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Parental verbal abuse of children is well-known, easily recognized, and often with devastating effects.  The dynamic is clear – parent as perpetrator and child as victim. The child needs and seeks approval and acceptance, but the parent is unwilling or unable to provide it. Parental verbal criticism and insults to the child leads to pervasive low self – esteem in children along with inevitable self – criticism. Signs of low self esteem include saying negative things and being critical of oneself, joking about oneself in a negative way, focusing on one’s negative traits and ignoring one’s accomplishments, blaming oneself when things go wrong, thinking that other people are always better and that a person with low self – esteem does not deserve to have fun.

Self – esteem itself is formed generally through two major sources. The primary contributor is the verbal and non-verbal appraisals of the child by his/her parents and/or other caretakers. A less powerful – but still significant – contributor to self – esteem is the child’s self-appraisal of his/her own abilities, skills, and assets. While children are certainly capable of recognizing their own strengths and skills, their appraisal of themselves as competent or deficient is determined more by parental appraisal and feedback than by the child’s self-assessment. When the child does demonstrate significant ability in the context of verbal criticism and abuse, it sometimes makes the verbal abuse harder to live with. The conflict between the two sources of esteem creates substantial distress for the child and emerging adult, but also provides an opportunity for remediation.

So why do some parents verbally abuse their children? The most obvious answer is that the parent may be conflicted about having the child. On one hand he/she may feel the need to do the right thing by taking care of the child’s often very substantial needs for nourishment, caring, and affection. On the other hand, parents on a deeper level may not like the child or not like the responsibility of caring for the child. The child may not have been wanted, and after birth required lots of time and attention. Verbally abusive parents may be already struggling to take care of their own needs – both physical and emotional – and with the addition of one or more children, they have to subsume their own needs in favor of the child’s needs.  Some parents may resent this requirement, or what may be worse, demand something in return from the child for the sacrifice the parent is making. The parents themselves may have been deprived, abused, criticized, or depreciated as children. With respect to self – esteem, the parent himself/herself may have low confidence and low self – esteem and therefore is unable to model it for the child. Moreover, the parent may overtly or covertly require the child to compensate the parent by demonstrating some behavior(s) that brings pride to the insecure and self-depreciating parent.   Some parents may consider the child as an investment to provide a feeling of success to a parent who otherwise feels like a failure with low self – worth. In this way parents often live vicariously through their children and require the child to achieve what the parent was unable to accomplish.

Children and adults who were verbally abused by their parents have been shown repeatedly to demonstrate self – criticism and low self – esteem as they grow older.  Verbally abused people seem to develop an INTERNALIZING way of reacting which often leads to the development of anxiety, depression and somatization.

By way of contrast, EXTERNALIZING behavior and disorders are characterized primarily by actions in the external world, such as acting out, antisocial behavior, hostility, and aggression. INTERNALIZING behaviors and disorders are characterized primarily by processes WITHIN THE SELF such as anxiety, depression and somatization.  Adults who were subjected to severe and persistent verbal abuse as children spend large portions of their life struggling within themselves to enjoy life unencumbered by insecurity, inner criticism, self – doubt and not liking themselves. It’s as if they alone know how they think and feel about themselves internally but are reluctant to reveal their inner selves to other people and the outside world.  In many cases the internalizing process is unconscious and may require psychotherapy to uncover the underlying source of anxiety and depression.

In the context of psychotherapy, people with low self = esteem may become aware of the multitude of verbally abusive remarks made to their developing self as a child,  sometimes said angrily and other times in a matter-of-fact manner. Statements such as “you are good for nothing”, “you should be ashamed of yourself,” it’s your own fault” (when an accident occurs) “if you weren’t so bad this wouldn’t happen”, “you are a horrible person”, ”you don’t deserve any good things”, “why can’t you be like someone else who behaves like a good and obedient child”. These are just a few of the many examples of abusive statements made to children.  In addition, some parents use guilt inducing statements as verbal abuse such as accusing the child of not appreciating or being ungrateful for all the caring that the parent has given to the child, and expecting gratitude in return.

