CHAPTER 1: INTRODUCTION

Conceptual framework

1.1 Physical and mental health

1.2 Migraine

1.3 Asthma

1.4 Anxiety

1.5 Stress

1.6 Mind-body relation

1.7 Hypnosis and hypnotherapy

1.8 Rationale
Chapter 1: Introduction

1.1 Physical & mental health

According to the (http://www.ontario.cmha.ca , 2003) mental health conditions

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.

Likewise, physical illness has a negative impact on mental health. A.ccording to

recent research completed by the University of Washington School Of Medicine
(Katon, 2003) patients with chronic physical illness have a high prevalence of
major depressive illness. Indeed, patients with cancer, arthritis, asthma,
diabetes, and heart disease may experience intensified feelings of anxiety,
depression, and stress. Mental health is a term used to describe a level
of cognitive or emotional well-being or an absence of a mental disorder
(About.com, 2006). From perspectives of the discipline of positive
psychology or holism mental health may include an individual's ability to enjoy
life and procure a balance between life activities and efforts to
achieve psychological resilience.

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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

contribution to his or her community” (WHO, 2005). It was previously stated

that there was no one "official" definition of mental health. Cultural differences,
subjective assessments, and competing professional theories all affect how
"mental health" is defined.

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

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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,

which can impact brain function (Evans et al., 2005).

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,

McIntyre et. al., 2006).

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

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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

et al., 2008). However, providing psychological therapies to recovering heart

patients has been shown to improve emotional well-being and survival rates and
reduce hospital stays and re-hospitalization rates (American Psychological
Association, 2009). Both depression and schizophrenia are risk factors for the
development of type 2 diabetes due to their impact on the body’s resistance to
insulin (Ottawa, 2008, Dixon et al, 2000). People with mental illnesses also

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experience many of the other risk factors for diabetes, such as obesity and high

cholesterol levels. Antipsychotic medications have been shown to significantly

impact weight gain; obesity rates are up to 3.5 times higher in people with

serious mental illnesses in comparison to the general population (Coodin, 2001).

Studies indicate that depression may hasten progression to full-blown AIDS
through physiological and emotional changes (Evans et al., 2005).

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 stigma associated with mental illness continues to be a barrier to the

diagnosis and treatment of chronic physical conditions in people with mental
illnesses. Stigma can prevent people from seeking health care services, and can
lead to a misdiagnosis of physical ailments as psychologically based. This
“diagnostic overshadowing” occurs frequently and can result in physical
symptoms being either ignored or downplayed (Disability Rights Commission
[UK], 2006).

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

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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

health conditions. Descriptions of the behaviors now labeled as symptomatic of

mental illness or disorder were sometimes framed in quite different terms, such
as possession by supernatural forces. Anthropological work in non-Westem
cultures suggests that there are many cases of behavior that Western psychiatry
would classify as symptomatic of mental disorder, which are not seen within

their own cultures as signs of mental illness.

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,

psychological, and social dimensions, argue that, while maintain a distinction

between the psychological and the biological ways of understanding peoples
illnesses, no particular illness is purely mental or purely physical. It seen as
compatible with such an approach, even does not directly endorse it.

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

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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

classification of mental disorders, although standard guideline criteria are

widely accepted. Over a third of people in most countries report meeting criteria
for the major categories at some point in their life. The causes are often
explained in terms of a diathesis-stress model and biopsychosocial model.
Services are based in psychiatric hospitals or in the community, and mental

health professionals diagnose individuals by various methods, often relying on

observation and questioning in interview. Psychotherapy and psychiatric
medication are two major treatment options as are social interventions, peer
support and self-help.

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.

Anxiety or fear that interferes with normal functioning may be classified as an

anxiety disorder ("Mental Health: Types of Mental Illness",2009) Commonly
recognized categories of anxiety disorders include specific phobia, generalized

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anxiety disorder, social anxiety disorder, panic disorder, agoraphobia,

obsessive-compulsive disorder and post-traumatic stress disorder.

Affective (emotion/mood) states also become disordered. Mood disorder

involving unusually intense and sustained sadness, melancholia or despair is
known as Clinical depression (or Major depressive disorder). Milder but
prolonged depression can be diagnosed as dysthymia. Bipolar disorder involves

abnormally "high" or pressured mood states, known as mania or hypomania,

alternating with normal or depressed mood. Whether unipolar and bipolar mood
phenomena represent distinct categories of disorder, or whether they usually
mix and merge together along a dimension or spectrum of mood, is under

debate in the scientific literature (Akiskal & Benazzi, 2006).

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

showing aspects of both schizophrenia and affective disorders. Schizotypy is a

category used for individuals showing some of the characteristics associated

with schizophrenia but without meeting cut-off criteria.

Personality Disorder-The fundamental characteristics of a person tha:

influence his or her thoughts, and behaviors across situations and time -
considered disordered if it is thought to be abnormally rigid and maladaptive.
Categorical schemes list a number of different such personality disorders, from
those classed as eccentric (ex: paranoid personality disorder, schizoid
personality disorder, schizotypal personality disorder), to those described as
dramatic or emotional (antisocial personality disorder, borderline personality

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disorder, histrionic personality disorder, narcissistic personality disorder) or

those seen as fear-related (avoidant personality disorder, dependent personality

disorder, obsessive-compulsive personality disorder). There is, however, an
emerging consensus that personality disorders, like personality traits in the

normal range, incorporate a mixture of more acute dysfunctional behaviors that

resolve in short periods, and maladaptive temperamental traits that are more
stable (Clark, 2006).

Causes of Mental Disorder:

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).

An eclectic or pluralistic mix of models may be used to explain particular

disorders, and the primary paradigm of contemporary mainstream Western
psychiatry is said to be the biopsychosocial (BPS) model, incorporating

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

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been some tentative inconsistent links found to certain viral infections (Yolken
& Torrey, 1995) to substance misuse, and to general physical health.

Abnormal functioning of neurotransmitter systems has been implicated,

including serotonin, norepinephrine, dopamine and glutamate systems.

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

cognitive (e.g. reason), emotional processes, personality, temperament and

coping style.

Social influences have been also found to be important, including abuse,

bullying and other negative or stressful life experiences. The specific risks and
pathways to particular disorders are less clear, however. Aspects of the wider
community have also been implicated, including employment problems,
socioeconomic inequality, lack of social cohesion, problems linked to
migration, and features of particular societies and cultures.

Causes related to Society, Culture and Ethnicity

Different societies or cultures and even different individuals in a culture can

disagree as to what constitutes optimal versus pathological biological and
psychological functioning. Research has demonstrated that cultures vary in the
relative importance placed on, for example, happiness, autonomy, or social
relationships for pleasure. Likewise, the fact that a behaviour pattern is valued,
accepted, encouraged, or even statistically normative in a culture does not
necessarily mean that it is conducive to optimal psychological functioning.

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People in all cultures find some behaviors bizarre or even incomprehensible.

But just what they feel is bizarre or incomprehensible is ambiguous and

subjective (Heinimaa, 2002). These differences in determination can become
highly contentious.

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.

In the scientific and academic literature on the definition or classification of

mental disorder, one extreme argues that it is entirely a matter of value

judgements (including of what is normal; while another proposes that it is or
could be entirely objective and scientific (Berrios, 1999). Common hybrid
views argue that the concept of mental disorder is objective but a "fuzzy
prototype" that can never be precisely defined, or alternatively that it inevitably
involves a mix of scientific facts and subjective value judgments (Perring,
2005).

Intangible Experiences

Religious, spiritual, or transpersonal experiences and beliefs are typically not

defined as disordered, especially if widely shared, despite meeting many criteria
of delusional or psychotic disorders (Pierre, 2001, Johnson & Friedman, 2008).
Even when a belief or experience can be shown to produce distress or disability
- the ordinary standard for judging mental disorders - the presence of a strong

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cultural basis for that belief, experience, or interpretation of experience,
generally disqualifies it from counting as evidence of mental disorder.

Western Bias

Current diagnostic guidelines have been criticized as having a fundamentally

Euro-American outlook. They have been widely implemented, but opponents
argue that even when diagnostic criteria are accepted across different cultures, it
does not mean that the underlying constructs have any validity within those
cultures; even reliable application can prove only consistency, not legitimacy
(Widiger & Sankis, 2000).

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).

Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is

ironically illustrated in the introduction of cultural factors to the DSM-IV: that
disorders or concepts from non-Westem or non-mainstream cultures are
described as "culture-bound", whereas standard psychiatric diagnoses are given
no cultural qualification whatsoever, reveals to Kleinman an underlying
assumption that Western cultural phenomena are universal (Kleinman, 1997).
Kleinman's negative view towards the culture-bound syndrome is largely shared
by other cross-cultural critics, common responses included both disappointment
over the large number of documented non-Westem mental disorders still left out

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and frustration that even those included were often misinterpreted or

misrepresented (Bhugra, & Munro., 1997).

Many mainstream psychiatrists are dissatisfied with the new culture-bound

diagnoses, although for different reasons. Robert Spitzer, a lead architect of the
DSM-III, has opined that adding cultural formulations was an attempt to placate

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).

Relationships and Morality

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,

2001) & (Lewis B, 2000).

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Such approaches, along with cross-cultural and "heretical" psychologies centred

on alternative cultural and ethnic and race-based identities and experiences,

stand in contrast to the mainstream psychiatric community's active avoidance of
any involvement with either morality or culture (Kwate, 2005). In many
countries there are attempts to challenge perceived prejudice against minority
groups, including alleged institutional racism within psychiatric services.

1.2 Migraine:

Migraine is a neurological syndrome characterized by altered bodily

perceptions, severe headaches, and nausea. Physiologically, the migraine
headache is a neurological condition more common to women than to men.
(Stovner, Zwart, Hagen, Terwindt, Pascual, 2006) and (The International
Classification of Headache Disorders, 2nd Edition, 2004). The word migraine
was borrowed from Old French migraigne (originally as "megrim", but
respelled in 1777 on a contemporary French model). The French term derived
from a vulgar pronunciation of the Late Latin word hemicrania, itself based on
Greek hemikrania, from Greek roots for "half and "skull”, http:// www.
Etymonline (2009).

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

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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.

There are migraine headache variants, some originate in the brainstem

(featuring intercellular transport dysfunction of calcium and potassium ions)
and some are genetically disposed (Ogilvie, Russell & Dhall, et al., 1998).
Studies of twins indicate a 60 to 65 percent genetic influence upon their
propensity to develop migraine headache (Gervil, Ulrich, Kaprio, Olesen, &
Russell, 1999) and (Ulrich, Gervil, Kyvik, Olesen & Russell, 1999). Moreover,
fluctuating hormone levels indicate a migraine relation; 75 percent of adult
patients are women, although migraine affects approximately equal numbers of
prepubescent boys and girls; propensity to migraine headache is known to
disappear during pregnancy, although in some women migraines may become
more frequent during pregnancy (Lay & Broner, 2009).

Classification of Migraine:

The International Headache Society (IHS) offers guidelines for the

classification and diagnosis of migraine headaches, in a document called "The
International Classification of Headache Disorders, 2nd edition" (ICHD-2)
(“The International Classification of Headache Disorders: 2nd edition, 2004").

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According to 1CHD-2, there are seven subclasses of migraines (some of which

include further subdivisions):

• Migraine without aura, or common migraine, involves migraine

headaches that are not accompanied by an aura (visual disturbance, see

below).

• Migraine with aura usually involves migraine headaches accompanied by

an aura. Less commonly, an aura can occur without a headache, or with a
non-migraine headache. Two other varieties are Familial hemiplegic
migraine and sporadic hemiplegic migraine, in which a patient has
migraines with aura and with accompanying motor weakness. If a close
relative has had the same condition, it is called "familial", and otherwise
it is called "sporadic". Another variety is basilar-type migraine, where a
headache and aura are accompanied by difficulty speaking, vertigo,
ringing in ears, or a number of other brainstem-related symptoms, but not

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.

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 • Probable migraine describes conditions that have some characteristics of

migraines but where there is not enough evidence to diagnose it as a

migraine with certainty.

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

• 2 or more of - unilateral location, pulsating quality, moderate to severe

pain, aggravation by or avoidance of routine physical activity
• 1 or more accompanying symptoms - nausea and/or vomiting,
photophobia, phonophobia

For migraine with aura, only two attacks are required to justify the diagnosis.

The mnemonic Pounding (Pulsating, duration of 4-72 hours, Unilateral,

Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met,
then the positive likelihood ratio for diagnosing migraine is 24 (Detsky,
McDonald, Baerlocher, Tomlinson, McCrory & Booth, 2006).

The presence of either disability, nausea or sensitivity, diagnose migraine with;

(Lipton, Dodick & Sadovsky, et al., 2003).

