1. Caxton Opere, MD DP & M Institute Baton Rouge, LA

2. Are divorcees at any greater risk of becoming sick or dying, i.e, do divorcees have higher morbidity or mortality when compared to non-divorcees Which divorcee is at risk or greatest risk of morbidity or mortality? What is the divorcee at risk of? Is there a need for public health intervention programs specially directed at divorcees?

3. The medical complications of divorce result from a combination of both well known and poorly understood mechanisms. Foremost and well known is the nature or dynamics of human relationships and the capacity of humans to inflict unimaginable cruelty on each other and to complicate the simplest and sweetest of human experiences, that is, the marital experience. As a result of this Homo sapiens tendency, there are about 30 million divorcees in the United States alone or 10% of the entire US population or an even greater percentage of the US adult population.

4. Much less is understood about how a divorce can directly or indirectly affect the physical health of the divorcee for worse. Regardless of our understanding or lack however, the divorced individual is still at much greater risk of disease, death and disability.

5. Bette, twenty-seven, and Ross, twenty-five got married two weeks after completing their masters degrees in social work. Bette desired to start a family right away so she stayed home after graduating. Ross on the other hand, wanted to wait for another five to seven years before having children. They fought constantly. Bette threatened to file for divorce. She claimed she was sick of Ross selfishness, immaturity and insensitivity to her own needs. After twelve months of verbally and emotionally tormenting Ross for not being man enough to start a family, Bette filed for divorce.

6. Fay was a physical therapist at a nearby hospital. Her husband filed for divorce 5 years after marriage. Fay sought consultation after reading The 36 Well Kept Secrets of Successful Marriages & Divorce. When asked if he was a good husband and if he loved their two daughters, Fay said yes. She admitted she did not know what was most important to men in a marriage until after she read the book and did not want to repeat the same mistake again.

7. Jeff is a 43-year old divorced father of two with joint custody of his two teenage girls. One evening while dropping off the kids, he had an argument with his ex-wife that was accompanied by sudden onset of severe left-sided chest pain. His ex-wife called the ambulance immediately. He survived a massive heart attack. He confessed to his cardiologist that he was very angry at his ex-wife just before the onset of the chest pain. He promised never to let that happen again.

8. Bloom & Asher Marital breakup precipitates mental illness Mental illness twice as high in divorcees Psychiatric hospitalizations more than tripled in divorcees Psychiatric hospitalizations more than doubled in widows Psychological Bulletin, 1978

10. Kposowa Divorced and separated men in the National Longitudinal Mortality Survey were twice as likely to commit suicide as married men. Singles, widows and women did not have such high risks. J Epid & Comm Health April 2000

11. While divorce can increase the risk of suicide and other psychiatric illnesses, the mental stress of a bad marriage or divorce can trigger life-threatening changes in the body.

12. Dr. Laveau and colleagues reported in their study of 16 subjects in volume 118 of the American Heart Journal that within just one minute following exposure to mental stress, the ejection fraction of the heart, that is, the proportion of blood pumped out from the heart with each heartbeat, dropped significantly. And it did this without causing any chest pain in the study participants.

13. Mental stress reduced blood flow to the heart and forearm in 10 healthy subjects subjected to mental stress by giving them arithmetic problems to solve. Sarabi & Lund Vascular Medicine, 2001.

14. Divorce is a recognized source of stress. It is rated high on the Rahe-Holmes Scale and considered to be next to the death of a loved one on that scale.

15. Divorce is not only stressful, it creates a state of stress which depending on the circumstances, may be temporary or permanent. Asides from suicide, divorcees are at a greater risk of death, disease and disability.

16. Epidemic = Occurrence in a community or region of cases of an illness, specific health- related behavior or health-related events clearly in excess of normal expectations.

17. Epidemic = 30 million divorcees/300 million people = 10 % of American population are divorced

18. Dr. Koskenvuo et al: Using death certificates, Dr. Koskenvuo and colleagues in Helsinki, Finland, looked at the different causes of death in 44,548 deceased Finnish men and women between the ages of 25 and 64 years. Their findings were published in 1979 in volume 13A of Social Science and Medicine.

