Professional Documents
Culture Documents
Conceptual framework
1.2 Migraine
1.3 Asthma
1.4 Anxiety
1.5 Stress
1.8 Rationale
Chapter 1: Introduction
negatively affect physical health. For example, anxiety and stress are often
associated with severe headaches, stomach ulcers, and hypertension. According
to Chapman, Perry & Strine (2005) anxiety and stress have also been reported to
aggravate asthma symptoms. In addition, excessive stress heighten the
likelihood of developing arthritis, and people who report chronic anxiety are
often also at greater risk of developing heart disease. Further, mental health
conditions weaken the immune system, which greatly increases the likelihood
of developing chronic physical illnesses.
[i]
The World Health Organization defines mental health as "a state of well-being
in which the individual realizes his or her own abilities, cope with the normal
stresses of life, work productively and fruitfully, and is able to make a
Mental health and physical health are fundamentally linked. People living with
a mental illness are at greater risk of experiencing a wide range of physical
health problems (Ottawa, 2008). The reverse relationship is also true: people
living with chronic physical health conditions experience depression and
anxiety at twice the rate of the general population. All research and evidence
suggests a strong connection between body and mind. Given that this
connection exists the good news is that leading a healthy lifestyle can have a
positive impact on both mental and physical health. Therefore, making healthy
choices such as being physically active, eating healthy foods, not smoking,
going for annual medical examinations, and developing appropriate coping
strategies may prevent many physical and mental health conditions. Truth is,
good mental health promotes a healthy body and that should provide some
peace of mind.
Both mind and body are affected by biological and emotional changes, as well
as by social factors such as income and housing. These three pathways of
biology, illness experience, and the social determinants of health increase the
likelihood of someone living with a mental illness or chronic physical condition
[2]
developing a co-existing condition. Mental illnesses alter hormonal balances,
sleep cycles, and immune system function, while many psychiatric medications
have side-effects ranging from weight gain to irregular heart rhythms (Evans et
al, 2005, Leucht et al., 2007). These symptoms create an increased
vulnerability to a range of physical health problems. Similarly, poor physical
health may cause high blood sugar levels and disrupt the circulation of blood,
People with arthritis are at elevated risk of developing mood and anxiety
disorders, particularly among younger age groups (Patten, Williams & Wang,
2006). People with mental illnesses have a increased likelihood of developing a
range of chronic respiratory conditions including chronic obstructive pulmonary
disease (COPD), chronic bronchitis and asthma, (Himelhoch et al., 2004,
People with mental illnesses have high smoking rates, due in part to historical
acceptability of smoking in psychiatric institutions, the impact of nicotine on
symptom control, and the positive social aspects of smoking. Social factors such
as poverty, unstable housing, unemployment and social exclusion may also
impact upon both smoking rates and the development of respiratory conditions.
Stress and high emotions can aggravate asthma symptoms and even generate an
asthma attack. Chemicals released by the body during times of stress and high
emotion lead to tightening of the muscles around air passages in the lungs,
thereby narrowing the air tubes and making it difficult to breathe. Furthermore,
asthma attacks can be life threatening. People who experience asthma attacks
have a greater likelihood of experiencing anxiety and panic disorders than the
[3]
general public (Goodwin, Jacobi & Thefeld, 2003). Elevated rates of anxiety
and/or depression have similarly been found in people living with COPD
(Maurer et al., 2008).
The research linking mental illness and cancer has yielded mixed results with
study findings suggesting that people with mental illnesses have greater than
normal risk of developing some cancers (e.g., breast, bowel, lungs and pharynx)
but lower rates of other respiratory cancers (Lichtermann et al., 2001),
(Disability Rights Commission [UK], 2006), (Hippisley-Cox, Vinogradova,
Coupland, & Parker, 2007, Jacobs & Bovasso, 2000).
People with mental illnesses face higher risk of developing heart disease.
Factors influencing this relationship include physical changes caused by some
mental illnesses and antipsychotic medications (including elevated heart rates,
high cholesterol and abnormal heart rhythms), as well as the higher risk faced
by people with mental illnesses to experience poor nutrition, lack of access to
preventive health screenings, and obesity (Goff et al., 2005).
About one in three people who have a heart attack also experience depression
(NIMH, 2009). Mental health problems co-existing with heart disease
contribute to higher health care utilization and worse health outcomes (Kurdyak
[4]
experience many of the other risk factors for diabetes, such as obesity and high
According to the Ontario AIDS Network, about three in five people with
HIV/AIDS meet the diagnostic criteria for depression (Rourke, Kennedy &
McGee, 2006). People with serious mental illnesses who have access to primary
health care are less likely to receive preventive health checks than patients
without a mental illness. They also have less access to specialist care and lower
rates of surgical treatments following diagnosis of a chronic physical condition
( Kisely et al., 2007).
The mental health of people with chronic physical conditions is also frequently
overlooked. Diagnostic overshadowing can mask psychiatric complaints,
particularly for the development of mild to moderate mental illnesses; and short
appointment times are often not sufficient to discuss mental or emotional health
[5]
for people with complex chronic health needs (Craven, Cohen, Campbell,
Williams, & Kates, 1997). A variety of strategies are available to address these
gaps and enhance health care for people with co-existing mental and physical
First, certain researchers with a strong reductionist inclination argue that mental
disorders are ultimately brain disorders; mental disorders are best explored
through neuroscience. Second, some researchers with a strong belief in a
biopsychosocial approach, according to which all disorders have biological,
Mental Disorder:
There are many different categories of mental disorder, and many different
facets of human behavior and personality that become disordered (Gazzaniga, &
Heatherton, 2006), (WebMD Inc, 2005, July 01), (United States Department of
(Health & Human Services., 1999, Phillip M.D., 1995-2008, NIMH, 2005). A
mental disorder or mental illness is a psychological or behavioral pattern that
occurs in an individual and is thought to cause distress or disability that is not
[6]
expected as part of normal development or culture. The recognition and
understanding of mental health conditions has changed over time and across
cultures, and there are still variations in the definition, assessment, and
The definition and classification of mental disorders is a key issue for mental
health and for users that is and providers of mental health services. Most
international clinical documents use the term "mental disorder."
There are currently two widely established systems that classify mental
disorders - ICD-10 Chapter V: Mental and behavioral disorders, part of the
International Classification of Diseases produced by the World Health
Organization (WHO), and the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) produced by the American Psychiatric Association (APA).
Both list categories of disorder and provide standardized criteria for diagnosis.
[7]
anxiety disorder, social anxiety disorder, panic disorder, agoraphobia,
On the other aspect patterns of belief, language use and perception can become
disordered. Psychotic disorders in this domain include schizophrenia, and
delusional disorder. Schizoaffective disorder is a category used for individuals
[8]
disorder, histrionic personality disorder, narcissistic personality disorder) or
Mental disorders can arise from a combination of sources. In many cases there
is no single accepted or consistent cause currently established. A common view
is that disorders result from genetic vulnerabilities exposed by environmental
stressors (Diathesis-stress model).
biological, psychological and social factors, although this may not always be
applied in practice. Biopsychiatry has tended to follow a biomedical model,
focusing on "organic" or "hardware" pathology of the brain. Psychoanalytic
theories have been popular but are now less so. Studies have indicated that
genes often play an important role in the development of mental disorders,
although the reliable identification of connections between specific genes and
specific categories of disorder has proven more difficult. Environmental events
surrounding pregnancy and birth have also been implicated. Traumatic brain
injury may increase the risk of developing certain mental disorders. There have
[91
been some tentative inconsistent links found to certain viral infections (Yolken
& Torrey, 1995) to substance misuse, and to general physical health.
Differences have also been found in the size or activity of certain brains regions
in some cases. Psychological mechanisms have also been implicated, such as
[10]
People in all cultures find some behaviors bizarre or even incomprehensible.
The process by which conditions and difficulties come to be defined and treated
as medical conditions and problems, and thus come under the authority of
doctors and other health professionals, is known as medicalization or
pathologization.
Intangible Experiences
[ii]
cultural basis for that belief, experience, or interpretation of experience,
generally disqualifies it from counting as evidence of mental disorder.
Western Bias
Advocating a more culturally sensitive approach, critics such as Carl Bell and
Marcello Maviglia contend that the cultural and ethnic diversity of individuals
is often discounted by researchers and service providers (Shankar Vedantam,
2010).
[12]
and frustration that even those included were often misinterpreted or
cultural critics and that the formulations lack any scientific motivation or
support. Spitzer also posits that the new culture-bound diagnoses are rarely
used, maintaining that the standard diagnoses apply regardless of the culture
involved. In general, mainstream psychiatric opinion remains that if a diagnostic
category is valid, cross-cultural factors are either irrelevant or are significan:
only to specific symptom presentations (Widiger & Sankis, 2000).
Clinical conceptions of mental illness also overlap with personal and cultural
values in the domain of morality, so much so that it is sometimes argued that
separating the two is impossible without fundamentally redefining the essence
of being a particular person in a society (Clark, 2006) . In clinical psychiatry,
persistent distress and disability indicate an internal disorder requiring
treatment; but in another context, that same distress and disability can be seen as
an indicator of emotional struggle and the need to address social and structural
problems (Karasz, 2005) & (Tilbury & Rapley, 2004). This dichotomy has
leaded some academics and clinicians to advocate a postmodernist
conceptualization of mental distress and well-being (Bracken P, Thomas P,
[13]
Such approaches, along with cross-cultural and "heretical" psychologies centred
1.2 Migraine:
The typical migraine headache is unilateral (affecting one half of the head) and
pulsating, lasting from 4 to 72 hours; (The International Classification of
Headache Disorders, 2nd Edition,2004) symptoms include nausea, vomiting,
photophobia (increased sensitivity to light), and phonophobia (increased
sensitivity to sound) (Gallagher & Cutrer, 2002). Approximately one-third of
people suffer migraine headache perceive an aura—unusual visual, olfactory, or
[14]
other sensory experiences that are a sign that the migraine will soon occur
(“British Association for the Study of Headache", 2007).
Initial treatment is with analgesics for the headache, an antiemetic for the
nausea, and the avoidance of triggering conditions. The cause of migraine
headache is unknown; the most common theory is a disorder of the serotonergic
control system.
Classification of Migraine:
[15]
According to 1CHD-2, there are seven subclasses of migraines (some of which
motor weakness.
• Childhood periodic syndromes that are commonly precursors of migraine
include cyclical vomiting (occasional intense periods of vomiting),
abdominal migraine (abdominal pain, usually accompanied by nausea),
and benign paroxysmal vertigo of childhood (occasional attacks of
vertigo).
• Retinal migraine involves migraine headaches accompanied by visual
disturbances or even blindness in one eye.
• Complications of migraine describe migraine headaches and/or auras that
are unusually long or unusually frequent, or associated with a seizure or
brain lesion.
[16]
• Probable migraine describes conditions that have some characteristics of
Diagnosis of Migraine:
Migraines are underdiagnosed (Lipton RE, Stewart WF, Celentano DD, Reed
ML, 1992) and misdiagnosed (Schreiber CP, Hutchinson S, Webster CJ, Ames
M, Richardson MS, Powers C, 2004). The diagnosis of migraine without aura,
according to the International Headache Society, made according to the
following criteria, the "5, 4, 3, 2, and 1 criteria":
• 5 or more attacks
• 4 hours to 3 days in duration
For migraine with aura, only two attacks are required to justify the diagnosis.
[171
• sensitivity of 81 %
• specificity of 75%
characteristic of a migraine.
The signs and symptoms of migraine vary among patients. Therefore, what a
patient experiences before, during and after an attack not be defined exactly.
