CHAPTER 1 Health Psychology- field devoted to understanding psychological influences on how people stay healthy, why they become

ill, and how they respond to illness as well as developing interventions to help people stay well or get over illness Health- a complete state of physical, mental, and social well-being Wellness- optimal balance of physical, mental, and social well-being Focused on health promotion and maintenance, prevention of illness, etiology and correlates of health, illness and dysfunction and improvements to the health care system and the formulation of health policy Etiology- origins or causes of illness espesicially behavioral and social factors that contribute to health, illness and dysfunction Conversion Hysteria- specific unconscious conflicts can produce particular physical disturbances that symbolize repressed psychological conflicts through the voluntary nervous system (loss of senses, tremors, paralysis, and eating disorders) Psychosomatic Medicine- conflicts produce anxiety which becomes unconscious and takes a physiological toll on the body via the automatic nervous system producing an actual organic disturbance (ulcers, hyperthyroidism, arthritis, hypertension, colitis, and asthma) Conflict or personality type is insufficient to produce illness but also requires genetic, environmental, and behavioral contributions Biomedical Model- illness explained on the basis of aberrant somatic bodily processes, such as biochemical imbalances or neurophysiological abnormalities with psychological and social factors being minimally relevant Limitations include that it is reductionistic single-factor model that reduces illness to low-level biological processes, implicitly assumes a mind-body dualism, and emphasizes illness over health Materialism- assumes that all is physical including diseases which is biological deviation from norm and that treatment is a physical agent to correct deviation Limited by its passivity, other possible causal influences, variability, and alternative treatments Reductionism- assumes all functions are reducible to parts with single-factor biological causes Limited by multiple causal pathways Biopsychosocial Model- health and illness are consequences of the interplay of biological, psychological and social factors Assumes that mind and body cannot be distinguished in matters of health and illness and emphasizes health as well as illness Systems Theory- all levels of organization are linked to each other hierarchically and that change in any one level will effect change in all other levels

Process of diagnosis should always consider the interacting role of biological, psychological, and social factors in assessing an individuals health or illness so that an interdisciplinary team approach may be the best way to make a diagnosis Recommendations for treatment must involve all factors and tailor treatment uniquely to each individual An effective patient-practitioner relationship improves the patients use of services, the efficacy of treatment, and the rapidity with which illness is resolved Acute Disorders- short-term illnesses that often result from a virus or bacterium and are amenable to cure (tuberculosis, pneumonia, etc) Dominant cause of illness and death until 20th century Chronic Disorders- slowly developing diseases with which people live for many years and that typically cannot be cured but only managed (heart disease, cancer, diabetes) Chronic disorders helped the form health psychology because psychological and social factors are implicated as causes as well as causing psychological and social ills Epidemiology- study of the frequency, distribution, and causes of infectious and noninfectious diseases in a population Morbidity- number of cases of a disease that exist at some given point in time Morbidity may be expressed as the number of new cases (incidence) or as the total number of existing cases (prevalence) Mortality- number of deaths due to particular causes Health psychologists emphasize prevention to reduce the cost of healthcare and design more user-friendly healthcare systems CHAPTER 3 Health Promotion- good health is a personal and collective achievement that involves developing a program of good health habits early in life and carrying them through ones life as well as helping those at risk offset or monitor their risks The media can promote information and the government can mandate legislation Impetus for health promotion is due to limitations of the biomedical model, rising health care costs, consumer advocacy, and the demonstrated importance of health behaviors Nearly half the deaths in the United States are caused by preventable factors (heart disease, cancer, stroke, accidental injuries, and chronic lung disease) Obesity is expected to overtake tobacco as the most preventable cause of death in the United States Health Behaviors- behaviors undertaken by people to enhance or maintain their health Health Habit- health-related behavior that is firmly established and often performed automatically, without awareness and usually develop by age 11 or 12 Initially developed through positive reinforcement but eventually maintained independently

