BBC NEWS, 2007

Having a high-pressure job doubles the risk of depression and anxiety in young adults, warn UK researchers. A study of 1,000 32-year-olds found 45% of new cases of depression and anxiety were attributable to stressful work. They defined a highly demanding job as involving a lack of control, long hours, non-negotiable deadlines, and a high volume of work.

Experts said the paper in Psychological Medicine showed employers needed to do more to protect workers' mental health. We have got to get people to work much more flexibly, using technology to our advantage rather than keeping people in an office environment for long hours Professor Cary Cooper, Lancaster University Researchers looked at people who had taken part in a major, long-term study being carried out in Dunedin, New Zealand, to follow their progress through life. They had a wide range of jobs including actress, brain surgeon, teacher, helicopter pilot, dustbin man, journalist and policeman. They were asked whether they had workload and time pressures, had to work longer hours than they would like, had too much work to do everything well, whether their job was hectic, were often unclear about what they had to do and have to work too hard.

Overall 10% of men and 14% of women in the study suffered a first episode of depression or anxiety over the year-long study. But the risk was double in those with the highest pressure jobs.

Mental health Study leader Dr Maria Melchior, epidemiologist at the Institute of Psychiatry, Kings College London, said: "Our study shows that work stress appears to bring on diagnosable forms of depression and anxiety in previously healthy young workers." She added that those taking part in the study were at an age where they were settling into their careers and are less likely to have opted out of less stressful jobs. "There are a number of possible mechanisms - previous research suggests there could be an effect on stress hormones in the brain which could lead to depression, also fatigue and lack of sleep." People in high-pressure jobs may also have less time to take part in social activities, she added. Co-author, Professor Terrie Moffitt, also at Kings College London added that jobs where failure was highly visible, such as working as a head chef in a busy restaurant, were among the most demanding.

What is National Stress Out Week? (November 11-17, 2007)

National Stress Out Week is a week-long awareness campaign sponsored by the Anxiety Disorders Association of America (ADAA) to encourage people to take time to de-stress and to discover the differences between everyday stress and an anxiety disorder. This year National Stress Out Week highlights the connection between anxiety and sleep. The National Stress Out Week website includes information about anxiety disorders and tips for managing stress and sleeping soundly.

Survey Highlights: Connection Between Stress and Sleep

Seven out of ten adults in the U.S. say they experience stress or anxiety daily, and nearly half of those adults say it interferes with their lives every day. Also, eight out of ten adults have experienced some type of sleep-related difficulty, and women are significantly more likely than men to have trouble falling asleep, staying asleep, and not feeling rested after sleep.

These are among the findings of the 2007 Stress & Anxiety Disorders Survey, commissioned by ADAA, the sponsor of National Stress Out Week. The survey also found:

Those who experience daily stress or anxiety are significantly more likely to experience physical ailments, especially in relation to poor sleep.

Three-fourths of adults whose sleep is affected by stress or anxiety say that their sleep problems have also increased their stress and anxiety.

57 percent of women and 49 percent of men report that anxiety-induced sleep problems affect their relationships, but only half of adults who experience sleep difficulties have consulted a professional.

Two-thirds of adults who missed work due to sleep-related difficulties have not told their employer the real reason they missed work.

Take a deep breath. Now exhale slowly. You're probably not aware of it, but your heart has just slowed down a bit. Not to worry; it will speed up again when you inhale. This regular-irregular beat is a sign of a healthy interaction between heart and head. Each time you exhale, your brain sends a signal down the vagus nerve to slow the cardiac muscle. With each inhale, the signal gets weaker and your heart revs up. Inhale, beat faster. Exhale, beat slower. It's an ancient rhythm that helps your heart last a lifetime. And it leads to lesson No. 1 in how to manage stress and avoid burnout.

NO. 1 REMEMBER TO BREATHE

EVOLUTION HAS BEQUEATHED TO OUR BRAINS A variety of mechanisms for handling the ups and downs of life--from built-in chemical circuit breakers that shut off the stress hormones to entire networks of nerves whose only job is to calm you down. The problem, in the context of our always wired, always on-call world, is that they all require that you take regular breaks from your normal routine--and not just an occasional weekend trip. You can try to ignore the biological need to periodically disengage, but there's growing evidence that it will eventually catch up with you. Insurance claims for stress, depression and job burnout are now the U.S.'s fastest-growing disability category.