20. Dr. Hu and Dr. Goldman Demography May 1990 They reviewed mortality differences on an international scale and published their findings in the May 1990 issue of Demography. They showed that divorced persons, especially divorced men, had the highest death rates among the unmarried groups. The unmarried groups consisted of the never- married singles, divorcees and the widowed. In France, Japan and Hungary, relative mortality ratios for divorced men were reported as 85%, 55% and 67% respectively higher than they were for married men.

21. In 13 of sixteen developed countries surveyed, divorced males had the highest relative mortality ratios (except Portugal, Taiwan and France) Yuanreng Hu, Noreen Goldman, 1990 Relative mortality ratios corrected for other correlates of mortality – (sex) suggests that divorced males in North America(+Brooklyn) suffer greater excess mortality than their European Countries

23. Dr. Kposowa J Epid & Comm Health April 2000 According to the results of the National Longitudinal Mortality Survey Divorced and separated men were more than twice as likely to commit suicide as married men. Singles, widows and women did not have such high risk, implying that marital breakup is what increased the suicide risk and not just being single in these men.

24. Why a Divorce can Kill? The divorce cost my ex-wife and me more than $250,000 plus three years of excruciating, non-stop, mind-numbing stress-that should have cost only a few thousand dollars. The irony is that the final custody arrangements, support payments, and division of assets set by the attorneys negotiations and the judges rulings ended up being exactly what my wife and I had verbally agreed upon in our kitchen conversation two years before. David Bell author of Divorce: Making The Break

25. Divorce can kill. So can its first cousin, a bad marriage and its other cousin, conflicts in marriage. All three must be understood by anyone wishing to do something significant to protect their health, life or property particularly with the current divorce epidemic.

26. We are soon filled with anger, bitterness, hostility, anxiety, vengeance with which we trapped our souls in an unending cycle of pain long after our assailant hath departed from the shadows of our life. Anon.

27. Contact with ex in past 1 year MaleFemaleAverage None232223 Once a year788 Several times/yr171817 1-3/month182119 Once a week171617 > Once a week181517 Source: Statistical Handbook of The American Family. 2 nd edition. Oryx Press. Edited by Bruce Chadwick & Tim B Heaton

28. Describe Your Current Relationship with ex MaleFemaleAverage Very unfriendly211920 Somewhat U101714 Neither U nor F322930 Somewhat F21 Very F161415 U – unfriendly F - friendly Source: Statistical Handbook of The American Family. 2 nd edition. Oryx Press. Edited by Bruce Chadwick & Tim B Heaton.

29. Frequency of arguments with spouse in year b4 separation MaleFemaleAverage Hardly/not at all151615 Couple times/month161415 Once a week171114 Several times a week33*3132 At least every day16*1415 Many times a day 4*107 Source: Statistical Handbook of The American Family. 2 nd edition. Oryx Press. Edited by Bruce Chadwick & Tim B Heaton

30. Outcome of arguments with spouseMale Yes(No) Female Yes(No) Did arguments ever become physical? 17(83)33(67) Were you ever cut, bruised or seriously injured in a fight with him/her? *52(48)*64(36) Was your husband/wife ever cut, bruised or seriously injured in a fight with you? *30(70)*15(85) Were you involved with someone else just before your marriage ended? 17(83)18(82) Was your spouse involved with someone else just before your marriage ended? Yes/No/Dont know 42/40/1839/42/19 Source: Statistical Handbook of The American Family. 2 nd edition.

31. According to the Center for Disease Control, about 20% of the general population in the United States have levels of hostility high enough to be dangerous to their health. Monthly Vital Statistics Report supplement March 22, 1995

32. 20 percent of 300 million = 60 million individuals intoxicated with hostility. It is very easy to fit in the 30 million divorcees into this group of 60 million intoxicated individuals. Anger, disgust and vengefulness are negative emotions (also measures of hostility) that accompany divorce in the law courts according to Seton Hall University Law Professor Solangel Maldonado who is recommending forgiveness education program for high conflict divorced parents.

