INSTRUCTOR MANUAL for Health: The Basics, The Mastering Health Edition 12th Edition by Rebecca Donat

CHAPTER

1

Accessing Your Health

Overview This chapter will help lay the foundation for good health and positive behavior change. The terms health and wellness are used interchangeably to describe the entire dynamic process of fulfilling one’s potential in the physical, social, emotional, spiritual, intellectual, and environmental dimensions of life. Multiple factors contribute to the status of one’s health, many of which are within a person’s control. To be healthy, one must make decisions about when to maintain current healthy behaviors and when and how to change unhealthy ones. Chapter 1 provides an understanding of how behavior change occurs and how one can improve their health behaviors. A major focus is the decision-making section and the self-assessment of one’s health. Chapter 1 sets the tone for the remainder of the book.

Learning Outcomes 1. Describe the immediate and long-term rewards of healthy behaviors and the effects that your health choices may have on others.

2. Compare and contrast the medical model of health and the public health model, and discuss the six dimensions of health.

3. Identify the modifiable and nonmodifiable personal and social factors that influence your health; discuss the importance of a global perspective on health; and explain how gender, racial, economic, and cultural factors influence health disparities.

4. Compare and contrast the health belief model, the social cognitive model, and the transtheoretical model of behavior change, and explain how you might use them in making a specific behavior change.

5. Identify your current risk behaviors, the factors that influence those behaviors, and the strategies you can use to change them.

Lecture Outline I. Why Health, Why Now? A. Choose Health Now for Immediate Benefits 1. Subtle choices including sleep, smoking, and drinking can impact your well-being, academic performance, driving, immune functioning, and mood.

2. When you’re nourished, fit, rested, and free from the influence of nicotine, alcohol, and other drugs, you’re more likely to avoid illness, succeed in school, maintain supportive relationships, participate in meaningful work and community activities,

and enjoy your leisure time.

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B. Choose Health Now for Long-Term Rewards 1. The choices you make today are like seeds: Planting good seeds (health) and nurturing them along the way (healthful choices) mean you’re more likely to enjoy the fruits of good health, including not only a longer life, but higher quality of life. On the other hand, poor choices increase the likelihood of a shorter life, illness, addiction, and other problems.

2. Life Expectancy a. According to current mortality rates, the average life expectancy at birth in the United States is projected to be 78.8 years for a child born in 2013. b. Life expectancy has increased significantly over the past 100 years, largely because our susceptibility to infectious disease has changed. c. Leading causes of death have now shifted to chronic diseases such as heart disease, cerebrovascular disease, cancer, and chronic lower respiratory diseases. d. Advances in diagnostic technologies and medications have continued the trend of increasing life expectancy into the twenty-first century. e. Life expectancy in the United States is several years below that of many nations due to many complex factors.

3. Healthy Life Expectancy a. Healthful choices increase your healthy life expectancy, the number of years of full health you enjoy, without disability, chronic pain, or significant illness. b. Health-related quality of life (HRQoL) is a multidimensional concept that includes elements of physical, mental, emotional, and social function. c. Closely related to HRQoL is well-being, which assesses the positive aspects of a person’s life, such as positive emotions and life satisfaction.

C. Your Health Is Linked to Your Community 1. Our personal health choices affect the lives of others because they contribute to national health and the global burden of disease.

2. For example, along with its associated health problems, obesity burdens the U.S. health care system and the U.S. economy with direct medical costs and indirectly through reduced tax revenues. a. Direct and indirect costs are also associated with smoking, excessive consumption of alcohol, and use of illegal drugs.

3. At the root of this issue is an ethical question: to what extent should the public be held accountable for an individual’s unhealthy choices? Should we require individuals to somehow pay for their poor choices? a. We already tax cigarettes and alcohol at a higher rate, and some states exclude things like candy and sweetened soft drinks from tax exemptions for food items. b. Others argue that smoking, drinking, and overeating should be treated behaviors that require treatment, not punishment.

Key Terms: mortality, life expectancy, chronic disease, healthy life expectancy, healthrelated quality of life (HRQoL), well-being Figure and Table: Figure 1.1 Top Ten Reported Impediments to Academic Performance—Past 12 Months Table 1.1 Leading Causes of Death in United States, 2012, Overall and by Age Group (15 and older) See It! Video: Helping Others Could Be Good for Your Health

II. What Is Health?

1. The definition of health has evolved throughout history.

A. Models of Health 1. Our current model of health has broadened from a focus on the physical body to an understanding of health as a reflection not only of ourselves, but also of our communities.

2. Medical Model a. The medical model focused primarily on the individual and his or her tissues and organs, and the surest way to improve health was to cure the individual’s disease.

3. Public Health Model a. The public health model views diseases and other negative health events as a result of an individual’s interaction with his or her social and physical environment. b. Recognition of the public health model enabled health officials to prioritize hygiene and sanitation as being integral to health. c. By the 1940s, progressive thinkers began calling for even more policies, programs, and services to improve individual health and that of the population as a whole. d. The World Health Organization defines health as “the state of complete physical, mental, and social well-being, not just the absence of disease or infirmity.” e. Health promotion includes policies and programs that promote health behaviors known to support good health. f. Health promotion programs identify people engaging in risky behaviors (those that increase susceptibility to negative health outcomes) and create environments conducive to positive behavior change.

B. Wellness and the Dimensions of Health 1. René Dubos defined health as “a quality of life, involving social, emotional, mental, spiritual, and biological fitness on the part of the individual, which results from adaptations to the environment.” a. This concept of adaptability became key to our overall understanding of health.

2. Later, the concept of wellness enlarged Dubos’s definition of health by recognizing gradations of health. a. To achieve high-level wellness, a person must move progressively higher on a continuum of positive health indicators. Those who fail to achieve these levels may slip into illness.

3. Today health and wellness are often used interchangeably to describe the dynamic, ever-changing process of trying to achieve one’s potential in the six interrelated dimensions of health.

4. The dimensions of health include: a. Physical health (body size and shape; ability to perform activities of daily living). b. Social health (ability to have satisfying interpersonal relationships). c. Intellectual health (ability to think clearly, reason objectively, analyze critically, use brainpower to meet life’s challenges). d. Emotional health (the ability to express and control appropriate emotions). e. Spiritual health (having a sense of meaning and purpose in your life). f. Environmental health (an appreciation of the external environment and the roles individuals play to protect and improve environmental conditions).

5. Achieving wellness means attaining the optimal level of well-being for your unique limitations and strengths.

Key Terms: health, medical model, ecological or public health model, disease prevention, health promotion, risk behaviors, wellness Figures: Figure 1.2 The Ten Greatest Public Health Achievements of the Twentieth Century Figure 1.3 The Wellness Continuum Figure 1.4 The Dimensions of Health

III. What Influences Your Health?

1. Public health experts refer to the factors that influence health as determinants of health, a term the U.S. Surgeon General has defined as “the range of personal, social, economic, and environmental factors that influence health status.”

2. Healthy People 2020 has four overarching goals: a. Attain high-quality, longer lives free of preventable diseases. b. Achieve health equity, eliminate disparities, and improve the health of all groups. c. Create social and physical environments that promote good health for all. d. Promote quality of life, healthy development, and healthy behaviors across all life stages.

3. Healthy People 2020 classifies health determinants into five large groupings: a. Individual behavior b. Biology and genetics c. Social factors d. Health services e. Policymaking A. Individual Behavior 1. Individual behaviors can help you attain, maintain, or regain good health, or they can undermine your health and promote disease.

2. Modifiable determinants of health are things that you can change and include: a. Lack of physical activity b. Poor nutrition c. Excessive alcohol consumption d. Tobacco use B. Biology and Genetics 1. Biological and genetic determinants are nonmodifiable determinants and are things you can’t typically change or modify.

2. Biological and genetic determinants include inherited traits, conditions, and predispositions as well as innate characteristics like race, age, ethnicity, sex, metabolic rate, and body structure. Sex is also a key biological determinant.

C. Social Factors 1. Social determinants include the social and physical conditions of the environment in which people are born or live. a. Social factors include disparities in income and education, exposure to crime and violence, the availability of healthful foods, the state of buildings and roads, and the quality of air, soil, water, and climate.

2. Economic Factors a. People in lower socioeconomic brackets on average have substantially shorter life expectancies than those who are wealthy. b. Economic disadvantages exert their effects on human health within nearly all domains of life.

3. The Built Environment a. Built environment includes anything created or modified by human beings, from buildings to roads, to recreation areas and transportation systems, to electric transmission lines and communication cables. b. Changes to the built environment can improve the health of communities and individuals.

4. Pollutants and Infectious Agents a. When individuals and communities are exposed to toxins, radiation, irritants, and infectious agents via their environment, they can suffer significant harm.

D. Access to Quality Health Services 1. The health of individuals and communities is also determined by access to quality health care, including services for physical and mental health, as well as accurate and relevant information and products such as eyeglasses, medical supplies, and medications.

2. Individuals without health insurance or those with a high deductible may delay going to the doctor for regular preventive care.

E. Policymaking 1. Public policies can have a powerful and positive effect on the health of individuals and communities.

2. Health policies serve a key role in protecting public health and motivating individuals and communities to change.

Key Terms: determinants of health, health disparities Figures: Figure 1.5 Healthy People 2020 Determinants of Health Figure 1.6 Four Leading Causes of Chronic Disease in the United States See It! Video: Measles on the Rise

IV. How Does Behavior Change Occur?

1. Over the years, social scientists and public health researchers have developed a variety of models to illustrate how individual behavior change occurs.

A. Health Belief Model 1. Studies show that beliefs subtly influence behavior. a. A belief is an appraisal of the relationship between some object, action, or idea and some attribute of that object, action, or idea.

2. Health Belief Model (HBM) describes the ways in which beliefs affect behavior change, and holds that several factors must support a belief before change is likely: a. Perceived seriousness of the health problem b. Perceived susceptibility to the health problem c. Perceived benefits

d. Perceived barriers e. Cues to action B. Social Cognitive Model 1. The social cognitive model (SCM) proposes that three factors interact in a reciprocal fashion to promote and motivate change: a. Social environment b. Thoughts or cognition c. Behaviors C. Transtheoretical (Stages of Change) Model 1. The transtheoretical (stages of change) model proposes that we must go through a series of changes to adequately prepare ourselves for change.

2. According the model, the likelihood of behavior change will be enhanced if we have proper reinforcement and help during each of the following phases: a. Precontemplation b. Contemplation c. Preparation d. Action e. Maintenance f. Termination 3. We do not necessarily go through these stages sequentially, but realizing where we are is useful so that we can consider the appropriate strategies to move us forward.

Key Terms: belief, health belief model (HBM), social cognitive model (SCM), transtheoretical model Figure: Figure 1.7 Transtheoretical Model

V. How Can You Improve Your Health Behaviors?

1. Change is not a singular event but instead is a process that requires preparation, has several steps or stages, and takes time to occur. A four step plan integrates ideas from each of the behavior change models into a simple guide to moving forward.

A. Step One: Increase Your Awareness 1. Before you can decide what to change, you need to learn what researchers know about the behaviors that contribute and detract from your health.

2. This is a good time to take stock of the health determinants in your life.

B. Step Two: Contemplate Change 1. Examine Your Current Health Habits and Patterns a. Health behaviors involve elements of personal choice and are also influenced by other determinants, including predisposing, enabling, and reinforcing factors.

2. Identify a Target Behavior a. What do I want? b. Which change is the greatest priority at this time? c. Why is this important to me?

3. Learn More about the Target Behavior a. Learn everything you can—positive and negative—about your target behavior.

4. Assess Your Motivation and Readiness to Change

a. Motivation is not just a feeling but a social and cognitive force that directs your behavior. b. Motivation must be combined with common sense, commitment, and a realistic understanding of how best to move from point A to point B. c. Readiness is the state of being that precedes a behavior change.

5. Develop Self-Efficacy a. Self-efficacy—the belief that you are capable of achieving your goals and influencing events in life—is a critical factor influencing your health status.

6. Cultivate an Internal Locus of Control a. People who have a stronger internal locus of control believe that they have power over their actions. b. They are more driven by their own thoughts and are more likely to state their opinions and be true to their own beliefs.

C. Step 3: Prepare for Change 1. Set SMART Goals a. Specific b. Measureable c. Action-oriented d. Realistic e. Time-orientated 2. Use Shaping a. Shaping involves starting slowly, keeping steps small and achievable, and mastering one step before moving on to the next.