The basic paradigm of verbal abuse is that parental verbal criticism is an insidious ongoing process that leads to self – criticism, subsequent low self – esteem and various degrees of anxiety, depression, and somatization in the child.  Remediation occurs when the adult victim of childhood verbal abuse gradually becomes able to recognize and eventually reject the critical and depreciating narrative that has become an essential part of the victim’s sense of self, but is neither true or necessary to maintain.

In response to the Covid 19 pandemic people are naturally becoming afraid of acquiring the viral infection, either in themselves or in people they love.
This fear – also called anxiety – is very uncomfortable and just as the infection itself can be mild, moderate or severe, so too the resulting anxiety can be mild, moderate or severe, sometimes leading to panic. Doctors and scientists know that it is hard to predict who will develop mild or severe symptoms when exposed to the virus. Yet it is well known that elderly people and those with pre-existing chronic medical conditions are more likely to have a more severe illness. Similarly with respect to anxiety, it is hard to predict the potential severity of any one person’s level of fear and worrying, except for people with a pre-existing chronic anxiety disorder. In particular there is a sizable number of people who suffer with health anxiety which is an intense and pervasive worrying and preoccupation with acquiring and suffering with a catastrophic, life threatening disease. It is for this group of people for whom the Covid 19 pandemic is especially frightening. Having worked with these people for many years it is a group that I know well.

People with Health Anxiety (HA) have difficulty thinking rationally about health risks. Intense anxiety disables rational thinking and puts in its place thoughts about potential catastrophic outcomes and “what if” thinking. The rational thinking
process looks at probabilities, whereas HA thinking reflects the belief that if something could happen then it will happen. People with HA need absolute certainty that a disease is not – or will not – be present in order to reduce their anxiety.
They also behave in ways they believe will reduce their anxiety, such as checking
their body for abnormalities, and asking for reassurance from doctors, family members and friends. The problem with these attempts to reduce anxiety is that while they may lower anxiety levels momentarily, the excessive attention to what could happen actually increases anxiety over time, leading to a state of chronic anxiety.

Covid 19 acts as a trigger to bring into awareness the fear that something bad can happen along with recommendations about prevention, i.e. hand washing, social distancing, wearing masks, disinfecting surfaces, etc. People with HA tend to be obsessively fixated on these potential threats and find it difficult to switch back to a more rational perspective. The reminders to be careful are constant, coming from the media and the opinions of experts. So the checking, need for reassurance and overall suffering with anxiety continues within a fearful perspective for people with chronic health anxiety. Without some kind of intervention it is likely that the fear and mental anguish will continue to have increasingly adverse effects on well-being for these individuals.

For people with health anxiety the internet can be constructive or destructive, a blessing or a curse. The internet contains enormous amounts of health information, some of it reputable and some just not true. It can provide information about diseases, symptoms, treatments, research studies, testimonials from patients and names of doctors and other practitioners able and willing to help. With just a few clicks one can visit numerous websites and accumulate huge amounts of information. In my office I have a large library of books, which I hardly ever consult anymore, since there is so much current information constantly being added online.
So why would this be a problem? It seems like learning about diseases and other health and illness information would answer so many questions, inform people about the diseases they are concerned about, and generally put to rest the uncertainty and confusion that people have about their health concerns.
Many people do actually derive a great benefit from being informed as a result of searching the internet. Yet for some people, especially for people with health anxiety, the internet can make matters much worse.

There are two major concerns one should have when searching for health information. The first is whether the information is valid. Just because something is posted on the internet doesn’t mean it is true. Anyone can post health information without anyone judging if it is true or misleading. So how can someone with limited knowledge know what is true or false? The answer is to go to reputable websites put online by government agencies or hospital organizations. The National Institutes of Health (NIH.gov.), The Mayo Clinic (mayoclinic.org) are just a few examples of reputable websites to obtain health information.

