Stress, Depression, Marital Stress and Doctors ...

Volume 2 '

Number 3, 1989

Stress, Depression,Schizophrenia, and the

Marital Stress and Doctors

Immune SystemStress has been thought to play a role in certain casesof depression and schizophrenia. The mechanism ofaction is not clear but may involve changes in brainneurotransmitter levels or their ratios. There is somesuggestion that both disorders are associated withimmune system abnormalities. In one report, therewas an increase in antibodies against brain receptorsfor beta endorphins which promote a feeling of wellbeing. There was also an increase in antibodies tosomatostatin, which plays an important role in regula-ting the brain's electrical activity. 2Wo of schizo-phrenics, but only 2% oI controls, demonstrated animmune response against extracts from the hippo-campus, a region of the brain that integrates thoughtprocesses. When schizophrenics go into remission,these changes are less prominent. It is not clearwhether immune system disturbances in mentalillness represent cause or effect. However, it has beensuggested that a virus may set off an immuneresponse which then ultimately causes damage to acritical area in the brain. Since stress can decreaseresistance to a variety of viral infections, this couldexplain its possible causative role in certain cases ofmental illness.

ALSO INCLUDED IN THIS ISSUE

Depression, Cancer, and DopamineComputer Therapy to Reduce Stress?More on the Health Effects of Laughing

.....2

.....2How to De-Stress Your Job ........3Hostile L:wyers and Heart Attacks ..................3Post Traumatic Stress Adequate Defense for Murder................4Did Stress Cause Ditka's Heart Attack?. ............4Reducing Stress in Chickens and Vvaldi ............4Fluctuating Blood Pressure and BehaviorMore on Stress and Gashointestinal DiseaseIs Stress Emerging As a Major Factor in AIDS? '.....................'6Best Stress Buffer for Senior Citizens Is Good Heatth .............-6Stress and Post Corqnary Arrthymia and Death .....................' 7It's Stress, Not Hormones That Cause Menopausal Problems...... 7Job Related Mental Streas without Physical Injury

Is Compensable

"Medicine is a jealous mistress" and that seems tobe confirmed by the high rates of divorce, separa-tion, and marital discord reported in physicians.Long working hours, increased opportunities forextramarital affairs with patients, nurses and otherhealth professionals may contribute to the problem.According to one psychiatrist who has written abook on the subject, maritalproblems are apt to begreatest in physicians who marry other high-powered professionals such as lawyers and evenother doctors. Frequent fights, separation anddivorce are much higher in this group than in thosewhose spouses do not work. It is well known thatphysicians are often reluctant to seek assistance inresolving other social problems such as alcoholismandsubstance abuse because of feelings of superior-ity or fear of tarnishing their image. Similarly, theyare apt to avoid seeking professional help whenthey find their marriages are in trouble eitherbecause of similar attitudes as wellas guilt feelings.The author suggests "it's important-especially formale physicians-to cultivate friends with whomthey can share their feelings." He also urges them todevelop skills aimed at "keeping romance alive"which might be "as simple as remembering to sayhello when they come home."

"The measure of a manb real character is wha t he woulddo if he knew he would never be found out."

- Thomas Babington Macaulay

For further information on the original source of abstracts and otherreprints available on similar subjects, please send a self-addressedstamped envelope to: Reprint Division, American Institute of Stress,124 Park Avenue, Yonkers, NY 10703.

The Newsletter of THE AMERICAN INSTITUTE OF STRESSNEWSLETTER is published monthly by The American InstituteofStress. Subscription rates: $35.00 annually. Copyrisht@ 1987by The American Institute of Stress. All rights reserved.

The Newsletter of THE AMERICAN INSTITUTE OF STRESS

THT AMERICAN INSTITUTE OT

Paul J. Rocch, M.D., F.A.C.P.Editor-in-Chief

Contributing Editorr frorn The Board of Tructeec ofThe Arnerican Inatitute of Strere

Robert Ader, Ph.D., Rochester, NYHerbert Benlon, M.D., Boston, MANorman Courinl, Los Angeles, CAMichael E. DeBakey, M.D., Houston, TXJoel Elher, M.D., Louisville, KYJohn Laragh, M.D., New York, NYJanee J. Lynch, Ph.D., Baltimore, MDKenneth R. Pelletier, Ph.D., M.D., Berkeley, CARay H. Rolenrnan, M.D., Menlo Park, CACharlec F. Stroebel, Ph.D., M.D., Hartford, CTAlvin Toffler, New York, NYSue Thomar, RN, Ph.D., Baltimore, MD