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 • sensitivity of 81 %
• specificity of 75%

Migraine differentiated from other causes of headaches such as cluster

headaches. These are extremely painful, unilateral headaches of a piercing

quality. The duration of the common attack is 15 minutes to three hours. Onset
of an attack is rapid, and most often without the preliminary signs that are

characteristic of a migraine.

Signs and symptoms of 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

migraine attack to another in the same migraine:

• The prodrome, which occurs hours or days before the headache.

• The aura, which immediately precedes the headache.

• The pain phase, also known as headache phase.

• The postdrome.

• Prodrome phase

Prodromal symptoms occur in 40-60% of migraineurs (migraine sufferers).

This phase consist of altered mood, irritability, depression or euphoria, fatigue,

yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff

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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).

Visual aura is the most common of the neurological events. There is a

disturbance of vision consisting usually of unformed flashes of white and/or
black or rarely of multicolored lights (photopsia) or formations of dazzling
zigzag lines (scintillating scotoma; often arranged like the battlements of a
castle, hence the alternative terms "fortification spectra" or "teichopsia” ). Some
patients complain of blurred or shimmering or cloudy vision, as though they
were looking through thick or smoked glass, or, in some cases, tunnel vision

and hemianopsia.

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The somatosensory aura of migraine consists of digitolingual or cheiro-oral

paresthesias, a feeling of pins-and-needles experienced in the hand and arm as

well as in the nose-mouth area on the same side. Paresthesia migrate up the arm
and then extend to involve the face, lips and tongue.

• Pain phase

The typical migraine headache is unilateral, throbbing, and moderate to severe

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.

The pain of migraine is invariably accompanied by other features. Nausea

occurs in almost 90 percent of patients, and vomiting occurs in about one third
of patients. Many patients experience sensory hyper excitability manifested by

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.

There may be localized edema of the scalp or face, scalp

tenderness, prominence of a vein or artery in the temple, or stiffness and
tenderness of the neck. Impairment of concentration and mood are common.

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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,

gastrointestinal symptoms, mood changes, and weakness (Kelman L, 2006).

Some people feel unusually refreshed or euphoric after an attack, whereas
others note depression and malaise. Often, some of the minor headache phase
symptoms continue, such as loss of appetite, photophobia, and lightheadedness.
For some patients, a 5- to 6-hour nap may reduce the pain, but slight headaches
still occur when the patient stands or sits quickly. These symptoms go away
after a good night's rest, although there is no guarantee. Some people suffer and
recover differently than others.

Triggers

A migraine trigger is any factor that, on exposure or withdrawal, leads to the

development of an acute migraine headache. Triggers categorized as behavioral,
environmental, infectious, dietary, chemical, or hormonal. In the medical
literature, these factors are known as 'precipitants.'

Migraine attacks triggered by:

• Allergic reactions
• Bright lights, loud noises, and certain odors or perfumes

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 • Physical or emotional stress

• Changes in sleep patterns

• Smoking or exposure to smoke
• Skipping meals

• Alcohol
• Menstrual cycle fluctuations, birth control pills, hormone fluctuations

during the menopause transition

• Tension headaches
• Foods containing tyramine (red wine, aged cheese, smoked fish, chicken
livers, figs, and some beans), monosodium glutamate (MSG) or nitrates

(like bacon, hot dogs, and salami)

• Other foods such as chocolate, nuts, peanut butter, avocado, banana,
citrus, onions, dairy products, and fermented or pickled foods (Kantor,

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

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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

Many migraine sufferers report reduced incidence of migraines due to

identifying and avoiding their individual food triggers.

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

on an empty stomach was associated with adverse symptoms including

headache more often than was placebo (Yang, Drouin, Herbert, Mao & Karsh,
1997 & Millichap, Yee, 2003). However another trial found no effect when
3.5g of MSG was given with food (Tarasoff, Kelly, 1993).

Tyramine The National Headache Foundation has a specific list of triggers

based on the tyramine theory, detailing allowed, with caution and avoid triggers.
However, a 2003 review article concluded that there was no scientific evidence
for an effect of tyramine on migraine (Jansen, van Dusseldorp, Bottema &
Dubois, 2003).

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

evidence associated notorious suspected triggers like chocolate, cheese,

histamine, tyramine, nitrates, or nitrites with migraines. However, the review
authors also note that while general dietary restriction has not been
demonstrated to be an effective migraine therapy, it is beneficial for the
individual to avoid what has been a definite cause of the migraine.

[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:

1. Temperature mixed with humidity. High humidity plus high or low

temperature was the biggest cause.
2. Significant changes in weather
3. Changes in barometric pressure

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:

Migraines once thought to be initiated exclusively by problems with blood

vessels. The vascular theory of migraines is now considered secondary to brain
dysfunction (Alexander Mauskop; Fox, Barry, 2001). And claimed to have been
discredited by others (Cohen & Goadsby, 2005). Trigger points at least part of

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

Animation of cortical spreading depression

A phenomenon known as cortical spreading depression cause migraines

(Lauritzen, 1994). In cortical spreading depression, neurological activity is
depressed over an area of the cortex of the brain. This situation results in the
release of inflammatory mediators leading to irritation of cranial nerve roots,

[26]
most particularly the trigeminal nerve, which conveys the sensory information
for the face and much of the head.

This view is supported by neuroimaging techniques, which appear to show that

migraine is primarily a disorder of the brain (neurological), not of the blood
vessels (vascular). A spreading depolarization (electrical change) begin 24

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

Serotonin is a type of neurotransmitter, or "communication chemical" which

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

Both vascular and neural influences cause migraines.

1. stress triggers changes in the brain

2. these changes cause serotonin to be released
3. blood vessels constrict and dilate

[28]
 4. chemicals including substance P irritate nerves and blood vessels causing

neurogenic inflammation and pain (Alexander Mauskop; Fox, Barry,

2001).

Prevention of Migraine:

Preventive (also called prophylactic) treatment of migraine is an important

component of migraine management. Such treatments take many forms,
including everything from taking certain drugs or nutritional supplements, to
lifestyle alterations such as increased exercise and avoidance of migraine
triggers.

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:

Disability-adjusted life year for migraines per 100,000 inhabitants in 2002.

Migraine is an extremely common condition which will affect 12-28% of
people at some point in their lives (Stovner, Zwart, Hagen, Terwindt & Pascual.
2006). However this figure — the lifetime prevalence — does not provide a

[30]
very clear picture of how many patients there are with active migraine at any

one time. Typically, therefore, the burden of migraine in a population is

assessed by looking at the one-year prevalence — a figure that defines the
number of patients who have had one or more attacks in the previous year. The

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.

Based on the results of a number of studies, one year prevalence of migraine

ranges from 6-15% in adult men and from 14-35% in adult women (Stovner,
Zwart, Hagen, Terwindt & Pascual, 2006). These figures vary substantially
with age: approximately 4-5% of children aged fewer than 12 suffer from
migraine, with little apparent difference between boys and girls (Mortimer, Kay
& Jaron, 1992).

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

seen in women of reproductive age is mainly due to migraine without aura.

Thus in pre-pubertal and post-menopausal populations, migraine with aura is
somewhat more common than amongst 15-50 year olds (Bigal, Liberman &
Lipton, 2006). There is a strong relationship between age, gender and type of
migraine (Stewart, Linet, Celentano, Van Natta & Ziegler, 1991).

Geographical differences in migraine prevalence are not marked. Studies in

Asia and South America suggest that the rates there are relatively low, (Wang
SJ., 2003) and (Lavados & Tenhamm, 1997) but they do not fall outside the
range of values seen in European and North American studies (Lipton &
Stewart, 1993). The incidence of migraine is related to the incidence of epilepsy
in families, with migraine twice as prevalent in family members of epilepsy
sufferers, and more common in epilepsy sufferers themselves (Ottman &
Lipton, 1994).

1.3 Asthma

Asthma is a predisposition to chronic inflammation of the lungs in which the

airways (bronchi) are reversibly narrowed. Asthma affects 7% of the population
of the United States, 6.5% of British people and a total of 300 million
worldwide (Christopher & Engl, 2009).

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

attacks. Attacks prevented by avoiding triggering factors such as allergens or

rapid temperature changes and through drug treatment such as inhaled

corticosteroids and then long-acting beta-2 agonists if necessary.

Although asthma is a chronic obstructive condition, it is not usually considered

as a part of chronic obstructive pulmonary disease as this term refers
specifically to combinations of bronchiectasis, chronic bronchitis, and
emphysema. Unlike these diseases, the airway obstruction in asthma is usually
reversible; left untreated, asthma result in chronic inflammation of the lungs and
irreversible obstruction. In contrast to emphysema and bronchiectasis, asthma

affects the bronchi, not the alveoli (Schiffman, 2009).

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,

2009).Public attention in the developed world has recently focused on the

predisposition because of its rapidly increasing prevalence, affecting up to one

quarter of urban children (Lilly, 2005).

Classification of Asthma: Asthma is clinically classified according to the

frequency of symptoms, FEVi and peak expiratory flow rate (Yawn, 2008).

[33]
 Table no. 1.1

Clinical classification of asthma severity

Peak expiratory Variability of

Symptom Nighttime flow rate or peak expiratory

Severity
frequency symptoms FEVj of flow rate or

predicted FEVj

< twice per

Intermittent < once a week >80% predicted < 20%
month

> once per

Mild > twice per
week but < >80% predicted 20-30%
persistent month
once per day

Moderate > once per 60-80%

Daily > 30%
persistent week predicted

Severe
Daily Frequent < 60% predicted > 30%
persistent

Asthma classified as atopic (extrinsic) or non-atopic (intrinsic), based on

whether symptoms are precipitated by allergens (atopic) or not (non-atopic)
(Kumar, Abbas, Fausto & Aster., 2010).

134]
Signs and symptoms:

Table no. 1.2

Severity of asthma attack (Document on severe acute asthma and

emergency management.)

Sign/Symptom Mild Moderate Severe Pending arrest

May show
Alertness Agitated Agitated Confused/Drowsy
agitation

On
Breathlessness On walking Even at rest
talking

Talks in Sentences Phrases Words

Wheeze Moderate Loud Loud Absent

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

PaC02 <45 <45 >45

[35]
Because of the spectrum of severity within the asthma, some people with

asthma only rarely experience symptoms, usually in response to triggers, where

as other more severe cases have marked airflow obstruction at all times.

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.

Common symptoms of asthma in a steady-state include: nighttime coughing,

shortness of breath with exertion but no dyspnea at rest, a chronic 'throat­
clearing' type cough, and complaints of a tight feeling in the chest. Severity
often correlates to an increase in symptoms. Symptoms worsen gradually and
rather insidiously, up to the point of an acute exacerbation of asthma. It is a
common misconception that all people with asthma wheeze—some never
wheeze, and their disease confused with another chronic obstructive pulmonary
disease such as emphysema or chronic bronchitis.

An acute exacerbation of asthma is commonly referred to as an asthma attack.

The cardinal symptoms of an attack are shortness of breath (dyspnea),
wheezing, and chest tightness (Saunders, 2005). Although the former is often
regarded as the primary symptom of asthma, (McFadden., 2004). Some patients
present primarily with coughing, and in the late stages of an attack, air motion
so impaired that no wheezing heard. When present the cough sometimes
produces clear sputum. The onset sudden, with a sense of constriction in the
chest, as breathing becomes difficult and wheezing occurs (primarily upon
expiration, but sometimes in both respiratory phases). It is important to note
inspiratory stridor without expiratory wheeze however, as an upper airway

[36]
obstruction manifest with symptoms similar to an acute exacerbation of asthma,

with stridor instead of wheezing, and remain unresponsive to bronchodilators.

Signs of an asthmatic episode include wheezing, prolonged expiration, a rapid

heart rate (tachycardia), and rhonchous lung sounds (audible through a

stethoscope). During a serious asthma attack, the accessory muscles of
respiration (sternocleidomastoid and scalene muscles of the neck) may be used,
shown as in-drawing of tissues between the ribs and above the sternum and
clavicles, and there may be the presence of a paradoxical pulse (a pulse that is
weaker during inhalation and stronger during exhalation), and over-inflation of
the chest.

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:

Asthma is caused by environmental and genetic factors, (Martinez,2007) which

influence how severe asthma is and how well it responds to medication
(Choudhry, Seibold & Borrell, et al., 2007). Some environmental and genetic
factors have been confirmed by further research, while others have not been.

[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

Many environmental risk factors have been associated with asthma

development and morbidity in children, but a few stands out as well-replicated
or that has a meta-analysis of several studies to support their direct association.

Environmental tobacco smoke, especially maternal cigarette smoking, is

associated with high risk of asthma prevalence and asthma morbidity, wheeze,
and respiratory infections. Low air quality, from traffic pollution or high ozone
levels, has been repeatedly associated with increased asthma morbidity and has
a suggested association with asthma development that needs further research
(Gold & Wright., 2005 & http://www.arb.ca.gov).