The four phases of a migraine attack listed below are common but not
necessarily experienced by all migraine sufferers. Additionally, the phases
experienced and the symptoms experienced during them vary from one
• The postdrome.
• Prodrome phase
[18]
muscles (especially in the neck), constipation or diarrhea, increased urination,
and other visceral symptoms (Kelman, 2004). These symptoms usually precede
the headache phase of the migraine attack by several hours or days, and
experience teaches the patient or observant family how to detect that a migraine
attack is near.
• Aura phase
For the 20-30% (Silberstein, Stephen, 2005) and (Mathew, Ninan, Evans &
Randolph, 2005) of migraine sufferers experience migraine with aura, this aura
comprises focal neurological phenomena that precede or accompany the attack.
They appear gradually over 5 to 20 minutes and generally last fewer than 60
minutes. The headache phase of the migraine attack usually begins within 60
minutes of the end of the aura phase, but it is sometimes delayed up to several
hours, and it missing entirely. Symptoms of migraine aura are visual, sensory,
or motor in nature (Silberstein & Stephen, 2002).
and hemianopsia.
[19]
The somatosensory aura of migraine consists of digitolingual or cheiro-oral
• Pain phase
and aggravated by physical activity. Not all these features are necessary. The
pain bilateral at the onset or start on one side and become generalized, and
usually it alternates sides from one attack to the next. The onset is usually
gradual. The pain peaks and then subsides and usually lasts 4 to 72 hours in
adults and 1 to 48 hours in children. The frequency of attacks is extremely
variable, from a few in a lifetime to several a weeks, and the average migraine
experiences one to three headaches a month. The head pain varies greatly in
intensity.
photophobia, phonophobia, and osmophobia and seek a dark and quiet room.
Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor, or sweating may be
noted during the headache phase.
[20]
The extremities tend to feel cold and moist. Vertigo may be experienced; a
variation of the typical migraine, called vestibular migraine, has also been
described. Lightheadedness, rather than true vertigo, and a feeling of faintness
may occur.
• Postdrome phase
The patient feel tired or "hungover" and have head pain, cognitive difficulties,
Triggers
• Allergic reactions
• Bright lights, loud noises, and certain odors or perfumes
[21]
• Physical or emotional stress
• Alcohol
• Menstrual cycle fluctuations, birth control pills, hormone fluctuations
D., 2006).
Sometimes the migraine occurs with no apparent "cause". The trigger theory
supposes that exposure to various environmental factors precipitates, or triggers,
individual migraine episodes. Migraine patients have long been advised to try to
identify personal headache triggers by looking for associations between their
headaches and various suspected trigger factors and keeping a "headache diary"
recording migraine incidents and diet to look for correlations in order to avoid
trigger foods. It must be mentioned, that some trigger factors are quantitative in
nature, e.g., a small block of dark chocolate not because a migraine, but half a
slab of dark chocolate almost definitely cause migraine, in a susceptible person.
In addition, being exposed to more than one trigger factor simultaneously more
likely cause a migraine, than a single trigger factor in isolation, e.g., drinking
[22]
and eating various known dietary trigger factors on a hot, humid day, when
feeling stressed and having had little sleep probably result in a migraine in a
susceptible person, but consuming a single trigger factor on a cool day, after a
good night's rest with minimal environmental stress mean that the sufferer will
not develop a migraine after all. Migraines complex to avoid, but keeping an
accurate migraine diary and making suitable lifestyle changes have a very
positive effect on the sufferer's quality of life. Some trigger factors are virtually
impossible to avoid, e.g. the weather or emotions, but by limiting the avoidable
trigger factors, the unavoidable ones have less of an impact on the sufferer.
• Food
Gluten One food elimination that has proven to reduce or eliminate migraines in
a percentage of patients is gluten. For those with (often undiagnosed) celiac
disease or other forms of gluten sensitivity, migraines are symptom of gluten
intolerance. One study found that migraine sufferers were ten times more likely
than the general population to have celiac disease, and that a gluten-free diet
eliminated or reduced migraines in these patients. Another study of 10 patients
with a long history of chronic headaches that had recently worsened or were
resistant to treatment found that all 10 patients were sensitive to gluten. MRI
scans determined that each had inflammation in their central nervous systems
caused by gluten-sensitivity. Seven out of nine of these patients that went on a
gluten-free diet stopped having headaches completely.
[23]
MSG: MSG is frequently reported as a dietary trigger (12%). In a placebo-
controlled trial, monosodium glutamate (MSG) in large doses (2.5 grams) taken
A 2005 literature review found that the available information about dietary
trigger factors relies mostly on the subjective assessments of patients
(Holzhammer & Wober, 2006). Some suspected dietary trigger factors appear
to genuinely promote or precipitate migraine episodes, but many other
suspected dietary triggers have never been demonstrated to trigger migraines.
The review authors found that alcohol, caffeine withdrawal, and missing meals
are the most important dietary migraine precipitants, that dehydration deserved
more attention, and that some patients report sensitivity to red wine. Little or no
[24]
• Weather
Several studies have found some migraines are triggered by changes in weather.
One study noted 62% of the subjects thought weather were a factor but only
51 % were sensitive to weather changes (Prince, Rapoport, Sheftell, Tepper &
Bigal, 2004). Among those whose migraines did occur during a change in
weather, the subjects often picked a weather change other than the actual
weather data recorded. Most likely to trigger a migraine were, in order:
Another study examined the effects of warm chinook winds on migraines, with
many patients reporting increased incidence of migraines immediately before
and/or during the Chinook winds. The number of people reporting migrainous
episodes during the Chinook winds was higher on high-wind Chinook days. The
probable cause was thought to be an increase in positive ions in the air (Cooke,
Rose & Becker, 2000).
• Other
One study found that for some migraineurs in India, washing hair in a bath was
a migraine trigger. The triggering effect also had to do with the hair was later
dried (Ravishankar, 2006).
[25]
Strong fragrances have also been identified as potential triggers, and some
sufferers report an increased sensitivity to scent as an aura effect.
Pathophysiology of Migraine:
the cause, and perpetuate most kinds of headaches. Migraine headaches are
symptom of Hypothyroidism since both caused by anxiety disorders
(Culpepper, 2009). A melanopsin-based receptor has been linked to the
association between light sensitivity and migraine pain (Noseda, Kainz &
Jakubowski, et ai, 2010).
• Depolarization theory
O min
[26]
most particularly the trigeminal nerve, which conveys the sensory information
for the face and much of the head.
hours before the attack, with onset of the headache occurring around the time
when the largest area of the brain is depolarized. A French study in 2007, using
the Positron Emission Tomography (PET) technique identified the
hypothalamus as being critically involved in the early stages (Denuelle, Fabre ,
Payoux, Chollet & Geraud, 2007).
• Vascular theory
Migraines begin when blood vessels in the brain contract and expand
inappropriately. This start in the occipital lobe, in the back of the brain, as
arteries spasm. The reduced flow of blood from the occipital lobe triggers the
aura that some individuals have migraines experience because the visual cortex
is in the occipital area. When the constriction stops and the blood vessels dilate,
they become too wide. The once solid walls of the blood vessels become
permeable and some fluid leaks out. This leakage is recognized by pain
receptors in the blood vessels of surrounding tissue. In response, the body
supplies the area with chemicals which cause inflammation. With each heart
beat, blood passes through this sensitive area causing a throb of pain (Alexander
Mauskop; Fox, Barry, 2001). The vascular theory of migraines is now seen as
secondary to brain dysfunction (Welch, 1993).
[27]
Serotonin theory
passes messages between nerve cells. It helps to control mood, pain sensation,
sexual behaviour, sleep, as well as dilation and constriction of the blood vessels
among other things. Low serotonin levels in the brain may lead to a process of
constriction and dilation of the blood vessels which trigger a migraine. Triptans
activate serotonin receptors to stop a migraine attack (Alexander Mauskop; Fox,
Barry, 2001).
• Neural theory
When certain nerves or an area in the brain stem become irritated, a migraine
begins. In response to the irritation, the body releases chemicals which cause
inflammation of the blood vessels. These chemicals cause further irritation of
the nerves and blood vessels and results in pain. Substance P is one of the
substances released with first irritation. Fain then increases because substance P
aids in sending pain signals to the brain (Alexander Mauskop; Fox, Barry,
2001).
• Unifying theory
[28]
4. chemicals including substance P irritate nerves and blood vessels causing
Prevention of Migraine:
The goals of preventive therapy are to reduce the frequency, painfulness, and/or
duration of migraines, and to increase the effectiveness of abortive therapy
(Modi & Lowder, 2006). Another reason to pursue these goals is to avoid
medication overuse headache (MOH), otherwise known as rebound headache,
which is a common problem among migraneurs. This is believed to occur in
part due to overuse of pain medications, and can result in chronic daily
headache (Diener & Limmroth, 2004) and (Fritsche & Diener, 2002).
Many of the preventive treatments are quite effective: Even with a placebo, one-
quarter of patients find that their migraine frequency is reduced by half or more,
and actual treatments often far exceed this figure (van der Kuy & Lohman,
2002). There are many medicines available to prevent or reduce frequency,
duration and severity of migraine attacks. They may also prevent complications
of migraine. Propranolol, atenolol, metoprolol, flunarizine, sodium valproate,
[29]
topiramate are some of the commonly used drugs. But they need to be taken for
about 3 months or more.
Prognosis of Migraine:
Cardiovascular risks:
The risk of stroke increased two- to threefold in migraine sufferers. Young aduk
sufferers and women using hormonal contraception appear to be at particular
risk (Etminan, Takkouche & Isoma, et al, 2005). The mechanism of any
association is unclear, but chronic abnormalities of cerebral blood vessel tone
may be involved. Women who experience auras have been found to have twice
the risk of strokes and heart attacks over non-aura migraine sufferers and
women who do not have migraines (Kurth, Gaziano, Cook, Logroscino, Diener
& Buring, 2006). Migraine sufferers seem to be at risk for both thrombotic anc
hemorrhagic stroke as well as transient ischemic attacks (Becker, Brobert.
Almqvist, Johansson, Jick & Meier, 2007). Death from cardiovascular causes
was higher in people with migraine with aura in a Women's Health Initiative
study, but more research is needed to confirm this (Waters, Campbell &
Elwood, 1983).
Epidemiology of Migraine:
[30]
very clear picture of how many patients there are with active migraine at any
third figure, which helps to clarify the picture, is the incidence — this relates to
the number of first attacks occurring at any given age and helps understanding
of how the disease grows and shrinks over time.
There is then a rapid growth in incidence amongst girls occurring after puberty,
(Linet, Stewart, Celentano, Ziegler & Sprecher, 1989), (Ziegler, Hassanein &
Couch, 1977, Selby & Lance, 1960) which continues throughout early adult life
(Anttila, Metsahonkala & Sillanpaa, 2006). By early middle age, around 25%
of women experience a migraine at least once a year, compared with fewer than
10% of men (Rasmussen & Olesen, 1992). After menopause, attacks in women
tend to decline dramatically, so that in the over 70s there are approximately
equal numbers of male and female sufferers, with prevalence returning to
around 5% (Lipton & Stewart, 1993).