Making matters worse, Americans tend to cope with stress in all the wrong ways. A November survey by the advocacy group Mental Health America found that we frequently deal with chronic stress by watching television, skipping exercise and forgoing healthy foods. The problem with these coping mechanisms is that they keep you from doing things that help buffer your stress load--like exercising or relaxing with friends or family--or add greater stress to your body. Indeed, using many of our most cherished time-saving gadgets can backfire. Cell phones and mobile e-mail devices--to give just two examples--make it harder to get away from the office to decompress. Working from home may, in some cases, exacerbate the situation because it isolates employees while simultaneously blurring the line between work and leisure.

We also have a lot of misconceptions about who gets stressed out and why. Twenty years ago, psychologists almost exclusively blamed job stress on high workloads or lack of control on the job. More recent studies, says Christina Maslach, a pioneer in burnout research at the University of California, Berkeley, show that unfairness and a mismatch in values between employees and their companies play an increasing role in triggering stress. "Probably one of the strongest predictors is when there's a vacuum of information--silence about why decisions were made the way they were," Maslach says. "Another is having to operate in conflict with your values. Do you need to shade the truth to get authorization from the insurance company? Are you selling things that you know people don't really need?"

NO. 2 STRESS ALTERS YOUR BLOOD CHEMISTRY

FOR YEARS PSYCHOLOGISTS HAVE concentrated on the behavioral symptoms of burnout: lost energy, lost enthusiasm and lost confidence. Now, thanks to new brain scans and more sophisticated blood tests, scientists can directly measure some of the effects of stress on mind and body--often with surprising results.

You are probably familiar with the signs of an adrenaline surge (racing pulse, hairs on the neck standing on end), which evolved to help us fight or flee predators and other immediate dangers. And you may have heard of cortisol, another stress hormone, which is produced more slowly than adrenaline and lingers in the bloodstream longer. But did you know that too little cortisol in your bloodstream can be just as bad as too much? Or that tucking into comfort foods, while soothing in the short term, can sabotage your long-term stress response by increasing the number of inflammatory proteins in your body?

What's emerging is a complex picture of the body's response to stress that involves several interrelated pathways. Scientists know the most about cortisol because until now that has been the easiest part to measure. "But when one thing changes, all the others change to some degree," says Bruce McEwen, a neuroendocrinologist at Rockefeller University who has spent decades studying the biology of stress, primarily in animals. So just because you see an imbalance in one area doesn't mean you understand why it is happening. "We're learning that post-traumatic stress disorder (PTSD), burnout, chronic fatigue syndrome and fibromyalgia are all related in some ways," McEwen says. The next step is to figure out if there are any genetic predispositions that tip the response to stress toward one set of symptoms or another.

NO. 3 YOU CAN'T AVOID STRESS

EVEN GETTING OUT OF BED CAN BE TOUGH ON THE BODY. SEVERAL hours before you wake each morning, a tiny region at the base of your cerebrum called the hypothalamus sends a signal that ultimately alerts your adrenal glands, which sit on top of your kidneys, to start pumping out cortisol, which acts as a wake-up signal. Cortisol levels continue to rise after you become conscious in what is sometimes referred to as the "Oh, s___! It's another day" response. This may help explain why so many heart attacks and strokes occur between 6 a.m. and 8 a.m.

Because cortisol is a long-acting hormone, you can dally under the covers a bit without losing any steam. But your brain is already taking steps to protect you from the shock of starting a new day. Rising cortisol levels signal the hypothalamus to stop sounding the alarm. Other parts of the brain chime in, and eventually the adrenal glands ratchet down their cortisol production. In other words, the brain's stress response contains its own off switch.

Most people's cortisol, as measured by a saliva test, peaks a few hours after waking. Levels then gradually decline during the course of the day--with a few blips scattered here and there. That pattern typically changes, however, in people who are severely depressed. Their cortisol level still rises early in the morning, but it stays high all day long. It's almost as if their hypothalamus has forgotten how to turn off the stress response. (Intriguingly, people who are sleep deprived also exhibit a high, flat cortisol level.)