3. Anticipate Barriers to Change a. General barriers to change include: overambitious goals, self-defeating beliefs and attitudes, lack of support and guidance, and emotions that sabotage your efforts and sap your will.

4. Enlist Others as Change Agents a. Modeling is learning by observing and imitating role models. b. Family members, friends, and professionals can all offer unique and valuable support in our efforts to make behavioral changes.

5. Sign a Contract a. A behavior change contract serves many purposes: a public declaration of intent; an organized plan; a list of barriers and ways to overcome them; and a reminder of the benefits of sticking with your program.

D. Step 4: Take Action to Change 1. Visualize New Behavior a. Use imagined rehearsal to reach your goals.

2. Learn to “Counter” a. Substitute a desired behavior for an undesirable one.

3. Control the Situation a. Any behavior has antecedents (aspects of the situation that come beforehand) and consequences (the results of the behavior). b. Once you recognize the antecedents you can use situational inducement to seek settings, people, and other circumstances that support your efforts to change, and avoid those likely to derail your change.

4. Change Your Self-Talk

a. There is a close relationship between what people say to themselves and how they feel. b. Changing negative self-talk can help you recover from disappointment and take positive steps to correct the situation. c. Practice stopping and blocking negative thoughts, and concentrate on taking positive steps forward to positive behavior change.

5. Reward Yourself a. Positive reinforcement can increase the likelihood that a behavior will occur. b. Positive reinforcers are classified as consumable, activity, manipulative, possessional, and social.

6. Journal a. Write down your personal experiences, interpretations, ideas for improvement, and results; this is an important skill for behavior change.

7. Deal with a Relapse a. A relapse is a return to a previous pattern of negative behavior. b. To deal with a relapse you should: figure out what went wrong; use countering; consider getting help in making your change.

E. Let’s Get Started!

1. Create a behavior change contract that incorporates the goals and skills discussed in this chapter and put it where you can see it every day.

Key Terms: motivation, self-efficacy, locus of control, shaping, modeling, imagined rehearsal, countering, situational inducement, self-talk, positive reinforcement, relapse Figures: Figure 1.7 Transtheoretical Model Figure 1.8 Example of a Completed Behavior Change Contract See It! Video: Life-Changing Resolutions

Discussion Questions 1. What is your definition of health? What factors in your life have influenced this definition? How might these factors change in the future?

2. How do you think the six dimensions of health relate to one another? How do they fit together in your life?

3. Discuss the major gender differences between men and women as they relate to health issues.

4. Describe the major contributors to health disparities in the United States.

5. Were you aware of the leading causes of death for Americans ages 15–24? Why do you think they are so different from the leading causes for all ages combined? What changes can you make to lower your risks for major diseases?

6. Provide examples of predisposing, enabling, and reinforcing factors that might influence the decision of a young college student deciding whether to drink and drive.

7. Describe how factors of the health belief model might affect a young woman deciding to smoke her first cigarette and her last cigarette.

8. Can you think of an example of how your family or significant others have affected your health behaviors? Was the influence positive or negative?

Critical Thinking Questions 1. Predict how advances in technology might influence morbidity and mortality rates in the United States and globally. How do technological advances influence each of the six dimensions of health? Provide one example of each.

2. What would happen to a person’s overall health and well-being if any one of the six dimensions of health was not a part of the person’s lifestyle and/or experiences?

3. Examine the Healthy People 2020 objectives and select two of them. How does accomplishing these two objectives improve the overall health of individuals in the United States? Suggest two behavior changes that could support accomplishing the two objectives you’ve selected.

4. What are some of the effects of a lack of affordable and reliable health insurance for all?

5. Review the stages of the transtheoretical model of behavior change. Now, think of a behavior you’d like to change. At what stage do you belong in the process of changing your identified behavior? How can you go about adequately preparing yourself to move to the next step in the change process?

6. Which behavior change technique—shaping, visualization, modeling, controlling the situation, reinforcement, changing self-talk—do you think would be most effective for you personally if you were making a behavior change to improve your health? Why? Do you think this technique is the best technique for all behavioral changes you might make in a lifetime? Why or why not?

7. How would a person’s genetic predisposition influence that person’s health decisions?

Student Activities Individual 1. Complete the How Healthy Are You? assessment, and pick a behavior you would like to change. Outline the steps you will take, and identify the factors that might influence this change. Write out three specific objectives for this change.

2. Conduct a search for websites that focus on health issues in your community or on your college campus. Identify three issues you consider the most important. Describe how you could participate or contribute to positive change.

Community 1. Go online and look over Healthy People 2020. Pick a national objective and find local or community statistics on that specific health problem. Find out if there are resources in the community to help achieve this objective on a local level.

2. Talk to your local elected officials about their views on important health issues in the community. Find out if they have specific plans to improve the health of local residents.

Diverse Population/Nontraditional 1. Use the Internet to research the leading causes of death by age in a different country or region of the world. Compare the statistics to the leading causes of death in the United States.

2. Countries such as Canada and Great Britain provide universal health care for all their citizens. Research the pros and cons of these health care systems, and propose a way in which a similar program might be implemented in the United States.

Additional References N. E. Adler and D. H. Rehkopf, “U.S. Disparities in Health: Descriptions, Causes, and Mechanisms.” Annual Review of Public Health, 29, (2008): 235–253.

R. J. DiClemente, R. A. Crosby, and M. C. Kegler, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health (San Francisco, CA: Jossey-Bass, 2002).

S. R. Hawks, T. Smith, H. G. Thomas, H. S. Christley, N. Meinzer, and A. Pyne, “The Forgotten Dimensions in Health Education Research.” Health Education Research, doi:10.1093/her/cym035, (2007).

K. H. Mayer, J. B. Bradford, H. J. Makadon, R. Stall, H. Goldhammer, and S. Landers, “Sexual and Gender Minority Health: What We Know and What Needs to Be Done.”

American Journal of Public Health, 98, no. 6 (2008): 989–995.

L. W. Nelms, E. Hutchins, D. Hutchins, and R. J. Pursley, “Spirituality and the Health of College Students.” Journal of Religion and Health, 46, (2006): 249–265.

J. O. Prochaska, J. Norcross, and C. DiClemente, Changing for Good: A Revolutionary Six–Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward (New York: Avon Books, Inc., 1995).

B. J. Turnock, Public Health: What It Is and How it Works (Sudbury, MA: Jones and Bartlett Publishers, 2009).

U.S. Department of Health and Human Services. “Healthy People 2020: The Road Ahead.” http://healthypeople.gov/HP2020/default.asp Y. Wang, M. A. Beydoun, L. Liang, B. Caballero, and S. K. Kumanyika, “Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the U.S. Obesity Epidemic,” Obesity, 16, (2008): 2323–2330.

For Further Information Toll-Free Numbers for Health Information http://health.gov/nhic/pubs/tollfreenumbers/ Footprint Calculator www.footprintnetwork.org/en/index.php/GFN/page/calculators

Go Ask Alice!

Health-Related Questions and Answers www.goaskalice.columbia.edu Healthy People www.healthypeople.gov Population Reference Bureau http://prb.org Health Topics A to Z http://healthfinder.gov/HealthTopics U.S. Department of Health and Human Services www.hhs.gov World Health Organization www.who.int/en

Additional Media In Sickness and in Wealth, 56 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “How does the distribution of power, wealth, and resources shape opportunities for health?” www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107 Not Just a Paycheck, 30 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “Why do layoffs take such a huge toll in Michigan but cause hardly a ripple in Sweden?” www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107 Place Matters, 29 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “Why is your street address such a strong predictor of your health?” www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107

CHAPTER

1A

Focus On: Improving Your Financial Health

Overview If the correlation between GDP and life-expectancy is any indication, there is a very real correlation between financial health and physical health. This brief chapter looks at different ways to improve your financial health. After a discussion on the link between health and wealth, the chapter describes common financial struggles faced by college students and their families, and recent proposals aimed at making college more affordable. The chapter then explains different actions that students can take to improve their financial health, including budgeting, understanding debt and credit, and avoiding fraud and identity theft.

Learning Outcomes 1. List and explain factors that influence the relationship between health and wealth.

2. Describe common financial struggles college students face as well as strategies families employ to make college more affordable.

3. Explain how to successfully manage finances through budgeting, understanding debt and credit, and avoiding identity theft.

Lecture Outline I. The Link Between Health and Wealth 1. Individuals of a greater socioeconomic status (SES) tend to live longer lives than those living in poverty.

2. The relationship between health and wealth is based on many interconnected factors, including the determinants of health (individual behavior, the physical environment, and access to health services) and socioeconomic factors.

A. Money and Stress 1. Because money is valued as an indicator of success, those with financial insecurity may experience increased feelings of inferiority, low self-esteem, and self-doubt. a. These feelings are partly due to relative deprivation, or the inability of lowerincome groups to sustain the same lifestyle as higher-income groups in the same community.

2. These feelings of inferiority and insecurity can progress to chronic stress, which is associated with a plethora of negative health outcomes.

B. Money and Access to Resources

1. People with lower SES often live in areas where they lack access to social services as well as to affordable, nutritious foods (food deserts).

C. Poverty, Early Care, and Education 1. Disadvantages early in life can have a lasting impact on health. a. Inadequate preconception and prenatal care negatively affects fetus. b. Poverty in childhood has many lasting effects.

Key Terms: socioeconomic status (SES) Figure: Figure 1 Life Expectancy at Birth and GDP Per Capita, 2011 (or nearest year)

II. Financial Struggles in College A. Making College More Affordable 1. For more than half of all incoming college first-year students, financial aid was a major determining factor in the college they chose to attend.

2. In 2013, President Obama proposed reforms to make college more affordable. The proposals include: a. A new rating system that ties financial aid to college performance b. Holding those who receive financial aid responsible for receiving a degree c. Matching student loan repayment plans to income 3. Families are also taking steps to make college more affordable by having students reduce spending, increase workload, or take on another roommate.

Figure: Figure 2 How Families Cut Costs to Make College More Affordable

III. Actions to Improve Your Financial Health 1. Financial health involves being smart about what you spend and how you save for the future.

2. Smart financial choices will allow you to receive a degree, successfully manage debt, and learn to save money.

A. Prioritizing Health Insurance 1. Planning for the potentially devastating outcomes from an unexpected injury or illness is a key to financial health.

B. Making a Budget 1. A budget is an estimate of spending and income over a set period of time.

2. Set Goals a. Your goals and budget should match current income level, expenses, and priorities.

3. Track Expenses a. Fixed expenses are those costs that do not change much in the short term. b. Discretionary spending is money spent on things you like but don’t necessarily need.

4. Track Income a. Income is the money you have to spend, and generally includes wages and interest from investments. b. When you earn more than you spend, you have a budget surplus.

c. If expenses are greater than income, you have a budget deficit.

5. Making the Budget Numbers Add Up a. To track spending accurately, watch your expenses for several weeks, write down everything, and keep receipts. b. Budget cutting is hard, and the Skills for Behavior Change box gives some examples of little things you can do to help trim spending.

C. Understanding Debt and Credit Basics 1. Debt is the condition of owing money for something that was purchased.

2. Credit is a loan, or the ability to incur debt.

3. The original amount borrowed is called the loan principal, and loans also include interest charges. a. Fixed interest rate loans have payments that will not fluctuate for the life of the loan. b. Variable interest rate loans have interest rates that fluctuate over time.

4. Types of Student Aid a. Financial aid options may come from the university itself, from the government, or through private banks or firms. b. Student loans refer to aid options that require repayment. c. Grants refer to money you don’t repay (most scholarships are grants). d. Federal work study is an arrangement by which part-time jobs help pay for education. e. If you take out student loans if is crucial to understand details relating to repayment, deferrals, interest rates, and loan length.

D. Credit Cards 1. Credit cards are unsecured loans, meaning the only thing guaranteeing their repayment is your promise. a. This is different from a secured loan where the loan giver is allowed to seize an asset if payments are not made on time.

2. Interest and Fees a. Banks and firms that issue credit cards make money by charging interest on what you owe (your account balance), as well as other fees (advance fees, annual fees, late fees). b. Interest is calculated in a variety of ways, but a good starting point is the annual percentage rate (APR).

3. Your first credit card is one created in your name without any cosigners, and will like have a small credit limit.

4. Many credit cards do not charge interest if you pay the balance off in full each month.

The period of time between a credit card’s billing cycle and the payment due date is known as the grace period.