The other concern for people with health anxiety is that the internet is used to manage their anxiety with respect to the diseases or health conditions that frighten them. Typically health anxious people pay attention to body sensations or symptoms that leads them to catastrophically worry about whether they may have a life-threatening medical condition. Also, they often look only at partial information, just enough to confirm and heighten their fears. Sometimes they become so fearful they can’t continue reading a full description of the disease that frightens them. Sometimes it is useful to learn all you can about the disease you are afraid of, but at other times getting partial information while feeling terrified about a particular sensation or symptom, can generate very high levels of anxiety, and should be avoided.

As I indicated in a previous blog post, there is no such thing as absolute certainty,
There are only probabilities that something will or will not happen. For many people this is not a problem because a very high probability is enough to enable them to behave in ways that fulfill their needs and desires. However, for people with severe anxiety, especially health anxiety, a high probability that a feared event will not happen is not sufficient to relieve their anxiety. These people need a 100% guarantee.The probability of a domestic commercial plane crashing is one in many millions. Similarly, the probability of a bodily sensation being a malignant tumor is extremely low. In both cases people with severe anxiety need a guarantee that there is no chance of an adverse outcome. Focusing on actual, factual probabilities changes the narrative from irrational fear to logical reasoning and therefore, reduces worrying.

In spite of our attempts to avoid adversity and control our own reality, accidents happen, people get sick, unexpected events occur, and natural environmental incidents can cause havoc in our lives. In response to this reality some people adopt an attitude that accepts uncertainty as a fact of life. These people may assign responsibility for outcomes to chance, luck, some spiritual being, or other factors outside their control. The benefit of this attitude is that it minimizes or eliminates worrying about what can happen and protects the individual against self-blame if something undesirable occurs. The downside is that it sometimes leads people to deny personal responsibility for what happens to them, and to avoid making changes in their lives that would improve their health and well being.

As often happens, people develop bad habits that affect their lives adversely. Poor nutrition, lack of exercise, cigarette smoking, excessive alcohol and drug use, and relationships that cause more stress than comfort are examples of behaviors that are destructive to health. Good health, as well as anxiety reduction, can be achieved by people changing their behaviors or adopting new ones .These behavioral changes can sometimes lead to dramatic improvements in health and well being, and increase the probability of avoiding serious illness as well as increased longevity.

For people with health anxiety, thinking about the actual statistical probability of having a serious illness has the effect of reducing the anxiety, worrying, checking one’s body for symptoms and asking for reassurance that they don’t have symptoms of the disease they are afraid of. A more constructive approach would be to behave in ways that actually increase the probability of avoiding the illness that a person is afraid of. In other words, thinking of the actual statistical probability of having a disease –rather than how terrible it would be – does decrease the anxiety and the strong emotions associated with that disease. However, changing one’s health-related behavior actually decreases the probability that the disease will occur. It is better to do something that will decrease risk, rather than spend one’s time worrying about getting the disease one is afraid of.

There are many diverse mental health care professionals who work with people having anxiety, depression, relationship difficulties and/or many other problems in living. While there is significant diversity between mental health workers in terms of education and training, there are similarities as well. All mental health professionals have decided that they want to devote their working life trying to relieve the suffering of their patients. Of course some people are more effective than others. Sometimes effectiveness is related to education and training but other times it is due to the personal characteristics of the mental health worker. Empathy and listening ability are a few examples of the kinds of traits that promote effective treatment, and these traits may be similar in different levels of mental health professionals including psychiatrists, psychologists, and psychoanalysts.

A Psychiatrist is a medical doctor (MD) who after college goes to medical school for 4 years and then takes a Residency Training Program in psychiatry that usually lasts 3-4 years. Psychiatrists being medical doctors are able to prescribe psychiatric medications for patients that can often be very helpful in relieving the distress that patients feel. Their training includes developing expertise in the administration of medications to relieve the symptoms of mental illness. Psychiatrists are also trained to listen, advise and promote rational decision making by patients. Nevertheless, psychiatrists are mostly called upon to prescribe medications, often in conjunction with other professionals – including psychologists – who primarily talk with patients.