Researchers figured something similar had to be happening in burnout victims. But rather than finding a prominent cortisol peak, investigators discovered a shallow bump in the morning followed by a low, flattened level throughout the day. Intriguingly, such blunted cortisol responses are also common among Holocaust survivors, rape victims and soldiers suffering from PTSD. The difference seems to be that people with PTSD are much more sensitive to cortisol at even these low levels than those with burnout. "We used to blame everything on high cortisol," says Rachel Yehuda, a neurochemist and PTSD expert at the Mount Sinai School of Medicine in New York City. "Now we can blame things on low cortisol as well."

NO. 4 STRESS CAN AGE YOU BEFORE YOUR TIME

SCIENTISTS HAVE LONG SUSPECTED THAT unremitting stress does damage to the immune system, but they weren't sure how. Then two years ago, researchers at the University of California, San Francisco, looked at white blood cells from a group of mothers whose children suffered from chronic disorders like autism or cerebral palsy. The investigators found clear signs of accelerated aging in those study subjects who had cared the longest for children with disabilities or who reported the least control over their lives.

The changes took place in microscopic structures called telomeres, which are often compared to the plastic wrappers on the ends of shoelaces and which keep chromosomes from shredding. As a general rule, the youngest cells boast the longest telomeres. But telomeres in the more stressed-out moms were significantly shorter than those of their counterparts, making them, from a genetic point of view, anywhere from nine to 17 years older than their chronological age.

NO. 5 STRESS IS NOT AN EQUAL-OPPORTUNITY EMPLOYER

IN 1995, IN A NOW CLASSIC EXPERIMENT, SCIENTISTS AT THE University of Trier in Germany subjected 20 male volunteers to a situation guaranteed to raise their stress levels: participating in a mock job interview and solving arithmetic problems in front of strangers who corrected them if they made mistakes. As expected, each subject's cortisol level rose at first. But by the second day of the trial, most of the men's cortisol levels did not jump significantly. Experience had taught them that the situation wasn't that bad. Seven of the men, however, exhibited cortisol spikes every bit as high on the fourth day as the first. Only by the fifth day did their stress reaction begin to disappear.

More recently, researchers have found that subjects with low self-esteem are more vulnerable to stress. Jens Pruessner at McGill University in Montreal believes that the hippocampus, a finger-size structure located deep in the brain, is at least partially responsible. It turns out that the hippocampus, which helps you form new memories and retrieve old ones, is particularly sensitive to the amount of cortisol flooding your cerebrum. So when cortisol levels begin to rise, the hippocampus sends a set of signals that help shut down the cortisol cascade.

Using several different types of brain scans, Pruessner has shown that people who test below average on self-esteem also tend to have smaller-than-average hippocampi. The differences become clear only when you compare groups of people, Pruessner notes, so you can't look at any single person's brain scan and determine whether he or she has low self-esteem. But when you look at overall results, they suggest that a smaller hippocampus simply has more trouble persuading the rest of the brain to turn off the stress response.

Still unclear is how the body goes from having repeated activation of the stress response to showing the typically blunted cortisol levels of someone suffering from burnout. "We are still studying this," says Samuel Melamed of Tel Aviv University in Israel. "But if there is no relief and the cortisol stays up for long periods of time, the body stops responding and readjusts the level."

NO. 6 THERE'S MORE THAN ONE WAY TO RELIEVE STRESS

THIS IS PROBABLY THE TOUGHEST LESSON TO INTERNALIZE BECAUSE when stress overwhelms the system, your choices often seem more limited than they are. Behavioral scientists have a name for this psychological reaction. They call it learned helplessness, and they have studied the phenomenon closely in laboratory rodents, whose nervous system bears striking similarities to that of humans.

Here's how the experiment works: if you provide mice with an escape route, they typically learn very quickly how to avoid a mild electrical shock that occurs a few seconds after they hear a tone. But if the escape route is blocked whenever the tone is sounded, and new shocks occur, the mice will eventually stop trying to run away. Later, even after the escape route is cleared, the animals simply freeze at the sound of the tone--despite the fact that they once knew how to avoid the associated shock.