Depregqion, Cancer,And Dopamine

As noted previously, numerous studies reveal stronglinks between depression and the development aswell as the clinical course of cancer. Prospectivestudies on cancer patients reveala higher incidenceof depression preceding any signs, symptoms orclinicaldiagnosis of malignancy. Depression is alsoassociatedwith lower levels of the brain neurotrans-mitter, dopamine, although whether this is cause orelfect is not entirely clear. Further support for adopamine cancer link, however, comes from anIndian study demonstrating that dopamine injec-tions markedly reduced tumor growth in mice.Tumor size decreased by about 507o and the meanlife span of the treated mice increased 40%. Otherresearch revealed that the earlier dopamine isinjected in the stage of tumor growth, the better theresults. It is interesting that studies attempting tocorrelat€ personality types with neurotransmitterlevels show higher dopamine ratios in novelty-seeking individuals. Individuals with high levels ofcuriosity have been reported to have better immunedefenses. In addition, psychotherapeutic approachesfor cancer patients often emphasize the develop-ment of novelty and creativity.

some of the benefits of a therapy s€ssion may stemfrom the fact that some troubled individuals feelbetter just by having someone to talk to. "People

are more willing to revealthemselves to a computerthan to a human being they are meeting for the firsttime," according to the editor of the journal,Computers in Psychiatry/Psychology. The computerasks leading questions to which the patient respondsby striking the appropriate key which results inanother series of answers or questions and so on.One example is "l feelstress in my . . ." with possibleresponses being work life, sociallife, emotional life,family life, schoollife, day-to-day life, and physicalhealth. The employee may select up to four answers.Subsequent interactions are designed to determinethe source of stress, explain the feelings andbehaviors that are associated with the problem, andfinally to outline a series of steps that can be takento avoid or diminish stress and its effects. Unlikeother programs, this one does not utilize voiceresponses and privacy and confidentiality are furtherinsured since patients retain the disk containingtheir answers as wellas any printouts which havebeen made. The program consists of ten hourlysessions, and therapists evaluate individual pro-gress after the second, sixth, and final interview.When indicated, treatment by a human therapistmay be recommended. According to the manufac-turer, 80% of users require no further counselingafter they have completed the program. Somepsychologists and psychiatrists are concerned aboutthis approach, pointing out that in patients withserious personality disorders like schizophrenia orsevere depression, it may delay diagnosis and usefuldrug treatment, which could have disastrous cons€-quences. In addition, they feel that "some humaninteraction is a prerequisite for etlective therapywith most disorders." Nevertheless, although theprogram costs $10,000, the company finds it "more

cost effective than using a human therapist to treatpatients at an average cost of $125 an hour."

"The world is run not by thought, not byimagination, but by opinion." - Elizabeth Drew

Computer Therapy toReduce Stress?

We have previously reported on interactivecomputer programs that attempt to simulate asession with a therapist or psychiatrist. "Confes-

sion is good for the soul" and, in many instances,

"The public will choase to believe a simple lie inpreference to a complicated truth."

- DeToqueville

More on the Health EffectsOf Laughing

As Jonathan Swift noted, "the best doctors are Dr.Diet, Dr. Quiet, and Dr. Merry-Man." The Bibletells us that "a merry heart doeth good like amedicine," which may explain why kings and nobilityoften retained court jesters in their entourage.Humor therapy really took offwhen Norman Cousinsrecounted its salubrious benefits in "Anatomy of AnIllness." As noted previously, a growing number of(Continued on page 3)


More on the Health EffectsOf LaUghing (continued from page 2)health professionals are now also trying to teachpatients to "laugh their troubles away." One hospitalstocks a multimedia humor library with cartoonbooks and videos, In another MentalHealth Center,patients and staff members dress up as clowns toperform skits. At the University of Louisville, thedistinguished psychiatrist, Dr. Joel Elkes, runs aHealth Awareness Workshop, teaching medicalstudents about the beneficial health effects of"laughter, relaxation and awareness." Some hos-pitals hold regular meetings of doctors and nursesto discuss the use of laughter and humor in patientcare and their own lives. According to one psychi-atrist, laughing 100-200 times a day is good exerciseand about the equivalent of 10 minutes of rowing, Agood belly laugh has been described as "internaljogging" with powerful effects on the heart, lungs,and various muscles in the body, following whichthere is a sense of general relaxation.An optimistic attitude also may improve health andperformance. One study of 1,100 life insurancesalesmen found that optimists outsold pessimistsby 20o/". The Director of the Humor Project, a non-profit group that serves as a clearing house onhumor, health information and laughter therapy,notes that the Reader's Digest has been remindingus for many years that "Laughter Is the BestMedicine." Perhaps future doctors willbe prescrib-ing a half hour of Eddie Murphy, Candid Camera, orthe Honeymooners, along with or as a replacementfor tranquilizers and pain killers.