5. Know Your Consumer Rights a. You have the right to know why your credit card application has been rejected. b. Credit Card Accountability and Responsibility Act (2009) includes rules to prevent predatory practices aimed at young consumers. c. Consumer Financial Protection Bureau (CFPB) educates, conducts research, and enforces federal laws that protect consumers.

E. Protecting against Fraud and Identity Theft

1. Identity theft occurs when someone steals personal information and uses it without permission. Some common types include the following: a. Credit Card Theft b. Bank (Debit) Card Theft 2. Protecting Personal Information and Avoiding Scams a. Steer clear of phishers. b. Update smart phone operating systems and computer software regularly. c. Remove key information from social media accounts.

3. Get a Smart Card 4. Password Lock your Smartphone and PC 5. Shred Anything with Your Credit Card Number on It 6. Cleaning Up Identity Theft Messes a. Once you discover identity theft, you should take the following four steps as quickly as possible: place fraud alert on your credit reports, close up any accounts that were misused or set up fraudulently, fill out dispute forms, file a police report to document the crime, and file a complaint with the Federal Trade Commission.

Key Terms: budget, discretionary spending, budget surplus, budget deficit, debt, credit, principal, interest, grant, federal work study, annual percentage rate (APR), credit limit, identity theft Table: Table 1 Differences between Federal and Private Student Loans See It! Video: This Frugal Family Has Mastered Living Cheaply

Discussion Questions 1. Why are life expectancy and wealth so closely correlated?

2. Why might it be a good idea to start a budget, even if you don’t have a lot of money?

3. What is the difference between a grant and a loan? What are the differences between a federal loan and a private loan?

4. Why is credit important, and how does a person responsibly build it?

5. How does a credit card differ from the type of loan a person takes out to purchase a car or a home?

Critical Thinking Questions 1. Have you ever used a budget to try to bring your spending under control? What worked and what didn’t work?

2. What would you tell a young person who is about to get his or her first credit card?

3. What are some creative ways a college student might cut spending?

4. Do you have student loans?

5. In terms of potential for identity theft, what are your vulnerabilities? What steps should you take to protect yourself against fraud and identity theft?

Student Activities Individual 1. Using the assessment at the back of the chapter, create a realistic budget.

2. Use the Internet to explore different credit cards. Compare grace periods, interest rates, and fees, then determine which card offers the greatest value to a consumer.

3. Use the Internet to research different private and federal loans. Compare, contrast, and determine which offer the greatest value.

Community 1. What kind of impact can predatory lending have on a community? What role do statutes like the CARD Act play in preventing predatory practices?

2. What kind of budgeting and other financial tools are available to your school or community? How could they be more useful, or reach more people?

3. What kind of public outreach might be beneficial in terms of raising awareness about the importance of managing personal finances, credit, and debt?

Diverse Population/Nontraditional 1. Use the Internet to research the prevalence of debt in a different culture or country.

How does that prevalence of and attitudes toward debt compare to the United States?

2. Use the Internet to research GDP and life expectancy in another country. How do they compare, and what general conclusions might you draw?

Additional References Javelin Strategy & Research, “The 2011 Identity Fraud Report: Social Media and Mobile Forming the New Fraud Frontier,” February 2012, www.javelinstrategy.com.

Centers for Disease Control and Prevention (CDC), “Obesity and Socioeconomic Status in Adults: United States, 2005-2008,” NCHS Data Brief, no. 50 (December 2010), www.cdc.gov National Survey of Student Engagement, NSSE Annual Results 2012: Promoting Student Learning and Institutional Improvement: Lessons from NSSE at 13 (Bloomington, IN: Indiana University Center for Postsecondary Research, 2012), http://nsse.iub.edu State Higher Education Executive Officers Association, “The Economic Value of Post Secondary Degrees,” December 2012, www.sheeo.org Sallie Mae and Ipsos, How American Pays for College 2012: A National Study, 2012, www1.salliemae.com Bankruptcy Abuse Prevention and Consumer Protection Act of 2005. Full text available at www.govtrack.us Federal Trade Commission, “Equal Credit Opportunity: Understanding Your Rights Under the Law,” May 2009, www.ftc.gov

For Further Information AnnualCreditReport.com Free Credit Report www.annualcreditreport.com Federal Trade Commission Consumer Information www.consumer.ftc.gov Consumer Financial Protection Bureau www.consumerfinance.gov Federal Trade Commission Identity Theft www.ftc.gov

Additional Media Richard Wilkinson: How Economic Inequality Harms Societies, 17 minutes A talk on the impact inequality has on societies. www.youtube.com/watch?v=cZ7LzE3u7Bw Avoid ID Theft by FTC, 10 minutes A public service announcement by the FTC. www.youtube.com/watch?v=hWhZrOJqS3I How to Make a Shoebox Budget, 6 minutes A video on a simple way to track your expenses and build a realistic budget. www.youtube.com/watch?v=nQvkBbtgXLI Annual Percentage Rate (APR) and Effective APR, 7 minutes A video looking at APR and Effective APR. www.youtube.com/watch?v=RuPMsK0mQC8

CHAPTER

2

Promoting and Preserving Your Psychological Health

Overview Psychological health contributes significantly to our quality of life, and our ability to appreciate life is directly related to our psychological health. Chapter 2 discusses the mental, emotional, social, and spiritual qualities of health that make up the very heart of how we perceive our life experiences. This chapter discusses the keys to enhancing psychological health, and explores the roles of self-efficacy and self-esteem, emotional intelligence, personality, and happiness in psychological well-being. The chapter also describes various psychological disorders and explains their causes and treatment. The risk factors and warning signs of suicide are discussed, helping the student to understand when to get help or how to recognize when friends need help. Tips for avoiding negative thoughts and focusing on the positive aspects of life are also provided in this chapter.

Learning Objectives 1. Define each of the four components of psychological health, and identify the basic traits shared by psychologically healthy people.

2. Discuss the roles of self-efficacy and self-esteem, emotional intelligence, personality, and happiness in psychological well-being.

3. Describe and differentiate psychological disorders, including mood disorders, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, personality disorders, and schizophrenia, and explain their causes and treatments.

6. Discuss risk factors and possible warning signs of suicide, as well as actions that can be taken to help a person contemplating suicide.

7. Explain the different types of treatment options and professional services available to those experiencing mental health problems.

Lecture Outline I. What Is Psychological Health?

A. Psychological health is the sum of how we think, feel, relate, and exist in our day-to-day lives.

1. Psychologically healthy people share many basic elements: a. They feel good about themselves. b. They feel comfortable with other people and feel respect and compassion for others.

c. They are “self-compassionate.” d. They control tension and anxiety. e. They meet the demands of life. e. They curb hate and guilt. f. They maintain a positive outlook. g. They value diversity. h. They appreciate and respect the world around them.

2. Basic needs must be met before we can achieve the characteristics of psychologically healthy people. a. This idea is described by Abraham Maslow’s hierarchy of needs. b. Hierarchy of needs is composed of the following levels: i. Survival Needs: food, water, sleep, exercise, sexual expression ii. Security Needs: shelter, safety, protection iii. Social Needs: belonging, affection, acceptance iv. Esteem Needs: self-respect, respect for others v. Self-Actualization: creativity, spirituality, fulfillment of potential c. According to Maslow’s Hierarchy of Needs, a person’s needs must be met at each level before that person can be truly healthy.

B. Mental Health 1. Mental health describes the “thinking or rational” part of psychological health.

2. A mentally healthy person perceives life in realistic ways, can adapt to change, can develop rational strategies to solve problems, and can carry out personal and professional responsibilities. a. A mentally healthy person has intellectual health, or the intellectual ability to learn and use information effectively and to strive for continued growth.

C. Emotional Health 1. Emotional health refers to the feeling, or subjective, side of psychological health.

2. Emotions are intensified feelings or complex patterns of feelings we experience.

3. Emotionally healthy people are able to respond in a stable and appropriate manner to upsetting events. Emotionally unhealthy people are much more likely to let their feelings overpower them.

D. Social Health 1. Social health includes your interactions with others on an individual and group basis, your ability to use social resources and support in times of need, and your ability to adapt to a variety of social situations.

2. Families have a significant influence on psychological development.

3. Healthy, nurturing families are more likely to produce well-adjusted adults.

4. Children raised in dysfunctional families may have a harder time adapting to life and run an increased risk of psychological problems.

5. Presence of key social support consists of networks or people and services with whom we share ties. a. This includes both tangible support (money to pay the bills) and intangible support (encouraging you to share your concerns).

E. Spiritual Health

1. Spirituality is broader than religion and is defined as a person’s sense of peace, purpose and connection to others, and beliefs about the meaning in life.

2. Spiritual health refers to the sense of belonging to something greater than the purely physical or personal dimensions of existence. a. See Focus On: Cultivating Your Spiritual Health to explore your spiritual health.

Key Terms: psychological health, resiliency, mental health, emotional health, emotions, social health, dysfunctional families, social support, spiritual health Figures: Figure 2.1 Psychological Health Figure 2.2 Characteristics of Psychologically Healthy and Unhealthy People Figure 2.3 Maslow’s Hierarchy of Needs

II. Keys to Enhancing Psychological Health A. Self-Efficacy and Self-Esteem 1. Self-efficacy refers to a person’s belief about whether he or she can successfully engage in and execute a specific behavior.

2. Self-esteem refers to one’s sense of self-respect or self-worth.

3. Learned Helplessness versus Learned Optimism a. Learned helplessness is a response to continued failure where people give up and fail to take action to help themselves. b. It is thought that self-help programs can promote the principle of “learned optimism.”

B. Emotional Intelligence 1. Emotional intelligence (EI) is our ability to identify, use, understand, and manage our own emotions as well as those of others. EI consists of the following: a. Self-awareness b. Self-regulation/self-management c. Internal motivation d. Empathy e. Social skills 2. Your emotional intelligence quotient (EQ) is an indicator of social and interpersonal skills—your ability to successfully maneuver in emotionally changed settings.

C. Personality 1. Your personality is the unique mix of characteristics that distinguish you from others.

2. Heredity, environment, culture, and experience influence how each person develops.

3. A leading personality theory, the five factor model, distills personality in five traits (the “Big Five”): a. Agreeableness b. Openness c. Neuroticism d. Conscientiousness

e. Extroversion D. Happiness and the Mind-Body Connection 1. At the core of the mind–body connection is psychoneuroimmunology (PNI), or the study of the interactions of behavioral, neural, and endocrine functions and the functioning of the body’s immune system.

2. Happiness or related mental states such as hopefulness, optimism, and contentment appear to reduce the risk or limit the severity of cardiovascular disease, pulmonary disease, diabetes, hypertension, colds, and other infections.

3. Subjective well-being (SWB) is that uplifting feeling of inner peace, which is defined by three central components: a. Satisfaction with present life b. Relative presence of positive emotions c. Relative absence of negative emotions 4. People with SWB are typically resilient, are able to look on the positive side, get back on track quickly, and do not despair as deeply over setbacks.

5. Some scientists suggest that some people may be biologically predisposed to happiness and well-being. Others say that we can develop happiness by practicing positive psychological actions. a. See the Skills for Behavior Change box for ways to incorporate positive psychology into your own life.

Key Terms: self-efficacy, self-esteem, learned helplessness, learned optimism, emotional intelligence, psychoneuroimmunology (PNI), subject well-being

III. When Psychological Health Deteriorates A. Mental illnesses are disorders that disrupt thinking, feeling, moods, and behaviors and cause a varying degree of impaired functioning in daily living.

1. They are believed to be caused by a variety of biochemical, genetic, and environmental factors. a. Most common risk factors are genetic or familial disposition and excessive, unresolved stress.

B. An estimated 22.5 percent of Americans aged 18 and older, 1 in 5 adults, suffer from a diagnosed mental disorder each year. Many suffer from more than one at a time.

1. Mental disorders are the leading cause of disability in the United States.

C. Mental Health Threats to College Students 1. Mental health problems are common among college students, and they appear to be increasing in number and severity.

2. The National College Health Assessment survey illustrates some of the difficulties college students face today. Anxiety, depression, and relationship problems top the list of mental health problems faced by college students.

D. Health Headlines box: When Adults Have ADHD. For more information about the myths and facts of adults with ADHD. E. Mood Disorders 1. Chronic mood disorders are disorders that affect how you feel, such as persistent sadness or feelings of euphoria. They include major depression, persistent depressive disorder, bipolar disorder, and seasonal affective disorder.