Obviously, humans have more intellectual resources at their disposal than mice do, but the underlying principle remains. When too many of the rules change, when what used to work doesn't anymore, your ability to reason takes a hit. Just being aware of your nervous system's built-in bias toward learned helplessness in the face of unrelieved stress can help you identify and develop healthy habits that will buffer at least some of the load (see box).

But the one thing you should not do is ignore the risks. Animal research has shown that there is a relatively small window for reversing the physiological effects of chronic stress. Studies of people are starting to produce similar results. Once a person's cortisol level gets completely blunted, it seems to stay that way for years. You owe it to yourself and your loved ones not to let that happen.

Some stressful events seem to turn a person's hair gray overnight. Now a team of researchers has found that severe emotional distress - like that caused by divorce, the loss of a job, or caring for an ill child or parent - may speed up the aging of the body's cells at the genetic level. The findings, being reported today, are the first to link psychological stress so directly to biological age. The researchers found that blood cells from women who had spent many years caring for a disabled child were, genetically, about a decade older than those from peers who had much less caretaking experience.

The study, which appears in Proceedings of the National Academy of Sciences, also suggests that the perception of being stressed can add years to a person's biological age. Though doctors have linked chronic psychological stress to weakened immune function and an increased risk of catching colds, among other things, they are still trying to understand how tension damages or weakens tissue. The new research suggests a new way that such damage may occur and opens the possibility that the process can be reversed. "This is a new and significant finding," said Dr. Bruce McEwen, director of the neuroendocrinology laboratory at Rockefeller University in New York. He said the research provided some of the clearest evidence yet "of the price in wear and tear on the tissues that everybody pays during a stressful life." "And we know as we get older," Dr. McEwen continued, "we have a greater tendency to put on fat, to develop heart disease and diabetes."

In the experiment, Dr. Elissa Epel and Dr. Elizabeth Blackburn of the University of California at San Francisco led a team of researchers who analyzed blood samples from 58 young and middle-aged mothers, 39 of them caring for a child with a chronic disorder like autism or cerebral palsy. Using genetic techniques, the doctors examined the DNA of white blood cells, which are central to the body's immune response to infection. The scientists focused on a piece of DNA, called the telomere, at the very tip of each cell's chromosomes. Like the head of a split matchstick, the telomere shrinks each time a cell divides and duplicates itself. Cells may reproduce themselves many times throughout life to repair and strengthen their host organs, to grow or to fight disease. A chemical called telomerase helps restore a portion of the telomere with each division. But after 10 to 50 divisions or so - the number varies by tissue type and health, and biologists still do not understand the system well - the telomere gets so short that the cell is effectively retired and no longer able to replicate.

People born with a genetic disease called dyskeratosis congenita, which causes accelerated shortening of telomeres, die young, usually by middle age, most often as a result of complications from weakened immunity. Change in telomere length over time, in short, is thought to be a rough measure of a cell's age, its vitality. And when the researchers compared the DNA of mothers caring for disabled children, they found a striking trend: after correcting for the effects of age, they calculated that the longer the women had taken care of their child, the shorter their telomere length, and the lower their telomerase activity. Some of the more experienced mothers were years older than their chronological age, as measured by their white blood cells. "When people are under stress, they look haggard, it's like they age before your eyes, and here's something going on at a molecular level" that reflects that impression, said Dr. Blackburn, a professor of biochemistry and biophysics.

The researchers also gave the women a questionnaire, asking them to rate on a three-point scale how overwhelmed they felt by daily life, and how often they were unable to control the important things in their lives. The women who perceived that they were under heavy stress also had significantly shortened telomeres, compared with those who felt more relaxed - whether they were raising a disabled child or not. "Some of the women who had a lot of objective, real stress also had a low perceived amount of stress, and the next step is trying to understand what it is that promotes this kind of resilience," said Dr. Epel. She said the group had plans to test the effect of meditation, mindfulness training and yoga on both perceived stress and telomere length.