"Serendipity is searching for a needle in a haystack andfrnding instead the farmerb daughter."

- Seymour Kety

How to De-Stress Your JobA recent Blue Cross/Blue Shield report notes thatjob stress is "considered by many experts to be themajor adult health problem today." ln addition, jobsassociated with stress-related illnesses are notnecessarily highJevel executive occupations. Rather,"they are those such as assembly line workers, thathave little variation, heavy workload demands, lowsatisfaction, and lack of control." Stress-relatedproblems range from complaints such as headache,fatigue, anxiety, depression and insomnia to moreserious illnesses such as heart disease and possiblyeven cancer, The Academy of Family Physiciansestimates that stress is responsible for two-thirds ofall visits to their membership. Often stress stemsnot from major upsets such as a death in the family,but an accumulation of minor irritating daily hassles,many of which are job related. Suggestions for

minimizing such problems include:. Leave plenty of time for commuting.. Set priorities and reasonable goals. Divide tasks

into "musts" and "can wait.". Organize time. Perform tasks at your most pro-

ductive hours.. Deal with one stressful situation at a time.. When you need help, ask,. Don't expect to be perfect or to accomplish too

much in too little time.. Focus on the task, not your ability to perform.. Take specific steps to improve your situation.. Share concerns with others.. Keep a sense of humor.. Live clean - eat well; sleep well; get plenty of

exercise (non-competit ive); and avoid cig-arettes, drugs, and excess alcohol.

"The scientific method, as far as it is a method, is nothingmore than doing oneb damndest with one's mind, noholds barred'"

-p.w. Bridgman

Hostile Lawyers andHeart Attacks

A variety of recent reports suggest that not allTypeA's are headed for heart attacks and it is primarilythose who are hostile that are at increased risk. Thelatest study followed up on 118 lawyers who hadtaken the MMPI personality test in law school 25years previously. Those with higher hostility scoreswere reported to have a death rate of 4.2 timeshigher than those with low scores. As noted at ourrecent conference (Vol. 2, No. 1), not everyoneagrees with the interpretation of these findings. Allof these studies are retrospective and based on theso-called hostility or Ho Cook-Medley Subscalewhich is derived from responses to the MMPLSome authorities doubt that this really measureshostility per se as opposed to things such ascompetitiveness and aggression. Furthermore, highHo ratings correlate with overall mortality ratherthan coronary heart disease alone. Increasing evidencesuggests that anger and its expression representthe components of Type A behavior most predictivefor future coronary events. This is supported by theresearch of Eysenck and Grossarth-Maticek whohave shown in several prospective studies thatindividuals high in suppressed anger are at greatestrisk. Even more significant are the preliminaryresults of intervention studies using behavioraltherapy and stress reduction approaches, Teachingpeople to figuratively, and perhaps literally, getthings off their chest and to learn how to cope withstress resulted in a significant reduction in theanticipated rate of subsequent cardiovascular diseasewhen compared to matched untreated controls.


Post Traumatic StressDisorder Adequate Defense

For MurderA veteran who received a bench warrant formenacing his ex-wife, promptly obtained a rifle andhandgun and set out to find her. She was spotteddriving with her new husband, and he pursued themthrough town, firing wildly until they took refuge atpolice headquarters. The veteran then was chasedby a state trooper and wounded in an ensuingshoot-out. He was arrested and charged with threecounts of attempted murder. During the trial, apsychologist presented the results of psychologicaltesting and showed a videotape interview duringwhich a number of questions were asked, Thesewere designed to demonstrate that the defendantwas suffering from post-traumatic stress disorderas a result of the killing of three Vietnamesechildren. The jury found the veteran not guilty byreason of mental disease and he was committed to aState psychiatric hospital.In a curious twist, the veteran received no treat-rnent because it was determined there that he wassuffering from a personality disorder rather thanpost-traumatic stress. He was released after eightmonths to the care of a psychologist, who told himthat he believed that the Veterans Administrationhad been negligent in discharging him withoutrecognizing his emotional state and the need forhospitalization. Accordingly, the veteran and hisex-wife sued the government for $9.5 million. Hewas subsequently interviewed by two VA psychia-trists, who again diagnosed his condition as post-traumatic stress disorder and he was awarded 100%disability, although this was later reduced to apermanent 30% rating. The government denied thedamage claims and the couple then filed an actionunder the FederalTort Claims Act. In the UnitedStates District Court hearing, he testified thatduring his 4-1/2 months of duty in Vietnam as ahelicopter crew chief, he had personally killed 30Vietnamese, including the three children, and alongwith his crew, had probably killed hundreds more.He also testified that he received the DistinguishedFlying Cross and a Bronze Star. His psychologistagain showed the videotape, testifuing that hispatient was suffering from post-traumatic stressand thus was not responsible for his actions.Subsequent investigation revealed tht the patienthad never seen actual combat nor had he recievedthe military decorations he claimed. The two psychi-atrists who had approved the stress disorder diag-nosis admitted that they had largely depended uponthe truth of the veteran's statements. His lawyerthen asserted that even if his client did not engage incombat in Vietnam and his mental condition wasnot related to that, the government should stillbeheld liable for the VA's negligent treatment, How-

