other states, such as California, prohibitTASERs from being carried into public facilitiessuch as airports.

SOURCE:Kehaulani Goo, Sara. “Korean Air Stun Guns

Approved.” Washington Post. Available online. URL:http://www.washingtonpost.com/wp-dyn/articles/

TASERs 359

A35529-2004Nov8html. Downloaded on June 22,2005.

U.S. Government Accountability Office. Report to theChairman, Subcommittee on National Security,Emerging Threats and International relations, Com-mittee on Government Reform, House of Representa-tives. “Taser Weapons: Use of Tasers by Selected LawEnforcement Agencies.” May 2005. Available online.URL: http://www.gao.gov//cgi-bin/getrpt?GAO-05-464; www.gao.gov/new.items/d05464.pdf. Last down-loaded October 7, 2005.

FOR INFORMATION:TASER International7860 East McClain Drive, Suite 2Scottsdale, AZ 85260(800) 978-2737 (toll-free)(480) 991-0797(480) 991-0791http://www.taser.com

technostress See CHANGING NATURE OF WORK;ELECTRONIC DEVICES.

teenage pregnancy See PREGNANCY; UNWED

MOTHERS.

teenage workers Finding a job is stressful forteenage workers. Teens face many stresses in find-ing jobs as well as while they work. According tothe National Institute of Occupational Safety andHealth (NIOSH), teens are often injured on the jobdue to unsafe equipment and working too fast.Also, teens may not receive adequate supervisionor safety training because they are regarded astemporary workers.

Teenage employees have the right to reportsafety problems to OSHA, and they may refuse towork if the job is immediately dangerous to life orhealth. By law, an employer must provide a safeand healthful workplace and safety and healthtraining for workers of all ages.

Particular stresses that face teenage workersinclude slippery floors and hot cooking equipmentin the food service industry, heavy lifting and vio-lent crimes in retail sales, toxic chemicals in clean-ing jobs, and office politics in clerical jobs.

In some cases teenage workers are asked towork long hours, particularly when other staff

members have time off. However, federal childlabor laws protect younger teens from working toolong, too late, or too early. Some states have lawson the hours that older teens may work.

teeth grinding Known medically as bruxism, aHABIT many people practice when they feel stressedor anxious. Some people grind their teeth duringthe day and some do it only at night.

For about 5 percent of the population, teethgrinding causes serious consequences. For exam-ple, it is possible to grind the enamel off the teeth,making them more susceptible to cavities and verysensitive to heat and cold. Years of grinding cancause facial and jaw pain from fatigued muscles.Grinding also may damage the joint between thejaw and the cranium (temporomandibular joint).When a person eats, the muscles responsible forchewing exert just enough pressure to hold inplace the disk of cartilage that cushions the joint.When the person grinds his or her teeth, this diskgradually becomes displaced, causing soreness,inflammation and even ARTHRITIS.

Dentists can prepare plastic retainer-like appli-ances called mouth guards or night guards thatprevent grinding. Many people find that RELAX-ATION therapy, GUIDED IMAGERY, HYPNOSIS, andBIOFEEDBACK also help to relieve this unwantedhabit.

See also TEMPOROMANDIBULAR JOINT SYNDROME.

telecommuting Working at a distant location;commuting by state-of-the art technological com-munication aids instead of physically traveling toone’s job. Telecommuting permits workers to workin a distant city or distant place in the same area.Working in this way reduces the stress of travelingto work by car or public transportation. Manyemployees enjoy the time saved by not having totravel to work.

Globalization is making telecommuting increas-ingly common, as more managers supervise work-ers in different cultures and in different time zones.According to Kris Maher, writing in the Wall StreetJournal, the trend is occurring because of fasterbroadband Internet connections between homeand office, concerns about terrorism that makeemployers think about placing executives geo-

360 technostress

graphically apart to help reduce disruptions, andthe comfort of employees who may prefer workingin their own homes. OUTSOURCING of jobs to othercountries also plays a role in the increased numberof workers who telecommute on a regular basis.

The number of Americans who work fromhome at least one day per month rose to 24.1 mil-lion in 2004 from 23.5 million in 2003. The num-ber of people telecommuting full time rose 41percent, to 12.4 million from 8.8 million, accordingto Dieringer Research Group, a Milwaukee, Wis-consin, market research and consulting company.

Not all work can be handled effectively fromremote locations. In many businesses, managersand other workers are called together to a centrallocation to meet to discuss agendas that cannot becovered by telephone, fax, or e-mail.

The downside to telecommuting is that it makesit difficult to develop relationships with coworkers.Also, it may be difficult for managers to motivatestaff members. E-mails and phone messages can bemisinterpreted, causing gaps in communication.

See also CHANGING NATURE WORK; ELECTRONIC

DEVICES.

SOURCE:Maher, Kris. “Corner Office Shift: Telecommuting Rises

in Executive Ranks.” Wall Street Journal, September21, 2004, p. B1.

telemarketers See RANDOM NUISANCES.

telephones As modern technology has made dra-matic advances in design and function of tele-phones as communication devices, sources of stresshave also escalated. Now there are cordless tele-phones used in homes which can be misplacedunder piles of newspapers and other clutter. Find-ing the phone when it rings causes stress among thefamily to find the phone. Mobile phones are a greatconvenience for making calls away from a “landline,” but stresses arise when each child in a familywants their own personal phone. Telephone serv-ice itself has become stressful because of the com-petition between providers and the difficulty ofcomparing services and prices.

Call waiting is an option with many phone serv-ices. When one person calls another and then isput on hold because another call is waiting, the

first caller is often annoyed that the other call isconsidered more important than theirs. Call for-warding can also be a convenience and an annoy-ance because the call can arrive at an inopportunetime for the recipient.

Camera Phones: A New Source of Stress

Cellular mobile telephones with the capability of tak-ing pictures were made widely available in the early2000s. They are a convenience and a source of funbut they are also a source of stress for many because,anyone, anywhere can take pictures with them andeasily transmit them to others. Modern technologyhas created this new stressor in our society.

Concerned about privacy violations, some com-panies have barred camera phones at the work-place. Dennis Nishi, writing in the Chicago Tribune,reported that camera phones have been banned inhealth clubs, courtrooms, and in 2004, in SaudiArabia and North Korea. Legislators are consider-ing making it illegal to take private photos of any-body without consent.

According to Nishi, visitors to General Motors(GM) are asked to surrender cell phones in high-security research areas. Employees abide by anhonor system and agree not to bring the phones towork. “It is a challenge considering all the cameraphones and PDAs [personal digital assistants] outthere, said Jim Burke, a GM spokesman. “We haveemployees dealing with confidential and propri-etary information.” Signs are posted at GM facili-ties to reinforce the policy, and random checks areconducted.

The U.S. Air Force has declared camera phones“an unacceptable risk to homeland security” andhas banned them from all areas dealing with clas-sified information. Federal officials said in a newsrelease: “It is not just a good idea to limit their usein secure rooms where classified information isbeing processed. You should watch how you useand carry those anywhere you’re dealing with sen-sitive or proprietary information.”

One solution posed in Nishi’s article is legisla-tion requiring camera phones to emit an audiblenoise or flash when taking pictures. South Koreaalready requires manufacturers to include this fea-ture in new phones; however, existing phones areexempt from this rule.

See also RANDOM NUISANCES.

telephones 361

SOURCE:Nishi, Dennis. “Camera Phones Give View of Need to

Boost Security.” Chicago Tribune, July 17, 2004, pp. 3–4.

television A popular form of entertainment andeducation that has been available for about 40 to50 years. Now, sitting in front of the television setoccupies so many Americans for so long that theyhave been labeled “couch potatoes.” The averageAmerican adult watches over 30 hours of televi-sion a week. While a common reason for watchingTV is RELAXATION, a major study indicated that thelonger viewers spent in front of the screen, themore stress they felt, because of guilt over fritter-ing away their time or avoiding responsibilities.

An additional source of stress felt by manyAmericans involves both the purchase of TV setsand selection of TV programming. When buying aTV, people do not have time to deal with the brandclutter on the retail shelves and to determine thebest price offered by competitive dealers. A similarcompetition for TV viewers exists among the vari-ous TV networks and the growing number of cablechannels. An example of this is the tremendousincrease in television talk shows that occurred dur-ing the 1990s, many of which seek the same TVaudience market and often run concurrently dur-ing the daytime and evening hours.

Estimates indicate that early in the 21st century,there will be as many as 250 cable and networkchannels from which viewers will be able tochoose. This dilemma, plus the production of digi-tal TVs, which will make current sets obsolete, willhave viewers stressed for years to come.

temporomandibular joint syndrome (TMJ) TMJoccurs when the ligaments and muscles that con-trol and support the jaw, face, and head do notwork together properly. The disorder can bebrought on by a spasm of the chewing muscles,teeth grinding (bruxism), or clenching the teeth asa response to STRESS and tension.

Symptoms of TMJ may include tenderness of thejaw, HEADACHES, and dull, aching facial pain, jawsthat lock, pain brought on by chewing or yawning,and a clicking or popping noise when opening thejaw.

Psychological counseling sometimes helps indi-viduals overcome the underlying causes of tension

and cope better with the stresses in their lives.Some people try GUIDED IMAGERY and RELAXATION

exercises.Treatment may include relieving pain by apply-

ing moist heat to the face, taking muscle-relaxantdrugs, and using a bite splint at night to preventteeth clenching and grinding. Some individualsundergo orthodontia to correct their bite whileothers undergo surgery on the jaw.

See also MEDITATION; TEETH GRINDING.

tendinitis An inflammation of a tendon, usuallycaused by injury. Because people who are understress often do not play attention to their bodies’signals, they increase the possibility that they aresitting, standing, and moving in ways that can leadto tendinitis. Precautions are necessary, particu-larly when people bend or lift. Additionally, peopleunder stress are less likely to take the time to exer-cise regularly, leaving the muscles more vulnerableto strain when used for strenuous effort.

Those most at risk for tendinitis perform repeti-tive motions for long periods of time. The repeatedmotions may be at work or during sports activities.Under most conditions, their bodies may be able tohandle the repetitiveness; however, if they areunder the demand of deadlines and other stressors,or fail to rest, stretch, or relax at regular intervals,tendinitis may occur.

Exercising—which includes conditioning, stretch-ing, and relaxation—can help to reduce the muscu-lar symptoms of stress, and should be continuedeven after aches and pain disappear. When musclesare strong and healthy, they are far better able to tol-erate the tensions that occur in everyday living.

See also REPETITIVE STRESS INJURY.

tension headache See HEADACHES.

terrorism The systematic use of terror as a meansof coercion is a worldwide problem. Terrorismmakes many people fearful and apprehensiveabout traveling and trusting strangers. It increasestheir levels of stress in airports and other publicplaces; long waits often ensue because of securitychecks that are not fail-safe.

On September 11, 2001 (9/11), the worst eventof terrorism in the history of the United States

362 television

occurred. More than 3,000 people died as a result oftwo hijacked airliners crashing into the World TradeCenter Towers in New York City. A third hijackedairliner crashed into the Pentagon. A fourth planecrashed in Somerset County, Pennsylvania.

The bombing of the Alfred P. Murrah FederalBuilding in Oklahoma City in 1995 was anotherexample of terrorism that killed many people andterrorized countless others, particularly those work-ing in government buildings around the world.Hostage taking, which has made the headlines manytimes in the latter 1990s, is an act of terrorism.

Terrorists are individuals who are fanaticalabout their cause and often have no concern fortheir victims or for their own lives. Most terroristgroups are supported by governments who findterrorism an effective and inexpensive way towage wars in comparison to the high cost of a con-ventional military force.

While little can be done to protect against mosttypes of terrorism, certain precautions, such asawareness of surroundings in public places and of“unusual” people, should be taken. Knowing thatthere will be long waits for baggage searches, pass-port checks, and other forms of questioning at air-ports, buildings, and other security checks toensure safety should help to reduce an individual’slevels of stress.

See also AIRPORT SECURITY; HOSTAGES; POST-TRAU-MATIC STRESS DISORDER; SEPTEMBER 11, 2005.

therapeutic touch A nontraditional therapy(alternative or complementary) developed by Dr.Dolores Krieger, professor of nursing at New YorkUniversity, in which she relieves the pain and dis-tress of illness by passing her hands over thepatient. It is also known as healing touch and isderived from the laying-on of hands. Her methodis described in her book The Therapeutic Touch, Howto Use Your Hands to Help or to Heal.

How the Technique Works

The healer eases into an altered state of conscious-ness while focusing energy on the patient, thenslowly passes his or her hands about four to sixinches above the patient’s body in an effort tosense a transfer of energy. The healer scans thebody for an area of temperature change as an indi-

cation that part of the body is troubled, then layshands on the affected area, while the patientsenses a change in temperature, perhaps a feelingof deep heat, in the area being touched.

According to Dr. Krieger, at the very least, themethod produces a relaxation response in thepatient and works well for inflammation, muscu-loskeletal problems, and psychosomatic disorders.Explanation by healers whose patients have beenhelped say that energy passes between themselvesand their patients. Skeptics believe that this heal-ing has a PLACEBO EFFECT, but it seems to work forsome individuals.

Historically, physicians touched their patientsfar more than they do today with the advent of somany highly technical diagnostic machines. Untilthe invention of the stethoscope in the mid-1800s,physicians pressed their naked ears to the bodies ofpatients to listen for heartbeats and other internalsounds. This intimate gesture probably had asoothing effect on the patient, much as therapeutictouch has today. As author Lewis Thomas wrote inThe Youngest Science, “It is hard to imagine a friend-lier human gesture, a more intimate signal of per-sonal concern and affection, than the close-bowedhead affixed to the skin.”

Now, many nurses and other health care practi-tioners, including body therapists, realize the needfor human touch and practice healing touch eitherknowledgeably or unconsciously, along with mas-sage and other techniques.

See also ALTERNATIVE MEDICINE; BODY THERAPIES;MASSAGE THERAPY; RELAXATION RESPONSE.

SOURCES:Locke, Steven, and Douglas Colligan. The Healer Within.

New York: New American Library, 1986.Macrae, J. Therapeutic Touch: A Practical Guide. New York:

Alfred A. Knopf, 1988.Thomas, Lewis. The Youngest Science. New York: Viking

Press, 1983.

therapy See PHARMACOLOGICAL APPROACH; PSY-CHOTHERAPIES.

THG A substance called tetrahydrogestrinone(THG) that is reportedly used by athletes toimprove their performance. Based on an analysisof this product, the U.S. Food and Drug Adminis-

THG 363

tration (FDA) has determined that THG is an unap-proved new drug. As such, it cannot be legallymarketed under the FDA’s rigorous approval stan-dards, meant to ensure that the drugs sold toAmerican consumers are safe and effective. Ath-letes and coaches who recommended this sub-stance viewed the news as a source of stress.

The use of THG by athletes, as an alternative toother banned anabolic steroids, was disclosed in2003 by the U.S. Anti-Doping Agency. This sub-stance is closely and structurally related to twoother synthetic anabolic steroids, gestrinone andtrenbolone. Anabolic steroids, which build musclemass, can have serious long-term health conse-quences in men, women, and children.

SOURCE:U.S. Food and Drug Administration. “FDA Statement on

THG,” Available online. URL: http://www.fda.gov/bbs/topics/NEWS/2003/NEW00967.html. Downloadedon June 8, 2005.

Thich Nhat Hanh (1926– ) A VietnameseBuddhist monk, poet, peace activist, and author ofBeing Peace, The Miracle of Mindfulness, and manyother books. Many who are stressed by modernsociety find relaxation and peace in his poetry andwritings, which appeal to people from various reli-gious, spiritual, and political backgrounds. Hispractice of mindfulness helps people of all faiths byhelping them resist and transform the speed andviolence of modern society.

His meditation community in the south ofFrance is an abode of harmony, peace, and ethnicdiversity. An example of his 14 precepts follows:

Do not think that the knowledge you presentlypossess is changeless, absolute truth. Avoid beingnarrow-minded and bound to present view. Learnand practice non-attachment from views in orderto be open to receive others’ viewpoints. Truth isfound in life and not merely in conceptual knowl-edge. Be ready to learn throughout your entire lifeand to observe reality in yourself and in the worldat all times.

SOURCE:Spiritwalk FoundationP.O. Box 1022Thousand Oaks, CA 91358(818) 999-2922http://www.spiritwalk.org

tic An involuntary, repetitive movement of amuscle or muscle groups, mostly affecting the face,shoulders, or arms. Typical tics are blinking,twitching of the mouth, and shoulder shrugging.They are also a characteristic of Gilles de laTourette Syndrome, a disorder of the nervous sys-tem that is characterized by tics and involuntarynoises.

Tics are often the result of a minor psychologi-cal disturbance and may begin during childhood,affecting three times as many boys as girls. Theyare worsened by stress or by drawing attention tothem. Tics appear to release emotional tension, sovoluntary control is of questionable value. Ticsusually stop within a year of onset, but some caseslast to adulthood.

In some individuals, stress-induced tics can beovercome with BEHAVIOR THERAPY, GUIDED IMAGERY,HYPNOSIS, or RELAXATION training.

FOR FURTHER INFORMATION:Tourette Syndrome Association42-40 Bell BoulevardBayside, NY 11361(800) 237-0717 (toll-free)http://www.tsa-usa.org

time management Realistically prioritizing proj-ects and avoiding procrastination. Time manage-ment was a catchword during the 1980s and 1990sas organizations strived to educate employees, par-ticularly middle managers, to avoid the STRESS

caused by a growing need to define business prior-ities and deal with the paper pile-up in their in-boxes. Seminars on time management were oftensponsored by date book and planning calendarmanufacturers who offered products as solutionsto the time management problem. However, it per-sists and is compounded today by staff reductionsthat add responsibilities to existing jobs and bycomputerization that has raised the standards forquality and promises to reduce time and effort,when in fact the opposite is often true.

Another aspect of time management is thegrowing stress of balancing career and family.While this is applicable to both men and women, itis a particular problem for the working mother(both married and single) who continues to havemajor responsibility for running the home and car-

364 Thich Nhat Hanh

ing for the children, as she shares in meeting thefamily’s income needs.

See also PERFECTION; PRESENTEEISM; WORKPLACE.

tipping Gratuities given to service people. Theword tip may have originated as an abbreviation ofthe phrase “to insure promptness.” Tipping usuallyis a sign of a job well done. Waiters and waitresses,taxi drivers, parking attendants, hotel concierges,cruise ship staff, and many others, particularly inthe United States, expect tips and depend on tips aspart of their income.

Many people are stressed over the question ofwho to tip and how much. As a general guideline,table service waitstaff get 15 to 20 percent of thecheck, before tax, taxi drivers get 10 to 15 percent,and up to 20 percent if they help with luggage ormake extra stops, and a parking valet gets $2.Guides on bus tours get 10 to 20 percent of the costof the tour. Individuals who do not expect tips, andoften refuse them if offered, include camp coun-selors, lifeguards, tennis and golf instructors, andnursing home aides.

tiredness See CHRONIC FATIGUE SYNDROME.

TM See MEDITATION; TRANSCENDENTAL MEDITATION.

TMJ See TEMPOROMANDIBULAR JOINT SYNDROME.

tobacco See SMOKING.

toilet training A process of teaching a child touse the toilet for urination and bowel movements.It can be an exercise in stress and anxiety for boththe child and the parent because children generallywill become toilet trained when they are ready.There is little to gain in speeding up the toilet-

training process at a very early age or holding thechild to a rigid, demanding schedule.

Some professionals connect toilet training, if itoccurs when a child is too young or is too harsh inits administration, with later behavior that is obe-dient but resentful. On the other hand, a childwhose toilet training was delayed may develop aself-centered personality.

Even when trained, accidents happen and chil-dren can revert to soiling or wetting, particularlywhen they are anxious or under stress. The bestadvice for parents is to begin toilet training at areasonable age; view the training as an educationalexperience; exhibit a great deal of patience; sup-port performance with praises and rewards; andaccept occasional accidents even after training iscompleted.

See also BEDWETTING; PARENTING.

toxic shock syndrome See MENSTRUATION.

traffic See RANDOM NUISANCES.

transactional analysis (TA) Group or individualtherapy in which the goal is to develop an individ-ual’s identity and independence and help him or herdevelop better COPING skills to interact with others.TA was developed by Eric Berne, a Canadian-bornAmerican psychoanalyst (1910–70), and describedby Thomas A. Harris in the book I’m OK, You’re OK:A Practical Guide to Transactional Analysis (1969).

In TA, all behavior, thinking, feeling, and experi-ence is categorized into three ego states: parent(critical and/or loving), adult (practical and evalua-tive) and child (feelings, such as dependency, fun-loving, and caring). All three states are consideredto serve a valuable purpose. Individuals can learn toidentify which ego state is in control by identifyingboth nonverbal changes and verbal changes such asvoice tone and use of expressions and words.

See also ALTERNATIVE MEDICINE; PSYCHOTHERAPIES.

SOURCE:Harris, Thomas A. I’m OK, You’re OK: A Practical Guide to

Transactional Analysis. New York: Harper & Row, 1969.

Transcendental Meditation (TM) One of theWestern world’s oldest and most scientifically doc-umented techniques known to elicit the RELAX-

Transcendental Meditation 365

TIME MANAGEMENT TIPS TO REDUCE STRESS

• Set realistic goals; don’t overestimate what youcan do.

• Don’t procrastinate.• Establish priorities; make lists.• Pace yourself; set “time-outs.”

ATION response. TM is a revised and simplified formof YOGA and is the method on which most otherMEDITATION techniques are based.

Developed by Maharishi Mahesh Yogi, TM isbased on ancient Hindu writings. It was introducedinto the United States in the early 1960s by HER-BERT BENSON, M.D., who studied people who prac-ticed TM and developed his own methods foreliciting relaxation. His method is described in hisbook, The Relaxation Response.

Typically, a TM meditator spends two 20-minuteperiods a day sitting quietly with eyes closed andattention focused totally on the verbal repetition ofa special sound or mantra. Repetition of themantra blocks distracting thoughts. The effectachieved is better relaxation and relief from stress.TM has also been referred to as mystic union.

See also ALTERNATIVE MEDICINE.

SOURCE:Yogi, Mahesh. Science of Being and Art of Living: Transcen-

dental Meditation. New York: Meridian, 1995.

travel See AIRPLANES; RANDOM NUISANCES; VACA-TIONS.

trends in work hours Annual hours worked perperson have increased in the United States, whilethey have been declining in a number of Europeancountries and Japan. Longer work hours may con-tribute to increased stress for U.S. workers. Annualwork hours in the United States have surpassedJapan’s and are now the longest among wealthyindustrialized countries. Americans work about200–400 more hours (five to 10 more weeks) peryear than workers in France, Germany, Norway,Sweden, or Denmark, according to Paul Landsber-gis, M.P.H., Ph.D., Mount Sinai School of Medicine,who spoke at a forum called “The Way We Workand Its Impact on Our Health,” in Los Angeles, Cal-ifornia, in April 2004.

More workers are working more. Between 1976and 1993, the proportion of men aged 25–54working 49 hours or more hours increased from22.2 percent to 29.2 percent, and the proportion ofwomen aged 25–54 working such long hoursincreased from 5.7 percent to 12 percent. Theincrease for women is due to the greater propor-tion of women who now work for pay and who areemployed in year-around jobs.

Extended Work Hours and Health

According to Landisbergis, extended work hourshave been associated with work accidents andinjuries and with musculoskeletal disorders andpain. Working more than 60 hours per week wasassociated with a 2.75 times greater risk of disabil-ity retirement among Finnish men. Some studies,according to Landisbergis, have found linksbetween long work hours and psychological symp-toms, perceived stress, excessive alcohol use, andsmoking; however, other studies have not foundsuch associations.

Overtime has been associated with fatigue andshorter sleep hours. Insufficient sleep can increasethe activity of the sympathetic nervous system,heart rate, and blood pressure, and there may be aconnection between long work hours and illness.Sleeping less than six hours per day is associatedwith an increased risk of heart disease comparedwith normal sleep hours of seven to eight hoursper day.

Several studies, beginning in 1958, suggestedthat long working hours may increase the risk ofheart disease. Two Japanese studies found an asso-ciation between long work hours and first heartattack in men, with a twofold increase in risk forweekly hours over 60 in one study. Another studyfound an increased risk for either short days (fewerthan seven hours) or long days (more than 11hours) in the previous month.

The impact of overtime on health may begreater for workers in stressful jobs, such as profes-sional driving, or those with poor social relations,or more physically demanding jobs. Shift workersworking more than 48 hours per week experiencegreater mental and physical health problems. Theimpact may also be greater for older workers andwomen, especially if housework is also considered.More research is needed to see if overtimeincreases the risk of gastrointestinal, musculoskele-tal, reproductive system, or immmune systems dis-orders.

See also CHANGING NATURE OF WORK; SHIFT WORK;WOMEN.

SOURCE:Landisbergis, Paul. “Extended Work Hours and Health,”

Forum, “The Way We Work and Its Impact on OurHealth.” Los Angeles, April 2004.

366 travel

trichotillomania See HABITS; HAIR LOSS; HAIR-PULLING.

tricyclic antidepressants See DEPRESSION; PHAR-MACOLOGICAL APPROACH.

truck drivers Those who drive trucks for specificpurposes, such as installing and repairing utilitycompany lines, fighting fires, or towing cars, faceparticular sources of stress. General sources ofstress for truck drivers may include responsibilitiesfor paperwork, preparing receipts for loads, collect-ing payments, maintaining telephone or radio con-tact with supervisors or to receive deliveryinstructions, loading and unloading the truck, per-forming emergency roadside repairs, and carryingout inspections.

Loss of control while driving heavily loadedtrucks on slippery roads is a hazard. Mechanicalfailure can lead to accidents and overturning of aheavily loaded truck. Accidents may occur becauseof lengthy driving periods, night driving, drivingunder unfavorable weather conditions and on badroad conditions. Also, the lure of bonus paymentsmay induce some truck drivers to speed. Driversmay suffer physical and mental fatigue, drowsi-ness, and irregular eating because of long drivinghours. They are exposed to NOISE and may sufferdelayed hearing loss, and are exposed to extremesof heat and cold, which may result in heat stress orfrostbite. Low back pain and pains in their armsand legs may be cause by prolonged driving, sittingin uncomfortable seats, visual discomforts and eyeproblems caused by inadequate illumination andeyestrain, and effects of continued vibration.

Accidents happen to truck drivers while theyare lifting heavy items, changing tires, unfasteningtight ropes, or using various maintenance andrepair tools. They may encounter acute poisoningby exhaust gases, including carbon monoxide.They face fire hazards resulting from or as a resulta road collision or overturning spills and leaks ofinflammable materials.

According to the fourth edition of the Ency-clopaedia of Occupational Health and Safety, truck driv-ers also experience the stress of exposure tochemical toxicity because of hauling toxic andradioactive substances; skin diseases and condi-

tions caused by exposure to chemicals such ascleaning compounds, brake fluids, gasoline, anddiesel oil; and chronic effects caused by inhalinggasoline or diesel fuel fumes and exhaust gasescontaining carbon monoxide, nitrogen oxides, andhydrocarbons.

Smoking inside the cabin of the truck may affectthe health of drivers. Also, truck drivers may bevictims of violent crime because of valuable cargoin their trucks.

See also BACK PAIN; NOISE; SLEEP; SMOKING; VIO-LENCE.

SOURCE:Mager-Stellman, Jeanne. Vol. IV, Encyclopaedia of Occupa-

tional Health and Safety, 4th ed. Geneva: InternationalLabour Office, 1998.

tsunami A Japanese word for “harbor wave.” OnDecember 26, 2004, a giant tsunami hit the coastsof 13 countries in southern Asia, killing more than238,000 people and leaving more than 14,000missing, according to the USGS Earthquake Haz-ards Program. Thailand, Sri Lanka, Indonesia, andIndia were the countries most damaged by thewave. By far the highest death toll was on theremote northern end of the Indonesian island ofSumatra, which suffered the double shock of thequake and the earliest strike of the tsunami;100,000 people died in Indonesia.

The stress on surviving populations in all areashit by the wave was inestimable. Hundreds ofthousands lost loved ones, were made homeless,had their source of livelihood wiped out, had nosource of medical care, and became dependent oncharities for survival.

In the aftermath of the tragedy, survivors fearedanother killer wave. While aftershock earthquakesdid occur far out in the ocean, no wave hit theshores.

Tsunamis are a result of a disturbance on theocean floor. The 2004 tsunami happened after anearthquake hit off the coast of Sumatra, an islandin Indonesia. According to Seth Stein, a geologicalsciences professor at Northwestern University,Evanston, Illinois, “The sea floor moves up as aresult of the earthquake. That is what pushes up anenormous amount of water. The giant waves cantravel for 2,000 miles and grow as large as 30 feetor more when they hit the coast.”

tsunami 367

Warning systems exist elsewhere in the world,but there was no system in place in South Asia.Shortly after the 2004 tsunami, plans were under-way to install a warning system.

SOURCES:Aravind, Adiga, et al. “Magnitude 9.0-Sumatra-Andaman

Islands Earthquake,” Available online. URL: http://earthquake.usgs.gov/eqinthenews. Downloaded onJune 22, 2005.

LeBeau, Emilie. “Killer Waves Devastating but FairlyRare.” Chicago Tribune, January 11, 2005.

tuberculosis A treatable, communicable diseasethat is caused by bacteria called Mycobacteriumtuberculosis. The threat of tuberculosis is a souce ofstress because if TB is not treated, it can be debili-tating or fatal. For many years, it was the leadingcause of death in the United States. After WorldWar II, there was a striking reduction in diseasebecause of more effective treatments. Compla-cency led to disinterest in tuberculosis eliminationand to dismantling of tuberculosis control pro-grams. Basic public health measures were neg-lected, including surveillance activities, contacttracing, outbreak investigations, and case manage-ment services to ensure completed treatment oflatent infection and active disease. This led to theresurgence of tuberculosis in the 1980s when newcircumstances emerged, particularly the HIV andAIDS epidemic, the increase in the rate of mul-tidrug-resistant disease (largely due to incompletetreatment), and expanded immigration to theUnited States from areas with high rates of tuber-culosis. In 2003, there were 14,874 cases in theUnited States.

TB is spread through the air from one person toanother. The bacteria get into the air when a per-son with active TB of the lungs coughs or sneezes.People may breathe in these bacteria and becomeinfected. However, not everyone who breathes inthe bacteria becomes ill. Those without symptomshave latent TB infection and cannot spread diseaseto others. However, some people who have latentTB infection go on to get TB. Those with active TBcan be treated and cured if they seek medical helpsoon enough. With few exceptions, only thosewho have active tuberculosis in the lungs or larynxcan infect others, usually by coughing, sneezing, orotherwise expelling tiny infectious particles that

someone else inhales. People with active TB aremost likely to spread it to people they spend timewith every day, such as family members, cowork-ers, and friends.

Conclusions of a study undertaken by theNational Academy of Sciences and authorized bythe U.S. Congress reflected the changing epidemi-ology of TB, continuing geographic variation in TBcase rates, evolving institutional and publicresponses to TB in the workplace and the commu-nity, and ongoing risk from people with undiag-nosed infectious TB.

TB bacteria usually grow in the lungs and maycause symptoms such as a bad cough that lastslonger than two weeks, pain in the chest, andcoughing up blood or phlegm from deep inside thelungs. Other symptoms of active TB may includeweakness or fatigue, fever, chills, weight loss, andloss of appetite.

A skin test, chest X-ray, or positive sputumsmear or culture can be administered to determinewhether or not a person has a TB infection. Per-sons who believe they may have been infectedmay find relief from stress by getting a negativediagnosis.

See also ACQUIRED IMMUNODEFICIENCY SYN-DROME; HUMAN IMMUNODEFICIENCY VIRUS (HIV);HEALTHCARE WORKERS.

FOR FURTHER INFORMATION:Centers for HIV, STD and TB PreventionDivision of Tuberculosis Elimination1600 Clifton Road NE, Mailstop E-10Atlanta, GA 30333(404) 639-8135http://www.cdc,giv/nchstp/tb/faqs

SOURCE:Field, Marilyn J., Tuberculosis in the Workplace. Washing-

ton, D.C.: National Academy Press, 2001.

Type A personality Refers to hard-driving, fast-paced, and fast-talking individuals characterized byimpatience, aggression, and ambition. They areworkaholics, extremely competitive, and filled withfeelings of ANXIETY, WORRY, ANGER, and HOSTILITY.Type A people constantly worry about problemsthey cannot solve, a self-destructive type of behav-ior that can lead to FRUSTRATION and BURNOUT.

368 tuberculosis

Many of these individuals neglect family respon-sibilities in favor of working and tending to businessinterests. They tend to feel guilty if not working andtake little pleasure in other activities. They may takeon multiple commitments and become preoccupiedwith meeting deadlines. These attitudes lead to stressupon the family and interpersonal relationships.

The Type A personality pattern was found todouble the risk of developing heart disease, partic-ularly in men under the age of 60. The power ofthe Type A behavior pattern to predict heart dis-ease has been shown in many countries, with thedata from Belgium, China, India, Japan, andLithuania. Even when account is taken of otherheart disease risk factors, such as cigarette smok-ing, HIGH BLOOD PRESSURE, and elevated serum cho-lesterol, the Type A pattern appears to contribute afurther risk in many, but not all, people.