At all ages, migraine without aura is more common than migraine with aura,
with a ratio of between 1.5:1 and 2:1 (Steiner, Scher, Stewart, Kolodner,
[31]
Liberman & Lipton, 2003). Incidence figures show that the excess of migraine
1.3 Asthma
During asthma attacks (exacerbations of asthma), the smooth muscle cells in the
bronchi constrict, the airways become inflamed and swollen, and breathing
becomes difficult. This is often referred to as a tight chest and is a sign to
immediately take medication. Asthma causes 4,000 deaths a year in the United
[32]
States. Medicines such as inhaled short-acting beta-2 agonists used to treat acute
The National Heart, Lung and Blood Institute defines asthma as a common
chronic disorder of the airways characterized by variable and recurring
symptoms, airflow obstruction, bronchial hyper responsiveness
(bronchospasm), and an underlying inflammation (http://www.nhlbi.nih.gov,
[33]
Table no. 1.1
predicted FEVj
Severe
Daily Frequent < 60% predicted > 30%
persistent
134]
Signs and symptoms:
May show
Alertness Agitated Agitated Confused/Drowsy
agitation
On
Breathlessness On walking Even at rest
talking
Usually not
Accessory muscle Used Used
used
Respiratory rate
Increased Increased Often >30
(/min)
<60
Pulse rate (/min) 100 100-120 >120
(Bradycardia)
<60 possible
Pa02 Normal >60
cyanosis
[35]
Because of the spectrum of severity within the asthma, some people with
Asthma exists in two states: the steady-state of chronic asthma, and the acute
state of an acute asthma exacerbation. The symptoms are different depending on
what State the patient is in.
[36]
obstruction manifest with symptoms similar to an acute exacerbation of asthma,
During very severe attacks, an asthma sufferer turn blue from lack of oxygen
and experience chest pain or even loss of consciousness. Just before loss of
consciousness, there is a chance that the patient feel numbness in the limbs and
palms start to sweat. The person's feet become cold. Severe asthma attacks
which are not responsive to standard treatments, called status asthmaticus, are
life-threatening and lead to respiratory arrest and death. Though symptoms very
severe during an acute exacerbation, between attacks a patient show few or even
no signs of the disease (Longmore & Murray et al., 2007).
Cause of Asthma:
[37]
Underlying both environmental and genetic factors is the role of the upper
airway in recognizing the perceived dangers and protecting the more vulnerable
lungs by shutting down the airway. Prophet has argued (Profet, 1991) that
allergens look to our immune systems like significant threats. Asthma, in this
view, is seen as an evolutionary defense. This view also suggests that removing
or reducing airborne pollutants successful at reducing the problem.
• Environmental
Recent studies show a relationship between exposure to air pollutants (e.g. from
traffic) and childhood asthma. (Salam et al, 2008).This research finds that both
the occurrence of the disease and exacerbation of childhood asthma are affected
compared to those who were not. It was proposed that this is due to modified
[38]
bacterial exposure during Caesarean section compared with vaginal birth,
which modifies the immune system (as described by the hygiene hypothesis)
Psychological stress has long been suspected of being an asthma trigger, but
only in recent decades has convincing scientific evidence substantiated this
hypothesis. Rather than stress directly causing the asthma symptoms, it is
thought that stress modulates the immune system to increase the magnitude of
the airway inflammatory response to allergens and irritants (Chen E, Miller GE.,
2007). Viral respiratory infections at an early age, along with siblings and day
care exposure, protective against asthma, although there have been controversial
results, and this protection depend on genetic context (Harju, Leinonen &
Nokso-Koivisto, et ai, 2006 & Richeldi, Ferrara, Fabbri, Lasserson & Gibson,
2005).Antibiotic use early in life has been linked to development of asthma in
several examples; it is thought that antibiotics make one susceptible to
development of asthma because they modify gut flora, and thus the immune
system (as described by the hygiene hypothesis) (Marra, Lynd & Coombes et
al.,2006).
The hygiene hypothesis is a hypothesis about the cause of asthma and other
allergic disease, and is supported by epidemiologic data for asthma. For
example, asthma prevalence has been increasing in developed countries along
with increased use of antibiotics, c-sections, and cleaning products. All of these
things negatively affect exposure to beneficial bacteria and other immune
system modulators that are important during development, and thus cause
increased risk for asthma and allergy.Recently scientists connected the rise in
[39]
prevalence of asthma, to the rise in use of paracetamol, suggesting the
possibility that paracetamol cause asthma (Eneli, Sadri, Camargo & Barr 2005).
It has been suggested that viral infections such as HSV, VSV and CSV are
correlated to asthma episodes (Harju, Leinonen & Nokso-Koivisto, et al. ,2006,
Richeldi, Ferrara, Fabbri, Lasserson & Gibson, 2005).
• Genetic:
Over 100 genes have been associated with asthma in at least one genetic
[40]
Many of these genes are related to the immune system or to modulating
populations that have been tested (Ober & Hoffjan, 2006). This indicates that
these genes are not associated with asthma under every condition, and that
researchers need to do further investigation to figure out the complex
interactions that cause asthma. One theory is that asthma is a collection of
several diseases, and that genes might have a role in only subsets of asthma. For
example, one group of genetic differences (single nucleotide polymorphisms in
17q21) was associated with asthma that develops in childhood (Bouzigon,
• Gene-environment interactions
Research suggests that seme genetic variants only cause asthma when they are
combined with specific environmental exposures, and otherwise not be risk
factors for asthma. The genetic trait, CD 14 single nucleotide polymorphism
(SNP) C-159T and exposure to endotoxin (a bacterial product) are a well-
and farms. Researchers have found that risk for asthma changes based on a
person’s genotype at CD 14 C-159T and level of endotoxin exposure (Martinez,
2007).
[41]
Table no. 1.4
C- 159T
Endotoxin
CC genotype TT genotype
levels
High
Low risk High risk
exposure
Low
High risk Low risk
exposure
Studying the prevalence of asthma and related diseases such as eczema and hay
fever have yielded important clues about some key risk factors. The strongest
risk factor for developing asthma is a family history of atopic disease; (Bai,
Mak & Barnes, 1992) this increases one's risk of hay fever by up to 5x and the
risk of asthma by 3-4x. (Ronmark, Lundback & Jonsson, et ah, 1997). In
children between the ages of 3-14, a positive skin test for allergies and an
increase in immunoglobulin E increases the chance of having asthma (Burrows,
Martinez & Holonen, et ah, 1989). In adults, the more allergens one reacts
positively to in a skin test, the higher the odds of having asthma (Simpson,
Custovic & Simpson, et ah, 2001).
[42]
Because much allergic asthma is associated with sensitivity to indoor allergens
and because Western styles of housing favor greater exposure to indoor
Strict reduction of dust mite allergens, for example, reduces the risk of allergic
sensitization to dust mites, and modestly reduces the risk of developing asthma
up until the age of 8 years old (Chan-Yeung, Manffeda & Dimich-Ward, et al.,
2000 & Custovic, Simpson & Simpson, et al.,2001 & Arshad, Bojarskas
Tsitoura, et al., 2002 & Arshad, Bateman, Matthews, 2003).
However, studies also showed that the effects of exposure to cat and dog
allergens worked in the Converse fashion; exposure during the first year of life
was found to reduce the risk of allergic sensitization and of developing asthma
later in life (Celedon, Litonjua, Ryan, et al.:2002 & Ownby, Johnson, Peterson,
2002 & Perzanowski, Ronmark, Platts-Mills & Lundback, 2002).
The inconsistency of this data has inspired research into other facets of Western
society and their impact upon the prevalence of asthma. One subject that
appears to show a strong correlation is the development of asthma and obesity.
In the United Kingdom and United States, the rise in asthma prevalence has
echoed an almost epidemic rise in the prevalence of obesity (Kuczmarski,
Flegal, Campbell, Johnson, 1960-1991 & Troiano, Flegal, Kuczmarski, et al.,
1995). In Taiwan, symptoms of allergies and airway hyper-reactivity increased
[43]
in correlation with each 20% increase in body-mass index (Huang, Shiao, Chou,
1998).
Hygiene hypothesis
One theory for the cause of the increase in asthma prevalence worldwide is the
so-called "hygiene hypothesis"—that the rise in the prevalence of allergies and
asthma is a direct and unintended result of the success of modem hygienic
practices in preventing childhood infections. Studies have shown repeatedly that
children coming from environments one would expect to be less hygienic (Von
Mutius, Martinez & Fritzsch, et al., 1994) families with many children,
(Strachan, 1989 & Jarvis, Chinn, Luczynska, Bumey: 1997) day care
environments, (Celedo, Litonjua, Weiss, Gold, 1999 & Ball, Castro-Rodriguez,
Griffith, et al., 2000) tended to have lower incidences of asthma and allergic
diseases.
This seems to run counter to the logic that vimses are often causative agents in
exacerbation of asthma. (Pattemore, Johnston, Bardin, 1992, Nicholson, Kent,
Ireland., 1993 & Tan, Xiang, Qiu, et al., 2003).
Additionally, other studies have shown that viral infections of the lower airway
[44]
Population disparities
Asthma prevalence in the US is higher than in most other countries in the world,
but varies drastically between diverse US populations (Gold & Wright., 2005).
Filipinos, Irish Americans, and Native Hawaiians, and lowest in Mexicans and
Koreans (Lara, Akinbami, Flores & Morgenstem, 2006, Davis, Kreutzer,
Lipsett, King, Shaikh, 2006 & Johnson, Oyama, LeMarchand, Wilkens, 2004).
Asthma prevalence also differs between populations of the same ethnicity who
are bom and live in different places (Gold & Acevedo-Garcia, 2005). US-bom
Mexican populations, for example, have higher asthma rates than non-US bom
Mexican populations that are living in the US (Eldeirawi & Persky, 2006).
Asthma prevalence and asthma deaths also differ by gender. Males are more
likely to be diagnosed with asthma as children, but asthma is more likely to
persist into adulthood in females (Osman, Flansell, Simpson, Hollowed &
Helms, 2007).Women account for nearly 65% of all asthma related deaths. This
difference attributable to hormonal differences, among other things. In support
of this, girls who reach puberty before age 12 were found to have a later
[45]
diagnosis of asthma more than twice as much as girls who reach puberty after
age 12. Asthma is also the number one cause of missed days from school.
Socioeconomic factors
Asthma incidence and quality of treatment varies among different racial groups,
though this due to correlations with income (and thus affordability of health
care) and geography. For example, African Americans are less likely to receive
outpatient treatment for asthma despite having a higher prevalence of the
disease. They are much more likely to have emergency room visits or
hospitalization for asthma, and are three times as likely to die from an asthma
attack compared to whites. The prevalence of "severe persistent" asthma is also
greater in low-income communities compared with communities with better
access to treatment (National Heart, Lung, and Blood Institute, 2004 & National
Center for Health Statistics, 2006). It is important that parents, most especially
of those families with relatively low socioeconomic status are educated and
informed of all necessary information about asthma since their family,
particularly their children are vulnerable to persistent asthma. For this reason,
more health organizations participate in the move for education and information
as fight against asthma.
[46]
Asthma and athletics
Occupational asthma
Asthma as a result of (or worsened by) workplace exposures is the world's most
commonly reported occupational respiratory disease. Still most cases of
occupational asthma are not reported or are not recognized as such. Estimates
by the American Thoracic Society (2004) suggest that 15-23% of new-onset
asthma cases in adults are work related. In one study monitoring workplace
asthma by occupation, the highest percentage of cases occurred among
operators, fabricators, and laborers (32.9%), followed by managerial and
professional specialists (20.2%), and in technical, sales and administrative
support jobs (19.2%). Most cases were associated with the manufacturing
(41.4%) and services (34.2%) industries. Animal proteins, enzymes, flour,
natural rubber latex, and certain reactive chemicals are commonly associated
with work-related asthma. When recognized, these hazards mitigated, dropping
the risk of disease (http://www.cdc.gov/niosh, 2008)
[47]
Pathophysiology of Asthma:
Bronchoconstriction
l.Inscle? fljonno
airways) contract into spasm (an "asthma attack"). Inflammation soon follows,
'late' response, where this initial insult is followed 3-12 hours later with further
bronchoconstriction and inflammation (Robert, Mason, John, Murray & Jay,
2005).
initiates bronchoconstriction.