Alameda County Health Habits- sleeping 7 to 8 hours, not smoking, eating breakfast every day, having no more than one or two alcoholic drinks, getting regular exercise, not eating between meals, being no more than 10% overweight Such habits reduce illnesses, increase well-being, and greatly reduce mortality (28% male mortality and 43% female mortality) Primary Prevention- taking measures to combat risk factors before they develop into a condition Installing good health habits is a form of primary prevention by either preventing poor health habits or instilling good ones Young, affluent, better-educated people with low stress and high social support for better health habits and cultural or personal values are also a contributing factor Health habits are formed in childhood, decline in adolescence and return in adulthood Perceptions that ones health is under personal control also determines health habits Health Locus of Control- measures degree to which people perceive themselves to be in control of their health, perceive powerful others to be in control of their health, or regard chance as the major determinant of their health Social support and access to health care delivery system influence the practice of health behavior Barriers to health promotion include healthcare (underemphasized prevention, little training, changing guidelines, little insurance reimbursement), individual (gradient of reinforcement through immediate gratification, unrealistic optimism, fatalism) People often have little immediate incentive for practicing good health behavior while unhealthy behaviors are often pleasurable, automatic, addictive and resistant to change Health habits are only modestly related to each other and are unstable over time and controlled by different factors and the same health behavior may be influenced by different factors Health habits may change over time and the initial instigating factors may not longer be significant and factors controlling a health behavior may change across a persons lifetime Health habits are influenced by parents and teachers as well as peers as role models Teachable moment- certain times are better than others for teaching particular health practices Window of Vulnerability- certain times when individuals are more vulnerable to poor health habits People are unrealistically optimistic about their vulnerability to health risks and tend to view their poor health behavior as widely shared while their health behaviors are seen as unique Focusing on at risk populations can make them over cautious or it can make them defensive Complications of reporting risk are blame and psychological stress or depression Lack of exercise, alcohol consumption, lack of medication or income, self doubt and risk of depression are contributing factors in the poor health of adults African American and Hispanic women get less exercise than Anglo women Anglo and African American women are more likely to smoke than Hispanic women Alcohol consumption is greater in men than women

Communications should be colorful and vivid rather than steeped in statistics and jargon The communicator should be expert, prestigious, trustworthy, likeable, and similar to the audience Strong arguments should be presented at the beginning and end of a message, not the middle Message should be short, clear and direct Messages should state conclusions explicitly Extreme messages produce more attitude change but only if paired with recommendations For illness detection behavior, emphasizing the problems that may occur is most effective while for health promotion behavior, emphasizing the benefits to be gained is most effective If the audience is receptive to changing a health habit then the communication should include only favorable points but if the audience is not favorable then both sides should be discussed Interventions should be sensitive to the cultural norms of the community to which they are directed Fear Appeal- make people fearful that a particular habit is harmful so that they will change behavior Too much fear will undermine health behavior change or may not result in long-lasting change unless coupled with recommendations for action and information about the efficacy of behavior Merely providing information does not ensure that people will perceive the information accurately because sometimes negative information is processed defensively and the problem may be seen as less serious or more common Messages that emphasize potential problems seem to work better for behaviors that have uncertain outcomes or for health behaviors that need to be practiced only once while messages that emphasize benefits seem to be more persuasive for behaviors with certain outcomes People who approach a message with the desire to maximize benefits do best with messages that emphasize benefits while people who avoid harm do better with messages that emphasize harm Promotion messages may be more successful in initiating behavior but avoidance messages may be more successful in maintaining behavior Health Belief Model- whether a person practices a particular health behavior depends upon whether the person perceives a personal health threat and whether the person believes that a particular health practice will be effective in reducing that threat Perception of circumstances is more important than the reality of them Perception of health threat is influenced by general health values, beliefs of personal vulnerability, and beliefs about the consequences of the disorder Perception that a health measure will reduce the threat depends on whether the individual thinks the health behavior will be effective and whether the benefits exceed its cost Leaves out emotional responses and beliefs that one will be able to engage in the health behavior Self-Efficacy- belief that one is able to control ones practice of a particular behavior Strong relationship between perceptions of self-efficacy and both initial health behavior change and long-term maintenance of change

Theory of Planned Behavior- health behavior is a direct result of a behavioral intention which are made up of attitudes towards the specific action, subjective norms regarding the action, subjective norms regarding the action and perceived behavioral control Attitudes towards the action are based on beliefs about the likely outcomes of the action and evaluations of the outcomes, subjective norms are what a person believes others think that person should do, and their motivation to comply with those norms, and perceived behavioral control is the perception that one is capable of performing the action and that the action undertaken will have the intended effect Having an intention to change health behavior can occasionally be sufficient to bring it about Self-Determination Theory- autonomous motivation and perceived competence are fundamental to behavior change and people are autonomously motivated if they experience free will and choice when acting so that behavior change is more likely when the change is personally important and tied to personal values People may perceive a health threat as less relevant, may falsely see them as less vulnerable, may see themselves as dissimilar to those at risk and may have a false sense of security when engaging in health threatening behavior Cognitive Behavior Therapy- Attempt to change the conditions that elicit and maintain health behavior and the factors that reinforce it Self-observation and self-monitoring define the dimensions of a problem, stimulus control enables a person to modify antecedents of behavior, self-reinforcement controls the consequences of behavior, and social skills training may be added to replace the maladaptive behavior one it has been brought under some degree of control The therapeutic plan can be tailored to each individuals problem and the range of skills imparted by multimodal interventions may enable people to modify several health habits simultaneously Self-Monitoring- person must understand the dimensions of the target behavior before change can begin, self-monitoring assesses the frequency of a target behavior and the antecedents and consequences of that behavior First step is to learn the discriminate the target behavior, second stage is charting the behavior Self-monitoring may at times be sufficient for behavior change but such changes are often shortlived