Many individuals make efforts to change theirpersonality traits after a serious illness, and, as aresult, relax more and take advantage of theirleisure in enjoyable ways. Studies involving Type Aindividuals show that they can change their behav-ior by learning RELAXATION techniques, developinga sense of HUMOR, and making other life-stylechanges, thus becoming a combination of Type Aand Type B personalities.

A study reported by psychologist D. Ariel Ker-man, Ph.D., in her book, The H.A.R.T. Program: LowerYour Blood Pressure without Drugs, indicated thatresearchers at Duke University found that whenType A personalities participated in a walking/jogging program (three miles per day, three days aweek), their Type A characteristics became lessdominant in their lives.

Type B personality A Type B individual usually haspersonality traits that enable him or her to enjoyactivities that are not necessarily competitive. TypeBs are not particularly goal-oriented, do not con-stantly worry about work, and, when they are work-ing, do so without agitation or sense of urgency.

Relationship of Type A and B Personalities toStress and Employment

Successful executives are often people who canmove back and forth between the Type A and TypeB characteristics, depending on the situation.

These combined personality types are scatteredfairly evenly among top and middle management.

For optimal coping with stress, it seems that acombination of the A and B traits may be best. Theseindividuals can enjoy a balanced life with aspects ofwork, family, love, FRIENDS, recreation, and fun.

See also HOBBIES.

SOURCES:Armand, M., Jr., ed. The New Harvard Guide to Psychiatry.

Cambridge, Mass.: Belknap Press of Harvard Univer-sity, 1988.

Kerman, D. Ariel. The H.A.R.T. Program: Lower Your BloodPressure without Drugs, New York: HarperCollins, 1992.

Pelletier, Kenneth. Healthy People in Unhealthy Places. NewYork: Delacorte Press, 1984.

Type C personality Individuals who have Type Cpersonalities refuse to let any negative feeling show.They usually seem happily in CONTROL and do notexpress emotion, especially regarding ANGER, fear,sadness, or even joy.

Type Cs tend to be patient and cooperative andare highly focused on meeting other people’s needswhile showing little or no concern for their own.Usually, Type Cs tend to stay in stressful situations,such as bad marriages or frustrating jobs, longerthan other people. They don’t recognize their emo-tions and may not even realize when they areunder STRESS. However, their bodies produce stresshormones, including cortisol, which has beenknown to suppress the immune system.

Because they don’t express their emotions, TypeC people do not produce natural opiates, the brainchemicals that have a painkilling effect similar toartificial drugs such as morphine. This, too, reducesthe overall effectiveness of their immune system.

Type C personality 369

TAKING THE STRESS OUT OF TYPE C PERSONALITIES

• Be aware of your emotions; get psychotherapeu-tic help if necessary.

• Be able to express your anger in a constructiveway.

• Become more assertive; learn how to say “no”when you want to.

• Develop RELAXATION techniques that work bestfor you.

According to psychologist Lydia Temoshok,Ph.D., author of The Type C Connection: The Behav-ioral Link to Cancer and Your Health, Type C person-alities often are in the relapse group whencompared with recoveries by individuals in otherpersonality categories.

See also ASSERTIVENESS TRAINING; CODEPENDENCY;DEPRESSION; SELF-ESTEEM.

SOURCE:Temoshok, Lydia. The Type C Connection: The Behavioral

Links to Cancer and Your Health. New York: RandomHouse, 1992.

370 Type C personality

UUFOs (unidentified flying objects) Many indi-viduals and groups of people experience stresswhen they think they see UFOs. Stresses aboutsighting of UFOS are related to the times. Forexample, in the 20th century when space travelbecame a reality, there was increased speculationabout life on other planets, and some came to fearinvasion by alien beings. Movies and fictionalbooks have probably increased these fears formany people. Stress arising from fear of UFOS is anexample of fear of the unknown because no one issure where the UFOs are from or exactly what theyare, if they exist at all.

ulcers See PEPTIC ULCER.

underachievement An individual who is of aver-age or superior ability but performs poorly inschool or at work is an underachiever. Under-achievement may be applied to specific areas suchas arithmetic or reading ability or failure toadvance in a chosen field; it is a source of stress forthe person involved as well as parents, teachersand employers.

Underachievement may be a result of faults inthe academic environment. For example, largeclass sizes or school systems lacking personnel andtechniques to address cases of poor performancemay cause or exacerbate a child’s learning prob-lems. Teachers who have personality conflicts withcertain students can contribute to their poor per-formance by ignoring them. Underachievement,particularly in very bright students, may resultfrom BOREDOM when the teacher does not stimu-late them or challenge their abilities. Average orbright students with short attention spans can alsoappear to be below normal.

Underachievement can also result from a child’srelationship with his/her parents. Parents who arehigh achievers themselves may have unrealisticexpectations for their children. This creates avicious cycle in which the child’s low SELF-ESTEEM

as a reflection of parental attitudes causes his evenpoorer performance. Parents with average abilitieswho produce a child with exceptional intelligencemay not understand and even discourage theirchild’s superior performance. Family problemssuch as DIVORCE, conflict, death, or serious illnessof a parent may cause poor performance.

Children may also become underachieversbecause they are perceived as different and are notsocially well-adjusted to their PEER GROUP. Suchfactors as exceptionally high intelligence, ethnic orreligious difference, a financial status that is farabove or below classmates, or very mature orimmature behavior patterns may set a child apart,limit friendships, and lower school performance.Achievement is also reduced when a child desiresto become a member of the gang so badly thathe/she associates with troublemakers or other stu-dents who perform poorly in school.

See also PERFECTION.

SOURCES:Dejnozka, Edward. “Underachievement,” in American

Educator’s Encyclopedia. Westport, Conn.: GreenwoodPress, 1982.

Thiel, Ann, Richard Thiel, and Penelope B. Grenoble.When Your Child Isn’t Doing Well in School. Chicago:Contemporary Books, 1988.

unemployment Unemployment relates to allpeople who want to work but have been unable tofind jobs—those who have worked but are laid off,recent high school and college graduates, peoplewith disabilities, the poor and uneducated, women

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returning to the workplace after child-rearing, andretirees who need additional income and/or stimu-lation. Because unemployment often means finan-cial hardship, it can cause STRESS not only for thepeople directly involved, but also for their spouses,children, parents, and friends.

Unemployment is also a source of stress forthose who have jobs but are constantly threatenedwith losing them. However, a 1995 poll conductedby Towers Perrin, a management consulting firm,found that most workers are “amazingly stresshardy, pragmatic and coping with the uncertaintiesof corporate America.” The poll also showed thatone measure of a worker’s adjustment to today’sclimate of job instability is that less than half of theworkers surveyed expect to spend their entirecareers with one company. Among those underage 34, only one-third counted on retiring fromtheir present employer.

According to the U.S. Department of Labor, inSeptember 2005, the unemployment rate rose to5.1 percent; in August, it was 4.9 percent. In 2004,the average unemployment rate was 5.5 percent.The Bureau of Labor Statistics reports the unem-ployment rate on a monthly basis. Unemploymentstatistics data are released on the first Friday of themonth for the previous month.

In September 2005, the report indicated unem-ployment rates for most major worker groups—adult men (4.5 percent), adult women (4.6percent), whites (4.5 percent), and Hispanics orLatinos (6.5 percent)—rose in September. The job-less rates for teenagers (15.8 percent) and blacks(9.4 percent) showed little change during 2005.The unemployment rate for Asians was 4.1 per-cent, not seasonally adjusted.

Measures of employment and unemploymentreported in September 2005 reflected both theimpact of Hurricane Katrina, which struck the GulfCoast in late August 2005, and ongoing labor mar-ket trends. Hurricane Rita made landfall during theSeptember data collection period. As a result,response rates to surveys were lower than normalin some areas, but the impact of the storm onmeasures of employment and unemployment wasnegligible, according to the Department of Labor.

For college graduates, the job outlook was strongduring 2005. Employers hired more 2004–05 grad-

uates than they hired in 2003–04 and were offeringnew hires larger salaries than were offered to lastyear’s graduating class. In a survey done annually bythe National Association of Colleges and Employers,more than 75 percent of employers polled nation-wide described the job market as good (56 percent)or very good (22 percent). Many jobs would beavailable in the manufacturing or the service sec-tors, according to the survey. The manufacturingsector predicted an increase in hiring of 12.9 per-cent, compared to the previous year when they saidthey would hire 3.4 percent. Service sector employ-ers planned to hire 12.1 percent more new collegegraduates in 2004–05. Government/nonprofitemployers said they planned to hire 19.8 percentmore new graduates.

According to Leana and Feldman in their book,Coping with Job Loss, “Unemployment as a fact oflife will continue, if not worsen. Current statisticson unemployment and layoffs underestimate thedimensions of the problem. Even with unemploy-ment at six percent, there would still be seven mil-lion people out of work. Because governmentstatistics do not include the discouraged job seekers(individuals who have stopped applying for newpositions) and those who have joined the expand-ing ranks of the permanently unemployed, thesefigures vastly underrepresented the number ofpeople actually out of work.”

Leana and Feldman also reported that amongthe many situational factors influencing how aperson reacts to a stressful life event, such as losinga job, perception of unemployment levels has a“substantial influence.” They write, “The higherworkers perceive the unemployment rates in theircommunities and/or professions to be, the morepessimistic they will be about the prospects forfinding new jobs, especially ones at equal pay.”

Fran Lowry, in Canadian Medical Association Jour-nal, says “Now when unemployment is still animportant problem in many parts of the country[Canada], idle hands are making more work forphysicians. People who are out of work make morevisits to their physicians for a variety of complaints.Areas of high unemployment also report a higherincidence of alcohol use, and more marital andfamily abuse and violence. Because unemploy-ment causes stress, it can have bad health conse-

372 unemployment

quences not only for the unemployed but for thepeople who are closest to them.”

See also GENERAL ADAPTATION SYNDROME; LAY-OFFS; LIFE CHANGE SELF-RATING SCALE.

SOURCES:Leana, Carrie R., and Daniel C. Feldman. Coping with Job

Loss: How Individuals, Organizations and CommunitiesRespond to Layoffs. New York: Lexington Books, 1992.

Lowry, Fran. “Larger Private Sector Role in Health CareNeeded Now, Think Tank Warns.” Canadian MedicalAssociation Journal 154, no. 4 (February 15, 1995):549–551.

unwed mothers A woman who becomes pregnantand delivers a baby out of wedlock is referred to asan unwed mother. She faces many stresses in mak-ing a myriad of decisions. In most cases, she has sev-eral options to consider. She may choose to eitherterminate the pregnancy with a legal ABORTION orhave the child, then choose between single parent-hood or giving the child up for ADOPTION. Dependingon her relationship with the baby’s father, theunwed mother may also choose marriage.

In 1994, approximately one-half of pregnanciesin the United States were unintended, according tothe Centers for Disease Control and Prevention(CDC). The United States has set a national goal ofdecreasing unintended pregnancies to 30 percent by2010. Better forms of contraception, increasing con-traceptive use and adherence, and reducing riskybehavior may decrease unintended pregnancy.

According to Stanley K. Henshaw in Family Plan-ning Perspectives, 54 percent of the unintended preg-nancies concluding in 1994 ended in abortion.Forty-eight percent of women aged 15–44 in 1994had had at least one unplanned pregnancy sometimein their lives. Twenty-eight percent of women aged15–44 have had an unplanned birth. Between 1987and 1994, the rate of unintended pregnancy fell from54 pregnancies per 1,000 women of reproductive ageto 45 per 1,000, a decrease of 16 percent.

Changing social standards and even the exam-ples of celebrities have encouraged unwed mothersto keep and raise their babies, but they still mustface problems of providing financial support, cop-ing with illness and other childhood problemswhile working, and being responsible for child-rearing alone.

Often grandparents participate very actively indecision-making about an out-of-wedlock PREG-NANCY and also in rearing the child. The results oftheir decision-making depend on the flexibility oftheir attitudes. However, if a child is reared byone’s grandparents it adds several stressors to thepicture. The unwed woman and her parents mayhave different ideas of appropriate behavior, withresultant mixed messages for the child. Also, thegrandparents may be at an age and stage of life atwhich having a young child around interferes withtheir long-planned activities.

Pregnancy by Choice: Single Women

In addition to women who unintentionally becomepregnant, an increasing number of single womenchoose unwed motherhood. Some single womenfeel the “biological clock” ticking. That means theyare in their late thirties and want to have a child.These single women may choose adoption or chooseto become impregnated by a man whom they knowbut will not marry, sometimes even retaining afriendly relationship with the man. Still others maychoose artificial insemination, but must recognizethe reluctance of some doctors to inseminate singlewomen and the psychological difficulties of know-ing very little or nothing about the father of theirchild. In all of these cases, even though social stan-dards are changing, unwed mothers still must even-tually cope with the possibility that their childrenmay feel different because they lack fathers. Theymay face many questions growing up in a peergroup of children who have two known parents,even though many of these children will be in step-families or merged families.

See also BIOLOGICAL CLOCK; PARENTING.

urinary incontinence Inability to control theevacuation of liquids from the body. It affects peo-ple of all age groups; an overwhelming number ofthem are women. Incontinence is a cause ofextreme stress for the individual who must copewith a problem that can mean personal FRUSTRA-TION, emotional devastation, social isolation, andphysical discomfort.

Incontinence in Women

According to a study by the National Institutes ofHealth in 1996, 26 percent of women aged 30 to 59

urinary incontinence 373

have experienced episodes of urinary incontinence.The most common form, stress incontinence,occurs when the pelvic floor muscles become weakand no longer support the bladder. Without sup-port, such everyday events as laughing, coughing,or lifting a heavy object apply stress or pressure tothe bladder. In younger women, childbirth oftencauses the weakening of the pelvic floor muscles;estrogen deficiency brought on by MENOPAUSE isoften a cause of this weakness in older women.

Urge incontinence usually occurs during invol-untary bladder contractions, which may be causedby a variety of problems, including urinary infec-tions. Help is available from urogynecologists(gynecologists who are specially trained in prob-lems of the urinary tract). Surgical techniques forcorrecting the problem have advanced dramati-cally in the latter part of the 20th century. Exer-cises are also sometimes prescribed (Kegelexercises) by gynecologists to help restore musclestrength, particularly in milder cases. These exer-cises involve tightening the urinary muscles (as ifto stop urination) repeatedly for 5–10 minutes at atime, with repetitions several times a day.

Urinary incontinence is sometimes a symptom ofnervousness and tension. In many cases, anxietycan affect one’s control over urinating, causing oneto either feel the urge very frequently, or to beunable to void even though the urge seems present.

Understanding the mechanisms for the problemcan help one cope with its attendant stressful fac-tors. A thorough examination by a physician isessential to determine possible physical causes.

Male Incontinence

In males, the cause of incontinence is frequentlyan enlarged prostate gland, which presses on andblocks the duct through which urine leaves thebody. As more urine accumulates in the bladderand dilates it, the bladder cannot hold any moreand it dribbles out. After surgical removal of theprostate, nerves controlling the urinary sphinctermay be damaged, leaving a man incontinent. Radi-ation treatment for cancer also sometimes con-tributes to male incontinence.

Symptoms of a prostate problem in a maninclude having trouble emptying the bladder, get-ting up several times a night to urinate, takinglonger than usual to start and, after starting, notic-

ing a very slow stream, dribbling after finishing,and having the urge to void again just after void-ing, or rectal pain. Any man experiencing thesesymptoms should consult a physician.

Elderly people sometimes develop urinaryincontinence because of neurological reasons, suchas after a stroke or a spinal-cord injury. In somecases, a diuretic prescribed for high blood pressureor heart failure may increase the output of urineand lead to incontinence.

Bladder Training

The National Institute on Aging recommends stepsfor bladder training to help some individuals con-

374 urinary incontinence

HOW TO TAKE THE STRESS OUT OF INCONTINENCE

• Keep a diary for a week or so noting how oftenyou urinate, how often you leak, and what youare doing at the time of the incontinent episode.You may notice a pattern, either in the length oftime you are able to wait between episodes or inthe circumstances surrounding these episodes.

• If you find that you are wet every hour or two,empty your bladder as completely as you canevery 30 to 60 minutes.

• Try to stop the urge to void a unscheduled timesby relaxing or distracting yourself. For example,if you are at home, do a small household taskuntil the urge to urinate passes; then voidaccording to your planned schedule.

• If you become too uncomfortable to wait untilthe scheduled time, go and use the toilet, butvoid again at the next scheduled time.

• Reward yourself for staying on schedule. It takeseffort, practice, and patience.

• Keep a daily log to track your progress. If youare aware of fewer incontinent episodes andhave been able to void on schedule for about aweek, extend the times between voiding periodsby 30 minutes or so each week.

• Extend the intervals until you reach a comfort-able schedule, such as two and a half to threehours between voidings.

• If bladder training doesn’t help, ask your physi-cian about other forms of treatment, such asmedications or surgery. A combination of severaltherapies may be the most helpful.

trol the voiding reflex by teaching them to urinateat scheduled times. When starting the program,the scheduled times are every 30 minutes to onehour. Over a period of six weeks to several months,the time between trips increases.

In the late 1990s, advertisements for adult dia-pers and products to hide the problem of inconti-nence attest to the fact that urinary incontinenceis a common problem, and as the elderly popula-tion increases, the prevalence of the problem willalso increase. According to the Harvard Health Let-ter, many people resign themselves to wearingadult diapers or pads because they mistakenlybelieve that urinary incontinence is a normal partof aging. Others are too embarrassed to bring it upat their doctor’s attention or they fear that inva-sive tests and surgery might result. Those who

have the condition can benefit from discussingthe problem with a caring and knowledgeablephysician.

See also BEDWETTING; STRESS INCONTINENCE.

FOR FURTHER INFORMATION:The SIMON Foundation for ContinenceP.O. Box 815Wilmette, IL 60091(800) 23SIMON (toll-free)(847) 864-3913http://www.simonfoundation.org

Help for Incontinent People (HIP)P.O. Box 544Union, SC 29379(800) BLADDER (toll-free)http://www.shands.org

urinary incontinence 375

Vvacations Breaks from the usual routine, some-times involving travel, sightseeing, visiting friends orrelatives, or remaining at home and just doing noth-ing. Many people who feel very stressed by work orfamily responsibilities look forward to vacations andanticipate relaxation and escape from stress. Accord-ing to The Complete Guide to Your Emotions and YourHealth, “getting away from it all, breaking free fromroutine, can bring a new perspective to old dilem-mas, put a positive charge in your mental outlook,and help to fan those waning embers of enthusiasm.You’ll get to know yourself a little better. When youcome home, you’ll be happier, healthier, and muchmore effective in coping with stress.”

Vacations as a Source of Stress

However, vacations do not always result in stressreduction; they can add to an individual’s stress load.First there is stress that comes from the choice of howto travel: by car, train, ship, or plane, and makingthose reservations can be stressful, too. Packing pres-ents difficulties and ensuring those left behind aretaken care of can give parents many anxious momentsthat continue all through the vacation. When grand-parents take on the responsibilities of caring for thechildren, INTERGENERATIONAL CONFLICTS may result.

Delays of trains and planes, missed connections,and accommodations not up to expectations can be

stressful. Bad weather can do more than dampenone’s spirits, as it affects the enjoyment of manysights. Additionally, interpersonal relationships arereally put to the test on vacations, when friends incouples or other groupings are together every day.These and many other vacation stressors can makeyou wish you’d stayed at home.

See also CLIMATE; HOBBIES; RANDOM NUISANCES;RECREATION.

SOURCES:Curtis, Richard. Taking Off. New York: Harmony Books,

1981.Padus, Emrika. The Complete Guide to Your Emotions and

Your Health: Hundreds of Proven Techniques to HarmonizeMind and Body for Happy, Healthy Living. Emmaus, Pa.:Rodale Press, 1992.

vaccinations One of the main types of immuniza-tion, a protective measure to stimulate or bolsterthe body’s immune system. Usually vaccinationsinvolve an injection administered by a health pro-fessional. Some persons who are phobic about nee-dles and encounters with health professionalsexperience stress when faced with or thinkingabout any type of vaccination.

Vaccination, or active immunization, is a proce-dure in which killed or weakened microorganismsare introduced into the body. These microorgan-isms sensitize the immune system; if disease-caus-ing organisms of the same type enter the bodylater, they are quickly destroyed by the action ofantibodies produced by the immune system or byother immune mechanisms.

Vaccines Are Available for Many Diseases

Some vaccines require several doses, spaced someweeks apart; others require only one dose. The effec-tiveness of vaccines varies from near total protection

376

HOW VACATIONS CAN HELP RELIEVE STRESS

• Afford a release from the daily routine.• Provide opportunities for relaxation.• See new sights, enjoy beauty, and have different

experiences.• Learn new skills; participate in an adventure.• Anticipate pleasure and remember the joy.

in most cases, to only partial or weak protection (fortyphoid or cholera). The duration of effectivenessalso varies from a few months to lifelong.

Vaccines by injection are now available to protectagainst a wide variety of infectious diseases, includ-ing measles, mumps, and rubella, yellow fever,diphtheria and tetanus, cholera, pertussis, rabies,and influenza. The polio vaccine is given orally.

In 2004, a shortage of vaccine for influenzacaused stress for many people, particularly olderadults and those with weakened immune systems.

See also NEEDLESTICK INJURIES; PHOBIAS.

Valium Trade name for an antianxiety drugchemically known as diazepam and in a class ofdrugs called the benzodiazepines. Valium is effec-tive in the management of extreme stress thataccompanies generalized anxiety disorder andpanic disorder in appropriately selected patients. Itis also sometimes used for skeletal muscle relax-ation, seizure disorders, preanesthetic medicationor intravenous anesthetic induction, and for allevi-ating symptoms during alcohol withdrawal.

Valium has been used more extensively in treat-ing more conditions than any of the other benzo-diazepines. The drug is subject to abuse and mayproduce physical dependence after prolonged use.

See also BENZODIAZEPINE DRUGS; DEPRESSION;PHARMACOLOGICAL APPROACH.

vasectomy A surgical operation that makes aman sterile, or unable to father a child. The deci-sion to undergo this procedure is a difficult andstressful one for many men as well as their part-ners. It is chosen by men who have completedtheir families or by men who do not want children.

According to Planned Parenthood Federation ofAmerica, reasons to consider vasectomy include:

• You want to enjoy having sex without causingpregnancy

• You do not want to have a child in the future

• Your partner agrees that your family is complete,and no more children are desired

• You and your partner have concerns about sideeffects of other methods

• Other methods are unacceptable

• Your partner’s health would be threatened by afuture pregnancy

• You don’t want to pass on a hereditary illness ordisability

• You want to spare your partner the surgery andexpense of tubal sterilization—sterilization forwomen is more complicated and costly

Reasons not to consider vasectomy, according tothe Planned Parenthood Federation include:

• You want to have a child in the future

• You are being pressured by your partner, friends,or family; you must want the operation

• You have marriage or sexual problems, short-term mental or physical illnesses, financial wor-ries, or you are out of work; vasectomy is not agood solution for temporary concerns

• You have not considered possible changes inyour life, such as divorce, remarriage, or deathof children

• You have not discussed it fully with your partner

• You plan to bank sperm in case you change yourmind. Sperm banks collect, freeze, and thawsperm for alternative insemination. However,some men’s sperm does not survive freezing.After six months, frozen sperm may begin tolose the ability to fertilize an egg

Vasectomy is used as a means of contraceptionin many parts of the world. A total of about 50 mil-lion men have had a vasectomy, a number thatcorresponds to roughly 5 percent of all marriedcouples of reproductive age. In comparison, about15 percent of couples rely on female sterilizationfor birth control. According to the National Insti-tutes of Health, approximately 500,000 vasec-tomies are performed in the United States eachyear. About one out of six men over age 35 hasbeen vasectomized, the prevalence increasingalong with education and income.

Vasectomy involves blocking the tubes throughwhich sperm pass into the semen. Sperm are pro-duced in a man’s testes and stored in an adjacentstructure known as the epididymis. During sexualclimax, the sperm move from the epididymisthrough a tube called the vas deferens and mix

vasectomy 377

with other components of semen to form the ejac-ulate. All vasectomy techniques involve cutting orotherwise blocking both the left and right vas def-erens, so the man’s ejaculate will no longer containsperm, and he will not be able to make a womanpregnant. After vasectomy, sperm dissolve and areabsorbed into the body.

Vasectomy offers many advantages as a methodof birth control. Like female sterilization, it is ahighly effective one-time procedure that providespermanent contraception. Vasectomy is medicallymuch simpler than female sterilization; it has alower incidence of complications and is much lessexpensive. However, the chief disadvantage ofvasectomy is its permanence. Reversing it is diffi-cult, expensive, and often unsuccessful. Researchis under way for surgical methods that would allowmore successful reversal.

Vasectomy should be undertaken only by menwho are prepared to accept the fact that they willno longer be able to father a child. The decisionshould be considered along with other contracep-tive options and discussed with a professionalcounselor. Men who are married or in a seriousrelationship should also discuss the issue with theirpartners.

Concerns after Vasectomy

After vasectomy, the man will probably feel sore fora few days, should rest for at least one day, andexpect to recover completely in less than a week. Aman can resume sexual activity within a few daysafter vasectomy, but precautions should be takenagainst pregnancy until a test shows that his semenis free of sperm. Usually this test is performed afterthe man has had 10–20 post-vasectomy ejaculations.

Vasectomy does not affect production or releaseof testosterone, the male hormone responsible fora man’s sex drive, beard, deep voice, and othermasculine traits. The operation also has no effecton sexuality. Erections, climaxes, and the amountof ejaculate usually remain the same.

While vasectomy is effective for preventingpregnancy, vasectomy does not offer protectionagainst AIDS or other SEXUALLY TRANSMITTED DIS-EASES. It is important that vasectomized men con-tinue to use condoms, which offer considerableprotection against the spread of disease in any sex-

ual encounter that carries the risk of contracting ortransmitting infection.

See also CONDOMS; CONTRACEPTION.

FOR FURTHER INFORMATION:American Foundation for Urologic Disease1000 Corporate Boulevard, Suite 410Linthicum, MD 21090(800) 828-7866 (toll-free)(410) 689-3990(410) 689-3998 (fax)http://www.afud.org

National Institutes of HealthNational Institute of Child Health and Human

DevelopmentPublic Information and Communications Branch31 Center DriveBuilding 31, Room 2A32Bethesda, MD 20892-2425(301) 496-5133(310) 496-7101 (fax)http://ww.nichd.nih.gov

Planned Parenthood Federation of America434 West 33rd StreetNew York, NY 10001(212) 541-7800(212) 245-1845http://www.plannedparenthood.org

venereal diseases See HERPES SIMPLEX VIRUS; SEX-UALLY TRANSMITTED DISEASES.

verbal slips See SLIPS OF THE TONGUE.

vertigo An illusion that one’s surroundings orself are spinning horizontally or vertically. It isstressful because attacks may come on suddenlyand last for a few moments or even hours. Healthypeople may experience vertigo when sailing, onamusement park rides, or even while watching amovie. Severe vertigo should be investigated by ahealth professional, as it may be a symptom of anunderlying disease.

Vertigo may be caused by normal stimulation ofthe hair cells and other nerve endings in thevestibular (ear) apparatus. Wind or even loudnoises can stimulate these tiny hair cells. According

378 venereal diseases

to the American Medical Association Home MedicalEncyclopedia, vertigo is sometimes erroneouslyreferred to as dizziness, which can also result fromseeing a phobic stimulus or being in a phobic situ-ation, such as looking down from the top of a highbuilding.

Individuals who experience vertigo because ofphobias should sit, lie down, or brace themselves.Sitting with the head between the legs is a goodprecaution against losing consciousness, but itmight not stop the dizziness. Behavior therapiessometimes help people who experience dizzinessbecause of phobic reactions.

Some people who have atherosclerosis sufferfrom vertigo upon sudden movement of the head.Vertigo that comes on suddenly is often treatedwith rest and antihistamine drugs or anticholiner-gic drugs.

See also BEHAVIOR THERAPY; DIZZINESS; PHOBIA.

violence In the early 2000s, violence is a cause ofstress all over the world. People are touched directlyor indirectly by violence, such as TERRORISM, wars,murders, shootings, knifings, beatings, and otheraggressive assaults. Violence can occur everywhere,including in the home, schools, and workplaces.

In the United States, according to the NationalInstitute of Occupational Safety and Health(NIOSH), homicide is the second leading cause ofdeath on the job (second only to motor vehiclecrashes). Homicide is the leading cause of death forworkers under 18 years of age and of workplacedeath among female workers. However, men are ata three times higher risk of becoming victims ofworkplace homicides than women. The majority ofworkplace homicides are related to robberies (71percent) with only 9 percent committed by cowork-ers or former coworkers. Seventy-six percent of allworkplace homicides are committed with a firearm.

There may be a difference between the circum-stances of workplace violence and those of othertypes of homicides. While most workplace homi-cides are robbery-related, less than 10 percent ofhomicides in the general population occur duringrobberies. Also, about 50 percent of all murder vic-tims in the general population were related to theirassailants, whereas the majority of workplacehomicides are believed to occur among people who

are unknown to each other. The Bureau of JusticeStatistics (BJS) analyzed relationship of victims tooffenders for violent acts. They found that femaleworkers were most likely to be attacked by some-one they knew, although only 5 percent of victim-izations were attributed to a husband, ex-husband,boyfriend, or ex-boyfriend.

Prediction and Prevention of Violence at Work

According to Julian Barling, workplace violence canbe predicted with the development of a profile of apotentially violent or disgruntled employee. Possiblecharacteristics include being male, white, age 20–33,a loner, probably an alcohol abuser, and having afascination with guns. Factors such as low self-esteem or a history of aggression in the family, mayalso contribute to violence at work. Stressful feelingsof job insecurity, perceptions that management andsupervision policies are harsh and unjust, electronicmonitoring, perceived crowding, and extreme heatand noise may contribute to acts of violence.

Risks of violence are higher in certain occupa-tions than others, although anyone can becomethe victim of a workplace assault. Occupationswith the highest homicide rates are taxicab driv-ers/chauffeurs, sheriffs/bailiffs, police and detec-tives, gas station/garage workers, and securityguards. Taxicab drivers are at the highest risk, at41.4 per 100,000, nearly 60 times the national

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FACTORS CONTRIBUTING TO VIOLENCE AT WORK

• Working in high-crime areas• Guarding valuable goods or property• Dealing with unstable people• Working with volatile persons in health care,

social service, or criminal justice• Interacting with the public• Exchanging money• Having a mobile workplace, such as a taxicab or

police cruiser• Delivering services or goods• Working late at night or during early morning

hours• Working alone or in small numbers

Source: NIOSH

average of .70 per 100,000. The taxicab industry isfollowed by liquor stores (7.5), detective/protectiveservices (7.0), gas service stations (4.8), and jew-elry stores (4.7).

The majority of nonfatal acts of violenceoccurred in the service and retail trade industries.Specifically, 27 percent occurred in nursing homes,13 percent in social services, 11 percent in hospi-tals, 6 percent in grocery stores, and 5 percent ineating and drinking places.

NIOSH suggests that while no single strategy isappropriate for preventing violence in all work-places, all workers and employers should assess therisk of violence in their workplaces and take appro-priate action to reduce those risks. Many environ-mental, administrative, and behavioral strategiesmay reduce these risks. These include employeetraining, good visibility and lighting within and out-side the workplace, cash-handling policies, staffingpatterns, physical separation of workers from cus-tomers or clients, and security devices. NIOSH alsosuggests that prevention programs in workplacesinclude a system for documenting incidents, proce-dures to be taken when incidents occur, and com-munication between employers and workers.Appropriate referrals to EMPLOYEE ASSISTANCE PRO-GRAMS or local mental health services may be appro-priate for debriefing sessions after critical incidents.

Adolescent violence in workplaces, schools, andthe community is a public health issue with globalrelevance and far-reaching health consequences.According to Susanne Jordan, it impairs the well-being of those involved and makes demands onhealth services. The author contends that violenceprevention in cities in particular relating to youngpeople has relevance for current public healthresearch and action.

Center for the Study and Prevention of Violence

The Center for the Study and Prevention of Vio-lence (CSPV) was founded in 1992 with a grantfrom the Carnegie Corporation of New York to pro-vide informed assistance to groups committed tounderstanding and preventing violence, particu-larly adolescent violence. Since that time, theCSPV’s mission has expanded to encompass vio-lence across the life cycle.

The mission of the CSPV includes collectingresearch and resources regarding causes and pre-

vention of violence, providing information servicesto the public with topical searches on customizeddatabases, and offering technical assistance forevaluating and developing programs for prevent-ing violence.

See also AGGRESSION; DOMESTIC VIOLENCE; HEALTH

CARE WORKERS; STRESS.