2. Major Depression a. Major depression (clinical depression) is the most common mood disorder, affecting approximately 6.3 percent of the U.S. population.

b. Major depression is characterized by a combination of symptoms that interfere with work, study, sleep, appetite, relationships, and enjoyment of life. c. Depression in college students can be a major obstacle to academic success and healthy adjustment. d. Depression in men is often masked by alcohol or drug abuse or by working excessively long hours. Men are less likely to admit they are depressed. e. Women are more than twice as likely to experience depression, which is likely the result of a combination of biological, genetic, psychosocial, and environmental factors.

3. Persistent Depressive Disorder a. Persistent depressive disorder (PDD) is a less severe form of chronic, mild depression. Individuals may appear to function well, but may lack energy, fatigue easily, or be short-tempered.

4. Seasonal Affective Disorder a. Seasonal affective disorder (SAD) strikes during the winter months and is associated with reduced exposure to sunlight. People with SAD suffer from irritability, apathy, carbohydrate craving and weight gain, increased sleep time, and general sadness. b. Light therapy is the most beneficial treatment for SAD. 5. Bipolar Disorder a. Bipolar disorder (formerly called manic depression) is often characterized by mood swings, ranging from extreme highs (mania) to extreme lows (depression).

F. What Causes Mood Disorders?

1. Mood disorders are believed to be caused by the interaction of environmental, psychological, biological, and genetic factors.

2. The most promising, yet unproven, theory of causation involves neurotransmitters, chemicals in the brain that cause an imbalance.

G. Anxiety Disorders 1. Anxiety disorders are characterized by persistent feelings of threat and worry. a. Anxiety disorders are the largest mental health problem in the United States.

2. Generalized Anxiety Disorder a. Generalized anxiety disorder (GAD) is a common form of anxiety disorder; it can be severe enough to significantly interfere with daily life. b. To be diagnosed one most exhibit three of the following symptoms for more days than not during a 6-month period: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and/or sleep disturbances.

3. Panic Disorder a. Panic disorders are characterized by the occurrence of panic attacks, a form of acute anxiety reaction that brings on an intense physical reaction.

4. Phobic Disorders a. Phobias involve a persistent and irrational fear of a specific object, activity, or situation, often out of proportion to the circumstances. b. Social anxiety disorder, or social phobia, is an anxiety disorder characterized by the persistent fear and avoidance of social situations.

5. What Causes Anxiety Disorders? a. There are no clear reasons as to why a person develops an anxiety disorder.

b. The cause may be biological, environmental, or within cultural and social roles.

H. Obsessive-Compulsive Disorder 1. Obsessive-compulsive disorder (OCD) occurs when people feel compelled to perform rituals repeatedly; are fearful of dirt or contamination; have an unnatural concern about order, symmetry, and exactness; or have persistent intrusive thoughts that they cannot shake.

I. Post-Traumatic Stress Disorder 1. Post-traumatic stress disorder (PTSD) is a collection of symptoms that may occur as a delayed response to a traumatic event or series of events.

2. Symptoms of PTSD include dissociation of the mind from the body, intrusive recollections of the traumatic event, and acute anxiety or nervousness, insomnia and difficulty concentrating, and intense physiological reactions when something reminds the person of the traumatic event.

J. Personality Disorders 1. Personality disorders are characterized by inflexible patterns of thought and beliefs that lead to socially distressing behavior.

2. Common types of personality disorders include the following: a. Paranoid personality disorder: pervasive, unfounded suspicion and mistrust of other people, irrational jealousy, and secretiveness. b. Narcissistic personality disorders: exaggerated sense of self-importance and self-absorption c. Borderline personality disorders (BPD): severe emotional instability, mood swings, impulsiveness, poor self-image, and erratic and risky behaviors.

K. Schizophrenia 1. Schizophrenia is characterized by the alteration of senses; the inability to sort out incoming stimuli and to make appropriate responses; an altered sense of self; and radical changes in emotions, movements, and behaviors.

2. Schizophrenia is treatable but not curable.

Key Terms: chronic mood disorder, major depression, persistent depressive disorder, seasonal affective disorder (SAD), bipolar disorder, anxiety disorders, generalized anxiety disorder (GAD), panic attack, phobia, social anxiety disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), personality disorder, schizophrenia Figure: Figure 2.4 Mental Health Concerns of American College Students, Past 12 Months See It! Video: What are the Causes for Depression?

III. Suicide: Giving Up on Life A. Suicide is the second leading cause of death for 19-24-year-olds and the third leading cause of death for 15-19-year-olds in the United States.

B. Overall Suicide Risk 1. Risk factors for suicide include previous suicide attempts, excessive drug and alcohol use, prolonged depression, financial difficulties, serious illness in oneself or a loved one, and loss of a loved one through death or rejection.

2. LGBT people are significantly more likely to have thought about or attempted suicide.

3. Nearly 4 times more men die by suicide than women.

4. Firearms, suffocation, and poison are the most common methods.

C. Warning Signs of Suicide 1. In most cases, suicide does not occur unpredictably.

2. There are several common warning signs of suicide intent.

D. Preventing Suicide 1. Get involved if someone you know threatens suicide or displays warning signs. a. Monitor the warning signals. b. Take threats seriously. c. Let the person know how much you care. d. Ask directly. e. Take action. f. Do not belittle the person’s feelings. g. Help the person think about alternatives to suicide. h. Tell your friend’s spouse, partner, parents, siblings, or counselor.

IV. Seeking Professional Help for Psychological Problems A. Although estimates show that 20 percent of adults have some kind of mental disorder, only 6 to 7 percent of adults use mental health services.

B. Mental Illness Stigma 1. Very few people who suffer with mental illness are dangerous.

2. The stigma of mental illness often leads to feelings of shame, guilt, loss of self-esteem, and a sense of isolation and hopelessness.

C. Getting Evaluated for Treatment 1. A thorough examination before receiving professional help for a psychosocial problem includes three parts: a physical checkup, a psychiatric history, and a mental status examination.

D. Mental Health Professionals 1. Several types of mental health professionals offer help and treatment for psychosocial problems. See Table 2.1.

E. What to Expect in Therapy 1. The first visit serves as a sizing up between you and your therapist.

2. It is critical to the success of your treatment that you trust your therapist enough to be open and honest.

F. Treatment Models 1. Many different types of counseling exist, including psychodynamic therapy, interpersonal therapy, and cognitive therapy, behavioral therapy, and cognitive-behavioral therapy.

G. Pharmacological Treatment 1. Psychotherapeutic treatment often combines talk therapy with drug therapy. a. Psychotropic drugs are medicines that alter chemicals in the brain and affect mood and behavior such as antianxiety and antidepressants.

2. Potency, dosage, and side effects of drugs can vary greatly, and it is vital to talk with your health care provider and completely understand the risks and benefits of the medication prescribed.

Key Terms: stigma, psychotropic drugs

Table: Table 2.1 Mental Health Professionals See It! Video: Psychological Disorders

Discussion Questions 1. What is psychological health? How do you know if you are psychologically healthy?

What areas in your life could use improvement? Why do you think the college environment may provide a challenge to your psychological health?

2. Do you know anyone who has high self-esteem? What characteristics does this person possess?

3. Why do you think the number of women with depression outnumbers that of men?

4. How do discrimination and stigma influence depression among LGBT youth? How are these things related to suicide rates among this population?

5. How might you know if a person is clinically depressed or temporarily sad, lonely, unhappy, or moody? What might you do?

6. How have psychological disorders been portrayed in movies? What are some specific examples? Do you think the media has helped remove some of the stigma surrounding these disorders?

7. What actions could you take if a close friend shows some of the warning signals of suicide?

Critical Thinking Questions 1. Based on the examples given in the book showing an association between emotions and the immune system, substantiate whether or not you believe in this concept. Describe two separate situations when you think your emotions affected your health.

2. Consider Maslow’s Hierarchy of Needs. Explain how each lower level in the pyramid affects the next highest level. Describe how your needs are met at each level. From your personal experience, how does one level being out of balance affect other levels? How might not having needs met at any level influence depression?

3. From your personal experience, describe a situation in your life when you might have experienced learned helplessness. What situation caused you to feel this way? What did you do to overcome this situation?

4. Review the list of the “Big Five” personality traits. Which of these personality traits do you possess? Do you identify with more than one category of personality traits? Give evidence to support your responses.

5. Current research suggests that drugs might be more beneficial in treating a person with SAD than environmental methods such as light treatment. If you had a loved one who experienced SAD, what course of treatment would you encourage that person to follow?

What questions would you ask about the proposed pharmacological treatment?

6. What would be the first steps you would take if you suspected that a loved one was suffering from a psychosocial disorder?

Student Activities Individual 1. Make a list of five short-term goals to complete by the end of this term. Next to each goal, write the percentage (from 1%–100%) of self-efficacy you feel toward that goal.

If there are any goals with percentages under 80 percent, rework the goal until you have a high level of self-efficacy toward achievement of the goal.

2. Visit the website for Spirituality & Health: www.spiritualityhealth.com, and find out how to improve your own spiritual health. Write a short paragraph commenting on the site.

3. Research new drugs available to treat a category of mental illnesses of your choice.

Explain how the new drugs are better than previous drugs.

Community 1. What resources are available on campus for psychosocial health? Visit the counseling center and write a short summary of services available and usage rates.

2. Find out how mental health services in your community are suffering from both state and federal budget cuts. What is being done to bridge the gap between need and services offered? What type of city/county legislation is being proposed to maintain adequate funding for mental health?

Diverse Population/Nontraditional 1. How do people in other cultures regard and care for people with mental illness? Conduct Internet research for a country of your choice. Find out the rates of psychosocial disorders such as depression, bipolar disorder, and schizophrenia and compare them to rates in the United States.

2. Conduct Internet research to determine if women in other countries disproportionately suffer from depression. Suggest an explanation for your findings.

Additional References Helpguide.org, Improving Emotional Health, Strategies and Tips for Good Mental Health, 2012, http://helpguide.org R. H. Aseltine Jr., A. James, E. A. Schilling, and J. Glanovsky, “Evaluating the SOS Suicide Prevention Program: A Replication and Extension.” BMC Public Health, 7, (2007): 161.

L. J. Cook, “Striving to Help College Students with Mental Health Issues.” Journal of Psychosocial Nursing and Mental Health Services, 45, (2007): 40–44.

S. J. Garlow, J. Rosenberg, J. D. Moore, A. P. Haas, B. Koestner, H. Hendin, and C. B. Nemeroff, “Depression, Desperation, and Suicidal Ideation in College Students: Results from the American Foundation for Suicide Prevention College Screening Project at Emory University.” Depression & Anxiety, 25, (2008): 482–488.

D. Eisenberg, M. F. Downs, E. Golberstein, and K. Zivin, “Stigma and Help Seeking for Mental Health among College Students.” Medical Care Research and Review, 66, (2009): 522–541.

M. D. Rudd, A. L. Berman, T. E. Joinder, Jr., M. K. Nock, M. M. Silverman, M. Mandrusiak, K. Van Orden, and T. Witte, “Warning Signs for Suicide: Theory, Research, and Clinical Applications.” Suicide and Life-Threatening Behavior, 36, (2006): 255–262.

D. L. Tosevski, M. P. Milovanevic, and S. D. Gajic, “Personality and Psychopathology of College Students.” Current Opinion in Psychiatry, 23, (2010): 48–52.

K. Zivin, D. Eisenberg, S. E. Gollust, and E. Golberstein, “Persistence of Mental Health Problems and Needs in a College Student Population.” Journal of Affective Disorders, 117, (2009): 180–185.

For Further Information American Association for Suicidology Prevention www.suicidology.org American Psychiatric Association www.psychiatry.org National Empowerment Center www.power2u.org National Mental Health Association www.nmha.org Schizophrenia Awareness Association www.schizophrenia.org.in SAVE: Suicide Awareness Voices of Education www.save.org

Additional Media Depression in College Students University of Wyoming, 3 minutes A video production of the University of Wyoming. The video discusses what depression is, the prevalence of depression among college students, and why college students may experience depression. www.youtube.com/watch?v=p0cVi3k2NAk Lidia Bernik on PBS Healthy Minds, 4 minutes A video of the National Suicide Prevention Lifeline. Lidia Bernik shares the story of her sister, who committed suicide while Lidia was in college. www.youtube.com/watch?v=rKZCeYo9gyM&feature=channel National Survivors of Suicide Day, 8 minutes A video of the American Foundation for Suicide Prevention. Eight people share how their lives have been affected by suicide. www.youtube.com/watch?v=MD7Odg3RnAg&feature=related

Get complete Order files download link below:

https://www.mediafire.com/file/ pg5yrfjufrtqwcd/IM+Health+The +Basics,+12e+Rebecca+Donatelle .zip/file If The link does not work with a click, then copy the complete Download link in internet explorer/google chrome and get all files download successfully.