Classical Conditioning- the pairing of an unconditioned reflex with a new stimulus, produces a conditioned reflex Classical conditioning is effective, but patients are aware of this and thus can opt out of it Operant Conditioning- pairing of a voluntary behavior with systematic consequences When a behavior is paired with positive reinforcement that behavior is more likely to occur again Reinforcement schedule must be continuous or risk extinction People typically feel positively reinforced as they move towards their goal but the closer they get to the goal the greater positive reinforcement they require to maintain motivation

Modeling- learning that occurs by virtue of witnessing another person perform a behavior The perception of similarity is crucial to individuals engaging in modeling For individuals who are fearful it is more beneficial to perceive fearful but controlled models as they are easier to identify with Discriminative Stimulus- stimuli that elicit target behavior Stimulus-Control Interventions- ridding the environment of discriminative stimuli and created new beneficial discriminative stimulating environments Self-Control- individual acts as their own therapist and with guidance learns to control the antecedents and consequences of the target behavior to be modified Self-control is not an unlimited resource and using it to control one behavior may drain it for another Self-Reinforcement- systematically rewarding oneself to increase or decrease the occurrence of a target behavior Positive self-reinforcement introduces something which negative self-reinforcement removes something Positive self-punishment works better than negative self-punishment and even better if paired with positive self-reward Contingency Contracting- individual forms a contract with another person, detailing what rewards or punishments are contingent upon the performance of behavior Cognitive Restructuring- trains people to recognize and modify these internal monologues to promote health behavior change First trained to monitor monologues in stress-producing situations and then modify them, often with the assistance of modeling Motivational Interviewing- interviewer is non-judgmental and supportive with the goal of helping the client express whatever positive or negative thoughts he or she has Meditation- teaches people to focus on the present moment without becoming distracted or distressed or distracted by stress Relaxation Training- deep breathing and progressive muscle relaxation which decreases heart rate and blood pressure while increasing oxygenation to reduce anxiety Relapse Prevention Model (Merlatt/Gordon)- increase initial commitment, identify high risk situation, develop coping strategies, counter cognitive influence (abstinence violation effect), lifestyle rebalancing (family, school, work, community, environment) Relapse is a particular problem for addictive disorders Reasons for relapse include genetic factors, low social status, stress, absence of specific goals, withdrawal symptoms, conditioned associations between cues and physiological responses, low self-efficacy, lack of motivational goals, negative effect, or lapse in vigilance Abstinence Violation Effect- feeling of loss of control when a person violates self-imposed rules

Relapse often causes negative affect, helplessness, and apathy towards other changes but at times can paradoxically have the opposite effect Relapse prevention centers upon initial commitment, identifying high risk situations, developing coping strategies, countering cognitive influences, life style rebalancing, and abstinence Transtheoretical Model of Behavior Change- analyzes the stages and processes people go through in attempting to bring about a change in behavior and suggested treatment goals and interventions for each stage Precontemplation- occurs when a person has no intention of changing his or her behavior and is unaware of the problem though those around them may well be Treatment is sought out only by pressure from others and often revert to poor health habits Contemplation- occurs when people are aware that a problem exists and are thinking about it but have not yet made a commitment to take action Often remain in contemplation stage for years and weight both pros and cons of changing behavior Preparation- occurs when people intend to change their behavior but may not yet have begun to do so Action- occurs when people modify their behavior to overcome the problem and requires the commitment of time and energy as well as stopping the behavior and modifying the environment Maintenance- occurs when people work to prevent relapse and to consolidate the gains they have made Typically if person has consistently avoided poor health behavior for 6 months, they are in maintenance stage Particular interventions may be more valuable at one stage than another Information is valuable in the precontemplation stage, exploration of thoughts and emotions is valuable at the contemplation stage, commitments are valuable at the preparation stage, and selfreinforcement as well as stimulus control and coping skills are valuable at the action and maintenance stage Social Engineering- modifying the environment in ways that affect peoples ability to practice a particular health behavior Social engineering is often more successful than individualized programs Therapist- advantage of therapist is one-to-one individualized treatment while disadvantage is the limitation of focusing on one behavior at a time Family- family life is more routine and mutually influential and supportive and are advantageous for family-centered cultures such as Latino, Black, Asian or southern European Managed Care- provide education and programs designed to change health habits Self-Help Groups- brings people together with same habits and offers collective solutions with the benefit of role models Schools- intervention at a young age maintains health habits throughout life Workplace- can influence health habits through social engineering but is limited to jobs of higher prestige