FOR FURTHER INFORMATION:Center for the Study and Prevention of ViolenceInstitute of Behavioral Science, Building 9University of Colorado, 442 UCBBoulder, CO 80309-0442(303) 492-3968(303) 449-8479 (fax)http://www.colorado.edu/ibs

SOURCES:Barling, Julian. “Workplace Violence.” Encyclopaedia of

Occupational Health and Safety, 4th ed. Geneva: Inter-national Labor Organization, 1998.

Jordan, Susanne. Vol. 5, International Public Health Series.Lage, Germany: Jans Jacobs Editing Company, 2000.

Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,and Health Issues. New York: Facts On File, 2004.

National Institute of Occupational Safety and Health.Current Intelligence Bulletin 57: Violence in the Workplace:Risk Factors and Prevention Strategies. DHHS (NIOSH)Publication No. 96–100.

volunteerism Involves making the personalchoice to give of time or effort to some cause. Thesecauses include a vast range of concerns, beliefs, atti-tudes, and needs of the diverse American popula-tion. There is a wide variety of options open toindividuals, making it possible for them to findsomething to volunteer for that meets a real need.At the same time, it fits what they like to do or givesthem an opportunity to learn. This “right match” iswhat most often brings fulfillment and may bringrelief from personal stress to the volunteer.

Often during life’s major transitions, such as lossof a loved one, moving to a new community, loss ofa job, or divorce, individuals experience great lone-liness. According to Marlene Wilson, in her book,You Can Make a Difference, during these times, vol-unteering can be a very helpful and healing experi-ence, because it is in the reaching out to others thatpeople “get out” of themselves and remove them-selves from their own personal sources of stress.

380 volunteerism

According to the U.S. Department of Labor,about 64.5 million people age 16 and over did vol-unteer work at least once from September 2003 toSeptember 2004. The proportion of the populationwho volunteered during the year held steady at28.8 percent. In this survey, volunteers weredefined as persons who did unpaid work (exceptfor expenses) through or for an organization.

Volunteers spent a median of 52 hours on vol-unteer activities during the period from Septem-ber 2003 to September 2004. Most volunteerswere involved with one or two organizations.Individuals with higher educational attainmentwere more likely to volunteer for multiple organ-izations than were individuals with less education.Older volunteers were more likely to work mainlyfor religious organizations than were theiryounger counterparts. For example, 45.2 percentof volunteers age 65 and over performed volun-teer activities mainly through or for a religiousorganization, compared with 28.5 percent of vol-unteers age 16 to 24 years. Younger individuals

were more likely to volunteer through or for edu-cational or youth service organizations.

In fall 2005, countless people of all ages volun-teered across the United States, particularly insouthern states, to aid victims of Hurricanes Kat-rina and Rita. Many volunteered through the RedCross.

See also HOBBIES; RETIREMENT.

FOR FURTHER INFORMATION:Volunteer Management Associates320 South Cedar Brook RoadBoulder, CO 80304-0468(720) 304-3637(720) 304-3638 (fax)http://www.volunteermanagement.com

SOURCE:U.S. Bureau of Labor Statistics. “Volunteering in the

United States, 2004.” Available online. URL: http://www.bls.gov/news.release/volun.nr0.htm. Down-loaded on October 4, 2005.

Wilson, Marlene. You Can Make a Difference! Boulder: Vol-unteer Management Associates, 1990.

volunteerism 381

Wwar neurosis Symptoms of anxiety caused by theextreme emotional and physical stresses ofwartime experiences, including bombings, expo-sure to combat conditions, and internal conflictsover killing. Symptoms include ANXIETY, night-mares, irritability, DEPRESSION, and fears. The termhas been generally replaced with POST-TRAUMATIC

STRESS DISORDER. The terms war neurosis or shellshock were commonly used after World War I andinto the mid-20th century.

weapons of mass destruction See NUCLEAR

WEAPONS.

weather See CLIMATE; SEASONAL AFFECTIVE DISOR-DERS; TSUNAMI.

weekend depression A type of DEPRESSION thatsome individuals experience when away from theirwork. Particularly for some individuals who livealone, facing solitude creates a stressful situation.

To overcome the stresses of being alone, as wellas the change in mood from the work week whenone is surrounded by people, individuals canschedule pleasurable activities with FRIENDS or like-minded others so that they will not spend theentire weekend alone. Weekend depression shouldbe distinguished from chronic depression, or SEA-SONAL AFFECTIVE DISORDER, which affects someindividuals during dark months of the year.

See also AFFECTIVE DISORDERS; PHARMACOLOGICAL

APPROACH.

weight gain and loss Weight gain and loss aresometimes related to EATING DISORDERS such asanorexia nervosa or bulimia. Many individualsbecome worried and impose stress on themselvesbecause of concern about their weight. Acceptance

of oneself and one’s body shape contributes toreduction of stress.

Concern about one’s weight is often related toone’s mental perception of BODY IMAGE and SELF-ESTEEM. Some individuals who fear gaining weightpractice bulimia, the “bingeing and purging” syn-drome, in which they gorge themselves and theninduce vomiting.

See also DIETING.

Weil, Andrew (1942– ) American physician andauthor; known for his work in promoting alterna-tive therapies and his books dealing with MIND-BODY

CONNECTIONS. Among his best-selling books thatinclude tips for beating stress are 8 Weeks to OptimumHealth and Spontaneous Healing. He advocates self-administered, commonsense cures such as eatingless fat, getting more exercise, and reducing stress.He also suggests herbalism, acupuncture, naturopa-thy, osteopathy, chiropractic, and hypnotism.

See also ALTERNATIVE MEDICINE.

West Nile virus (WNV) An infection carried bymosquitoes. People get WNV from the bite of amosquito that is infected with the virus. The threatof WNV is a source of stress for many people, par-ticularly in certain areas of the United States. Mos-quitoes become infected with WNV when theyfeed on infected birds that carry the virus in theirblood. Once infected, the mosquito can spread thevirus to humans and other animals.

Anyone can become infected with WNV, butpeople over age 50 and those with diseases such asheart disease or cancer, or immunocompromisedpersons, may be more at risk for serious illness.Most human cases occur in north America in thelate summer and early fall. In tropical climates,WNV can be transmitted year-round.

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WNV has been found in Africa, the Middle East,and in parts of Europe, Russia, India, and Indone-sia. WNV may have entered the United Statesthrough an infected traveler, bird, or mosquito andfirst appeared on the East Coast of the UnitedStates in 1999. The virus has since spread and cannow be found in nearly every state.

Symptoms and Treatment

Most people infected with WNV have no symptomsand never become ill. However, estimates indicatethat 20 percent of all people who become infectedwill develop West Nile fever. Some people maybecome ill three to 15 days after being bitten by aninfected mosquito. Symptoms may include fever,headache, and body aches. More severe symptomsmay be a high fever, stiff neck, confusion, and mus-cle weakness. Symptoms of severe infection (WestNile encephalitis or meningitis) include stupor, dis-orientation, coma, tremors, convulsions, muscleweakness, and paralysis. Estimates are that one in150 persons infected with WNV will develop amore severe form of the disease.

There is no specific treatment or vaccine forWNV. Those who believe they have been infectedshould contact their physician.

Avoiding WNV

According to the National Center for InfectiousDiseases, there are steps to take to avoid being bit-ten by an infected mosquito.

• Check areas around the outside of houses forplaces that mosquitoes may breed.

• Remove old tires, tin cans, buckets, drums, andother containers that can hold water from out-door areas.

• Empty plastic wading pools weekly or storeupside down when not in use.

• Change water every few days in bird baths.

• Limit time outdoors when mosquito activity isheaviest (dusk to dawn).

• If outside, wear socks, shoes, long pants, and along-sleeved shirt. Light colored, loose-fittingclothing is best.

• Use repellents containing 25–35 percent DEET(N,n-diethyl-meta-toluamide).

• Use mosquito netting over infant carriers andstrollers.

• Store boats covered or upside down.

• Keep weeds and grass cut short.

• Install or repair window screens to keep mos-quitoes out.

• Keep gutters around the house clean and ingood repair.

• Know that some mosquito control methods suchas bug zappers are not effective in controllingbiting mosquitoes.

Dead Bird Locations

The presence of dead crows and blue jays in a com-munity is a sign of possible WNV in the area. If youfind a dead bird, particularly a blue jay or crow,report your sighting to the local health depart-ment. Their staff will tell you if you need to pick upthe bird for laboratory testing. Information regard-ing proper methods of handling and disposing of adead bird is also available from local health author-ities. (If you pick it up, use gloves or a shovel, dou-ble-bag the bird, and wait for instructions.)

Blood Transfusions

The Centers for Disease Control and Preventionbelieves that the virus can be spread through organtransplantation or blood transfusion. To preventthe spread of the virus through blood, all blooddonated in the United States for transfusion isscreened for the presence of West Nile virus. Thereis also evidence that the virus can be spreadthrough breast milk, and from the mother to thefetus while still in the uterus.

FOR FURTHER INFORMATION:Centers for Disease ControlDivision of Vector-Borne Infectious DiseasesP.O. Box 2087Fort Collins, CO 80522http://www.cdc.gov/ncidod/dvbid/westnile

wet dreams Nocturnal emissions from the penisduring sleep. Nocturnal emissions or ejaculationsare part of normal adolescent development and arecaused by accumulated normal tensions that findrelease while the young man is asleep. For a young

wet dreams 383

man who does not understand the normalprocesses of PUBERTY, these events can be stressful.A solid foundation of sex education is essential.

wheezing Coughing and shortness of breath,usually related to ASTHMA. The breathless feelingcauses stress for the sufferer as well as theonlooker. Often individuals can identify a specificchemical compound, dust, or fume that causescoughing, shortness of breath, or wheezing. Ifsomething unique to a particular workplace orother site causes coughing or wheezing, the diag-nosis may be asthma or occupational bronchitis.

In classic allergic occupational asthma, a specif-ically inhaled substance from the workplace “sen-sitizes” the worker’s airways. Later exposure to thesame vapor, dust, or fume can cause coughing,wheezing, or difficulty in breathing, all symptomsof an asthma attack.

Many workers who inhale organic dusts areexposed to many types of microbes and other sub-stances associated with plants, trees, animals, andcrops. Some workers experience asthma symp-toms, while other symptoms mimic pneumonia,with fever and shortness of breath. Most of theorganic-dust reactions are allergic in nature andonly affect some of the exposed population. Largeamounts of inhaled dust are more likely to causeactual irritation of the lung passages. Genetic andadditional environmental risk factors also play apart. Some 250 substances can cause occupationalrespiratory disorders, including chemicals, enzymes,animal proteins, and plant allergens.

According to Brobson Lutz, in New Orleans Mag-azine, treatment for wheezing or asthma is thesame whether work-related or not. It is best forpeople to avoid fumes and dusty areas as much aspossible. For continuous exposures, workplacemodifications and engineering controls are morepractical than masks and respirator equipment.

For those affected with occupational lung aller-gies, the stressful consequences from persistentexposure range from chronic cough to permanentlung damage. If it is not possible to avoid or safelyreduce exposure to an asthma-causing dust orfumes, a job change or move may be the onlyalternative.

See also ALLERGIES; STRESS.

SOURCES:Kahn, Ada P. Encyclopedia of Work-Related Injuries, Illnesses,

and Health Issues. New York: Facts On File, 2004.Lutz, Brobson. “Wheezing While You Work: Occupa-

tional Allergies Are Nothing to Sneeze At,” NewOrleans Magazine, 36, no. 3 (December 2001): 30(2).

“white coat” hypertension See HIGH BLOOD

PRESSURE.

women Today, both women and men face dailystresses about family, relationships, hassles at workand in traffic, loan repayments, and uncertaintiesabout the future. However, recent roles of womenin society were homemaking and child-rearing. Inthe latter part of the 20th century these roles wereexpanded to include increasing participation inbusiness, the military, government, and other fieldspreviously considered “men’s fields.” The change inwomen’s roles has led in many cases to stress forwomen and for the men in their lives, as competi-tion between the sexes increases, jealousies overbeing the provider in the family occur, and malesfeel an increasing loss of power and CONTROL overwomen in their personal and professional lives.

For different women and at different times,stressors may vary; they may be emotional, physi-cal, or environmental. An emotional stressor maybe a RELATIONSHIP concern, a physical stressor maybe an illness or pain, and an environmental stressormay be noise or air pollution. The same stresses thata woman meets with equanimity at one time maybe overwhelming and a threat to her wellness atanother. In reacting to stressful situations, womenhave choices: be overwhelmed, adjust, or adapt.Without adjustment or adaptation, cumulativedemands may lead to lower resistance to illness.

Statistically, women live longer than men. Para-doxically, women report more sick days and minorphysical illnesses, and are more prone to ANXIETY

and DEPRESSION than men; women make more vis-its to physicians’ offices. For many women, somecomplaints such as stomach and digestive problems,HEADACHES and sleeping difficulties may be tradedto the cumulative effect of personal stressors.

Gender-Related Stressors

Different stressors occur at different stages of awoman’s life; responses vary between women.

384 wheezing

Some young women are concerned about physicaland breast development, MENSTRUATION, and thenPREGNANCY and PARENTING. Young women face DAT-ING in this age of an epidemic of SEXUALLY TRANSMIT-TED DISEASES and ACQUIRED IMMUNODEFICIENCY

SYNDROME (AIDS) and contemplation of MARRIAGE

at a time when 50 percent of marriages end inDIVORCE. During their twenties, thirties, and forties,some women’s stressors may include the BIOLOGICAL

CLOCK, INFERTILITY, child care, balancing home andwork, and the GLASS CEILING in the corporate world.

Many midlife women find MENOPAUSE stressful.Conflicting research reports on use of hormonereplacement therapy make arriving at an informeddecision a real dilemma. Midlife women also mayface caring for their own ELDERLY PARENTS and inmany cases the parents of their partners. At all ages,many women cope with being alone if they do notmarry, as well as after divorce or widowhood.

Additional contemporary societal stressors alsoinclude delayed marriages, two-career relationships,later childbearing, single parenting, remarriages andreconstituted families, adult children returninghome, coping with a husband or partner’s loss of job,husband’s early retirement, one’s own unplannedretirement, chemical dependencies of self or partner,DOMESTIC VIOLENCE, crime victimization, rising costsof living, and proposed cuts in Medicare. In the year2000 more than 19 million women were over theage of 65 and many of them had not planned for thefinancial implications of old age.

More Stress: Men or Women?

Until women went to work in great numbers,there was a popular notion that working menexperienced more stress than women. At the sametime, men were viewed as deriving satisfaction andSELF-ESTEEM from their work. Now nearly half ofAmerica’s workforce is female; while many may bederiving satisfaction from work, others experiencegender-related work stressors. Women may be inlow-pay jobs or in situations in which they havelittle AUTONOMY or receive SEXUAL HARASSMENT

from the bosses and colleagues. Wives or singlemothers who now have the dual role of balancingcommitments to family and work are often tired,and may feel inadequate because they can’t live upto their own expectations on all fronts.

At home, women may be shouldering thegreater proportion of household chores and childcare responsibility, despite an increasing numberof “househusbands” and cooperative partners. Formany women, home is not always the place torelax. A team from Cornell Medical Center in NewYork City found that men’s blood pressure tendedto fall as soon as they went home, while women’sblood pressure, particularly that of working moth-ers, experienced no decline and in some casesrose. Researchers at the Karolinska Institute inStockholm, Sweden, found that men andwomen’s blood pressures varied with their emo-tions. The men’s tended to rise most sharply whenthey were angry, while the women’s rose whenthey were anxious.

The term “Type A personality,” relating to ahard-driving behavior pattern, was originallyapplied to men. It was thought that the effects ofsuch behavior in men led to high blood pressureand heart disease. Some women exhibit Type Apersonalities, but it is more prevalent in employedwomen than among women who work at home.According to the American Heart Association, theincidence of heart disease in women is increasinglyrecognized, and heart problems are the number-one killer of postmenopausal women.

Traditionally, many women have been socializedto be the family nurturers and caregivers. They maybe conciliatory rather than assertive (Type C per-sonality). Some hide their anger rather than pro-voke an argument. They are haunted with guiltfeelings, such as “I should.” From advertising andmedia messages, many are dissatisfied with theirBODY IMAGE, accounting for money spent on faddiets and weight-loss programs that do not work.

Coping Successfully with Stress

There are a variety of effective means of COPING forwomen on an everyday basis as well as during par-ticularly stressful situations. Techniques includeMEDITATION, use of audiotapes for progressive relax-ation, GUIDED IMAGERY, BIOFEEDBACK, JOURNALING,YOGA, and MASSAGE THERAPY. Jogging, walking,swimming, tennis, bicycle riding, dancing, and aer-obic exercise groups also are effective. They areactivities that use up the extra adrenaline stimu-lated by stress, help distract from stressors, leavemuscles relaxed, and increase a sense of control.

women 385

Women who cope well with stress have learnedto be more assertive, to say no when they want to,to prioritize demands on them, make choices, andleave guilt feelings behind. They develop a morepositive self-image regarding their bodies, andmore realistic expectations of their roles at workand within the family. Increasingly, women arerealizing that PERFECTION on all fronts can’t beachieved, but adequate planning and preparationwill move them in that direction. They solve prob-lems instead of worrying about them; some prob-lems may be best handled by acceptance whileothers may require action. They learn to anticipatecertain predictable stressors, such as upcoming hol-idays or starting a new job. They fight fatigue andkeep their energy high with good nutrition andregular exercise. They learn to find HUMOR in themundane. They avoid burnout by taking time totake care of themselves.

According to the U.S. Census Bureau 2000 data,of the U.S. population of nearly 3 million, therewere 14,409,25 males over age 65 and 20,582,128females over age 65. Males of this age make up 5.1percent of the total population, and females com-prise 7.3 percent. Approximately 62 percent ofpeople age 70 or older are married and living withtheir spouse and about 28 percent are widowed.Only 3.1 percent were never married, and 5.5 per-cent are divorced or separated. By age 90, thenumber of persons who are married and livingwith a spouse declines to 12.7 percent, and thenumber of widowed people increases to 76.5 per-cent. Because of longer life expectancies ofwomen, there is a higher incidence of widowhoodamong women.

Women are the largest subgroup of the elderlypoor. The International Longevity Center reportedthat as of 2000, one-fifth of all women over 65who lived alone, whether widowed, divorced, ornever married, were below the poverty line andrepresented 70 percent of all older people living inpoverty.

Many women were either lifelong homemakersor changed jobs frequently as they cared for chil-dren, parents, or both and missed out on promo-tions and pay raises. At a time when some olderadults receive pensions from their former jobs,many women do not. High costs of health care,

prescription drugs, housing, and transportationtake a large part of their savings.

Women, Stress, and Job-Related Injuries

According to a 1998 U.S. Department of Labor,Bureau of Labor Statistics, survey (U.S. Depart-ment of Labor, Bureau of Labor Statistics, Sum-mary 98-8, July, 1998), women experience fewerjob-related injuries and deaths than men. Womenincurred less than one-tenth of the job-related fatalinjuries and about one-third of the nonfatalinjuries and illnesses that required time off to recu-perate in the period 1991–96. During this period,women accounted for slightly less than 50 percentof the nation’s workforce.

One explanation for this discrepancy is thatwomen are employed in relatively less dangerousjobs. Few women work in high-risk jobs wherework is generally performed outdoors. However, asmore women enter high-risk occupations, theirrisk of injury or death may increase.

Fatal Injuries

Of the 32,000 job-related fatalities that occurredduring the period 1991–96, slightly more than2,500 (8 percent) occurred to women. Two-thirdsof these work injury deaths were attributed tohomicides and highway incidents.

Homicides. Women accounted for 20 percent ofall job-related homicides in the period 1991–96.Most homicide victims were shot; women werestrangled or beaten to death relatively more oftenthan men. Two-thirds of the homicides occurred inthe retail and service industries. About one-third ofthe women who were murdered on the jobworked in sales occupations either as cashier,supervisor, proprietor, or clerk. Robbery was theprimary motive for these fatal assaults. More than25 percent of the female victims of job-relatedhomicides were assaulted by people they knew(coworkers, clients, spouses, or friends). About 16percent of female homicides resulted from domes-tic disputes that spilled over into the workplace.

Highway vehicle crashes. Job-related highwayincidents claimed the lives of 650 women duringthe period 1992–96, a little more than 2 percent ofall fatalities during the period. Health care andsocial service workers accounted for almost 20 per-cent of these deaths, about the same number as

386 women

motor vehicle operators, such as truck and busdrivers and driver-sales workers.

Other causes of fatalities. About 15 percent of thefatal injuries to women resulted from other trans-portation-related incidents, such as aircraft crashesor being struck by a vehicle. Falls accounted for 5percent of the job-related fatalities among women,compared with 11 percent for men. Another 5 per-cent of female workers’ fatalities resulted fromcontact with objects and equipment, such as beingcrushed in running machinery or struck by afalling object. Death by exposure to harmful sub-stances or environments, such as electrocutions,drownings, and the inhalation of chemicals,accounted for 4 percent of the fatalities amongwomen workers. Two percent of the women killedat work were victims of fire and explosions.

Nonfatal Injuries and Illnesses

Women incurred slightly more than a third of the2 million cases of work-related injuries and ill-nesses resulting in days away from work thatoccurred among private-sector wage and salaryworkers in 1995.

Sprains and strains among women accountedfor 45 percent of their job-related injury and illnesscases, compared to 42 percent among men.Women accounted for more cases than men ofcarpal tunnel syndrome, tendinitis, respiratory sys-tem diseases, infectious and parasitic diseases, anddisorders resulting from anxiety or STRESS.

Almost half of the female workers’ injuries andillnesses resulted from bodily reaction or exertion,such as overexertion in lifting or pushing andrepetitive grasping of hand tools. Falls, primarilyon the same level, and contact with objects (suchas being struck by falling objects, striking againstobjects, or getting caught in running equipment)each accounted for about 20 percent of the job-related injuries among women.

Women were more likely to be assaulted thanmen and accounted for about 65 percent of thenearly 123,000 reported assault-related injuries.The manner in which women were assaulted var-ied. About 70 percent resulted in days away fromwork and occurred in the service industries, suchas nursing homes, social services, and hospitals.Another 20 percent occurred in retail industries,the most vulnerable workers being female stock

handlers who incurred about 25 percent of thoseassaults.

See also AGING; DOMESTIC VIOLENCE; HAVING IT ALL;INTIMACY; WOMEN’S MOVEMENT; VIOLENCE; WORKING

MOTHERS.

FOR FURTHER INFORMATION:U.S. Department of LaborBureau of Labor StatisticsPostal Square Building, Room 28502 Massachusetts Avenue, NEWashington,DC 20212-0001http://stats.bls.gov/oshhome.htmcfoistaff@bls.gov

SOURCES:U.S. Department of Labor, Bureau of Labor Statistics,

Issues in Labor Statistics, “Women Experience FewerJob-Related Injuries and Deaths than Men.” Availableonline. URL: http://www.bls.gov/opub/ils/pdf/opbils23.pdf. Downloaded on June 17, 2005.

Genasci, Lisa. “For Many Women, the Ending Is Not SoHappy.” Chicago Tribune, August 30, 1995.

Kahn, Ada P. “Woman and Stress.” Sacramento Medicine,September 1995.

women’s movement Activities undertaken dur-ing the 1960s, 1970s, and early 1980s to elevateWOMEN from inferior positions in business, the pro-fessions, and social clubs, and to gain equal paywith men in the same work. Additionally, activitiesduring the women’s movement were geared tohelp women gain freedom from the sexual doublestandard, and from total responsibility for childrearing and homemaking. The women’s move-ment confronted stresses on women entering pre-viously male-dominated domains and on men whofor the first time experienced working with, study-ing with, or socializing with women.

The movement worked toward less overalldominance by men and against the traditionalstereotype of women as dependent, passive, andfragile. It has enabled a generation of women tofollow career paths not open to their mothers orgrandmothers, to enjoy motherhood at the sametime, and to participate in previously male-domi-nated professional and social organizations. At thesame time, WORKING MOTHERS and women profes-sionals have experienced unique stresses in theirlives.

women’s movement 387

The SEXUAL REVOLUTION, during which womenbegan to express sexuality with an increase in pre-marital and extramarital relationships,was an out-growth of the women’s liberation movement.

Significant steps in the women’s liberationmovement include publication of The Feminine Mys-tique (1963) by Betty Friedan, which exploded themyth of the happy housewife, passage of the EqualPay Act by the U.S. Congress in 1963, the foundingof the National Organization for Women (1966),the first accredited women’s studies course at Cor-nell University (1969), publication of Sexual Politics(1970) by Kate Millett, the founding of the NationalWomen’s Political Caucus (1971), the historic Roe v.Wade decision by the U.S. Supreme Court legalizingabortion (1973), the election of the first womangovernor (Ella Grasso, Connecticut, 1974), the dec-laration of 1975 as the International Year of theWoman by the United Nations, the First NationalWomen’s Conference in Houston (1977), themarch in 1978 of nearly 100,000 women in Wash-ington to support the Equal Rights Amendment,the appointment of Sandra Day O’Connor as thefirst woman associate justice of the U.S. SupremeCourt, and the candidacy of Democrat GeraldineFerraro for vice president in 1984.

The International Women’s Conference heldin Beijing in 1995, which brought together manywomen from developing as well as developednations, was another phase in the women’smovement.

SOURCE:Cott, Nancy F. The Grounding of Modern Feminism. New

Haven: Yale University Press, 1989.

workers’ compensation Laws that provide bene-fits for workers injured or killed in work-relatedsituations; benefits are also provided for depend-ents of workers. Some laws also protect employersand fellow workers by limiting the amount aninjured employee can recover from an employerand by eliminating the liability of coworkers inaccidents. Understanding these benefits and mak-ing claims may be a source of stress for those whobelieve they should be covered and reimbursed.

To relieve the stress involved in understandingwhat benefits are available and making claims,workers should talk with their benefits supervisors

to learn about applicable laws. For example, theFederal Employment Compensation Act providesworkers compensation for nonmilitary federalemployees. Many of its provisions are typical ofmost worker compensation laws. Compensation isawarded for disability or death sustained whileperforming the employee’s duties but not causedwillfully by the employee or by intoxication. Theact provides compensation for survivors ofemployees who are killed. The act is administeredby the Office of Workers’ Compensation Programs.

The Federal Employment Liability Act (FELA),while not a workers’ compensation statute, pro-vides that railroads engaged in interstate com-merce are liable for injuries to their employees ifthey have been negligent. The Merchant MarineAct (the Jones Act) provides seamen with the sameprotection from employer negligence as FELA pro-vides railroad workers.

Congress enacted the Longshore and HarborWorkers’ Compensation Act to provide workers’compensation to specified employees of privatemaritime employers. The Office or Workers’ Com-pensation Programs administers the act.

The Black Lung Benefits Act provides compen-sation for miners suffering from black lung (pneu-moconiosis). This act requires liable mine operatorsto pay disability payments and establishes a fundadministered by the secretary of labor providingdisability payments to miners in cases where themine operator is unknown or unable to pay. TheOffice of Workers’ Compensation programs admin-isters the act.

The Workers’ Compensation Act in California isan example of a comprehensive state compensa-tion program applicable to most employers. Thestatute limits the liability of the employer and fel-low employees. California also requires employersto obtain insurance to cover potential workers’compensation claims and sets up a fund for claimsagainst which employers have illegally failed toinsure.

See also STRESS; STRESS MANAGEMENT.

FOR FURTHER INFORMATION:Legal Information InstituteCornell Law SchoolMyron Taylor HallIthaca, NY 14853

388 workers’ compensation

SOURCE:Treaster, Joseph B. “Cost of Work Injuries Soars across

U.S.” New York Times, 23 June 2003.Adapted from: Legal Information Institute, “Worker’s

Compensation: An Overview,” Available online.URL: http://www.law.cornell.edu/topics/workers.compensation.htm. Downloaded on June 17, 2005.

work flow See CHANGING NATURE OF WORK;WORKPLACE.

work hours Annual work hours in the UnitedStates have surpassed those in Japan and are nowthe longest among wealthy industrialized coun-tries, while annual hours worked per person havebeen declining in a number of European countriesand Japan. According to Paul Landsbergis, M.P.H.,Ph.D., of the Mount Sinai School of Medicine,Americans work about 200–400 more hours (fiveto 10 more weeks) per year than workers inFrance, Germany, Norway, Sweden, or Denmark.Longer work hours contribute to family stressbecause of the absence of the worker and fatiguewhen the worker is present.

For married couples with children in which thehead of household is aged 25–54, between 1979and 2000, annual hours increased by 388, or 11.6percent. The large increase in work hours “pro-vides compelling evidence of some of the stressesfacing families trying to manage their work andfamily lives,” said Landsbergis.

See also CHANGING NATURE OF WORK.

working mothers Many working MOTHERS arestressed by role conflicts between home andemployment responsibilities. Despite these con-flicts, they have feelings of self-fulfillment andrealize economic advantages. Many find coopera-tion from their husbands or other family membershelpful.

Working mothers are a major issue for employ-ers. About 60 percent of all women are working,compared with nearly 75 percent of all men.According to the U.S. Bureau of Labor Statistics,the long-term increase in the female labor forcereflects the greater frequency of paid work amongmothers. Women now account for 47 percent ofthe labor force, up from 40 percent in 1975. In

2003, 71.1 percent of mothers with children under18 were working. Of those, more than 53 percentwere mothers of infants.

According to the Bureau of Labor Statistics,working mothers tend to earn less lifelong paythan men, due to some combination of loss of jobexperience, less productivity at work, and a ten-dency to seek lower-paying mother-friendly jobs.

Since 1985, Working Mother magazine hasassembled a list of family friendly companies.Those named in October 2005 to the “100 best” listregarding working women exhibited flexiblescheduling, child care options, time off for newparents, and many other perks.

An example was McGraw-Hill, which in 2004introduced backup dependent care for its 13,500-plus employees in North America. Employees canuse 100 hours of backup care per year at a fractionof the actual cost: $2 per hour per child for drop incare and $4 per hour for in-home care, withMcGraw-Hill paying the balance. The program alsocovers elder care. At McGraw-Hill, flexibilityincludes options of flextime, compressed work-weeks, and job sharing.

Allstate Insurance Company was recognized forits family friendly work/life policies and advance-ment opportunities for women. Allstate’s policiesencouraged effective use of flexible work arrange-ments to help meet objectives of the business aswell as needs of employees. Many Allstate workingmothers choose flexible work options, such aschanges in workday schedule, job sharing,telecommuting, compressed workweeks, and part-time status.

The inclusion of Pfizer Inc. on the list was basedon the company’s commitment to advancingwomen, its total compensation for working moth-ers, and its time-off policies for new parents andcaregivers. According to Sylvia Montero, senior vicepresident of human resources, “Helping our col-leagues live balanced, integrated lives is somethingwe take very seriously, and we are committed toproviding opportunities to manage the life-workbalance, including care and referral programs, on-site facilities to manage health and options to carefor children and other family members.”

DuPont’s appearance on the 100 best list in 2005was partly due to the fact that the firm makes flex-

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time widely available. More than half of DuPont’s28,000 full-time employees took advantage of it.The company’s on-site child care center looks afterabout 150 infants, toddlers, and preschoolers at atime. Parent support services at headquartersinclude health fairs and family nights, in whichemployees and their children participate in com-pany-sponsored activities. In addition to 26 weeksof maternity leave, with eight weeks fully paid,employees can take a six-month unpaid familyleave for paternity, adoption, placement of a fosterchild, or to care for a sick family member.

Because there are so many working mothers,DAY CARE facilities have become widespread. Formany women, placing children in day-care facili-ties is a stressful and GUILT-ridden experience,which they must work through to come to termswith the reality of trying to remain in the workforce as well as raise a family.

See also COPING; HAVING IT ALL; PARENTING;WOMEN’S MOVEMENT.

SOURCE:Evans, Carol. “100 Best Companies.” Working Mother 28,

no. 10 (October 2005): 71–180.

workplace Stress at the workplace occurs for mostpeople in varying degrees and for many varied rea-sons. Some people are stressed because they havetoo much work, while others are stressed because

they are bored due to not enough work. cOWORKERS

and interactions with coworkers and the boss canlead to stress. Additional sources of stress includeenvironmental situations, such as noise, poor light-ing or lack of fresh air, as well as the FRUSTRATION ofbeing underpaid and overworked.

Contemporary technological stressors at theworkplace range from back strain due to sitting ata computer terminal, to REPETITIVE STRESS INJURIES

(CARPAL TUNNEL SYNDROME) from use of computers,to standing on a manufacturing assembly line.

Each occupation carries with it particularstresses, many of which are hidden by the employ-ees. For example, many secretaries may resentdoing the same chores over and over. Data proces-sors may be bored with their work. Physicians findregulations imposed on them by managed carecompanies and insurance companies stressful.Accountants find the tax preparation season par-ticularly stressful, while air traffic controllers areunder constant pressure every minute while atwork. LAWYERS must meet the demands of theirclients as well as their superiors in their law firms.

The issue of CONTROL is an important one indetermining level of workplace stress. Those whofeel they have more control over their situations,such as flexibility with work schedule, or decision-making about setting their own deadlines, mayexperience less stress than those who have nosense of control. PERSONAL SPACE is another issue.Workers who feel they have no privacy may feelmore stressed than those who have offices orspaces with doors.