Bronchial inflammation
[49]
of the allergen to other immune system cells. In most people, these other
immune cells (TH0 cells) "check" and usually ignore the allergen molecules. In
asthma patients, however, these cells transform into a different type of cell
(Th2), for reasons that are not well understood.
The resultant TH2 cells activate an important arm of the immune system, known
as the humoral immune system. The humoral immune system produces
antibodies against the inhaled allergen. Later, when a patient inhales the same
allergen, these antibodies "recognize" it and activate a humoral response.
Inflammation results: chemicals are produced that cause the wall of the airway
to thicken, cells which produce scarring to proliferate and contribute to further
’airway remodeling', causes mucus producing cells to grow larger and produce
more and thicker mucus, and the cell-mediated arm of the immune system is
activated. Inflamed airways are more hyper-reactive, and more prone to
bronchospasm.
Stimuli
[50]
grass pollen, mold spores, and pet epithelial cells (Adkinson, Bochner,
Busse,. Holgate, Lemanske & Simons, 2008).
• Food allergies such as milk, peanuts, and eggs. However, asthma is rarely
the only symptom, and not all people with food or other allergies have
asthma (Adkinson, Bochner, Busse,. Holgate, Lemanske & Simons,
2008).
• Use of fossil fuel related allergenic air pollution, such as ozone, smog,
summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to
[51]
be one of the major reasons for the high prevalence of asthma in urban
[52]
experience a worsening of their asthma during pregnancy whereas others
[53]
central to all atopic diseases, this was a watershed moment in the world of
allergy (Kowalak & Hughes et al. (eds), 2001).
Diagnosis of Asthma:
• ^0% difference on at least three days in a week for at least two weeks;
[54]
• ^0% improvement of peak flow following treatment, for example:
exercise).
[55]
their children's symptoms, studies suggest that children themselves are reliable
sources as early as age 7 and perhaps even as early as age 6 (Hirsch & Pohl,
2007).
In adults and older children, diagnosis made with spirometry or a peak flow
meter (which tests airway restriction), looking at both the diurnal variation and
any reversibility following inhaled bronchodilator medication. The latest
guidelines from the U.S. National Asthma Education and Prevention Program
(NAEPP) recommend spirometry at the time of initial diagnosis, after treatment
is initiated and symptoms are stabilized, whenever control of symptoms
deteriorates, and every 1 or 2 years on a regular basis (Sapp & Niven, 2008).
[56]
response to treatment. More recently, exhaled nitric oxide has been studied as a
breath test indicative of airway inflammation in asthma.
Differential diagnosis
After a pulmonary function test has been earned out, radiological tests, such as
a chest X-ray or CT scan, required excluding the possibility of other lung
diseases. Occasionally, a bronchial challenge test performed using methacholine
or histamine to assess bronchial hyper-responsiveness.
157]
aspiration, fevers might also indicate aspiration pneumonia. Direct aspiration
Asthma is categorized by the United States National Heart, Lung, and Blood
Institute as falling into one of four categories; intermittent, mild persistent,
moderate persistent and severe persistent. The diagnosis of "severe persistent
asthma" occurs when symptoms are continual with frequent exacerbations and
frequent night-time symptoms, result in limited physical activity and when lung
function as measured by PEV or FEVi tests is less than 60% predicted with PEE
Prognosis:
The prognosis for asthma is good, especially for children with mild disease
(Tippets & Guilbert, 2009) of asthma diagnosed during childhood, 54% of cases
are no longer carry the diagnosis after a decade. The extent of permanent lung
damage in people with asthma is unclear. Airway remodeling is observed, but it
is unknown whether these represent harmful or beneficial changes (Maddox &
Schwartz, 2002). Although conclusions from studies are mixed, most studies
show that early treatment with glucocorticoids prevents or ameliorates decline
[58]
in lung function as measured by several parameters (Beckett PA, Howarth PH,
2003). For those who continue to suffer from mild symptoms, corticosteroids
can help most to live their lives with few disabilities. It is more likely to
consider immediate medication of inhaled corticosteroids as soon as asthma
The mortality rate for asthma is low, with around 6,000 deaths per year in a
population of some 10 million patients in the United States. Better control of the
condition help prevent some of these deaths.
Epidemiology:
Disability-adjusted life year for asthma per 100,000 inhabitants in 2004 {WHO,
2009).
The prevalence of childhood asthma in the United States has increased since
confounded by changes in how asthma has been described and defined over
[59]
data (Woolcock, 1987). All factors considered, even studies that maintain a
asthma prevalence since the 1960s (Grant, Wagner & Weiss 1999).
monumental study which involved 155 centers in 56 countries was one of the
first to reliably compare the prevalence of asthma worldwide. Surveying nearly
half a million children 13-14 years of age, this study found great disparities (as
high as a 20 to 60-fold difference) in asthma prevalence across the world, with a
trend toward more developed and westernized countries having higher asthma
prevalence. Rote westernization however does not explain the entire difference
in asthma prevalence between countries, and the disparities may also be affected
by differences in genetic, social and environmental risk factors. There are also
Current research therefore suggests that the prevalence of childhood asthma has
been increasing, and this increased prevalence is greater than that in adults
(Peat, Gray & Mellis, et al., 1994). According to the Centers for Disease
Control and Prevention's National Health Interview Surveys, some 9% of US
children below 18 years of age had asthma in 2001, compared with just 3.6% in
1980 (see figure). The WHO reports that some 8% of the Swiss population
suffers from asthma today, compared with just 2% some 25-30 years ago
[60]
Although asthma is more common in affluent countries, it is by no means a
problem restricted to the affluent; the WHO estimate that there are between 15
and 20 million people with asthma in India. In the U.S., urban residents,
Hispanics, and African Americans are affected more than the population as a
whole. Striking increases in asthma prevalence have been observed in
populations migrating from a rural environment to an urban one, (Ng'ang'a,
1.4 Anxiety
Another view is that anxiety is "a future-oriented mood state in which one is
ready or prepared to attempt to cope with upcoming negative events" (Barlow,
1611
David H., 2002). Suggesting that it is a distinction between future vs. present
reaction to stress. It may help a person to deal with a difficult situation, for
example at work or at school, by prompting one to cope with it. When anxiety
becomes excessive, it falls under the classification of an anxiety disorder
(National Institute of Mental Health Retrieved September 3, 2008).
Physical effects of anxiety include heart palpitations, fatigue, nausea, chest pain,
shortness of breath, stomach aches, or headaches. Physically, the body prepares
the organism to deal with a threat. Blood pressure and heart rate are increased,
sweating is increased, blood flow to the major muscle groups is increased, and
immune and digestive system functions are inhibited (the fight or flight
response). External signs of anxiety may include pale skin, sweating, trembling,
and pupillary dilation. Someone suffering from anxiety also experience it as a
sense of dread or panic. Although panic attacks are not experienced by every
anxiety sufferer, they are a common symptom. Panic attacks usually come
without warning, and although the fear is generally irrational, the perception of
danger is very real. A person experiencing a panic attack often feel as if he or
she is about to die or pass out. Panic attacks confused with heart attacks
therefore only a doctor can differentiate between a panic attack and a heart
attack.
Anxiety does not only consist of physical effects, there are many emotional
ones as well. They include "feelings of apprehension or dread, trouble
concentrating, feeling tense or jumpy, anticipating the worst, irritability,
restlessness, watching (and waiting) for signs (and occurrences) or danger, and.
[62]
feeling like your mind's gone blank" (Smith, Melinda, 2008) as well as
[63]
Pre-existing health issues including chronic obstructive pulmonary disease
(COPD), heart failure, and arrhythmia these are the cause of anxiety or anxiety
Types of Anxiety:
• Existential anxiety
dread associated with the "dizziness of freedom" and suggested the possibility
for positive resolution of anxiety through the self-conscious exercise of
responsibility and choosing. In Art and Artist (1932), psychologist Otto Ran.<
wrote that the psychological trauma of birth was the pre-eminent human symbol
of existential anxiety and encompasses the creative person's simultaneous fear
of--and desire for—separation, individuation and differentiation.
in a decline in performance.
[64]
Test anxiety is the uneasiness, apprehension, or nervousness felt by students
who have a fear of failing an exam. Students suffering from test anxiety may
experience any of the following: the association of grades with personal worth,
fear of embarrassment by a teacher, fear of alienation from parents or friends,
While the term "test anxiety" refers specifically to students, many adults share
the same experience with regard to their career or profession. The fear of failing
a task and being negatively evaluated for it can have a similarly negative effect
on the adult.
of development in young people. For others, it may persist into adulthood and
become social anxiety or social phobia. "Stranger anxiety" in small children is
not a phobia. Rather it is a developmental^ appropriate fear by toddlers and
preschool children of those who are not parents or family members. In adults,
an excessive fear of other people is not a developmentally common stage; it is
[65]
• Trait anxiety
Anxiety can be either a short term 'state' or a long term "trait." Trait anxiety
• Paradoxical anxiety
[66]
Anxiety in Positive psychology
Mifili-
Anxieiv Flow
Symptoms of Anxiety:
In order to understand the diagnosis and treatment of anxiety, it is helpful to
of physical complaints.
[67]
• BEHAVIORAL. Behavioral symptoms of anxiety include pacing,
awareness.
• Displacement. Anxiety from one source is attached to a different object or
event. Phobias are an example of the mechanism of displacement in
psychoanalytic theory.
• Rationalization. The person justifies the anxious feelings by saying that
any normal person would feel anxious in their situation.
joint pain.
[68]
• Delusion formation. The person converts anxious feelings into conspiracy
common (e.g. muscle tension), while others are somewhat more rare (e.g.
numbness). The following briefly covers the most common physical
(somatic) symptoms and problems associated with anxiety and concludes
with a brief overview of panic attacks. The most basic normal
physiological reactions that are linked to anxiety, such as increased heart
rate and sweating. (Meek, 2008)
• Muscle Tension
One of the most common somatic symptoms for anyone experiencing some
level of anxiety is muscle tension. Many people carry tension in their bodies,
which often leads to tense shoulders, back, jaw and neck muscles. This also
manifest as clenched jaw and teeth grinding. Some people find success at
reducing these symptoms with some sort of muscle relaxation therapy.
• Digestive Problems
[69]
with GAD often have changes in their appetite when stress increases,
either eating more than normal or less. In many cases, people also
experience nausea. All of these cause concern since it can take a direct
toll on your physical health, and it also means your body is not
functioning at optimal levels, which makes it harder to deal with stress.
• Changes in Sleep
• Panic Attacks
Causes of Anxiety:
[70]
• Life issues: Anxiety disorder in children because of highly perfectionist
or overly critical parents. If children are not appreciated any way, then
they might react with anxious behavior. Insomnia and stress possible
causes of anxiety disorder. Witnessing a major accident or violent attack
also cause of anxiety disorder. Distressing thoughts, nightmares and
Anxiety disorder leads to low self esteem, fear of being rejected, extreme
feeling of loneliness and helplessness. Many people develop a panic
disorder due to major life stress such as financial problems, relationship
problems, moving home, physical illness, loss of employment etc. Hence,
[71]
it becomes very essential to make proper diagnosis of anxiety disorder in
order to decide appropriate treatment plan.