A psychologist is also a doctor, either a Doctor of Philosophy (PH.D) or Doctor of Psychology (Psy.D) The PhD program involves more research in addition to clinical training while the Psy.D training is almost entirely clinical. Psychologists are trained to pay attention to social and environmental determinants of behavior and mental Illness. Psychologists often recognize the need for medication and refer the patient to a psychiatrist for this purpose. Similarly, a psychiatrist often recognizes the need for a patient to have expert psychological intervention involving interpersonal issues arising either in the present or in the past, and, therefore, refers the patient to a psychologist. In some states psychologists can prescribe medication, and in some instances psychiatrists concentrate on talking at length with patients without prescribing medication. Nevertheless, in the majority of cases psychiatrists primarily prescribe medication while psychologists primarily talk and interact with patients at length.

A psychoanalyst can be either a psychiatrist or a psychologist who has had advanced training in how unconscious processes affect interactions with others and general well being. The best known psychoanalytic spokesperson has been attributed to Sigmund Freud, but there are many other psychoanalysts who have developed their own programs and who have lots of followers and practitioners. In psychoanalysis, what happens in childhood is crucial to the understanding of the patient as an adult. Training in psychoanalysis usually is done part-time over a long period of time. A central feature of this training is the requirement for trainees to have their own psychoanalysis which will help them understand the psychoanalytic process when they become analysts themselves.

The prescribing and monitoring of psychoactive medications is referred to as psychopharmacology. Talking to patients in an effort to reduce their distress or change their behavior is known as psychotherapy. One major type of psychotherapy is Psychodynamic Psychotherapy which follows psychoanalysis by emphasizing the importance of uncovering unconscious memories or behaviors that are presumed to affect behavior and distress in the present. Another major type of psychotherapy is Cognitive – Behavioral Therapy, which is the basis for most talk therapies practiced currently. Most therapists who talk with patients try to modify irrational or self-defeating beliefs(cognitive) and to gradually allow patients to change their behaviors that are also self destructive. This often requires a gradual diminishing of fear associated with behavior change.

Psychologists are prominent in both psychodynamic psychotherapy and cognitive-behavioral psychotherapy. Research has demonstrated the efficacy of individual talk therapy without medication. There is also research support for the efficacy of psychiatric medication without including psychotherapy. However the research seems to indicate that the largest improvement is when medication and psychotherapy are utilized together.

Can we have absolute certainty about anything? We certainly think that we can.
Many of us believe that we know what is going to happen in the near future, whether it is in a few minutes, a few hours, a few days, or a few years.
We “know” that a short drive will take 10 minutes, that a TV program will start
at a particular time, that we have friends and family who care about us, that we have an identity, and many other things that we “know” are true. In addition we
have beliefs about politics, religion, how to bring up children, etc, that we also “know” are true.

While it is true that in the overwhelming majority of events what we expect actually happens, it is not absolutely, 100% certain that the expected outcome will turn out to be what we expect it to be. Occasionally or even rarely, something unexpected happens. Flat tires, drunk drivers, a TV or electrical outage, betrayal by a friend, a change in who we thought we were, even changes in religious or political beliefs do happen and usually come as a complete surprise. It appears more accurate to say that what we believe to be absolutely certain is actually a high degree of probability.

So why is this important? Does it really matter if we think we are certain when in fact we can only have a very high degree of probability that what we expect to happen will actually happen. The answer can be both yes or no depending on how
this question impacts particular people. People who are being calm and rational will not be affected by this disparity, and can easily accept the premise that there is no
absolute certainty. On the other hand, people who are experiencing high anxiety and who (irrationally) expect some catastrophic outcome to occur, will not be satisfied to learn that there is a high probability that what they are terrified of will in all probability not happen the way they think it will. For example if someone is afraid of flying on a commercial airliner because of the possibility that the plane could crash, he or she is not comforted by the fact that crashes occur less than once in over 2 million flights. For people who are terrified, only an absolute guarantee that the plane will not crash is sufficient to relieve their terror. Since absolute certainty doesn’t exist in the airline industry, the person’s anxiety is maintained.