33. ANGER and HOSTILITY have been recognized as potential risk factors for Coronary heart disease Kawachi I, Sparrow D, Spiro A, Vokonas P, Weiss T. A prospective study of anger and coronary heart disease: The normative aging study. Circulation 1996;94:2090–5. Dembroski TM, MacDougall JM, Costa PT Jr, Grandits GA. Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial. Psychosom Med 1989;51:514–22.

34. ANGER and HOSTILITY have also been recognized as potential risk factors for Hyperlipidemia Lipid-lowering medication use and aggression scores in women: a report from the NHLBI-sponsored WISE study. Olson MB et al. J Womens Health. 2008 Mar;17(2):187-94. Olson MB AIM: examine the association between the use of lipid-lowering medication and aggressive responding, hostility, cynicism, and depression scores in women undergoing coronary angiography. METHODS: 498 women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study.

35. ANGER and HOSTILITY have also been recognized as potential risk factors for Hyperlipidemia RESULTS: Women receiving lipid-lowering pharmacotherapy were Older (62 vs. 55 years, p < 0.001) More aggressive 3.0 +/- 1.8 vs. 2.7 +/- 1.7, respectively Had more CAD, defined as > or =50% stenoses in at least one epicardial artery) (all p < 0.003). This association persisted after adjustment for coronary risk factors, education, and extent of angiographic disease (CAD) (p < 0.005), Hypertension Dyslipidemia Diabetes

36. ANGER and HOSTILITY have also been recognized as potential risk factors for Hospitalization for angina Nonfatal myocardial infarction Stroke CHF, other vascular events and death) during 3 to 6 years Psychosomatic Medicine 67:546–552 (2005) 506 women with suspected CAD from the NHLBI WISE Study.

37. In 1995, Dr. Mittleman reported in issue 92 of Circulation that anger could triple the risk of a heart attack and was the trigger in close to 18 percent of the 1623 patients in their study. An anger episode within two hours was noted to more than double the risk for a heart attack in the group studied.

38. In a prospective study of anger and coronary artery disease published in Circulation in November 1996 by Dr Kawachi and colleagues at Harvard School of Public Health, anger was shown to increase the risk of fatal and non-fatal heart attacks almost three times. This Normative Aging Study looked at 1,305 male community dwelling veterans average age 61 and was the seed for the ARIC Study

39. The ARIC study, unlike the Normative aging study, which consisted mainly of white males, was a more extensive one with 12,990 subjects and included Black and White men and women between the ages of 45 and 64 at enrolment. The ARIC study findings reported by Dr. Williams and colleagues in the August 1, 2001 issue of the American Journal of Epidemiology as well as the subsequent data analysis of ARIC published more recently in the September 2007 issue of the Annals of Family Medicine by Dr. Player and colleagues at the Medical University of South Carolina show that anger increases the risk of a heart attack.

40. Dr. Players study also showed that long-term psychological stress increases the risk of CAD (the greatest killer) by about 1.68 and that men with prehypertension were 1.7 times more likely to develop hypertension and 1.9 times more likely to develop coronary heart disease.

41. Not having a mate decreases the effectiveness of an intervention according to the multicenter trial ENRICHD Burg et al Psychosomatic Medicine 67:879- 888, 2005. N = 1305, Effect of treatment assignment on Low Perceived Social Support, (LPSS)death and recurrent MI were examined. 29 months f/u Death/non-fatal MI-MI group 10%; 23% in LPSS group

42. Only half of cardiovascular disease risk has been explained by conventional risk factors. Gorelick PB. Stroke. 2002;33:862– 875

43. Anger trait increased the likelihood of carotid artery thickening and plaque formation Mary Bleil et al. Psychosomatic Medicine 2004