Community- advantage of outreach to multitude of individuals and can build social support as well as modifying the environment but are controversial due to expenses and lack of maintenance over time This may be solved by partnering community based interventions with already existing organizations Mass Media- bring about modest attitude change but without long-term change but consistent messages could be more successful Many messages do not contain the necessary action recommendation, dont address multiple determinants of behavior, and are not tailored to the individual Internet- low cost access to health messages and augmentation for other interventions and increase a sense of personal autonomy and self-efficacy CHAPTER 4 Aerobic Exercise- sustained exercise that stimulates and strengthens the heart and lungs, improving oxygen use marked by high intensity, long duration, and requisite high endurance Iso-kinetic exercises may be satisfying and build muscle but have less effect on health because they build on short-term stores of glycogen rather than long-term energy conversion system Benefits include increased oxygen consumption, slow-wave sleep, HDL cholesterol, longevity, immune system function and decreased resting hear rate, blood pressure, energy use such as glutamine, risk of cancer, diabetes, CHD, obesity, menstrual cycle length, and negative mood as well as promoting growth of new neurons 75% inactive in 1961, only 24% currently innactive Over 60% of Americans do not achieve recommended levels of physical activity and about 40% do not engage in any leisure-time physical activity Inactivity is higher in women than men, Blacks and Hispanics and Whites, older than younger, and lower income than higher income 77% of men and 71% of women do not have any regular leisure-time source of physical activity Exercise can increase life by 2 years if person has exercised for an entire two years over lifetime Typical exercise prescription for an adult is 30 minutes of moderate-intensity activity on most if not all days of the week or 20 minutes of vigorous activity at least 3 days a week A person with low cardiopulmonary fitness may derive benefits from even less activity BPM- minimum 160-age, maximum 200-age Regular exercise improves mood and reduces stress immediately after a work-out and there may be long-term benefits as well while sedentary behavior may be a risk factor for depression Social support during exercise increases the likelihood that people will maintain their exercise programs An improved sense of self-efficacy can also underlie some of the mood effects of exercise Effects are small but improve planning and reasoning as well as memory Exercise may benefit the immune system through an increase in endogenous opoid pain inhibitors Exercise reduces absenteeism, increased satisfaction, decreased health care costs

Exercise begins in childhood but by adolescence declines significantly, especially among girls Only half of those that initiate voluntary exercise maintain it after 6 months Maintaining commitment in the first 3 to 6 months is critical People who value exercise, are supported to exercise, have self-efficacy, and enjoy exercise as well as being male, younger, educated and participate in sports are more likely to participate in it Overweight people are less likely to exercise while those with cardiovascular disease are more likely to but outside of these there is little relationship to health status and exercise Lack of resources, time, energy, safety, social support and self-efficacy are barriers to exercise Interventions are successful if they incorporate behavioral control, self-monitoring, and motivation Perceived importance of physical activity predicts initiation of exercise but control over deterrents predicts longevity and awareness of obstacles predicts relapse prevention Linking exercise with other health behaviors, so long as it is not exceedingly complex, helps Promotion of exercise achieved through assessment of benefits and barriers, commitment, selection of conditions tailored to purpose, setting of goals and contingencies, record keeping and relapse prevention People adhere 50% on their own, while CBT interventions increase this to 60-75% Number of people participating in regular exercise has increased by more than 50% over past few decades Accidents are most common cause of death and disability for children under age 5 Parents are most likely to prevent injury if they believe that the recommended steps are effective, if they feel competent and if they are aware of what is required Pediatricians are incorporating such training into their interactions with new parents Accidents in the workplace have decreased since the 1930s but home accidents have increased The majority of injuries involve the elderly falling which can be prevented through diet, physical activity, and home modification Greatest cause of accidental deaths are motorcycle and automobile accidents People often correctly perceive the risk of automobile accidents but this has little impact on their driving Breast cancer reduced through better mammogram screenings with the number of women getting screenings is increasing Women over 50 and at risk women over 40 are recommended to get a mammogram every year This is important because the prevalence of breast cancer remains high, the majority of breast cancer tends to be detected in women over age 40, and early detection can improve survival rates 59% of women are screened for breast cancer over a 2 year period and only 27% have had the age appropriate number of repeat screening mammograms and the use of mammograms declines with age due to fear, embarrassment, pain, and costs of procedure