Prevalence of Anxiety:
The World Health Organization's Global Burden of Disease project did not
include generalized anxiety disorders. In lieu of global statistics, here are some
prevalence rates from around the world:
5. United States: approx. 3.1 percent of people age 18 and over in a given
year (9.5 million)
There are an infinite number of human experiences that cause normal anxiety.
Life offers us the experience of many anxiety-provoking “firsts” a first date, the
first day of school, the first time away from home. As we journey through life,
there are many important life events, both good and bad, that cause varying
amounts of anxiety. These events can include things such as, taking a school
exam, getting married, becoming a parent, getting divorced, changing jobs,
coping with illness and many others.
The discomfort anxiety brings in all of these situations is considered normal and
even beneficial. Anxiety about an upcoming test to work harder in preparing for
[72]
the exam. The anxiety feel when walking through a dark and deserted parking
lot to car cause to be alert and cautious of surroundings, or better yet, get an
escort to vehicle.
While it’s pretty clear to see that anxiety is normal and even beneficial, for
many people it becomes a problem. The main difference between normal
anxiety and problem anxiety is in the source and the intensity of the experience.
[73]
anticipate disaster, and are overly concerned about everyday matters such as
headaches, nausea, numbness in hands and feet, muscle tension, muscle aches,
difficulty swallowing, bouts of difficulty breathing, trembling, twitching,
irritability, sweating, insomnia, hot flashes, and rashes. These symptoms must
be consistent and on-going, persisting at least 6 months, for a formal diagnosis
of GAD to be introduced. Approximately 6.8 million American adults
experience GAD.
Diagnosis of GAD:
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 3rd Ed,)
[74]
B. There is significant difficulty in controlling the anxiety and worry. If
someone has a very difficult struggle to regain control, relax, or cope with the
C. The presence for most days over the previous six months of 3 or more (only
in daily life. "Clinically significant" is the part that relies on the perspective of
the treatment provider. Some people can have many of the aforementioned
symptoms and cope with them well enough to maintain a high level of
functioning.
Generalized anxiety disorder (GAD) can affect both adults and children. People
with GAD often have psychological and physical symptoms. They may visit the
[75]
doctor many times before they are diagnosed. They often ask the doctor to help
them with the complaints related to GAD, such as headaches or trouble falling
• Irritability or restlessness
• Difficulty sleeping
• Headaches
• Fatigue
• Trembling
• Muscle tension
• Sweating
• Light-headedness
• Shortness of breath
• Nausea
• Frequent urination in adults and bed-wetting in children
[76]
• Dry mouth
• Difficulty swallowing
• Racing heart
Some research suggests that GAD may run in families (Kendler, Neale &
Kessler, et al, 1992) and it may also grow worse during stress. GAD usually
begins at an earlier age and symptoms may manifest themselves more slowly
than in most other anxiety disorder (Robins, Regier eds, 1991). Some people
with GAD report onset in early adulthood, usually in response to a life stressor.
Once GAD develops, it can be chronic, but can be managed, if not all-but-
alleviated, with proper treatment (Rickels & Schweizer, 1990).
• Substance induced
[77]
good health. Symptoms may temporarily worsen however, during alcohol
withdrawal or benzodiazepine withdrawal.
• Neurology
connectivity of the amygdala and its processing of fear and anxiety (Etkin,
Prater, Schatzberg, Menon & Greicius, 2009).Sensory information enters the
and sensory cortices. Another area the adjacent central nucleus of the amygdala
that controls species-specific fear responses its connections brainstem,
hypothalamus, and cerebellum areas. In those with general anxiety disorder
these connections functionally seem to be less distinct and there is greater gray
matter in the central nucleus. Another difference is that the amygdala areas have
decreased connectivity with the insula and cingulate areas that control general
stimulus salience while having greater connectivity with the parietal cortex and
prefrontal cortex circuits that underlie executive functions. The latter suggests a
compensation strategy for dysfunctional amygdala processing of anxiety. This is
consistent with cognitive theories that suggest the use in this disorder of
attempts to reduce the involvement of emotions with compensatory cognitive
strategies (Etkin, Prater, Schatzberg, Menon & Greicius, 2009).
[78]
GAD Prevalence Rates:
experience during their lives, the subgroup of people who have Generalized
Anxiety Disorder (GAD) is much smaller. According to DSM-IV,
One notable fact about GAD is that it affects a larger number of women than
men. Summarized current prevalence estimates, and reported that the most
current information shows that there is a 2:1 female/male ratio for GAD. A
recent German study found that 6.6% of women and 3.6% of men at some
point during the lifespan. DSM-IV has slightly different figures and reported
that between 55-60% of sufferers are women. Despite some slight
differences, there is consensus opinion that GAD is experienced more
frequently by women than men.
Research has also found that Generalized Anxiety Disorder (GAD) affect
people at different rates based on age. Summarized current prevalence
estimates, and reported that although research on GAD and the elderly is not
complete, 17% of elderly men and 21.5% of elderly women experience severe
anxiety Furthermore, the rate of GAD in this population the highest of any age
[79]
group. They also reported that the lowest prevalence rates are for people
between the ages of 15-24. Finally, DSM-IV notes that GAD over-diagnosed in
children presenting with anxiety. GAD affects people of all ages, and although
many people experience some of the symptoms at a very early age, it fully
develop at any point during the lifespan (American Psychiatric Association
(2000).
One notable fact about Generalized Anxiety Disorder (GAD) is that it affects a
larger number of women than men. Summarized current prevalence estimates,
and reported that the most current information shows that there is a 2:1
female/male ratio for GAD. A recent German study found that 6.6% of women
and 3.6% of men at some point during the lifespan. DSM-IV has slightly
different figures and reported that between 55-60% of sufferers are women.
Despite some slight differences, there is consensus opinion that GAD is
experienced more frequently by women than men.
GAD affects about 6.8 million American adults, (Kessler, Chiu, Dernier, &
Walters, 2005) including twice as many women as men. The disorder develops
gradually and can begin at any point in the life cycle, although the years of
highest risk are between childhood and middle age (Robins, Regier, eds, 1991).
There is evidence that genes play a modest role in GAD (Kendler, Neale &
Kessler, et al„ 1992 ).
[80]
Anxiety Disorder (GAD) is much smaller. According to DSM-IV,
approximately 3% of people will develop the disorder during a given year, and
5% of people have GAD at some point in their lives. (American Psychiatric
Association, 2000)
Epidemiology of GAD:
The usual age of onset is variable - from childhood to late adulthood, with the
median age of onset being approximately 31. Most studies find that GAD is
associated with an earlier and more gradual onset than the other anxiety
disorders.
Women are two to three times more likely to suffer from generalized anxiety
disorder than men, although this finding appears to be restricted to only
developed countries, the spread of GAD is somewhat equal in developing
nations. . GAD is also common in the elderly population (Cameron, Alasdair,
2004). When their anxiety level is mild, people with GAD function socially and
hold down a job. Although they don’t avoid certain situations as a result of their
disorder, people with GAD have difficulty carrying out the simplest daily
activities if their anxiety is severe.
Physiology of anxiety:
Several parts of the brain are key actors in the production of fear and anxiety
(LeDoux, 1998) Using brain imaging technology and neurochemical techniques,
scientists have discovered that the amygdala and the hippocampus play
significant roles in most anxiety disorders.
[81]
The amygdala is an almond-shaped structure deep in the brain that is believed to
be a communications hub between the parts of the brain that process incoming
sensory signals and the parts that interpret these signals. It can alert the rest of
the brain that a threat is present and trigger a fear or anxiety response. It appears
that emotional memories are stored in the central part of the amygdala and may
play a role in anxiety disorders involving very distinct fears, such as fears of
dogs, spiders, or flying.
The hippocampus is the part of the brain that encodes threatening events into
memories. Studies have shown that the hippocampus appears to be smaller in
some people who were victims of child abuse or who served in military comb
(Bremner, Randall & Scott, et al. 1995, Stein MB, Hanna C, Koverola C, et al.,
1997). Research will determine what causes this reduction in size and what role
it plays in the flashbacks, deficits in explicit memory, and fragmented memories
of the traumatic event that are common in PTSD.
By learning more about how the brain creates fear and anxiety, scientists able to
devise better treatments for anxiety disorders. For example, if specific
neurotransmitters are found to play an important role in fear, drugs developed
that block them and decrease fear responses. (Molavi, 2005)
1.5 Stress
Stress is a term in psychology and biology, first coined in the 1930s, which has
in more recent decades become a commonplace of popular parlance. It refers to
the consequence of the failure of an organism - human or animal - to respond
appropriately to emotional or physical threats, whether actual or imagined.
[82]
Stress is defined as the adverse relation of the people to excessive pressure or
[83]
aches and pains, diarrhea or constipation, nausea, dizziness, chest pain, rapid
heartbeat, eating too much or not enough, sleeping too much or not enough,
social withdrawal, procrastination or neglect of responsibilities, increased
alcohol, nicotine or drug consumption, and nervous habits such as pacing about
or nail-biting.
Stress is how the body reacts to a stressor, real or imagined, a stimulus that
causes stress. Acute stressors affect an organism in the short term; chronic
Selye researched the effects of stress on rats and other animals by exposing
them to unpleasant or harmful stimuli (Selye, 1950). He found that all animals
display a similar sequence of reactions, manifesting in three distinct stages. He
labeled this universal response to stressors the general adaptation syndrome or
[84]
Alarm is the first stage. When the threat or stressor is identified or realized, the
body's stress response is a state of alarm. During this stage adrenaline produced
in order to bring about the fight-or-flight response. There is also some activation
of the HPA axis, producing cortisol.
Exhaustion is the third and final stage in the GAS model. At this point, all of
the body's resources are eventually depleted and the body is unable to maintain
normal function. The initial autonomic nervous system symptoms reappear
(sweating, raised heart rate etc.). If stage three is extended, long term damage
result as the capacity of glands, especially the adrenal gland, and the immune
system is exhausted and function is impaired resulting in decompensation.
[85]
evaluation of the resources available to cope with the problem, and alter the
primary appraisal.
In other words, primary appraisal also includes the perception of how stressful
the problem is; realizing that one has more than or less than adequate resources
to deal with the problem affects the appraisal of stressfulness. Further, coping is
flexible in that the individual generally examines the effectiveness of the coping
on the situation; if it is not having the desired effect, s/he generally tries
different strategies (Aldwin & Carolyn, 2007).
The locus ceruleus and other noradrenergic cell groups of the adrenal medulla
and pons, collectively known as the LC/NE system, also become active and use
brain epinephrine to execute autonomic and neuroendocrine responses, serving
as a global alarm system.
The autonomic nervous system provides the rapid response to stress commonly
known as the fight-or-flight response, engaging the sympathetic nervous system
and withdrawing the parasympathetic nervous system, thereby enacting
cardiovascular, respiratory, gastrointestinal, renal, and endocrine changes.
[86]
The hypothalamic-pituitary-adrenal axis (HPA), a major part of the
Impact on disease
Chronic stress has also been shown to impair developmental growth in children
by lowering the pituitary gland's production of growth hormone, as in children
[87]
associated with a home environment involving serious marital discord,
alcoholism, or child abuse
Prevalence of Stress:
Future projections of the effects of stress are staggering: all of the top five
diseases identified by the World Health Organization as causing the greatest
global disease burden by 2020, have stress as an underlying contributing or
complicating factor (Murray & Lopez, eds, 1998).
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Types of stress
Stress is the part of life. Basically, it is of two kinds:- Eustress and Distress.