WHO: Mental Health, 5 minutes A video produced by the World Health Organization that discusses the prevalence of mental health issues, with an emphasis on an international perspective. www.youtube.com/watch?v=L8iRjEOH41c

CHAPTER

2A

Focus On: Cultivating Your Spiritual Health

Overview Spirituality is one of the six key dimensions of health. And, just as individuals exercise to improve physical fitness, specific activities can strengthen the spiritual dimension of health as well. In this chapter, students begin to understand what spirituality is and how it is similar to and different from religion. Students learn that spirituality has three interconnected facets, and that spirituality contributes to physical health, psychosocial health, and reduced stress.

Students learn how to focus on their spiritual health by being in tune with themselves and their surroundings, training their bodies, expanding their minds, and reaching out to others.

Learning Outcomes 1. Define spirituality, describe its three facets, and distinguish between religion and spirituality.

2. Discuss the evidence that spiritual health has physical benefits, has psychological benefits, and lowers stress.

3. Describe three ways you can develop your spiritual health.

Lecture Outline 1. In the fall of 2014, of those surveyed, nearly 36 percent of incoming college freshman related themselves as above average in spirituality.

2. Spiritual health is one of the six key dimensions of health.

I. What Is Spirituality?

A. At some point, we come to realize that acquiring new possessions and striving to keep up with others does not necessarily make us happy or improve our sense of self-worth.

B. Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning, and about our relationship with the sacred or transcendent.

1. Many who become interested in spirituality seek out mentorship from a spiritual teacher, or a person who is versed in the nature of spirituality and spiritual practice who can help people achieve a deeper recognition of what spirituality means to them.

C. Spirituality means different things to different people; it is about learning to accept life on its own terms.

D. Spirituality and Religion 1. Spirituality may or may not lead to participation in organized religion.

2. Even though spirituality and religion share some common elements, they are not the same thing. a. Table 1 identifies some characteristics you can use to distinguish religion and spirituality.

E. Spirituality Integrates Three Facets 1. Three facets of human experience constitute the core of human spirituality. a. Relationships b. Values: the fundamental rules by which we conduct our lives. c. Meaningful purpose in life F. Spiritual Intelligence 1. Our relationships, values, and sense of purpose together contribute to our overall spiritual intelligence (SI). a. SI helps us use meanings, values, and purposes to live a richer and more creative life. b. See the Assess Yourself box to find out your own spiritual IQ. Key Terms: spirituality, spiritual teacher, values, conscious living, spiritual intelligence (SI) Table and Figure: Table 1 Characteristics Distinguishing Religion and Spirituality Figure 1 Three Facets of Spirituality

II. The Benefits of Spiritual Health A. Physical Benefits 1. Evidence supports a positive influence of spirituality on health. a. Connection may be due to improved immune function, cardiovascular function, or a combination of physiological changes.

2. When we get sick, spiritual or religious well-being may help restore health and restore quality of life in the following ways: a. By decreasing anxiety, depression, anger, discomfort, and feelings of isolation b. By decreasing alcohol and drug abuse c. By decreasing blood pressure and the risk of heart disease d. By increasing a person’s ability to cope with the effects of illness and with medical treatments e. By increasing feelings of hope and optimism, freedom from regret, satisfaction with life, and inner peace B. Psychological Benefits 1. Studies have found a benefit of spirituality in reducing levels of anxiety and depression. a. It may also protect against academic burnout.

2. People who have found a spiritual community also benefit from increased social support among members.

3. Stress reduction is one probable mechanism among spiritually healthy people for improved health and longevity and for better coping with illness.

Key Term: spiritual community

III. Cultivating Your Spiritual Health 1. Enhancing your spiritual side takes just as much work as becoming physically fit.

A. Tune In to Yourself and Your Surroundings 1. Inner wisdom is perpetually available to us, but if we fail to tune our “receiver,” we will not be able to hear it for all the “static” of our daily lives.

2. Four ancient practices still used throughout the world can help you to tune into yourself and your surroundings. a. Contemplation (studying): the practice of concentrating the mind on a spiritual or ethical question or subject, a view of the natural world, or an icon or other image representative of divinity b. Mindfulness (observing): a practice of focused, nonjudgmental observation in which we are fully present in the moment. c. Meditation (quieting): practice of cultivating a still or quiet mind. d. Prayer (communing with the divine): communication with a transcendent Presence B. Train Your Body 1. Traditional forms of yoga include controlled breathing and physical postures as well as meditation, chanting, and other practices believed to cultivate unity with the Atman, or spiritual life principle of the universe.

2. There are several types of yoga including, but not limited to, hatha yoga and ashtanga yoga. Each type of yoga has its own unique techniques and you can explore classes on campus, at the YMCA, or at a dedicated yoga center.

3. Eastern meditative movement practices like tai chi or qigong can also increase physical activity and mental focus.

4. Training your body to improve your spiritual health does not necessarily require you to engage in a formal practice. a. Any exercise you do every day can contribute to your spiritual health.

C. Expand Your Mind 1. For many people, psychological counseling is a first step toward improving their spiritual health.

2. Another way to expand your mind is to study the sacred texts of the world’s major religions and spiritual practices.

3. Expand your awareness of different spiritual practices by exploring on-campus meditation or service-oriented groups, taking classes in spiritual or religious subjects, attending religious meetings or services, attending public lectures, or checking websites of various spiritual and religious organizations.

D. Reach Out to Others 1. Altruism, the giving of oneself out of genuine concern for others, is a key aspect of a spiritually healthy lifestyle. a. Volunteering to help others, working for a nonprofit organization, and donating money or other resources to a food bank or other program are all ways to serve others and simultaneously enhance your own spiritual health.

Key Terms: contemplation, mindfulness, meditation, prayer, yoga, altruism See It! Video: Meditation Becoming More Popular Among Teens

Discussion Questions 1. What are the differences between spirituality and religion? Why is this distinction important?

2. What is environmental mindfulness? Do you think it is important for each individual to become environmentally mindful? Describe one change you could make to become more environmentally mindful.

3. What are the differences between the various forms of meditation, such as mantra meditation, breath meditation, color meditation, and candle meditation?

4. What evidence supports the statement that spirituality and religion are not the same thing?

5. What is the role of altruism in a spiritually healthy lifestyle?

Critical Thinking Questions 1. Do you consider yourself a spiritual person? A religious person? How can a person be both spiritual and religious? In what ways do spirituality and religion play out in your life?

2. Which of the three facets of spirituality—relationships, values, and purpose in life—have you explored in your life? What prompted you to explore this aspect of your spirituality?

3. Have you ever used contemplation, mindfulness, meditation, or prayer in a situation from your life that was stressful or emotionally difficult? How did it help you deal with the situation? What are the benefits of these techniques?

4. Which of the qualities of mindfulness illustrated in Figure 2 do you possess? What can you do to improve your qualities of mindfulness? Provide two strategies that you could use to improve qualities of mindfulness in your life.

5. Have you ever experienced a “helpers high” after volunteering? Why do you think altruism is a key component of spiritual health?

Student Activities Individual 1. Practice mindfulness while completing an everyday task or activity. Record your feelings and observations in a journal.

2. Use the Internet to explore one of the types of meditation discussed in the chapter.

Practice that type of meditation for two weeks to a month, and keep a journal about the way the meditation made you feel. Did you feel more relaxed? More peaceful? More focused? What were the tangible and intangible changes in your life?

3. Use the Internet to explore the many and varying yoga philosophies that are the foundation of the practices commonly offered in yoga studios and on campus. Describe how these spiritual philosophies contribute to yoga as a spiritual practice.

Community 1. What kind of spiritual and/or religious programs and/or services are offered on your campus? Do these campus services have any connections to similar services offered in the community? Have you ever taken advantage of these programs or services?

2. What types of yoga classes are available on your campus? Attend a yoga class to see if this form of spirituality is appropriate for you. Talk with the instructor and other class participants to find out the benefits they gain from yoga.

3. Find out what kind of spiritual retreat centers are offered in your community or in your area. What services—meditation, yoga, or other—are offered at the center? How do you register to attend the center?

Diverse Population/Nontraditional 1. Use the Internet to research aspects of spirituality in a different culture or country. How does that concept of spirituality compare to the concept in the United States?

2. Find books and sacred texts for a religion that interests you. Take the time to read these books and understand their approach to spiritual fulfillment.

Additional References B. Seaward, Managing Stress: Principles and Strategies for Health and Well Being, 7th ed.

(Sudbury, MA: Jones and Bartlett, 2012).

D. Zohar, “Learn the Qs,” 2010, http://danahzohar.com A. N. Bryant and H. S. Astin, “The Correlates of Spiritual Struggle during the College Years,” The Journal of Higher Education, 79, (2008): 1–27.

A. Chiesa and A. Serretti, “Mindfulness-based Stress Reduction for Stress Management in Healthy People: A Review and Meta-analysis,” The Journal of Alternative and Complementary Medicine, 15, (2009): 593–600.

E. Nagel and S. Sgoutas-Emch, “The Relationship between Spirituality, Health Beliefs, and Health Behaviors in College Students,” Journal of Religion and Health, 46, (2007): 141–154.

D. Oman, S. L. Shapiro, C. E. Thoresen, T. G. Plante, and T. Flinders, “Meditation Lowers Stress and Supports Forgiveness among College Students: A Randomized Controlled Trial,” Journal of American College Health, 56, (2008): 569–578.

S. L. Shapiro, D. Oman, C. E. Thoresen, T. G. Plante, and T. Flinders, “Cultivating Mindfulness: Effects on Well-being,” Journal of Clinical Psychology, 64, (2008): 840–862.

L. A. Taliaferro, B. A. Rienzo, R. M. Pigg, M. D. Miller, and V. J. Dodd, “Spiritual Well-being and Suicidal Ideation among College Students,” Journal of American College Health, 58, (2009): 83–90.

For Further Information Beliefnet www.beliefnet.com University of Maryland Medical Center Spirituality www.umm.edu/altmed/articles/spirituality-000360.htm University of California at Riverside Spiritual Wellness http://wellness.ucr.edu/spiritual_wellness.html UCLA Mindful Awareness Research Center http://marc.ucla.edu

Additional Media Mindfulness, Stress Reduction and Healing, 1 hour and 14 minutes A Google TechTalks presentation by Jon Kabat-Zinn, from the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. www.youtube.com/watch?v=rSU8ftmmhmw Yoga Meditation Exercises: Guided Meditation for Yoga Exercises, 3 minutes An ExpertVillage video in which Jennifer Kostel leads the viewer through guided meditation. www.youtube.com/watch?v=k_G4o0EaR58 Yoga Meditation Exercises: Using Mantras for Yoga Meditation, 2 minutes An ExpertVillage video in which Jennifer Kostel teaches the viewer about mantras. www.youtube.com/watch?v=JU2e5n1FeMU Yoga Meditation Exercises: Yoga Breathing for Meditation, 2 minutes An ExpertVillage video in which Jennifer Kostel leads the viewer through yoga breathing for meditation. www.youtube.com/watch?v=8ljVqV5IDTo

CHAPTER

3

Managing Stress and Coping with Life’s Challenges

Overview The powerful influence of stress in our lives and on our health is just becoming clear. The science of psychoneuroimmunology (PNI) is beginning to unravel the secrets of just how greatly stress affects our immune systems and, therefore, different disease processes.

Chapter 3 informs students about stress, what stress is, when stress is healthy, and when it is not. After reading Chapter 3, students will have techniques for positive stress management that can alter life toward greater health and happiness.

Learning Outcomes 1. Define stress, and examine its potential impact on health, relationships, and success in college and life.

2. Explain the phases of the general adaptation syndrome and the physiological changes that occur during them.

3. Examine the physical health risks that may occur with chronic stress.

4. Examine the intellectual and psychological health risks that may occur due to high levels of stress.

5. Discuss sources of stress and examine the unique stressors that affect young adults, particularly college students.

6. Explain key individual factors that may influence whether or not a person is able to cope with stressors.

7. Explore stress-management and stress reduction strategies, ways you can cope more effectively with stress, and ways you can enrich your life experiences to protect against the effects of stress.