Social support is most beneficial for low-income and elderly women Mammograms need to be better integrated into general health care rather than being a special focus Colorectal cancer is second leading cause of cancer deaths Community-based interventions can attract older people to engage in screening behavior Past 4 years have shown a four-fold increase in skin cancer in the US These are the most preventable forms of cancer being due to excessive UV radiation exposure Sun-protective behavior are practiced consistently by less than a third of Americans and more than three-quarters of American teens get at least one sunburn a summer Important to stress the immediate consequences of sun-damage to youth Only 14% of adults get recommended servings every day and unhealthy eating contributes to over 400,000 deaths each year Dietary change is critical for people at risk or already diagnosed with chronic diseases (coronary hearth disease, hypertension, diabetes, cancer) which are diseases that poor people are at greater risk for who do not have access to good diets Cholesterol leads to atherosclerosis plaque build-up 80% of cholesterol is produced in blood and plaque formations depend upon cholesterol-carrying proteins (lipoproteins) Low density lipoproteins (LDL) result from food and are detrimental while high density lipoproteins (HDL) result from exercise and are beneficial to health Lipoprotein (A)- thickens blood and stiffens artery walls and is caused by genetics and trans fats but can be reverse with red wine and asperin Switching from trans fats (fried food) and saturated fats (meat, dairy and coconut and palm oil) to polyunsaturated fats (vegetable oil, nuts, and fish) and monosaturated fats (olive and canola oil) is widely recommended along with whole grains, fiber, and 5 servings of fruit and vegetables a day Omega-3 fish oil reduces CHD risk by 30% with two or more servings per week Diet is implicated in colon, stomach, pancreas and breast cancer and may contribute to 30% of all cancers Diet high in fiber protects against obesity and cardiovascular disease by lowering insulin levels while a diet high in fruit, vegetables, whole grains, peas and beans, poultry and fish and low in refined grains, potatoes and red meats lowers risk for CHD Mediterranean diets have higher adherence rates have beneficial effects on lipids and glycemic control Statin drugs substantially reduce cholesterol and when paired with diet modification significantly lower cholesterol levels Reduced caloric diet increases life-span in other species and may do so as well in humans People typically change diet for appearance, not health concerns and fewer than half of US adults meet dietary recommendations for reducing fat and sodium levels and for increasing fiber, fruit and vegetable levels

Some dietary recommendations are restrictive, monotonous, expensive and require drastic changes Tastes are hard to alter and comfort foods which are high in fat and sugar may help to turn off stress hormones such as cortisol Stress results in more fats and less vegetables, more snacks and less breakfasts as does a lowstatus job, high workload, and lack of control at work Any dietary modification must begin with education and self-monitoring and include social support and self-efficacy Family meetings and meals can improve dietary habits and generally improves health habits and coping Computerized nutrition information decreases high fat and minimally increases high-fiber consumption and banning unhealthy food in schools is effective Leptin and insulin circulate in the blood that are proportionate to body fat mass and decrease appetite by inhibiting neurons that produce the molecules neuropetitde Y (NPY) and agoutirelated peptide (AgRP) that would stimulate eating and also stimulate leacortin-producing neurons in the hypothalamus which inhibits eating Letpin signals whether the body has sufficient energy stores of fat or whether it needs additional energy and ghrelin is secreted in the stomach spiking just before meals and dropping afterwards which makes people hungry Obesity- excessive accumulation of body fat above 20-27% in women and 15-22% in men 400 million people worldwide are obese and a further 1.6 billion are overweight including 20 million children under age 5 being more prevalent than malnutrition and will surpass smoking in terms of associated diseases and deaths Stems from a combination of genetics, increasing availability of high-fat and high-energy food and low levels of physical activity 67% of US population is overweight and 34% is obese with women more than men and the trend leveling off but not reversing Body-Mass Index- overweight = 25-29, obese = 30+ Obesity contributes to cancer, especially colon, rectum, lever, gallbladder, pancreas, kidney, esophagus, and lymphoma and may contribute to 14% of cancer in men and 20% in women Obesity is also associated with cardiovascular disease, atherosclerosis, hypertension, diabetes, gallbladder disease, arthritis, and heart failure and increases risks in surgery, anesthesia, and child-bearing Obesity results in disability and 50% of people 30-49 are considered disabled People obese at age 40 are likely to die 3 years earlier than non-obese people Abdominally localized fat is especially potent risk factor for cardiovascular disease, diabetes, hypertension, cancer and cognitive decline and increases in response to stress Obesity may result in personality disorders, depression, impulsivity and low conscientiousness 60% of overweight children and adolescents show risk factors such as elevated blood pressure, elevated lipid levels or hyperinsulemia with African American and Hispanic children being at particular risk