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

by outdoor air pollutants. Caesarean sections have been associated with

asthma when compared with vaginal birth; a meta-analysis found a 20%

increase in asthma prevalence in children delivered by Caesarean section

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)

(Thavagnanam, Fleming, Bromley, Shields & Cardwell, 2007).

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

association study. However, such studies must be repeated to ensure the

findings are not due to chance. Through the end of 2005, 25 genes had been
associated with asthma in six or more separate populations: (Ober, Hoffjan &
Hoffjan, 2006).

Table no. 1.3

. GSTM1 . LTA . STAT6 . 1L4 . HLA-

. IL10 . GRP A . NOS1 . IL13 DQB1
. CTLA-4 . NODI . CCL5 . CD14 . TNF
. SPINK5 . CC16 . TBXA2R . ADRB2 . FCER1B
. LTC4S . GSTP1 . TGFB1 (P-2 . IL4R
adrenerg . ADAM33
ic
receptor)
. HLA-
DRB1

[40]
Many of these genes are related to the immune system or to modulating

inflammation. However, even among this list of highly replicated genes

associated with asthma, the results have not been consistent among all of the

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,

Corda & Aschard, et al, 2008).

• 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-

replicated example of a gene-environment interaction that is associated with

asthma. Endotoxin exposure varies from person to person and come from
several environmental sources, including environmental tobacco smoke, dogs,

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

CD14-endotoxin interaction based on CD14 SNP

C- 159T

Endotoxin
CC genotype TT genotype
levels

High
Low risk High risk
exposure

Low
High risk Low risk
exposure

Risk factors of Asthma:

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

allergens, much attention has focused on increased exposure to these allergens

in infancy and early childhood as a primary cause of the rise in asthma (Peat
Tovey & Toelle, et al.: 1996, Custovic, Smith & Woodcock, 1998). Primary

prevention studies aimed at the aggressive reduction of airborne allergens in a

home with infants have shown mixed findings.

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

in some cases induce asthma, as a history of bronchiolitis or croup in early

childhood is a predictor of asthma risk in later life (Weiss, Tager, Munoz &
Speizer, 1985). Studies which show that upper respiratory tract infections are
protective against asthma risk also tend to show that lower respiratory tract
infections conversely tend to increase the risk of asthma (Illi, von Mutius & Lau
etal., 2001).

[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).

In the US, asthma prevalence is highest in Puerto Ricans, African Americans,

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).

Mortality rates follow similar trends, and response to Salbutamol is lower in

Puerto Ricans than in African Americans or Mexicans (Naqvi, Thyne &
Choudhry et al., 2007 & Burchard, Avila, Nazario et al., 2004). As with
worldwide asthma disparities, differences in asthma prevalence, mortality, and
drug response in the US explained by differences in genetic, social and
environmental risk factors.

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

The incidence of asthma is highest among low-income populations (asthma

deaths are most common in low to middle income countries

(http://www.who.int), which in the western world are disproportionately ethnic

minorities and are more likely to live near industrial areas. Additionally, asthma
has been strongly associated with the presence of cockroaches in living quarters,
which is more likely in such neighborhoods.

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

Asthma appears to be more prevalent in athletes than in the general population.

One survey of participants in the 1996 Summer Olympic Games, in Atlanta,

Georgia, U.S., showed that 15% had been diagnosed with asthma, and that 10%
were on asthma medication (Weiler, Layton & Hunt, 1998).

There appears to be a relatively high incidence of asthma in sports such as

cycling, mountain biking, and long-distance running, and a relatively lower
incidence in weightlifting and diving. It is unclear how much of these disparities
are from the effects of training in the sport (Helenius & Haahtela, 2000).

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:

Asthma is an airway disease that classified physiologically as a variable and

partially reversible obstruction to air flow, and pathologically with

overdeveloped mucus glands, airway thickening due to scarring and

inflammation, and bronchoconstriction, the nan-owing of the airways in the

lungs due to the tightening of surrounding smooth muscle. Bronchial
inflammation also causes narrowing due to edema and swelling caused by an

immune response to allergens.

Bronchoconstriction

E-ifoi* an \sihma episode After an asthma episode

*;v

l.Inscle? fljonno

Air.'Ayi ill tfi<- flir.’Av

■.itfi iniicn: m.trvl

Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a

result of the inflammatory response cause wheezing.

During an asthma episode, inflamed airways react to environmental triggers

such as smoke, dust, or pollen. The airways narrow and produce excess mucus,
making it difficult to breathe. In essence, asthma is the result of an immune
response in the bronchial airways (Maddox & Schwartz, 2002).

The airways of asthma patients are "hypersensitive" to certain triggers, also

known as stimuli (see below). (It is usually classified as type I
[48]
hypersensitivity.)). In response to exposure to these triggers, the bronchi (large

airways) contract into spasm (an "asthma attack"). Inflammation soon follows,

leading to a further narrowing of the airways and excessive mucus production,

which leads to coughing and other breathing difficulties. Bronchospasm resolve

spontaneously in 1-2 hours, or in about 50% of subjects, may become part of a

'late' response, where this initial insult is followed 3-12 hours later with further
bronchoconstriction and inflammation (Robert, Mason, John, Murray & Jay,

2005).

The normal caliber of the bronchus is maintained by a balanced functioning of

these systems, which both operate retlexively. The parasympathetic reflex loop
consists of afferent nerve endings which originate under the inner lining ot the
bronchus. Whenever these afferent nerve endings are stimulated (for example,
by dust, cold air or fumes) impulses travel to the brain-stem vagal center, then
down the vagal efferent pathway to again reach the bronchial small airways.
Acetylcholine is released from the efferent nerve endings. This acetylcholine
results in the excessive formation of inositol 1,4,5-trisphosphate (IP3) in
bronchial smooth muscle cells which leads to muscle shortening and this

initiates bronchoconstriction.

Bronchial inflammation

The mechanisms behind allergic asthma—i.e., asthma resulting from an

immune response to inhaled allergens—are the best understood of the causal
factors. In both people with asthma and people who are free of the disease,
inhaled allergens that find their way to the inner airways are ingested by a type
of cell known as antigen-presenting cells, or APCs. APCs then "present" pieces

[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.

The "hygiene hypothesis" postulates that an imbalance in the regulation of these

Th cell types in early life leads to a long-term domination of the cells involved
in allergic responses over those involved in fighting infection. The suggestion is
that for a child being exposed to microbes early in life, taking fewer antibiotics,
living in a large family, and growing up in the country stimulate the TH1
response and reduce the odds of developing asthma (Tippets & Guilbert, 2009).

Stimuli

• Allergens from nature, typically inhaled, which include waste from

common household pests, the house dust mite and cockroach, as well as

[50]
 grass pollen, mold spores, and pet epithelial cells (Adkinson, Bochner,
Busse,. Holgate, Lemanske & Simons, 2008).

• Indoor air pollution from volatile organic compounds, including perfumes

and perfumed products. Examples include soap, dishwashing liquid,

laundry detergent, fabric softener, paper tissues, paper towels, toilet
paper, shampoo, hairspray, hair gel, cosmetics, facial cream, sun cream,
deodorant, cologne, shaving cream, aftershave lotion, air freshener and
candles, and products such as oil-based paint (Adkinson, Bochner,
Busse,. Holgate, Lemanske & Simons, 2008).

• Medications, including aspirin, (Jenkins, Costello & Hodge, 2004) (3-

adrenergic antagonists (beta blockers), (Miller, Douglas & Zipes, 2007)

and penicillin (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).

• . Sulfite sensitivity Asthma can occur in reaction to ingestion or

inhalation of sulfites, which are added to foods and wine as preservatives.

(http://www.allergy.org)

• Salicylate sensitivity Salicylates trigger asthma in sensitive individuals.

Salicylates occur naturally in many healthy foods. Aspirin is also a
salicylate (Towns, & Mellis, 1984).

• 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

areas (Saunders, 2005).

• Various industrial compounds (e.g. toluene diisocyanate) (Mapp,

Boschetto, Maestrelli & Fabbri, 2005) and other chemicals, notably

sulfites; chlorinated swimming pools generate chloramines—
monochloramine (NH2C1), dichloramine (NHC12) and trichloramine
(NC13)—in the air around them, which are known to induce asthma

(Nemery, Hoet & Nowak, 2002).

• Early childhood infections, especially viral upper respiratory tract

infections. Children who suffer from frequent respiratory infections prior
to the age of six are at higher risk of developing asthma, particularly if
they have a parent with the condition. However, persons of any age have
asthma triggered by colds and other respiratory infections even though
their normal stimuli might be from another category (e.g. pollen) and
absent at the time of infection. In many cases, significant asthma not even
occurs until the respiratory infection is in its waning stage, and the person
is seemingly improving (Saunders, 2005). In children, the most common
triggers are viral illnesses such as those that cause the common cold

(Zhao, Takamura, Yamaoka, Odajima & likura, 2002).

• Exercise or intense use of respiratory system—the effects of which differ

somewhat from those of the other triggers, since they are brief. They are
thought to be primarily in response to the exposure of the airway

epithelium to cold, dry air.

• Hormonal changes in adolescent girls and adult women associated with
their menstrual cycle lead to a worsening of asthma. Some women also

[52]
 experience a worsening of their asthma during pregnancy whereas others

find no significant changes, and in other women their asthma improves

during their pregnancy (Saunders, 2005).

• Psychological stress. There is growing evidence that psychological stress

is a trigger. It modulate the immune system, causing an increased

inflammatory response to allergens and pollutants (Richeldi, Ferrara,

Fabbri, Lasserson & Gibson, 2005).

• Cold weather makes it harder for patients to breathe. Whether high

altitude helps or worsens asthma is debatable and vary from person to
person.

The fundamental problem in asthma appears to be immunological: young

children in the early stages of asthma show signs of excessive inflammation in
their airways. Epidemiological findings give clues as to the pathogenesis: the
incidence of asthma seems to be increasing worldwide, and asthma is now very'
much more common in affluent countries.

In 1968 Andor Szentivanyi first described The Beta Adrenergic Theory of

Asthma; in which blockage of the Beta-2 receptors of pulmonary smooth muscle
cells causes asthma (Szentivanyi, Andor, 1968). Szentivanyi's Beta Adrenergic
Theory is a citation classic (Lockey, Richard, 2006) using the Science Citation
Index and has been cited more times than any other article in the history of the
Journal of Allergy and Clinical Immunology. In 1995 Szentivanyi and
colleagues demonstrated that IgE blocks beta-2 receptors (Szentivanyi, Ali,
Calderon, Brooks, Coffey & Lockey, 1993).Since overproduction of IgE is

[53]
central to all atopic diseases, this was a watershed moment in the world of
allergy (Kowalak & Hughes et al. (eds), 2001).

Asthma and sleep apnea

It is recognized with increasing frequency that patients who have both

obstructive sleep apnea and asthma often improve tremendously when the sleep
apnea is diagnosed and treated (University of Michigan Health System, 2005).
CPAP is not effective in patients with nocturnal asthma only (Basner, 2006).

Asthma and gastro-esophageal reflux disease

If gastro-esophageal reflux disease (GERD) is present, the patient have

repetitive episodes of acid aspiration. GERD common in difficult-to-control
asthma, but according to one study, treating it does not seem to affect the
asthma (Leggett, Johnston, Mills, Gamble & Heaney, 2005).When there is a
clinical suspicion for GERD as the cause of the asthma, an Esophageal pH
Monitoring is required to confirm the diagnosis and establish the relationship
between GERD and asthma.

Diagnosis of Asthma:

Asthma is defined simply as reversible airway obstruction. Reversibility occurs

either spontaneously or with treatment. The basic measurement is peak flow
rates and the following diagnostic criteria are used by the British Thoracic
Society; (Pinnock & Shah, 2007)

• ^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:

o 10 minutes of inhaled (3-agonist (e.g., salbutamol);

o six weeks of inhaled corticosteroid (e.g., beclometasone);
o 14 days of 30 mg prednisolone.
• ^0% decrease in peak flow following exposure to a trigger (e.g.,

exercise).

In many cases, a physician diagnose asthma on the basis of typical findings in a

patient’s clinical history and examination. Asthma is strongly suspected if a
patient suffers from eczema or other allergic conditions—suggesting a general
atopic constitution—or has a family history of asthma. While measurement of
airway function is possible for adults, most new cases are diagnosed in children
who are unable to perform such tests.

In children, the key to asthma diagnosis is the sound of wheezing or a high-

pitched sound upon exhalation. Other clues are recurrent wheezing, breathing
difficulty, or chest tightness, or a history of coughing that is worse at night. The
doctor also know if the child's symptoms are worse with exercise, colds,or
exposure to certain irritants such as smoke, emotional stress, or changes in the

weather (Tippets & Guilbert, 2009).