There are many other instances in which this dilemma can be expressed by highly anxious people. With respect to health and illness, individuals who have Health Anxiety and are terrified of finding out that they have a fatal disease, frequently check their bodies for symptoms of disease and ask doctors for reassurance that they are free of disease. Of course doctors think and act on the basis of probabilities and after an examination of the patient can say with reasonable assurance that a patient in all likelihood does not have a fatal disease at a particular point in time. Highly anxious people need 100% certainty and a guarantee from the doctor that they are disease free., which doctors in all honesty are unable to provide. The way to manage anxiety is to confront it rather than seeking to reduce the external triggers and manifestations of the anxiety. For a more detailed discussion of this process please see the blog on anxiety or the monograph on health anxiety.

Many people complain about the medical care they receive, especially from doctors but also from nurses and other health care professionals. The most common complaint is that doctors don’t spend time with patients, listening to their concerns, fears and discomforts. Even when a patient tries to take the initiative and talk to the doctor, he or she is often interrupted with specific questions from the doctor. The disconnect between doctors and patients is particularly pronounced in hospitals where a continuous stream of health professionals interact with patients and perform various tasks including blood tests and transporting patients to other places in the hospital for other diagnostic tests. Regardless of whether a doctor is seeing patients in his or her office, or in the hospital there is sometimes a disparity between the behavior of doctors and the needs of patients. Understanding the perspective of doctors can help people better navigate the health care system and receive the medical care they need.

When a doctor has contact with a patient, and a doctor/patient relationship is established, there are ethical as well as legal requirements that oversee the contact.
Doctors first and foremost want to do no harm, and secondly want to use their training and knowledge to relieve suffering and if possible cure disease. For many chronic medical conditions doctors cannot cure the condition but rather try to manage the disease so as to minimize patient discomfort and prevent the disease from getting worse. Of course doctors have many patients and have a limited time to spend with each patient.

Generally doctors think in a systematic way based on their training and experience.
Their first concern is what the patient is complaining about and whether the complaint represents a serious medical condition, or worse, a medical emergency, which if course would require immediate medical treatment. The next concern is the history of the complaint – or if there is more than one complaint – the history of all complaints. Often this information is contained in a medical record either in a handwritten chart or increasingly on a computer screen. This may explain why doctors talk to patients but look at the medical record instead of looking directly at them. In this context doctors want to know what treatments and medications have been prescribed currently or previously to treat the condition the patient is complaining about, and how effective they have been. Based on how much time a doctor has allotted to spend with the patient, he or she may be asked to return for a subsequent visit to attend to other medical conditions that are not urgent or emergencies.

From the patient perspective relief from pain or other distress is paramount, along with feeling that the doctor shows caring and respect. Visits to doctor’s offices are stressful for some people, especially those with health anxiety. When people are stressed and anxious they typically forget what is on their mind and may also have some difficulty listening to what other people are saying or asking. Generally the amount of time spent is less important than the quality of the interaction between doctor and patient. Patients may not always be able to know if the doctor’s diagnosis and treatment is accurate. What they do know is how the doctor talks to them and whether the doctor listens attentively. This is especially so for people who are anxious when they talk to doctors. Some doctors pay attention to these interpersonal variables but many do not. They are primarily interested in making an accurate assessment and prescribing an effective treatment plan. This difference in doctor behavior is partly explained by personality factors, but also can be explained by understanding that doctors are primarily concerned with making a correct diagnosis and not missing anything associated with the patient’s illness. This may explain why a doctor may interrupt a patient to ask additional questions.