Lecture Outline I.

What Is Stress?

1. Stress is the mental and physical response and adaptation by our bodies to real or perceived changes and challenges.

2. A stressor is a real or perceived physical, social, or psychological event or stimulus that causes our bodies to react or respond.

3. Several factors influence one’s response to stressors. a. Characteristics of the stressor b. Biological factors c. Past experiences 4. Stress may be tangible (a failing grade) or intangible (angst of meeting your significant other’s parents for the first time).

5. Distress, or negative stress, is caused by events that result in debilitative tension and strain.

6. Change can also be a major stressor.

7. Positive stress is called eustress and may present the opportunity for personal growth and satisfaction that can actually improve health.

8. There are several types of distress: a. Acute stress, the most common type of stress, comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. b. Episodic acute stress is described as the state of reacting with wild, acute stress about one thing or another. c. Chronic stress may not appear as intense but can linger indefinitely and wreak havoc on your body systems. d. Traumatic stress is often the result of witnessing or experiencing events like major accidents, war, shootings, sexual violence, assault, or natural disasters.

Key Terms: stress, stressor, distress, eustress, acute stress, episodic acute stress, chronic stress, traumatic stress

II.

Your Body’s Stress Response A. The General Adaptation Syndrome 1. A body in homeostasis (balance) operates smoothly and maintains equilibrium.

2. An adaptive response is the body’s attempt to restore homeostasis following a trigger.

3. The general adaptive syndrome (GAS) has three phases: Alarm, resistance, and exhaustion.

4. Alarm Phase a. When the body is exposed to a real or perceived stressor, the fight-or-flight response kicks in and triggers an autonomic nervous system (ANS) response. b. The ANS is made up of two branches: sympathetic and parasympathetic. c. The hypothalamus is a structure in the brain that functions as a control center of the sympathetic nervous system and determines the overall reaction to stressors. d. Epinephrine causes more blood to be pumped with each heartbeat, dilates airways in the lungs, increases breathing rate, stimulates the liver to release glucose, and dilates pupils. e. Cortisol is a hormone that makes stored nutrients more readily available to meet energy demands. f. Other parts of the brain and body release endorphins, which can relieve the pain and anxiety that a stressor may cause.

5. Resistance Phase a. The body tries to return to homeostasis, but because some perceived stressor still exists, the body does not achieve complete calm or rest.

6. Exhaustion Phase

a. A prolonged response leads to allostatic load, or exhaustive wear and tear on the body; the physical and emotional energy used to fight a stressor has been depleted. b. Over time, cortisol can reduce immunocompetence, or the ability of the immune system to respond to attack.

B. Do Men and Women Respond Differently to Stress?

1. Research indicates that men and women may actually respond differently to stress. a. Men may be prone to fighting or fleeing. b. Women are more likely to “tend and befriend.”

Key Terms: homeostasis, adaptive response, general adaptation syndrome (GAS), fight-or-flight response, autonomic nervous system (ANS), sympathetic nervous system, parasympathetic nervous system, hypothalamus, epinephrine, cortisol, allostatic load, immunocompetence Figures: Figure 3.1 The General Adaptation Syndrome (GAS) Figure 3.2 Fight-or-Flight: The Body’s Acute Stress Response

III. Physical Effects of Stress A. Stress is often described as a “disease of prolonged arousal” that leads to a cascade of negative health effects.

B. Stress and Cardiovascular Disease 1. Research shows a correlation between chronic stress and an impact on heart rate, blood pressure, atherosclerosis, and other cardiovascular diseases.

2. The increased risk of CVD from chronic stress has been linked with arterial plaque buildup due to elevated cholesterol, hardening of the arteries, increases in inflammatory responses in the body, alterations in heart rhythm, increased and fluctuating blood pressure, and other CVD risks.

C. Stress and Weight Gain 1. Higher stress levels may drive us toward food because they may increase cortisol levels in the bloodstream. a. Cortisol seems to play a role in increased belly fat and increased eating behaviors.

D. Stress and Hair Loss: A Little Known Fact 1. Too much stress can lead to thinning hair, and even baldness, in men and women.

E. Stress and Diabetes 1. Controlling stress levels for preventing type II diabetes, as well as for successful shortand long-term diabetes management. a. See Focus On: Minimizing Your Risk for Diabetes F. Stress and Digestive Problems 1. Stress can be a trigger that causes nausea, vomiting, stomach cramps, and gut pain.

G. Stress and Impaired Immunity 1. Psychoneuroimmunology (PNI) analyzes the intricate relationship between the mind’s response to stress and the ability of the immune system to function effectively.

Key Term: psychoneuroimmunology (PNI)

Figure: Figure 3.3 Common Physical Symptoms of Stress See It! Video: Stress Can Damage Women’s Health

IV.

Stress and Your Mental Health A. Intellectual Effects of Stress 1. Research indicates that more than 50 percent of college students felt overwhelmed with all that they had to do within the past two weeks.

2. Stress can play a huge role in whether students complete school, get good grades, and succeed on their career paths.

3. Stress, Memory, and Concentration a. Animal studies provide compelling indicators of how stress hormones released from the adrenal cortex are believed to affect cognitive function and overall mental health. b. Recent laboratory studies with rats have linked prolonged exposure to cortisol to actual shrinking of the hippocampus, the brain’s major memory center.

B. Psychological Effects of Stress 1. Stress may be one of the single greatest contributors to mental disability and emotional dysfunction in industrialized nations.

2. Studies have shown that rates of mental disorders are associated with various environmental stressors.

V.

What Causes Stress?

A. A 2014 survey found that concerns over money, work, family responsibilities, and health were the biggest reported causes of stress for Americans.

1. College students, in particular, face stressors that come from internal sources as well as external pressures to succeed in a competitive environment.

B. Psychosocial Stressors 1. Psychosocial stressors refer to the factors in our social and physical environments that cause us to experience stress.

2. Adjustment to Change a. Any change to your routine can result in stress.

3. Hassles: Little Things That Bug You a. Cumulative hassles tax the physiological systems of the body and cause stressrelated wear and tear on the body. b. See the Tech & Health box for more on technostress.

C. The Toll of Relationships 1. Relationships can trigger some of the biggest fight-or-flight reactions.

D. Academic and Financial Pressure 1. Difficulties managing ever-increasing tuition, housing, and general expenses of college life are very stressful for students.

E. Frustrations and Conflicts 1. Conflict occurs when we are forced to decide among competing motives, impulses, desires, and behaviors or when we are forced to face pressures or demands that are incompatible with our own values and sense of importance.

F. Overload

1. Overload occurs when we are overextended and there are not enough hours in the day to do what we must get done.

G. Stressful Environments 1. For many college students, where they live and the environment around them cause significant levels of stress.

2. Background distressors in the environment, such as noise, air, and water pollution and environmental tobacco smoke, can contribute to stress.

H. Bias and Discrimination 1. Students come to campus from vastly different backgrounds and with very different life experiences. Often those perceived as dissimilar may become victims of subtle or not so subtle forms of bigotry, insensitivity, harassment, or hostility, or they may simply be ignored.

2. See the Health in a Diverse World box for more on stress and international students.

Key Terms: overload, burnout, background distressors Figure: Figure 3.4 What Do We Say Stresses Us?

VI.

Individual Factors that Affect Your Stress Response A. Appraisal 1. Appraisal is defined as the interpretation and evaluation of information provided to the brain by the senses.

B. Self-Esteem and Self-Efficacy 1. Self-esteem refers to your sense of self-worth; how you judge yourself in comparison to others. a. High stress and low self-esteem can significantly predict suicide ideation in you adults. b. You can improve your ability to cope with stress by increasing your self-esteem. c. Narcissism can be a dark side of self-esteem.

2. Self-efficacy refers to confidence in one’s skills and ability to cope with life’s challenges. a. Self-efficacy is critical to overcoming academic pressure and worries.

C. Type A and Type B Personalities 1. Personality can have an impact on whether you are happy and socially well-adjusted or sad and socially isolated.

2. Type A personalities are defined as hard-driving, competitive, time-driven perfectionists.

3. Type B personalities are described as relaxed, noncompetitive, and more tolerant of others.

4. Most researchers recognize that none of us are wholly Type A or Type B. 5. Not all Type A people experience negative health effects, but often those who are hostile are at increased risk for heart disease. a. Characteristics of hostility include disproportionate amounts of anger, distrust of others, and a cynical, glass-half-empty approach to life.

D. Type C and Type D Personalities

1. Type C personality is described as stoic, with a tendency to stuff feelings down and conform to the wishes of others. a. May be more susceptible to diseases like asthma, multiple sclerosis, autoimmune disorders, and cancer.

2. Type D personality is characterized by a tendency toward excessive negative worry, irritability, gloom, and inability to express these feelings due to social inhibition. a. May be up to eight times more likely to die of a heart attack or sudden death.

E. Psychological Hardiness 1. Psychological hardiness may negate self-imposed stress associated with Type A behavior.

2. Psychologically hardy people are characterized by: a. Control: ability to accept responsibility for their behaviors and work to change situation they discover to be debilitating. b. Commitment: have healthy self-esteem and know their purpose in life. c. Embrace challenge: see change as a stimulating opportunity for personal growth.

F. Psychological Resilience 1. Psychological resilience is a person’s capacity to maintain or regain psychological well-being in the face of adversity, trauma, tragedy, threats, or significant sources of stress.

G. Shift and Persist 1. New research proposes that in the midst of extreme, persistent adversity, youth are able to reframe appraisals of current stressors more positively (shifting), while persisting in focusing on the future.

Key Terms: appraisal, suicidal ideation, hostility, psychological hardiness, psychological resilience, shift and persist

VII. Managing Stress in College A. College students thrive under a certain amount of stress, but excessive stress can overwhelm many.

B. You can’t eliminate all life stressors, but you can train yourself to recognize the events that cause stress and to anticipate your reactions to them.

C. Coping is the act of managing events or conditions to lessen the physical or psychological effects of excess stress.

D. Practicing Mental Work to Reduce Stress 1. Stress management requires getting a handle on what is going on in your life, taking a careful look at yourself, and developing a plan of action.

2. Assessing Your Stressors and Solve Problems a. Start a journal; track your worries and factors that trigger stress every day for 1 week. b. Examine the causes. c. Consider the consequences of doing nothing versus taking action. d. List your options, including ones that you may not like very much. e. Outline an action plan, then act. f. After you act, evaluate.

g. One useful way of coping with your stressors, once you have identified them, is to consciously anticipate and prepare for specific stressors, a technique known as stress inoculation.

3. Change the Way You Think and Talk to Yourself a. Several types of negative self-talk exist: pessimism, perfectionism, “should-ing,” blaming, and dichotomous thinking. b. To combat negative self-talk, we must become aware of it, stop it, and finally replace negative thoughts with positive ones—a process called cognitive restructuring. c. See the Skills for Behavior Change box for other suggestions to rethink your thinking habits.

E. Developing a Support Network 1. While developing a stress management program, do not underestimate the importance of social networks and social bonds. a. Studies of college students have demonstrated the importance of social support in buffering individuals from the effects of stress.

2. You must invest time and energy into developing a healthy social support network. a. Spend more time in face-to-face interactions.

F. Cultivating Your Spiritual Side 1. One of the most important factors in reducing stress in your life is taking the time and making the commitment to cultivate your spiritual side: finding your purpose in life and living your days more fully.

2. See Focus On: Cultivating Your Spiritual Health.

G. Managing Emotional Responses 1. Stress management requires that you examine your emotional responses to interactions with others.

2. Fight the anger urge. a. Identify your anger style. b. Learn to recognize patterns in your anger responses and how to de-escalate them. c. Find the right words to de-escalate conflict. d. Plan ahead. e. Vent to your friends. f. Develop realistic expectations of yourself and others. g. Turn complaints into requests. h. Leave past anger in the past.

3. Learn to laugh, be joyful, and cry. a. For ideas on how to find more joy and laughter in your daily life, see the Health Headlines box.

H. Taking Physical Action 1. Get Enough Exercise a. Exercise can “burn off” stress hormones by directing them toward their intended metabolic function.

