HEALTH EDUCATION HEALTH 100 VERSION 3 1 2 Acknowledgements We would like to extend appreciation to the following people and organizations for allowing this textbook to be created: California Community Colleges Chancellor’s Office Chancellor Diane Van Hook Santa Clarita Community College District College of the Canyons Distance Learning Office Compiled by Garrett Rieck, MA, ACSM-CPT & Justin Lundin, MA Special Thank You to OER staff Alexa Johnson, Mitchell Norhiro, & Trudi Radtke for helping with formatting, editing, readability, and aesthetics. & COC Kinesiology Department for making it all possible. Cover Photo: Cougar Field PIO COC The contents of this textbook were developed under the Title V grant from the Department of Education (Award #P031S140092). However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government. Unless otherwise noted, the content in this textbook is licensed under CC BY 4.0 3 Table of Contents Acknowledgements .......................................................................................................................................... 2 CHAPTER 1: Introduction to Health .......................................................................................................... 6 Section 1.1 Definition and Concepts of Health .................................................................................................. 6 Section 1.2 Narrow Perspectives of Health ........................................................................................................ 6 Section 1.3 Broader Perspectives of Health ....................................................................................................... 6 Section 1.4 The Six Dimensions of Health ........................................................................................................... 7 Section 1.5 Life Expectancy at Birth ...................................................................................................................... 8 Section 1.6 Leading Causes of Death ..................................................................................................................... 8 Section 1.7 About Determinants of Health ......................................................................................................... 8 Section 1.8 Health Disparities ................................................................................................................................ 11 Section 1.9 Risk Factors and Levels of Disease Prevention ....................................................................... 13 Section 1.10 Levels of Disease Prevention ....................................................................................................... 14 Section 1.11 Behavior Change and Goal Setting ............................................................................................. 15 Section 1.12 SMART Goal Setting ......................................................................................................................... 17 CHAPTER 2: Psychological Health ........................................................................................................... 19 Section 2.1 Physiological Needs ............................................................................................................................ 20 Section 2.2 Safety Needs .......................................................................................................................................... 20 Section 2.3 Social Belonging ................................................................................................................................... 20 Section 2.4 Esteem ...................................................................................................................................................... 21 Section 2.5 Self-Actualization................................................................................................................................. 21 Section 2.6 Self-Transcendence ............................................................................................................................ 22 Section 2.7 Mental Health ........................................................................................................................................ 22 Section 2.8 Emotional Health ................................................................................................................................. 23 Section 2.9 Spiritual Health .................................................................................................................................... 24 Section 2.10 Social Health ....................................................................................................................................... 24 Section 2.11 Factors That Influence Psychological Well-Being ............................................................... 24 Section 2.12 Developing and protecting individual attributes ................................................................ 27 Section 2.13 Supporting families and communities ..................................................................................... 27 Section 2.14 Supporting vulnerable groups in society ................................................................................ 28 Section 2.15 Mental Illness ..................................................................................................................................... 28 Section 2.16 Mood Disorders ................................................................................................................................. 29 Section 2.17 Depression ........................................................................................................................................... 29 Section 2.18 Dysthymic Disorder ......................................................................................................................... 29 Section 2.19 Bipolar Disorder ................................................................................................................................ 30 Section 2.20 The Causes of Depression (depressive disorders).............................................................. 30 Section 2.21 Treating depression......................................................................................................................... 30 Section 2.22 Coping with Depression ................................................................................................................. 31 Section 2.23 Anxiety Disorders ............................................................................................................................. 31 Section 2.24 The Stigma of Mental Illness ........................................................................................................ 42 CHAPTER 3: Stress Management .............................................................................................................. 45 Section 3.1 Chronic Stress ....................................................................................................................................... 45 Section 3.2 The Effects of Stress on the Body.................................................................................................. 45 Section 3.3 Stress and the Brain ........................................................................................................................... 45 Section 3.4 Your Bodies Response to Stress .................................................................................................... 47 Section 3.5 General Adaptation Syndrome....................................................................................................... 47 4 Section 3.6 Distress may be destructive to health......................................................................................... 49 Section 3.7 Eustress ................................................................................................................................................... 49 Section 3.8 Burnout and Stress Related Illness .............................................................................................. 49 Section 3.9 Common Causes of Stress ................................................................................................................ 51 Section 3.10 Common signs and symptoms of stress .................................................................................. 52 Section 3.11 Do women react to stress differently than men?................................................................. 52 Section 3.12 Can Stress Affect My Health?........................................................................................................ 52 Section 3.13 The Effect of Stress on the Immune System .......................................................................... 52 Section 3.14 Does stress cause ulcers? NO ....................................................................................................... 53 Section 3.15 Post-traumatic stress disorder (PTSD).................................................................................... 53 Section 3.16 Stress is in the Eye of the Beholder ........................................................................................... 54 Section 3.17 Managing Stress ................................................................................................................................ 56 Section 3.18 Coping with Stress ............................................................................................................................ 58 Section 3.19 Exercise and Stress .......................................................................................................................... 58 Section 3.20 Meditation and Health .................................................................................................................... 59 Section 3.21 Relaxation Techniques ................................................................................................................... 60 Section 3.22 Resilience ............................................................................................................................................. 