In recent years patient satisfaction with medical care has become an important consideration for health care providers as well as organizations that evaluate the effectiveness of health care providers. There is increasing interest in finding out what doctors can do better with respect to maximizing patient satisfaction.
In addition, there is a lot patients can do to facilitate an effective medical encounter between doctor and patient. Recognizing that there is a limited amount of time, it is very helpful to use the time as efficiently as possible. Patients can start by writing down the questions or concerns they have for the doctor and letting the doctor know at the very beginning of the medical visit what those questions or concerns are. Most doctors will try to answer the questions as best they can at some point in the visit. Many patients don’t say anything until the doctor is finished and ready to move on to another patient. Although some doctors may ask patients if they have any questions, it is not surprising that when time is limited doctors may cut a patient short and defer further discussion to a subsequent visit.

Another thing patients can do to promote efficiency is to provide a list of medications, dosages, and dates of other treatment and illnesses. This information may be contained in the patient’s medical record but it is a good idea for patients to be aware of their own treatments and be able to communicate this information to the doctor, either verbally or in writing. It is often helpful to have another person accompany the patient both to provide information if necessary and to remember what the doctor said to the patient regarding diagnosis, and treatment. With or without another person being present, it can be very useful to listen carefully to what the doctor is saying and ask questions if something the doctor says is confusing or not fully understood. It can be helpful to write things down to remember better what the doctor said. Some patients may need a more knowledgeable and assertive family member or friend to advocate for their interests. Ideally both doctor and patient enter a collaborative relationship to promote the medical well being of the patient. The doctor contributes medical expertise and experience. Patients have the responsibility to provide information that can help the doctor do his or her job effectively. Perhaps the most important responsibility of patients is to be not only compliant with the doctor’s treatment plan, but also to live in a health promoting way. The most important question a patient can ask a doctor is “what can I do to better my own health”?

The words anxiety and fear are often used interchangeably to express the same feeling of dread that something terrible is going to happen momentarily or sometime in the future. Anxiety and fear are obviously similar but also quite different. The difference is that fear refers to an actual, realistic, objectively verifiable danger, whereas anxiety refers to a more subjective, unrealistic and often exaggerated fear response to something or someone that is not actually frightening. Anxiety refers to the feeling of fear for no apparent or logical reason.

Feeling frightened brings our attention to some danger or situation that can potentially harm us. This can be a good thing since it enables us to take the necessary steps to protect ourselves before the danger causes us harm. In fact we have the fear response built into our bodies. We don’t have to learn to be afraid in most circumstances that present a real, tangible danger to our well being.

Fear is felt in a number of ways. In our bodies we can feel muscle tension, difficulty breathing, sweating, nausea, and heart palpitations. Our thoughts tell us that something terrible is going to happen, either very soon or in the future. Driving on a slippery road, hearing strange noises, becoming lost especially at night, seeing someone who looks like they are about to attack us in some way, are just a few examples of the many circumstances that are frightening.

Anxiety is a similar feeling as fear, but is different in that there is no real danger or situation that can be harmful. Yet, if our bodies react with fear and we believe that we are in danger – even when there is no danger – then its called anxiety. Some people know that there is no actual danger but still can’t stop the feelings of fear and the thoughts of some catastrophe that is about to happen. Other people can’t tell the difference between a real danger and a feeling of fear when there is nothing to be afraid of. Examples of anxiety include intense fear of elevators, fear of driving over bridges, checking again and again to make sure a door is locked, and a fear that a person has a very serious disease. Of course there are many other fears that people have that are not really actual threats, but these are just a few examples.

There are some people who seem to be fearful of everything, whether it is realistic or not. For other people it seems like they are not afraid of anything.
These people have a spirit of adventure, take risks easily and sometimes even look for danger. Actually most people are somewhere in between these two extremes. The explanation for this difference is in the personalities of people. Fearful people are just very cautious, get scared easily, and are reluctant to take risks.

So why are people fearful when they don’t have to be? Why do they have anxiety when there is nothing to be afraid of? The answers to these questions can be found primarily in a person’s personal history, It also is based on an important difference between fear and anxiety. While the fear response in people is natural and is built into their bodies, the anxiety response – when there is no danger – is learned. When was it learned? How was it learned? Who was their main teacher? These questions are not easy to answer, and even if they could be answered it doesn’t get rid of the anxiety.