Other information important to diagnosis is the age at which symptoms began

and how they progressed, the timing and pattern of wheezing, when and how
often a child had to visit a clinic or hospital emergency department because of
symptoms, whether the child ever took bronchodilator medication for the
symptoms and the nature of the response to medication (Tippets & Guilbert,
2009). Although pediatricians may tend to ask parents for information about

[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).

The NAEPP guidelines do not recommend testing peak expiratory flow as a

regular screening method, because it is more variable than spirometry.
However, testing peak flow at rest (or baseline) and after exercise helpful,
especially in young patients who experience only exercise-induced asthma. It
also be useful for daily self-monitoring and for checking the effects of new
medications. Peak flow readings charted on graph paper charts together with a
record of symptoms or use peak flow charting software. This allows patients to
track their peak flow readings and pass information back to their doctor or nurse

(Sapp & Niven, 2008).

In the Emergency Department, doctors use a capnography which measures the

amount of exhaled carbon dioxide, (Corbo, Bijur, Lahn & Gallagher, 2005).
Along with pulse oximetry which shows the percentage of hemoglobin that is
carrying oxygen, to determine the severity of an asthma attack as well as the

[56]
response to treatment. More recently, exhaled nitric oxide has been studied as a
breath test indicative of airway inflammation in asthma.

Differential diagnosis

Before diagnosing someone as having asthma, alternative possibilities should be

considered. A clinician taking a history should check whether the patient is

using any known bronchoconstrictors (substances that cause narrowing of the

airways, e.g, certain anti-inflammatory agents or beta-blockers). Among elderly
patients, the presenting symptom fatigue, cough, or difficulty breathing, all of
which may be erroneously attributed to COPD, congestive heart failure, or
simple aging (deShazo & Stupko, 2008).

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.

Chronic obstructive pulmonary disease, is a syndrome which closely resembles

asthma, is correlated with more exposure to cigarette smoke, an older patient,
less symptom reversibility after bronchodilator administration (as measured by
spirometry), and decreased likelihood of family history of atopy (Hargreave &
Parameswaran, 2006). Most people found to have the syndrome are
subsequently found to have asthma and many diagnosed asthmatics go on to
develop the syndrome.

Pulmonary aspiration, whether direct due to dysphagia (swallowing disorder) or

indirect (due to acid reflux), show similar symptoms to asthma. However, with

157]
aspiration, fevers might also indicate aspiration pneumonia. Direct aspiration

(dysphagia) diagnosed by performing a Modified Barium Swallow test and

treated with feeding therapy by a qualified speech therapist. If the aspiration is

indirect (from acid reflux) then treatment directed at this is indicated.

A majority of children who are asthma sufferers have an identifiable allergy

trigger. Specifically, in a 2004 study, 71% had positive test results for more than
1 allergen, and 42% had positive test results for more than 3 allergens (Vargas,
Simpson & Gary Wheeler, et al, 2004).

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

variability greater than 30%

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

attacks occur. According to studies conducted, patients with relatively mild

asthma who have received inhaled corticosteroids within 12 months of their first

asthma symptoms achieved good functional control of asthma after 10 years of

individualized therapy as compared to patients who received this medication
after 2 years (or more) from their first attacks. Though they (delayed) also had
good functional control of asthma, they were observed to exhibit slightly less
optimal disease control and more signs of airway inflammation.

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

1980, especially in younger children. Tracking the epidemiology of asthma is

confounded by changes in how asthma has been described and defined over

the decades. Most epidemiological studies use questionnaires, self-reports of

asthma symptoms, and reports of physician diagnosis of asthma. This

information may or may not be accompanied by objective pulmonary function

[59]
data (Woolcock, 1987). All factors considered, even studies that maintain a

constant definition of "asthma" throughout time show worldwide increases in

asthma prevalence since the 1960s (Grant, Wagner & Weiss 1999).

The International Study of Asthma and Allergies in Childhood (ISAAC), a

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

worldwide disparities in asthma mortality, which is most common in low to

middle income countries (WHO, 2007). Asthma symptoms were most prevalent
(as much as 20%) in the United Kingdom, Australia, New Zealand, and
Republic of Ireland; they were lowest (as low as 2-3%) in Eastern Europe,
Indonesia, Greece, Uzbekistan, India, and Ethiopia.

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,

Odhiambo & Mungai, et al, 1998) or from a third-world country to

Westernized one (Waite, Eyles, Tonkin & O'Donnell., 1980).

1.4 Anxiety

Anxiety is a common experience that people feel in different ways. Some

people apprehensive, nervous, or even fearful. Anxiety is probably a very
adaptive, good part of our ability to cope with the world.

Anxiety is a psychological and physiological state characterized by cognitive,

somatic, emotional, and behavioral components (Seligman, Walker &
Rosenhan, 2001). These components combine to create an unpleasant feeling
that is typically associated with uneasiness, fear, or worry. Anxiety is a
generalized mood condition that occurs without an identifiable triggering
stimulus. As such, it is distinguished from fear, which occurs in the presence of
an observed threat. Additionally, fear is related to the specific behaviors of
escape and avoidance, whereas anxiety is the result of threats that are perceived
to be uncontrollable or unavoidable (Ohman, 2000).

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

dangers that divides anxiety and fear. Anxiety is considered to be a normal

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

"nightmares/bad dreams, obsessions about sensations,

(http://www.anxietycentre.com, 1987-2008) a trapped in your mind feeling, and
feeling like everything is scary". Cognitive effects of anxiety include thoughts

about suspected dangers, such as fear of dying.

Biological basis of anxiety:

Neural circuitry involving the amygdala and hippocampus is thought to underlie

anxiety (Rosen & Schulkin,1998). When confronted with unpleasant and
potentially harmful stimuli such as foul odors or tastes, PET-scans show
increased bloodflow in the amygdala (Zald & Pardo, 1997, Zald, Hagen, 2000
& Pardo, 2002). In these studies, reported moderate anxiety. This indicates that
anxiety is a protective mechanism designed to prevent the organism from
engaging in potentially harmful behaviors.

Research upon adolescents that were as infants highly apprehensive, vigilant,

and fearful finds that their nucleus acumens is more sensitive than that in other
people when they selected to make an action that determined whether they
received a reward (Bar-Haim, Fox, Benson, Guyer, Williams, Nelson, Perez-
Edgar, Pine & Ernst, 2009). This suggests a link between circuits responsible
for fear and also reward in anxious people. Although single genes have little
effect on complex traits and interact heavily both between themselves and with
the external factors, research is underway to unravel possible molecular
mechanisms underlying anxiety and comorbid conditions. One candidate gene
with polymorphisms that influence anxiety is PLXNA2 (Wray, James, Mah,
Nelson, Andrews, Sullivan, Montgomery, Birley, Braun & Martin, 2007).

[63]
Pre-existing health issues including chronic obstructive pulmonary disease

(COPD), heart failure, and arrhythmia these are the cause of anxiety or anxiety

symptoms (http://www.nps.org.au, 2009)

Types of Anxiety:

• Existential anxiety

Philosopher Soren Kierkegaard, in The Concept ofAnxiety, described anxiety or

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.

Theologian Paul Tillich characterized existential anxiety (Tillich, Paul, 1952).

as "the state in which a being is aware of its possible nonbeing" and listed three
categories for the nonbeing and resulting anxiety: ontic (fate and death), moral
(guilt and condemnation), and spiritual (emptiness and meaninglessness).

• Test and performance anxiety

According to Yerkes-Dodson law, an optimal level of arousal is necessary to

best complete a task such as an exam, performance, or competitive event.
However, when the anxiety or level of arousal exceeds that optimum, it results

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,

time pressures, or feeling a loss of control. Sweating, dizziness, headaches,

racing heartbeats, nausea, fidgeting, and drumming on a desk are all common.

Because test anxiety hinges on fear of negative evaluation, debate exists as to

whether test anxiety is itself a unique anxiety disorder or whether it is a specific

type of social phobia.

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.

• Stranger and social anxiety

Anxiety when meeting or interacting with unknown people is a common stage

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

called social anxiety.

[65]
 • Trait anxiety

Anxiety can be either a short term 'state' or a long term "trait." Trait anxiety

reflects a stable tendency to respond with state anxiety in the anticipation of

threatening situations (Schwarzer, 1997). It is closely related to the personality
trait of neuroticism.

• Choice or decision anxiety

Anxiety induced by the need to choose between similar options is increasingly

being recognized as a problem for individuals and for organizations;
http://www.selfgrowth.com". Today we’re all faced with greater choice, more
competition and less time to consider our options or seek out the right advice
(http://www.uk.capgemini.com).

• Paradoxical anxiety

Paradoxical anxiety is anxiety arising from use of methods or techniques which

are normally used to reduce anxiety. This includes relaxation or meditation
techniques (Bourne, Edmund, 2005). As well as use of certain medications
(Heide, Frederick & Borkovec, 1983). In some buddhist meditation literature,
this effect, although it is not referred to as anxiety there due to the religious
context of the writing, is described as something which arises naturally and
confronted and withstood in order to progress spiritually Gunaratana, Henepola.

[66]
Anxiety in Positive psychology

Mifili-
Anxieiv Flow

Low Skill level High

Positive psychology's view of anxiety as a region in a map of challenge level vs.

skill level. In Positive psychology, anxiety is described as a response to a
difficult challenge for which the subject has poor coping skills.

Symptoms of Anxiety:
In order to understand the diagnosis and treatment of anxiety, it is helpful to

have a basic understanding of its symptoms.

• SOMATIC. The somatic or physical symptoms of anxiety include

headaches, dizziness or lightheadedness, nausea and/or vomiting,
diarrhea, tingling, pale complexion, sweating, numbness, difficulty in
breathing, and sensations of tightness in the chest, neck, shoulders, or
hands. These symptoms are produced by the hormonal, muscular, and
cardiovascular reactions involved in the fight-or-flight reaction. Children
and adolescents with generalized anxiety disorder show a high percentage

of physical complaints.

[67]
• BEHAVIORAL. Behavioral symptoms of anxiety include pacing,

trembling, general restlessness, hyperventilation, pressured speech, hand

wringing, or finger tapping.

• COGNITIVE. Cognitive symptoms of anxiety include recurrent or

obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts

or ideas, and confusion, or inability to concentrate.

• EMOTIONAL. Feeling states associated with anxiety include tension or

nervousness, feeling "hyper" or "keyed up," and feelings of unreality,

panic, or terror.

• DEFENSE MECHANISMS. In psychoanalytic theory, the symptoms of

anxiety in humans may arise from or activate a number of unconscious
defense mechanisms. Because of these defenses, it is possible for a
person to be anxious without being consciously aware of it or appearing
anxious to others. These psychological defenses include:

• Repression. The person pushes anxious thoughts or ideas out of conscious

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.

• Somatization. The anxiety emerges in the form of physical complaints

and illnesses, such as recurrent headaches, stomach upsets, or muscle and

joint pain.

[68]
 • Delusion formation. The person converts anxious feelings into conspiracy

theories or similar ideas without reality testing. Delusion formation can

involve groups as well as individuals.

• Common Physical Symptoms of Anxiety

Many people who experience significant anxiety and generalized anxiety

disorder (GAD) have physical symptoms. Some of these are very

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

Another common somatic complaint is changes in the digestive system.

Many people experience constipation or diarrhea, which become
uncomfortable and difficult to routinely deal with. Additionally, people

[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

One of the largest complaints from people with GAD is difficulty

sleeping. Insomnia takes a toll on physical health and also leaves short on
mental resources to deal with stress. Many people take some form of
sleep aid, but these dealt with carefully since they lead to psychological
and sometimes physiological dependence.

• Panic Attacks

It is important to distinguish between GAD and panic disorder, which is

characterized by panic attacks. Essentially, the extreme and sudden onset

of racing heart, numbness and unusual physical sensations are less likely
for people with GAD, but many people with GAD also have panic
disorder.

Causes of Anxiety:

There are several factors that contribute to development of anxiety disorder

such as biological factors, childhood environment, stress overload, thought
patterns, lifestyle factors and genetic factors.

[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

emotional numbness are major symptoms of post-traumatic stress

disorder.
• Physical characteristics: Anxiety disorder hereditary, that means

children of highly sensitive parents are more anxious. Chemical

imbalances in brain, fight or flight response are also among possible
causes of anxiety disorder. Some medical conditions such as
hypoglycemia lead to anxiety. Anxious people may show strong reactions
to aspartame, amphetamines, caffeine and other stimulants.
• Environmental factors: Some environmental factors are likely to
responsible for developing anxiety disorder. They include trauma and
stressful events, divorce, death of beloved one and change in school or
job.
• Personality: According to researches, personality plays a major role in
developing anxiety disorder. People having poor coping skills and low
self-esteem are more prone to anxiety disorder. Constantly negative
thinking also gives rise to anxiety disorder symptoms.