65 CHAPTER 4: Relationships and Communication ................................................................................ 68 Section 4.1 Theories of Love................................................................................................................................... 68 Section 4.2 THEORIES OF MATE SELECTION ................................................................................................. 72 Section 4.3 Marriage .................................................................................................................................................. 77 Section 4.4 Cohabitation .......................................................................................................................................... 78 Section 4.5 Marrieds and Non-Marrieds ........................................................................................................... 79 CHAPTER 5: Gender and Sexuality .......................................................................................................... 92 Section 5.1 Sexual Scripts ........................................................................................................................................ 92 Section 5.2 Genital Development.......................................................................................................................... 93 Section 5.3 The Importance of Sexuality ........................................................................................................... 94 Section 5.4 Sexual Anatomy .................................................................................................................................... 95 Section 5.5 The Sexual Response .......................................................................................................................... 96 Section 5.6 The Sexual Experience ...................................................................................................................... 99 Section 5.7 Sex and Gender .................................................................................................................................. 100 Section 5.6 Sexuality ............................................................................................................................................... 102 CHAPTER 6: Sexual Health........................................................................................................................ 106 Section 6.1 Sexual Health ...................................................................................................................................... 106 Section 6.2 Sexuality ............................................................................................................................................... 106 Section 6.3 Public Health Approach to Sexual Health ............................................................................... 106 Section 6.4 Stigma .................................................................................................................................................... 106 Section 6.5 Sexual Dysfunction........................................................................................................................... 106 Section 6.6 Sexual Frequency.............................................................................................................................. 107 Section 6.7 Sex and Health ................................................................................................................................... 107 Section 6.8 Sexual Happiness .............................................................................................................................. 107 Section 6.9 Sexual Bias and Misconceptions................................................................................................. 107 Section 6.10 Reproductive Health ..................................................................................................................... 108 CHAPTER 7: Infectious diseases and Sexually Transmitted Infections (STI’s)...................... 131 Section 7.1 Introduction ........................................................................................................................................ 131 Section 7.2 What are infectious diseases? ..................................................................................................... 131 Section 7.3 Symptoms and signs of infection ............................................................................................... 132 Section 7.4 What causes infectious diseases? .............................................................................................. 132 Section 7.5 Direct person-to-person transmission of pathogens......................................................... 133 Section 7.6 Indirect person-to-person transmission of pathogens ..................................................... 134 5 Section 7.7 Animal-to-human transmission of pathogens ...................................................................... 136 Section 7.8 Immune Defenses Against Infectious Diseases .................................................................... 138 Section 7.9 Risk Factors and Levels of Disease Prevention .................................................................... 147 Section 7.10 Levels of Disease Prevention .................................................................................................... 148 Section 7.11 Sexually Transmitted Infections .............................................................................................. 149 Section 7.12 STD/STI Treatments..................................................................................................................... 155 Section 7.13 STD/STI Prevention: How to Prevent STI’s ........................................................................ 157 Section 8.1 Understanding Drug Use and Addiction ................................................................................. 161 Section 8.2 Types of Drugs ................................................................................................................................... 161 Section 8.3 Prescription Drugs ........................................................................................................................... 172 Section 8.4 Alcohol Abuse..................................................................................................................................... 176 Section 8.5 Tobacco................................................................................................................................................. 181 Section 8.7 Drug Addiction................................................................................................................................... 186 Section 8. 7 Treatment Approaches for Drug Addiction .......................................................................... 189 CHAPTER 9: Basic Nutrition and Healthy Eating .............................................................................. 196 Section 9.1 Nutrition and Health ....................................................................................................................... 196 Section 9.2 Planning a Diet................................................................................................................................... 208 Section 9.3 Popular Diets ...................................................................................................................................... 217 Section 9.4 Food Supplements and Food Replacements ......................................................................... 222 CHAPTER 10: Weight Management ....................................................................................................... 227 Section 10.1 Assessing Body Weight and Body Composition ................................................................ 230 Section 10.2 Factors Contributing to Overweight and Obesity ............................................................. 233 Section 10.3 Balancing Calories and Eating Healthfully .......................................................................... 239 Section 10.4 Body Image ....................................................................................................................................... 246 CHAPTER 11: Physical Fitness................................................................................................................. 251 Section 11.1 Health Benefits Associated with Regular Physical Activity.......................................... 251 Section 11.2 Health Related Components of Physical Fitness ............................................................... 253 Section 11.3 Adding Physical Activity to Your Life .................................................................................... 256 Section 11.4 Implementing Your Fitness Plan ............................................................................................. 262 CHAPTER 12: Cardiovascular Disease, Diabetes, and Cancer ...................................................... 271 Section 12.1 Stroke .................................................................................................................................................. 277 Section 12.2 Metabolic Syndrome ..................................................................................................................... 279 Section 12.3 Diabetes ............................................................................................................................................. 287 Section 12.4 Cancer ................................................................................................................................................. 292 CHAPTER 13: Environmental Health .................................................................................................... 305 Section 13.1 Overpopulation ............................................................................................................................... 306 Section 13.2 Air Pollution ..................................................................................................................................... 