Eustress is the stress or tension which comes into the events or incidents of
happiness like marriage, birth of a child, getting a new job etc. Distress is the
stress or tension which comes due to the effect of unpleasant events like loosing
a job, or death in a family or getting divorced etc.
a) Eustress
Etymology
Eustress is a word consisting of two parts. The prefix derives from the Greek eu
meaning either "well" or "good". When attached to the word "stress", it literally
means "good stress"!
Origins
The term eustress was first used by endocrinologist Hans Selye in 1975, when
he published a model dividing stress into two major categories: eustress and
distress (Selye, 1975). This article was an expansion on an earlier article he
wrote, where he discussed the idea of a General Adaptation Syndrome, or a
system of how the body responds to stress (Seyle, 1936).
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The difference between experiences which result in eustress or distress is
. Eustress, or positive stress, has the following characteristics: (Mills, Reiss, &
Dombeck, 2008).
b) Distress
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Animals, 1992). It can be evident in the presence of various phenomena, such as
inappropriate social interaction (e.g., aggression, passivity, or withdrawal).
People often find ways of dealing with distress, in both negative and positive
ways. Examples of positive ways are listening to music, calming exercises,
sports and similar healthy distractions. Negative ways are often drugs, alcohol
and anger, which lead to addictions and, later, more stress.
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• Hospitalization (oneself or a family member)
Work and employment concerns such as those listed below are also frequent
causes of distress:
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• Excessive job demands
• Job insecurity
• Conflicts with teammates and supervisors
• Inadequate authority necessary to carry out tasks
» Lack of training necessary to do the job
• Making presentations in front of colleagues or clients
Stressors are not always limited to situations where some external situation is
creating a problem. Internal events such as feelings and thoughts and habitual
behaviors also cause negative stress.
strangers at a party)
• Repetitive Thought Patterns:
• Worrying about future events (e.g., waiting for medical test results or job
restructuring)
• Unrealistic, perfectionist expectations
• Over scheduling
• Failing to be assertive
• Procrastination and/or failing to plan ahead
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(Mills, Reiss, & Dombeck, 2008)
Symptoms of Stress
While stress affects everyone in a unique way, there are certain factors that are
common. If you are experiencing any of the following, it could be a sign that
restorative.
• General Anxiety: Anxiety does serve an important function for survival,
but if you’re feeling anxious much of the time, it could be because you
have too many stressors in your life, or it may indicate a medical
condition like generalized anxiety disorder. If you experience an increase
less quickly.
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• Feelings of Frustration: If you’re faced with many demands at once, the
natural result for many people is increased frustration and irritability. The
Causes of Stress:
Both negative and positive stressors lead to stress. Some common categories
and examples of stressors include: sensory input such as pain, bright light, or
environmental issues such as a lack of control over environmental
circumstances, such as food, housing, health, freedom, or mobility.
Social issues also cause stress, such as struggles with conspecific or difficult
individuals and social defeat, or relationship conflict, deception, or break ups,
and major events such as birth and deaths, marriage, and divorce.
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2009) are thought to contribute to deficits in the maturity of an individual's
stress response systems. One evaluation of the different stresses in people's lives
A. Finances
Most studies agree that finances are a leading cause of stress. In an online poll
conducted in 2005 by Life Care, Inc., 23 percent of respondents named finances
as the leading cause of stress in their lives. Financial stress has led the list in
Some who name finances as the leading cause of stress cite major purchases
they have to make, such as a home or car. Others are stressed by a loss of
income, or mounting credit card debt. For some, financial stress will eventuate
in bankruptcy. While college students stress over paying for an education, Baby
Boomers and older senior citizens find that retirement income a major cause of
stress.
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B. Work
Closely tied to finances as a cause of stress is work. Our jobs or careers seem to
cause constant stress. In the LifeCare poll, 21 percent of those responding listed
this as the leading cause of stress in life.
Person worry about getting and keeping adequate employment. Person worry
about new types of work or new responsibilities. Person struggle to climb a
career ladder, overwhelmed by the demands. Work conditions may change, or
have interpersonal trouble at work. Students, especially teenagers and college
age students, cite school work as a cause of stress. Sometimes, work stress is
brought on by others. Sometimes, we bring it on ourselves.
C. Family
Family health is also a leading cause of stress. A sick family member, a serious
injury, pregnancy, miscarriage, or abortion all cause stress. Family changes of
other kinds bring stress, too. Adoption, relocation, and job changes for just one
family member cause stress for all.
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D. Personal Concerns
Personal concerns that are only indirectly created by others are another top
cause of stress. Lack of control tops the list of personal concerns. Every human
has a deep-seated desire for control over his or her own life. When control is
weak or missing in a given area, we experience stress. To many people, a lack
of control over their own time is a leading cause of stress. We want to determine
when we do tasks around the home, or at work. Holding a job, participating in
the children's carpool to school, driving family to soccer practices, shopping,
and scout meetings while trying to keep the household running create major
stress.
Most people find that personal health is a leading cause of stress. For some, the
stress is linked to obesity, and a desire to lose weight. For others, the stress is a
personal bas habit that affects health and must be changed. For example,
smoking, abuse of alcohol or other drugs. Illness or injury, whether less or more
serious, can be a leading cause of stress for many people. Incontinence can be
an ongoing concern. Personal health is more or less stressful according to the
degree of seriousness and our personal outlook on health.
Personal safety is also a leading cause of stress. Women, more than men, tend to
stress about their own and others' safety. Adults tend to stress more than young
people, who may act invincible.
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E. Personal Relationships
F. Death
Probably the most wrenching cause of stress is the death of a loved one or close
friend. Even the death of a pet is stressful. Children are always a source of stress
for parents, but when a child dies, the stress is overwhelming. The same is true
when a lifetime spouse passes on.
Every event in the environment, from the weather to the ringing telephone, has
some sort of impact on us. Some of these events are predictable. For instance,
the rent/mortgage payment due on the first of the month. Persons expected to
make small talk if they go to a party. Others are entirely unpredictable. It is hard
to know when the baby suddenly wake up sick and can't go to daycare, when
another driver cut off in traffic, or when spill coffee on new pants. Regardless of
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whether predict an event or not, the instant become aware of that event taking
place, have recognized a demand.
To understand what happens at this stage, you need to know a little bit about the
functioning of the human nervous system. The autonomic nervous system, or
ANS, controls all of the automatic functions in our body. For example, your
heartbeat, our body temperature, rate of breathing and digestion are all regulated
by the ANS.
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If person appraise an event as threatening, one branch of the ANS called the
adrenal glands. This system controls the body's reactions to stress, and also
handles a few other vital functions such as regulating digestion, the immune
system, mood, sexual behavior, and the body's overall energy usage.
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variety of sugar which is the body's primary fuel. Cortisol also increases levels
of glucose within the brain, which helps to sharpen our attention and quicken
our thinking process (just like stepping on the gas in a car causes more fuel to
go into the engine, causing it to produce more power). At the same time cortisol
dumps fuel into the body, it also functions to shut down body systems which are
not immediately important for handling a physical threat, such as digestion,
reproduction, and growth. This mobilizing effect of cortisol is generally
temporary in nature, because in addition to everything else it does, cortisol tells
the hypothalamus to gradually slow down production of CRH.
Once person’s body has been prepared for action by the various hormones and
neurotransmitters described in Stage 3 (above), you are ready to respond to the
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stressor by taking physical action. Physiologists call what happens next the
"fight-or-flight" response to highlight the two most common forms that this
physical response tends to take. When we fight, we try to influence or neutralize
the source of stress by striking out at it. Alternatively, we can flee and reduce
our stress by escaping from the place where the stress is occurring, leaving the
fighting for another day. Psychologists who conduct research on stress often add
a third response possibility to the classic fight and flight options. Sometimes,
rather than fighting or fleeing, we simply freeze instead. In many sports, this
response is called "choking."
The fight-or-flight response is automatic and fast, which was helpful to our
ancestors because it provided them with automatic responses to threats when
they didn't have time to think logically about how best to handle a situation.
Spending a long time debating the dangers of and potential responses to such a
situation would probably be fatal. When faced with such an intensely physical
threat, either fighting or fleeing as quickly as possible made the most sense in
terms of survival.
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Stage 5: Return to baseline
Once a stressor has been neutralized (or has been avoided successfully), the
parasympathetic nervous system (PaNS; the other branch of the ANS besides
the SyNS), starts to undo the stress response by sending out new signals telling
your body to calm down. The PaNS slows your heartbeat and breathing, causes
your muscles to relax, and gets your digestive juices flowing again. The PaNS
system is designed to promote growth, energy storage and other processes
important for long-term survival.
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bodily functions instantly and directly, while hormones have slower yet wider
effect on the body (Gross & Mcllveen, 1998). Both hormones and neurons
communicate with cells and create the delicate dynamic balance between the
body and its surrounding, through paired systems and feedback mechanisms
(Jacobs, 1973).
Increased heart rate, blood pressure and respiration. Pumping more blood to the
muscles, supplying more oxygen to the muscles and heart-lung system.
Increased sugar rates in the blood. Allowing rapid energy use, and accelerating
responses.
Prioritising - increased blood supply to peripheral muscles and heart, to motor
and basic-functions regions in the brain; decreased blood supply to digestive
system and irrelevant brain regions (such as speech areas), this also causes
There are further systems involved in the F or F response, and even more
consequences to it. It is clear that the F or F response is crucial to dealing with
some short-term dangers but it is incapable of dealing with long-term stress.
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The grave consequences of long-term stress on our body and mind, is a direct
Hormones:
Derived from the Greek word for excitation horomao, a hormone is a chemical
organic substance. It is produced by a system of ductless glands (the Endocrine
system) in small doses, and secreted into the bloodstream thus being targeted to
specific parts of the body. The hormones function as communication substances
- they regulate and integrate various bodily functions. Hormones are directed to
have a specific effect on the target areas. Unlike the nervous system, the glands
are distant from the 'target area'; thus the hormones are indirect, slower and their
influence is longer-lived than neural messages (Atkinson et al, 1996; Kandel,
1991; Lev, 1987; Thain, & Hickman, 1995).
• Adrenaline
There is a good reason why the first discovered hormone (1894) was
Adrenaline (Epinephrine in the US). Produced and secreted by the adrenal gland
(that all its hormones are known as 'stress hormones'), adrenaline is secreted as
a direct reaction to stressful situations, and its powerful effects are similar to
those of the sympathetic branch of the ANS (such as increasing heartbeats,
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Autonomic Nervous System - [ANS] processes). (Atkinson et al, 1996, Kandel,
1991, Lev, 1987, Rossi, & Cheek, 1988 & Thain, and Hickman, 1995).
Fight-or-FIight Response
When the stress response is initiated, immediate and powerful changes come
about because of the activation of a particular branch of the nervous system
called the autonomic nervous system (ANS). The ANS is responsible for many
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functions in the body that occur “automatically” such as digestion, heart rate,
blood pressure, and body temperature. The activity of the autonomic nervous
system takes place completely beyond human’s conscious control. It is
automatic.
There are two branches of the ANS that are designed to regulate the fight-or-
flight response on a constant basis. The sympathetic nervous system is the part
of the ANS that is responsible for initiating the fight-or-flight response. Each
time person have a thought of danger or pain, the sympathetic nervous system
initiates the fight-or-flight response to prepare them to handle the potential
danger or pain. It is an automatic reaction. Human only need to think that they
are in danger and the flood of physiological and emotional activity is turned on
and goes into perfect functioning to increase power, speed, and strength.
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The autonomic nervous system is controlled by the hypothalamus, which is
delivers a message through the nervous system that connects, like a hard-wire
neuron system, to every' other system of the body. The hypothalamus also
delivers a message to the endocrine system to initiate the secretion of hormones.