A form of counseling called cognitive therapy, in which people learn to temper their responses to stress, could also help, psychologists say. Personality and upbringing almost certainly account for some of this difference, however. In 2003, researchers who followed some 850 New Zealanders from birth to 26 reported that variations in a single gene helped predict which children would later become susceptible to depression, after stressful events like divorce or unemployment. Researchers at the National Institutes of Health have shown, in monkeys, that warm and attentive rearing of offspring can protect young animals from precisely this genetic variation, promoting resilience in genetically vulnerable individuals. Cold or abusive rearing, psychiatrists say, can have the opposite effect. "All of these factors intertwine to make up how a person handles stress," said Dr. Ronald Glaser, director of Ohio State University's Institute for Behavioral Medicine Research, who with his wife, Dr. Janice Kiecolt-Glaser, has documented the effect of stress on immune function.

"We now have evidence, from a broad range of fields, from studies of wound healing, of inflammation, of vaccines, and now of cell age that really make the case" that stress can cause real harm. Experts caution that the telomere study needs to be replicated and that no one has yet shown convincingly that psychological stress significantly shortens people's lives. And it is far from clear exactly how fretting over a child's learning disability, say, can cause a parent's telomeres to shorten before their time. Although researchers know that emotional strain of this kind prompts the release of stress hormones, like cortisol, which over time can damage cells, no one knows how these hormones or other stress-related toxins affect telomeres. "Right now, that is the black box," said Dr. Blackburn, "and that's what we're going to study next."

Jerry Seinfeld got a big laugh when he joked about a survey that found that the fear of public speaking ranks higher in most people's minds than the fear of death. "In other words," he deadpanned, "at a funeral, the average person would rather be in the casket than giving the eulogy." It's a funny line, but the comedian may have had it backward. Short-term stresses like speaking in public, it turns out, boost your immune system in ways that tend to keep you out of the coffin, not put you in it.

That's one of the findings that emerged from a study of 30 years of stress research published last week in Psychological Bulletin, a journal of the American Psychological Association. In a meta-analysis of more than 300 studies involving some 19,000 subjects, psychologists Gregory Miller at the University of British Columbia and Suzanne Segerstrom at the University of Kentucky combed through thousands of pages of research in search of common threads. What they discovered is that modern stresses prompt complex reactions beyond the simple fight-or-flight response - the primordial motivator that sends your heart racing and pumps up your blood pressure. In particular, stress triggers a variety of changes in the immune system - some beneficial, some decidedly less so - depending on how long the stress lasts and whether there is an end in sight.

To help make sense of it all, Miller and Segerstrom divided the modern universe of stressful situations into several major categories. Giving a Speech When test subjects were asked to speak in public or do mental math in the lab, the tasks tended to mobilize their fast-acting immune response - the body's all-purpose defense system for fending off infection and healing wounds. Compared with controls, people subjected to such short-term stresses had up to twice as many natural killer cells in their blood ready to fight the early stages of infection. Taking a Final Exam Short-term stressors with high stakes - like the SATs or the bar exam - appeared to hinder the immune response by suppressing Th1 cells, which normally activate killer cells and wound-healing chemicals called cytokines. This suppression can also boost the concentration of Th2 cells, which produce antibodies and can make allergies worse.

Surviving Natural Disasters

The results were less consistent for stressful events that give rise to a succession of future hardships, such as the death of a spouse or the effects of a natural disaster like an earthquake. Researchers believe that bereavement causes a decline in natural immunity, while a handful of studies suggest the trauma following a disaster may trigger a small immune boost. Enduring Layoffs Chronic stressors that alter a person's role in society or sense of himself and show no sign of ending, such as unemployment, permanent disability or the need to care for a parent with dementia, are bad news. They have significantly negative effects on almost all immune functions. So do people subjected to such stresses actually get sick? There have been surprisingly few studies to test that question, but research on long-term hardship at work finds that the stresses are associated with an increase in heart disease.