The reason anxiety is not easy to overcome is because it is maintained by a person avoiding the situation that brings out the anxiety. For example, if a person is terrified at the thought of getting into an elevator, the usual way it is handled is to walk up the stairs, and avoid the elevator altogether. This relieves the anxiety for the moment but unfortunately makes it more likely that anxiety will occur the next time there is an elevator to use. Another example is a person terrified of meeting other people for fear of being judged or criticized (social anxiety). The usual way of dealing with this anxiety is to avoid being with people, which relieves the anxiety for the moment but also makes it more likely that anxiety will occur the next time there is a social situation to attend. So avoiding the fearful situation makes a person feel better in the immediate present but feel worse in the future.

It is obvious that if there is a real danger then it is best to avoid the dangerous situation. For example, if a road is very slippery it is best to avoid driving on it. In this case the avoidance reduces both the fear and the chances of becoming seriously injured. With elevators and social situations however, the circumstances are different. Elevators or people themselves are not dangerous, nor are so many other things that make people anxious. Avoiding the elevator or the group of people reduces the fear temporarily, but does nothing to avoid injury. The problem is that the more a person avoids situations that cause anxiety, the harder it is to actually eliminate the anxiety. Sooner or later someone who wants to get rid of their anxiety will have to confront the fearful situation rather than avoiding it. By doing so it will become clear that no harm will occur and, therefore, there is no need to be afraid of it and to avoid it. In the examples just given, the more a person gets into an elevator, or associates with other people, the less the anxiety will occur until it goes away completely.

“Health care” is generally understood by most people to mean the diagnosis and treatment of diseases by doctors, hospitals, and other health care professionals. Also included in the understanding of “health care” is the financing arrangements that pay for this medical care. This usually involves health insurance companies, often referred to as “payers” of health care services. This so–called “health care” should more appropriately be called “sickness care” in the sense that people seek out medical care when they are feeling sick. Doctors take medical histories, perform physical examinations, refer patients for a variety of medical tests to help in ascertaining the diagnosis of the illness or disease for which the patient is seeking understanding and/or relief from pain and discomfort. Doctors are trained to provide sickness care but are not especially skilled in providing real health care.

Health care itself is what people do for themselves to maintain and improve their health. This involves living a healthy life style to the extent that individuals are able to make choices that promote health and the diminish illness and disease. Important aspects of health care include good nutrition, regular exercise, maintaining normal body weight, getting enough sleep, obtaining appropriate immunizations, avoiding cigarettes and excessive alcohol use, not using medications and drugs – legal or illegal – that are not prescribed by physicians for specific medical treatment, and managing stress effectively. Doctors can contribute to health care by recommending that patients follow the advice given for living healthy, but the actual health care is carried out by patients themselves. In fact people who engage in healthy behaviors are much less likely to become patients and receive sickness care from doctors.

Effective health care, therefore, contributes to maximizing health and minimizing illness. Most cases of illness and disease among people in the United States are for chronic diseases such as cardiovascular disease – heart disease and stroke, – many cancers, diabetes, chronic respiratory disease, and many others. While these diseases are partially caused by genetic inheritance, life style health care is for most people far more important. Following the healthy life style habits of ‘health care” will increase the probability of avoiding or postponing chronic illness, and therefore increase the probability of being healthy. In addition, people who practice effective health care seem to have a better quality of life and are more likely to have good mental health as well. A future post will consider the question of probability in the development of illness and disease.

Stress is a physiological or emotional response to certain environmental events. The environmental events are called stressors. Examples of stressors include illness or death of a loved one, marital separation or divorce, losing a job, moving to a new residence, and many others as well. Any environmental event can be a potential stressor. Signs of becoming aware of stressors involve feeling conflicted, frustrated, and/or pressured. Stressors can cause physiological arousal which is an automatic response of the body to a danger, requiring a person to fight or to run away. This is called the fight or flight reaction. A particular stressor may or may not cause an individual to experience a stress response. This depends on the individual’s cognitive appraisal of the environmental event and the meaning that the event has for the individual. Stressors can be any major occurrence or life event that requires an individual to make an adjustment or adaptation to the event.