The hormones, primarily adrenalin and cortisol, flood the bloodstream and
travel throughout the body to deliver information to cells and systems that aid in
creating the ability to be more speedy and powerful.
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Increased heart rate
Increased metabolism
Blood is shunted away from the digestive tract and directed into
the muscles and limbs
Blood thins
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• Capillaries under the surface of the skin constrict (which
• Saliva dries up
It is interesting that the physiological stress response has only one purpose.
The fight-or-flight response is designed to help us do one thing, and only one
thing, very well. That one and only purpose of this response is to help us
SURVIVE! Our bodies are designed for survival.
The instant human have the thought of danger this flood of physiological
activity happens automatically. It is like a magic switch inside that instantly,
and without our conscious command, turns on all of those systems in the body
that help faster and stronger. In the short run, this response is a powerful and
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useful process, however kept “on” for a longer period; this response produce
serious problems.
Notice that when human are in homeostasis, as they are playing a friendly round
of croquet, they are in a state of balance. Then something happens in our
environment, like a big bear charging out of the forest. This perception of
danger automatically initiates the fight-or-flight response. Once they sense no
more danger, they experience exhaustion and fatigue because they have
expended a tremendous amount of energy while running or fighting. Human are
exhausted but the stress response is no longer activated. Because they feel safe
again, the functions in the body that activate the stress response are turned off.
They gradually return to normal (homeostasis) and they are ready for more
relaxing rounds of croquet. So, physiologically, the stress response is
characterized by sympathetic nervous system activation, which ultimately
results in the secretion of chemicals into the bloodstream mobilizing the
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behavioral response. Whether the response culminates in “fight” or “flight”
Acute Stress
You can probably think of times when your body has responded to a
danger in a manner similar to Ashley's response. Here are other examples of
acute stress in which the demand, danger or threat is quick, immediate, very
real, and usually does not last very long:
• Hiking down a trail when you trip and start to tumble down a
steep decline
• During an earthquake
You get the point. Acute stress does happen and in the very short run and
in the right amounts, an appropriate amount of tension is helpful, beneficial, and
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may even save your life. However, in reality, these types of experiences are a
Chronic Stress
If the stress response is allowed to stay in the “on” position for more time
than is necessary to escape the big bear, the result damage to human health. This
stage calls the continued sympathetic nervous system activation “chronic
stress.” The diagram that used earlier altered slightly to demonstrate the stress
response staying “on.” It looks like this:
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thinking, and muscle pain. On the other hand, a healthy choice like a nice,
relaxing jog can result in feeling balanced, alert, refreshed, and energized. The
body is sending messages that jogging a healthy decision.
1.6 Mind
Subconscious
The term subconscious is used in many different contexts and has no single or
precise definition. This greatly limits its significance as a meaning-bearing
concept, and in consequence the word tends to be avoided in academic and
scientific settings.
In everyday speech and popular writing, however, the term is very commonly
encountered. There it will be employed to refer to a supposed 'layer' or 'level' of
mentation (or/and perception) located in some sense 'beneath' conscious
awareness though, again, the notion's dependence upon informal 'folk-
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psychological' models that remain vague means that the precise nature and
properties of this 'underlying' layer are either never made explicit or possess an
ad hoc quality. At different times, references to the 'subconscious' as an agency
may credit it with various abilities and powers that exceed those possessed by
consciousness: the 'subconscious' may apparently remember, perceive and
determine things beyond the reach or control of the conscious mind. The idea of
the 'subconscious' as a powerful or potent agency has allowed the term to
become prominent in the New Age and self-help literatures, in which
investigating or controlling its supposed knowledge or power is seen as
advantageous. The 'subconscious' also be supposed to contain (thanks to the
influence of the psychoanalytic tradition) any number of primitive or otherwise
disavowed instincts, urges, desires and thoughts.
Freud's own terms for mentation taking place outside conscious awareness were
das Unbewusste (rendered by his translators as 'the Unconscious') and das
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Vorbewusste ('the Preconscious'); informal use of the term 'subconscious' in this
context thus creates confusion, as it fails to make clear which (if either!) is
meant. The distinction is of significance because in Freud's formulation the
Unconscious is 'dynamically' unconscious, the Preconscious merely
Consciousness
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ending with loss of movement in response to painful stimulation (Giizeldere,
1995).
Unconscious mind
The unconscious mind defined as that part of the mind which gives rise to a
collection of mental phenomena that manifest in a person's mind but which the
person is not aware of at the time of their occurrence. These phenomena include
unconscious feelings, unconscious or automatic skills, unnoticed perceptions,
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unconscious thoughts, unconscious habits and automatic reactions, complexes,
hidden phobias and concealed desires.
The unconscious mind seen as the source of night dreams and automatic
thoughts (those that appear without apparent cause). It seen as the repository of
memories that have been forgotten but that nevertheless is accessible to
consciousness at some later time. It seen as the locus of implicit knowledge, i.e.
all the things that we have learned so well that we do them without thinking.
One familiar example of the operation of the unconscious is the phenomenon
where one fails to immediately solve a given problem and then suddenly has a
flash of insight that provides solution maybe days later at some odd moment
during the day.
Probably the most detailed and precise of the various notions of 'unconscious
mind' and the one which most people will immediately think of upon hearing
the term is that developed by Sigmund Freud and his followers. It lies at the
heart of psychoanalysis.
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Consciousness, in Freud's topographical view (which was his first of several
psychological models of the mind) was a relatively thin perceptual aspect of the
mind, whereas the subconscious was that merely autonomic function of the
brain. The unconscious was considered by Freud throughout the evolution of his
psychoanalytic theory a sentient force of will influenced by human drive and yet
operating well below the perceptual conscious mind. For Freud, the unconscious
is the storehouse of instinctual desires, needs, and psychic actions. While past
thoughts and memories may be deleted from immediate consciousness, they
direct the thoughts and feelings of the individual from the realm of the
unconscious.
Freud divided mind into the conscious mind or Ego and two parts of the
Unconscious: the Id or instincts and the Superego. He used the idea of the
unconscious in order to explain certain kinds of neurotic behavior.
In this theory, the unconscious refers to that part of mental functioning of which
subjects make themselves unaware (Geraskov, 2007).
For psychoanalysis, the unconscious does not include all that is not conscious,
rather only what is actively repressed from conscious thought or what the
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person is averse to knowing consciously. In a sense this view places the self in
For Freud, the unconscious was a repository for socially unacceptable ideas,
wishes or desires, traumatic memories, and painful emotions put out of mind by
the mechanism of psychological repression. However, the contents did not
necessarily have to be solely negative. In the psychoanalytic view, the
unconscious is a force that can only be recognized by its effects — it expresses
itself in the symptom.
Carl Jung developed the concept further. He divided the unconscious into two
parts; the personal unconscious and the collective unconscious. The personal
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unconscious is a reservoir of material that was once conscious but has been
forgotten or suppressed.
The collective unconscious is the deepest level of the psyche containing the
accumulation of inherited psychic structures and archetypal experiences. There
is a considerable two way traffic between the ego and the personal unconscious.
For example, your attention can wander from this article to a memory of
something you did yesterday.
It is the idea that the mind and body are not separate entities. Rather, they are
intricately connected, interacting with each other in many ways. The body's
three main regulatory systems are the central nervous system (which includes
the brain), the endocrine system (which produces hormones), and the immune
system. These three systems work together and affect one another. Researchers
who study the mind-body connection examine these interactions, and are
particularly interested in the effects of emotions and thoughts on physical
health.
The concept of the interconnection between the brain and body has been around
for quite a while. Ancient healing practices, such as Traditional Chinese
Medicine and Ayurvedic medicine emphasized important links between the
mind and body. Hippocrates once wrote: "The natural healing force
within each one of us is the greatest force in getting well." This statement
reflects the belief of ancient philosophers that emotions and health are deeply
connected.
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In later centuries, however, this belief was cast aside. Medical professionals
Proof of a Connection
Scientists have been finding increasing evidence which proves the close
connection between the body and mind. For example, in 1986, David Speigel,
an M.D. at Stanford University School of Medicine, did a landmark study which
illustrated the power of the mind to heal. He observed a group of 86 women
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with late-stage breast cancer. Half of the women received standard medical care,
while the other half participated in weekly support sessions in addition the the
Speigel observed that the women who were involved in the support group, and
were able to share their feelings of grief and triumph, lived twice as long as the
women who did not participate in the group. A similar study was conducted in
1999, which showed that breast cancer patients who felt hopeless and depressed
had a lesser chance of survival, (http:// www.ajc.com/health/altmed).
In one study for example, a psychologist, Richard Totman, and his colleagues
assessed the psychological profiles of healthy volunteers, and then infected
them with cold inducing rhinoviruses. The individuals with more stressful lives
had significantly greater incidences of infection, as well as greater severity of
cold symptoms. The results of this study and many others show a direct link
between mental state and disease (Martin, 1997).
Mind-body therapy understands the direct link between one's emotional and
physical health. It focuses on the conscious use of the mind to affect the process
of healing. Although many techniques are used in mind-body therapy, we will
discuss four of the most commonly used techniques.
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One technique used is biofeedback, in which people learn to control certain
internal bodily processes that are normally occur involuntarily, such as heart
rate or blood pressure. These activities are measured with electrodes and
displayed on a moniter. The moniter provides feedback to the participant about
the internal workings of his or her body, and the person can then be taught to
use this information to gain control over these involuntary activities.
hypnosis, the person's body relaxes, and his or her thoughts become more
focused. The person enters a state of deep concentration, and becomes highly
responsive to a hypnotherapist's suggestions.
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patients as collections of molecules, rather than seeing them as human beings
with feelings. To these doctors, any malady a person is suffering from is purely
technical: if a person is depressed, it's because they're not producing enough
serotonin; if they have high blood pressure, they are producing too much
angiotesin.
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intimate connection between the mind and body. They view the person as a
While it's important for health care professionals to understand the mind-body
connection, it's vital for the public to be educated in this area as well. People
should be aware of the strong relationship between their mental and physical
states. Individuals should recognize the importance of good health in both areas,
and leam to take care of their bodies and brains by keeping active, sleeping
properly, eating nutritiously, and taking time to relax. Furthermore, people
should understand that moods matter, not just too mental health, but to phsyical
health as well. If someone is suffering from an emotional illness such as
depression or anxiety, they should seek treatment, since evidence is mounting
that these conditions can lead to physical illness and a shorter life.
1,8 Hypnosis
I lypnosis is a mental state (state theory) or set of attitudes and beliefs (non
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the subject, or self-administered ("self-suggestion" or "autosuggestion"). The
The words 'hypnosis' and 'hypnotism' both derive from the term "neuro
hypnotism" (nervous sleep) coined by the Scottish surgeon James Braid around
1841. Braid based his practice on that developed by Franz Mesmer and his
Characteristics
Skeptics point out the difficulty distinguishing between hypnosis and the
placebo effect, proposing that hypnosis is so heavily reliant upon the effects of
suggestion and belief that it would be hard to imagine how a credible placebo
control could ever be devised for a hypnotism study.
It said that hypnotic suggestion is explicitly intended to make use of the placebo
effect. For example, Irving Kirsch has proposed a definition of hypnosis as a
"non-deceptive mega-placebo," i. e., a method which openly makes use of
suggestion and employs methods to amplify its effects.