Jobs with fairly controllable situations includecomputer programmer, writer, artist, appliancerepairperson, and truck driver. While these jobscan be very demanding, the minute-to-minutepace may be unhurried. Certain positions may beslow-paced but with uncontrollable factors. Theseinclude janitor, security guard, and bus driver.Fast-paced and controllable professions includesome physicians in private practice, business exec-utives, and city administrators. Fast-paced anduncontrollable professions include waiter, cashier,firefighter, and nurse.

Job mismatches can lead to stress. For someindividuals, leaving the job is the solution. How-ever, for many, that solution is not practical. Mostpeople cannot walk away from their professions or

390 workplace

TIPS FOR WORKING MOTHERS TO REDUCE STRESS

• Prioritize your home and work projects.• Develop realistic expectations for yourself and

others.• Delegate projects to others in the family.• Know that you have choices.• Identify your key stressors and ways to reduce

them.• Learn to say NO to excessive demands at home

or work.• Ask for help when you need it.• Realize that perfection is not a realistic goal.• Make time for your own physical, emotional,

and spiritual needs.• Find humor in everyday situations; learn to

laugh more.

businesses. The more realistic solution is learningto cope with the current pressures.

Coping with Workplace Stress

Some of the stresses of workplace relationships canbe eased by taking certain actions. Listen carefullywhen someone is speaking to you instead of plan-ning your response as they are speaking. CarefulLISTENING can help prevent misunderstandings,which might make you angry. Additionally, ask forFEEDBACK, which is another person’s perception ofwhat you are doing or saying. Feedback is not eval-uative or judgmental. Speak with your coworkersor superiors at an appropriate place and time. Donot initiate a difficult conversation without appro-priate privacy. Finally, always ask for a clear state-ment of performance expectations. Confront asuperior with questions about job role andexpected outcomes.

Today workers are faced with additional stressesof possible and actual DOWNSIZING of corporationsduring which many employees are laid off, neces-sitating early retirement by many and finding newjobs by others. The term right-sizing has arisen tomean scaling down the number of employees to anefficient and profitable level.

See also AUTONOMY; BOREDOM; CHANGING NATURE

OF WORK; COPING; CUBICLES; JOB CHANGE; JOB SECU-RITY; LAYOFFS; WOMEN; WORKING MOTHERS.

SOURCES:Adams, Scott. The Dilbert Principle: A Cubicle’s-Eye View of

Bosses, Meetings, Management Fads and Other WorkplaceAfflictions. New York: Harper-Business, 1997.

Field, Tiffany, Olga Quintino, et al. “Job Stress ReductionTherapies.” Alternative Therapies 3, no. 4 (July 1997).

Murphy, Lawrence R. “Stress Management in Work Set-tings: A Critical Review of the Health Effects.” Ameri-can Journal of Health Promotion 11, no. 2 (November–December 1996): 112–35.

Peterson, Michael. “Work, Corporate Culture, and Stress:Implications for Worksite Health Promotion. AmericanJournal of Health Behavior 21, no. 4 (1997): 243–252.

Rosch, Paul J. “Measuring Job Stress: Some Commentson Potential Pitfalls.” American Journal of Health Pro-motion 11, no. 6 (July–August 1997): 400–401.

workplace shootings The number of workplaceshootings in the United States nearly doubled in2003 from the previous year, increasing stress in

many workplaces. According to a report by Hand-gun-Free America, there were 25 workplace shoot-ing incidents and 33 victims killed in 2002. In 2003,that number rose dramatically to 45 incidents, with69 people killed and another 46 wounded. Thereport identified a five-year trend showing anincrease in the number of American workplaceshootings since 1998, when there were only nine.

The report also indicated that about half ofthose who commit workplace shootings had expe-rienced a “negative change in employment,” suchas firing, demotion, suspension, or involvement indisputes. Nearly one-third of the workplace shoot-ings occurred in white-collar job settings, and morethan 90 percent of the shooters in these incidentsare male. Further, at least 13.4 percent of the casesreviewed indicated the shooter had a publiclyknown history of mental health problems, and 9.1percent of the shooters displayed warning signsprior to the shootings but these warning signs wereignored by those who noticed them. At least 13.4percent of the incidents reviewed involved sometype of domestic violence as the motive. The reportconcluded that California and Florida are the mostdangerous states when it comes to workplaceshootings.

According to Chris McGrath, executive directorof Handgun-Free America, “The unifying factoramongst all these tragedies is the availability offirearms, especially semi-automatic handguns,which are the weapons of choice for rampage andworkplace shooters.”

See also DOMESTIC VIOLENCE; SUICIDE; VIOLENCE.

FOR FURTHER INFORMATION:Handgun-Free America1600 Wilson Boulevard, Suite 800Arlington, VA 22209(703) 465-0474(703) 465-5603 (fax)http://www.handgunfree.org

worksite wellness programs Wellness promo-tion, through organized programming at the work-place, that encourages voluntary behavior changesincluding STRESS MANAGEMENT in employees.Worksite wellness activities are designed to reducehealth risks and enhance individual productivity.Wellness programs provide employees with the

worksite wellness programs 391

advantage of making the intentional choice towarda more stress-free physical, emotional, psychologi-cal, and occupational existence.

In the late 1980s, the Wellness Councils of Amer-ica was formed to help member companies buildand sustain wellness programs. Since the inceptionof the Wellness Councils of America, much has beenlearned about the art and science of worksite healthpromotion. From improving health and well-beingand reducing STRESS to demonstrating cost benefit,the discipline of worksite health promotion has rap-idly gained acceptance among a variety of con-stituents, including business and industry, healthcare, education, and government.

About half of companies with more than 750employees offer a comprehensive employee healthpromotion program, according to a National Work-site Health Promotion Survey from 1999, the mostrecent year such a survey was done. According tothe Wellness Councils of America and Canada,more than 81 percent of U.S. businesses with 50 ormore employees have some form of health promo-tion program. The most popular ones are stressmanagement, exercise, weight loss programs, stop-smoking classes, and back care programs.

Health Promotion/Stress Reduction: Controlling Health Care Costs

Health promotion is important to employersbecause health care costs continue to be an issue ofmajor concern. More than $1 trillion is spent in theUnited States on health care, more than any othernation in the world. The average annual healthcare cost per person in the United States farexceeds $3,000. Lifetime costs per person are inthe area of $225,000.

Because much of these costs are linked to stress-ful habits, it is possible for employers to take actiontoward reducing health care utilization and contain-ing costs by providing health promotion activities.

A factor in rising health costs is Americans’growing tendency toward obesity. David Hunni-cutt, president of the Wellness Councils of Amer-ica, has asserted that most Americans spend themajority of their time at sedentary jobs. Healthexperts say it is incumbent on employers to findways to get workers to exercise and become moreconcerned about their health. A federal govern-ment survey in 2000 found that 56.4 percent of

Americans are overweight. Obesity can result inhigher health insurance claims and employeeabsenteeism. A National Center for Health Statis-tics report released in April 2002 said seven in 10adults do not exercise regularly and nearly four in10 are not physically active at all.

Companies say wellness programs have proveneffective, with reductions in stress, blood pressure,smoking, and cholesterol levels.

About 1,000 people participated in CIGNA’sweight management program in 2001, and theaverage weight loss was 10 to 15 pounds, accordingto Catherine Hawkes, assistant vice president of theinsurer’s employee health and work-life programs.

To reduce stress, autoworkers at General MotorsCorp. relax and stretch with yoga and t’ai chiclasses offered just floors above the assembly linesin Flint, Michigan. Union Pacific Railroad employ-ees can use a fitness center at many remote spots;the company used to have traveling fitness railcarsbefore workers started staying in hotels. ChryslerGroup offers incentives for its employees to use itsprograms, giving out “well bucks” that can beredeemed for gym bags, golf balls, and other gear.Employees earn the well bucks if they get a healthscreening, check out a book or video from thecompany health library, or get a workplace mas-sage, which can provide some stress relief.

Increased Technology: A Source of Stress

The typical American now works 47 hours a week.Because of modern technological conveniencessuch as laptop computers, modems, personalpagers, fax machines, e-mail and cellular phones,traditional boundaries of work have been erased.These devices are convenient but they become athreat to good health if they use up time peoplemight have devoted to exercise or relaxing recre-ational activities. Progressive health promotionprograms and stress management activities at theworksite can help alleviate some of these concerns.

Additionally, increased reliance on technologyhas ushered in much new health concerns includ-ing repetitive stress injuries, low back problems,and compromised vision. Because almost one-thirdof the workforce now spends most of the dayseated at desks or workstations, sedentary lifestyleshave become a concern.

392 worksite wellness programs

Stress Level High in Many Jobs

The pace of technological change and the challengeof information management has increased thelevel of stress for both employers and employees.According to the Wellness Councils of America, arecent nationwide poll indicated that 78 percent ofAmericans describe their jobs as stressful. High lev-els of organizational stress exact a toll on business.Increased accidents, reduced productivity, unnec-essary absenteeism, and increased medical carecosts show that the impact of stress is devastating.

Increasingly, more business leaders and healthpromotion practitioners look to health promotionprograms as a means of reducing, managing and, insome instances, even eliminating harmful sourcesof stress. By implementing a comprehensive stressmanagement intervention, it is possible to success-fully combat prevalent stressors in the workplace.

Examples of stress reduction techniques includeteaching employees stress management skills,implementing flexible work schedules, increasingthe quality and quantity of social interaction, andincreasing participation in the company decision-making process can all have significant effects.

Increased Workforce Diversity May Cause Stress

Because of increasing diversity in the workforce,there is a need to address many health and well-ness issues to keep employees healthy and produc-tive. For example, jobs generated by small firmsare more likely to be filled by younger workers,older workers, and women. According to recentstatistics obtained from the Small Business Admin-istration, the number of women-owned firms andthe firms owned by people of color have increasedsignificantly. Between 1987 and 1992, the numberof women-owned businesses rose approximately43 percent. In 1996, nearly 8 million women-owned firms provided jobs for 18.5 million per-sons, more people than are employed in theFortune 500 industrial firms.

Data on black-owned businesses revealed anincrease of 46 percent. Hispanic-owned businessesproved to be one of the fastest growing segments,increasing 82.7 percent between 1987 and 1992.Businesses owned by Asian Americans, AmericanIndians, Alaska Natives, and Pacific Islandersincreased 87.2 percent between 1987 and 1992.With increasing diversity comes the challenge of

being responsive to many additional health con-cerns. Because health promotion programs helppinpoint specific health issues of most concern,such initiatives can be used to identify and addressa variety of diverse health issues.

Stress Management Helps Prevent Illnesses

Many causes of illnesses are preventable. Estimatesare that preventable illnesses make up approxi-mately 70 percent of the entire burden of illnessand associated costs in the United States. Pre-ventable factors include stress, tobacco use, high-risk alcohol consumption, sedentary lifestyle, andpoor nutritional habits. By offering a health promo-tion initiative, employers can take important stepstoward preventing unnecessary sickness and death.

See also ABSENTEEISM; BACK PAIN; REPETITIVE

STRESS INJURIES; STRESS; WORKERS’ COMPENSATION.

FOR FURTHER INFORMATION:Wellness Councils of America9802 Nicholas Street, Suite 315Omaha, NE 68114(402) 827-3590(402) 827-3594 (fax)http://www.welcoa.org

SOURCE:Moses, Alexandra R. “Wellness Programs a Fit for Bottom

Lines.” Chicago Tribune, 28 April 2002, Sec. 5, p. 9.

workstation See COMPUTERS; CUBICLES; ERGONOM-ICS; PERSONAL SPACE.

World Trade Center See SEPTEMBER 11, 2001.

worry A state of mental uneasiness, distress, oragitation due to concern for a past, impending, oranticipated stressful event, threat, or danger. Somedegree of worrying is a common, everyday occur-rence for most people. For some people, however,excessive worry adds to their stress levels. Individ-uals who have ANXIETY DISORDERS tend to worrymore than others. For example, people who haveAGORAPHOBIA may worry about what will happen ifthey go out of their homes, or people with a PHO-BIA may worry about what will happen if theyencounter a phobic object or situation.

Worrying may be called negative imagery,because the worrier focuses on negative images or

worry 393

worst-case scenarios (CATASTROPHIZEs). Worrying toexcess can be an unhealthy stressor because itcauses the body to react; the heart pounds, breath-ing quickens, and sweating may occur. For someindividuals, GUIDED IMAGERY techniques, throughwhich they imagine themselves in a given situationwith a pleasant outcome, may be useful. Addition-ally, RELAXATION techniques, such as MEDITATION

and BIOFEEDBACK, may be helpful. In a relaxedstate, individuals can think more constructivelyand in a more organized manner.

See also ANXIETY; COPING; GENERAL ADAPTATION

SYNDROME; STRESS MANAGEMENT.

SOURCES:Diamond, David. “Bound to Worry.” Health, July–August

1992.Padus, Emrika, ed. The Complete Guide to Your Emotions and

Your Health, rev. ed. Emmaus, Pa.: Rodale Press, 1992.

writer’s block An obstacle to the free expressionof ideas on paper; between the thought and therecording of it, there is an interruption in the flow.When a block occurs, the writer may feel stressed,frustrated, and stuck. Unable to go on while waiting

for an inspiration, the writer may have self-doubtsabout his or her capabilities, hopes, and even future.

Many writers suffer from writer’s block at onetime or another. The block may involve an inabil-ity to get started with a writing project, or to setwords down on paper; it may occur in the middleof a project and the writer will feel unable to go on.Writers may be concerned about the validity oftheir topic, ability to communicate on paper, andacceptance by teachers, readers, or publishers.

Too much STRESS can paralyze the writer, andtoo little stress can lead to apathy. The ideal state ofmind, the one that unblocks, was called “eustress,”or good stress, by HANS SELYE, the Canadian authorof The Stress of Life (1956) and Stress without Distress(1974). That middle point in the stress spectrum isthe state of relaxed concentration accompanied byenergy. Because writing can be hard work, onemust be in the right mental framework to takerisks and to have confidence and SELF-ESTEEM

regarding one’s own abilities.

Overcoming the Stress of Writer’s BlockWriting usually involves several steps: incubation,planning, research, organization, first draft, incu-bation, revision, and final draft. Before starting, thewriter unconsciously develops ideas and insightsfor the written material; this is the important incu-bation process. To bring these ideas out of the mindand onto paper, and break writer’s block, he or shemust reach a state of relaxed, energized concentra-tion in which self-criticism is set aside and there isroom for creative thoughts.

There are a number of exercises one can per-form to help reach the state of energized relax-ation. Physical EXERCISE energizes and is conduciveto a relaxed state of mind. MEDITATION and imageryexercises are also very useful in reducing stress andminimizing the self-doubt that obstructs expres-sion. Proper nutrition and enough SLEEP are simi-larly important to the writer.

Another way to avoid writer’s block is to avoidpeople who are critical of the writer’s work or ideasin the early stage of the project. While their criti-cisms may be helpful later, early in the project crit-icism may be stifling.

See also CREATIVITY; FRUSTRATION.

SOURCE:Sloane, Beverly LeBov. “Creativity.” Town Hall of Califor-

nia Reporter, March–April 1987, 6–7.

394 writer’s block

REDUCE STRESS: WORRY LESS

• When you try not to worry about something, it islikely that you will worry about it more. It maybe advantageous to stay with the worry andreally concentrate on it, because you may stopworrying and begin solving your problem.

• Make a distinction between matters you can dosomething about and those you cannot.

• Instead of asking yourself repeatedly “whatif . . .,” write down a number of possible solu-tions to a specific problem and then list theadvantages and disadvantages of each idea.

• Use a diversionary technique, such as going fora walk, doing some other form of exercise, play-ing a musical instrument, or listening to music.Doing so will help you organize your thoughtsand come up with possible solutions. The bestsolutions may occur when you are not thinkingabout the immediate problem.

• Various forms of psychotherapy and self-helpcan relieve the stresses of excessive worrying formany people.

XXanax The trade name for alprazolam, a tria-zolobenzodiazepine compound with antianxietyand sedative-hypnotic actions. It is approved bythe U.S. Food and Drug Administration for use inpanic disorder and generalized ANXIETY DISORDER.

Studies suggest that alprazolam also has antide-pressant activity in moderate depression.

See also BENZODIAZEPINE DRUGS; AGORAPHOBIA;DEPRESSION; PANIC ATTACKS AND PANIC DISORDER;PHARMACOLOGICAL APPROACH.

395

Yyawning Yawning is an easy way to reduce stressbecause doing so relaxes the throat, palate, upperneck, and the base of the brain. It helps balance theflow of cerebrospinal fluid, which helps keep thebrain and spine clean and flexible. It also increasesproduction of saliva and so improves digestion.Yawning also increases fluid flow to the eyes,which washes and soothes them. It also increasesthe brain’s production of serotonin, the neuro-transmitter that tends to balance mood. Because ofincreased serotonin, yawning helps to induce sleepwhen one is tired but has trouble relaxing enoughto sleep.

How to Induce a Yawn

• Take in a deep breath.

• At the top of the breath, open your mouth wide,lift your soft palate (the upper back of yourthroat), and make yawning sounds. This shouldtrigger a yawn. Try it again off and on, relaxing asmuch as you can, until you find yourself yawning.

• Be with people who yawn and let their yawningtrigger yours.

FOR FURTHER INFORMATION:Zapchen ResourcesP.O. Box 6392Napa, CA 94581(707) 233-7120

SOURCE:Henderson, Julie. Embodying Well-Being: How to Feel as

Good as You Can in Spite of Everything. Napa, Calif.:Zapchen Resources, 2003.

yoga A system of Indian philosophy and practicethat is used as a stress management technique bymany people. The word youga means “union.”Yoga teaches the means by which one can learn tocommune with universal energy. Humans consistof both material and nonmaterial entities; thematerial entity is the physical body and the non-material entities are the mind and the soul. Yogaattempts to bring together the body, mind, andsoul, or the physical side, the social side (life inaction), and the spiritual side.

There are several types of yoga with varyingemphasis on physical, mental, and social activity.Different paths for developing the mind are basedon the fact that the mind has three different aspects:knowing, feeling, and willing. A popular type ofyoga practiced in the United States is hatha yoga,which involves regulation of the mind and bodythrough different breathing exercises. There areover 200 balanced physical postures (asanas) toEXERCISE every muscle in the body. They areplanned to maintain flexibility of the body, teachphysical and mental control, and are useful forRELAXATION. There are exercises for tapping intokundalini (a large reservoir of energy thought to besituated at the base of the spinal cord).

Research studies have indicated that yoga isuseful in the area of hypertension, coronary heartdisease, anxiety disorders, asthma, and diabetes.

See also ALTERNATIVE MEDICINE; MEDITATION.

youngest children See BIRTH ORDER; SIBLING

RELATIONSHIPS.

396

ZZen A form of Buddhism used as a basis forRELAXATION and STRESS MANAGEMENT; it is concernedwith the individual meaning of a person’s life ratherthan just removal of symptoms or improvement ofhis or her adjustment to life. The goal of Zen is pur-

sued through contemplation of the nature ofhumankind. With this process, individuals releasetensions and experience oneness with the universe.

See also ALTERNATIVE MEDICINE; MEDITATION;TRANSCENDENTAL MEDITATION.

397

399

Acoustical Society of America (ASA)2 Huntington Quadrangle, Suite 1NO1Melville, NY 11747-4502(516) 576-2360(516) 576-2377 (fax)http://asa.aip.org

Agency for Toxic Substances and DiseasesRegistry (ATSDR)

1600 Clifton Road NEAtlanta, GA 30333(888) 422-8737 (toll-free)(404) 498-0057 (fax)www.atsdr.cdc.gov

AIDS Clinical Trials Information ServiceP.O. Box 6421Rockville, MD 20849-6421(800) TRIALS-A (toll-free)http://www.actis.org

AIDS Health Project1930 Market StreetSan Francisco, CA 94102(415) 476-6430http://www. ucsf-ahp.org

Al-Anon/Alateen Family Group Headquarters,World Service Office (AFG)

1600 Corporate Landing ParkwayVirginia Beach, VA 23454-5617(800) 344-2666 (toll-free)(800) 4AL-ANON(757) 563-1600(757) 563-1655 (fax)http://www.al-anon.alateen.org

Alcoholics Anonymous (AA)A.A. World Services, Inc.P.O. Box 459 Grand Central StationNew York, NY 10163

(212) 870-3400http://www.aa.org

American Academy of Ophthalmology (AOA)P.O. Box 7424San Francisco, CA 94120-7424(415) 561-8500(415) 561-8533 (fax)http://www.aao.org

American Association for CFS (AAFCFS)c/o Harborview Medical Center325 9th AvenueBox 359780Seattle, WA 98104(206) 521-1932(206) 521-1930 (fax)E-mail: debrap@washington.edu

American Association of NaturopathicPhysicians (AANP)

8201 Greensboro Drive, Suite 300McLean, VA 22102-3814(877) 969-2267(703) 610-9037(703) 610-9005 (fax)http://www.naturopathic.org

American Association of Occupational HealthNurses (AAOHN)

2920 BrandyWine Road, Suite 100Atlanta, GA 30341(770) 455-7757(770) 455-7271 (fax)http://www.aaohn.org/

American Association of Oriental Medicine(AAOM)

433 Front St.Catasauqua, PA 18032-2506

APPENDIX IASSOCIATIONS AND ORGANIZATIONS

400 The Encyclopedia of Stress and Stress-Related Diseases

(888) 500-7999 (toll-free)(610) 266-1433(610) 264-2768 (fax)http://www.aaom.org

American Cancer Society (ACS)1599 Clifton Road NEAtlanta, GA 30329(800) 227-2345 (toll-free)(404) 315-9348 (fax)http://www.cancer.org

American Chemical Council (ACC)1300 Wilson BoulevardArlington, VA 22209(703) 741-5000(703) 741-6000 (fax)http://americanchemistry.com

American Chemical Society (ACS)1155 16th Street NWWashington, DC 20036(800) 227-5558 (toll-free)(202) 872-4600(202) 872-4615 (fax)http://www.acs.org

American Chiropractic Association (ACA)1701 Clarendon BoulevardArlington, VA 22209(800) 986-4636 (toll-free)(703) 276-8800(703) 243-2593 (fax)http://www.amerchiro.org

American Civil Liberties Union AIDS Project132 West 43rd StreetNew York NY 10036(212) 944-9800

American College of Medical Toxicology(ACMT)

777 E. Park DriveP.O. Box 8820Harrisburg, PA 17105-8820(888) 633-5784(717) 558-7846(717) 558-7841 (fax)http://www.acmt.net

American College of Occupational andEnvironmental Medicine

1114 North Arlington Heights RoadArlington Heights, IL 60004-4770

(847) 818-1800, ext. 368(847) 818-9266 (fax)http://www.acoem.org

American College of Toxicology (ACT)9650 Rockwell PikeBethesda, MD 20814(301) 571-1840(301) 571-1852 (fax)http://actox.org

American Conference of GovernmentalIndustrial Hygienists (ACGIH)

1330 Kemper Meadows Drive, Suite 600Cincinnati, OH 45240(513) 742-2020(513) 742-6163(513) 742-3355 (fax)http://www.acgih.org

American Council of the Blind (ACB)1115 15th Street NW, Suite 1004Washington, DC 20005(800) 424-8666 (toll-free)(202) 467-5081(202) 467-5085 (fax)http://www.acb.org

American Council on Science and Health(ACSH)

1995 Broadway, 2nd FloorNew York, NY 10023-5860(212) 362-7044(212) 362-4919 (fax)http://acsh.acsh.orgE-mail: acsh@acsh.org

American Diabetes Association (ADA)1701 North Beauregard StreetAlexandria, VA 22311(800) DIABETES (toll-free)(703) 549-1500(703) 836-7439 (fax)http://www.diabetes.org

American Environmental Health Foundation(AEHF)

8345 Walnut Hill Lane, Suite 225Dallas, TX 75231(800) 428-2343 (toll-free)(214) 361-2534 (fax)http://www.aehf.com

American Federation of Labor-Congress ofIndustrial Organizations (AFL-CIO)

815 16th Street NWWashington, DC 20006(202) 637-5000(202) 637-5058 (fax)E-mail: feedback@aflcio.org

American Group Psychotherapy Association(AGPA)

25 East 21st Street, Sixth FloorNew York, NY 10010(212) 477-2677(212) 979-6627 (fax)http://www.agpa.orgE-mail: groupsinc@aol.com

American Headache Society (AHS)19 Mantua RoadMt. Royal, NJ 08061(856) 423-0043(856) 423-0082 (fax)http://www.aashnet.org

American Healthcare Association (AHA)1201 L Street, NWWashington, DC 20005-4014(202) 841-4444(202) 842-3860 (fax)http://www.ahca.org

American Heart Association (AHA)7272 Greenville AvenueDallas, TX 75231-4596(800) 242-USA1 (toll-free)(214) 373-6300(214) 987-4334 (fax)http://www.americanheart.org

American Industrial Hygiene Association(AIHA)

2700 Prosperity Avenue, Suite 250Fairfax, VA 22031(703) 849-8888(703) 207-3561 (fax)http://www.aiha.org

American Institute of Stress (AIS)124 Park AvenueYonkers, NY 10703(914) 963-1200(914) 965-6267 (fax)http://www.stress.org

American Lung Association (ALA)1740 BroadwayNew York, NY 100019-4374(800) LUNG USA (toll-free)(212) 315-8700(212) 315-8872 (fax)http://www.lungusa.org

American Massage Therapy Association (AMTA)820 Davis Street, Suite 100Evanston, IL 60201-4444(888) 843-2682 (toll-free)(847) 864-0123(847) 864-1178 (fax)http://www.amtamassage.org

American Mental Health CounselorsAssociation (AMHCA)

801 North Fairfax Street, Suite 304Alexandria, VA 22314(800) 326-2642 (toll-free)(703) 548-6002(703) 548-4775 (fax)http://www.amhca.orgE-mail: vmoore@amhca.org

American Nurses Association600 Maryland Avenue SW, Suite 100WWashington, DC 20024-2571(800) 274-4ANA (toll-free)(202) 651-7000http://www.nursingworld.org

American Psychiatric Association (APA)1400 K Street NWWashington, DC 20005(202) 692-6850http://www.psych.orgE-mail: apa@psych.org

American Psychological Association (APA)750 First Street NEWashington, DC 20002-4242(800) 374-3120 (toll-free)(202) 336-5700(202) 336-5568 (fax)http://www.apa.orgE-mail: webmaster@apa.org

American Public Health Association (APHA)800 I Street NWWashington, DC 20001-3710

Appendix I 401

(202) 777-2742(202) 777-2534 (fax)http://www.apha.org

American Red Cross National Headquarters(ARC)

431 18th Street NWWashington, DC 2006(800) 797-8022 (toll-free)(202) 639-3520(202) 942-2024 (fax)http://www.redcross.org

American Sleep Apnea Association (ASAA)1424 K Street NW Suite 302Washington, DC 20005(202) 293-3650(202) 293-3656 (fax)http://www.sleepapnea.org

American Society of Addiction Medicine(ASAM)

4601 North Park Avenue Arcade, Suite 101Chevy Chase, MD 20815(301) 656-3920(301) 656-3815 (fax)http://www.asam.org

Anorexia Nervosa and Related EatingDisorders (ANRED)

P.O. Box 5102Eugene, OR 97405(541) 344-1144http://www.anred.com

Anxiety Disorders Association of America(ADAA)

8700 Georgia AvenueSilver Spring, MD 20910(240) 487-0120http://www.adaa.org

Association for Advancement of BehaviorTherapy

305 Seventh Avenue, 16th FloorNew York, NY 10001-6008(212) 647-1890(212) 647-1865 (fax)http://www.aabt.orgE-mail: info@aabt.org

Association of Applied Psychophysiology andBiofeedback (AAPB)

12267 West 44th Avenue, #304Wheat Ridge, CO 80303

(303) 422-8436(303) 422-8894 (fax)http://www.aapb.org

Association of Occupational andEnvironmental Clinics (AOEC)

1010 Vermont Avenue NW, Suite 513Washington, DC 20005-1503(202) 347-4976(202) 347-4950 (fax)http://www.aoec.org

Better Hearing Institute (BHI)P.O. Box 1840Washington, DC 20013(800) EAR-WELL (toll-free)(703) 684-6048 (fax)http://www.betterhearing.orgCDC National AIDS Hotline: (800) 342-2437TTY/TDD: (800) 243-7889English Hotline: (800) 342-AIDSSpanish Hotline: (800) 344-SIDA

CDC National Prevention InformationNetwork (NPIN)

Box 6003Rockville, MD 20849-6003(800) 458-5231 (toll-free)(800) 243-7012(301) 562-1050 (fax)http://www.cdcnpin.org

Center for Substance Abuse Prevention (CSN)5600 Fishers Lane, Rockwall IIRockville, MD 20857(301) 443-0365http://www.samhsa.govE-mail: nnadal@samhsa.gov

CFIDS Association of America, Inc.P.O. Box 2203398Charlotte, NC 29222-0398(800) 442-3437 (toll-free)(704) 365-9755 (fax)http://www.cfids.org

Chronic Fatigue Immune DysfunctionSyndrome Activation Network (CAN)

P.O. Box 345Larchmont, NY 10538(212) 280-4266(914) 636-6515 (fax)E-mail: cfidsnet@aol.com

402 The Encyclopedia of Stress and Stress-Related Diseases

Cocaine Anonymous World Services (CAWS)3740 Overland Avenue, Suite CLos Angeles, CA 90034-6337(800) 347-8998 (toll-free)(310) 559-5833(310) 559-2554 (fax)http://www.ca.org

Commission on Mental and Physical DisabilityLaw

American Bar Association740 15th Street NWWashington, DC 20005(202) 662-1570(202) 662-1032 (fax)http://www.abanet.org/disabilityE-mail: cmpdl@abanet.org

Depression and Bipolar Support Alliance730 North Franklin Street, Suite 501Chicago, IL 60610-3526(800) 826-3632 (toll-free)(312) 642-0049(312) 642-7243 (fax)http://www.dbsalliance.org

Depression and Related Affective DisordersAssociation

Johns Hopkins Hospital, Meyer 3-181600 North Wolfe StreetBaltimore, MD 21287-7381(410) 955-4647(410) 614-3241 (fax)http://www.med.jhu.edu/dradaE-mail: drada@jhmi.edu

Easter Seals National Headquarters230 West Monroe Street, Suite 1800Chicago, IL 60606(800) 221-6827 (toll-free)(312) 726-6200(312) 726-1494 (fax)http://www.easter-seals.org

Eating Disorders Awareness and Prevention,Inc. (EDAP)

603 Stewart Street, Suite 803Seattle, WA 98101(800) 931-2237 (toll-free)(206) 382-3587(206) 292-9890 (fax)http://www.edap.orgE-mail: info@edap.org

Employee Assistance Professionals Association(EAPA)

2101 Wilson Boulevard, Suite 500Arlington, VA 22201-3062(703) 387-1000(703) 522-4585 (fax)http://www.eap-assn.com

Employment Law Center1663 Mission Street, Suite 400San Francisco, CA 94103(415) 864-8848

Environmental Health ClearinghouseMeridian Parkway, Suite 115Durham, NC 27713(800) 643-4794 (toll-free)(919) 361-9408 (fax)http://www.infoventures.com

Environmental Protection Agency (EPA)1200 Pennsylvania Avenue NWWashington, DC 20460(202) 564-6953(202) 501-1450 (fax)http://www.epa.gov

Equal Employment Opportunity Commission(EEOC)

1801 L Street NWWashington, DC 20507(202) 663-4001(202) 663-4110 (fax)http://www.eeoc.gov

Feldenkrais Guild of North AmericaC/O Ruth A. Hurst3611 South West Hood Avenue, Suite 100Portland, OR 97201(800) 775-2118 (toll-free)(503) 221-6612(503) 221-6616 (fax)http://www.feldenkrais.com

Gamblers Anonymous (GA)P.O. Box 17173Los Angeles, CA 90017(213) 386-8789(213) 386-0030 (fax)http://gamblersanonymous.org

Health Research Group (HRG)1600 20th Street NWWashington, DC 20009

Appendix I 403

(202) 588-1000(202) 588-7796 (fax)http://www.citizen.org/hrg

International Association of Eating DisordersProfessionals (IAEDP)

P.O. Box 1295Pekin, IL 61555-1295(309) 346-3341(309) 346-2874 (fax)http://www.iaedp.com

International Foundation for Homeopathy(IFH)

P.O. Box 7Edmonds, WA 98020(425) 776-1499 (fax)E-mail: ifh@nwlink.com

International Occupational HygieneAssociation (IOHA)

I0HA SecretariatSuite 2, Georgian HouseGreat Northern RoadDerbyDE ILTUnited Kingdom+44 1332 298101+44 1332 298099 (fax)http://www.ioha.com

International Safety Equipment Association(ISEA)

1901 North Moore StreetArlington, VA 22209-1762(703) 525-1695(703) 528-2148 (fax)http://www.safetyequipment.org

International Society for Traumatic StressStudies (ISTSS)