ever, the court ruled that the veteran did not sufferpost-traumatic stress disorder and that the acts ofviolence committed had no relationship to his warexperiences. Further, there was no patient-thera-pist relationship between the veteran and the VAand therefore the government agency was notguilty of any of the negligent acts charged against it.

"l thank the dear God a thousand times that he allowedme to become an atheist''"orge

christoph Lichtenberg

Did Stress CauseDitha's Heart Attack?

The heart attack on November 2 oI the ChicagoBears footballcoach, Mike Ditka, apparently cameas a complete surprise. He had none of the fivemajor risk factors (smoking, cholesterol, hyper-tension, obesity, etc.) and exercised routinely.However, it was pointed out that head coaches areunder tremendous stress because of unsympatheticfans, extremely long working hours during theseason, and the tremendous sums of money thathinge on win-loss records. Many head coaches getto this position because they are Type A individualswith high levels of aggression and competition andalso have a strong need for order and organization.Ditka was described as intense and easilyexcitable.In addition, part of his normal routine was vigorousexercise consisting of lifting weights and runningshort sprints at 5:30 A.M. As noted previously,heart attacks and strokes are most apt to occur inthe early morning hours, probably because ofincreased levels of stress-related hormones thatquicken clotting and cause heart damage.

"ltb not death fm afraid of - itb dying.'- Montaigne

Reducing Stress inChickens and Vivaldi

The chicken industry is big business in the UnitedStates, although it operates on a very narrow profitmargin. Feed accounts for 607o of costs so that anysaving in this regard could provide huge returns.Americans consume almost 14 million broilers a dayand Perdue farms alone sells six million chickensdaily. When you are dealing with numbers like that,the logistics of housing and feeding are overwhelm-ing. Standard conditions include wire cages 22inches long by 13 inches wide and 13 inches highstacked in rows. Each cage holds five chicks, someof whom are socrowdedthat they can barely budgeand their necks are pink from.hostile pecking.(Continued on page 5)


Reducinq Stress in Chickenshnd Vivaldi

(Continued from page 4)Unhygienic sanitary conditions due to excretionsadd to the stressfulness of the environment, Stressedchickens dissipate energy because of their anxietyand frequent pacing and other attempts to get outof their cages.Now, a Cornellresearcher reports that profits canbe markedly increased simply by reducing chickenstress. This can be accomplished by hanging a redmitten in the cage (to remind the little chicks ofMom) and apparently playing a little Vivaldi. Themusic seems to reduce their natural jumpy andcombative nature, making them more serene. Asthe avian physiologist noted, "you can see in theireyes they're happy." In the Cornell experiment, thestress-free environment resulted in a weight gain ofonly 2% over fretfulbirds, but that would translateinto a potential saving for the industry of 60 milliondollars a year in feed alone. The chickens re-sponded differently to various portions of Vivaldi'sFour Seasons. "ln the winter segment, the birds juststayed together. In spring, the chickens, especiallythe little chicks, "jump and run and chase eachother. Just l ike l i t t le birds outside." Resultsobtained with other composers and musicalselec-tions have not been released. Adding certain toyssuch as plastic windmills, pingpong balls, key chainswith bells, etc. also seem to reduce stress anddistract the chicks from establishing a peckingorder which causes physical injury as differentcontestants try to get to the top. The results ofother stress-reduction strategies are being keptsecret since Cornellis patenting this technique for"environmental enrichment" for chickens. It waspointed out, however, that red mittens for com-mercially grown chickens are not recommendedbecause they are expensive and quickly destroyedby the chickens. An acceptable substitute has beenfound but was not mentioned "for competitivereasons" since "everything is in the patent process,so we don't want to be specific."