Risk factors include genetics, sedentary lifestyles, lack of physical education, family support, overeating and access to foods high in fat 14% of obese infants become obese adults and 70% of obese children become obese adults One in four people over age 50 is obese which increases risk for illnesses and death and decline in cognitive function Obesity depends on the number and volume of fat cells with the level of obesity increasing both Number and size of fat cells is determined within first years due to diet and genetics with a high number of fat cells leading to marked propensity for fat storage thus promoting obesity but poor eating later in life affect the size but not their number Obesity is itself a risk factor for further obesity which tends to increase exponentially Yo-Yo Dieting- reducing food intake slows metabolic activity allowing individuals to gain more weight and thus they tend to regain more weight than they lost if they relapse especially if they favor food high in fat following weight loss Set Point Theory- each individual has an ideal biological weight which cannot be greatly modified and thus efforts to lose weight may be compensated for by adjustments of energy expenditure or psychological changes such as depression and irritability Half of people eat more from stress and half eat less For the nondieting and nonobese person, stress may suppress eating but for the obese person stress may disinhibit dieting Men tend to eat less when stressed and women tend to eat more People who eat in response to stress usually consume more low-calorie and salty food, although when not under stress, stress eaters prefer high-calorie foods Stress eaters experience greater anxiety and depression than nonstress eaters as do the obese Those that eat in a response to negative emotions show a preference for sweet and high-fat foods Dieting is a stressor that can increase cortisol and may itself produce health risks Weight loss through dieting is small and rarely maintained for long and rarely matches expectations Low-carbohydrate or low-fat diets do the best at reducing weight initially but are hardest to maintain Gastric surgeries is the most common surgical procedure but is reserved for people who are at least 100% overweight and have failed repeatedly to lose weight with health complications Use of surgery has increased dramatically, leading insurance companies to phase out coverage Self-monitoring makes clients more aware of their eating and gives them greater control Individuals are instructed to limit their eating in time and place and to change their eating environment to remove stimuli that prompt overeating Individuals are instructed to increase the time between bites Meditation, mindfulness training and ACT are implemented to reduce stress

Relapse prevention begins with effective screening of individualized treatment and moves on to restructure the environment, rehearse high risk situations and develop coping strategies CBT programs produce weight loss of 2 pounds a week for up to 20 weeks and long term maintenance over 2 years Critical of food industry for marketing high-calorie, low nutrient food to children and calls for food labels that contain more nutrition and serving size information, a special tax on high fat and sugar foods and restriction of advertising to children on required health warnings Women age 15-24 are most likely to have eating disorders Genetic factors of serotonin, dopamine, and estrogen systems are implicated in anxiety and food regulation and are involved in eating disorders as well as hypothalamic abnormalities or autoimmunity problems Women with eating disorders show abnormalities in hear rate and blood pressure as well as a tendency towards depression, anxiety and low self-esteem Eating disorders are tied to insecure attachment in relationships and expectations of criticism Maudsley Model- 10 to 20 sessions with family members over a period of 6 to 12 months Parents urged to assume complete control over eating and gradually grant control to anorexic Stress health risks to those at risk and normalize disorder to those with it Bulimics respond to dropping below set weight as though they are starving and metabolism slows Bulimics have altered HPA axis and elevated cortisol levels which promote eating Bulimia disrupts hormonal functioning and the production of leptin which controls eating because of malnutrition First step is to convince bulimics they have a problem with a combination of medication and CBT being most effective NREM sleep- light sleep marked by theta waves which turn out the sound around us, breathing and heart rate even out while body temperate drops and brain waves alternate between short bursts and large K-complex waves, then deep sleep marked by delta waves which are important for restoring energy, strengthening immune system and prompting body to release growth hormone REM sleep- eyes dart back and forth, breathing and heart rates flutter and dream vividly marked by beta waves which are important for consolidating memories, solving problems and turning knowledge into memories At least 40 million Americans have a sleep disorder, most have insomnia 39% of adults sleep less than 7 hours a night and 54% experience insomnia at least once a week These may be tied to the hormonal levels related to menopause in women Insufficient sleep effects cognitive function, mood, work performance, and quality of life