60 Revere Drive, Suite 500Northbrook, IL 60062(847) 480-9028(847) 480-9282 (fax)http://www.istss.orgE-mail: istss@istss.org

Judge David L. Bazelon Center for MentalHealth Law

1101 15th Street NW, Suite 1212Washington, DC 20005-5002(202) 467-5730

(202) 223-0409 (fax)http://www.bazelon.orgE-mail: bazelon@nicom.com

Narcolepsy NetworkP.O. Box 294Pleasantville, NY 10570(401) 667-2523(401) 633-6567http://www.narcolepsynetwork.org

Narcotics Anonymous (NA)P.O. Box 9999Van Nuys, CA 91409(818) 773-9999(818) 700-0700 (fax)http://www.na.org

National Alliance for Hispanic Health1501 Sixteenth Street NWWashington, DC 20036(202) 387-5000(202) 797-4353 (fax)http://www.hispanichealth.org/

National Alliance for the Mentally Ill (NAMI)Colonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22203-3754(800) 950-6264 (toll-free)(703) 524-7600(703) 524-9094 (fax)http://www.nami.org

National Alliance for Research onSchizophrenia and Depression (NARSAD)

60 Cutter Mill Road, Suite 404Great Neck, NY 11021(800) 829-8289 (toll-free)(516) 829-0091(516) 487-6930 (toll-free)http://www.narsad.org

National Association of Anorexia Nervosa andAssociated Disorders (ANAD)

P.O. Box 7Highland Park, IL 60035(847) 831-3438(847) 433-4632 (fax)http://www.anad.orgE-mail: anad20@aol.com

404 The Encyclopedia of Stress and Stress-Related Diseases

National Association of Cognitive-BehavioralTherapists (NACBT)

P.O. Box 2195Weirton, WV 26062(800) 853-1135 (toll-free)(304) 723-3982 (fax)http://www.nacbt.orgE-mail: nacbt@nacbt.org

National Association of People with AIDS(NAPWA)

8401 Colesville Road, Suite 750Silver Spring, MD 20910(240) 247-0880(240) 247-0574 (fax)http://www.napwa.orgE-mail: info@napwa.org

National Association of Protection andAdvocacy Systems (NAPAS)

900 Second Street NE, Suite 211Washington, DC 20002(202) 408-9514(202) 408-9520 (fax)http://www.protectionandadvocacy.comE-mail: napas@vipmail.earthlink.net

National Association of Social Workers (NASW)750 First Street NE, Suite 700Washington, DC 20002-4241(800) 638-8799 (toll-free)(202) 408-8600(202) 336-8310 (fax)http://www.socialworkers.org

National Cancer Institute/NIHNCI Public Inquiries OfficeSuite 3036A6116 Executive Boulevard, MSC 8322Bethesda, MD 20892-8322(800) 4-CANCER(800) 422-6237(301) 435-3848http://www.nci.nih.gov

National Center for Complementary andAlternative Medicine (NCCAM)

National Institutes of Health (NIH)P.O. Box 7923Gaithersburg, MD 20898(888) 644-6226(301) 435-6549 (fax)http://www.nccam.nih.gov

National Center for Farmworker Health (NCFH)1770 FM 967Buda, TX 78610-2884(512) 312-2700(512) 312-2600 (fax)http://www.ncfh.org

National Center for Homeopathy (NCH)801 North Fairfax Street, Suite 306Alexandria, VA 22314(703) 548-7790(703) 548-7792 (fax)http://www.homeopathic.org

National Center for Post-Traumatic StressDisorder (NCPTSD)

VA Medical CenterWhite River Junction, VT 05001(802) 296-5132E-mail: ncptsd@ncptsd.orghttp://www.ncptsd.org

National Chronic Fatigue Syndrome andFibromyalgia Association (NCFSFA)

P.O. Box 18426Kansas City, KS 64133(816) 313-2000(816) 524-6782 (fax)http://www.ncfsfa.org

National Clearinghouse for Alcohol and DrugInformation (NCADI)

11426 Rockville PikeRockville, MD 20852(800) 729-6686 (toll-free)http://www.health.orgE-mail: info@health.org

National Council on Alcoholism and DrugDependence (NCADD)

20 Exchange Place, Suite 3902New York, NY 10005-3201(800) 622-2255 (toll-free)(212) 269-7797(212) 269-7510 (fax)www.ncadd.org

National Council on Problem Gambling (NCPG)216 G Street NE, Suite 200Washington, DC 20002(202) 547-9204(202) 547-9206 (fax)http://www.ncpgambling.orgE-mail: ncpg@ncpgambling.org

Appendix I 405

National Eating Disorders Association (NEDA)603 Stewart Street, Suite 803Seattle, WA 98101(206) 382-3587(206) 829-8501 (fax)http://www.nationaleatingdisorders.orgE-mail: info@nationaleatingdisorders.org

National Fire Protection Association (NFPA)1 Batterymarch ParkP.O. Box 9101Quncy, MA 02269-9101(800) 344-3555 (toll-free)(617) 770-0700 (fax)http://www.nfpa.org

National Foundation for Depressive Illness(NFDI)

P.O. Box 2257New York, NY 10116(800) 239-1265 (toll-free)http://www.depression.org

National Headache Foundation (NHF)820 North Orleans, Suite 217Chicago, IL 60610(888) NHF-5552 (toll-free)(773) 388-6399(773) 525-7357 (fax)http://www.headaches.org

National Heart, Lung and Blood Institute/NIH(NHLBI)

P.O. Box 30105Bethesda, MD 20824-0105(301) 592-8573(301) 402-0818 (fax)http://www.nhlbi.nih.gov

National Highway Traffic SafetyAdministration (NHTSA)

Transporation Department400 Seventh Street SWWashington, DC 20590(202) 366-1836(202) 366-2106 (fax)http://www.nhtsa.dot.gov

National Institute for Occupational Safety andHealth (NIOSH)

Centers for Disease Control and Prevention200 Independence Avenue SWWashington, DC 20201(202) 401-6997

(202) 260-4464 (fax)http://www.cdc.gov/niosh

National Institute of Allergy and InfectiousDiseases/NIH (NIAID)

6610 Rockledge Drive, MSC 6612Bethesda, MD 20892-6612(301) 496-2263(301) 496-5717(301) 496-5509 (fax)http://www.niaid.nih.gov

National Institute of Arthritis andMusculoskeletal and Skin Diseases/NIH(NIAMS)

I AMS CircleBethesda, MD 20892-3675(301) 495-4484(301) 718-6366 (fax)http://www.niams.nih.gov

National Institute of Environmental HealthSciences/NIH (NIEHS)

Building 31 #B1CO231 Center Drive, MSC 2256Bethesda, MD 20892-2256(301) 496-3511(301) 496-0563 (fax)http://www.niehs.nih.gov

National Institute of Mental Health (NIMH)6001 Executive Boulevard, Room 8184Bethesda, MD 20892-9663(800) 421-4211 (toll-free)(301) 443-4513(301) 443-4279 (fax)http://www.nimh.nih.govE-mail: nimhinfo@nih.gov

National Institute on Aging (NIA)Building 31, Room 5C2731 Center Drive, MSC 2292Bethesda, MD 20892(301) 496-9265(301) 496-2525 (fax)http://www.nih.gov/nia

National Institute on Alcohol Abuse andAlcoholism (NIAAA)

5635 Fishers Lane, MSC 9304Bethesda, MD 20892-9304(301) 496-4452http://www.niaaa.nih.gov

406 The Encyclopedia of Stress and Stress-Related Diseases

National Institute on Disability andRehabilitation Research (NIDRR)

U.S. Department of Education400 Maryland Avenue SWWashington, DC 20202-2572(202) 245-7640(202) 245-7316 (TDD)Web site: none

National Institute on Drug Abuse (NIDA)National Institutes of Health6001 Executive Boulevard, Room 5213Bethesda, MD 20892-9561(800) 644-6432 (toll-free)http://www.nida.nih.gov

National Institutes of Health (NIH)31 Center Drive, MSC-0148 Building 1, #126Bethesda, MD 20892-0148(301) 496-2433(301) 402-2700 (fax)http://www.nih.gov

National Mental Health Association (NMHA)2001 North Beauregard Street, 12th FloorAlexandria, VA 22311(800) 969-6642 (toll-free)(703) 684-7722(703) 684-5968 (fax)http://www.nmha.orgE-mail: infoctr@nmha.org

National Oceanic and AtmosphericAdministration (NOAA)

U.S. Department of Commerce14th Street and Constitution Avenue NW, Room 6217Washington, DC 20230(202) 482-6090(202) 482-3154 (fax)http://www.noaa.gov

National Safety Council (NSC)1121 Spring Lake DriveItasca, IL 60143-3201(800) 621-7619 (toll-free)(630) 285-1121(630) 285-1315 (fax)http://www.nsc.org

National Self-Help Clearinghouse (NSHC)365 Fifth Avenue, Suite 3300New York, NY 10016(212) 817-1822

(212) 817-2990 (fax)http://www.selfhelpweb.org

National Sleep Foundation1522 K Street NW, Suite 500Washington, DC 20005(202) 347-3471(202) 347-3472 (fax)http://www.sleepfoundation.org

Obsessive Compulsive Foundation (OCF)676 State StreetNew Haven, CT 06511(203) 401-2070(203) 401-2076 (fax)http://ocfoundation.org

Occupational Safety and HealthAdministration (OSHA)

200 Constitution Avenue NWWashington, DC 20210(202) 693-1900(202) 693-2106 (fax)http://www.osha.gov

Office of Minority Health (OMH)Public Health ServiceU.S. Department of Health and Human ServicesP.O. Box 37337Washington, D.C. 20013-7337(800) 444-6472 (toll-free)(301) 443-5084(301) 251-2160 (fax)http://www.omhrc.gov/omhrc/

Office of Smoking and Health (OSH)Centers for Disease Control and PreventionMailstop K-504770 Buford Highway NEAtlanta, GA 30341-3724(800) CDC-1311 (toll-free)(770) 488-5705(770) 488-5939 (fax)http://cdc.gov/tobacco

Office of the Americans with Disabilities Act(OADA)

U.S. Department of Justice950 Pennsylvania Avenue NWCivil Rights DivisionDisability Rights Section - NYAVWashington, DC 20025-6118

Appendix I 407

(202) 514-0301(202) 514-0383 (TDD)http://www.usdoj.gov/crt/ada/adahoml.htm

President’s Committee on Employment ofPeople with Disabilities

1331 F Street NW, 3rd FloorWashington, DC 20004(202) 376-6200(202) 376-6205 (TDD)

Project Inform (PI)National HIV Treatment Line205 13th Street 2001San Francisco, CA 94103(800) 822-7422(415) 558-0684 (fax)http://www.projinf.org

The Psychonomic Society1710 Fortview RoadAustin, TX 78704(512) 462-2442(512) 462-1101 (fax)http://www.psychonomic.org

Recovery, Inc.802 North Dearborn StreetChicago, IL 60610(312) 337-5661(312) 337-5756 (fax)http://www.recovery-inc.com

Registry of Toxic Effects of ChemicalSubstances (RETECS)

National Institute of Occupational Safety & Health4676 Columbia ParkwayCincinnati, OH 45226(800) 356-4674http://www.cdc.gov/niosh/rtecs/default.html

Rehabilitation Services Administration (RSA)U.S. Department of EducationMary E. Switzer Building, Room 3028330 C Street SWWashington, DC 20202-2531(202) 732-1282

Self-Help for Hard of Hearing People (SHHH)7910 Woodmont Avenue, Suite 1200Bethesda, MD 20814(301) 657-2248(301) 657-2249(301) 913-9413 (fax)http://www.shhh.org

Skin Cancer Foundation (SCF)245 5th Avenue, Suite 1403New York, NY 10016(800) SKI-N490 (toll-free)(212) 725-5751 (fax)http://www.skincancer.org

Social Security Administration (SSA)Office of Disability, Room 545Altimeyer Building6401 Security BoulevardBaltimore, MD 21235(301) 965-3424http://www.ssa.gov/disability

Society for Chemical Hazard Communication(SCHC)

P.O. Box 1392Annandale, VA 22003-9392(703) 658-9246(703) 658-9247 (fax)http://www.schc.org

Society of Environmental Toxicology andChemistry (SETAC)

1010 North 12th AvenuePensacola, FL 32501-3367(888) 899-2088 (toll-free)(850) 469-1500(850) 469-9778 (fax)http://www.setac.org

Society of Fire Protection Engineers (SFPE)7315 Wisconsin Avenue, Suite 1225WBethesda, MD 20814(301) 718-2910(301) 718-2242 (fax)http://www.sfpe.org

Special Interest Group on Phobias and RelatedAnxiety Disorders (SIGPRAD)

c/o Carol Lindemann, Ph.D.245 East 87th StreetNew York, NY 10128(212) 860-5560http://www.cyberpsych.org/anxsig.htm

Stress and Anxiety Research Society (STAR)Anxiety, Stress, and CopingKrys Kaniasty, EditorDepartment of PsychologyIndiana University of PennsylvaniaIndiana, PA 15705(724) 357-5579(724) 357-2214

408 The Encyclopedia of Stress and Stress-Related Diseases

Stress and Anxiety Research SocietyConference OfficeUniversiteit van AmsterdamP.O. Box 192681000 GG Amsterdam+ 31 (0)20 525 4791 (phone)+ 31 (0)20 525 4799 (fax)E-mail: congres@uva.nl

Substance Abuse and Mental Health ServicesAdministration (SAMHSA)

Center for Mental Health ServicesP.O. Box 42557Washington, DC 20015(800) 789-2647 (toll-free)(301) 443-2792http://mentalhealth.samhsa.gov

U.S. Nuclear Regulatory Commission (NRC)11555 Rockville Pike, MSO16C1Rockville, MD 20852(301) 415-1759(301) 415-1757 (fax)http://www.nrc.gov

U.S. Veterans Administration (USVA)Mental Health and Behavioral Sciences Services810 Vermont Avenue NW, Room 915Washington, DC 20410(202) 389-3416

Volunteer Management Associates (VMA)320 South Cedar Brook RoadBoulder, CO 80304-0468(800) 944-1470 (toll-free)(720) 304-3637(720) 304-3638 (fax)http://www.volunteermanagement.com

Wellness Councils of America (WELCOA)9802 Nicholas Street, Suite 315Omaha, NE 68114(402) 827-3590(402) 827-3594 (fax)http://www.welcoa.orgE-mail: wellworkplace@welcoa.org

Appendix I 409

ACQUIRED IMMUNODEFICIENCYSYNDROME (AIDS)Alexandrova, Anna (ed.) AIDS, Drugs, and Society.

New York: International Debate EducationAssociation, 2002.

Banish, Roslyn. Focus on Living: Portraits of Ameri-cans with HIV and AIDS. Amherst: University ofMassachusetts Press, 2003.

Clambrone, Desiree. Women’s Experiences withHIV/AIDS: Mending Fractured Selves. New York:Haworth Press, 2003.

Gedatus, Gustav Mark. HIV and AIDS. Mankato,Minn.: Lifematters, 2000.

Gifford, Allen. Living Well with HIV and AIDS. PaloAlto, Calif.: Bull Publishers, 2000.

Goosby, Eric. Living with HIV/AIDS: The Black Per-son’s Guide to Survival. Roscoe, Ill.: Hilton Pub.Co., 2004.

Guest, Emma. Children of AIDS: Africa’s Orphan Cri-sis. London: Sterling, Va.: Pluto Press, 2003.

Holmes, Wendy. Protecting the Future: HIV Prevention,Care and Support among Displaced and War-AffectedPopulations. Bloomfield, Conn.: Kumarian Press,2003.

Jasper, Margaret C. AIDS Law. Dobbs Ferry, N.Y.:Oceana Publications, 2000.

Jenkins, Mark. HIV/AIDS: Practical Medical, and Spiri-tual Guidelines for Daily Living When You’re HIV-Pos-itive. Center City, Minn.: Hazelden Information &Educational Services, 2000.

Null, Gary. AIDS: A Second Opinion. New York:Seven Stories Press, 2002.

Peterson, Paula W. Penitent, with Roses: An HIV+Mother Reflects. Hanover, N.H.: Middlebury Col-lege Press, published by University Press of NewEngland, 2001.

Roleff, Tamara L., ed. AIDS: Opposing Viewpoints.Farmington Hills, Mich.: Greenhaven Press,2003.

Siplon, Patricia D. AIDS and the Policy Struggle in theUnited States. Washington, D.C.: GeorgetownUniversity Press, 2002.

White, Katherine G. Everything You Need to Knowabout AIDS and HIV. New York: Rosen Pub.Group, 2001.

ADDICTIONS (See also ALCOHOLISM; EATING DISORDERS; SMOKING)Chopra, Deepak. Overcoming Addictions: The Spiritual

Solution. New York: Harmony Books, 1997.Dodes, Lance M. The Heart of Addiction. New York:

HarperCollins, 2002.Gerdes, Louise I., ed. Addiction: Opposing Viewpoints.

San Diego: Greenhaven Press, 2005.Hodgson, Barbara. In the Arms of Morpheus: The

Tragic History of Laudanum, Morphine, and PatentMedicines. Buffalo, N.Y.: Firefly Books, 2001.

Knauer, Sandy. Recovering from Sexual Abuse, Addic-tions, and Compulsive Behaviors: “Numb” Survivors.New York: Haworth Social Work Practice Press,2002.

Pawlowski, Cheryl. Glued to the Tube: The Threat ofTelevision Addiction to Today’s Family. Naperville,Ill.: Sourcebooks, 2000.

White, Robert K., and Deborah George Wright,eds. Addiction Intervention: Strategies to Motivate.New York: Haworth Press, 1998.

Young, Kimberly S. Caught in the Net: How to Rec-ognize the Signs of Internet Addiction and a Win-ning Strategy for Recovery. New York: J. Wiley,1998.

BIBLIOGRAPHY

410

AFFECTIVE DISORDERS (See BIPOLAR DISORDER,DEPRESSION)

AIR TRAVELBeyer, Mark. Sky Marshals. New York: Children’s

Press, 2003.Bogosian, Mark H., et al. Never Again: A Self-Defense

Guide for the Flying Public. Dallas: Brown Books,2004.

Steward, Frank A. The Plane Truth: Shift Happens at35,000 Feet. Manassas Park, Va.: Impact Publica-tions, 2004.

ALCOHOLISMCarson-DeWitt, Rosalyn, ed. Encyclopedia of Drugs,

Alcohol & Addictive Behavior. New York: Macmil-lan Reference USA, 2001.

Cotter, Bruce. When They Won’t Quit: A Call to Actionfor Families, Friends and Employers of Alcohol andDrug-addicted People. Hunt Valley, Md.: Holly Hill,2002.

Ketchum, Katherine, and William F. Asbury.Beyond the Influence: Understanding and DefeatingAlcoholism. New York: Bantam Books, 2000.

Marshall, Shelly. Young, Sober & Free: Experience,Strength, and Hope for Young Adults. Center City,Minn.: Hazelden, 2003.

O’Brien, Robert. Encyclopedia of Understanding Alco-hol and Other Drugs. New York: Facts On File,1999.

Rotskoff, Lori. Love on the Rocks: Men, Women, andAlcohol in Post-World War II America. Chapel Hill:University of North Carolina Press, 2002.

Torr, James D., ed. Alcoholism. San Diego: Green-haven Press, 2000.

Walton, Stuart. Out of It: A Cultural History of Intoxi-cation. New York: Harmony Books, 2002.

ALTERNATIVE MEDICINEFacklam, Howard. Alternative Medicine: Cures or

Myths? New York: Twenty-First-Century Books,1996.

Gordon, James S. Manifesto for a New Medicine: YourGuide to Healing Partnerships and Wise Use of Alter-native Therapies. Reading, Ma.: Addison-WesleyPublishing Company, 1996.

Gordon, Rena J., Barbara Cable Nienstedt, andWilbert M. Gesler. Alternative Therapies: Expand-ing Options in Health Care. New York: SpringerPub. Co., 1998.

Mackenzie, Linda. Inner Insights, the Book of Charts:Alternative Medicine & Awareness Quick ReferenceCharts. Manhattan Beach, Calif.: Creative Health& Spirit, 1996.

Mayo Clinic Health Information. Alternative Medi-cine and Your Health. Philadelphia, Pa.: MasonCrest Publishers, 2002.

Sachs, Judith. Nature’s Prozac: Natural Therapies andTechniques to Rid Yourself of Anxiety, Depression,Panic Attacks & Stress. Englewood Cliffs, N.J.:Prentice Hall, 1997.

Scully, Nicki. Alchemical Healing: A Guide to Spiritual,Physical, and Transformational Medicine. Rochester,Vt.: Bear & Company, 2004.

Trivieri, Larry and John W. Anderson, eds. Alterna-tive Medicine: The Definitive Guide. Berkeley:Celestial Arts, 2002.

ANGER AND ANGER MANAGEMENTMcKay, Gary D., and Steven A. Maybell. Calming

the Family Storm: Anger Management for Moms,Dads, and All the Kids. Atascadero, Calif.: ImpactPublishers, 2004.

Salmansohn, Karen. Burn Your Anger Book: Fill inYour Ire and Set It on Fire. New York: Source-books, Inc., 2001.

Schiraldi, Glenn R. Anger Management Sourcebook.New York: McGraw-Hill, 2002.

Semmelroth, Carl. Anger Habit Workbook: ProvenPrinciples to Calm the Stormy Mind. Naperville, Ill.:Sourcebooks Inc., 2004.

ANXIETY AND ANXIETY DISORDERSBeckfield, Denise F. Master Your Panic and Take Back

Your Life! 3rd ed. Atascadero, Calif.: Impact Pub-lishers, 2004.

Bourne, Edmund J. Beyond Anxiety and Phobia: AStep-By-Step Guide to Lifetime Recovery. Oakland,Calif.: New Harbinger Publications, 2001.

Dattilio, Frank M., and Jesus A. Salas-Auvert. PanicDisorder: Assessment and Treatment Through a Wide-Angle Lens. Phoenix, Ariz.: Zeig, Tucker & Co.,2000.

Bibliography 411

Doctor, Ronald M., and Ada P. Kahn. The Encyclope-dia of Phobias, Fears, and Anxieties, 2nd ed. NewYork: Facts On File, 2000.

Kahn, Ada P., and Ronald M. Doctor. Facing Fears:The Sourcebook for Phobias, Fears, and Anxieties.New York: Checkmark Books, 2000.

Lark, Susan M. Anxiety & Stress Self-Help Book: Effec-tive Solutions for Nervous Tension, Emotional Dis-tress, Anxiety, and Panic. Berkeley, Calif.: CelestialArts, 1996.

Root, Benjamin A. Understanding Panic and OtherAnxiety Disorders. Jackson: University Press ofMississippi, 2000.

Strong, Kenneth V. Anxiety Disorders: The Caregivers:Information for Support People, Family, and Friends.New York: SelectBooks, 2003.

Trego, Elizabeth, and Judith Trego. The Undercur-rents of Anxiety: The Revolutionary Approach toDealing with and Recovering from: Anxiety, Panic,Agoraphobia and Stress. Kearney, Neb.: MorrisPublishing, 1998.

BACKACHEAmir, Mark, and Perry Bonomo. Why Does My Back

Hurt So Much?: A Comprehensive Guide to Help YouPrevent and Treat Lower Back Pain. New York:ErgAerobics, 2001.

Borenstein, David G. Back in Control: Conventionaland Complementary Prescription for EliminatingBack Pain. New York: M. Evans, 2001.

Fox, Romy. 25 Natural Ways to Relieve Back Pain.Chicago: Keats Pub., 2001.

Kostuik, John J., Suzanne M. Jan de Beur, andSimeon Margolis. Back Pain and Osteoporosis. Bal-timore: Johns Hopkins Medical Institutions;New York: Medletter Associates, 2003.

Reed, Stephen Charles. The Complete Doctor’s HealthyBack Bible: A Practical Manual for Understanding,Preventing, and Treating Back Pain. Toronto: R.Rose, 2004.

Sauers, Joan, with Peter Edwards. Quick Fixes forEveryday Back Pain: Tips, Tricks, and Treatments toStop the Pain. New York: Marlowe & Company,2004.

Swezey, Robert L., and Annette M. Seezey. GoodNews for Bad Backs. Santa Monica, Calif.: CequalPub. Co., 2002.

BOREDOMLeckart, B., and L. G. Weinberger. Up from Boredom,

Down from Fear. New York: Richard Matek Pub-lishers, 1980.

Rediger, G. L. Lord, Don’t Let Me Be Bored. Philadel-phia: Westminster Press, 1986.

BURNOUTBerglas, Steven. Reclaiming the Fire: How Successful

People Overcome Burnout. New York: RandomHouse, 2001.

Glouberman, Dina. The Joy of Burnout: How the Endof the World Can Be a New Beginning. Maui, Hi.:Inner Ocean Pub., 2003.

Potter, Beverly. Beating Job Burnout: How to Trans-form Work Pressure Into Productivity. Berkeley,Calif.: Ronin Publishing, 1994.

Stevens, Paul. Beating Job Burnout: How to Turn YourWork Into Your Passion. Lincolnwood, Ill.: NTCPublishing Group, 1995.

CHRONIC FATIGUE SYNDROMEBerne, Katrina H. Chronic Fatigue Syndrome,

Fibromyalgia and Other Invisible Illnesses: TheComprehensive Guide. Alameda, Calif.: HunterHouse; Berkeley, Calif.: Publishers Group West,2002.

Forester, Jonathan. Conquering Chronic Fatigue. Ven-tura, Calif.: Gospel Light, 2003.

Patarca-Montero, Roberto. Chronic Fatigue Syn-drome and the Body’s Immune Defense System. NewYork: Haworth Medical Press, 2002.

Teitelbaum, Jacob. From Fatigued to Fantastic: AProven Program to Regain Vibrant Health, Based ona New Scientific Study Showing Effective Treatmentfor Chronic Fatigue and Fibromyalgia. New York:Avery, 2001.

COMPLEMENTARY THERAPIES (See ALTERNATIVE

MEDICINE)

CRISIS INTERVENTIONWright, H. Norman. The New Guide to Crisis and

Trauma Counseling. Ventura, Calif.: Regal Books,2003.

412 The Encyclopedia of Stress and Stress-Related Diseases

DEPRESSION/BIPOLAR DISORDER/MANICDEPRESSIONFawcett, Jan, Nancy Rosenfeld, and Bernard

Golden. New Hope for People with Bipolar Disorder.Roseville, Calif.: Prima Publishing, 2000.

Kim, Henny H. ed. Depression. San Diego: Green-haven Press, 1999.

Martin, Philip. The Zen Path through Depression. SanFrancisco: HarperSanFrancisco, 1999.

Preston, John. You Can Beat Depression. Atascadero,Calif.: Impact Publishers, 2004.

Reichenberg-Ullman, Judyth. Prozac-free: Homeo-pathic Medications for Depression, Anxiety and OtherMental and Emotional Problems. Rocklin, Calif.:Prima Health, 1999.

DOMESTIC VIOLENCE (See VIOLENCE)

DRUG ABUSE (See also ADDICTIONS)Carson-DeWitt, ed. Encyclopedia of Drugs, Alcohol, &

Addictive Behavior. New York: Macmillan Refer-ence USA, 2001.

Moe, Barbara. Drug Abuse Relapse: Helping Teens toGet Clean Again. New York: Rosen Pub. Group,2000.

Sullen, Jacob. Saying Yes: In Defense of Drug Use. NewYork: J. P. Tarcher/Putnam, 2003.

Torgoff, Martin. Can’t Find My Way Home: America inthe Great Stoned Age, 1945–2000. New York:Simon & Schuster, 2004.

Walsh, J. Michael, and Steven W. Gust, eds. Work-place Drug Abuse Policy: Considerations and Experi-ence in the Business Community. Rockville, Md.:Office of Workplace Initiatives, National Insti-tute on Drug Abuse, 1989.

EATING DISORDERSAndersen, Arnold E., Leigh Cohn, and Thomas

Holbrook. Making Weight: Men’s Conflicts withFood, Weight, Shapes & Appearance. Carlsbad,Calif.: Gurze Books, 2000.

Berg, Frances M. Women Afraid to Eat: Breaking Freein Today’s Weight-Obsessed World. Hettinger, N.Dak.: Healthy Weight Network, 2000.

Cassell, Dana K., and David H. Gleaves. The Ency-clopedia of Obesity and Eating Disorders. New York:Facts On File, 2000.

Kirkpatrick, Jim, and Paul Caldwell. Eating Disor-ders: Anorexia Nervosa, Bulimia, Binge Eating andOthers. Buffalo, N.Y.: Firefly Books, 2001.

Rocha, Toni L. Understanding Recovery from EatingDisorders. New York: Rosen Publishing Group,1999.

Schaefer, Jenni, with Thom Rutledge. Life withoutEd: How One Woman Declared Independence fromHer Eating Disorder and How You Can Too. NewYork: McGraw-Hill, 2004.

ERGONOMICS (HUMAN ENGINEERING)Chaffen, D. B., and G. B. J. Andersson. Occupational

Biomechanics. New York: John Wiley & Sons,1994.

Donkin, Scott W. Sitting on the Job: A Practical Sur-vival Guide to People Who Earn Their Living WhileSitting. North Bergen, N.J.: Basic Health Pub.,2002.

Grandjean, E. Fitting the Task to the Man: A Textbookof Occupational Ergonomics. New York: Taylor &Francis, 1988.

HEADACHESFinnigan, Jeffrey. Life Beyond Headaches. Olympia,

Wa.: Finnigan Clinic, 1999.Hartnell, Agnes. Migraine Headaches and the Foods

You Eat: 200 Recipes for Relief. Minneapolis:Chronimed, 1997.

Kahn, Ada P. Headaches. Chicago: ContemporaryBooks, 1983.

HEALTH AND WELL-BEINGGroopman, Jerome E. The Anatomy of Hope. New

York: Random House, 2004.Myss, Caroline. Anatomy of the Spirit: The Seven

Stages of Power and Healing. New York: HarmonyBooks, 1996.

———. Sacred Contracts: Awakening Your DivinePotential. New York: Harmony Books, 2001.

MENOPAUSEKagan, Leslee, Bruce Kessel, and Herbert Benson.

Mind over Menopause: The Complete Mind/BodyApproach to Coping with Menopause. New York:Free Press, 2004.

Bibliography 413

OBSESSIVE-COMPULSIVE DISORDERDeSilva, Padmal. Obsessive-Compulsive Disorder: The

Facts. Oxford; New York: Oxford UniversityPress, 1998.

Gravitz, Herbert L. Obsessive Compulsive Disorder:New Help for the Family. Santa Barbara, Calif.:Healing Visions Press, 1998.

OCCUPATIONAL STRESSAdams, John D. “Creating and Maintaining Com-

prehensive Stress-Management Training” inStress Management in Workplace Settings. NewYork: Praeger Publishers, 1980, 89–91.

Clay, Rebecca A. “Job Stress Claims Spin out ofControl.” American Psychological Association Moni-tor 29, no. 7, (July 1998): 52–55.

DeMarco, Tom. Slack: Getting Past Burnout, Busy-work, and the Myth of Total Efficiency. New York:Broadway Books, 2001.

Donatelle, R. J., and M. J. Hawkins. “EmployeeStress Claims: Increasing Implications for HealthPromotion Programs.” American Journal of HealthPromotion (1989): 19–25.

Fraser, Jill Andresky. White-Collar Sweatshop: TheDeterioration of Work and Its Rewards in CorporateAmerica. New York: Norton, 2001.

Grappel, Jack L. The Corporate Athlete: How to AchieveMaximal Performance in Business and Life. NewYork: Wiley, 2000.

Lazear, Jonathon. The Man Who Mistook His Job forHis Life. New York: Crown Publishers, 2001.

Lewis, Gerald W., and Nancy C. Zare. WorkplaceHostility: Myth & Reality. Philadelphia: Acceler-ated Development, 1999.

PANIC ATTACKS, PANIC DISORDER (See alsoANXIETY DISORDERS; PHOBIAS)Beckfield, Denise F. Master Your Panic and Take Back

Your Life!, 3rd ed. Atascadero, Calif.: ImpactPublishers, 2004.

PERFORMANCE ANXIETYDunkel, Stuart Edward. The Audition Process: Anxiety

Management and Coping Strategies. Stuyvesant,N.Y.: Pendragon Press, 1989.

Robert Moss. “Stage Fright Is Actors’ EternalNemesis,” New York Times, January 6, 1992, E2.

PHOBIASDoctor, Ronald M., and Ada P. Kahn. Encyclopedia of

Phobias, Fears, and Anxieties, 2nd ed. New York:Facts On File, 2000.

Kahn, Ada P., and Ronald M. Doctor. Facing Fears:The Sourcebook for Phobias, Fears, and Anxieties.New York: Checkmark Books, 2000.

Monroe, Judy. Phobias: Everything You Wanted toKnow, but Were Afraid to Ask. Springfield, N.J.:Enslow Publishers, 1996.