307 Section 13.3 Climate Change ............................................................................................................................... 308 Section 13.4 Water .................................................................................................................................................. 309 Section 13.5 Waste Management....................................................................................................................... 310 CHAPTER 14: Health Care Choices ......................................................................................................... 312 Section 14.1 Understanding your Health Care Choices ............................................................................ 312 Section 14.3 Health Care Choices: The Affordable Health Care Act (ACA)....................................... 319 Section 14.4 Health Insurance: Key Terms ................................................................................................... 321 Section 14.5 Choices in Medical Care............................................................................................................... 323 Section 14.6 Alternative Medical Practices ................................................................................................... 327 Section 14.7 Health Disparity ............................................................................................................................. 332 6 CHAPTER 1: Introduction to Health In this section, readers will learn about the nature of health, health education, health promotion and related concepts. This will help to understand the social, psychological and physical components of health. Section 1.1 Definition and Concepts of Health In the Oxford English Dictionary health is defined as: ‘the state of being free from sickness, injury, disease, bodily conditions; something indicating good bodily condition.” Clearly, health is not quite as simple as the definition implies. The concept of health is wide and the way we define health also depends on individual perception, religious beliefs, cultural values, norms, and social class. Generally, there are two different perspectives concerning people’s own definitions of health: a narrow perspective and a broader perspective. Section 1.2 Narrow Perspectives of Health People with a narrow perspective consider health as the absence of disease or disability or biological dysfunction. According to this view (or model), to call someone unhealthy or sick means there should be evidence of a particular illness. Social, emotional and psychological factors are not believed to cause unhealthy conditions. This model is narrow and limits the definition of health to the physical and physiological capabilities that are necessary to perform routine tasks. According to this definition, the individual is healthy if all the body parts, cells, tissues and organ systems are functioning well and there is no apparent dysfunction of the body. Using this model people view the human body in the same terms as a computer, or mechanical device, when something is wrong you take it to experts who maintain it. Physicians, unlike behavioral experts, often focus on treatment and clinical interventions with medication rather than educational interventions to bring about behavior change. Section 1.3 Broader Perspectives of Health The most widely used of the broader definitions of health is that within the constitution of the World Health Organization (WHO), which defines health as: A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This classic definition is important, as it identifies the vital components of health. Well-being includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. In simple terms, well-being can be described as judging life positively and feeling good. Well-being is associated with numerous health-, job-, family-, and economically related benefits. For example, higher levels of well-being are associated with decreased risk of disease, illness, and injury; better immune functioning; 7 speedier recovery; and increased longevity. Individuals with high levels of well-being are more productive at work and are more likely to contribute to their communities. Many practitioners have expanded their focus to include wellness at the positive end of the health continuum. Wellness is being in good physical and mental health. Because mental health and physical health are linked, problems in one area can impact the other. At the same time, improving your physical health can also benefit your mental health, and vice versa. It is important to make healthy choices for both your physical and mental well-being. Remember that wellness is not just the absence of illness or stress. One can still strive for wellness even if he/she is experiencing these challenges in life. To more fully understand the meaning of health, it is important to understand each of its individual components. Section 1.4 The Six Dimensions of Health 1.4.1 Physical Body size and functioning; recognizing the need for physical activity, healthy foods, and adequate sleep; avoiding unhealthy habits 1.4.2 Social Developing a sense of connection, belonging, and sustained support system; having positive relationships 1.4.3 Intellectual Recognizing creative abilities and finding ways to expand knowledge and skills; being open-minded 1.4.4 Emotional Coping effectively with life and expressing emotions in an appropriate manner 1.4.5 Spiritual Having a sense of purpose and meaning in life; establishing peace, harmony, and balance in our lives 1.4.6 Environmental Occupying pleasant, healthy, and safe environments that support wellbeing; positively impacting the quality of our surroundings (including protecting and preserving nature) Learning about the Six Dimensions of Health can help a person choose how to make wellness a part of everyday life. Wellness strategies are practical ways to start developing healthy habits that can have a positive impact on physical and mental health. 8 Section 1.5 Life Expectancy at Birth Life expectancy is a measure often used to gauge the overall health of a population. Life expectancy at birth represents the average number of years that a group of infants would live if the group were to experience the age-specific death rates present in the year of birth. Differences in life expectancy among various demographic subpopulations, including racial and ethnic groups, may reflect differences in a range of factors such as socioeconomic status, access to medical care, and the prevalence of specific risk factors in a particular subpopulation. During 1975–2015, life expectancy at birth in the United States increased from 68.8 to 76.3 years for males and from 76.6 to 81.2 years for females. During this period, life expectancy at birth for males and females was longer for white persons than for black persons. Racial disparities in life expectancy at birth persisted for both males and females in 2015, but continued to narrow. Section 1.6 Leading Causes of Death In 1975, the five leading causes of death were heart disease, cancer, stroke, unintentional injuries, and influenza and pneumonia. In 2015, the five leading causes of death were heart disease, cancer, chronic lower respiratory diseases, unintentional injuries, and stroke. Throughout 1975–2015, heart disease and cancer remained the top two leading causes of death. Section 1.7 About Determinants of Health The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. 1.7.1 Determinants of Health What makes some people healthy and others unhealthy? How can we create a society in which everyone has a chance to live a long, healthy life? Determinants of health are factors that contribute to a person’s current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. Scientists generally recognize five determinants of health of a population: Healthy People 2020 is exploring these questions by: • Developing objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies. 9 • Emphasizing an ecological approach to disease prevention and health promotion. An ecological approach focuses on both individual-level and population-level determinants of health and interventions. • • Genes and biology: for example, sex and age Health behaviors: for example, alcohol use, injection drug use (needles), unprotected sex, and smoking Social environment or social characteristics: for example, discrimination, income, and gender Physical environment or total ecology: for example, where a person lives and crowding conditions Health services or medical care: for example, access to quality health care and having or not having insurance Other factors that could be included are culture, social status, and healthy child development. • • • • Determinants of health fall under several broad categories: Policymaking Policies at the local, state, and federal level affect individual and population health. Increasing taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products. Some policies affect entire populations over extended periods of time while simultaneously helping to change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn reduced rates of injuries and deaths from motor vehicle accidents. Social Factors Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes. Examples of social determinants include: • • • • • • Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods Social norms and attitudes, such as discrimination Exposure to crime, violence, and social disorder, such as the presence of trash Social support and social interactions Exposure to mass media and emerging technologies, such as the Internet or cell phones Socioeconomic conditions, such as concentrated poverty 10 • • • • Quality schools Transportation options Public safety Residential segregation Examples of physical determinants include: • Natural environment, such as plants, weather, or climate change • Built environment, such as buildings or transportation • Worksites, schools, and recreational settings • Housing, homes, and neighborhoods • Exposure to toxic substances and other physical hazards • Physical barriers, especially for people with disabilities • Aesthetic elements, such as good lighting, trees, or benches Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment. For example, millions of people in the United States live in places that have