Other studies, conducted by Sheldon Cohen, a professor of psychology at Carnegie Mellon University, found that people suffering chronic stress on the job or in relationships are at least twice as likely to get sick from a cold or flu. The more stress people endure, Cohen concluded, the better their chances of falling ill. But that's not true for everyone, and researchers would love to identify the psychological quirks that protect some people and sabotage others. Small studies suggest that the immune systems of optimistic law students are more robust than those of pessimists and that worrywarts suffer deeper hits to their immune system after a traumatic event than do nonworriers.

We're not all born with sunny dispositions, but experts have identified stress-management strategies that anyone can adopt. Avoid situations that you know cause stress, for example. Discuss problems with friends, family or a mental-health professional before they take on a life of their own. Face stress head-on and don't resort to coping mechanisms - smoking, eating more and exercising less - that only add to the strain. You can't avoid stress altogether, but you can learn to keep it at bay.

Article: "Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry," Suzanne C. Segerstrom,Ph.D., University of Kentucky, and Gregory E. Miller, Ph.D., University of British Columbia; Psychological Bulletin, 2004,130.

It is the first published scale that focuses specifically on perfectionism from a multidimensional perspective. According to Flett, who collaborated with UBC psychology Prof. Paul Hewitt, perfectionists are people who not only hold unrealistically high standards but also judge themselves or others as always falling short. "Perfectionism is the need to be - or to appear - perfect," says Flett. "Perfectionists are persistent, detailed and organized high achievers. Perfectionists vary in their behaviors: some strive to conceal their imperfections; others attempt to project an image of perfection. But all perfectionists have in common extremely high standards for themselves or for others." Moreover, Flett, who is also Canada Research Chair in Personality and Health, adds that certain forms of perfectionism can be linked to a host of emotional, physical and relationship problems, including depression, eating disorders, marital discord and even suicide.

"Perfectionism is not officially recognized as a psychiatric disorder. However extreme forms of perfectionism should be considered an illness similar to narcissism, obsessive compulsiveness, dependent-personality disorder and other personality disorders because of its links to distress and dysfunction." For instance, a 1994 experiment with 30 preschoolers at a computer camp in Toronto showed that even 4- and 5-year-olds possess marked traits for perfectionism. Interviewers asked the children five questions tapping perfectionism levels ("How would you like to be perfect?"). They then gave the kids a computer task that was rigged to not work.

The highly perfectionistic children showed greater signs of extreme distress, such as elevated anger and anxiety, explains Flett. He adds that perfectionists reveal themselves in three distinct ways: first, a "self-promotion" style, that involves attempts to impress others by bragging or displaying one's perfection (this type is easy to spot because they often irritate other people); second, by shunning situations in which they might display their imperfection (common even in young children); and third, a tendency to keep problems to oneself (including an inability to admit failure to others).

Ten Top Signs Your a Perfectionist: Are you a perfectionist?

Flett has devised a list of telltale signs: 1. You can't stop thinking about a mistake you made. 2. You are intensely competitive and can't stand doing worse than others. 3. You either want to do something "just right" or not at all. 4. You demand perfection from other people. 5. You won't ask for help if asking can be perceived as a flaw or weakness. 6. You will persist at a task long after other people have quit. 7. You are a fault-finder who must correct other people when they are wrong. 8. You are highly aware of other people's demands and expectations. 9. You are very self-conscious about making mistakes in front of other people. 10. *You noticed the error in the title of this list!

Secret #1: Stress happens

Stress has become an all-purpose gimmick to get our attention. Many magazines and TV shows love nothing more than suggesting that we can't make it through the day without practically dying from stress. Yes, we all have stress. But not all day, not every day. I find it downright insulting to hear that we can't keep it together when we're merely going about our good, if sometimes complicated, lives. The newest research says that the best way to handle stress is not by checking into a day spa or anything else where the goal is stress reduction. That sort of binge-and-purge approach does little to keep us relaxed. Instead, we should simply acknowledge that life is full of little tensions because, hey, that's life. And we should handle it moment by moment the way people always have, by taking a deep breath and getting some perspective.

Secret #2: Check your "balance"

Stop worrying about achieving balance in your life, especially when you have kids. Kids take up all available time-it's the basic law of parenthood. No matter how much time you give them, whether you work from eight to eight or are around the house all the time, you'll still feel you haven't been there enough for them. Every American child born since 1970 seems to have the innate capacity to make his or her parents feel guilty. Here's the deal: While your children are around, you won't have time to put your life in perfect balance. That's really not so terrible. You are supposed to think more about your kids than about yourself. You had time for "you, you, you" before the kids were around. Trust me, you'll have time after they've left home.