POST-TRAUMATIC STRESS DISORDER (PTSD)Porterfield, Kay Marie. Straight Talk about Post-Trau-

matic Stress Disorder: Coping with the Aftermath ofTrauma. New York: Facts On File, 1996.

Rosen, Marvin. Understanding Post-Traumatic StressDisorder. Philadelphia: Chelsea House, 2003.

Shay, Jonathan. Odysseus in America: Combat Traumaand the Trials of Homecoming. New York: Scribner,2002.

Semmelroth, Carl, and Donald E. P. Smith. TheAnger Habit: Proven Principles to Calm the StormyMind. Naperville, Ill.: Sourcebooks, Inc., 2004.

PSYCHOLOGY, CONTEMPORARYThich Nhat Hanh. Peace Is Every Step: The Path of

Mindfulness in Everyday Life. New York: BantamBooks, 1992.

RELAXATIONBenson, Herbert. The Relaxation Response. New

York: Avon Books, 1975.———. Beyond the Relaxation Response. New York:

Berkeley Press, 1985.———. Your Maximum Mind. New York: Times

Books, 1987.Benson, Herbert, Eileen M. Stuart, and staff of the

Mind/Body Medical Institute. The Wellness Book:The Comprehensive Guide to Maintaining Health andTreating Stress-Related Illness. New York: Carol,1992.

SMOKING (See also TOBACCO)Hirschfelder, Arlene B. Encyclopedia of Smoking and

Tobacco. Phoenix, Ariz.: Oryx Press, 1999.

414 The Encyclopedia of Stress and Stress-Related Diseases

SOCIAL ANXIETIES AND PHOBIAS (See alsoPHOBIAS)Antony, Martin M. The Shyness & Social Anxiety

Workbook: Proven Techniques for Overcoming YourFears. Oakland: New Harbinger, 2000.

Markway, Barbara G. Dying of Embarrassment: Helpfor Society Anxiety and Phobia. Oakland: New Har-binger Publications, 1992.

Dayhoff, Signe A. Diagnonally Parked in a ParallelUniverse: Working through Social Anxiety. Placitas,N. Mex.: Effectiveness-Plus Publications, 2000.

STRESS AND STRESS MANAGEMENTAdams, John D. “Creating and Maintaining Com-

prehensive Stress-Management Training” inStress Management in Workplace Settings. PraegerPublishers, New York: 1989, 89–91.

Boenisch, Ed, and C. Michele Haney. The StressOwner’s Manual: Meaning, Balance and Health inYour Life, 2nd ed. Atascadero, Calif.: Impact Pub-lishers, 2004.

Evans, Karin. “Is Stress Wrecking Your Mood?”Health 14, no. 3 (April 2000): 119–124.

Gonthier, Giovinella, and Kevin Morrissey. RudeAwakenings: Overcoming the Civility Crisis in theWorkplace. Chicago: Dearborn Trade, 2002.

Kahn, Ada P. The A-Z of Stress: A Sourcebook for Fac-ing Everyday Challenges. New York: Facts On File,2000.

Lehrer, Paul M., and Robert L. Woolfolk, (eds.)Principles and Practice of Stress Management, 2nded. New York: Guilford Press, 1993.

Sapolsky, Robert M. Why Zebras Don’t Get Ulcers.New York: W. H. Freeman & Company, 1994.

Van Duyne, Sara. Stress and Anxiety-Related Disor-ders. Berkeley Heights, N.J.: Enslow, 2003.

TOBACCOLovell, Georgina. You Are the Target: Big Tobacco: Lies,

Scams—Now the Truth. Vancouver: Chryan Com-munications, 2002.

VIOLENCEAllcorn, Seth. Anger in the Workplace. Westport,

Conn. Quorum Books, 1994.Blythe, Bruce T. Blindsided: A Manager’s Guide to Cat-

astrophic Incidents in the Workplace. New York:Portfolio, 2000.

Carll, Elizabeth K. Violence in Our Lives: Impact onWorkplace, Home, and Community. Boston, Mass.:Allyn and Bacon, 1999.

Kelleher, Michael D. Profiling the Lethal Employee:Case Studies of Violence in the Workplace. Westport,Conn.: Praeger, 1997.

Paulk, Daniel. Alert and Alive: Defusing Anger andViolence in the Workplace. West Des Moines, Iowa:American Media, 1999.

Remsberg, Charles. Tactics for Criminal Patrol: VehicleStops, Drug Discovery and Officer Survival. North-brook, Ill.: Calibre Press, 2000.

Smith, Shawn T. Surviving Aggressive People: PracticalViolence Prevention Skills for the Workplace and theStreet. Boulder: Sentient Publications, 2003.

WOMEN AND STRESSFreudenberger, Herbert, and Gail North. Women’s

Burnout: How to Spot It, How to Reverse It, and Howto Prevent It. Garden City, N.Y.: Doubleday &Company, Inc., 1985.

Kahn, Ada P. “Women and Stress,” Sacramento Med-icine 46, no. 9 (September 1995): 16–17.

Powell, J. Robin. The Working Woman’s Guide toManaging Stress. Englewood Cliffs, N.J.: PrenticeHall, 1994.

Siress, Ruth Hermann. Working Women’s Communi-cations Survival Guide: How to Present Your Ideaswith Impact, Clarity, and Power and Get the Recogni-tion You Deserve. Englewood Cliffs, N.J.: PrenticeHall, 1994.

WORKPLACE STRESS (See OCCUPATIONAL STRESS)

Bibliography 415

Note: Page numbers in boldface indicatemain entries.

AAA. See Alcoholics AnonymousAAD. See American Academy of

DermatologyAAMA. See American Academy of

Medical AcupunctureAAMI. See age-associated memory

impairmentAARP. See American Association of

Retired PersonsABA. See American Bar Associationabdominal (diaphragmatic) breathing 73,

74abortion 1, 292, 373, 388. See also

miscarriageabsenteeism 2, 76, 291, 392abuse 79, 110, 114. See also domestic

violenceACA. See American Chiropractic

Associationaccidents 2. See also injuries

Chernobyl 82–83of child workers 84, 360falling merchandise as 146–147farming and 149personal protective equipment for

prevention of 152, 216, 267, 275slips, trips, and falls 16, 85, 152,

284, 313, 336, 358, 387accountants 2–3, 390acculturation 3–4, 240–241. See also

homesicknessAccutane 5ACE inhibitors 183acid rain 21, 22acne 4–5acquired immunodeficiency syndrome

(AIDS) 5–7. See also humanimmunodeficiency virus

medicinal marijuana use in 230reference service on 20statistics on 5–6, 194transmission of 6, 99, 174, 178,

194, 195, 217, 329

ACR. See American College of Radiologyacrophobia 7, 178ACS. See American Cancer SocietyACSM. See American College of Sports

MedicineACTIS. See AIDS Clinical Trials

Information Serviceacupressure 7, 69, 173, 233acupuncture 8–9, 69, 81, 142, 173, 264ADA. See Americans with Disabilities

Actadaptability 159Adaptation to Life (Valliant) 102addiction 9–10. See also alcoholism and

alcohol dependence; smoking;substance abuse

acupuncture for 8to barbiturates 58and codependence 93eating disorders as 133, 134endorphins and 142gambling as 157–158to hallucinogens 167hopelessness and 189journaling for 211to marijuana 229–230to methamphetamines 91–92recognizing 9severity index of 10

adenosine 77ADHD. See attention-deficit/hyperactivity

disorderadolescents 299–300. See also peer group

acne in 4–5angry 34binge drinking 62–64chronic fatigue syndrome in 87dating 109depression in 120developing autonomy 52HIV/AIDS in 6, 7irritable bowel syndrome in 208lonely 223, 224masturbation in 234menstruation in 238methamphetamine use in 91–92migraine in 171, 172

obese 259occupational injuries of 84parenting 299–300, 345personality disorders in 274pregnant 289shy 331suicide in 120, 351–352thyroid cancer in 82wet dreams of 383–384in workplace 84, 360, 380

Adopting Your Child (Reynolds) 10adoption 10, 118, 373adrenaline (epinephrine) 10–11, 34, 143,

145, 150, 184, 356advance directives 113–114, 136advertising 11, 63–64, 143, 272AED (automated external defibrillator).

See defibrillatorsaffective disorders 11–13. See also specific

disordersaffective equivalents. See masked

depressionaffirmation 78African Americans 6, 25, 293, 352, 393after-school programs 270age-associated memory impairment

(AAMI) 31, 236age discrimination 14Ageless Body, Timeless Mind (Chopra) 86,

87Agent Orange 14aggression 14–15, 25, 75, 128, 131. See

also anger; hostilityaging 15–16. See also elderly; retirement

and Alzheimer’s disease 31and deafness 111and employment 14, 81and forgetting 154and hair loss 166and infertility 204and memory 31, 236and midlife crisis 240and osteoarthritis 42overtime and 265premature 345and sex drive 326and sleep 334

INDEX

417

agoraphobia 17–20, 24, 37, 268, 269,282, 318, 333, 340, 357, 393

AHP. See Association of HumanisticPsychology

AIDS. See acquired immunodeficiencysyndrome

AIDS Clinical Trials Information Service(ACTIS) 20

AIDSinfo 20air conditioning 91, 332airplanes 20–21

avian flu precautions 54jet lag 65, 90, 210and motion sickness 248phobia about 20, 21, 101, 178, 281and security 21, 22–23stun guns on 359and terrorism 21

air pollution 21–22, 90–91, 142, 155,245, 332

airport screening machines 21, 22–23.See also terrorism

alcoholas antistress drug 277and barbiturates 58and benzodiazepines 62as coping mechanism 36and depression 118and dizziness 127effects of 25for fear of flying 21and hangover 168and high blood pressure 183and insomnia 206and methamphetamines 91and panic disorder 269physical tolerance for 24

Alcoholics Anonymous (AA) 25–26, 140

alcoholism and alcohol dependence23–26

acupuncture for 8in agoraphobia 17, 19, 24in anxiety disorders 40and appetite 258aversion therapy for 52, 61behavior therapy for 59binge drinking 24, 62–64causes of 23–24in chronic illness 89and codependence 93definition of 24denial of 114as disease 25and domestic violence 127, 128in dysfunctional families 131in gamblers 158in grief 163in homeless 186

in immigrants 3journaling for 211loneliness and 223as public health problem 24–25self-help groups for 25–26statistics on 24, 25symptoms and stages of 25

Alexander, F. Matthias 26Alexander technique 26–27allergic alveolitis. See hypersensitivity

pneumonitisallergic contact dermatitis 27allergic rhinitis 27, 156, 169, 245allergic sinusitis 169allergies 27–28, 79, 82, 121, 159, 164,

184, 201, 284, 291. See also asthmaAlpern, Lynne 196–197alpha blockers 39, 183alprazolam (Xanax) 21, 28, 62, 269, 279,

395alternative medicine 28–31, 187, 346. See

also specific therapiesfor addiction 9for arthritis 42–43for breast cancer 72v. conventional medicine 29for headaches 173health insurers and 30for menopause 237selecting 30statistics on 28–29

altophobia 178Alzheimer, Alois 31Alzheimer’s Association 32Alzheimer’s disease 16, 31–33

and caregivers 31, 32, 147diagnosis of 31–32fear of developing 235and immune system 201statistics on 31support groups for 32, 355symptoms of 31

Alzheimer’s Disease and Related DisordersAssociation 32

Alzheimer’s Disease International 32AMA. See American Management

Association; American MedicalAssociation

A Matter of Degree (AMOD) 62–63ambient inhalation (aromatherapy) 41ambivalence 33amenorrhea 238American Academy of Allergy and

Immunology 27American Academy of Dermatology

(AAD) 353American Academy of Medical

Acupuncture (AAMA) 9American Academy of Orthopedics 216

American Animal Hospital Association276

American Association of Retired Persons(AARP) 15, 80, 142, 341, 352

American Bar Association (ABA) 25, 142American Board of Plastic Surgery 102American Cancer Society (ACS) 227American Chiropractic Association (ACA)

85American College of Radiology (ACR)

227American College of Sports Medicine

(ACSM) 182American Council of Life Insurers 224American Dental Association 115American Diabetes Association 122American Foundation for Homeopathy

187American Heart Association 86, 176, 385American Industrial Hygiene Association

203American Institute of Stress 78American Lung Association 43American Management Association

(AMA) 130American Massage Therapy Association

(AMTA) 232, 233American Medical Association (AMA)

25, 62, 63, 141, 142, 187, 227,320–321, 379

American Psychiatric Association 40,246, 262, 295. See also Diagnostic andStatistical Manual

American Social Health Association 181American Society for Bariatric Surgery

260American Society of Plastic and

Reconstructive Surgeons 72, 102American Society of Suicidology 352Americans with Disabilities Act of 1990

(ADA) 33, 80American Urinary Association 348amnesia 236Amnesty International Canada 359AMOD. See A Matter of DegreeANAD. See National Association of

Anorexia Nervosa and AssociatedDisorders

analytical play therapy. See play therapyAnatomy of an Illness as Perceived by the

Patient (Cousins) 103, 197, 217anger 33–35. See also aggression; hostility

alcohol and 25approaching death and 112breast cancer and 72in chronic illness 89control and 34, 101divorce and 126downsizing and 130

418 The Encyclopedia of Stress and Stress-Related Diseases

Index 419Index 419

in grief 35negative 34and physiological changes 34positive 34repressed 34

angina pectoris 35angioedema 27, 184angiotensin-converting enzyme (ACE)

inhibitors 183ankylosing spondylitis 103, 197anniversary reaction 35anorexia nervosa 68, 133, 204, 238, 258,

382anorgasmia 35, 155, 327anthrax 35, 208antianxiety drugs 13, 36, 38–40, 277,

280, 282. See also specific drugsantibodies 197, 201anticipatory anxiety 20–21, 39anticonvulsants 39, 62, 119antidepressants 13, 117, 119–120,

277–280. See also specific drugsfor anxiety disorders 38for bed-wetting 58for chronic fatigue syndrome 88in elderly 16historical development of 278for manic-depressive disorder

229mechanisms of 277–278, 325for panic disorder 269for post-traumatic stress disorder

286side effects of 117, 119–120and teen suicide 120

antigens 197antihistamines 39anti-inflammatory drugs 46–47antipsychotic drugs 39–40, 229anxiety 36

airplanes and 20–21in anorexia nervosa 133anticipatory 20–21, 39biofeedback for 65causes of 36coping with 36domestic violence and 127in elderly 15, 311v. fear 36hypnosis for 198and immune system 201and irritable bowel syndrome 208mathematics 234music for 250–251performance 39, 73, 76, 273–274.

See also public speaking; stagefright

rape and 303research on 348

separation 323–324witnessing crime and 106

anxiety disorders 36–41. See also specificdisorders

causes of 37cognitive therapy for 94diagnosis of 37hostility in 192secrets and 319social costs of 40support groups for 40, 321treatment of 37–40, 59. See also

antianxiety drugsanxiolytics 39ARI. See Autism Research Institutearomatherapy 41–42Arrhenius, Svante 161arrhythmia 42, 267–268arthritis 42–43, 162, 291, 297, 360Artress, Lauren 215asbestos 22, 43–44, 152, 284asbestosis 22, 44Asian Americans 25, 372Asperger, Hans 44Asperger’s syndrome (AS) 44–45aspirin 162, 172, 176, 272assertive behavior 45, 97, 386assertiveness training 34, 45assisted reproduction techniques

204–205, 290assisted suicide 113, 141, 352–353Association of Humanistic Psychology

(AHP) 195–196asthma 21, 27, 45–47, 155, 156, 169,

245, 384atherosclerosis 47, 86, 102, 182, 379ATIS. See HIV/AIDS Treatment

Information Serviceatonic constipation 100atopic dermatitis 121attention-deficit/hyperactivity disorder

(ADHD) 47–49, 220autism 49–50. See also Asperger’s

syndromeAutism Research Institute (ARI) 49autogenic training 50autohypnosis 198autoimmune disorders 50, 164. See also

specific disordersautomated external defibrillator. See

defibrillatorsautomated teller machines (ATMs) 50–51automation in the workplace 51, 81,

98–99, 138, 205, 392automobiles 51–52, 248, 313, 367,

386–387autonomy 52, 73, 88, 98, 131, 283. See

also controlaversion 52

aversion therapy 52, 61avian flu 52–54Aviation and Transportation Security Act

of 2001 (ATSA) 22Ayres, A. Jean 323Ayurveda 54–55, 86azapirones 39

Bbaby boomers 56Bach flower remedies 188back pain 56–57, 69, 232, 288, 367Bandura, Albert 319barbiturate drugs 57–58, 62, 277Bardwell, Chris B. 274Barling, Julian 379Barnes, John 69Barnett, Rosaline 270battered women 127–128battle fatigue. See combat fatigue; war

neurosisBeck, Aaron 94bed-wetting 52, 58–59behavior therapy 59–61, 296. See also

specific therapiesfor affective disorders 13for agoraphobia 18for anxiety disorders 59for claustrophobia 90for depression 59, 60, 119for fear of dentistry 115goal of 59for habits 166, 254for hair pulling 167for hostility 192with hypnosis 198for inhibition 206meditation in 235for nausea 253for obsessive-compulsive disorder

37, 40, 59, 60, 261for pain 266for palpitations 268for panic disorder 269for phobias 37, 40, 59, 60, 282, 333for sexual difficulties 59for stage fright 342

belching 203Benson, Herbert 61, 241–242, 287–288,

307, 342, 344, 366benzodiazepine drugs (BZDs) 39, 58, 62,

277. See also Valium; Xanaxbereavement. See griefBereavement of Loss Center 163Bernard, Claude 188Berne, Eric 365beta blockers 39, 100, 183, 280Beth Israel Hospital 242bibliotherapy 62, 69, 335

bicyclic antidepressants 280binge drinking 24, 62–64. See also

alcoholism and alcohol dependencebinge eating 133–134, 382biobehavioral healing 103–104biofeedback 61, 64–65

for arthritis 42–43for chronic fatigue syndrome 88for constipation 101for diabetes 122for fear of dentistry 115for fibromyalgia 151with galvanic skin response 157for habits 166for headaches 65, 173for high blood pressure 65, 182with meditation 65, 234–235for pain 266for phobias 282for urinary incontinence 349

biogenic amines 13biological clock 56, 65, 230, 373biorhythms 65. See also circadian

rhythmsbipolar disorder. See manic-depressive

disorderbird fancier’s lung 197“bird flu.” See avian fluBirdwhistell, Ray L. 214birth control 65–66, 99, 172, 289, 303,

315, 329, 373, 377–378birth order 66–67, 331bisexuality 329black lung 388bladder training 374–375Bleuler, Eugen 33blindness 160–161, 180bloating 203blog (Web log) 67blood pressure 181, 182, 254, 256, 278.

See also high blood pressureblood transfusion 178, 383Bloom, Peter B. 198BLS. See Bureau of Labor Statisticsblue (color) 95Blumenfeld, Esther 196–197body image 67–68, 320, 385, 386

breast reconstruction and 72and cosmetic surgery 102, 284and dieting 124and eating disorders 133, 134, 382exercise and 145hair loss and 166and inferiority complex 204nutrition and 258, 346

body language 44, 68, 97, 214, 218,222–223

body mass index (BMI) 259body temperature 89–90

body therapies 68–69. See also mind-bodyconnections; specific therapies

books as stress relief 62, 69, 335borderline depression. See masked

depressionboredom 15, 69–70, 196, 219, 223, 311,

371Borysenko, Joan 242Bostwick, John 72bovine spongiform encephalopathy. See

“mad cow” diseaseBowditch, James L. 239–240brain death 113brainstorming 70, 105brainwashing 70–71, 108breast cancer 71–72, 207, 227–228,

355–356breast-feeding. See nursing mothersbreast reconstruction 72breath-holding spells 73breathing 73–74

exercise and 144in guided imagery 164inefficient 73–74. See also asthma;

emphysema; hyperventilationin meditation 234sighing 333during sleep 73, 334, 339styles of 73t’ai chi and 358wheezing 384in yoga 74

breathing exercises 73, 74for agoraphobia 18in autogenic training 50and coping skills 101for fear of dentistry 115for high blood pressure 182for performance anxiety 274

Brent, David A. 352Broder, Betsy 200Brodt, Susan E. 274bronchodilators 46–47brothers. See sibling relationshipsBrowne, Richard 250Brubaker, Linda 348bruxism 360, 362Buber, Martin 308“building-related illness.” See sick building

syndromebulimarexia 134bulimia 68, 133–134, 382bullies 74–75, 204, 317, 320, 354Bullock, Kim D. 26Bunker, Barbara 231Buono, Anthony F. 239–240buproprion 119, 120, 280bureaucracy 75

Bureau of Labor Statistics (BLS) 84, 154,224, 257, 262–264, 372, 386, 389

Burke, Jim 361burnout 3, 75–76, 347, 386burping 203buspirone 280butterflies in the stomach 76BZDs. See benzodiazepine drugs

Ccaffeine 77, 171, 206, 335, 346, 347,

357calcium channel blockers 183camera phones 361Canadian Family Physician 4, 206, 283Canadian Psychological Association

292cancer 78–79. See also specific types of cancer

in firefighters and rescue workers152

guided imagery for 29, 78hypnosis for 78meditation for 234in mining workers 244psychoneuroimmunology and 297religion for 308support groups for 78, 333

Cannon, Walter B. 188carbon dioxide 22, 161carbonless copy paper 79carbon monoxide 21, 142, 338, 367“carefrontation” 333caregivers 79–80, 110, 147

to Alzheimer’s patients 31, 32, 147chronic illness and 88, 345to elderly 79–80, 135, 136, 186,

224, 256–257, 355, 385long-term care insurance and 224research on 344–345and sick role 333support groups for 136, 355

Carnoy, David 149–150Carnoy, Martin 149–150carpal tunnel syndrome 80–81, 310, 390Carr, John A. 124cars. See automobilesCartwright, Rosalind 334castor beans 312catastrophize 81, 119, 319, 394cats 27, 276cell phones 361Census Bureau, U.S. 248–249, 386Center for the Family 126Center for the Study and Prevention of

Violence (CSPV) 380Center for the Study of Autism (CSA)

49Center on Alcohol Marketing and Youth

63–64

420 The Encyclopedia of Stress and Stress-Related Diseases

Index 421Index 421

Centers for Disease Control andPrevention (CDC)

on accidents 2on arthritis 42on avian flu 53, 54on fireworks 153on HIV/AIDS 6, 7, 194on needlestick injuries 253on obesity 259on ricin 312on sarin 315on SARS 316–317on SIDS 350on teen suicide 120on unwed mothers 373on West Nile virus 383

CFS. See chronic fatigue syndromeChallela, Mary S. 124changing nature of work 81–82. See also

mergersChao, Elaine 143chemical hazards 82, 169–170, 191, 249,

275, 284, 367chemotherapy 71, 230, 251, 258Chernobyl 82–83chest (thoracic) breathing 73child abuse 128

by caregivers 79in day care 110in dysfunctional families 131and self-esteem 320

childbirth 83, 180, 288, 348, 374. See alsopostpartum depression

child labor 83–85, 360, 380Child Labor Coalition (CLC) 84–85children. See also fathers; mothers;

parenting/parents; peer group; school;sibling relationships

ADHD in 47–48, 220adopted 10, 118, 373advertising aimed at 11, 272allergies in 27angry 34, 358anxiety disorders in 37Asperger’s syndrome in 44–45asthma in 45, 46autistic 49autonomy developed by 52bed-wetting in 58–59birth order of 66–67, 331breath-holding spells by 73bullies 74, 75, 204, 317, 320, 354chronic fatigue syndrome in 87codependence and 93colicky 95colors attracting 95competition and 98criticism received by 106–107, 204,

317, 320

in day care 110, 221, 247, 389, 390death of 163, 165, 338, 350at dentist 115depression in 118diabetic 122disabled 80, 124–125divorce and 126in dysfunctional families 131emotions of 139of farmers 149fireworks-related injuries in 153frustrated 155, 358helpless 178hemophiliac 178herpes virus in 180HIV/AIDS in 6–7, 194homeless 187homesick 188–189inferiority complex in 204jealous 210“latch key” 247, 270of lawyers 218learned optimism in 219learning disabilities in 219–220left-handed 220lice on hair of 221living with grandparents 271, 373memory in 235mental retardation in 220, 239modeling in 245and money 246nail biting in 252nightmares of 255obese 259obsessive-compulsive disorder in

260pet loss and 276phobias in 281play therapy for 284post-traumatic stress disorder in

287psoriasis in 294reading books 69relocation and 309remarriage and 309rheumatoid arthritis in 42security object of 319self-object of 321sensory integrative dysfunction in

322–323separation anxiety in 323–324of shift workers 330shy 331sleepwalking 335in stepfamilies 343stuttering 349tantrums of 323, 358thyroid cancer in 82tics in 364

toilet training of 217, 365underachievers 371

chiropractic medicine 85chlamydia 328cholesterol 47, 85–86, 182, 276Chopra, Deepak 55, 86–87chronic fatigue syndrome (CFS) 87–88,

355chronic illness 88–89. See also specific

illnessesand anger 34and caregivers 88, 345and depression 88, 117and immune system 201music for 250, 251self-help groups for 321and sexual fears 327and sleep 334and unpaid leave 148

chronic obstructive pulmonary disease(COPD) 234

cigarettes. See smokingcircadian rhythms 89–90, 210, 318, 330civil unions 231Clark, David 352Clark, Yolanda 359classic (Pavlovian) conditioning 99classic migraine 171claustrophobia 18, 20, 90, 99, 138, 281CLC. See Child Labor CoalitionClean Air Act of 1990 90–91climate 91, 161–162, 318clinical depression. See exogenous

depressionclinical psychology 296closed-angle glaucoma 161club drugs 91–92cluster headaches 170–171COBRA (Consolidated Omnibus Budget

Reconciliation Act) 92cocaine 8, 92–93codependency 93cognitive theory of depression 118cognitive therapy 13, 48, 93–94, 119, 269cohabitation 94, 329. See also live-in;

marriagecold air 46, 184. See also climatecold stress 94–95Coletti, Linda 154colic 95collagen injections 349colleagues. See coworkersCollege of Family Physicians of Canada

311–312Colligan, Douglas 296color 95color blindness 95–96combat fatigue 96, 286. See also post-

traumatic stress disorder; war neurosis

comfort foods 96commercials. See advertisingcommon migraine 171communication 97–98. See also body

language; listeningwith blog 67in conflict resolution 99–100about divorce 126in dysfunctional families 131failure of 97gender differences in 97–98“golden rule” of 98hazard 169–170laughter as 217lawyers and 218in parenting 69about sexual problems 155sharing secrets 319

commuter marriage 231commuting 51competition 98, 107, 218, 331, 350, 368complementary medicine. See alternative

medicinecomplete abortion 244Complete Guide to Your Emotions and to Your

Health, The (Padus) 223–224, 376compulsive behavior 260–261. See also

obsessive-compulsive disorderin agoraphobia 18gambling as 157–158in lawyers 218masturbation as 234and migraine 171and panic disorder 269shopping as 331

computerized axial tomography (CT scan)32, 173

computers 51, 81, 98–99, 138, 205, 310,341, 390, 392

concentration-type meditation 235conditioning 99, 281, 282condoms 6, 99, 194, 315, 328, 378confined spaces 90, 99, 138, 242, 281,

284, 332conflict resolution 99–100congenital syphilis 328–329congestive heart failure 100conscience. See guiltConsolidated Omnibus Budget

Reconciliation Act. See COBRAconstipation 100–101, 179, 208, 288constructive criticism 107consumers 11, 143contact dermatitis 27, 284contraception. See birth controlcontrol 101. See also autonomy

airplanes and 20, 21alcohol and 25Alzheimer’s disease and 31

anger and 34, 101behavior therapy and 59brainstorming and 70chronic illness and 88computers and 98at dentist 115farming and 148grief and 163and hardiness 168–169, 274and helplessness 219and hopelessness 189, 190in hospital 190hostages and 192journaling and 211judicial proceedings and 211layoffs and 219menopause and 193money and 246music and 251and panic disorder 269powerlessness and 287sick building syndrome and 332

convergent thinking 105COPD. See chronic obstructive pulmonary

diseasecoping 101–102, 144, 345, 347, 348

in agoraphobia 19with anxiety 36Ayurveda and 54and cancer 78defense mechanisms in 114definition of 101in diabetes 122with disability 124–125with domestic violence 127hair pulling as 167and health 101–102and homeostasis 188laughter for 216with migration 241for physicians 283self-efficacy and 320self-esteem and 320support groups for 120transactional analysis for 365women 385–386in workplace 101, 391

Coping with Crisis and Handicap (Carr) 124Coping with Job Loss (Leana and Feldman)

372copy paper, carbonless 79coronary artery disease 35, 47, 86, 102,

176, 182corporate buyout 102. See also mergerscorticosteroids 46, 50, 78, 81, 151, 294cortisol 118cortisone 8, 184cosmetic surgery 102–103, 240. See also

plastic surgery

co-therapy 298counseling 103. See also psychotherapiesCousins, Norman 103–104, 197, 216–217covert modeling 60, 104covert rehearsal 104covert reinforcement 104covert sensitization 52coworkers 75, 76, 104–105, 291, 379,

388, 390, 391crab lice 221crack cocaine 93creativity 70, 95, 105–106, 144, 145, 394“crib death.” See sudden infant death

syndromecrime, witnessing 106criminal complaint 128crisis 106criticism 97, 106–107, 109, 204, 281,

317, 336, 394Crocker, Allen C. 125crowding 107, 275cruise ship virus 107crying 107–108, 223, 224, 288. See also

colicCSA. See Center for the Study of AutismCSPV. See Center for the Study and

Prevention of ViolenceCT scan 32, 173cubicles 108cults 71, 108culture shock 241cumulative trauma disorders (CTD) 143cyclothymia 12

DDallman, Mary 96dance therapy 109date rape 62, 303–304dating 109–110, 126, 328, 329Davis, Lisa 275day care 110–111, 135, 136, 221, 247,

389, 390daydreaming 111day shift. See shift workdeadlines 111deafness 111, 255, 367death 112–114. See also chronic illness;

end-of-life care; grief; suicideadvance directives 113–114, 136from affective disorders 11–12from AIDS 6from Alzheimer’s disease 31anniversary of 35from binge drinking 62of child 163, 165, 338, 350ethical and moral aspects 113, 141facing one’s own 112of firefighters and rescue workers

152, 324

422 The Encyclopedia of Stress and Stress-Related Diseases

Index 423Index 423

from heart attack 176in hospital 113–114, 191karoshi 213–214legal aspects 113–114of loved one 112of mining workers 242–243of spouse 112, 163, 305, 344–345.