2. Get Enough Sleep a. Adequate amounts of sleep allow you to refresh your vital energy, cope with multiple stressors more effectively, and be productive when you need to be. See Focus On: Improving Your Sleep for more in-depth discussion of the benefits of sleep.

3. Eat Healthfully a. Eating a balanced, healthy diet will help provide the stamina you need to get through problems and will stress-proof you in ways that are not fully understood. b. It is important to avoid sympathomimetics, or substances in foods that mimic stresslike responses, such as caffeine.

I. Managing Your Time 1. Managing your time is an essential aspect of stress management.

2. Procrastination is defined as a voluntary delay doing some task despite expecting to be worse off for the delay.

3. Setting clear “implementation intentions,” a series of goals to accomplish toward a specific end, is key. a. Have a plan that has specific deadlines to help keep you on track. b. Get started early and set an end date that is well ahead of the deadline.

4. Time management tips include: taking on only one thing at a time; cleaning off your desk; prioritizing your tasks; finding a clean, comfortable place to work; avoiding interruptions; rewarding yourself for work completed; working when you’re at your best; breaking overwhelming tasks into smaller pieces and allocating time to each; and remembering that time is precious. a. See the Skills for Behavior Change box on suggestions for saying no to people and projects that “steal” your time.

J. Consider Downshifting 1. Downshifting involves a fundamental alteration in values and honest introspection about what is important in life.

2. It is important to move slowly and have a plan when contemplating any form of downshifting.

K. Relaxation Techniques for Stress Management 1. Yoga a. Yoga is an ancient tradition that combines meditation, stretching, and breathing exercises designed to relax, refresh, and rejuvenate (See Focus on: Cultivating Your Spiritual Health for additional information on yoga).

2. Qigong and Tai Chi a. Qigong is an ancient Chinese practice that involves becoming aware of and learning to control vital energy (qi) in your body. b. “Meditation in motion,” tai chi is another Chinese form of movement that provides stress reduction, greater balance, and increased flexibility.

3. Diaphragmatic or Deep Breathing a. This technique fills the lungs to maximum capacity.

4. Meditation a. Mediation generally involves sitting quietly, focusing on your thoughts, blocking out the “noise,” controlling breathing, and ultimately relaxing.

5. Visualization a. Visualization involves using your imagination to create mental scenes. Recalling physical sensations of sight, sound, smell, taste, and touch can replace stressful stimuli with peaceful or pleasurable thoughts.

6. Progressive Muscle Relaxation

a. Progressive muscle relaxation involves systematically contracting and relaxing the different muscle groups in your body.

7. Massage Therapy a. Massage therapy helps relax muscles, initiating the relaxation response.

8. Biofeedback a. Biofeedback is a technique in which a person learns to use the mind to consciously control bodily functions, such as heart rate, body temperature, and breathing rate.

Key Terms: coping, stress inoculation, cognitive restructuring, sympathomimetics, procrastinate, downshifting, meditation, visualization, biofeedback

Figures: Figure 3.5 Diaphragmatic Breathing Figure 3.6 Progressive Muscle Relaxation

Discussion Questions 1. What major life events over the past year have been very stressful to you? How did you choose to cope with each situation? Pick one of the coping techniques discussed in the chapter. How would your coping have differed with this new technique?

2. Can you think of a situation where your perception of the event was quite different from the perception of one of your friends? Did your perception of the event lead to more or less stress in your life? How might you have perceived things differently?

3. Describe the daily hassles in your life that are stressful to you. Do you find these situations more stressful than major life events that you have dealt with? Considering the techniques discussed in this chapter, how might you minimize the daily hassles in your life?

4. Jack is taking too many classes, working part time, and playing intramural sports. He is starting to have interpersonal problems and his grades are starting to drop. What could Jack do to reduce his stress levels?

5. Why is college life so stressful? What preventive measures can college students take in order to reduce the chances of overload? How could students and professors work together to reduce the changes of overload?

6. Describe situations that involve conflict for college students. What can be done to resolve these conflicts?

7. Give an example of a situation where imagined stressors can invoke the stress response.

8. Have you ever tried any of the stress management techniques listed in the text? Which ones do you think work the best for you?

Critical Thinking Questions 1. Discrimination can be subtle or overt. What kinds of subtle and overt discrimination have you observed that might be stressful to people of minority groups in your community? What can you do to reduce the discrimination and, as a result, reduce the stress levels for individuals within that group?

2. How does technostress affect you on a daily basis? How much time each day are you electronically “connected” to devices such as a cell phone, smartphone, computer, or PDA? How does this amount of time compare to the amount of time you spend each day in face-to-face interactions with other individuals? Do you turn these devices off or at least not use them when you are in a social situation?

3. Think about a time of high stress in your life. What change caused the stress? Was the change good or bad? What behaviors did you adopt to reduce the stress? How did these behaviors influence your overall health?

4. Do you think you suffer from overload? What are three behaviors you can adopt to minimize the feeling of being overwhelmed?

5. What mental skills do you have to deal with stress as it occurs? How often do you put them to work to diminish feelings of stress?

6. Are you guilty of negative self-talk? What steps can you take to reduce negative self-talk and make it more positive?

7. Are you a procrastinator or a good time manager? What steps can you take to improve your time management skills?

8. What type of personality do you think you are: A, B, C, or D? What characteristics do you exhibit that fit that personality type?

Student Activities Individual 1. Make a list of the primary stressors in your life. Give the list to a friend or significant other. Discuss the list, and ask your friend or significant other if he or she shares the same stressors. When you both realize your main sources of stress, make a stress management plan together. Social support in stress management can foster success.

2. Use the Internet to search for a stress management website that provides recommendations for ways to relax and bring calm to your life. Identify from this site five ways you can effectively reduce stress in your life.

3. Keep a daily journal of factors in your life that cause stress. At the end of a week, analyze your entries and identify the primary triggers that cause stress. Develop a stress management plan to avoid these triggers.

4. Attend a campus event for stress management.

Community 1. Identify at least three resources in the community that can help people with high stress levels. Resources can include counseling services, child-care services, massage therapists, or educational classes.

2. What resources that help with stress or time management are available on your campus?

What kinds of services are offered? How does one go about taking advantage of the services offered?

Diverse Population/Nontraditional 1. Do people in other cultures experience the same stressors as those in the United States?

In your local community? How do people in other cultures manage their stress? What kinds of activities do they participate in to reduce stress? How does this relate to on-campus groups for minority students?

2. What different kinds of stressors do nontraditional college groups, such as mothers returning to college and adults who have lost their jobs, experience as students? What resources are available to help these individuals reduce their stress levels?

Additional References American Psychological Association, “Stress in America: Our Health at Risk,” Monitor on Psychology 43, no. 3 (2012): 18, www.apa.org E. Chiauzzi, J. Brevard, C. Thurn, S. Decembrele, and S. Lord, “MyStudentBody-Stress: An Online Stress Management Intervention for College Students,” Journal of Health Communication: International Perspectives, 13, (2008): 555–572.

M. R. Clark, “Negotiating the Freshman Year: Challenges and Strategies among First-year College Students,” Journal of College Student Development, 46, (2005): 296–316.

T. J. Connor, “Don’t Stress Out Your Immune System—Just Relax, Brain,” Behavior, and Immunity, 22, (2008): 1128–1129.

L. Dusselier, B. Dunn, Y. Wang, M. C. Shelley II, and D. F. Whalen, “Personal, Health, Academic, and Environmental Predictors of Stress for Residence Hall Students,” Journal of American College Health, 54, (2005): 15–24.

J. K. Giancola, M. J. Grawitch, and D. Borchert, “Dealing with the Stress of College: A Model for Adult Students,” Adult Education Quarterly, 59, (2009): 246–263.

K. Renk and T. Smith, “Predictors of Academic-related Stress in College Students: An Examination of Coping, Social Support, Parenting, and Anxiety,” Journal of Student Affairs Research and Practice, 44, (2007): 405–431.

M. Steinhardt and C. Dolbier, “Evaluation of a Resilience Intervention to Enhance Coping Strategies and Protective Factors and Decrease Symptomology,” Journal of American College Health, 56, (2008): 445–453.

For Further Information American Mental Health Counselors Association www.amhca.org American Psychiatric Association Patients & Families www.healthyminds.org American Psychological Association www.apa.org Association for Applied Psychophysiology and Biofeedback www.aapb.org Benson-Henry Institute for Mind Body Medicine www.massgeneral.org/bhi Mayo Clinic Biofeedback www.mayoclinic.com/health/biofeedback/MY01072

National Mental Health Information Center Substance Abuse and Mental Health Services Administration http://store.samhsa.gov/home

Additional Media Dahn Yoga: ABC News, 7 minutes Dr. Sung Lee is interviewed in this ABC news clip and discusses the proven ability of Dahn Yoga to reduce stress. Dr. Lee also provides four techniques. www.youtube.com/watch?v=3kYyeijZKA8&NR=1 Health Benefits of Tai Chi, 2 minutes MSNBC program, “The Mind-Body Connection,” focuses on the research of the health effects of Tai Chi. www.youtube.com/watch?v=_cTlHy7D4uw Health Matters: Stress Management, 29 minutes A UCTelevision production in which doctors David Granet and Steven Hickman of UCSD School of Medicine discuss the mind–body connection. www.youtube.com/watch?v=lT17Jr1EEJQ&feature=related Progressive Muscle Relaxation, 10 minutes Inner Health Studio production in which a script is used to guide a progressive muscle relaxation exercise. www.youtube.com/watch?v=HFwCKKa--18 Stress Relief Yoga: Yoga Breathing Techniques, 2 minutes This video, produced by Expert Village, has expert Elizabeth Cafferky teaching a breathing exercise designed to relieve stress. www.youtube.com/watch?v=W41V8w00E6o

CHAPTER

3A

Focus On: Improving Your Sleep

Overview Sleep—we never seem to get enough, and we always need and want more. In this section you learn about sleep and why our bodies need sleep to maintain both our physical and psychosocial health. This section will explain what happens when we sleep and describes the differences between REM and non-REM sleep. This chapter also describes how much sleep a person really needs for optimal health and daily performance and provides strategies on how to get the sleep you need to stay healthy.

Learning Outcomes 1. Describe the problem of sleep deprivation in the United States.

2. Explain why we need sleep and what happens if we don’t get enough, including potential physical, emotional, social, and safety threats to health.

3. Explain the processes of sleep, including circadian rhythms, non-REM (NREM) sleep, REM sleep, and sleep needs.

4. Explore what you can do to make sure you get enough sleep.

7. Describe the common sleep disorders insomnia, sleep apnea, restless legs syndrome, and narcolepsy, and what can be done to prevent or treat them.

Lecture Outline I. Sleepless in America 1. According to a recent survey, only 11.9 percent of students reported getting a sufficient amount of sleep. a. Nearly 62% said they often go to bed late and get up early, resulting in sleep deprivation—a condition that occurs when sleep is insufficient for a given age.

2. Lack of sleep leads to somnolence—drowsiness, sluggishness, and lack of mental alertness that can affect daily performance. a. Sleep deficiencies have been linked to a host of problems, including poor academic performance, weight gain, increased alcohol abuse, accidents, daytime drowsiness, relationship issues, depression, and other problems.

3. People likely to fall asleep unintentionally during the day are suffering from a condition known as excessive daytime sleepiness.

A. Why So Sleep Deprived?

1. Several factors can lead to sleep deprivation:

a. Shift work b. Long haul driving c. Drugs and medications d. Sleep habits e. Gender f. Sleep disorders B. Wired and Tired 1. Technology has invaded the bedrooms of millions. See Skills for Behavior Change box for safeguarding your sleep against blue lights.

Key Terms: somnolence, excessive daytime sleepiness or excessive sleepiness, sleep deprivation Figure: Figure 1 International Sleep Statistics

II.

The Importance of Sleep A. Sleep serves at least two important biological purposes: it conserves body energy and it restores you both physically and mentally.

B. Sleep and Health 1. Sleep has beneficial effects on most body systems.

2. The physical benefits of sleep include the following: a. Sleep helps maintain your immune system. b. Sleep helps reduce your risk for cardiovascular disease. c. Sleep contributes to a healthy metabolism and body weight. d. Sleep contributes to neurological functioning. e. Sleep improves motor tasks, particularly driving. f. Sleep plays a role in stress management and mental health.

See It! Videos: How Sleep Affects Your Memory

III.

The Processes of Sleep A. Your normal circadian rhythm is the 24-hour cycle by which you are accustomed to going to sleep, waking up, and performing daily tasks.