unhealthy levels of ozone or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of asthma in both adults and children compared with state and national averages. Poor air quality can worsen asthma symptoms, especially in children. Health Services Both access to health services and the quality of health services can impact health. Healthy People 2020 directly addresses access to health services as a topic area and incorporates quality of health services throughout a number of topic areas. Lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment. Barriers to accessing health services include: • Lack of availability • High cost • Lack of insurance coverage • Limited language access These barriers to accessing health services lead to: • Unmet health needs • Delays in receiving appropriate care • Inability to get preventive services • Hospitalizations that could have been prevented 11 Individual Behavior Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking, his or her risk of developing heart disease is greatly reduced. Many public health and health care interventions focus on changing individual behaviors such as substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the rates of chronic disease in this country. Examples of individual behavior determinants of health include: • Diet • Physical activity • Alcohol, cigarette, and other drug use • Hand washing Biology and Genetics Some biological and genetic factors affect specific populations more than others. For example, older adults are biologically prone to being in poorer health then adolescents due to the physical and cognitive effects of aging. Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition that people inherit when both parents carry the gene for sickle cell. The gene is most common in people with ancestors from West African countries, Mediterranean countries, South or Central American countries, Caribbean islands, India, and Saudi Arabia. Examples of biological and genetic social determinants of health include: • Age • Sex • HIV status • Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis • Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer • Family history of heart disease Section 1.8 Health Disparities Although the term disparities is often interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations. Healthy People strives to improve the health of all groups. To better understand the context of disparities, it is important to understand more about the U.S. population. In 2008, the U.S. population was estimated at 304 million people. 12 • • • • • In 2008, approximately 33%, or more than 100 million people, identified themselves as belonging to a racial or ethnic minority population. In 2008, 51%, or 154 million people, were women. In 2008, approximately 12%, or 36 million people not living in nursing homes or other residential care facilities, had a disability. In 2008, an estimated 70.5 million people lived in rural areas (23% of the population), while roughly 233.5 million people lived in urban areas (77%). In 2002, an estimated 4% of the U.S. population ages 18 to 44 identified themselves as lesbian, gay, bisexual, or transgender. During the past 2 decades, one of Healthy People’s overarching goals has focused on disparities. In Healthy People 2000, it was to reduce health disparities among Americans. In Healthy People 2010, it was to eliminate, not just reduce, health disparities. In Healthy People 2020, that goal expanded even further: to achieve health equity, eliminate disparities, and improve the health of all groups. Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” Over the years, efforts to eliminate disparities and achieve health equity have focused primarily on diseases or illnesses and on health care services. However, the absence of disease does not automatically equate to good health. Powerful, complex relationships exist between health and biology, genetics, and individual behavior, and between health and health services, socioeconomic status, the physical environment, discrimination, racism, literacy levels, and legislative policies. These factors, which influence an individual or population’s health, are known as determinants of health. For all Americans, other influences on health include the availability of and access to: • High-quality education • Culturally sensitive health care providers • Nutritious food • Health insurance • Decent and safe housing • Clean water and non-polluted air • Affordable, reliable public transportation 13 Throughout the next decade, Healthy People 2020 will assess health disparities in the U.S. population by tracking rates of illness, death, chronic conditions, behaviors, and other types of outcomes in relation to demographic factors including: • • • Race and ethnicity Gender Sexual identity and orientation • • Disability status or special health care needs Geographic location (rural and urban) Section 1.9 Risk Factors and Levels of Disease Prevention What is a Risk Factor? Part of learning how to take charge of one’s health requires understanding risk factors for different diseases. Risk factors are things in life that increase your chances of getting a certain disease. Some risk factors are beyond your control. A person may be born with them or have exposure with no fault assigned. Some risk factors that you have little or no control over include: • • • Family history of a disease Sex/gender — male or female Ancestry Some controllable risk factors include: • • • • • What you eat How much physical activity you get Whether you use tobacco How much alcohol you drink Whether you misuse drugs In fact, it has been estimated that almost 35 percent of all U.S. early deaths in 2000 could have been avoided by changing just three behaviors: • • • Stopping smoking Eating a healthy diet (for example, eating more fruits and vegetables and less red meat) Getting more physical activity A person can have one risk factor for a disease or he/she can have many. The more risk factors a person has, the more likely he/she will get the disease. For example, if people eat healthy, exercise on a regular basis, and control blood pressure, their chances of getting heart disease are less than those of diabetics, smokers, and sedentary people. To lower 14 your risks, take small steps toward engaging in a healthy lifestyle, and you’ll see big rewards. People with a family health history of chronic disease may have the most to gain from making lifestyle changes. You can’t change your genes, but you can change behaviors that affect your health, such as smoking, inactivity, and poor eating habits. In many cases, making these changes can reduce your risk of disease even if the disease runs in your family. Another change you can make is to have screening tests, such as mammograms and colorectal cancer screening. These screening tests help detect disease early. People who have a family health history of a chronic disease may benefit the most from screening tests that look for risk factors or early signs of disease. Finding disease early, before symptoms appear, can mean better health in the long run. Section 1.10 Levels of Disease Prevention Prevention includes a wide range of activities — known as “interventions” — aimed at reducing risks or threats to health. You may have heard researchers and health experts talk about three categories of prevention: primary, secondary and tertiary. What do they mean by these terms? Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: • • • Legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) Education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) Immunization against infectious diseases. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: • • • Regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer) Daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes Suitably modified work so injured or ill workers can return safely to their jobs. 15 Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: • • • Cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.) Support groups that allow members to share strategies for living well Vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible. Section 1.11 Behavior Change and Goal Setting Transtheoretical Model (Stages of Change) The transtheoretical model of behavior change, developed by Prochaska and DiClemente, assesses an individual’s readiness to implement a healthier behavior and provides insight into the decision making process that leads to action. For many people, changing or modifying a behavior that is unhealthy or potentially harmful can be quite challenging. Here are the stages that lead to behavior change: • • • • • Precontemplation (Not Ready) – You are not intending to take action in the foreseeable future, and can be unaware that your behavior is problematic Contemplation (Getting Ready) – You are beginning to recognize that your behavior is problematic, and start to look at the pros and cons of your continued actions Preparation (Ready) – You are intending to take action in the immediate future, and may begin taking small steps toward behavior change Action – You are making actual changes to your problem behavior by incorporating healthy choices/behaviors into your life Maintenance – You have been able to sustain action for at least six months and are working to prevent relapse into previous unhealthy behaviors Stage 1: Precontemplation (not ready) People at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behavior: they are encouraged to think about the pros of changing their behavior and to feel emotions about the effects of their negative behavior on others. Precontemplators typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes. 16 One of the most effective steps that others can help with at this stage is to encourage them to become more mindful of their decision-making and more conscious of the multiple benefits of changing an unhealthy behavior. Stage 2: Contemplation (getting ready) At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the pros of changing, their cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action. People here learn about the kind of person they could be if they changed their behavior and learn more from people who behave in healthy ways. Others can influence and help effectively at this stage by encouraging them to work at reducing the cons of changing