Secret #3: Be fear-less

When it wants to make a big impression, the media isn't shy about scaring us out of our wits. Reporting and pessimism have become totally intertwined in so many areas, especially in stories about health and the environment. We're supposed to fear everything, from killer celery to weapons of mass destruction. How to protect yourself from the effects of these constant guerrilla tactics? Kimberly Thompson of the Harvard School of Public Health suggests remembering that how we perceive and process information depends upon how it's presented, positively or negatively. If you hear about a small number of people stricken by a rare illness, it follows, doesn't it, that a large number of people (including you) are perfectly fine. Remember, almost all media scare stories are about something dastardly that happened to a very small group of people, like the unlucky women who happened to share the same infected foot basin in just one nail salon in California. In your fight against fear: "h Compare the hype to the facts. A little healthy skepticism is in order. "h Be wary of pictures. Just because someone is crying does not mean she is telling the truth. "h Don't let impressive sounding jargon convince you. "h Always ask, Is there a specific agenda at work in this story? "h Watch the disclaimers. "Might" or "could" doesn't mean that you or your family are really at risk.

Secret #4: Nobody's perfect

Here's what a lot of the media want us to believe: One day, we'll get everything right about our appearance. Our hair will look fabulous, our skin will be smooth and crease-free, men will have perfect six-pack abs and we'll be three sizes smaller than we are now. We'll look so good we'll have made over not just our looks but our lives. Magazines, TV and films like to encourage people to aim high. And to a certain extent, that's fine. But recent advertising studies confirm that people prefer images of themselves that reflect reality. We've become wary of a fantasy life and are shrewd enough to know that in reality the fantasy is often liposuctioned, implanted, lifted, tightened and Botoxed. Of course, we all want to look good, but without going to extremes or over budget. We also know you cannot buy sex appeal. Men are more frightened by women who are too obsessed with looking perfect than by those who are relaxed about their standard-issue bumps, lumps and blemishes. And women are getting sick of men's narcissism brought on by the metrosexual craze. The bottom line? The people important to you-the ones who are in your life-already like the way you look. And better yet, they like you more for what's going on inside than what can be seen on the outside.

In the early 1970's, demographers began to notice a strange pattern in life span data: married people tended to live longer than their single, divorced and widowed counterparts. The so-called marriage benefit persists today, with married people generally less likely to have surgery and to die from all causes, including stroke, pneumonia and accidents. At its widest, the gap is striking, with middle-aged men in most developed countries about twice as likely to die if they are unmarried.

Many have argued that the difference in life expectancy is actually because healthier people are more likely to marry. But an emerging group of marriage advocates has put a spotlight on the medical potential of the institution. "Marriage is sort of like a life preserver or a seat belt," argues Dr. Linda Waite, a professor of sociology at the University of Chicago and an author of "The Case for Marriage," published in 2000. "We can put it in exactly the same category as eating a good diet, getting exercise and not smoking." But even as marriage is being packaged as a boon to health, there is a new caveat. While people in good, stable partnerships do, on average, have less disease and later death, mounting evidence suggests that those in strained and unhappy relationships tend to fare worse medically.

Women seem to bear the brunt of marriage's negative health consequences. In some ways, the physical perils of bad pairings should be obvious, with domestic violence just the most drastic illustration of how romance can lead to bodily havoc. At its best, marriage acts as a balm against loneliness and stress, each associated with ill health. The marriage benefit probably extends also to gay couples in committed romantic partnerships and to unmarried heterosexual couples who have been together for years, many researchers agree. But at its worst, marriage can also be a cause of isolation. And, not surprisingly, the tensions and arguments of marriage can often lead to depression, with many studies finding increases in depressive symptoms among those who have reported marital discord compared with those who have not reported such discord.