By subjecting individuals to too much change in tooshort a time, we induce disorientation and shat-tering stress. - Alvin Toffler

Fluctuating Blood PressureAndBehavior

Ambulatory blood pressure monitoring continuesto provide additional confirmation of the strongrelationship between emotional stress and hyper-tension. A classicalexample is the white coat effecturhen the patient's blood pressure rises sharply inthe doctor's office or other medical setting, but

remains relatively normal when measured at home.A variety of studies show that bloodpressures tendto be highest while at work, and lowest during sleepor other relaxing activities such as reading. Physicalactivity causes significant rises but even these aregreater when the patient is angry or anxious. Ingeneral, readings tend to be highest in the morningand lowest at night, but these seem to be behavioraleffects rather than reflections of some underlyingcircadian rhythm after activity and emotional factorsare considered. When workers are transferred tonight shifts, these fluctuations in blood pressurepersist, with the highest readings being obtainedduring the work period, regardless of the time ofday. In hypertensive patients, the same variationsare seen, although at a higher level.Job stress (as measured by increased psychologicaldemand with decreased decision making control)has been shown to be correlated with coronaryheart disease. A recent study of 200 male workers inManhattan revealed that those with high demandjobs over which they had little control had thehighest mean blood pressure readings both at workand at home. Conversely, those with the least jobstress had the lowest readings. It is not clearwhether "white coat" hypertension simply reflectsanxiety rather than some sort of conditioned reflex.In one report, half of a group of young people withelevated blood pressures were so informed by letterand the other half were not. When blood pr€ssureswere remeasured, they averaged 15 millimetershigher in those who had been informed than in thecontrol group. It was suggested that once a patientis told that his blood pressure is elevated, aconditioned reflex may result in a physiologicalresponse that leads to a "self perpetuating fallacy."These findings underscore the difficulty in decidingat what leveloffice measurem€nts of bloodpressurerequire drug treatment. There is no good evidenceto indicate that office hypertension or markedelevations of blood pressure in response to stressfulsituations lead to sustained hypertension.

More on Stress andG astrointestinal Disease

As noted in prior issues of this Newsletter, stresshas been incriminated as a causative or aggravatingfactor in a variety of gastrointestinaldisorders suchas peptic ulcer, irritable bowel syndrome, andulcerative colitis. A new study from England confirmssuch relationships, suggesting that stress may evenbe associated with the development of acute appendi-citis. Appendectomy patients between the ages of17-30 were evaluated at three separate hospitals.Another study group consisted of patients aged18-60 from three gastroenterology clinics complain-(Continued on page 6)


More on Stress andGastrointestinal Disease

(Continued from page 5)ing of abdominal pain and other symptoms forwhich no organic basis could be identified. A thirdgroup consisted of drug overdose patients betweenthe ages of 17-35. All three groups were rated forstressful life change events in the preceding 38weeks. These included job changes, problems withhousing, loss of close socialrelationships, stressfulencounters with the police, etc. In comparison tomatched healthy controls, allthree groups reporteda significantly greater degree of stress prior toseeking medical attention. In the gastroenterologyclinic group, threatening long-term stresses such asmarital separation, loss of a family member, ordisruption of important social relationships occur-red as frequently as those reported by the overdosegroup. Those gastroenterology clinic patients whohad clear physical evidence of their diseasereported reported significantly tewer antecedentlife stress scores.

"Truth is not only violated by falsehood; it may be equallyoutraged by silence."

- Amiel

Is Stress Emerging As aMajor Factor in AIDS?

Persons infected with the AIDS virus appear tocome down with the full blown disease at verydifferent rates. This seems to depend upon how welltheir immune system is functioning. Since it is wellknown that stress can depress the immune system,it seems plausible that it could play a significant rolein the course or progression of this viralinfection. Avariety of anecdotal reports suggest that AIDSpatients who have a positive outlook, avoid distress-ful relationships and lifestyles and reduce stress bytaking more control over their lives seem to behealthier and live longer. One recent study of 40 gaymen found that "positive thinking, social support,and stress reduction" delayed the time for HIV-infected patients to develop clinical AIDS. In anotherstudy of 18 AIDS patients, those who handledstress well and had positive attitudes had betterimmune function than those who were distressedand passive. An additional report of "long survi-vors" with AIDS showed a similar correlation ofsuch factors with positive immune measures. Oneprominent authority in the field indicated that"behavioral interventions should be able to en-hance or optimize" immune defenses, Strategiesmight include psychotherapy, relaxation tech-niques, imaging, biofeedback, meditation, andhypnosis. One serious danger is that many such

services are ofilercd by unqualified individuals anddesperate AIDS patients may not be able to discrim-inate between authentic approaches and thosewhich are merely entrepreneurial or wishfulthinking. In addition, for many patients, alreadyguilt ridden, it would be harmfuland cruelto implythat their illness or failure to respond to treatment isdue to some deficiency of character since this couldhave a very negative effect.

"I believe I've found the missing link between animal andcivilized man. It is us."