their behavior. Stage 3: Preparation (ready) People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior. People in this stage should be encouraged to seek support from friends they trust, tell people about their plan to change the way they act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are, the more likely they are to keep progressing. Stage 4: Action (current action) People at this stage have changed their behavior within the last 6 months and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back. People in this stage progress by being taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways. Stage 5: Maintenance (monitoring) People at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behavior—particularly stressful situations. It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in healthy activities to cope with stress instead of relying on unhealthy behavior. Relapse (recycling): Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol, only to resume these unhealthy 17 behaviors. Individuals who attempt to quit highly addictive behaviors such as drug, alcohol, and tobacco use are at particularly high risk of a relapse. Achieving a long-term behavior change often requires ongoing support from family members, a health coach, a physician, or another motivational source. Supportive literature and other resources can also be helpful to avoid a relapse from happening. Section 1.12 SMART Goal Setting Figure 1. SMART Acronym Have you ever said to yourself that you need to “eat healthier” or “exercise more” to improve your overall health? How well did that work for you? In most cases, probably not very well. That’s because these statements are too vague and do not give us any direction for what truly needs to be done to achieve such goals. To have a better chance at being successful, try using the SMART acronym for setting your goals (S= Specific, M= Measurable, A=Attainable, R= Realistic, T= Time-oriented): Specific – Create a goal that has a focused and clear path for what you actually need to do. Examples: • • • I will drink 8 ounces of water 3 times per day I will walk briskly for 30 minutes, 5 times per week I will reduce my soda intake to no more than 2 cans of soda per week Do you see how that is more helpful than just saying you will eat healthier or exercise more? It gives you direction. Measurable – This enables you to track your progress, and ties in with the “specific” component. The above examples all have actual numbers associated with the behavior change that let you know whether or not it has been met. 18 Attainable – Make sure that your goal is within your capabilities and not too far out of reach. For example, if you have not been physically active for a number of years, it would be highly unlikely that you would be able to achieve a goal of running a marathon within the next month. Realistic – Try to ensure that your goal is something you will be able to continue doing and incorporate as part of your regular routine/lifestyle. For example, if you made a goal to kayak 2 times each week, but don’t have the financial resources to purchase or rent the equipment, no way to transport it, or are not close enough to a body of water in which to partake in kayaking, then this is not going to be feasible. Time-oriented – Give yourself a target date or deadline in which the goal needs to be met. This will keep you on track and motivated to reach the goal, while also evaluating your progress. References Behavior Change and Goal Setting https://courses.lumenlearning.com/suny-monroecc-hed110/chapter/three-levels-ofhealth-promotiondisease-prevention/ CC BY SA Centers for Disease Control https://www.cdc.gov/nchs/data/hus/hus16.pdf%23019 CC BY SA Contemporary Health Issues http://hlth21fall2012.wikispaces.com/home CC BY SA Healthy People https://www.healthypeople.gov CC BY SA Transtheoretical Model https://en.wikipedia.org/wiki/Transtheoretical_model CC BY SA 19 CHAPTER 2: Psychological Health Figure 2. Maslow’s Motivation Model Maslow's hierarchy of needs is a theory in psychology proposed by Abraham Maslow in his 1943 paper "A Theory of Human Motivation" in Psychological Review. Maslow used the terms "physiological", "safety", "belonging" and "love", "esteem", "self-actualization", and "self-transcendence" to describe the pattern that human motivations generally move through. The goal of Maslow's Theory is to attain the sixth level of stage: self-transcendent needs. Maslow's hierarchy of needs is often portrayed in the shape of a pyramid with the largest, most fundamental needs at the bottom and the need for self-actualization and selftranscendence at the top. The most fundamental and basic four layers of the pyramid contain what Maslow called "deficiency needs" or "d-needs": esteem, friendship and love, security, and physical needs. If these "deficiency needs" are not met – with the exception of the most fundamental (physiological) need – there may not be a physical indication, but the individual will feel anxious and tense. Maslow's theory suggests that the most basic level of needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs. The human brain is a complex system and has parallel processes running at the same time, thus many different motivations from various levels of Maslow's hierarchy can occur at the same time. Maslow spoke clearly about these levels and their satisfaction in terms such as "relative", "general", and "primarily". Instead of stating that the individual focuses on a certain need at any given time, Maslow stated that a certain need "dominates" the human organism. Thus Maslow acknowledged the likelihood that the different levels of motivation could occur at any time in the human mind, but he focused on identifying the basic types of motivation and the order in which they should be met. 20 Section 2.1 Physiological Needs Physiological needs are the physical requirements for human survival. If these requirements are not met, the human body cannot function properly and will ultimately fail. Physiological needs are thought to be the most important; they should be met first. Air, water, and food are metabolic requirements for survival in all animals, including humans. Clothing and shelter provide necessary protection from the elements. While maintaining an adequate birth rate shapes the intensity of the human sexual instinct, sexual competition may also shape said instinct. Section 2.2 Safety Needs Once a person's physiological needs are relatively satisfied, his/her safety needs take precedence and dominate behavior. In the absence of physical safety – due to war, natural disaster, family violence, childhood abuse, etc. – people may (re-)experience post-traumatic stress disorder or transgenerational trauma. In the absence of economic safety – due to economic crisis and lack of work opportunities – these safety needs manifest themselves in ways such as a preference for job security, grievance procedures for protecting the individual from unilateral authority, savings accounts, insurance policies, disability accommodations, etc. This level is more likely to be found in children as they generally have a greater need to feel safe. Safety and Security needs include: • • • • Personal security Financial security Health and well-being Safety net against accidents/illness and their adverse impacts Section 2.3 Social Belonging After physiological and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of belongingness. This need is especially strong in childhood and it can override the need for safety as witnessed in children who cling to abusive parents. Deficiencies within this level of Maslow's hierarchy – due to hospitalism, neglect, shunning, ostracism, etc. – can adversely affect the individual's ability to form and maintain emotionally significant relationships in general, such as: • • • Friendships Intimacy Family According to Maslow, humans need to feel a sense of belonging and acceptance among their social groups, regardless whether these groups are large or small. For example, some large 21 social groups may include clubs, co-workers, religious groups, professional organizations, sports teams, and gangs. Some examples of small social connections include family members, intimate partners, mentors, colleagues, and confidants. Humans need to love and be loved – both sexually and non-sexually – by others. Many people become susceptible to loneliness, social anxiety, and clinical depression in the absence of this love or belonging element. This need for belonging may overcome the physiological and security needs, depending on the strength of the peer pressure. Section 2.4 Esteem All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Esteem presents the typical human desire to be accepted and valued by others. People often engage in a profession or hobby to gain recognition. These activities give the person a sense of contribution or value. Low self-esteem or an inferiority complex may result from imbalances during this level in the hierarchy. People with low self-esteem often need respect from others; they may feel the need to seek fame or glory. However, fame or glory will not help the person to build their self-esteem until they accept who they are internally. Psychological imbalances such as depression can hinder the person from obtaining a higher level of self-esteem or self-respect. Most people have a need for stable self-respect and self-esteem. Maslow noted two versions of esteem needs: a "lower" version and a "higher" version. The "lower" version of esteem is the need for respect from others. This may include a need for status, recognition, fame, prestige, and attention. The "higher" version manifests itself as the need for self-respect. For example, the person may have a need for strength, competence, mastery, self-confidence, independence, and freedom. This "higher" version takes precedence over the "lower" version because it relies on an inner competence established through experience. Deprivation of these needs may lead to an inferiority complex, weakness, and helplessness. Maslow states that while he originally thought the needs of humans had strict guidelines, the "hierarchies are interrelated rather than sharply separated". This means that esteem and the subsequent levels are not strictly separated; instead, the levels are closely related. Section 2.5 Self-Actualization "What a man can be, he must be."