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:

1. Australia: 3 percent of adults (WHO).

2. Canada: Between 3-5 percent of adults
3. Italy: 2.9 percent
4. Taiwan: 0.4 percent

5. United States: approx. 3.1 percent of people age 18 and over in a given
year (9.5 million)

Anxiety is Normal and Beneficial

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.

Anxiety can be a Problem

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.

Normal anxiety is intermittent and is expected based on certain events or

situations. Problem anxiety, on the other hand, tends to be chronic, irrational
and interferes with many life functions. Avoidance behavior, incessant worry'
and concentration and memory problems all stem from problem anxiety. These
symptoms so intense that they cause family, work and social difficulties.

The components of problem anxiety include the physical responses to the

anxiety (such as palpitations and stomach upset), distorted thoughts that become
a source of excessive worry and behavioral changes affecting the usual way one
lives life and interacts with others. Left unchecked, problem anxiety may lead to
an anxiety disorder.

Generalized Anxiety Disorder (GAD)

(DSM-IV code 300.02) is an anxiety disorder that is characterized by

excessive, uncontrollable and often irrational worry about everyday things that
is disproportionate to the actual source of worry. This excessive worry often
interferes with daily functioning, as individuals suffering GAD typically

[73]
anticipate disaster, and are overly concerned about everyday matters such as

health issues, money, death, family problems, friend problems, relationship

problems or work difficulties (NIMH, 2008).

They often exhibit a variety of physical symptoms, including fatigue, fidgeting,

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,)

is the book used by qualified mental health professionals to make a diagnosis of

Generalized Anxiety Disorder (GAD). The following is a summary of the
required symptom makeup to be used as a guide. However, it is important to
know that only a qualified professional who also relies on clinical judgment can
make an accurate diagnosis. (American Psychiatric Association,2000).

A. At least 6 months of "excessive anxiety and worry" about a variety of events

and situations. Generally, "excessive" can be interpreted as more than would be
expected for a particular situation or event. Most people become anxious over
certain things, but the intensity of the anxiety typically corresponds to the
situation.

[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

anxiety and worry, then this requirement is met.

C. The presence for most days over the previous six months of 3 or more (only

1 for children) of the following symptoms:

1. Feeling wound-up, tense, or restless

2. Easily becoming fatigued or worn-out
3. Concentration problems
4.1rritability
S.Significant tension in muscles
6. Difficulty with sleep

D. The symptoms are not part of another mental disorder.

E. The symptoms cause "clinically significant distress" or problems functioning

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.

F. The condition is not due to a substance or medical issue

Symptoms of Generalized Anxiety Disorder (GAD)

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

asleep. Reluctance to discuss emotional problems and worries may lead to a

delay in the diagnosis.

Psychological symptoms of GAD include:

• Excessive ongoing worrying, even when there are no signs of trouble

• Inability to relax
• Difficulty concentrating, mind going “blank”
• Feeling tense, edgy, or jumpy

• Irritability or restlessness
• Difficulty sleeping

Physical symptoms of generalized anxiety disorder include:

• Headaches
• Fatigue
• Trembling
• Muscle tension
• Sweating

• Light-headedness
• Shortness of breath
• Nausea
• Frequent urination in adults and bed-wetting in children

• Aches and pains

• Gastrointestinal discomfort, including diarrhea , heartburn, and flatulence

[76]
 • Dry mouth

• Cold, clammy hands

• Difficulty swallowing
• Racing heart

Potential Causes of GAD:

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

In one study in 1988-1990, (Cohen, 1995). illness in approximately half of

patients attending mental health services at one British hospital psychiatric

clinic, for conditions including anxiety disorders such as panic disorder or social
phobia, was determined to be the result of alcohol or benzodiazepine
dependence. In these patients, cessation of their anxiety symptoms
corresponded with stopping the use of the benzodiazepine or alcohol.
Sometimes anxiety pre-existed alcohol or benzodiazepine dependence but the
dependence was acting to keep the anxiety disorders going and often
progressively making them worse. Recovery from benzodiazepines tends to take
a lot longer than recovery from alcohol but people can regain their previous

[77]
good health. Symptoms may temporarily worsen however, during alcohol
withdrawal or benzodiazepine withdrawal.

• Neurology

Generalized anxiety disorder has been linked to disrupted functional

connectivity of the amygdala and its processing of fear and anxiety (Etkin,
Prater, Schatzberg, Menon & Greicius, 2009).Sensory information enters the

amgydala through the nuclei of the basolateral complex (consisting of lateral,

basal, and accessory basal nuclei). The basolateral complex processes sensory
related fear memories and communicate their threat importance to memory and
sensory processing elsewhere in the brain such as the medial prefrontal cortex

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:

Despite significant anxiety being a common thing for many people to

experience during their lives, the subgroup of people who have Generalized
Anxiety Disorder (GAD) is much smaller. According to DSM-IV,

approximately 3% of people develop the disorder during a given year, and 5%

of people have GAD at some point in their lives. Furthermore, approximately a
quarter of the people who attend anxiety treatment clinics have GAD.

Women Affected at Higher Rates

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.

Elderly Are at Greater Risk

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).

• Prevalence Rates for Men and Women

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 ).

Despite significant anxiety being a common thing for many people to

experience during their lives, the subgroup of people who have Generalized

[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

other types of demand placed on them (Parry, 2005).

It is a condition or feeling experienced when a person perceives that “demands

exceed the personal and social resources the individual is able to mobilize”

Stress symptoms commonly include a state of alarm and adrenaline production,

short-term resistance as a coping mechanism, and exhaustion, as well as

irritability, muscular tension, inability to concentrate and a variety of

physiological reactions such as headache and elevated heart rate. Stressors
therefore can be defined as external or internal forces that attempt to disrupt this
internal homeostasis, and stress can be defined as "threatened homeostasis"
(Sternberg, Chrousos, Wilder & Gold, 1992).

Origin and terminology of Stress:

The term stress was first employed in a biological context by the

endocrinologist Hans Selye in the 1930s (Selye, 1982). He later broadened and
popularized the concept to include inappropriate physiological response to any
demand. In his usage stress refers to a condition and stressor to the stimulus
causing it. It covers a wide range of phenomena, from mild irritation to drastic
dysfunction that cause severe health breakdown.

Signs and Symptoms of Stress:

Signs of stress cognitive, emotional, physical or behavioral. Signs include poor

judgment, a general negative outlook, excessive worrying, moodiness,
irritability, agitation, inability to relax, feeling lonely, isolated or depressed.

[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.

Body reaction of stress:

General adaptation syndrome (GAS) model:

Kcvni.ir<<’

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

stressors over the longer term.

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

GAS (Selye, 1936)

[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.

Resistance is the second stage. If the stressor persists, it becomes necessary to

attempt some means of coping with the stress. Although the body begins to try
to adapt to the strains or demands of the environment, the body cannot keep this
up indefinitely, so its resources are gradually depleted.

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.

Lazarus: cognitive appraisal model

Lazarus (Lazarus, 1966) argued that in order for a psychosocial situation to be

stressful, it must be appraised as such. He argued that cognitive processes of
appraisal are central in determining whether a situation is potentially
threatening, constitutes a harm/loss, a challenge, or is benign.

This primary appraisal is influenced by both person and environmental factors,

and triggers the selection of coping processes. Problem-focused coping is
directed at managing the problem, while emotion-focused coping processes are
directed at managing the negative emotions. Secondary appraisal refers to the

[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).

Neurochemistry and physiology of stress:

The neurochemistry of the stress response is now believed to be well

understood, although much remains to be discovered about how the components
of this system interact with one another, in the brain and throughout in the body.
In response to a stressor, corticotropin-releasing hormone (CRH) and arginine-
vasopressin (AVP) are secreted into the hypophyseal portal system and activate
neurons of the paraventricular nuclei (PVN) of the hypothalamus.

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

neuroendocrine system involving the interactions of the hypothalamus, the

pituitary gland, and the adrenal glands, is also activated by release of CRH and
AVP.

This results in release of adrenocorticotropic hormone (ACTH) from the

pituitary into the general bloodstream, which results in secretion of cortisol and
other glucocorticoids from the adrenal cortex. The related compound, cortisone,
is frequently used as a key anti-inflammatory component in drugs that treat skin
rashes and in nasal sprays that treat asthma and sinusitis. Recently, scientists
realized the brain also uses cortisol to suppress the immune system and reduce
inflammation within the body. These corticoids involve the whole body in the
organism's response to stress and ultimately contribute to the termination of the
response via inhibitory feedback (Tsigos, & Chrousos, 2002).

Impact on disease

Stress significantly affect many of the body's immune systems, as an

individual's perceptions of, and reactions to, stress. The term
psychoneuroimmunology is used to describe the interactions between the
mental state, nervous and immune systems, as well as research on the
interconnections of these systems. Immune system changes create more
vulnerability to infection, and have been observed to increase the potential for
an outbreak of psoriasis for people with that skin disorder.

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

Studies of female monkeys at Wake Forest University (2009) discovered that

individuals suffering from higher stress have higher levels of visceral fat in their
bodies. This suggests a possible cause-and-effect link between the two, wherein
stress promotes the accumulation of visceral fat, which in turn causes hormonal
and metabolic changes that contribute to heart disease and other health
problems (Park, 2009).

External and Internal Stressors

People can experience stress from external or internal factors.

• External stressors include adverse physical conditions (such as pain or hot

or cold temperatures) or stressful psychological environments (such as
poor working conditions or abusive relationships).
• Internal stressors also be physical (infections and other illnesses,
inflammation) or psychological (such as intense worry about a harmful
event that may or not occur). As far as anyone tells, internal
psychological stressors are rare or absent in most animals except humans.

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).

[88]
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

Eustress is a term coined by endocrinologist Hans Selye which is defined in the

model of as stress that is healthy, or gives one a feeling of fulfillment or other
positive feelings. Eustress is a process of exploring potential gains.

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).

[89]
The difference between experiences which result in eustress or distress is

determined by the disparity between an experience (real or imagined), personal

expectations, and resources to cope with the stress. Alarming experiences, either
real or imagined, trigger a stress response (Kloet, Joels & Holsboer, 2005).

. Eustress, or positive stress, has the following characteristics: (Mills, Reiss, &
Dombeck, 2008).

• Motivates, focuses energy

• Is short-term
• Is perceived as within our coping abilities
• Feels exciting
• Improves performance

Eustress Compared with distress

Distress is the most commonly-referred to type of stress, having negative

implications, whereas eustress is a positive form of stress, usually related to
desirable events in a person's life. Both can be equally taxing on the body, and
are cumulative in nature, depending on a person's way of adapting to a change
that has caused it. The body itself cannot physically discern between distress or
eustress (Kabat-Zinn, 1996).

b) Distress

In medicine, distress is an aversive state in which an animal is unable to adapt

completely to stressors and their resulting stress and shows maladaptive
behaviors (Recognition and Alleviation of Pain and Distress in Laboratory

[90]
Animals, 1992). It can be evident in the presence of various phenomena, such as
inappropriate social interaction (e.g., aggression, passivity, or withdrawal).

Stress created by influences such as work, school, peers or co-workers, family

and death. Other influences vary upon age. This means that distress is the
opposite of eustress, a positive stress that motivates us. People under constant
distress are more likely to become sick, mentally or physically.

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.

In contrast, Distress, or negative stress, has the following characteristics:

• Causes anxiety or concern

• Can be short- or long-term

• Is perceived as outside of our coping abilities

» Feels unpleasant
•> Decreases performance
• Can lead to mental and physical problems

Examples of negative personal stressors include:

• The death of a spouse

» Filing for divorce
• Losing contact with loved ones
^ The death of a family member

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 • Hospitalization (oneself or a family member)

• Injury or illness (oneself or a family member)

• Being abused or neglected

• Separation from a spouse or committed relationship partner

• Conflict in interpersonal relationships
• Bankruptcy/Money Problems
• Unemployment
• Sleep problems

• Children's problems at school

• Legal problems

Examples of positive personal stressors include;

• Receiving a promotion or raise at work

• Starting a new job
• Marriage
• Buying a home
• Having a child
• Moving
• Taking a vacation
• Holiday seasons
• Retiring
• Taking educational classes or learning a new hobby

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

• Unproductive and time-consuming meetings

• Commuting and travel schedules

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.

Common internally caused sources of distress include:

• Fears: (e.g., fears of flying, heights, public speaking, chatting with

strangers at a party)
• Repetitive Thought Patterns:
• Worrying about future events (e.g., waiting for medical test results or job
restructuring)
• Unrealistic, perfectionist expectations

Habitual behavior patterns that lead to stress include:

• Over scheduling
• Failing to be assertive
• Procrastination and/or failing to plan ahead

[93]
 (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

you’re being affected by stress; ( Scott, 2009)

. Headaches: Certain types of headaches can be related to stress. If

you’re experiencing more headaches, especially tension headaches,

stress could be the culprit.