44. Raises blood pressure significantly Smith & Gallo Psychosomatic Medicine 1999

45. Divorce increases the risk of stroke, sometimes more than three to 16 times. Engstrom et al, Cerebrovascular Disease 2004

46. 2.5 x increase in violent and accidental deaths in divorcees according to the NHANES. Smith & Waitzmann. Demography 1994

47. 3 x increase in serious traffic accidents in divorced or separated persons according to the GAZEL study. Legarde et al. Epidemiology 2004

48. Many enter a marriage without knowing what they are getting into, thinking only of what they might get, ignoring what they might have to pay to get what they desire in the marriage. Expectations are often twisted, even amongst the smart, rich or righteous. Very few realize it is much easier to enter a marriage than it is to get out and that hardly anyone ever comes out unscathed. It is 8,760 times less difficult to into a marriage than it is to get out of one and so many go into marriage without counting the costs.

49. The cost of entering a marriage should be determined by calculating not only The wedding expenses or The cost of a marriage license or certificate but also The cost of a bad marriage, What it costs to end the marriage, as well as the subsequent Ripple Effect (p39) that inevitably follows the divorce. Few ever make these calculations and even fewer come to reasonable conclusions as evidenced by the high divorce rates of about 50 percent. The preparation that should precede going into a marriage =parental care discipline, sacrifices made by parents(time, money, prayers, etc) and the children themselves(avoiding premarital pregnancies etc). For some unfortunately, the preparation is NONE.

50. Justice of Peace Marriage Costs TIME = 1 hour MONEY = $25.00(marriage.about.com)

51. Divorce Proceedings One year (vs. 1 hour )= 365 $1,500(vs. $25) = 60 Do we multiply 60 x 365

52. We soon discovered that not only did we not get what we bargained for in the marriage, the way out was not as smooth as the one in. Alas! Hence mine hostility, my anger, and my anxiety offered no solace but rather robbed me of my health wealth and dignity! Anon

53. Mortality Morbidity Mental Illness = Psychiatric Morbidity

54. Divorce Marriage

59. MEDICAL COMPLICATIONS OF DIVORCE

60. True or False? Divorce can be considered a risk factor for A. Stroke. B. Breast Cancer C. Death D. Motor Vehicle Accidents

61. True or False There are no prospective or retrospective clinical trials showing that divorce is a risk factor for stroke.

62. True or False Persons at greater risk for stroke include A. Divorced individuals B. Angry people C. Hypertensive patients

63. After a divorce, the risk of a heart attack may A. Double B. Is unchanged

64. Which of these studies showed an increased risk of suicide in divorcees A. National Longitudinal Mortality Survey B. Harvard Mastery of Stress C. Malmo Study D. MRFIT

65. True or False. The most predominant emotions linked to diseases in divorcees include A. Anger B. Anxiety C. Hostility D. Depression E. None of the above

66. T or F. Stressful life events can lead to physical illness depending on a. The nature or severity of the event b. The individuals biological attributes c. The psychological attributes of the individual d. All of the above e. None of the above

67. Long term psychological stress can increase the risk of coronary artery disease by 1.68 times. A. True B. False A. ARIC Study

68. Which one of the following is true The Medical complications of Divorce A. Do not exist and are a myth B. Are a poorly understood public health issue

69. Potential Risk factors for stroke include A. Hostility (WISE) B. Divorce (MALMO) C. Stress Adaptive Capacity (EPIC-Norfolk)

70. He is the author of seven books and multiple audio CD teaching programs on relationships. Two of his books, The DNA of Highly Successful Marriages and HOW DIVORCE KILLS are also ebooks available online at apple and other online stores. He is a marriage building coach and is available for strategic curriculum planning for colleges, speaking engagements and coaching of individuals. He is a fulltime physician, busy father, author speaker and Contact information: Email – drcaxton@yahoo.comdrcaxton@yahoo.com Website – www.doccaxton.comwww.doccaxton.com YouTube search word – Pastor Caxton Opere Preaching