[ This quotation forms the basis of the perceived need for self-actualization. This level of need refers to what a person's full potential is and the realization of that potential. Maslow describes this level as the desire to accomplish everything that one can, to become the most that one can be. Individuals may perceive or focus on this need very specifically. For example, one individual may have the strong desire to become an ideal parent. In another, the desire may be expressed athletically. For others, it may be expressed in paintings, pictures, or inventions. As previously mentioned, Maslow believed that to understand this level of need, the person must not only achieve the previous needs, but master them. 22 Section 2.6 Self-Transcendence In his later years, Abraham Maslow explored a further dimension of needs, while criticizing his own vision on self-actualization. The self only finds its actualization in giving itself to some higher goal outside oneself, in altruism and spirituality, which is essentially the desire to reach infinite. "Transcendence refers to the very highest and most inclusive or holistic levels of human consciousness, behaving and relating, as ends rather than means, to oneself, to significant others, to human beings in general, to other species, to nature, and to the cosmos" (Farther Reaches of Human Nature, New York 1971, p. 269). Section 2.7 Mental Health According to the World Health Organization (WHO), mental health includes "subjective wellbeing, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one's intellectual and emotional potential, among others." The WHO further states that the well-being of an individual is encompassed in the realization of their abilities, coping with normal stresses of life, productive work and contribution to their community. Cultural differences, subjective assessments, and competing professional theories all affect how "mental health" is defined. A widely accepted definition of health by mental health specialists is psychoanalyst Sigmund Freud's definition: the capacity "to work and to love”. Mental Health Issues Are Prevalent Among College Students Mental health issues are a leading impediment to academic success among college students. Untreated mental illness in the college student population — including depression, anxiety and eating disorders — is associated with lower GPA and higher probability of dropping out of school. Treatment is effective and available yet because of an unnecessary shame surrounding these issues, mental health is not discussed and too many students are suffering in silence • • • An estimated 26 percent of Americans ages 18 and older – or about 1 in 4 adults - live with a diagnosable mental health disorder. Half of all serious adult psychiatric illnesses – including major depression, anxiety disorders, and substance abuse – start by 14 years of age. Three-fourths of them are present by 25 years of age. Compared to older adults, the 18-24 year old age group shows the lowest rate of help-seeking. Mental Health Issues Impact Students' Ability To Succeed: • Almost one third of all college students report having felt so depressed that they had trouble functioning. 23 • • Mental health issues in the college student population, such as depression, anxiety, and eating disorders, are associated with lower GPA and higher probability of dropping out of college. More than 80 percent of college students felt overwhelmed by all they had to do in the past year and 45 percent have felt things were hopeless. Mental health issues can be deadly: • • • • Suicide is the 2nd leading cause of death among college students, claiming the lives of 1,100 students each year. 67% of college students tell a friend they are feeling suicidal before telling anyone else. More than half of college students have had suicidal thoughts and 1 in 10 students seriously consider attempting suicide. Half of students who have suicidal thoughts never seek counseling or treatment. 80-90% of college students who die by suicide were not receiving help from their college counseling centers Section 2.8 Emotional Health Emotional well-being is a term that has been used increasingly in recent decades. The implications of decreased emotional well-being are related to mental health concerns such as stress, depression, and anxiety. These in turn can contribute to physical ill-health such as digestive disorders, sleep disturbances, and general lack of energy.[1] The profile of a person prone to emotional distress is usually someone with low self-esteem, pessimistic, very self-critical, etc. and people who need to constantly assert themselves through their behavior. They also tend to be afraid, overly worried about the future, and focused on the past. On the positive side, enhanced emotional well-being is seen to contribute to upward spirals in increasing coping ability, self-esteem, performance and productivity at work, and even longevity. Thoughts determine feelings, and thoughts are nothing more than firings of neurons. And those feelings that thoughts generate make the body release extremely addicting substances like adrenaline and cortisol. Like with any other addiction, the need to continually feed off these addicting substances tends to make the body think and feel in a certain way. When someone decides to disengage from these emotional addictions, he/she must learn to think differently. Emotions and feelings are part of every step a person takes. A person must learn how to manage himself/herself in order to reach the maximum potential in all aspects of life. Good emotional health leads to better physical health, prevents diseases, and makes it possible to enjoy life and be happier. In this way you can become a “medicine person” through mirror neurons, those that lead to empathy and fire to imitate the emotions of others. Mirror neurons are what make you feel good when you’re with someone who is positive, cheerful 24 and motivational. At the other extreme are the so-called “toxic people”, who make others around them feel bad. Section 2.9 Spiritual Health The spiritual dimension is understood to imply a phenomenon that is not material in nature, but belongs to the realm of ideas, beliefs, values and ethics that have arisen in the minds and conscience of human beings, particularly ennobling ideas. Ennobling ideas have given rise to health ideals, which have led to a practical strategy for Health for All that aims at attaining a goal that has both a material and non-material component. If the material component of the strategy can be provided to people, the non-material or spiritual one is something that has to arise within people and communities in keeping with their social and cultural patterns. The spiritual dimension plays a great role in motivating people’s achievement in all aspects of life. [7] Section 2.10 Social Health The capacity for an individual to develop and flourish is deeply influenced by immediate social surroundings – including their opportunity to engage positively with family members, friends or colleagues, and earn a living for themselves and their families – and also by the socioeconomic circumstances in which said individual find himself/herself. Restricted or lost opportunities to gain an education and income are especially pertinent socio-economic factors. Psychoneuroimmunology is defined as the examination of the interactions among psychological, behavioral, and social factors with immunological and neuroendocrine outcomes. It is now well established that psychological factors, especially chronic stress, can lead to impairments in immune system function in both the young and older adults. In several studies of older adults, those who are providing care for a relative with dementia report high levels of stress and exhibit significant impairments in immune system functioning when compared with non-caregivers. Stress-induced changes in the immune system may affect a number of outcomes, including slowing the wound healing process and increasing susceptibility to infections. Section 2.11 Factors That Influence Psychological Well-Being Infancy and Early Childhood There is a strong body of evidence to show the importance of attachment by neonates to their mothers or other primary caregivers for subsequent social and emotional development. Separation from the primary caregiver - due for example to parental absence or rejection - leads to anxiety, stress and insecurity. Post-natal depression among new mothers can likewise contribute to sub-optimal attachment and development. Parents who have difficulties in bonding, have limited skills or exhibit negative attitudes place their children at increased risk of exposure to stress and behavioral problems. Other important 25 risks to physical and cognitive development in infancy and early childhood include maltreatment and neglect (by parents and other caregivers), malnutrition and infectious or parasitic diseases. Individual attributes and behaviors These relate to a person's innate and learned ability to deal with thoughts and feelings and to manage him/herself in daily life ('emotional intelligence'). It is also the capacity to deal with the social world around by partaking in social activities, taking responsibilities or respecting the views of others ('social intelligence'). An individual’s mental health state can also be influenced by genetic and biological factors; that is, determinants that persons are born or endowed with, including chromosomal abnormalities (e.g. Down's syndrome) and intellectual disability caused by prenatal exposure to alcohol or oxygen deprivation at birth. Social and economic circumstances The capacity for people to develop and flourish is deeply influenced by their immediate social surroundings – including their opportunity to engage positively with family members, friends or colleagues, and earn a living for themselves and their families – and also by the socioeconomic circumstances in which they find themselves. Restricted or lost opportunities to gain an education and income are especially pertinent socio-economic factors. Environmental factors The wider sociocultural and geopolitical environment in which people live can also affect an individual’s, household’s or community’s mental health status, including levels of access to basic