Cognitive appraisal of stressors is an essential part of the stress response system and consists of a two-part mental process which determines if an environmental event will be stressful. Primary appraisal is concerned with determining if an event is potentially harmful or threatening to an individual’s well being. Secondary appraisal is an evaluation of one’s ability to cope with events that are appraised to be harmful or threatening. Both primary and secondary appraisals are based mostly on an individual’s prior experiences and learning. Stress occurs when a person PERCEIVES that a stressor is threatening and believes that he or she is not able to cope effectively with the stressor.

Physiological arousal is an important manifestation of stress. Sympathetic stimulation of the Autonomic Nervous System promotes increased heart rate, blood pressure and respiration, along with decreased digestion during the experience of stress. The Endocrine System of glands, particularly the pituitary and adrenal glands, are also involved in the manifestation of stress. The catecholamines, norepinephrine and epinephrine (adrenalin), are closely involved in prolonging the sympathetic response and arousing the body for action. Corticosteroids such as cortisol increase metabolism, provide energy and decrease the immune system inflammatory response. These changes represent the emergency activating system of the body and reflect the “fight or flight” reaction of the body to perceived danger. Stress occurs in response to the perception of danger even when in fact there is no danger. Similarly, stress does not occur when there is no perception of danger even when in fact there is real danger. Perception, therefore, is the key to understanding how and why stress occurs in response to various stressors.

Perception itself is based on behavioral traits that develop throughout a person’s lifetime and are mostly learned. Traits such as pessimism or shyness, feelings of guilt or worry, and fears of rejection or failure can clearly influence how a particular person perceives a stressor. These behavioral traits may actually be very important indicators of how intensely environmental stressors are experienced. Therefore, they are sometimes referred to as internal stressors that interact with external, environmental stressors to cause stress. Regardless of how they are classified, behavioral traits influence how stressors are perceived and influence both the occurrence and the intensity of the stress response. Further discussion of the relationship between internal and external stressors will be the subject of a future blog post on the similarities and differences between stress, anxiety and fear.

HEALTH EFFECTS OF STRESS

Stress has been associated with the development of many illnesses, including heart disease, cancer and diabetes. The evidence to support this association is not conclusive, although there is some evidence that events perceived as stress are associated with increases in catecholamines and corticosteroids which correspond to changes in the immune system. Some people experience stress very intensely while others have relatively mild reactions. This is related to the degree of physiological arousal that occurs in different people. Most diseases are caused by many factors and stress should be considered as one of these potential causes.

Stress can affect illness directly through stress induced physiological changes. This is particularly the case with chronic stress, which occurs repeatedly in response to the same stressors. Stress can also affect illness indirectly by influencing individual health behaviors. People who experience high levels of stress are more likely to smoke, use alcohol, get into accidents, overeat, and engage in other behaviors that make illness more likely to occur. This often overlooked effect of stress on health behaviors may well be the basis for public health programs that seek to change destructive health habits. Individual health behaviors are intrinsic to the development of chronic diseases such as heart disease, stroke, diabetes and some cancers, Managing stressors effectively can, therefore, promote health and minimize illness.

From a public health perspective there are additional stressors that should be considered in understanding how large groups of people can experience stress, which can affect their health and well-being. Poverty is at the top of this list, and represents a formidable task for promoting health in this population. Poverty itself is a powerful stressor but it is also associated with additional stressors such as overcrowding, crime, noise, abuse, trauma and neglect. Various stress management techniques are available to reduce stress and improve health but they have to be tailored to particular individuals or groups.

In a separate blog post I will discuss the various mediators of stress that can increase or decrease the intensity of the stress response. In addition I will describe a variety of stress management techniques that have been developed, some of which are supported by good evidence for their efficacy in preventing or reducing stress.