1. The hypothalamus and a tiny gland in your brain called the pineal body—which is responsible for the drowsiness-inducing hormone called melatonin—are key to these cyclical rhythms.

B. There are two primary sleep states: 1. REM sleep: a state in which rapid eye movement and dreams occur, and brain-wave activity appears similar to that which occurs when you are awake.

2. Non-REM (NREM) sleep: is a period of restful sleep with slow brain activity that is not characterized by rapid eye movement.

3. Throughout the night, you alternate through periods of of NREM and REM sleep, repeating one full cycle about once every 90 minutes. a. You spend about 75 percent of each night in NREM sleep and 25 percent in REM sleep.

C. Non-REM Sleep 1. The body rests during NREM sleep. Body temperature is reduced and energy use drops; sensation is dulled; and heart rate, breathing, and brain waves slow down.

2. You do not typically dream during NREM sleep.

3. Four characteristic stages occur during NREM sleep. a. Stage 1: The lightest stage of sleep that lasts only a few minutes. b. Stage 2: Eyes are closed, body movement slows, and you disengage from your environment. c. Stage 3 and 4: Your brain generates slow delta waves and blood pressure, heart rate, and respiration slow. Human growth hormone is released, signaling the body to repair worn tissues.

D. REM Sleep 1. Dreaming takes place primarily during REM sleep.

2. The brain waves of a person during REM sleep are almost undistinguishable from someone who is wide awake.

3. Deep phases of slow-wave sleep consolidate the day’s information, while REM sleep stabilizes consolidated memory.

E. Your Sleep Needs 1. Researchers find most people need between 7 and 8 hours of sleep per day.

2. Individual variations occur depending on age, gender, and other factors.

F. Sleep Debt 1. Sleep debt is the total number of hours of missed sleep you’re carrying around with you.

G. Napping 1. Naps cannot completely cancel sleep debt, but they can improve mood, alertness, and performance.

2. Regular naps may also improve immune function and help ward off infections.

3. It is best to nap early to mid-afternoon.

4. Never nap in the late afternoon, as it could interfere with your ability to fall asleep at night.

5. Keep naps short to avoid sleep inertia, characterized by cognitive impairment, grogginess, and disoriented feelings.

Key Terms: circadian rhythm, melatonin, REM sleep, non-REM (NREM) sleep, sleep debt, sleep inertia Figure: Figure 2 The Nightly Sleep Cycle

IV. Getting a Good Night’s Sleep A. The following tips can help you get a more restful night’s sleep.

1. Let there be light—light is the best tool for reigning in your internal clock.

2. Stay active.

3. Sleep tight—use proper, comfortable bedding.

4. Create a sleep “cave”—keep your bedroom quiet, cool, and dark; turn off your computer and cell phone.

5. Condition yourself into better sleep—go to bed and wake at the same time each day.

Condition yourself into better sleep—establish a bedtime ritual; go to bed and get up at the same time each day.

6. Make your bedroom a mental escape—clear your mind of worries and frustrations.

7. Don’t get revved by emotional upheavals—stop all incoming messages 1 hour before bed.

8. Don’t toss and turn—if you are not asleep after 20 minutes, try reading something relaxing.

9. Avoid foods and drinks that keep you awake—large meals, nicotine, energy drinks, caffeine, and alcohol close to bedtime can affect your ability to get to sleep and stay asleep. Drinking liquids may contribute to nocturia, or overactive bladder, meaning you have to get up several times during the night.

10. Don’t take nonprescribed sleeping pills or nighttime pain medications—casual use of over-the-counter sleeping aids can interfere with your brain’s natural progression through the healthy stages of sleep.

V. Sleep Disorders A. As many as 70 million Americans suffer from sleep-related disorders.

B. During a sleep study, sensors and electrodes record data that will be reviewed by a sleep specialist to determine the precise nature of your sleep problem. See Figure 3 for an example of a sleep diary.

C. Insomnia 1. Difficulty in falling asleep quickly, frequent arousals during sleep, or early morning awakening.

2. Symptoms and Causes a. Symptoms of insomnia include difficulty falling asleep, waking up frequently during the night, difficulty returning to sleep, waking up too early in the morning, unrefreshing sleep, daytime sleepiness, and irritability. b. Insomnia can be related to stress and worry, to disruptions in the circadian rhythms, or as a side effect of certain medications.

3. Treatment for Insomnia a. Cognitive behavioral therapy is often a part of treatment for insomnia. b. In some cases, hypnotic or sedative medication may be prescribed. c. Relaxation strategies like yoga and meditation can be helpful. d. Exercise done early in the day can also reduce stress and promote deeper sleep.

D. Sleep Apnea 1. A disorder in which breathing is briefly and repeatedly interrupted during sleep; breathing pauses last at least 10 seconds.

2. Symptoms and Causes of Sleep Apnea a. Central sleep apnea occurs when the brain fails to tell the respiratory system to initiate breathing. b. Obstructive sleep apnea is more common and occurs when air cannot move in and out of a person’s nose or mouth. c. Risk factors include being overweight, smoking, alcohol use, being over 40, and ethnicity. Anatomical risk factors include a small upper airway, a recessed chin, small jaw or large overbite, and a large neck. Genetics may also play a role.

3. Treatment for Sleep Apnea

a. Most commonly prescribed treatment is continuous positive airway pressure (CPAP), which consists of an airflow device, long tube, and mask that is worn during sleep. b. Other methods include dental appliances and surgery to remove tissue in the upper airway. c. Lifestyle changes like losing weight, avoiding alcohol, and quitting smoking are also ways to reduce symptoms.

E. Restless Legs Syndrome 1. RLS is a neurological disorder characterized by unpleasant sensations in the legs when at rest combined with an uncontrollable urge to move in an effort to relieve these feelings.

2. Symptoms and Causes of RLS a. Restless legs syndrome sensations are often described as burning, creeping, or tugging, or like insects crawling inside the legs. b. A family history is seen in approximately 50 percent of the cases. RLS also appears to be related to other conditions, including Parkinson’s disease, kidney failure, diabetes, peripheral neuropathy, and anemia.

3. Treatment of RLS a. Treatment options include use of prescribed medications, decreasing tobacco and alcohol use, and applying heat to the legs. For some, practicing relaxation techniques or performing stretching exercises can help alleviate symptoms.

F. Narcolepsy 1. Narcolepsy is a neurological disorder caused by the brain’s inability to properly regulate sleep-wake cycles resulting in excessive, intrusive sleepiness and daytime sleep attacks.

2. Symptoms and Causes of Narcolepsy a. Characterized by overwhelming and uncontrollable sleepiness during the day. b. Sleep attacks can last from a few seconds to a few minutes. c. Other symptoms include: cataplexy (sudden loss of voluntary muscle tone); hallucinations during sleep or upon waking; brief episodes of paralysis during sleep-wake transitions. d. Appears to be caused by a deficiency of sleep-regulating chemicals in the brain.

Key Terms: sleep study, insomnia, sleep apnea, restless legs syndrome (RLS), narcolepsy Figure and Table: Figure 3 Sample Sleep Diary

Discussion Questions 1. Based on your reading of Chapter 3A, explain the reasons why this statement is true: “When you don’t get enough sleep, your academic performance deteriorates.”

2. Describe how you feel in the morning if you do not get enough sleep at night. Do you feel better or worse as the day goes on? What changes would you need to make in order to get 7 to 8 hours of sleep every night?

3. How does your brain restore itself during REM sleep?

4. What behaviors do you follow to get a good night’s sleep?

Critical Thinking Questions 1. Many people have jobs that require them to work at night and sleep during the day.

How do you think the circadian rhythms of these individuals are affected by their schedules? What strategies would you suggest to help them get enough sleep?

2. Do you think a person who sleepwalks is getting the proper rest his or her body needs?

Why or why not?

3. What have you done in the past to help you fall asleep when you have insomnia?

What behaviors described in the chapter will you try the next time you have difficulty falling asleep?

4. Have you ever fallen asleep during class? Describe three strategies and behaviors you can adopt to prevent falling asleep in class in the future.

5. How have your sleep patterns changed—for better or worse—since you have been at college? How do your current sleep patterns differ from those you had while living at home? What adjustments could you make to improve your sleep patterns?

Student Activities Individual 1. Conduct research on the Internet to find out how snoring affects sleep. Share your findings with your classmates.

2. Keep a sleep diary for 2 weeks. Calculate how much sleep you get each night and how much sleep debt you have. Create and follow a plan to help you reduce your sleep debt.

Community 1. Find out if your campus or community has a sleep clinic. What kinds of services does the clinic provide? Who in your community can take advantage of these services?

2. Investigate automobile crashes in your community attributed to the driver falling asleep at the wheel. Does this number surprise you? What does the community do to prevent such accidents? What other steps might be taken to reduce the number of accidents even further?

3. Work with your dorm, student health center, or another organization to develop an awareness-raising campaign concerning the important aspects of sleep and health.

Diverse Population/Nontraditional 1. Use the Internet to research the beds and bedding people use in different cultures. Are traditional designs for beds, pillows, and bedding still used? What materials are used in the traditional bedding? How do these materials and designs differ from modern bedding used in the United States?

2. Do people in other countries sleep as much or as little as people in the United States? Use the Internet to research sleep patterns of people in other cultures or countries.

Additional References American College Health Association, American College Health Association-National College Health Assessment II: Reference Group Data Report Fall 2012 (Hanover, MD: American College Health Association, 2013), www.acha-ncha.org D. Bailly, I. Bailly-Lambin, D. Querleu, R. Beuscart, and C. Collinet, “Sleep in Adolescents and Its Disorders: A Survey in Schools,” Encephale, 30, (2004): 352–359.

W. C. Buboltz, J. Loveland, S. M. Jenkins, F. Brown, B. Soper, and J. Hodges, “College Student Sleep: Relationship to Health and Academic Performance,” In College Students: Mental Health and Coping Strategies (pp. 1–29). M. V. Landow (Ed.). (New York: Nova Science Publishers, 2006).

D. R. Jensen, “Understanding Sleep Disorders in a College Student Population,” Journal of College Counseling, 6, (2003): 25–34.

W. E. Kelly, K. E. Kelly, and R. C. Clanton, “The Relationship between Sleep Length and Grade-point Average among College Students,” College Student Journal, 35, (2001): 84–86.

For Further Information Discovery Health Sleep Hygiene Test http://cl1.psychtests.com/take_test.php?idRegTest=2985 Mayo Clinic Insomnia www.mayoclinic.com/health/insomnia/DS00187 Sleep Treatment Chronic Insomnia Assay https://sleeptreatment.com/index.php/assess-your-sleep/chronic-insomnia-assay Sleep Treatment Sleep Quality Index https://sleeptreatment.com/index.php?option=com_content&view=article&id=236:sleepquality-index&catid=931:assess-your-sleep&Itemid=1144

Additional Media Insomnia Consequences—Sleep, Sex, and Death (Health Guru Tip), 1 minute In this illumistream production, Mark Haltrecht, D.O., discusses the consequences of not meeting your daily sleep requirement. www.youtube.com/watch?v=P0mPWzLfLdU&feature=related

Sleep Disorders Decoded (Sex Health Guru Health Tip), 1 minute In this illumistream production, Mark Haltrecht, D.O., demystifies sleep disorders, such as insomnia, and provides tips on what to do if you think you have a sleep disorder. www.youtube.com/watch?v=sO4hOQGh0zo&feature=related Understanding Sleep (Insomnia #1), 3 minutes In this illumistream health production, Mark Haltrecht, D.O., discusses the stages of sleep, the purpose of each stage, and common sleep disorders. www.youtube.com/watch?v=H9XtWxjkw2o What’s Keeping You Awake? (Insomnia #2), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses acute and chronic insomnia, circadian rhythm disorders, snoring, and sleep apnea. www.youtube.com/watch?v=0CKHA9iAwCQ&feature=channel Treating Sleep Disorders (Insomnia #4), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses behavioral and medical interventions used to treat sleep disorders. www.youtube.com/watch?v=xFUrw7g6Dw4&feature=channel Preventing Sleepless Nights (Insomnia #5), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses sleep hygiene tips for preventing sleepless nights. www.youtube.com/watch?v=B9QWtAJwENM&feature=related

INSTRUCTOR RESOURCE AND SUPPORT MANUAL

Health: The Basics TWELFTH EDITION

Rebecca J. Donatelle

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