commodities and services (water, essential health services, the rule of law), exposure to predominating cultural beliefs, attitudes or practices, as well as by social and economic policies formed at the national level; for example, the on-going global financial crisis is expected to have significant mental health consequences, including increased rates of suicide and harmful alcohol use. Discrimination, social or gender inequality and conflict are examples of adverse structural determinants of mental well-being. Personality Personality measures turn out to be good predictors of your health, your sexual promiscuity, your likelihood of divorce, how happy you typically are—even your taste in paintings. Personality is a much better predictor of these things than social class or age. The origin of these differences is in part innate. That is to say, when people are adopted at birth and brought up by new families, their personalities are more similar to their blood relatives than to the ones they grew up with. The differences begin to emerge early in life and are surprisingly stable across the decades. This is not to say that people cannot change, but major change is the exception rather than the rule. Personality differences tend to manifest themselves through the quick, gut-feeling, intuitive, and emotional systems of the 26 human mind. The slower, rational, deliberate systems show less variation in output from person to person. Deliberate rational strategies can be used to over-ride intuitive patterns of response, and this is how people wishing to change their personalities or feelings have to go about it. So what are the major ways personalities can differ? The dominant approach is to think of the space of possible personalities as being defined by a number of dimensions. Each person can be given a location in the space by their scores on all the different dimensions. Virtually all theories agree on two of the main dimensions, though they differ on how many additional ones they recognize. Five factors • • • • Openness to experience: (inventive/curious vs. consistent/cautious). Appreciation for art, emotion, adventure, unusual ideas, curiosity, and variety of experience. Openness reflects the degree of intellectual curiosity, creativity and a preference for novelty and variety a person has. It is also described as the extent to which a person is imaginative or independent and depicts a personal preference for a variety of activities over a strict routine. High openness can be perceived as unpredictability or lack of focus. Moreover, individuals with high openness are said to pursue selfactualization specifically by seeking out in tense, euphoric experiences. Conversely, those with low openness seek to gain fulfillment through perseverance and are characterized as pragmatic and data-driven—sometimes even perceived to be dogmatic and closed-minded. Some disagreement remains about how to interpret and contextualize the openness factor. Conscientiousness: (efficient/organized vs. easy-going/careless). A tendency to be organized and dependable, show self-discipline, act dutifully, aim for achievement, and prefer planned rather than spontaneous behavior. High conscientiousness is often perceived as stubbornness and obsession. Low conscientiousness is associated with flexibility and spontaneity, but can also appear as sloppiness and lack of reliability. Extraversion: (outgoing/energetic vs. solitary/reserved). Energy, positive emotions, surgency, assertiveness, sociability and the tendency to seek stimulation in the company of others, and talkativeness. High extraversion is often perceived as attention-seeking, and domineering. Low extraversion causes a reserved, reflective personality, which can be perceived as aloof or self-absorbed. Agreeableness: (friendly/compassionate vs. challenging/detached). A tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others. It is also a measure of one's trusting and helpful nature, and whether a person is generally well-tempered or not. High agreeableness is often seen as naive or submissive. Low agreeableness personalities are often competitive or challenging people, which can be seen as argumentativeness or untrustworthiness. 27 • Neuroticism: (sensitive/nervous vs. secure/confident). The tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, and vulnerability. Neuroticism also refers to the degree of emotional stability and impulse control and is sometimes referred to by its low pole, "emotional stability". A high need for stability manifests itself as a stable and calm personality, but can be seen as uninspiring and unconcerned. A low need for stability causes a reactive and excitable personality, often very dynamic individuals, but they can be perceived as unstable or insecure. Assess yourself! This is an interactive version of the IPIP Big-Five Factor Markers, a measure of the big five personality traits: Big 5 Personality Test Section 2.12 Developing and protecting individual attributes At its core, mental health and well-being rests on the capacity of individuals to manage their thoughts, feelings and behavior, as well as their interactions with others. It is essential that these core attributes of self-control, resilience and confidence be allowed to develop and solidify in the formative stages of life, so that individuals are equipped to deal with the complex choices and potential adversities they will face as they grow older. Alcohol, tobacco and drug use pose risks to mental and physical health, particularly among pregnant women and adolescents. Raising awareness about the health risks of substance use can be accompanied by implementation of a number of proven strategies for reducing their use, including fiscal measures (namely, increased excise taxes) and regulatory instruments (such as comprehensive restrictions on advertising, minimum age of use and restrictions on smoking in public places). Maintaining a healthy diet and regular physical exercise are also protective factors for mental health and can be considered as part of a holistic approach to health promotion and protection in the population. Section 2.13 Supporting families and communities Individual-level mental health and well-being is strongly mediated by the immediate social context in which people live, work and carry out their day-to-day activities. The focus of family- and community-level attention is therefore to foster living and working conditions that enable psychosocial development (particularly among vulnerable persons) and promote positive interactions within and between families and social groups. Certain mental health promotion and protection strategies are targeted at specific groups, including: home-based interventions for socioeconomically disadvantaged families and for children with a mentally ill parent; prevention of intimate partner violence; school-based interventions for children and adolescents exhibiting emotional or behavioral problems; work-based interventions for adults looking for employment or struggling to cope at work; community-based interventions aimed at enhanced social participation of older adults; and psychosocial support for persons affected by conflict or disaster. 28 Section 2.14 Supporting vulnerable groups in society At the level of social and environmental determinants, key predictors of – and also consequences of – mental ill-health include lack of access to basic amenities and services, social exclusion, discrimination and exposure to violence, conflict or disasters. State-wide policy instruments that can address these failings and contribute towards social equality, inclusion and security include: anti-discrimination laws and campaigns; social protection for the poor; and elaboration of peaceful relations within and across national or ethnic boundaries. Section 2.15 Mental Illness We have all had some exposure to mental illness, but do we really understand it or know what it is? Many of our preconceptions are incorrect. A mental illness can be defined as a health condition that changes a person’s thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning. As with many diseases, mental illness is severe in some cases and mild in others. Individuals who have a mental illness don’t necessarily look like they are sick, especially if their illness is mild. Other individuals may show more explicit symptoms such as confusion, agitation, or withdrawal. Even if you or a family member has not experienced mental illness directly, it is very likely that you have known someone who has. Estimates are that at least one in four people is affected by mental illness either directly or indirectly. Consider the following statistics to get an idea of just how widespread the effects of mental illness are in society: • • • • • • According to recent estimates, approximately 20 percent of Americans, or about one in five people over the age of 18, suffer from a diagnosable mental disorder in a given year. Four of the 10 leading causes of disability—major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder—are mental illnesses. About 3 percent of the population have more than one mental illness at a time. About 5 percent of adults are affected so seriously by mental illness that it interferes with their ability to function in society. These severe and persistent mental illnesses include schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder. Approximately 20 percent of doctors’ appointments are related to anxiety disorders such as panic attacks. Eight million people have depression each year. Two million Americans have schizophrenia disorders, and 300,000 new cases are diagnosed each year. 29 Section 2.16 Mood Disorders Major mood disorders are depression, bipolar disorder, and dysthymic disorder. Like anxiety, depression might seem like something that everyone experiences at some point, and it is true that most people feel sad or “blue” at times in their lives. A true depressive episode, however, is more than just feeling sad for a short period. It is a long-term, debilitating illness that usually needs treatment to cure. And bipolar disorder is characterized by dramatic shifts in energy and mood, often affecting the individual’s ability to carry out day-to-day tasks. Bipolar disorder used to be called manic depression because of the way that people would swing between manic