Chronic insomnia can compromise the ability to produce insulin and can increase the risk for coronary heart disease and affect weight gain Six nights of poor sleep in a row can impair metabolic and hormonal function and can reduce pain tolerance and aggravate the severity of hypertension and diabetes while good sleep in contrast can act as a stress buffer and behavioral control in children Lack of sleep impairs memory formation, role performance, and reduction of calories thus contributing indirectly to obesity Depression, hostility, uncontrollability and arousal can result in poor sleep quality A good night of sleep includes regular exercise, keep the bedroom cool, sleep in a comfortable bed, establish a regular schedule, develop nightly rituals to prepare for bed, mask background noise, dont consume too much alcohol or smoke, dont each too much or too little, dont have strong smells in the room, dont nap after 3 PM, cut back on caffeine CHAPTER 5 Drinking, smoking, drugs, unsafe sex, and taking risks all begin in adolescents and can cluster together as part of a behavior problem syndrome These behaviors are heavily tied to peer influence, especially among males, in order to appear attractive, sophisticated, and able to cope with stress These behaviors occur gradually and can be predicted by some of the same factors and are related to the larger social structure in which they occur and occur more often in lower class Dependence- repeatedly self-administered resulting in tolerance, withdrawal, and compulsive behavior Physical Dependence- body has adjusted to substance and incorporates the use of it into normal functioning of bodily tissues Tolerance- process by which the body increasingly adapts to the use of a substance, requiring larger and larger doses of it to obtain the same effects Craving- strong desire to engage in a behavior or consume a substance which results from physical dependence and a conditioning process in which the substance is paired with environmental cues, the presence of which triggers an intense desire Addiction- physically or psychologically dependent on a substance following repeated use over time Withdrawal- unpleasant physical and psychological symptoms experienced when substance use ceases which include anxiety, irritability, craving, nausea, headaches, tremors and hallucinations Alcohol is third-leading cause of preventable death after smoking and diet with more than 20% Americans exceeding recommended drinking levels Linked to high blood pressure, stroke, cirrhosis of liver, cancer, fetal alcohol syndrome, sleep disorders, immune deficiency, and traffic related deaths Alcohol causes aggression, impulsive sexuality, poor negotiating skills, and poor cognitive function Alcoholic- someone physically addicted to alcohol who show withdrawal patterns when they stop drinking, have a higher tolerance, and cannot control drinking

Marked by daily need for alcohol, inability to cut down on drinking, repeated efforts to control drinking through temporary abstinence or restriction of alcohol, binge drinking, loss of memory, drinking despite health problems and drinking of non-beverage alcohol Physical dependence may manifest as drinking that maintains blood alcohol at a particular level, tolerance, increased frequency and severity of withdrawal, sense of loss of control over drinking Genetic and modeling factors are implicated with men being at greater risk than women Occurs as an effort to buffer stress and to enhance sociability and positive emotions People are taught to associate alcohol with pleasant social situations Married couples and parents reduce their risk of becoming alcoholics Windows of vulnerability are with chemical dependence age 12 to 21 and late middle age as a coping mechanism for stress Late-onset drinkers are more responsive to treatment and can manage better on their own As many as half of alcoholics stop or reduce drinking on their own and is more common later in life As many as 60% of people treated through CBT programs return to acohol abuse Success is contingent upon social class with upper class having success as high as 68% while low class individuals have success rates below 18% Detoxification- first phase of treatment that is carefully supervised where the alcoholic is weaned off of alcohol consumption Program then moves on to short-term intensive inpatient treatment, followed by continual outpatient treatment CBT goal is to decrease the reinforcing properties of alcohol, to teach people new behaviors, and to modify the environment Begin with self-monitoring and contingency contracting as well as motivational enhancement Some medication such as naltrexone is used to block the opoid receptors in the brain and thus reducing the rewarding effects of alcohol Campral is also used which modifies the action of GABA Stress managing techniques are introduced to provide alternatives to compensating with alcohol More than 50% of alcoholics relapse within the first 3 months which requires social skills training and normalization of relapsing Alcohol treatment programs that identify environmental factors and modify them or instill coping as well as providing outpatient aftercare and active family involvement show a 40% success rate Controlled drinking- techniques to manage ones consumption of alcohol Placebo drinking- drinking non-alcoholic beverages instead of, or between, alcoholic beverages Lifestyle rebalancing with a healthier diet, aerobic exercise, and reduction of other unhealthy behaviors