- Konrad Loren

Best Stress Buffer for SeniorCitizens Is Good Health

It has been wellestablished that increased stress isfrequently associated with poorer health, but doesthis represent cause or effect? A recent Floridasurvey of slmost 700 individuals over the age of 60suggests that "good health helps the elderly dealwith stress more than does religion, the support offamily and friends, or achievement of educationaland occupational goals," Physical or emotionaldisabilities which interfere with daily activities seemto be the most important factors that lower resistanceto stress. "Even if you only think you have yourhealth, that's a pretty good sign that you willcopewellwith stress,"The Senior Citizens were asked torate how they coped or perceived their ability toadapt to financial problems, poor health, loss offriendships, and death of a spouse. "Those peoplewho felt that they had control over their livesperceived themselves by far as better copers thanthose who felt their lives were controlled by outsideevents." Poor health was perceived as the greatestfactor leading to loss of control. As in other studies,women appeared to adjust better to loss of a spousethan men, probably because of a lesser need tochange their daily activities. Many widowers "don't

even know how to cook for themselves."

CASSETTE TAPECoping Tapes: A Program for MentalFitness

by Joan SuvalTwo audiocassettes, total time two hours

$22.95 (discount for bulk orders)from

Coping Tapes, Inc.,P.O. Box 1355, Riverdale, NY 10471

(212) 894-8170

(See review on page 8 of this Newsletter)


Stress and Post CoronaryArrhythmia and Death

A significant cause of sudden death following aheart attack is the development of fatal arrhyth-mias, usually ventricular fibrillation. This may bedue to the disease process itself and, in some cases,is facilitated by medications such as antidepres-sants or diuretics, which lower serum potassiumand the threshold for ventricular irritability. Avariety of other influences such as caffeine andstress can also increase ventricular irritability asmeasured by the number and nature of prematureventricular contractions. In one recent report, 125heart attack patients were followed with transtele-phonic ECG monitoring for over a year. They wereseparated based on the occurrence (59) or lack (65)of evidence of premature ventricular beats andrhythm disturbances. The patients also kept a dailydiary of perceived stress levels. The resultsindicated a direct and significant correlationbetween disturbances in ventricular rhythm andself-reported emotional stress, This relationshippersisted even when other relevant factors such ascardiac risk, age, use of medication, etc.weretakeninto consideration. Although there was no discus-sion of possible mechanisms of action, increasedsympathetic activity and adrenalin secretion wouldseem to be important factors. That may also explainwhy beta blockers, which interfere with such activ-ities, are effective in reducing prbmature ventricularcontractions and also increase life expectancyfollowing a heart attack.These same r€searchers had previously demon.strated that increased stress was associated withgreater mortality following a heart attack in postcoronarypatients followed over a three-year period.Those scoring highest in both life stress and socialisolation had four times as many deaths as thosewith a relative absence of such problems.

"Thereb a rhythm to the universe, and chanting isplugging into that rhythm"'

-Tina Turner

It's Stress, Not Hormones ThatCause Menopausal Problems

Some women have severe change of life problemswhile others seem to sail through this periodwithout any difficulty. According to one researcher,the major culprit may be the stress of shiftingdemands and changes in family life rather thanabrupt changes in the hormonal environment.Abrupt surgicalmenopause is much more apt to beassociated with various physical and mental prob-lems. Almost 2,500 women born between 1926 and7936 were interviewed at 9-month intervals. Out ofalmost 500 who underwent natural menopause

during the study, most reported no significantincrease in depression or physicalproblems exceptfor occasionalsleep disturbances due to hot flashes.About half consulted a physician less than once ayear and their responses were different from womenseen in a clinic setting who were more likely to bedepressed and be treated with tranquilizers orhormones. The 108 individuals who had undergonesurgical menopause were the least healthiest andhad the most physical and mental complaintspostoperatively, In general, health problemscorrelated much more with the distress of beingwidowed or divorced, having to care for an agedparent or ill husband, or having an adult child returnhome, than any temporal relationship to the periodof natural menopause itself.I t was suggested that physicians should notroutinely attribute symptoms of depression orother health complaints to menopause and empir-ically prescribe hormone replacement. Estrogensmay be useful in preventing osteoporosis, cardio-vascular disease, and vasomotor symptoms, butthere is no good evidence to indicate that they canprevent or cure depression.