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Definition of Hypnosis:
The earliest definition of hypnosis was given by Braid, who coined the term
"hypnotism" as an abbreviation for "neuro-hypnotism", or nervous sleep, which
he opposed to normal sleep, and defined as:
Braid elaborated upon this brief definition in a later work: The real origin and
essence of the hypnotic condition, is the induction of a habit of abstraction or
mental concentration, in which, as in reverie or spontaneous abstraction, the
powers of the mind are so much engrossed with a single idea or train of thought,
as, for the nonce, to render the individual unconscious of, or indifferently
conscious to, all other ideas, impressions, or trains of thought. The hypnotic
sleep, therefore, is the very antithesis or opposite mental and physical condition
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American Psychological Association (APA), published the following formal
definition:
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least some suggestions, scores on standardized scales range from high to
negligible. Traditionally, scores are grouped into low, medium, and high
categories. As is the case with other positively-scaled measures of
psychological constructs such as attention and awareness, the salience of
evidence for having achieved hypnosis increases with the individual's score.
Induction of hypnosis
Take any bright object between the thumb and fore and middle fingers of the
left hand; hold it from about eight to fifteen inches from the eyes, at such
position above the forehead as necessary to produce the greatest possible strain
upon the eyes and eyelids, and enable the patient to maintain a steady fixed
stare at the object.
The patient must be made to understand that he is to keep the eyes steadily fixed
on the object, and the mind riveted on the idea of that one object. It will be
observed, that owing to the consensual adjustment of the eyes, the pupils are at
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first contracted: they will shortly begin to dilate, and after they have done so to
a considerable extent, and have assumed a wavy motion, if the fore and middle
fingers of the right hand, extended and a little separated, are carried from the
object towards the eyes, most probably the eyelids will close involuntarily, with
a vibratory motion. If this is not the case, or the patient allows the eyeballs to
move, desire him to begin anew, giving him to understand that he is to allow the
eyelids to close when the fingers are again carried towards the eyes, but that the
eyeballs must be kept fixed, in the same position, and the mind riveted to the
one idea of the object held above the eyes. It will generally be found, that the
eyelids close with a vibratory motion, or become spasmodically closed.
Braid himself later acknowledged that the hypnotic induction technique was not
necessary in every case and subsequent researchers have generally found that on
average it contributes less than previously expected to the effect of hypnotic
suggestions (Barber, Spanos & Chaves, 1974). Many variations and alternatives
to the original hypnotic induction techniques were subsequently developed.
However, exactly 100 years after Braid introduced the method, another expert
could still state: "It is safely stated that nine out of ten hypnotic techniques call
for reclining posture, muscular relaxation, and optical fixation followed by eye
closure." (White, Robert, 1941).
Suggestion
When James Braid first described hypnotism, he did not use the term
"suggestion" but referred instead to the act of focusing the conscious mind of
the subject upon a single dominant idea. Braid's main therapeutic strategy
involved stimulating or reducing physiological functioning in different regions
of the body. In his later works, however, Braid placed increasing emphasis upon
the use of a variety of different verbal and non-verbal forms of suggestion,
including the use of "waking suggestion" and self-hypnosis. Subsequently,
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Hippolyte Bemheim shifted the emphasis from the physical state of hypnosis on
to the psychological process of verbal suggestion.
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conscious mind. Indeed, Braid actually defines hypnotism as focused
(conscious) attention upon a dominant idea (or suggestion). Different views
regarding the nature of the mind have led to different conceptions of suggestion.
Hypnotists who believed that responses are mediated primarily by an
"unconscious mind", like Milton Erickson, made more use of indirect
suggestions, such as metaphors or stories, who’s intended meaning concealed
from the subject's conscious mind. The concept of subliminal suggestion also
depends upon this view of the mind. By contrast, hypnotists who believed that
responses to suggestion are primarily mediated by the conscious mind, such as
Theodore Barber and Nicholas Spanos tended to make more use of direct verbal
suggestions and instructions.
Ideo-dynamic reflex
Post-hypnotic suggestion
Susceptibility
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Shor and Emily Carota Ome developed a similar group scale called the Harvard
Group Scale of Hypnotic Susceptibility (HGSHS).
Whereas the older "depth scales" tried to infer the level of "hypnotic trance"
based upon supposed observable signs, such as spontaneous amnesia, most
subsequent scales measure the degree of observed or self-evaluated
responsiveness to specific suggestion tests, such as direct suggestions of arm
rigidity (catalepsy).
Franz Mesmer
Franz Mesmer (1734- 1815) believed that there was a magnetic force or "fluid"
within the universe which influenced the health of the human body. He
experimented with magnets to influence this field and so cause healing. By
around 1774 he had concluded that the same effects could be created by passing
the hands, at a distance, in front of the subject's body, referred to as making
"Mesmeric passes." The word mesmerize originates from the name of Franz
Mesmer; and was intentionally used to separate its users from the various
"fluid" and "magnetic" theories embedded within the label "magnetism".
Mesmerism's were most likely due to belief and imagination rather than to any
sort of invisible energy ("animal magnetism") transmitted from the body of the
Mesmerist.
James Braid
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physiology and psychology. Braid quotes the following passage from Stewart:
(Braid, Magic, Witchcraft, etc., 1852).
In his later works, Braid reserved the term "hypnotism" for cases in which
subjects entered a state of amnesia resembling sleep. For the rest, he spoke of a
"mono-ideodynamic" principle to emphasise that the eye-fixation induction
technique worked by narrowing the subject's attention to a single idea or train of
thought ("monoideism") which amplified the effect of the consequent
"dominant idea" upon the subject's body by means of the ideo-dynamic
principle.
Sigmund Freud
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text of the subsequent tradition known as "hypno-analysis" or "regression
hypnotherapy."
It is very probable, too, that the application of our therapy to numbers will
compel us to alloy the pure gold of analysis plentifully with the copper of direct
[hypnotic] suggestion.
Milton Erickson
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Erickson had no hesitation in presenting any suggested effect as being
"hypnosis", whether or not the subject was in a hypnotic state. In fact, he Was
not hesitant in passing off behaviour that was dubiously hypnotic as being
hypnotic (Weitzenhoffer,, 2000).
In the latter half of the twentieth century, two factors contributed to the
development of the cognitive-behavioural approach to hypnosis. 1 Cognitive and
behavioural theories of the nature of hypnosis (influenced by the theories of
Sarbin (Sarbin, T.R. & Coe, W.C., 1972) and (Barber, Spanos & Chaves, 1974)
became increasingly influential. 2 The therapeutic practices of hypnotherapy
and various forms of cognitive-behavioural therapy overlapped and influenced
each other (Alladin, A., 2008). Although cognitive-behavioural theories of
hypnosis must be distinguished from cognitive-behavioural approaches to
hypnotherapy, they share similar concepts, terminology, and assumptions and
have been integrated by influential researchers and clinicians such as Irving
Kirsch, Steven Jay Lynn, and others (Chapman, R.A. (ed.), 2005).
[139]
Hypnotherapy
Applications include:
• pain management
Catherine, 1993).
• sports performance.
Self-hypnosis is popularly used to quit smoking and reduce stress, while stage
iVlcdical applications
Hypnotherapy has been used to treat irritable bowel syndrome. Researchers who
Two of three studies that investigated the use of hypnosis for IBS were well
designed and showed a clear effect for the hypnotic treatment of IBS (Moore, &
Tasso, 2000). Hypnosis for IBS has received moderate support in the National
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Institute for Health and Clinical Excellence guidance published for UK health
services.(http://www.nice.org.uk). It has been used as an aid or alternative to
chemical anaesthesia, ("Physician Studies Hypnosis As Sedation Alternative,"
University of Iowa News Service, 6 February 2003,(medicalnewstoday.com) &
(institute-shot.com) and it has been studied as a way to soothe skin ailments.
A number of studies show that hypnosis reduce the pain experienced during
bum-wound debridement, bone marrow aspirations, and childbirth. The
International Journal of Clinical and Experimental Hypnosis found that
hypnosis relieved the pain of 75% of 933 subjects participating in 27 different
experiments (Nash, Michael., July 2001).
ible subjects experienced no pain reduction from hypnosis when compared with
placebo. Ordinary non-hypnotic suggestion also caused reduction in pain
compared to placebo, but was able to reduce pain in a wider range of subjects
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(both high and low suggestible) than hypnosis. The results showed that it is
primarily the subjects responsiveness to suggestion, whether within the context
of 'hypnosis' or not, that is the main determinant of causing reduction in pain
(Mhttp://www.psychology-and-mental-health).
Hypnosis may be useful as an adjunct therapy for weight loss. A 1996 meta
analysis studying hypnosis combined with cognitive-behavioural therapy found
that people using both treatments lost more weight than people using CBT
alone.
Psychotherapy
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In a July 2001 article for Scientific American titled "The Truth and the Hype of
Hypnosis", Michael Nash wrote: using hypnosis, scientists have temporarily
created hallucinations, compulsions, certain types of memory loss, false
memories, and delusions in the laboratory so that these phenomena can be
studied in a controlled environment (Nash, Michael R., 2001).
Self-hypnosis
N europsychology
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result of imagination. However, in normal circumstances without hypnosis, the
brain regions associated with motion detection are activated both when motion
is seen and when motion is imagined, without any changes in the subjects'
perception or experience. This may therefore indicate that highly suggestible
hypnotic subjects are simply activating to a greater extent the areas of the brain
used in imagination, without real perceptual changes.
Hypnosis is not a unitary state and therefore should show different patterns of
EEG activity depending upon the task being experienced. In our evaluation of
the literature, enhanced theta is observed during hypnosis when there is task
performance or concentrative hypnosis, but not when the highly hypnotizable
individuals are passively relaxed, somewhat sleepy and/or more diffuse in their
attention (Horton & Crawford, et al., 2004).
The induction phase of hypnosis may also affect the activity in brain regions
which control intention and process conflict. Anna Gosline claims:
"Gruzelier and his colleagues studied brain activity using an fMRI while
subjects completed a standard cognitive exercise, called the Stroop task.
The team screened subjects before the study and chose 12 that were highly
susceptible to hypnosis and 12 with low susceptibility. They all completed the
task in the fMRI under normal conditions and then again under hypnosis.
Throughout the study, both groups were consistent in their task results,
achieving similar scores regardless of their mental state. During their first task
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session, before hypnosis, there were no significant differences in brain activity
between the groups.
But under hypnosis, Gruzelier found that the highly susceptible subjects showed
significantly more brain activity in the anterior cingulate gyrus than the weakly
susceptible subjects. This area of the brain has been shown to respond to errors
and evaluate emotional outcomes.
The highly susceptible group also showed much greater brain activity on the left
side of the prefrontal cortex than the weakly susceptible group. This is an
area involved with higher level cognitive processing and behaviour." (Gosline,
Anna., 2004, Egner, Jamieson, Gruzelier, 2005).
1.8 Rationale:
n n well known that the mind can ww-- physical symptoms. For example,
v Lei; v.e are afraid or anxious we may dm dap: a fast heart rate, palpitations.
knot m the stomach, and fast breathing., i fuse physical symptoms are due to
c eased activity of nervous impulses sea: from the brain to various parts of the
fr fry. and to the release of adrenaline aho the bloodstream when we are
ai xious.
However, the exact way that the mind can cause certain other symptoms is not
dear. Also, how the mind can affect actual physical diseases (rashes, blood
pressure, etc) is not clear. It may have something to do with nervous impulses
going to the body, which we do not fully understand. There is also some
evidence that the brain may be able to affect certain cells of the immune system,
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Some people also use the term psychosomatic disorder when menial factors
cause physical symptoms, but where there is no physical disease. For example,
a chest pain may be caused by stress, and no physical disease can be found.
Each disease has its own treatment options. For physical diseases, physical
(Yates, 2010).
problems. That’s why 1 take this topic of my study to see the effect of
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