• More Frequent Colds or Flu: There’s an inverse relationship between
stress and immunity, so if you’re under too much stress, you may be
getting sick more often.
• Sleep Problems: There are many ways that stress affects sleep. Too
much stress can rob you of sleep and make the sleep you get less

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

in anxiety, you may want to to talk to your doctor.

• ‘Fuzzy Thinking’: Your body’s stress response pumps your body with
hormones that make it possible for you to fight or flee quickly. When
triggered in excess, this stress response can actually cause you to think

less quickly.

[94]
 • Feelings of Frustration: If you’re faced with many demands at once, the
natural result for many people is increased frustration and irritability. The

trick is to find ways to prevent frustration and calm down quickly.

• Lowered Libido: Stress can affect your libido in several ways. If you’re
too tired for sex, or can’t seem find the time for your partner, this can be

due to stress in your life as well.

• Let's take a look at the process that leads from stress to anxiety, through
something called the "Transactional Model of Stress."

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.

Life experiences such as poverty, unemployment, depression, obsessive

compulsive disorder, heavy drinking (Glavas & Weinberg, 2006) or insufficient
sleep also cause stress. Students and workers face stress from exams, project
deadlines, and group projects.

Adverse experiences during development (e.g. prenatal exposure to maternal

stress, (Davis et al.,2007, O'Connor, Heron, Golding, Beveridge & Glover.,
2002). poor attachment histories, (Schore, Allan, 2003) sexual abuse (William,

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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

is the Holmes and Rahe stress scale.

Leading Causes of Stress

From the University of Washington, did a study on the connection between

significant life events and illness. As part of that study, they compiled a chart of
the major causes of stress. That chart, which contained 43 causes of stress in
1967, was updated to 55 causes in 2006. Apparently, society is finding more

causes to feel stressed.

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

many modem polls.

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, wonderful though each member is also a leading cause of stress.

Arguments erupt with a spouse or other family member. Parents divorce.
Children marry. The ebb and flow of family life is filled with stress. A child
moves out - an aging parent moves in.

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.

F. Personal Health and Safety:

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.

[98]
E. Personal Relationships

Whether it is a friendship, dating, separation, marriage, divorce, or re-marriage,

a relationship is a leading cause of stress for many. All want love, and that is
potentially available in relationships, but getting from A to B very stressful.
Some resort to online relationships that are easier to handle. Others withdraw
and become recluses. Either way, the demands on time, finances, and emotions
are cause ongoing stress.

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.

The Four Stages of Stress Reaction

(Mills Reiss, & Dombeck, Jun 30th 2008)

Stage 1: Recognition of environmental demand

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.

Stage 2: Appraisal of the demand

Understanding that a demand has occurred does not automatically cause us to

experience stress. In over 30 years of research, psychologists Richard Lazarus
and Susan Folkman found that it is our lightening fast, and largely unconscious
and automatic appraisal or judgment of our ability to meet the demand that
determines just how stressful experience it to be. The appraisal process partially
explains a particular event negatively stressful to one person but not to another.

We appraise a demand by asking ourselves two questions: 1) Does this event

present a threat to me? And 2) Do I have the resources to cope with this event?
If we come to believe that the event is a threat to our well-being, or if we come
to believe that we lack the means to effectively respond to the event, we then
subsequently feel stressed. We will return to a more detailed discussion of the
appraisal stage in a later section of this document.

Stage 3: Mobilization of the nervous system

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

sympathetic nervous system (SyNS) automatically signals our body to prepare

for action. During this mobilization phase, the SyNS prepares us for fighting or
fleeing (two primary biologically driven and useful means of reacting to a
physical threat) by triggering or activating the hypothalamic-pituitary-adrenal
axis, or HPA axis (sometimes called the brain's 'stress circuit'). The HPA axis
involves a complex set of interactions between multiple parts of the brain and
nervous system, including the hypothalamus, the pituitary gland, and 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.

In response to a stressor, the hypothalamus (which is a centrally located part of

the brain that sits above the brain stem, but below the cortex) releases
corticotropin-releasing hormone (CRH). In turn, CRH acts on the pituitary
gland, triggering the release of another hormone called adrenocorticotropin
(ACTH) into the bloodstream. Next, ACTH triggers the adrenal glands (which
are situated above the kidneys), to release the hormones cortisol and cortisone
as well as epinephrine (otherwise known as adrenaline) and norepinephrine
(otherwise known as noradrenaline). Both epinephrine and norepinepherine are
neurotransmitters or chemical messengers that serve the brain and nervous
system. Hormones are also chemical messengers, but they work primarily
within the blood stream, rather than inside the brain.

The presence of cortisol works to immediately increase the amount of energy

the body has available by raising glucose levels in the bloodstream. Glucose is a

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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.

Similar to cortisol, elevated levels of epinephrine and norepinephrin increase

your heart rate, elevate your blood pressure, speed up your reaction time, and
boost your energy level. Under the combined effects of cortisol, epinephrine,
and norepinephrine, the body diverts blood away from digestion and towards
the muscles and the brain (to enhance physical functioning); increases oxygen
levels in the blood (for an energy boost); increases the rate of perspiration (to
help cool us down); releases blood clotting chemicals into the blood stream (in
case of injury); and dilates the pupils (to help us see better in the dark). At the
same time that cortisol and epinephrine exert their effects, both the pituitary
gland (see below) and the brain are also busy releasing chemicals called
endorphins and enkephalins which help relieve pain and enhance a sense of
well-being.

Stage 4: Response to the threat

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.

The fight or flight response is optimized for responding to physical threats. It

isn't very useful with the sort of intangible threats that are most common in
today's world. It is never appropriate to punch your boss in the face, for
instance, no matter how many times he piles work on you, or passes you over
for a raise. Fleeing your workplace won't necessarily help you either, as you still
need to get a paycheck!

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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.

Introduction to the Physiology of Stress

Fight and Flight response

In the animal kingdom the rules of survival are simple - only the stronger
survives. When faced with danger, the two main options are fighting (when you
perceive the enemy to be weaker than you, or when defending your cubs or
herd), and running away (when you encounter a huge hungry lion, for example).
In face of danger, the body changes its inner-balance and priorities into a high
physiological arousal, to enable these two functions (Hayes, 1994).
The fight or flight response is a pattern of physiological responses that prepare
the organism to emergency. When the external balance is disputed, our body
changes its internal balance accordingly. The fact that modem problems do not
require such means is exactly the setting of stress-related problems (Atkinson et
al, 1996; Lev, 1987).
The manifestations of the F or F are mainly through two channels: the
sympathetic branch of the ANS and the Endocrine system - both are closely
interconnected (Atkinson et al, 1996; Carlson, 1994). The ANS affect many

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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

metabolism for emergency actions.

Thickening of the blood - to increase oxygen supply (red cells), enabling better
defence from infections (white cells) and to stop bleeding quickly (platelets).
Sharpening of senses. The pupils dilate; hearing is better etc., allowing rapid

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

secretion of body waists, leaving the body lighter.

Secretion of Adrenaline and other stress hormones - to further increase the

response, and to strengthen relevant systems.

Secretion of endorphins - natural painkillers, providing an instant defence
against pain. (Atkinson et al, 1996; Hanson, 1986; Kandel, 1991)

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

result of this inadequacy.

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,

blood pressure, sugar-levels, muscle activity etc.).

Besides its hormonal functions, adrenaline is also an excitatory neurotransmitter
in the CNS (indirectly controlling its own production). It is involved both in
neural and hormonal processes and its effects as a neurotransmitter is further
reinforced by its hormonal function (a positive feedback loop).
It is therefore by far the most important single hormone in regarding to stress -
taking a major role in the stress reaction (and staying longer in the body than

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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

An exciting flood of physiological processes in the body immediately

takes place automatically and precisely after the initial thought of “Uh-Oh!” It is
a state of physiological and psychological hyper arousal. A cascade of nervous
system firings and release of stress hormones lead to immediate responses that
help the person deal with danger either by fighting or running.

Harvard physiologist Walter Cannon coined the term fight-o^-flight

response to describe human body's automatic response when they perceive
threat or danger. This is a primitive response that gives them strength, power,
and speed to avoid physical harm. The fight-or-flight response activated to
protect both ourselves and others when they perceive danger.

This response is amazingly complex, involving interactions between

many organs and systems in human body. While it is not necessary for to
understand every detail of these complex interactions, it is important to
understand the science of what is happening in human body and mind when
their stress response is activated. They use this information to guide them in
developing an individualized program to prevent and manage stress.

Physiological Response to Stress

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

[107]
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.

The other branch of the autonomic nervous system is called the

parasympathetic nervous system. This branch of nervous activity is designed to
return the physiology to a state of homeostasis, or balance, after the threat,
danger, or potential pain is no longer perceived to be imminent. Homeostasis is
a state of internal stability of our physiology and human emotions.

The function of the parasympathetic nervous system is to slow things down,

to return us to a more calm state. During parasympathetic activity, blood
concentrates in the central organs for such processes as digestion and storage of
energy reserves. Breathing is slow, as is the heart rate. Blood pressure and body
temperature drops. In general, muscle tension decreases. During
parasympathetic activity (general relaxation) person are quiet and calm. The
body regenerates and restores for future activity.

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 The autonomic nervous system is controlled by the hypothalamus, which is

commonly known as the “master gland.” The hypothalamus receives the

message of danger from the higher-order thinking component of the mind and

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.

Epinephrine (adrenalin) and norepinephrine (noradrenalin) are released into

the bloodstream from the adrenal medulla. The adrenal medulla is the part of
the adrenal glands positioned on top of the kidneys. Cortisol is the other key
hormone released from a portion of the adrenal glands called the adrenal cortex.
Together, these hormones flood every cell in the body with the specific message
to prepare for fight-or-flight, for more power and speed when we are faced with
an oncoming big bear.

Autonomic Nervous System Responses

Some immediate physiological changes that result from autonomic nervous

system activation include;

• Increased central nervous system (CNS) activity

• Increased mental activity

• Increased secretion of adrenaline (epinephrine), noradrenalin

(norepinephrine) and cortisol into the bloodstream and to every
cell in the body

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Increased heart rate

Increased cardiac output

Increased blood pressure

Increased breathing rate

Breathing airways dilate

Increased metabolism

Increased oxygen consumption

Increased oxygen to the brain

Blood is shunted away from the digestive tract and directed into
the muscles and limbs

Increased muscle contraction which leads to increased strength

Increased blood coagulation (blood clotting ability)

Increased circulation of free fatty acids

Increased output of blood cholesterol

Increased blood sugar released by the liver to nourish the

muscles

Release of endorphins from the pituitary gland

Pupils of the eyes dilate

Hair stands on its end

Blood thins

Increased brainwave activity

Sweat glands increase secretion

Increased secretion from Apocrine glands resulting in foul body

odor

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 • Capillaries under the surface of the skin constrict (which

consequently increases blood pressure)

• There are also several processes in the body that tend to

decrease in functioning when the fight-or-flight response is
activated.

• Immune system is suppressed

• Constriction of blood vessels, except to running and fighting

muscles

• Reproductive and sexual systems stop working normally

• Digestive system stops metabolizing food normally

• Excretory system turns off

• Saliva dries up

• Decreased perception of pain

• Kidneys decrease output

• Bowel and Bladder sphincter close

The Purpose of the Fight-or-Flight Response

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

[in]
useful process, however kept “on” for a longer period; this response produce
serious problems.

The stress response, in a picture format, looks like this:

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

[112]
behavioral response. Whether the response culminates in “fight” or “flight”

depends on whether the threat or stressor is perceived as surmountable. Thus, an

appropriate stress response is essential to survival.

The fight-or-flight response is generally regarded as the prototypic human

response to stress. The tend-and-befriend theory you read about in the Research
Highlight - Biobehavioral Responses to Stress in Females provides some
interesting food for thought, however this research is still in the early stages.
While we know that there may be some differences in how males and females
respond physiologically to stress, we also know that there are many similarities.
The fight-or-flight response explains most clearly the chain of events that occur
in most people in response to stress.

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:

• Giving birth to a baby

• Driving down the highway and your tire blows

• Hiking down a trail when you trip and start to tumble down a
steep decline

• During an earthquake

• When lightning strikes

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

rare occurrence in daily life. Unless you happen to work in a high-risk

occupation such as a policeman in the inner city, fireman, or a whitewater
rafting guide, the percentage of our days that include actual threats to our lives
is less than 1% of the time. Contrary to how it may look from watching the
evening news, for most of us our society today is not one where acute threat or
danger is a daily occurrence.