See also widowsas taboo topic 357

death certificate 113Debtors Anonymous 331decision making 101, 114, 160, 211“decompression period” 191–192deep tissue massage 233, 313Deer, Patricia 233deer ticks 225defense mechanisms 114, 159, 163defibrillators (automated external

defibrillator: AED) 114–115dementia 16, 31denial 72, 115

of approaching death 112in chronic illness 89as defense mechanism 114and faith healing 146

dentists 115, 157, 251, 255, 276, 360depersonalization 17depression 115–121, 228–229. See also

antidepressants; dysthymia; manic-depressive disorder; seasonal affectivedisorder syndrome

in adolescents 120age of onset and incidence of 116in Alzheimer’s disease 31anger as 34anniversary reaction 35approaching death and 112back pain and 57behavior therapy for 59, 60, 119causes of 13, 117–118in children 118chronic fatigue syndrome and 87chronic illness and 88, 117cognitive therapy for 94, 119communication failure and 97crying in 107–108death rate in 11definition of 116in diabetics 122domestic violence and 127double 132downsizing and 130in eating disorders 133in elderly 15, 16, 116–117, 135,

298–299electroconvulsive therapy for 119,

138in empty nest syndrome 141endogenous 117, 145

exogenous 116, 117, 145genital herpes and 180glass ceiling and 160in grief 112, 163helplessness in 178, 219holiday 185in homeless 186homesickness and 189homosexuality and 189hopelessness in 189in hostages 191hostility in 192humor for 197and immune system 201and impotence 202inferiority complex and 204lack of friends and 154loneliness and 223, 224masked 232menopause and 193miscarriage and 244and obsessive-compulsive disorder

261personality and 13postpartum 285, 288–289powerlessness in 287during pregnancy 285, 288psychotherapies for 117, 118–119rape and 303relocation and 309secondary 318secrets and 319self-help and support groups for

120–121signs and symptoms of 115, 117and sleep 130, 206, 334social phobia and 281subsyndromal 116suicide in 11, 115, 120, 350–351treatment of 13weekend 382in women 116, 229

Depression and Related AffectiveDisorders Association (DRADA)120–121

depressive episodes 12, 18, 19, 116, 228depressive equivalents. See masked

depressiondepressive syndrome 12deprogramming 108dermatitis 27, 121, 284desensitization 282. See also exposure

therapy; Eye MovementDesensitization and Reprocessing;systematic desensitization

DeVryer, Miepje 256dexamethasone 261diabetes (diabetes mellitus) 121–123

causes of 122

comfort foods and 96constipation in 100diagnosis of 121–122insulin-dependent 50, 122meditation for 234mind-body connection for 242non-insulin-dependent 122–123obesity and 122, 259prevalence of 122treatment of 122

Diagnostic and Statistical Manual (DSM IV-R)123

on ADHD 47on agoraphobia 17on alcoholism 24on anxiety disorders 36on Asperger’s syndrome 44on panic attacks 268on phobia 281on serious mental illness 324

diaphragmatic (abdominal) breathing 73,74

diarrhea 100, 123–124, 208diary 211diastolic pressure 182diazepam. See ValiumDickread, Grantly 83diet. See nutritionDietary Guidelines for Americans 259–260dieting 124, 133, 259, 346, 382. See also

eating disordersDiMario, Francis, Jr. 73DIMS. See disorders of initiating or

maintaining sleepDinner, Dudley 334direct conditioning 281, 282direct exposure 18disabilities 124–125

and caregiving 80children with 80, 124–125and constipation 100coping with 124–125deafness 111depression as 116in elderly 125law on rights of people with 33,

80learning 201, 219–220and loneliness 223migraine headaches in 171self-help and support groups for

125workers’ compensation for 388

disk damage 57disorders of excessive sleep (DOES) 334,

335disorders of initiating or maintaining

sleep (DIMS) 334. See also insomniadissociation 114

dis-stress 125, 144, 344diuretics 183divergent thinking 105diversity 3–4, 125, 393divorce 125–126, 231, 306, 328. See also

remarriageanniversary of 35dating after 109, 126and immune system 201and loneliness 223midlife crisis and 240and parenting 126, 271relocation and 309

“Divorce: For Better Not For Worse”(Kahn) 126

dizziness 126–127, 168, 178, 197, 248,253, 268, 273, 286, 300. See alsovertigo

DOES. See disorders of excessive sleepdogs 276domestic violence 127–129. See also

battered women; child abuse; incestand anxiety 36dissociation in 114in dysfunctional families 131farming and 149legal rights of victims 128and self-esteem 127, 320

dopamine 118, 138, 277, 280Dossey, Larry 129–130, 288double depression 132downsizing 14, 102, 104, 130, 211, 218,

219, 240, 291–292, 311, 391. See alsolayoffs

DRADA. See Depression and RelatedAffective Disorders Association

dreams 58, 77, 130–131, 286, 335. Seealso nightmare; sleep; wet dreams

driving 51, 248, 313, 367, 386–387drug abuse. See also specific drugs

acupuncture for 8in agoraphobia 17in anxiety disorders 40in chronic illness 89as coping mechanism 36and domestic violence 127, 128in dysfunctional families 131in grief 163and HIV/AIDS 6in homeless 186loneliness and 223and REM sleep 130

drug testing, random 302DSM IV-R. See Diagnostic and Statistical

Manualduodenal ulcer 272, 273durable power of attorney for health care

113–114dust mites 46

“dying with dignity” 113–114, 141, 352dyscalculia 220dysfunctional family 131dysgraphia 220dyslexia 220dysmenorrhea 238dysmorphic disorder 68dyspareunia 131–132, 237, 327dysphoric mood 246dysthymia 12, 116, 132

EEAPA. See Employee Assistance

Professionals AssociationEAPs. See Employee Assistance Programsearly ejaculation 134Eastman, Charmaine I. 90eating disorders 68, 133–134, 204, 238,

258, 382. See also dietingECaP. See Exceptional Cancer PatientsEcstasy (MDMA) 91ECT. See electroconvulsive therapyeczema 27, 121EEG. See electroencephalogramejaculation 134–135. See also wet dreamsejaculation disorders 134–135, 202, 326,

327elderly. See also aging; retirement

age discrimination against 14anxiety in 15, 311caregivers of 79–80, 135, 136, 186,

224, 256–257, 355, 385climate and 91constipation in 100cosmetic surgery in 102, 240day care for 110, 135, 136, 389depression in 15, 16, 116–117, 135,

298–299disabled 125as fathers 149–150frustration in 155geropsychiatry for 298–299HIV/AIDS in 7medication-related concerns in 16mental health of 15–16in nursing homes 250, 256–257,

276, 304, 380parents 79–80, 135–136, 141, 206,

315, 345peptic ulcer in 272religious 308sex drive of 326slips, trips, and falls of 336, 358stereotypes of 14, 16, 206suicide in 16, 352urinary incontinence in 374–375volunteering 311, 381West Nile virus in 382

electricity 136–137, 284

electroconvulsive therapy (ECT) 119,137–138, 229

electroencephalogram (EEG) 32, 113,335

electronic devices 138elevated mood 246elevators 138ELISA test (enzyme-linked

immunosorbent assay) 138–139Elkin, Allen 185Ellis, Albert 70EMDR. See Eye Movement

Desensitization and Reprocessingemergency response 138, 139, 203, 324.

See also firefighters and rescue workers;police

Emotional Health Anonymous 139emotional release systems 69emotions 139. See also moods

in adolescents 299ambivalent 33and bed-wetting 58–59breast cancer and 72chronic illness and 88–89hypothalamus and 199and migraine 171music and 250during pregnancy 288serotonin and 325

emphysema 139–140. See also lungcancer

Employee Assistance ProfessionalsAssociation (EAPA) 140

Employee Assistance Programs (EAPs) 2,138, 140–141, 302, 380

Empower Yourself (Kahn and Kimmel)319

empty nest syndrome 141, 271“enabler” 93, 269, 333encephalitis 180, 383end-of-life care 141–142. See also deathendogenous depression 117, 145endorphins 8, 142, 144, 145, 173, 216,

314energy balancing systems 69enuresis. See bed-wettingenvironment 142. See also allergies

air pollution 21–22, 90–91, 142,155, 245, 332

Chernobyl 82–83global warming 161–162GM foods and 159–160

Environmental Protection Agency (EPA)23, 43, 90–91, 142–143, 170

environmental tobacco smoke (ETS) 22envy 143, 210, 246enzyme-linked immunosorbent assay test.

See ELISA testEpel, Elissa S. 345

424 The Encyclopedia of Stress and Stress-Related Diseases

Index 425Index 425

epinephrine (adrenaline) 10–11, 34, 143,145, 150, 184, 356

Equal Employment OpportunityCommission 33, 327

ergonomics 143–144erythrocyte sedimentation rate (ESR) 43Esalen 233essential oils 41–42estrogen 237, 238euphoric mood 246eustress 125, 144, 344, 394euthanasia 141euthymic mood 246evening primrose 88Everybody’s Guide to Homeopathic Medicines

(Cummings and Ullman) 188Exceptional Cancer Patients (ECaP) 333exercise 144–145

after heart attack 177for anger 34for arthritis 42and asthma 46and cholesterol 86for constipation 100for elderly 15and endorphins 142, 144, 145, 314for fibromyalgia 151during grief 112for high blood pressure 182for hostility 192and immune system 201for irritable bowel syndrome 208for lung power 47midlife crisis and 240and miscarriage 244for stress 345–346, 347and tachycardia 357and tendinitis 362and weight loss 124

exogenous depression 116, 117, 145exposure therapy 18, 21, 59–60, 282,

319extrinsic asthma 46extroversion 207, 332Eye Movement Desensitization and

Reprocessing (EMDR) 145

FFair and Accurate Credit Transaction Act

of 2004 200faith healing 146, 342. See also mind-

body connections; religionfalling merchandise 146–147family 147. See also children; marriage;

parenting/parents; sibling relationshipsof ADHD sufferers 47, 48aggression in 15. See also domestic

violenceof agoraphobics 17, 19

of AIDS patients 6of alcoholics 24of Alzheimer’s patients 31, 32of anorexics 133of asthma sufferers 45baby boomers and 56of cancer patients 78as caregivers 79–80, 147, 224,

256–257of chronically ill persons 88, 89of chronic fatigue syndrome

sufferers 87–88of cult recruits 108death in 112, 113of depressed persons 115, 116of diabetics 122of disabled persons 124–125dysfunctional 131envy in 143farming 148of gamblers 158intimacy in 207of mentally retarded child 239online communication of 67of panic disorder sufferers 269of physicians 283secrets in 319of shift workers 330sick role in 332–333stepfamilies 309, 310, 343

Family and Medical Leave Act of 1993(FMLA) 148

family conflicts 345, 346acculturation and 3friends and 154incest and 202intergenerational 206, 315, 345relocation and 309unemployment and 372

family therapy 131, 299farmer’s lung 197farming 35, 53, 148–149fathers 83, 149–150. See also mothers;

parenting/parentsFathers of a Certain Age (Carnoy and

Carnoy) 149–150Fathman, Robert 297fats, saturated 86FDA. See Food and Drug Administrationfear 150. See also phobias

of Alzheimer’s disease 235v. anxiety 36of dentistry 115of diseases 199hypothalamus and 199of intimacy 207v. phobia 150of pregnancy 289of public lavatories 217, 281

of school 317, 324sexual 327of surgery 292

Federal Trade Commission 200feedback 150, 222–223, 346, 391feelings. See emotionsFeiden, Karyn 355Feldenkrais, Moshe 68–69Feldman, Daniel C. 372Feminine Mystique, The (Friedan) 388feng shui 150fiber 100, 208–209fibromyalgia 151fight or flight response 143, 150, 151,

199, 344, 346Final Exit (Humphry) 352firefighters and rescue workers 151–152,

324fires 152–153, 367fireworks 153fitness. See exerciseflatulence 153, 203, 208Fleck, Carole 200flexible work hours (flex time) 153–154,

291, 389–390flooding 19, 59, 60flower remedies 188fluoxetine 119, 120, 280flying. See airplanesFMLA. See Family and Medical Leave Actfolk medical beliefs 3, 4, 29–30follicle stimulating hormone (FSH) 238food. See nutritionFood and Drug Administration (FDA)

on acupuncture 8on antianxiety drugs 38on antidepressants 120on anti-HIV medication 20on breast cancer 71on defibrillators 114on GM foods 160on herbal medicine 179on “mad cow” disease 226on radiation exposure 23on THG 363–364on Viagra 202on Xanax 395

Ford, Norman D. 266forest fires 152forgetting 154, 236Fourier, Jean 161Freud, Sigmund 34, 178, 195, 295, 321,

336Frey, William 107Friedan, Betty 388friends 143, 154–155, 206–207, 305,

311. See also peer groupfrigidity 155frostbite 94

frustration 143, 155and anger 33, 34in children 155, 358farming and 148–149glass ceiling and 160and hostility 192impotence and 202perfection and 273resolutions and 310–311

FSH. See follicle stimulating hormoneFullin, Kevin J. 128funeral arrangements 112fungi 155–156, 245

GGAD. See generalized anxiety disordergagging, hypersensitive 157Gahrmann, Natalie 265Gallup poll 71, 154–155, 158, 223galvanic skin response (GSR) 157Gamblers Anonymous 158gambling 157–158gamete intra-fallopian transfer (GIFT)

205gamma hydroxybutyrate (GHB) 91gamma-linolenic acid (GLA) 88Gareis, Karen 270G.A.S. See general adaptation syndromegastric bypass 260gastric ulcer 272gastrointestinal problems 16, 112, 163,

164. See also specific problemsgender. See also women

and ADHD 47and agoraphobia 17, 18and alcoholism 25and alternative medicine use 28–29and anger 34and bed-wetting 58and blood pressure 385and bullying 75and communication 97–98and depression 116and diabetes 122and friendships 154–155and heart attack 176and HIV/AIDS 6and homelessness 186and homicide 379and infertility 204, 205and irritable bowel syndrome 208and laughter 217and midlife crisis 240and migraine 171, 172and overtime 265and panic disorder 269and personal space 275and puberty 299and remarriage 309

and response to crowding 107and sleep 334and smoking 337

gender identity 158gender role 158–159Gendlin, Eugene 168general adaptation syndrome (G.A.S.)

101–102, 144, 159, 303, 322, 344generalized anxiety disorder (GAD) 36,

38, 39generation gap 206genetically modified foods (GM foods)

159–160genetic factors

of agoraphobia 18of alcoholism 24of autism 49of color blindness 95–96of depression 118of hemophilia 178of manic-depressive disorder 228of migraine 171of nail biting 252of obsessive-compulsive disorder

260of panic disorder 269of peptic ulcer 272of personality 274of rheumatoid arthritis 297of seasonal affective disorder

syndrome 318genital herpes 180, 328geropsychiatry 298–299gestalt therapy 160GHB. See gamma hydroxybutyrateGIFT. See gamete intra-fallopian transferGLA. See gamma-linolenic acidglass ceiling 160glaucoma 160–161global warming 161–162GM foods. See genetically modified foodsGoeckerman treatment 294Goff, John 150“golden rule” of communication 98Goldstein, Kurt 195Gondola, Joan C. 145gonorrhea 328gout 162–163grandparents 271, 373Greeley, Andrew 308green (color) 95“greenhouse” effect 161grief 112, 163–164

anger in 35another person’s 163–164crying in 107guilt in 165headaches in 112, 163, 171and immune system 201

insomnia in 163, 206and loneliness 223miscarriage and 244, 289–290overcoming 163pet loss and 276SIDS and 350stages of 163stillbirth and 343

group therapy 160, 286, 298. See alsoself-help groups; support groups

GSR. See galvanic skin responseguided imagery 164–165

for addiction 9for allergies 27, 164with biofeedback 65for cancer 29, 78for habits 166for high blood pressure 164, 182for phobias 282for worrying 394

Guilford, J. P. 105guilt 165

about chronic illness 89about day care 110, 390homosexuality and 189learning to stop assuming 219about masturbation 234about miscarriage 244, 290about remarriage 309survivor 192, 286witnessing crime and 106

Gulf War Illness 165guttate psoriasis 294

Hhabits 166, 198, 254, 260, 310. See also

specific habitsHahnemann, Samuel 187, 188hair loss 166hair pulling 166, 167Haizlip, Thomas M. 192Hakomi 167hallucinations 69, 163, 167, 171, 189,

191hallucinogens 167Handgun-Free America 391handicap. See disabilitieshangover 168hardiness 168–169, 274Harris, Thomas A. 365Harrison, Lee Hecht 254H.A.R.T. Program, The (Kerman) 369Hart, Robert W. 339Hartwell, Tyler D. 302Harvard Health Letter 358, 375Harvard Medical School 29, 61, 228,

242, 307, 342Hathaway, Starke Rosecrans 244“having it all” 56, 169, 247

426 The Encyclopedia of Stress and Stress-Related Diseases426 The Encyclopedia of Stress and Stress-Related Diseases

Index 427Index 427

Hawkes, Catherine 392hay fever 27, 28, 169hazard communication (HazCom)

169–170hazardous and toxic substances 82, 139,

170headaches 170–173

alternative medicine for 173biofeedback for 65, 173caffeine and 77, 171chiropractic medicine for 85cluster 170–171diagnosis of 173in grief 112, 163, 171in Gulf War Illness 165in hangover 168in inferiority complex 204meditation for 129, 173migraine 171–172, 173, 238prayer for 129in premenstrual syndrome 238relaxation for 172, 173in school phobia 317secrets and 319in separation anxiety 324in sick building syndrome 332temporomandibular joint 171, 362tension (muscle contraction) 170

head lice 221Healer Within, The (Locke and Colligan)

296Healing from Within (Jaffe) 305Healing Heart, The: Antidotes to Panic and

Helplessness (Cousins) 103, 104Healing Mind, The (Oyle) 283healing touch 363Healing Words (Dossey) 129, 288Health and Human Services, Department

of (HHS) 20, 227, 230, 259–260, 324health care workers 173–174. See also

dentists; physiciansand AIDS patients 6, 174exposure to infectious diseases 174,

191, 253–254exposure to nitrous oxide 255getting HIV from 195home care provided by 186in hospital 191hypochondriacs and 199needlestick injuries in 253–254sexual harassment of 327–328

Health Communication Standard169–170

health insurance 30, 92, 113, 174–175,190, 224, 228, 392

health maintenance organizations(HMOs) 175, 228

health promotion 175, 213, 262, 392hearing loss 111, 255, 367

heart attack 86, 176–177, 182death from 176defibrillators used during 114–115epinephrine injection during 143factors of 176sign of 35“silent” 176stresses after 177symptoms of 176–177

heartburn 177–178, 203, 288heart failure 93, 100heart rhythm. See arrhythmia; tachycardiaheights 7, 99, 178, 281Helicobacter pylori 272helplessness 163, 178, 351

learned 13, 101, 178, 219psychic 178

Hemlock Society 352hemophilia 178–179hemorrhoids 100, 179, 288Henshaw, Stanley K. 373hepatitis B virus 174, 328hepatitis C virus 174herbal medicine 29–30, 179–180, 187,

253Herbert, Tracy B. 201herbicide 14heroin 8, 93herpes simplex virus (HSV) 180–181, 328HHS. See Health and Human Services,

Department ofhidden depression. See masked depressionhierarchy of needs 181, 195high blood pressure 176, 181–183

biofeedback for 65, 182cocaine and 93diagnosis of 181–182drug treatment for 183guided imagery for 164, 182laughter for 216meditation for 129, 234music for 251prayer for 129relaxation for 61, 182, 307religion for 308smoking and 337t’ai chi for 182, 358“white coat hypertension” 182, 307

high-density lipoprotein (HDL)cholesterol 86

Hill, J. Edward 62Hispanic Americans 25, 372, 393HIV. See human immunodeficiency virusHIV/AIDS Treatment Information Service

(ATIS) 20hives 27, 184HMO Act of 1973 175HMOs. See health maintenance

organizations

hobbies 184–185, 223, 311, 346holiday depression 185holistic medicine 29, 185, 187. See also

alternative medicineHolmes, Thomas H. 185, 221home care 186. See also caregivershomelessness 186–187homeopathy 187–188homeostasis 188, 322, 344homesickness 188–189, 241, 256homicide 379, 386homophobia 189homosexuality 6, 189, 220, 231–232, 329homosexual panic 189Hope and Help for Chronic Fatigue Syndrome

(Feiden) 355hopelessness 189–190, 351hormone replacement therapy 237, 385hormones 171, 172, 193, 285, 296, 299hospitalization 190–191. See also health

care workers; surgerydeath during 113–114, 191domestic violence and 128of homeless 186in manic-depressive disorder 229music during 250, 251nitrous oxide exposure during 255

hostages 191–192, 363hostility 135, 192. See also aggression;

angerhot flashes 192–194, 237, 334hotlines 71, 106, 163, 181, 194HP. See hypersensitivity pneumonitisHSV. See herpes simplex virushuman immunodeficiency virus (HIV)

194–195. See also acquiredimmunodeficiency syndrome

ELISA test for diagnosing 138medications for 20reference service on 20statistics on 5–6, 194transmission of 6, 99, 174, 178,

194, 195, 217, 329humanistic psychology 195–196Human Side of Mergers and Acquisitions, The

(Buono and Bowditch) 239–240humming 196humor 103, 114, 196–197, 201, 216,

347, 386. See also laughterHumor at Work (Blumenfeld and Alpern)

196–197Humphry, Derek 352Hunnicutt, David 392Hurricane Katrina (2005) 372, 381hyperactivity 47–49, 220hypermnesia 236hypersensitive gagging 157hypersensitivity pneumonitis (HP) 156,

197, 245

428 The Encyclopedia of Stress and Stress-Related Diseases

hypersomnia 334hypertension. See high blood pressurehyperuricemia 162hyperventilation 18, 74, 127, 197–198,

268hypnosis (hypnotherapy) 61, 198–199

for cancer 78for fear of dentistry 115for fibromyalgia 151with guided imagery 164for habits 166, 198for high blood pressure 182for memory 198, 236for pain 198, 266for phobia about flying 21

hypoallergenic cosmetics 28hypochondriasis 199, 282hypomanic episodes 12, 228hyposophobia 178hypothalamus 199hypothermia 94hypothyroidism 101hypsiphobia 178

IIBS. See irritable bowel syndromeidentity theft 200illiteracy 200–201imagery. See also guided imagery

for agoraphobia 18–19for chronic fatigue syndrome 88in covert modeling 104in covert rehearsal 104in covert reinforcement 104in flooding 60in modeling 60in psycho-imagination therapy 295in systematic desensitization 60

imipramine 58–59, 269, 278immune system 201–202

adrenaline and 10climate and 91communication and 97deficiency of. See acquired

immunodeficiency syndrome;autoimmune disorders; humanimmunodeficiency virus

humor and 196, 201, 216massage therapy and 233relationships and 305–306relaxation and 307stress and 201

immunization 376–377I’m OK, You’re OK (Harris) 365implosive therapy 60impotence 202, 327incest 131, 202–203, 343, 357incomplete abortion 245indigestion 153, 177, 203, 273

indirect exposure 18indoor air pollution 22, 142, 155, 245,

332industrial hygiene 2, 136–137, 153,

203–204, 275inferiority complex 107, 204, 354infertility 56, 204–205, 290. See also

adoption; pregnancyInformation Anxiety (Wurman) 205information explosion 205inhalation therapy (aromatherapy) 41inhaled anthrax 35inhibited ejaculation 134inhibition 205–206, 331injuries 2. See also accidents

and back pain 57chemical 82, 169–170, 191, 249,

275, 284, 367chiropractic medicine for 85falling merchandise and 146–147farming and 149in firefighters and rescue workers

151–152fireworks-related 153in health care workers 173–174,

191, 253–254ladders and 147, 149, 215–216,

284, 336and lost work days 224in mining workers 242–244, 388muscle relaxants for 249needlestick 253–254in nursing home workers 257overtime and 264paintball and 267in plumbers 284and post-traumatic stress disorder

286repetitive stress 80–81, 143, 232,

310, 362, 390rotator cuff 313survey on 262–264tendinitis 362in truck drivers 367in women 386–387workers’ compensation for 388

in-laws 247–248insight-oriented meditation 235insomnia 206, 335. See also sleep

caffeine and 77, 206, 335in chronic fatigue syndrome 87in grief 163, 206in hostages 191hypnosis for 198jet lag and 90witnessing crime and 106

insulin 121insulin-dependent diabetes 50, 122intelligence 105

intergenerational conflicts 206, 315, 345interleukin-6 344–345International Chiropractors Association

85International Foundation for

Homeopathy 187International Longevity Center 386International Psychoanalytical Association

295Internet 67, 109–110, 207, 341, 360interpersonal theory of depression 118intimacy 206–207, 275, 306, 319. See also

relationshipsintraocular pressure (IOP) 161intrinsic asthma 46introversion 207, 332, 340inverse psoriasis 294in vitro fertilization (IVF) 204–205, 290irradiated mail 208“irregularity.” See constipationirritable bowel syndrome (IBS) 100, 123,

208–209irritable mood 246isotretinoin 5“I” statements 97

JJaffe, Dennis 305Jauregui, Maritza 291jealousy 210, 232, 332. See also envyjet lag 65, 90, 210job change 98, 102, 210, 390–391job security 14, 210–211, 218, 291–292,

372Jordan, Susanne 380journaling 211Journal of Personal and Social Psychology

168–169Journal of the American Medical Association,

The 3–4, 26, 171, 352judicial proceedings 211–212, 218Jung, Carl 204juvenile-onset diabetes. See insulin-

dependent diabetesjuvenile rheumatoid arthritis 42

KKabat-Zinn, Jon 213Kahn, Ada P. 126, 319karoshi 213–214Kempf’s disease 189Kennedy, Marilyn Moats 254Kerman, D. Ariel 369Kevorkian, Jack 352–353Kiecolt-Glaser, Janice 345Kimmel, Sheila 319kinesics 214Kleiman, Carol 153, 154Kloberdanz, Kristin 152

Index 429Index 429

Kobasa, Suzanne 168, 274Kohut, Heinz 321Krieger, Dolores 363

Llabor. See childbirthLabor, Department of 53, 148, 170, 257,

304, 372, 381, 386. See also Bureau ofLabor Statistics

labyrinth 215ladders 147, 149, 215–216, 284, 336La Leche League 258Lamaze, Fernand 83, 288Landers, Catherine R. 344Landsbergis, Paul 264, 265, 366, 389lasers 216“latch key” children 247, 270laughing gas. See nitrous oxidelaughter 103, 142, 196, 201, 216–217.

See also humorlavatories, public 217, 281Lawlis, C. Frank 213lawyers 212, 217–218, 390layoffs 36, 102, 104, 211, 218–219, 240,

274, 311, 372, 391. See also downsizingLDF. See Lyme Disease FoundationLeana, Carrie R. 372lean muscle mass 259learned helplessness 13, 101, 178, 219learned optimism 219Learned Optimism (Seligman) 219learning disabilities 48, 201, 219–220left-handedness 220Legionnaires’ disease 332lesbianism 189, 220–221. See also

homosexualityLH. See luteinizing hormoneLi, Ting-Kai 24lice 221lie detector 225life change self-rating scale 144, 185,

221–222life support systems 113ligament injuries 57, 232lightning 137, 222light therapy 318, 354Link, Nathan 7listening 97, 218, 222–223, 391lithium 13, 119, 229, 279live-in 223, 329. See also cohabitation;

marriageliving will 113Locke, Steven 296loneliness 223–224, 271, 276long-term care insurance 224long-term memory 154, 235loss. See death; grieflost work days 224Love, Medicine and Miracles (Siegel) 333

low-density lipoprotein (LDL) cholesterol85–86

Lowry, Fran 372ludotherapy. See play therapylump in the throat 225lung cancer 21, 22, 44, 244, 302, 338.

See also emphysemaluteinizing hormone (LH) 193, 238Lutz, Brobson 384lying 225Lyme disease 225Lyme Disease Foundation (LDF) 225

M“mad cow” disease (bovine spongiform

encephalopathy) 226–227Maddi, Salvatore 168magnetic resonance imaging (MRI) 173Maher, Kris 360Maier, Steven 219major depression. See exogenous

depressionmajor depressive episodes 12major depressive syndrome 12malingering pain 266malt worker’s lung 197mammography 71, 227–228managed care 228, 390manic-depressive disorder 228–229

death risk in 11–12and obsessive-compulsive disorder

261personality and 13self-help and support groups for

120–121, 355treatment of 13, 119, 229, 279

manic episodes 12, 228Man Who Mistook His Wife for a Hat, The

(Sacks) 250MAOIs. See monoamine oxidase

inhibitorsMarch of Dimes 194marijuana 229–230marital therapy 230, 326. See also sex

therapymarketing 11, 63–64, 143marriage 230–232. See also cohabitation;

dating; divorce; live-in; maritaltherapy; pregnancy

agoraphobic spouse in 17, 19alternative forms of 231–232baby boomers and 56breast reconstruction and 72codependence in 93commuter 231death of spouse 112, 163, 305,

344–345domestic violence in 127–128infertility in 204, 205

and in-laws 247–248jealousy in 210, 232of lawyers 218money and 246open 232of physicians 283remarriage 126, 309–310retirement of spouse 311“same-sex” 231–232spouse as caregiver in 79, 147spouse with chronic fatigue

syndrome 88masked depression 232Maslach, Christina 76Maslow, Abraham Harold 181, 195massage therapy 41, 151, 232–233, 341.

See also acupressure; reflexologymasturbation 234material safety data sheets (MSDSs) 170mathematics anxiety 234maturity-onset diabetes. See non-insulin-

dependent diabetesMaury, Marguerite 41May, Rollo 195, 308McGrath, Chris 391McKinley, John Charnley 244MDMA. See EcstasyMeaning and Medicine (Dossey) 129Medicare 114, 175Medicina Musica (Browne) 250meditation 234–235. See also

Transcendental Meditationfor addiction 9in autogenic training 50with biofeedback 65, 234–235colors for 95for constipation 101and coping skills 101for headaches 129, 173for high blood pressure 129, 234for hostility 192Kabat-Zinn (Jon) on 213learning 234–235and mind-body connections

234–235, 241for performance anxiety 274for phobias 282qi gong 301t’ai chi as 358Thich Nhat Hanh on 364types of 235

melancholia 116memory 154, 235–236

aging and 31, 236in Alzheimer’s disease 31circadian rhythms and 90in Gulf War Illness 165hypnosis for 198, 236poor 154, 235, 236

430 The Encyclopedia of Stress and Stress-Related Diseases

menarche 238menopause 236–237, 238, 385

hot flashes in 192–194, 237, 334and midlife crisis 240migraine in 171sleep difficulties in 334urinary incontinence in 348, 374

menstruation 237–239and agoraphobia 18as biorhythm 65cessation of. See menopauseand migraine 172as taboo topic 357

mental retardation 220, 239mergers 14, 102, 130, 211, 218, 219,

239–240, 308, 311MESA. See Mining Enforcement and

Safety Administrationmesothelioma 22, 44methamphetamines 91–92methylphenidate hydrochloride 48Michaelson, James 227–228midlife crisis 240migraine headaches 171–172, 173, 238migration 240–241. See also

homesickness; movingMillett, Kate 388mind-body connections 241–242, 344.