Bad marriages can also have some unexpected negative consequences for health. Men and women who reported low-quality marriages had more gum disease and cavities than happily married people. Two studies found marital strain to be linked to ulcers in the stomach and intestine. And people's satisfaction with their relationships appears to alter how they experience pain. Some of these physical effects seem to be direct results of behavior. A supportive partner can help a person stick to restrictive diets and exercise regimens, for instance.

Perhaps more important, according to Dr. James Coyne, a professor of psychiatry at the University of Pennsylvania, who has studied the effects of marital quality on recovery from congestive heart failure, a good marriage can give a person a reason to stay alive. "Even when your own determination to get better wavers, the commitment to your partner puts you back on track," Dr. Coyne said. In contrast, he said, a bad marriage can be worse than none at all. "Some of these people," he said, "if their spouses said, `breathe for the next half-hour,' they'd try to hold their breaths. It can get that stubborn in a bad marriage."

That bullheadedness can turn into a matter of life and death, according to Dr. Coyne's study, published last year in The American Journal of Cardiology. It found that the quality of patients' marriages predicted their recoveries as well as the pumping ability of their hearts. Dr. Coyne and his colleagues videotaped couples' arguments in their homes and grouped them according to the negativity of their interactions. Those heart patients who were more negative with their spouses were 1.8 times as likely to die within four years as those who were given less negative ratings. "That's powerful stuff," Dr. Coyne said. "We never expected the effect to be that big."

Perhaps even more surprising is the evidence that relationship strain can take a direct physiological toll. According to Dr. Janice Kiecolt-Glaser, a professor of psychiatry at Ohio State University, and her husband, Dr. Ronald Glaser, an immunologist, marital arguments cause changes in the endocrine and immune systems. During and after stressful conversations, levels of the hormones epinephrine and cortisol rise and can stay elevated for more than 22 hours afterward. Blood pressure and heart rate also tend to go up with relationship stress. A 1998 study showed that women who were unhappy with their marriages experienced increases in blood pressure readings just from thinking about fights they had had with their husbands. And while these biological markers suggest that marital tension can make a person vulnerable to health problems, several researchers have documented that relationship problems affect the actual severity of illnesses. One study of patients with Parkinson's disease documented an association between marital distress and symptoms like eye-blinking. Research on married people with Alzheimer's disease has shown that criticism from a spouse predicted symptoms.

And, in what may be the oddest study in the field, Dr. Kiecolt-Glaser and Dr. Glaser are now researching how the quality of a marriage affects the body's ability to repair itself. In the continuing study, the scientists admit subjects to a hospital, inflict minor wounds on their arms, and then chart their interactions with their spouses and their progress in healing. As with the overall "marriage benefit," which for women is smaller than for men - and possibly even nonexistent, according to some researchers - women are more vulnerable to relationship-related health problems. Illustrating the strong negative effect on women, a 15-year study of members of a large health maintenance organization in Oregon found that having unequal decision making power in marriage was associated with a higher risk of death for women, though not for men. In Dr. Coyne's study of congestive heart failure, there was a stronger association between marital discord and death among women. Seven of the eight women with the poorest marital quality died within two years of the first assessment. Studies consistently show that the physiological effects of marital stress are stronger and last longer in women.

"We don't know why women are so much more sensitive to negativity or hostility than men," Dr. Kiecolt-Glaser said. Nor do people agree on how to make use of the new data. Dr. Waite of the University of Chicago, who is also a board member of the pro-marriage Institute for American Values, suggests that H.M.O.'s should create programs to help people have better marriages. And Dr. Coyne is hoping cardiologists will begin to consider their patients' interpersonal relationships as well as their hearts. For Dr. Alex Zautra, a professor of psychology at Arizona State University in Tempe, who has shown an association between criticism from intimate partners and joint pain in women with rheumatoid arthritis, the lesson from this growing literature is not to think of interpersonal ties as either all positive or negative.

"In truth, all relationships have both good and bad aspects to them," Dr. Zautra said. The point, he said, is that, in all their complexity, they matter. "At the heart of this is how people's emotions affect their health. People need to start thinking about that."

Anxiety and Stress Disorders Institute of Maryland:
Treating anxiety disorders and stress-related disorders in Towson, Maryland, since 1978.