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:

Instead of returning to homeostasis, the fight or flight response is activated for

an extended period of time.

Listen to body. Body is designed to give feedback about the choices

make. For example, when a person is hung over from drinking too much the
night before, the body sends messages including headache, nausea, unclear

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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.

Remaining in the stress response is not healthy. The body gives us

feedback about excess stress with a host of signals. Some of those signals, if not
heeded, include damage to parts of the system. Although stress is not listed
among the top 10 causes of death in America, it is linked to many illnesses. This
does not necessarily mean that stress causes the problem, but it does mean that
stress contributes to the problem.

1.6 Mind

Mind (pronounced /GmaDnci/) is the aspect of intellect and consciousness

experienced as combinations of thought, perception, memory, emotion, will and
imagination, including all unconscious cognitive processes. The term is often
used to refer, by implication, to the thought processes of reason. Mind manifests
itself subjectively as a stream of consciousness.

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.

The ’Subconscious* and Psychoanalysis

Though lay persons commonly assume 'subconscious' to be a psychoanalytic

term, this is not in fact the case. Sigmund Freud had explicitly condemned the
word as long ago as 1915: "We shall also be right in rejecting the term 'sub
consciousness’ as incorrect and misleading".

Thus, as Charles Rycroft has explained, 'subconscious' is a term "never used in

psychoanalytic writings"(Charles Rycroft, 1995). And, in Peter Gay's words,
use of 'subconscious' where 'unconscious' is meant is "a common and telling
mistake" (Peter Gay, Freud, 2006) indeed, "when [the term] is employed to say
something 'Freudian', it is proof that the writer has not read his Freud" (Peter
Gay (ed.), 1995).

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

'descriptively' so: the contents of the Unconscious require special investigative

techniques for their exploration, whereas something in the Preconscious is
unrepressed and recalled to consciousness by the simple direction of attention.
The erroneous, pseudo-Freudan use of 'subconscious' and 'subconsciousness'
has its precise equivalent in German, where the words inappropriately employed
are Unterbewusst and Unterbewusstsein.

Consciousness

Consciousness is subjective experience or awareness or wakefulness or the

executive control system of the mind. It is an umbrella term that may refer to a
variety of mental phenomena (van Gulick, 2004). Although humans realize
what everyday experiences are, consciousness refuses to be defined,
philosophers note (e.g. John Searle in The Oxford Companion to Philosophy):

"Anything that we are aware of at a given moment forms part of our

consciousness, making conscious experience at once the most familiar and most
mysterious aspect of our lives." (Schneider & Velmans, 2007).

Consciousness in medicine (e.g., anesthesiology) is assessed by observing a

patient's alertness and responsiveness, and seen as a continuum of states ranging
from alert, oriented to time and place, and communicative, through
disorientation, then delirium, then loss of any meaningful communication, and

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ending with loss of movement in response to painful stimulation (Giizeldere,
1995).

Consciousness in psychology and philosophy has four characteristics;

subjectivity, change, continuity and selectivity (James, W. 1910). Intentionally
or aboutness (that consciousness is about something) has also been suggested by
philosopher Franz Brentano. However, within the philosophy of mind there is
no consensus on whether intentionality is a requirement for consciousness.

Consciousness is the subject of much research in philosophy of mind,

psychology, neuroscience, cognitive science, cognitive neuroscience and
artificial intelligence. Issues of practical concern include how the presence of
consciousness assessed in severely ill or comatose people; whether non-human
consciousness exists and if so how it can be measured; at what point in fetal
development consciousness begins; and whether computers can achieve a
conscious state (Butler, 2005, Shieber, 2004 , Marcus, 2002).

Unconscious mind

The unconscious mind is a term invented by the 18th century German

philosophy romantic philosopher Ser Christopher Riegel and later introduced
into English by the poet and essayist Samuel Taylor Coleridge. (Bynum,
Browne & Porter, 1981).

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.

Observers throughout history have argued that there are influences on

consciousness from other parts of the mind. These observers differ in the use of
related terms, including: unconsciousness as a personal habit; being unaware
and intuition. Terms related to semi-consciousness include: awakening, implicit
memory, the subconscious, subliminal messages, trance, hypnagogia, and
hypnosis. Although sleep, sleep walking, dreaming, delirium and coma may
signal the presence of unconscious processes, these processes are not the
unconscious mind. Science is in its infancy in exploring the limits of
consciousness.

Freud and the psychoanalytic unconscious

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).

Freud proposed a vertical and hierarchical architecture of human consciousness:

the conscious mind, the preconscious, and the unconscious mind - each lying
beneath the other. He believed that significant psychic events take place "below
the surface" in the unconscious mind.

Like hidden messages from the unconscious - a form of intrapersonal

communication out of awareness. He interpreted these events as having both
symbolic and actual significance.

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

relationship to their unconscious as an adversary, warring with it to keep what is

unconscious hidden. The therapist is then a mediator trying to allow the

unspoken or unspeakable to reveal it using the tools of psychoanalysis.

Messages arising from a conflict between conscious and unconscious are likely
to be cryptic. The psychoanalyst is presented as an expert in interpreting those
messages.

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.

Unconscious thoughts are not directly accessible to ordinary introspection, but

are supposed to be capable of being "tapped" and "interpreted" by special
methods and techniques such as meditation, random association, dream
analysis, and verbal slips (commonly known as a Freudian slip), examined and
conducted during psychoanalysis.

Freud's theory of the unconscious was substantially transformed by some of his

followers, among them Carl Jung and Jacques Lacan.

Jung’s collective unconscious

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.

The Mind-Body Connections

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.

History of the Mind-Body Connection

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: &quot;The natural healing force
within each one of us is the greatest force in getting well.&quot; 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

focused on identifying and treating symptoms through physical means such as

drugs and surgery, and mostly ignored the role of mental states in the prevention
and treatment of disease. To most doctors, the immune system was regarded as
an autonomous entity, operating independently of the mind and behavior. Since
the 1960's, however, researchers have realized that these ideas are incorrect, and
have since been looking at the mind-body connection more closely and with
more respect.

In 1964, George Solomon, a psychiatrist, noticed that rheumatoid arthritis

worsened when people were depressed. He was fascinated by this connection,
and began to investigate the impact of emotions on inflammation and immune
function in general. His studies were the beginning of the new field of
psychoneuroimmunology, which examines the relationships between the mind
(psyche), brain (neuro), and immune system (immunology).
Research progressed further in the (Herbert Benson, 1960's and early 1970's)
studied the effects of meditation on blood pressure, and when psychologist
Robert Adar showed that mental and emotional cues affect immunity. Since
then, mind-body science has been advancing as research continues to prove the
impact of thoughts and emotions on physical health.

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

standard medical care.

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).

The idea of psychological factors affecting physical health is further proven by

research done on the common cold. For centuries medical experts have believed
that stress can make one more vulnerable to minor infections such as colds and
flu. Today, this belief has been confirmed experimentally.

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).

Techniques are used in mind-body therapy

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.

A second technique is imagery, which is thinking that involves the senses.

Imagery can have a strong effect on a person's emotions and physiology. It is
often helpful in relaxation, pain relief, stimulation of healing responses in the
body, and for accessing insight and understanding about health problems and
their solutions. Interactive guided imagery is a specific way of using imagery
which is particularly effective in helping patients discover and improve attitudes
about health.

A third technique is relaxation. Relaxation techniques are perhaps the most

widely used and generally useful since stress is very often a significant factor in
illness and other health related issues. Reducing stress allows the patient to feel
better and regain a sense of control. Meditation, which involves concentrating
on a neutral or meaningful focus, is a common form of relaxation
Last, hypnosis is a common technique used in mind-body therapy. During

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.

Health Gare Professionals and the Mind-Body Connectionlt has

become quite common for medical experts to be pure scientists, viewing their

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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.

This approach to health is extremely mechanical, with very little recognition of

how a person's emotions contribute to their well-being. It would be very
beneficial for all health care professionals to understand the deep connection
between the mind and body, and to be attuned to patient's emotional needs.
Such understanding on behalf of the doctor would put patients more at ease,
thus enabling them to better cope with illness, and help them be more willing to
seek proper treatment.

Research has shown that despite the effectiveness of mind-body techniques in

healing many illnesses, only a small percentage of those battling these illnesses
seek mind-body treatment. In a survey done in 1997 by Dr. Peter M. Wolsko
and colleagues, only 20% of those with chronic pain, 13% of those with
insomnia, 18% of those with heart problems, 18% of those with headaches, 18%
of those with back or neck pain, and 10% of those with cancer had used mind-
body therapies for their condition in the last year. This is largely due to the fact
that many physicians are uneducated in the area of appropriate referrals to
competent mind-body professionals.

In addition to its relevance to physical health care professionals, the mind-body

connection is quite helpful to those in the field of mental health as well.
Psychotherapists who apply this approach in their practice recognize the

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intimate connection between the mind and body. They view the person as a

system, rather than a collection of parts working independently. The therapist

focuses on strengthening the client's body as well as their mind, and works to
create an atmosphere of acceptance and support. One technique the therapist
may use, for example, is breathing exercises to help relax a client who is very
anxious. This integrated approach to psychotherapy has proven helpful in many
cases. A Holistic View of Psychotherapy: Connecting Mind, Body, and Spirit.

T he Mind-Body Connection and the Public

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

state theory) usually induced by a procedure known as a hypnotic induction,

which is commonly composed of a series of preliminary instructions and

suggestions. Hypnotic suggestions delivered by a hypnotist in the presence of

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the subject, or self-administered ("self-suggestion" or "autosuggestion"). The

use of hypnotism for therapeutic purposes is referred to as "hypnotherapy".

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

followers ("Mesmerism" or "animal magnetism"), but differed in his theory as

to how the procedure worked. Contrary to a popular misconception - that
hypnosis is a form of unconsciousness resembling sleep - contemporary
research suggests that it is actually a wakeful state of focused attention and
heightened suggestibility, with diminished peripheral awareness (Spiegel,
Herbert and Spiegel, David., 1978). In the first book on the subject,
Neurypnology (1843), Braid described "hypnotism" as a state of physical
relaxation accompanied and induced by mental concentration ("abstraction").

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:

a peculiar condition of the nervous system, induced by a fixed and abstracted

attention of the mental and visual eye, on one object, not of an exciting nature.

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

to that which precedes and accompanies common sleep.

Braid therefore defined hypnotism as a state of mental concentration which

often led to a form of progressive relaxation termed "nervous sleep". Later, in
his The Physiology of Fascination (1855), Braid conceded that his original
terminology was misleading, and argued that the term "hypnotism" or "nervous
sleep" should be reserved for the minority (10%) of subjects who exhibited
amnesia, substituting the term "monoideism", meaning concentration upon a
single idea, as a description for the more alert state experienced by the others.

A new definition of hypnosis, derived from academic psychology, was provided

in 2005, when the Society for Psychological Hypnosis, Division 30 of the

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American Psychological Association (APA), published the following formal
definition:

New Definition: Hypnosis

The Division 30 Definition and Description of Hypnosis, American Psychology

Association (2)

Hypnosis typically involves an introduction to the procedure during which the

subject is told that suggestions for imaginative experiences presented. The
hypnotic induction is an extended initial suggestion for using one's imagination,
and may contain further elaborations of the introduction. A hypnotic procedure
is used to encourage and evaluate responses to suggestions. When using
hypnosis, one person (the subject) is guided by another (the hypnotist) to
respond to suggestions for changes in subjective

Experience, alterations in perception, sensation, emotion, thought or behavior.

Persons also learn self-hypnosis, which is the act of administering hypnotic
procedures on one's own. If the subject responds to hypnotic suggestions, it is
generally inferred that hypnosis has been induced. Many believe that hypnotic
responses and experiences are characteristic of a hypnotic state. While some
think that it is not necessary to use the word "hypnosis" as part of the hypnotic
induction, others view it as essential.

Details of hypnotic procedures and suggestions differ depending on the goals of

the practitioner and the purposes of the clinical or research endeavor.
Procedures traditionally involve suggestions to relax, though relaxation is not
necessary for hypnosis and a wide variety of suggestions used including those to
become more alert. Suggestions that permit the extent of hypnosis to be
assessed by comparing responses to standardized scales used in both clinical
and research settings. While the majority of individuals are responsive to at

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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

Hypnosis is normally preceded by a "hypnotic induction" technique.