and depressive episodes. Section 2.17 Depression Depression, or depressive disorders, is a leading cause of disability in the United States as well as worldwide. It affects an estimated 9.5 percent of American adults in a given year. Nearly twice as many women as men have depression. Depression is more than just being in a bad mood or feeling sad. Everyone experiences these feelings on occasion, but that does not constitute depression. Depression is actually not a single disease; there are three main types of depressive disorders. They are major depressive disorder, dysthymia, and bipolar disorder (manic-depression). While some of the symptoms of depression are common during a passing “blue mood,” major depressive disorder is diagnosed when a person has five or more of the symptoms nearly every day during a two-week period. Symptoms of depression include a sad mood, a loss of interest in activities that one used to enjoy, a change in appetite or weight, oversleeping or difficulty sleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty concentrating, and recurrent thoughts of death or suicide. When people have depression, their lives are affected severely: they have trouble performing at work or school, and they aren’t interested in normal family and social activities. In adults, an untreated major depressive episode lasts an average of nine months. At least half of the people who experience an episode of major depression will have another episode of depression at some point. Section 2.18 Dysthymic Disorder Dysthymia is less severe than major depressive disorder, but it is more chronic. In dysthymia, a depressed mood along with at least two other symptoms of depression persist for at least two years in adults, or one year in children or adolescents. These symptoms may not be as disabling, but they do keep affected people from functioning well or feeling good. Dysthymia often begins in childhood, adolescence, or early adulthood. On average, untreated dysthymia lasts four years in children and adolescents. 30 Section 2.19 Bipolar Disorder A third type of depressive disorder is bipolar disorder, also called manic-depression. A person who has bipolar disorder alternates between episodes of major depression and mania (periods of abnormally and persistently elevated mood or irritability). During manic periods, the person will also have three or more of the following symptoms: overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, increased goal-directed activity or physical agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences. While in a manic phase, adolescents may engage in risky or reckless behaviors such as fast driving and unsafe sex. Bipolar disorder frequently begins during adolescence or young adulthood. Adults with bipolar disorder often have clearly defined episodes of mania and depression, with periods of mania every two to four years. Section 2.20 The Causes of Depression (depressive disorders) Depression, like other mental illnesses, is probably caused by a combination of biological, environmental, and social factors, but the exact causes are not yet known. For years, scientists thought that low levels of certain neurotransmitters (such as serotonin, dopamine, or norepinephrine) in the brain caused depression. However, scientists now believe that the interplay of factors leading to depression is much more complex. Genetic causes have been suggested from family studies that have shown that between 20 and 50 percent of children and adolescents with depression have a family history of depression and that children of depressed parents are more than three times as likely as children with nondepressed parents to experience a depressive disorder. Abnormal endocrine function, specifically of the hypothalamus or pituitary, may play a role in causing depression. Other risk factors for depressive disorders in youths include stress, cigarette smoking, loss of a parent, the breakup of a romantic relationship, attention disorders, learning disorders, abuse, neglect, and other trauma including experiencing a natural disaster. Section 2.21 Treating depression A variety of antidepressant medications and psychotherapies are used to treat depression. The most effective treatment for most people is a combination of medication and psychotherapy. Many of us are aware that medications are available to treat depressive disorders—we see the ads on television and in magazines. Up to 70 percent of people with depression can be treated effectively with medication. Medications used to treat depressive disorders usually act on the neurotransmission pathway. For example, some medications affect the activity of certain neurotransmitters, such as serotonin or norepinephrine. Different depressive disorders require different medication therapies. For example, individuals who have bipolar disorder are often treated with a mood-stabilizing drug, such as lithium, during their manic phase and a combination of mood-stabilizer and antidepressant medications during their depressive phase. 31 Medications usually lead to relief from the symptoms of depression within six to eight weeks. If one drug doesn’t relieve symptoms, doctors can prescribe a different antidepressant drug. As with drugs to treat other mental illnesses, patients are monitored closely by their doctor for symptoms of depression and for side effects. Patients who continue to take their medication for at least six months after recovery from major depression are 70 percent less likely to experience a relapse. Psychotherapy helps patients learn more effective ways to deal with the problems in their lives. These therapies usually involve 6 to 20 weekly meetings. These treatment plans should be revised if there is no improvement of symptoms within three or four months. Section 2.22 Coping with Depression People who have depression (or another depressive disorder) feel exhausted, worthless, helpless, and hopeless. These negative thoughts and feelings that are part of depression make some people feel like giving up. As treatment takes effect, these thoughts begin to go away. Some strategies that can help a person waiting for treatment to take effect include setting realistic goals in light of the depression and assuming a reasonable amount of responsibility; breaking large tasks into small ones, setting some priorities, and doing what one can as one can; trying to be with other people and to confide in someone—it is usually better than being alone and secretive; participating in activities that may make one feel better; getting some mild exercise, going to a movie or a ball game, or participating in religious, social, or other activities; expecting one’s mood to improve gradually, not immediately (feeling better takes time); postponing important decisions until the depression has lifted and discussing big decisions with family or friends who have a more objective view of the situation; remembering that positive thinking will replace the negative thinking that is part of the depression as one’s depression responds to treatment; and letting one’s family and friends help. Section 2.23 Anxiety Disorders Anxiety Disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder. Panic Disorders “For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I’m losing control in a very extreme way. My heart pounds really hard, I feel 32 like I can’t get my breath, and there’s an overwhelming feeling that things are crashing in on me.” “It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying.” “In between attacks there is this dread and anxiety that it’s going to happen again. I’m afraid to go back to places where I’ve had an attack. Unless I get help, there soon won’t be anyplace where I can go and feel safe from panic.” Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control. A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack. Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited. Obsessive-Compulsive Disorder “I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.” “I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.” “Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the 33 thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.” People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them. For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts. Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary. OCD affects about 2.2 million American adults, and the problem can be accompanied by eating disorders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families. Post-Traumatic Stress Disorder “I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.” “Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.” “The rape happened the week before Thanksgiving, and I can’t believe the anxiety and fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I can’t relax, can’t sleep, don’t want to be with anyone. I wonder whether I’ll ever be free of this terrible problem.” Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have 34 been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes. People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again. Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic. PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders. Social Phobia (Social Anxiety Disorder) “In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick in my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.” “When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.” 35 Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends. While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward. Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family. Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them. Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety. A specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety. Specific phobias affect an estimated 19.2 million adult Americans and are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families. 36 Generalized Anxiety Disorder (GAD) “I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.” “When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment. “I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were. When I got a stomachache, I’d think it was an ulcer.” People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provok...
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