See also body therapiesAyurveda and 54–55, 86Dossey (Larry) on 129guided imagery and 164holistic medicine and 185Kabat-Zinn (Jon) on 213meditation and 234–235, 241psychoneuroimmunology and 296qi gong and 301reading about 62relaxation and 307

Mind/Body Effect, The (Benson) 61,241–242

Mind/Body Group 242Mind/Body Medical Institute 61, 342mind control. See brainwashingmindfulness 213, 235Mine Safety and Health Administration

(MSHA) 242–243minimal brain dysfunction 220Mining Enforcement and Safety

Administration (MESA) 243mining workers 242–244, 388Minnesota Multiphasic Personality

Inventory (MMPI) 244miscarriage 244–245, 289–290. See also

abortion; stillbirthmissed depression. See masked depressionmobile phones 361modeling 60, 245mold 27, 46, 156, 245

money 246, 249, 311–312, 372, 386monoamine oxidase inhibitors (MAOIs)

38, 117, 119, 278, 279, 280monogamy 230, 315. See also marriagemood disorders. See affective disordersmood episodes 12moods 199, 246, 251, 288. See also

emotionsmood syndrome 12Moon 246–247Moos, Rudolf H. 297Moreno, J. L. 295mosquitoes 382, 383mothers 247. See also children; fathers;

parenting/parents; pregnancychanging image of 247in childbirth 83, 180, 288, 348, 374of child with separation anxiety 324HIV/AIDS transmitted from 6, 7lesbian 220nursing 6, 257–258phobias in 281postpartum depression in 285,

288–289smoking 338unwed 285, 289, 373working 110, 169, 247, 257–258,

270, 364–365, 385, 387, 389–390mothers-in-law 247–248motion sickness 248. See also vertigomotivated forgetting 236mourning. See griefMourning and Melancholia (Freud) 34movement awareness systems 69moving 248–249, 308–309MRI. See magnetic resonance imagingMSDSs. See material safety data sheetsMSHA. See Mine Safety and Health

Administrationmucous colitis. See irritable bowel

syndromemugging 249Multiple Chemical Sensitivity syndrome

249muscle contraction (tension) headache

170muscle relaxants 62, 249, 362, 377muscle strain 57, 149, 232, 249, 387music 250–251, 255Mycobacterium tuberculosis 368mycotoxins 155–156, 245myocardial infraction. See heart attackmystic union 366

NNABCO. See National Alliance of Breast

Cancer Organizationsnail biting 52, 166, 198, 252NAMT. See National Association for Music

Therapy

narcissistic personality 321narcolepsy 335NASW. See National Association of Social

WorkersNational Academy of Sciences 245, 368National Accreditation Commission for

Schools and Colleges of Acupunctureand Oriental Medicine 8

National Alliance of Breast CancerOrganizations (NABCO) 71

National Association for Music Therapy(NAMT) 250

National Association of Anorexia Nervosaand Associated Disorders (ANAD) 134

National Association of Colleges andEmployers 372

National Association of Social Workers(NASW) 340

National Campaign to Prevent TeenPregnancy (NCPTP) 289

National Cancer Institute 71, 227National Center for Complementary and

Alternative Medicine (NCCAM) 28,252–253. See also Office of AlternativeMedicine

National Center for Health Statistics 66,392

National Center for Infectious Diseases226, 383

National Center for Post-Traumatic StressDisorder 286–287

National Center of Homeopathy 187National Council on Compulsive

Gambling 158National Depressive and Manic-

Depressive Association 120National Enuresis Society 59National Exercise for Life Institute 145National Fire Protection Association 153National Gay and Lesbian Task Force 220National Heart, Lung and Blood Institute

181, 237National Herpes Information Hotline 181National Institute of Mental Health 117National Institute of Occupational Safety

and Health (NIOSH) 22, 23, 84, 208,242–243, 255, 262, 360, 379, 380

National Institute on Aging 374–375National Institute on Alcohol Abuse and

Alcoholism (NIAAA) 24, 62National Institutes for Health (NIH) 24,

47, 87, 237, 373–374, 377. See alsoNational Center for Complementaryand Alternative Medicine; Office ofAlternative Medicine

National Organization for Women 388National Safety Council 224National Stroke Association (NSA) 349National Survey of Family Growth 66Native Americans 25, 146, 179

Index 431Index 431

natural childbirth 83naturopathy 253nausea 168, 171, 176, 198, 203, 230,

248, 253, 286, 288, 317NCCAM. See National Center for

Complementary and AlternativeMedicine

NCPTP. See National Campaign to PreventTeen Pregnancy

needlestick injuries (NSIs) 253–254Needlestick Safety and Prevention Act of

2000 253–254needs, hierarchy of 181, 195negative anger 34negative criticism 106–107negative feedback 150negative self-talk 321, 322nervous diarrhea. See irritable bowel

syndromenervous habits 166, 198, 254, 310. See

also specific habitsnetworking 254neurotransmitters 138, 254, 277, 280,

296. See also specific neurotransmittersneurotransmitter theory of depression

118New Guide to Rational Living, A (Ellis) 70NIAAA. See National Institute on Alcohol

Abuse and Alcoholismnicotine. See smokingnightmare 254–255, 286, 335night shift. See shift worknighttime alarm system 58–59NIH. See National Institutes for Health9/11. See September 11, 2001NIOSH. See National Institute of

Occupational Safety and HealthNishi, Dennis 361nitrogen dioxide 22, 142nitrous oxide 255Nocturnal Penile Tumescence Test (NPT)

202noise 255, 367nonassertive behavior 45non-insulin-dependent diabetes 122–123non-rapid eye movement sleep. See

NREM sleepnonsteroidal anti-inflammatory agents

(NSAIDs) 151, 162, 172nonverbal communication. See body

languagenoradrenaline. See norepinephrinenoradrenergic agents 39norepinephrine 13, 118, 138, 254, 256,

277, 280nostalgia 256NREM sleep 335–336NSA. See National Stroke AssociationNSIs. See needlestick injuries

nuclear power plant accident 82–83nuclear weapons 256nummular dermatitis 121nurses. See health care workersnursing homes 250, 256–257, 276, 304,

380nursing mothers 6, 257–258nutrition 253, 258. See also dieting;

eating disorders; obesity; weight gainand loss

and acne 5after heart attack 177and allergies 27and cholesterol 86comfort foods 96for constipation 100in diabetes 123GM foods 159–160in gout 162during grief 112and heartburn 177for high blood pressure 183and hives 184and indigestion 203for irritable bowel syndrome

208–209in menopause 193–194and migraine 172and motion sickness 248for peptic ulcer 272and stress relief 346

OOAM. See Office of Alternative Medicineobesity 96, 122, 183, 259–260, 392. See

also weight gain and lossobservational learning. See modelingobsessive behavior 260. See also

obsessive-compulsive disorderin agoraphobia 18in anorexia nervosa 133in Asperger’s syndrome 44journaling for 211masturbation as 234perfection and 273shopping as 331

obsessive-compulsive disorder (OCD) 37,260–261

behavior therapy for 37, 40, 59, 60,261

habits in 166, 260hostility in 192medications for 38, 261phobias in 282and unemployment 40

obstructive sleep apnea syndrome (OSAS)339

occupational health psychology (OHP)262

Occupational Safety and HealthAdministration (OSHA) 43, 53, 82,137, 143, 169–170, 253–254, 275, 332,360

occupational stress 211, 262–264Office of Alternative Medicine (OAM)

30, 129, 252. See also National Centerfor Complementary and AlternativeMedicine

Ohashiatsu 264Ohl, Dana 204Oklahoma City bombing (1995) 363Older Women’s League 79Oldham, Greg 251open-angle glaucoma 161open marriage 232operant conditioning 99optic nerve damage 160–161optimism, learned 219orange (color) 95organ transplants 190–191, 383orgasm 35, 326Oriental massage 233Ornstein, Robert 266Orton, Peter 283OSAS. See obstructive sleep apnea

syndromeOSHA. See Occupational Safety and

Health Administrationosteoarthritis 42overbreathing. See hyperventilationovertime 213, 264–265, 291, 366, 389Oxman, Thomas 308Oyle, Irving 283

PPacheco, Karin 245Pachter, Lee M. 3–4pain 266–267. See also headaches

acupuncture for 8in arthritis 42back 56–57, 69, 232, 288, 367in childbirth 83in chronic fatigue syndrome 87, 88in chronic illness 88–89endorphins and 142in fibromyalgia 151in gout 162guided imagery for 164in Gulf War Illness 165in heart attack 176in heartburn 177in hospital 190humor for 196, 216hypnosis for 198, 266during intercourse 131–132, 237,

327in irritable bowel syndrome 208massage therapy for 232

pain (continued)meditation for 234during menstruation 238music for 251in peptic ulcer 272relaxation for 266, 307in repetitive stress injuries 310in rotator cuff injuries 313and sleep 334therapeutic touch for 363

Painstoppers (Ford) 266paintball 267palpitations 90, 267–268, 282panic attacks and panic disorder 37,

268–270. See also phobiasin agoraphobia 17, 18, 19, 268,

269, 282caffeine and 77in claustrophobia 90at dentist 115diagnosis of 268, 269dizziness in 127, 178, 268homosexual 189hyperventilation in 74, 127, 268and irritable bowel syndrome 208medications for 38, 39, 62, 269meditation for 234and palpitations 268personality and 269post-traumatic stress disorder and

268, 286tachycardia in 357and unemployment 40

paradoxical therapy 197paramnesia 236parental afterschool stress (PASS) 270parenting/parents 270–271. See also

adoption; children; family; fathers;mothers

abusive 128ADHD sufferers 47, 48adolescents 299–300, 345anorexics 133bed-wetting children 58, 59binge drinkers 62birth order and 66–67breath-holding spells 73child with sensory integrative

dysfunction 322, 323child with separation anxiety

323–324and codependence 93colicky baby 95communication 69criticism by 107, 109, 204death of child 163, 165, 338, 350disabled child 124–125divorce and 126, 271in dysfunctional families 131

elderly 79–80, 135–136, 141, 206,315, 345

empty nest syndrome in 141, 271frustration in 155hemophiliacs 178online 67overtime of 265peer pressure 272and phobias 281, 282and sibling relationships 331, 332single 109, 110, 285, 289, 373in stepfamilies 343taboo subjects 246and underachievement 371

Parkerson, George R. 147PASS. See parental afterschool stresspassive aggression 15pathological lying 225Patient Self-Determination Act of 1991

113Pavlovian conditioning 99Peck, M(organ) Scott 271pediatric AIDS 6–7peer group 271–272, 299

and binge drinking 62in cult 108and dating 109in day care 110and developing autonomy 52and suicide 351and underachievement 371

peer pressure 272peptic ulcer 272–273perfection 131, 133, 171, 260, 273, 351,

386performance anxiety 39, 73, 76,

273–274. See also public speaking; stagefright

performance review 274peripheral vision 161Perls, Frederick S. 160Persian Gulf War (1991) 165, 191–192,

286personality 274–275

and cancer 78and creativity 105and depression 13extroverts 207, 332and high blood pressure 181introverts 207, 332, 340and manic-depressive disorder 13and migraine 171narcissistic 321and obsessive-compulsive disorder

260and panic disorder 269and sibling relationships 332and suicide 351, 352

personality disorders 274personality tests 244, 274–275

personality types 368–370personal protective equipment (PPE)

152, 216, 267, 275personal space 190, 275–276, 390. See

also cubiclespets 27, 276pharmacological approach 276–280. See

also placebo effect; specific medicationsphobias 37, 280–283. See also panic

attacks and panic disorder; specificphobias

v. aversion 52behavior therapy for 37, 40, 59, 60,

282, 333in chronic fatigue syndrome 87dizziness in 127v. fear 150hypnosis for 198and palpitations 90, 268, 282self-efficacy in 319statistics on 281and vertigo 379

physical manipulation systems 69physician-assisted suicide 113, 141,

352–353physicians 283, 363. See also dentists;

health care workersphytoestrogens 193Pillai, Sujatha 188Piorkowski, Geraldine 207, 306PIT. See psycho-imagination therapyplacebo effect 274, 283, 363Planned Parenthood 1, 377plastic surgery 5, 72, 284. See also

cosmetic surgeryplay therapy 284plumbing 284PMS. See premenstrual syndromepneumonitis, hypersensitivity 156, 197,

245PNI. See psychoneuroimmunologypoison ivy 27, 284–285police 285, 324, 359, 379, 380politically correct 285pollen 27, 28, 46Pollution Standard Index (PSI) 142polygraph 225Pomeranz, Bruce 8Porter, Laura S. 101positive anger 34positive feedback 150positive self-talk 321–322postal workers 208postpartum depression 285, 288–289post-traumatic stress disorder (PTSD) 37,

286–287. See also combat fatigue; warneurosis

Chernobyl and 82–83domestic violence and 127

432 The Encyclopedia of Stress and Stress-Related Diseases

Index 433Index 433

in firefighters and rescue workers152, 324

in hostages 192medications for 38, 39and nightmares 255, 286and panic attacks 268, 286prevention of 106rape and 303September 11, 2001 and 324witnessing crime and 106

powerlessness 287PPE. See personal protective equipmentprayer 129, 287–288, 308, 342preferred provider organizations (PPOs)

228pregnancy 288–291. See also abortion;

birth control; childbirth; infertility;menstruation; miscarriage; mothers;postpartum depression; stillbirth

biological clock and 56, 65, 230, 373crack use during 93depression in 285, 288diabetes in 122domestic violence during 128HIV/AIDS and 6, 7, 194migraine in 172music during 251smoking during 338symptoms of 288, 289syphilis in 328–329

premature ejaculation 134, 326, 327premenstrual syndrome (PMS) 238prepared childbirth 83presenteeism 291–292. See also

absenteeismpresurgical stress 292Proceedings of the National Academy of

Sciences 96, 344–345pro-choice and pro-life 1, 292progesterone 238progestin 237progressive muscle relaxation 292–293projection 114propranolol 21prostate cancer 293Provine, Robert R. 217Prozac. See fluoxetinePSI. See Pollution Standard Indexpsoriasis 293–294Psychiatric News 191–192psychiatrist 294–295, 298psychic helplessness 178psychoanalysis 118–119, 295psychoanalytic theory of depression 118psychodrama 295psychogenic deafness 111psychogenic pain 266psycho-imagination therapy (PIT) 295psychologist 295–296, 298

psychology 296humanistic 195–196occupational health 262self-psychology 321

psychoneuroimmunology (PNI) 42,71–72, 242, 296–297

Psychonomic Society 297psychosomatic deafness 111psychosomatic illness 146psychotherapies 103, 297–299, 347. See

also specific psychotherapiesfor alcoholism 25for anger 34for arthritis 43with behavior therapy 59for catastrophizing 81coping skills from 101for depression 117, 118–119for domestic violence victims 127for fibromyalgia 151for habits 166for hair pulling 167for hostility 192humor in 197for inferiority complex 204for irritable bowel syndrome 208for nausea 253for phobias 282for post-traumatic stress disorder

286for witness to crime 106

PTSD. See post-traumatic stress disorderpuberty 299–300. See also adolescentspubic lice 221public lavatories 217, 281public speaking 225, 245, 273, 281, 300,

340, 342–343purple (color) 95

Qqi gong 301

Rradiation exposure 22–23, 82–83, 208,

227, 244Radiological Society of North America

227“radiophobia” 82radon 302Rahe, Richard H. 185, 191–192, 221random drug testing 302random nuisances 302–303, 344rape 36, 62, 303–304rape crisis hotline 106rapid eye movement sleep. See REM sleeprationalization 114“raves” 91–92reactive depression. See exogenous

depression

reading 62, 69, 335reconstructive surgery. See cosmetic

surgery; plastic surgeryrecreation 304. See also exercise; hobbiesrecreational therapists 304–305red (color) 95reductions in force. See layoffsreflexology 233, 305Reich, Robert 153Reich, Wilhelm 68Reinthaler, Bee 97relationships 305–306. See also dating;

family; friends; intimacy; live-in;marriage

abusive 127–128codependent 93coping skills in 102dysfunctional 131envy in 143secrets in 319

relaxation 306–307, 347. See alsobreathing exercises

after heart attack 177for allergies 27for arthritis 42in autogenic training 50Benson (Herbert) on 61, 241, 307,

342, 344, 366in biofeedback 61for childbirth 83for chronic fatigue syndrome 88colors inducing 95for constipation 101and coping skills 101in diabetes 122Dossey (Larry) on 129for fear of dentistry 115for flying 21guided imagery and 164for habits 166for headaches 172, 173for herpes sufferers 181for high blood pressure 61, 182, 307hobbies for 184–185for hostility 192humming and 196for hyperventilation 198in hypnosis 198and immune system 201for indigestion 203for irritable bowel syndrome 208Kabat-Zinn (Jon) on 213labyrinth and 215massage for 232meditation for 234Ohashiatsu for 264for pain 266, 307for phobias 282prayer and 288

relaxation (continued)progressive 292–293for stage fright 342in systematic desensitization 60yoga and 396

Relaxation Response, The (Benson) 61, 241,307, 344, 366

religion 95, 215, 232, 235, 307–308, 342.See also cults; faith healing; mind-bodyconnections; prayer

relocation 248–249, 308–309remarriage 126, 309–310. See also

stepfamiliesREM sleep 77, 130, 254, 335, 336, 878repetitive nocturnal myoclonus 334repetitive stress injuries (RSI) 80–81,

143, 232, 310, 362, 390repressed anger 34rescue workers. See firefighters and rescue

workersresolutions 310–311restraining order 128retirement 15, 184–185, 218, 240,

311–312retrograde ejaculation 135Return of Merlin, The (Chopra) 86rheumatoid arthritis 42, 50, 297rhinitis, allergic 27, 156, 169, 245ricin 312–313Rigamer, Elmore 192Rinker, Candiss 98Ritalin. See methylphenidate

hydrochlorideRoad Less Traveled, The (Peck) 271road rage 313Robert Wood Johnson Foundation

(RWJF) 62, 64, 141Rogers, Carl 195Rolf, Ida 69, 313Rolfing 69, 313Roney, Stephen C. 249Rosentock, D. Linda 255Rosenzweig, Martin 289rotator cuff injuries 313Rothermich, Norman 297RSI. See repetitive stress injuriesRudley, Lloyd D. 89runner’s amenorrhea 238runner’s high 142, 314

SSacks, Oliver 250SADS. See seasonal affective disorder

syndrome“safe sex” 6, 99, 194, 315, 327, 328,

378“same-sex marriage” 231–232“sandwich” generation 315sarin 315–316

SARS (Severe Acute RespiratorySyndrome) 316–317

saturated fats 86Saturday Review 103, 104Schimmer, Barry M. 151schizophrenia 12, 16, 138, 186Schnall, Peter 291school 317–318

ADHD sufferers in 47, 48, 220binge drinking in 62–64bullies in 74, 75, 317, 320children with AIDS in 6–7criticism in 107, 317, 320diversity in 125learning disabilities in 220lice in 221new 309underachievement in 371

school avoidance 317, 324school phobia 317, 324Schultz, Johannes Heinrich 50seasonal affective disorder syndrome

(SADS) 116, 185, 318, 354seborrheic dermatitis 121secondary depression 318secondary gain 318“secondhand smoke” 22, 337secrets 318–319security object 319selective serotonin reuptake inhibitors

(SSRIs) 38, 117, 119, 280self-criticism 107, 394self-efficacy 319–320self-esteem 320, 346

acne and 4, 5ADHD and 48of adolescents 299and aggression 14assertiveness training and 45autonomy and 52body image and 68brainwashing and 71breast reconstruction and 72catastrophizing and 81chronic illness and 88criticism and 106, 107dating and 109divorce and 126domestic violence and 127, 320dysfunctional family and 131in dysthymia 132in eating disorders 133of elderly 311and envy 143exercise and 144, 145feedback and 150guilt and 165hair loss and 166hobbies and 185

illiteracy and 201in inferiority complex 204and jealousy 210layoffs and 219learning disabilities and 219loneliness and 224midlife crisis and 240money and 246obesity and 259and panic disorder 269plastic surgery and 284postpartum depression and 285public speaking and 300shyness and 331success and 350in superiority complex 354and underachievement 371

self-help groups 103, 320–321. See alsosupport groups

for addiction 9for agoraphobia 19for alcoholism 25–26for bed-wetting 59for chronic fatigue syndrome 88, 355in crisis intervention 106for depression 120–121for disabilities 125for manic-depressive disorder

120–121, 355self-hypnosis 198self-object 321self-psychology 321self-talk 81, 321–322Seligman, Martin 178, 219Selye, Hans 69, 101–102, 107, 125, 144,

159, 188, 303, 322, 344, 394sensate focus therapy 326Sensory Integration and the Child (Ayres)

323sensory integrative dysfunction 44,

322–323separation anxiety 323–324September 11, 2001 (9/11) 21, 152, 324,

362–363serious mental illness (SMI) 324–325serotonin 13, 118, 138, 254, 277, 280,

325, 396Serpell, James 276sertraline 119, 120severance package 240Severe Acute Respiratory Syndrome. See

SARSsex appeal 325–326sex drive 326sexism 326sex therapy 35, 202, 230, 237, 298, 326sexual difficulties 326–327

anorgasmia 35, 327dyspareunia 131–132, 237, 327

434 The Encyclopedia of Stress and Stress-Related Diseases

Index 435Index 435

ejaculation disorders 134–135, 202,326, 327

frigidity 155impotence 202, 327inhibition and 206transsexualism 158vaginismus 326, 327

sexual harassment 160, 327–328, 385sexual intercourse. See also rape

between family members 131,202–203, 343, 357

lack of satisfaction during 35, 155during menstruation 238painful 131–132, 237, 327during pregnancy 289

sexuality 328sexually transmitted diseases (STDs) 126,

303, 327, 328–329. See also “safe sex”;specific diseases

Sexual Politics (Millett) 388sexual preferences 189, 220, 231–232,

328, 329sexual response 326, 329sexual revolution 329, 388Shapiro, Francine 145“shell shock.” See combat fatigue; war

neurosisShepp, Elaine 345, 346–347Sherstein, Peter 359shiatsu 233, 264, 329–330. See also

acupressure; acupunctureshift work 81, 89–90, 264, 330, 366shopaholism 331. See also advertisingshort-term memory 154, 235shyness 331, 340sibling relationships 66–67, 331–332

disabled sibling 125elderly parents 135hemophiliac sibling 178jealousy 210in stepfamilies 343

sick building syndrome 22, 142, 155,245, 332

sick role 332–333SIDS. See sudden infant death syndromeSiegel, Bernie S(hepard) 333sighing 333sildenafil citrate. See Viagra“silent heart attack” 176silocosis 243simple phobia (single or specific phobia)

37, 268, 281, 282, 333single parents 109, 110, 285, 289, 373sinusitis, allergic 169sisters. See sibling relationshipssituationally bound panic attack 268situationally predisposed panic attack

268skin anthrax 35

skin cancer 353, 354sleep 333–336. See also dreams; insomnia;

nightmarebreathing during 73, 334, 339circadian rhythms and 89–90depression and 130, 206, 334excessive 334, 335initiating and maintaining 334NREM 335–336overtime and 265in post-traumatic stress disorder

286REM 77, 87, 130, 254, 335, 336research on 335serotonin and 325shift work and 330snoring during 334, 339–340t’ai chi and 358

sleep apnea 334, 339sleeping pills 57–58, 334, 335sleepwalking 335slips, trips, and falls 16, 85, 152, 284,

313, 336, 358, 387slips of the tongue 336SMI. See serious mental illnessSmith, Tom 359Smith-Coggins, Rebecca 330smog 21, 22smoking 336–339. See also marijuana

and asthma 46aversion therapy for 52as coping mechanism 36and emphysema 140hypnosis for 198in immigrants 3and insomnia 206journaling for 211and peptic ulcer 272quitting 336, 337, 338“secondhand” 22, 337truck drivers 367

snoring 334, 339–340SNS. See sympathetic nervous systemSobel, David S. 266social learning. See modelingsocial learning theory of depression 118social phobia 19, 37, 206, 268, 281–282,

300, 331, 340Social Readjustment Rating Scale 144social support system 186–187, 340, 345,

346. See also friends; support groupssocial workers 340, 347sodium 183sodium nitrite 172solar urticaria 184Solomon, George 297somatic pain 266somatization 341somatoform disorders 341

somnambulism. See sleepwalkingSorkin, David 341South Asian tsunami (2004) 367“space base” 93spam 341spas 341–342spastic colitis. See irritable bowel

syndromespeech disorders 349“speedball” 93Sperry, Len 207Spiegel, David 355–356“spinal adjustments” 85spirituality 342spontaneous abortion. See miscarriageSpontaneous Healing (Weil) 306sports massage 233SSRIs. See selective serotonin reuptake

inhibitorsstage fright 73, 225, 245, 273–274,

342–343. See also performance anxiety;public speaking

stammering 349Stampfl, Thomas 60Stanford University Arthritis Center 42STAR. See Stress and Anxiety Research

SocietySTDs. See sexually transmitted diseases“Stealing Your Life” (Fleck) 200steam inhalation (aromatherapy) 41Stein, Seth 367stepfamilies 309, 310, 343Stephens, Linda C. 323stillbirth 244, 343. See also miscarriageStone, Arthur A. 101stress 344–347

cold 94–95dis-stress 125, 144, 344endorphins and 142eustress 125, 144, 344, 394hypothalamus and 199and immune system 201occupational 211, 262–264parental afterschool 270post-traumatic. See post-traumatic

stress disorderpresurgical 292research on 344–345, 348sources of 345, 346understanding 344

Stress and Anxiety Research Society(STAR) 348

stress management 345–347, 348. Seealso specific programs

Stress Management and CounselingCenter 185

Stress of Life, The (Selye) 101–102, 107,159, 188, 322, 344, 394

Stress Reduction Clinic 213

stress urinary incontinence (SUI)348–349, 374

Stress without Distress (Selye) 188, 322,344, 394

stroke 86, 182, 349stun guns 358–359stuttering 349–350sublimation 114subluxation 85substance abuse. See also addiction;

alcoholism and alcohol dependence;drug abuse

and appetite 258in chronic illness 88–89denial of 114in homeless 186self-esteem and 320

subsyndromal depression 116Succeeding as a Super Busy Parent

(Gahrmann) 265success 350sudden infant death syndrome (SIDS)

165, 338, 350suicide 350–353

in adolescents 120, 351–352attempted 163, 186, 189on death certificate 113in depression 11, 115, 120, 350–351in elderly 16, 352and guilt 165hopelessness and 189physician-assisted 113, 141, 352prevention of 350–351recognizing intentions of 351, 352statistics on 350as taboo topic 357

suicide hotlines 106sulfur dioxide 21, 142Summers, Jane 289sunlight 353–354superiority complex 354superstition 354support groups 103, 298, 346, 354–356

for acne 5for addiction 9for agoraphobia 19for AIDS patients 6for Alzheimer’s disease 32, 355for anxiety disorders 40, 321for breast cancer 72, 355–356for cancer 78, 297, 333for caregivers 136, 355for chronic fatigue syndrome 88,

355for depression 120–121for diabetes 122for dieting 124for disabilities 125for emotional problems 139

for fibromyalgia 151for grief 163for guilt 165for herpes sufferers 181for infertility 205for manic-depressive disorder

120–121, 355and mind-body connections 241for pain 267for shopaholism 331for stepfamilies 343

suppression 114surgery. See also cosmetic surgery; plastic

surgeryfear about 292lasers in 216for reducing obesity 260

survivor guilt 192, 286Susan G. Komen Foundation 71swallowing 225Swedish massage 233swinging 232Syme, S. Leonard 305sympathetic inhibitors 183sympathetic nervous system (SNS) 10,

151, 199, 201, 256, 356symptom 356syndrome 356syphilis 328–329systematic desensitization 18, 21, 59, 60,

65systemic lupus erythematosus 50systolic pressure 182

TTA. See transactional analysisTabacchi, Mary 341taboos 246, 357tachycardia 357t’ai chi 68, 182, 357–358Talking from 9 to 5 (Tannen) 98, 222tampons 239Tannen, Deborah 98, 222tantrums 323, 358TASERs 358–360taxicab drivers 379–380TB. See tuberculosisTCAs. See tricyclic antidepressantsteachers 317–318, 371. See also schoolteamwork 98teenagers. See adolescents; pubertyteenage workers 84, 360teeth grinding 360, 362telecommuting 360–361telephones 361–362television 11, 63–64, 143, 335, 362telomere shortening 345Temoshok, Lydia 370temporary restraining order 128

temporomandibular joint (TMJ)headaches 171, 362

temporomandibular joint (TMJ)syndrome 69, 85, 360, 362

tendinitis 362tension (muscle contraction) headache

170terrorism 21, 35, 208, 312, 315, 324,

362–363. See also airport screeningmachines

TET. See tubal embryo transfertetrahydrocannabinol (THC) 229–230therapeutic touch 363Therapeutic Touch, How to Use Your Hands to

Help or to Heal, The (Krieger) 363THG (tetrahydrogestrinone) 363–364Thich Nhat Hanh 364Thomas, Lewis 363thoracic (chest) breathing 73threatened abortion 244thunderstorms 137, 222, 281thyroid cancer 82tic 364ticks 225“tight building syndrome.” See sick

building syndromeTillich, Paul 308time management 364–365time zones 90tipping 365TM. See Transcendental Meditationtobacco. See smokingtoilets. See lavatories, publictoilet training 217, 365. See also

bed-wettingToo Close for Comfort: Exploring the Risks of

Intimacy (Piorkowski) 207, 306Tourette’s syndrome 364toxic shock syndrome 239toxic substances. See hazardous and toxic

substancestractors 149traffic 51, 313tranquilizers 13transactional analysis (TA) 365Transcendental Meditation (TM) 61, 235,

307, 365–366Transportation Security Administration

(TSA) 22, 359transsexualism 158trench foot 94–95trends in work hours 81, 366trichotillomania 167tricyclic antidepressants (TCAs) 119,

278–279, 280for anxiety disorders 38for bed-wetting 58drug interactions 278–279for panic disorder 269side effects of 117, 278

436 The Encyclopedia of Stress and Stress-Related Diseases

Index 437Index 437

truck drivers 367TSA. See Transportation Security

Administrationtsunami 367–368tubal embryo transfer (TET) 205tubal sterilization 377, 378tuberculosis (TB) 174, 368Turback, Gay 68Turkle, Sherry 67Type A personality 176, 350, 368–369,

385Type B personality 369Type C Connection, The (Temoshok) 370Type C personality 78, 369–370, 385tyramine 172, 279

UUFOs (unidentified flying objects) 371ultraviolet light 294, 353–354underachievement 371underage drinking 62–64unemployment 14, 40, 104, 201, 291,

371–373. See also downsizing; layoffsunexpected panic attack 268unicyclic antidepressants 280unipolar depression 229. See also

exogenous depressionUnited Nations Children’s Education

Fund (UNICEF) 84Unsecular Man (Greeley) 308unstable angina 35unwed mothers 285, 289, 373uranium 165, 244, 302urge urinary incontinence 348, 374uric acid 162urinary incontinence 373–375. See also

bed-wettingin Alzheimer’s disease 31stress 348–349, 374urge 348, 374

urticaria. See hives

Vvacations 107, 341, 376vaccinations 376–377vaginismus 326, 327Vaillant, George 114Valium 377Valliant, George 102Valnet, Jean 41vascular headaches. See migraine

headachesvasectomy 377–378vasodilators 183venereal diseases. See sexually transmitted

diseasesvertebral subluxation complex 85vertigo 378–379. See also motion sicknessveterans 14, 26, 71, 96, 165, 191–192,

286–287, 308, 382

Veterans Affairs, Department of 14, 286Veterans Health Administration 14Viagra 202Vietnam War 14, 71, 96, 287violence 379–380. See also aggression;

anger; hostility; rapeand bullying 75domestic. See domestic violencemugging 249police and 285, 359, 379, 380and post-traumatic stress disorder

286prevention of 379–380at work 379–380, 386, 387, 391

visualization. See guided imagery;imagery

volunteerism 185, 201, 311, 380–381

Wwaist circumference 259Walking a Sacred Path, Rediscovering the

Labyrinth as a Sacred Tool (Artress)215

war neurosis 382Web log. See blogweddings 230–231weekend depression 382weight gain and loss 96, 183, 382, 392.

See also dieting; obesityWeil, Andrew 306, 382Weisaeth, Lars 83Weisman, Nancy 218Weissman, Myrna M. 40Wellbutrin. See buproprionWellness Councils of America 392, 393Western blacklegged ticks 225West Nile encephalitis 383West Nile fever 383West Nile virus (WNV) 382–383wet dreams 299, 383–384wheals. See hiveswheezing 384WHI. See Women’s Health Initiative“white coat hypertension” 182, 307“white lies” 225widows 109, 112, 163, 223, 305, 309,

328, 386“wife swapping” 232Wilson, Marlene 380win-win situation 99–100withdrawal symptoms 8, 9, 25–26, 28,

77, 142, 337, 338witnessing crime 106WNV. See West Nile virusWolpe, John 60women 384–387. See also gender;

mothersadvertising aimed at 11arthritis in 42

battered 127–128biological clock of 56, 65, 230, 373breast cancer in 71–72, 207,

227–228, 355–356breast reconstruction in 72as business owners 393as caregivers 79–80, 385carpal tunnel syndrome in 80chronic fatigue syndrome in 87coping 385–386cosmetic surgery in 102, 240crowding and 107depression in 116, 229dyspareunia in 131–132eating disorders in 133empty nest syndrome in 141fibromyalgia in 151flexible work hours of 153–154glass ceiling and 160as health care workers 173–174HIV/AIDS in 6, 194injuries in 386–387lesbian 189, 220lonely 223as marijuana users 230in menopause. See menopausemenstruation in. See menstruationmigraine in 171, 172, 238obese 259pregnant. See pregnancysex appeal of 325–326sexual harassment of 160, 327–328,

385sexual response in 329smoking 337, 338traditional role of 158, 384,

387–388unemployed 14, 372urinary incontinence in 348,

373–374veterans 286

Women’s Health Initiative (WHI) 237women’s movement 158, 326, 329,

387–388Wootton, Percy 62workaholics 3, 131, 320, 368–369workers’ compensation 388–389work hours 389

and absenteeism 2flexible 153–154, 291, 389–390overtime 213, 264–265, 291, 366,

389shift work 81, 89–90, 264, 330,

366of teenage workers 360trends in 81, 366

working mothers 110, 169, 247,257–258, 270, 364–365, 385, 387,389–390

438 The Encyclopedia of Stress and Stress-Related Diseases

workplace 390–391. See also healthinsurance; work hours; specificoccupations

absenteeism in 2, 76, 291, 392accidents in 2. See also accidents;

injuriesage discrimination in 14alcoholics in 24asbestos exposure in 43–44automation in 51, 81, 98–99, 138,

205, 392baby boomers in 56and back pain 56, 57brainstorming in 70, 105bullies in 74, 75bureaucracy in 75burnout in 3, 75–76, 347, 386carpal tunnel syndrome in 80–81,

310, 390changing nature of 81–82child labor in 83–85, 360, 380communication in 97–98coping in 101, 391corporate buyout 102coworkers 75, 76, 104–105, 291,

379, 388, 390, 391creativity in 105, 106criticism in 107cubicles in 108day care offered by 110, 389deadlines in 111death from overwork 213diversity in 125downsizing 14, 102, 104, 130, 211,

218, 219, 240, 291–292, 311, 391Employee Assistance Programs in 2,

138, 140–141, 302, 380employees from dysfunctional

families in 131employees with disabilities 33, 80

ergonomics in 143–144feng shui in 150glass ceiling 160health promotion in 175, 213, 262,

392humor in 196–197indoor air pollution in 22, 142,

155, 245, 332industrial hygiene 2, 136–137, 153,

203–204, 275job change 98, 102, 210, 390–391job security 14, 210–211, 218,

291–292, 372layoffs 36, 102, 104, 211, 218–219,

240, 274, 311, 372, 391lost work days 224managed care plans by 228, 390mergers 14, 102, 130, 211, 218,

219, 239–240, 308, 311music in 251networking in 254occupational health psychology in

262occupational stress in 211,

262–264performance review in 274presenteeism in 291–292random drug testing in 302and relocation 249, 308–309repetitive stress injuries in 80–81,

143, 232, 310, 390rotator cuff injuries in 313sexual harassment in 160,

327–328, 385smoking in 337stressors in 345, 346telecommuting 360–361time management in 364–365unemployment 14, 40, 104, 201,

291, 371–373

unpaid leave from 148violence in 379–380, 386, 387, 391

workplace shootings 379, 391worksite wellness programs 391–393. See

also Employee Assistance ProgramsWorld Health Organization 53, 120, 179,

316worry 393–394writer’s block 394Wurman, Richard 205

XXanax (alprazolam) 21, 28, 62, 269, 279,

395

Yyawning 396yellow (color) 95Y-ME Hotline 71Y-ME National Breast Cancer

Organization 71, 355–356Yoast, Richard A. 63yoga 68, 74, 88, 366, 396You Can Make a Difference (Wilson) 380Youngest Science, The (Thomas) 363“you” statements 97“yuppie flu.” See chronic fatigue

syndrome

ZZal, H. Michael 269Zane, Manuel 60Zeigler, Donald 62Zen 397Zerhouni, Elias 24Zoloft. See sertralineZwiefel, Jeff 145