Job Related Mental StressWithout Physical Injury

Is CompensableWorkmen's Compensation was originally estab-lished to protect male workers who sustainedphysical injuries on the job. Although regulationsvary in different states, the courts have increasinglyextended this to include disability due to job-relatedemotionalor mentalinjury. In one recent Louisianacourt decision, a home health care nurse wasrequired to care for patients in a particular cityhousing project even though another nurse hadpreviously been killed at the same location. Duringa visit, she received a phone callfrom her employerwho told her that her life had been threatened andthat he was calling the police to escort her to hercar. The following day, a neighbor told her husbandthat there had been a man with binoculars watchingthe nurse from a nearby roof. The claimant, whohad no history of any prior mental or emotionaldisturbance, became extremely frightened and de-pressed, suffered from nightmares, and had to seekpsychiatric assistance. She was unable to return towork and was, therefore, fired. She applied forWorker's Compensation benefits and the courtrejected the employer's claim that the mentaldisorders had not caused a physical injury. It ruledthat she was disabled because of her iob-relatedfears.

"lf people think nature is their friend, then they suredonT need an enemy." - Kurt Vonnegut

Book Reviews o Meetings and ltems of InterestAudio Caseette

Coplng Tapeer A Prograrn for Mcntat Fitncr by JoanSuval. Two audlocaeretter, total tfune 2 hourr, 029.9tt(dlrcount for bulk orderr). Coping Tapee, Inc., P.O.Box 1356, Rlverdale, New York l047l, (2t21894-8170.These tapes are designed to relieve tension, anxiety, obsessiwcompulsive behavior, phobic reactions, and insomnia. It is alsosaid to be useful in improving concentration abilities. Joan Suvalhas been conducting stress reduction and stress managementprograms for over 15 years and delivers her message in aprofessional manner that is enhanced by a very pleasant andrelaxing voice. The first side of Tape I provides an introduction tothe program and an explanation of why it is apt to be efficacious.Most of the questions that one might ask have been anticipatedand addressed. The second side provides a series of relaxationexercises which involve the use of breathing technQues andothers to reduce muscle tension. Tapes such as this are often aptto be dulland boring but this is avoided to a considerable extentby appropriate interspersed poetry readings which promote therelaxation process. The second tape employs a "listen andrepeat" technique to encourage conditioned responses that willfacilitate effective stress coping strategies.The final side is sort of fun and includes selections of verses fromGilbert and Sullivan. These have been carefully chosen toprovide a convenient technique to deal with disquieting thoughtsand moods and is claimed to be useful in dealing with high anxietyor phobic situations such as claustrophobia or fear of flying. Anattractive accompanying booklet containing selected questionsand answers from the tapes, as well as the Gilbert and Sullivanverses, is provided to facilitate the leaming process. The totalpackage is attractive and easy to listen to and shouldbe helpfultomany patients searching for low cost relief from a variety ofstress-related problems and behaviors.

Book ReviewDictionary of Behavloral Argersrnent Techniquec.Heruen, M. and Bellack, A.S. (eda.), Pergarnon Prela,lnc., Elmeford, N.Y., 1989,618 pp. $95.1Xt.This book is an extremely valuable contribution, and describessome three hundred commonly used behavioral assessmenttechniques. lt is comprehensive, but concise, and quite up todate, including Spielberger's State-Trait AngerScale. The source,description, purpose, psychometric characteristics and clinicaluse of each technique is clearly outlined, as well as its develop-mental background and potential future applications. A

monumental task, and extremely well done. This bookunfortunately does not have a Subject Index, but interestedrea&rs should have little difficulty i&ntifuing topics and assessnpnttechniques of particular interest.