Traditionally this was interpreted as a method of putting the subject into a
"hypnotic trance"; however subsequent "nonstate" theorists have viewed it
differently, as a means of heightening client expectation, defining their role,
focusing attention, etc. There are an enormous variety of different induction
techniques used in hypnotism. However, by far the most influential method was
the original "eye-fixation" technique of Braid, also known as "Braidism". Many
variations of the eye-fixation approach exist, including the induction used in the
Stanford Hypnotic Susceptibility Scale (SHSS), the most widely-used research
tool in the field of hypnotism. Braid's original description of his induction is as
follows:

James Braid's Original Eye-Fixation Hypnotic Induction Method

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.

define hypnotism as the induction of a peculiar psychical [i.e., mental]

condition which increases the susceptibility to suggestion. Often, it is true, the
[hypnotic] sleep induced facilitates suggestion, but it is not the necessary
preliminary. It is suggestion that rules hypnotism..

Bemheim's conception of the primacy of verbal suggestion in hypnotism

dominated the subject throughout the twentieth century, leading some
authorities to declare him the father of modem hypnotism (Weitzenhoffer,
2000). Contemporary hypnotism makes use of a wide variety of different forms
of suggestion including: direct verbal suggestions, "indirect" verbal suggestions
such as requests or insinuations, metaphors and other rhetorical figures of
speech, and non-verbal suggestion in the form of mental imagery, voice
tonality, and physical manipulation. A distinction is commonly made between
suggestions delivered "permissively" or in a more "authoritarian" manner. Some
hypnotic suggestions are intended to bring about immediate responses, whereas
others (post-hypnotic suggestions) are intended to trigger responses after a delay
ranging from a few minutes to many years in some reported cases.

Consciousness vs. unconscious mind

Some hypnotists conceive of suggestions as being a form of communication

directed primarily to the subject's conscious mind, whereas others view
suggestion as a means of communicating with the "unconscious" or
"subconscious" mind. These concepts were introduced into hypnotism at the end
of 19th century by Sigmund Freud and Pierre Janet. The original Victorian
pioneers of hypnotism, including Braid and Bernheim, did not employ these
concepts but considered hypnotic suggestions to be addressed to the subject's

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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

The first neuro-psychological theory of hypnotic suggestion was introduced

early on by James Braid who adopted his friend and colleague William
Carpenter's theory of the ideo-motor reflex response to account for the
phenomenon of hypnotism. Carpenter had observed from close examination of
everyday experience that under certain circumstances the mere idea of a
muscular movement could be sufficient to produce a reflexive, or automatic,
contraction or movement of the muscles involved, albeit in a very small degree.
Braid extended Carpenter's theory to encompass the observation that a wide
variety of bodily responses, other than muscular movement, thus affected, e.g.,
the idea of sucking a lemon can automatically stimulate salivation, a secretory
response. Braid therefore adopted the term "ideo-dynamic", meaning "by the
power of an idea" to explain a broad range of "psycho-physiological" (mind-
body) phenomena. Braid coined the term "mono-ideodynamic" to refer to the
theory that hypnotism operates by concentrating attention on a single idea in
order to amplify the ideo-dynamic reflex response. Variations of the basic ideo­
motor or ideo-dynamic theory of suggestion have continued to hold
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considerable influence over subsequent theories of hypnosis, including those of
Clark L. Hull, Hans Eysenck, and Ernest Rossi. It should be noted that in
Victorian psychology, the word "idea" encompasses any mental representation,
e.g., including mental imagery, or memories, etc.

Post-hypnotic suggestion

It has been alleged post-hypnotic suggestion used to change people's behaviour

after emerging from hypnosis. One author wrote that "a person act, some time
later, on a suggestion seeded during the hypnotic session" (Waterfield, R.,
2003).

Susceptibility

Braid made a rough distinction between different stages of hypnosis which he

termed the first and second conscious stage of hypnotism; he later replaced this
with a distinction between "sub-hypnotic", "full hypnotic", and "hypnotic coma"
stages. Jean-Martin Charcot made a similar distinction between stages named
somnambulism, lethargy, and catalepsy. However, Ambroise-Auguste Liebeault
and Bemheim introduced more complex hypnotic "depth" scales, based on a
combination of behavioural, physiological and subjective responses, some of
which were due to direct suggestion and some of which were not. In the first
few decades of the 20th century, these early clinical "depth" scales were
superseded by more sophisticated "hypnotic susceptibility" scales based on
experimental research. The most influential were the Davis-Husband and
Friedlander-Sarbin scales developed in the 1930s. Andre Weitzenhoffer and
Ernest R. Hilgard developed the Stanford Scale of Hypnotic Susceptibility in
1959, consisting of 12 suggestion test items following a standardised hypnotic
eye-fixation induction script, and this has become one of the most widely-
i Ecrenced research tools in the field of hypnosis. Soon after, in 1962, Ronald

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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

Following the French committee's findings, in his Elements of the Philosophy of

the Human Mind (Stewart, D. 1827), an influential academic philosopher of the
"Scottish School of Common Sense", encouraged physicians to salvage
elements of Mesmerism by replacing the supernatural theory of "animal
magnetism" with a new interpretation based upon "common sense" laws of

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physiology and psychology. Braid quotes the following passage from Stewart:
(Braid, Magic, Witchcraft, etc., 1852).

It appears to me, that the general conclusions established by Mesmer’s practice,

with respect to the physical effects of the principle of imagination are
incomparably more curious than if he had actually demonstrated the existence
of his boasted science [of "animal magnetism"]: nor can I see any good reason
why a physician, who admits the efficacy of the moral [i.e., psychological]
agents employed by Mesmer, should, in the exercise of his profession, scruple
to copy whatever processes are necessary for subjecting them to his command,
any more than that he should hesitate about employing a new physical agent,
such as electricity or galvanism (Stewart, D., 1827).

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

Sigmund Freud, the founder of psychoanalysis, studied hypnotism at Paris

school and briefly visited the Nancy school. Initially, Freud was an enthusiastic
proponent of hypnotherapy, and soon began to emphasise hypnotic regression
and reaction (catharsis) as therapeutic methods. He wrote a favorable
encyclopedia article on hypnotism, translated one of Bemheim's works into
German, and published an influential series of case studies with his colleague
Joseph Breuer entitled Studies on Hysteria (1895). This became the founding

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text of the subsequent tradition known as "hypno-analysis" or "regression
hypnotherapy."

However, Freud gradually abandoned hypnotism in favour of psychoanalysis,

emphasizing free association and interpretation of the unconscious. Struggling
with the great expense of time that psychoanalysis required, Freud later
suggested that it combined with hypnotic suggestion to hasten the outcome of
treatment.

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.

However only a handful of Freud's followers were sufficiently qualified in

hypnosis to attempt the synthesis. Their work had a limited influence on the
hypno-therapeutic approaches now known variously as "hypnotic regression",
"hypnotic progression", and "hypnoanalysis".

Milton Erickson

Milton H. Erickson, M.D. was one of the most influential post-war

hypnotherapists. He wrote several books and journal articles on the subject.
During the 1960s, Erickson popularized a new branch of hypnotherapy, known
as Ericksonian hypnotherapy, primarily characterised by indirect suggestion,
"metaphor" (actually analogies), confusion techniques, and double binds in
place of formal hypnotic inductions. However, the difference between
Erickson's methods and traditional hypnotism led contemporaries such as Andre
Weitzenhoffer, to question whether he was practicing "hypnosis" at all, and his
approach remains in question.

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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).

Cognitive-behavioural approach of hypnosis

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).

At the outset of cognitive-behavioural therapy during the 1950s, hypnosis was

used by early behaviour therapists such as Joseph Wolpe (Wolpe, J., 1958) and
also by early cognitive therapists such as Albert Ellis (Ellis, A. (1962). Barber,
Spanos & Chaves introduced the term "cognitive-behavioural" to describe their
"nonstate" theory of hypnosis in Hypnotism: Imagination & Human
Potentialities (1974) (Barber, Spanos & Chaves, 1974). However, Clark L.
Hull had introduced a behavioural psychology as far back as 1933, which in
turn was preceded by Ivan Pavlov (Hull, C.L., 1933). Indeed, the earliest
theories and practices of hypnotism, even those of Braid, resemble the
cognitive-behavioural orientation in some respects .

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Hypnotherapy

Modem hypnotherapy has been used in a variety of forms, such as regression

hypnotherapy (or "hypnoanalysis") and Ericksonian hypnotherapy. Hypnosis

has been studied clinically with varying success

Applications include:

• pain management

• weight loss (Kirsch, Irving, 1996)

• skin disease (Shenefelt, Philip D,2004)

• soothing anxious surgical patients

• psychological therapy ( Barrett, Dierdre,2001)

• habit control, a way to relax, (Vickers, Andrew and Zollman,

Catherine, 1993).

• sports performance.

Self-hypnosis is popularly used to quit smoking and reduce stress, while stage

hypnosis persuades people to perform unusual public feats.

iVlcdical applications

Relaxation techniques and suggestion have been used to reduce pain in

childbirth (sometimes called 'Hypnobirthing').

Hypnotherapy has been used to treat irritable bowel syndrome. Researchers who

recently reviewed the best studies in this area conclude:

The evidence for hypnosis as an efficacious treatment of IBS was encouraging.

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).

In 1996, the National Institutes of Health declared hypnosis effective in

reducing pain from cancer and other chronic conditions. Nausea and other
symptoms related to incurable diseases may also be managed with hypnosis
(Spiegelnd Moore, 1997 , Garrow, D. and Egede,2006, Mascot, C., 2004,
Kwekkeboom, and Gretarsdottir, 2006) For example, research done at the
Mount Sinai School of Medicine studied two patient groups facing breast cancer
surgery. The group that received hypnosis reported less pain, nausea, and
anxiety post-surgery. The average hypnosis patient reduced treatment costs by
an average $772.00. (Montgomery, et al 2007)

The American Psychological Association published a study comparing the

effects of hypnosis, ordinary suggestion and placebo in reducing pain. The
study found that highly suggestible individuals experienced a greater reduction
in pain from hypnosis compared with placebo, whereas less suggest

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).

Treating skin diseases with hypnosis (hypnodermatology) has performed well in

treating warts, psoriasis, and atopic dermatitis (Shenefelt, Philip D., 2004).

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

Professor Charcot (left) of Paris' Salpetriere demonstrates hypnosis on a

"hysterical" patient, "Blanche" (Marie) Wittman, who is supported by Dr.
Joseph Babihski.

Hypnotherapy is the use of hypnosis in psychotherapy. It is used by licensed

physicians, psychologists, and others. Physicians and psychiatrists may use
hypnosis to treat depression, anxiety, eating disorders, sleep disorders,
compulsive gaming, and posttraumatic stress.

Certified hypnotherapists who are not physicians or psychologists often treat

smoking and weight management. (Success rates vary: a meta-study researching
hypnosis as a quit-smoking tool found it had a 20 to 30 percent success rate,
similar to other quit-smoking methods, while a 2007 study of patients
hospitalised for cardiac and pulmonary ailments found that smokers who used
hypnosis to quit smoking doubled their chances of success

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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).

Controversy surrounds the use of hypnotherapy to retrieve memories, especially

those from early childhood or (alleged) past-lives. The American Medical
Association and the American Psychological Association caution against
repressed memory therapy in cases of alleged childhood trauma, stating that "it
is impossible, without corroborative evidence, to distinguish a true memory
from a false one." (American Psychological Association, 2009). Past life
regression, meanwhile, is often viewed with skepticism (Astin, et al., 2003).

Self-hypnosis

Self-hypnosis happens when a person hypnotises himself or herself, commonly

involving the use of autosuggestion. The technique is often used to increase
motivation for a diet, quit smoking, or reduce stress. People who practice self­
hypnosis sometimes require assistance; some people use devices known as mind
machines to assist in the process, while others use hypnotic recordings.

N europsychology

Neurological imaging techniques provide no evidence of a neurological pattern

that equated with a "hypnotic trance". Changes in brain activity have been found
in some studies of highly responsive hypnotic subjects. These changes vary
depending upon the type of suggestions being given (Raz, et al., 2005,
Derbyshire, et al; Whalley, MG; Stenger, VA; Oakley, DA., 2004). However,
what these results indicate is unclear. They may indicate that suggestions
genuinely produce changes in perception or experience that are not simply a

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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.

Another study has demonstrated that a color hallucination suggestion given to

subjects in hypnosis activated color-processing regions of the occipital cortex.
(Kosslyn, et al; Thompson, WL; Costantini-Ferrando, MF; Alpert, NM; Spiegel,
D., 2000). A 2004 review of research examining the EEG laboratory work in
this area concludes:

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.

Kvhag sick, shaking (tremor), sweating, a y mouth, chest pain, headaches, a

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,

which is involved in various physical diseases (Servan-Schreiber et al, 2000).

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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

treatments such as medication or operations are usually the most important

(Yates, 2010).

Psychological intervention like psychotherapy, hypnotherapy etc. is very

effective to control psychological symptoms behind the psychosomatic

problems. That’s why 1 take this topic of my study to see the effect of

hypnotherapy on migraine and asthma in correlation with anxiety and stress.

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