Biggest problem facing alcoholism is that as many as 85% of alcoholics do not receive treatment and thus social engineering may be the most promising solution by reducing alcohol advertisements, raising the drinking age, and more strict driving penalties Alcoholics may be able to drink in moderation if they are young, employed, have not been drinking for long and live in a supportive environment Moderate drinking represents a more realistic social behavior and reduces drop-out rates Preventive measures targeted at adolescents improve self-efficacy, changes social norms and represents a cost-effective option for low income areas Moderate alcohol intake (one or two drinks a day) may reduce risk of coronary artery disease, heart attack, lower blood pressure, lower risk of dying after a heart attack, decreased risk of heart failure, less thickening of arties with age, increase in HDL and fewer strokes and benefits for women may occur at even lower levels These benefits are especially true for the elderly but moderate drinking for adolescents may result in health risks Smoking is single greatest cause of preventable death and causes chronic bronchitis, emphysema, respiratory disorders, cancers, lower birth weight, and retarded fetal development as well as erectile dysfunction Cigarette smokers are generally less educated, less intelligent, more impulsive, and less health conscious and are more likely to be men Majority of smokers are American Indian, White, or Black with less being Hispanic or Asian) Smoking and drinking often cue one another Smoking and cholesterol intake increase each other beyond the mere addition of each problem added together Smoking and stress can increase heart rate reactivity in men and blood pressure in women and is exacerbated in lower class populations Thin smokers are at risk for greater mortality and smokers are less physically active Smoking increases risk of breast cancer in women four-fold after menopause Smoking interacts with depression elevating white blood cell count and increasing cancer growth and may itself cause depression Number of smokers in US has been reduced to merely 20% but is slightly increasing Critical of tobacco companies who target minority groups and other countries Genes that regulate dopamine function are likely influences on smoking, particularly whether they are able to stop smoking and resist relapse but the value of informing smokers of this information is questionable 22% of adolescents are smokers with the habit beginning in initial experimentation 70% of all cigarettes smoked by adolescents are done in the presence of a peer Smoking spreads through social ties, but so does the desire to stop-smoking by 60% if a spouse quits, 36% if a friend quits, and 25% if a sibling quits

Chippers- smoke in moderation and are socially deviant but value academic success, supportive relationships, less drug use, and smoke less among peers as well as being aware of tobacco company control efforts and addiction Low self-esteem, aggression, depression, withdrawal or repressive coping, dependency, feelings of powerlessness, and social isolation increase risk of smoking Smoking is more addictive than alcohol and heroine Smokers maintain nicotine blood levels to prevent withdrawal and nicotine alters levels of active neuroregulators which smokers may engage to temporarily improve performance of affect which consequently improves mood, concentration, recall, altertness, arousal, and psychomotor performance in habitual smokers all of which is reduced when smoking ceases Attitude changing approaches do not reduce smoking so most therapists rely on CBT First stage is to replace smoking with nicotine patches which offers significant imrpvoement Enhance motivation by emphasizing adverse health consequences and nevative social attitudes as well as promoting self-efficacy while more active solutions require time-tables, programs on how to quit, and awareness of obstacles to quitting Social support is more helpful for men than for women while smokers in ones social network predicts relapse CBT approaches are less successful with adolescents than with adults Adolescents smoke for positive image and self-control and effective quitting measures target these same cognitions Smoking abstinence reduces over time significantly and relapse prevention is most successful when it prepares the smoker for uncomfortable changes after they quit as well as contingency contracting Those who relapse are most likely to be young, dependent, and concerned about self-image Linking smoking to other unhealthy behaviors may increase the concern for an overall healthy lifestyle and prevent abstinence Managed care facilities have not yet included techniques to reduce smoking behavior through patient visits but have begun incorporating telephone counseling and newsletter methods Workplace interventions are effective only in so far as they remain smoke free Self-help programs are less expensive and while ineffective in the short term are just as effective as more complicated programs in the long term Social Influence Intervention- modeling and behavioral inoculation Goal of information about negative effects of smoking that appeal to adolescents, positive image of the non-smoker and peer group used to facilitate non-smoking behaviors Social engineering is most effective route to prevention by shifting expense onto tobacco companies, FDA regulation, heavy taxation, and restriction to particular locations California Campaign- 25 cent increase in cigarette tax, 5 cent tobacco control, decrease sale to youth, counter tobacco company influence, and decrease second hand smoke which successfully reduced smoking in California faster than whole of US