Meetinge and ltems of InterestAprll 2.7, Biologiel Alpct3 of Non.Psirchodc Du&r, World Fe&rafpn ol BiologicdPEchiatry, Jeru3alen brael. Wrtte to P.O. Box 983, Jerusahn 91009, tcrael.Aprll 7.9, Helping Pcople Change: Prctical cmepf and treatmeil ra.t€gies for the healthprohssional, Chkago, Th€ lnsdtue for tl|€ Mv|ncem€nt ol Hum.n B€hav'ror, P.O. Box 7225,Stanford, CA 94i!09, (415) 851€{ll. Alr[ t 9, T]E PoCli\,c Poer of Hrmr ard CreatMtv,Saratogr Sprin$, !f/. (518) 587.8770 q Hmc ard Cpfvity Confcrene, ffO Spring St.,Saratog. SpdrEr, tlY 12866.Aprll 7.9' Behaioral tlealthcare Tomw, bs Ansek lmtltut€ br &havl*al Healthcrre,P.O. Box 7226, Stanford, CA 94i[9, (415] 85r.841r.Atdl fe.l|, CoplngwtthSkarndAnftiy,Temple Unlwruity,&hoolotMedtcim, Srruotr,Fb. (8r3) 389.1766.Aprll lGl{, Intrcdrctlon io Mcdkd Hypnosb. Thc lnductbn and udllzldon of hypnorb brnedcalpractice. lJntuersiv of Cdilomi!, S.n Dhgo. [a Jolh (34 hom]. (619] 259-6790.Aprll 19.23, Asalation tor the Advrnc.[Ent ol lle.alth Eduotion, Boaton. Contact LlndaMoore (7fi|l 47634i17.Apr. 2&26, Stes Management Worlobp, Mdvtltler Unh,enlg, Harnilton, Ontarlo, Canrda,(416) 525.1940.Aprll 27.29, Heallng th€ H€art: Advanc€3 In the Pretcndon and Treatment of Coronary HeartDisease, boston, The NatlonalAe3ocl6tion lor the C[nlcalApplbatbn ofBehavloral Medhhp, Box523, Msddd c€nt€r, cT 6520, (208) 4566000.Aprll 28.29, Cosrdfrc Behavior llodiflcadon: Eftecttu€ hteru€ntioB with adults, childr€n sdadolecentc, Dallas lEtitute lor th€ Advane of Hlmn Behavior, P.O. Box 7226, Stanfor4 CA94309, (415) 851.8411.Mey 4.i, Cognitiw B€havbr Modificadon: Eff€ctlw lnteNentims with addb, chil&en andadolesnts, Pinsburgh lrotitute for the Advrerent ol Hrmn Behavlor, P.O. bx 7226,Stanford, CA 943@, (415) 851.8411.Mrrr d.7, The Pmr of Laughter and Play: Applicatioro in Health, Bulneq Educatim,RelatbmhipsandLifestyle (Sta,e Allen,Sld Caesarand Stan Allen, Jr., M.D., Rlch Caesar, M.D.),longBeach, CA. Theln3utute fdtheAdvscehentotHurDn B€havlor, P.O. Box 7226, Stanford,cA 91309, (41s) 851.8411.Mayt.7, Gukledlmagiery for Clnichnr: Anlntmstue TruidngProgam, S?:ttk, WA,lmtltute forthe Advmcement ol lluman Behavlc, Seattle, WA. Thelncdtut€ forth€Advrrumnt of tlum.nBehavtor, P.O. Box 226, Strntor4 CA 94i!09, (415) 85f€411.Mly l2.lt, Cognltlw Behavlor Modlicatloru: E t€ctlvc lnt€rwntlonc wlth adulq chldren andadolercenE,Washhgton, D.C.lBtltut€ lorth€AderE€rr€ntof Human Behador,P.O. Box 7226,srmtord, cA 94ilcB, (415) 851.8411.Mly 18.19, Cognltlve Behavlor Modt0catons: Effecd\rc hterventlors wlth adult!, chlldren andadol€sc€nls. Mlnneapoh, MN, Iruiitule for lh€ Advancem€nt ol Human Behavlor, P.O. Box 7226,Stanford, CA 94:109, (415) 851.&ll.Jrnc 1.3, Cognitiw Behavis Modfeiiom: Effe.ctiw interumtionc wlth ldrdtt, childr€n andrdohscenF. nfisburgh, PA, lEtltute tor the Advaffint ot Hutm Betuvic, P.O. Box 7226Stanford, CA 9$09, (415) 851.8411.Junc &9, The Pows of Artr Hmanism, Healng rnd Health Care. Kual Foundation forCondnuing Eduetiorl Polpu, Kual. Cnt*t Davld Ehem, M.D., P.O. Box 3650 Lihue, HI (808)24s.*'s1.Jrrc 6€, The Ecology of Work Improhg Producdvity rnd th€ Qualty of Work Llfe. Clncinmtl,OH. Contact Tom Chase, R.R, t2, box 44a, Norfimod, Ntl 03261.Jlnc 26-9cpt. 1, Tenth Capc Cod lruttute (Daib mornlng s€rles of lectur€s on NeuropcFholog,, Th€ Rehxatim Repore, Ditgrrclland Tr?drn€nt ots€xualProbleru, Chfiren ofDlvorce, Adohscpnb In Tmublq ClnlcalHWnoslr,lvlaitaltreray, etc.) Cape Cod,MA. ContactDr. Mkhad Peten, Alb€rt Einst€ln Colhgp of l'ledlche, 1308 Belfer Bldg., &onx, I$/ lffil (21214&.2307.Oct,lt.2t, Tk Ecobgyof Work ImpmvlngProducdrdb, rrd the Qudigof WorkLile. Toronlo,Ontado. Cmtact Tom Che, R.R. 12, Box 4th, Nortluood, NH 03261.Dcs t-7r hternadonal Rourd Table on Sll€nt Mirocrrdal bchemla. Fc &talhd Inlmtbnffit*t the CorEB S€creiarlat, Tel Avi4 contrct lftn€! Ltd., P.O. Box 50006, T3IAW 61500.

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