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Mental Health

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Articles 181 - 210 of 374

Full-Text Articles in Mental and Social Health

An Occupational Therapy Guidebook For Individuals With Substance Use Disorder, Cassidy B. Ardoin-Barnett, Steven M. Gerardi Aug 2022

An Occupational Therapy Guidebook For Individuals With Substance Use Disorder, Cassidy B. Ardoin-Barnett, Steven M. Gerardi

Summer 2022 Virtual OTD Capstone Symposium

Individuals with substance use disorder (SUD) experience barriers and challenges that impact their daily occupational performance, engagement, well-being, and quality of life. In addition to disrupting and distorting an individual’s unique occupational outcomes, SUDs can limit, replace, and dictate an individual’s daily meaningful activities, habits, routines, and skills that support healthy occupational engagement. Occupational therapy (OT) practitioners have a unique and valuable role in SUDs treatment as they are equipped to identify these barriers and implement strategies for supportive skill development or restoration. Based on the literature review conducted, OT practitioners do not have an OT practice guideline, protocol, or …


Social Support Protected Mental Health During The Covid-19 Pandemic, Jennifer Kowalkowski, Danielle C. Rhubart Aug 2022

Social Support Protected Mental Health During The Covid-19 Pandemic, Jennifer Kowalkowski, Danielle C. Rhubart

Population Health Research Brief Series

Social support can protect mental health from the stressors of life during times of widespread crisis, like the COVID-19 pandemic. Using nationally representative data on U.S. working-age adults (18-64), this brief shows that those who reported having emotional support from family and friends were less likely to report negative mental health effects from the COVID-19 pandemic (32.9%) compared to those without emotional support (50.2%). Adults with higher levels of instrumental support – being able to count on someone for a $200 loan or for a place to live - were also less likely than those without those types of support …


Employment Discrimination’S Impact On African American’S Professional And Personal Lives, Trey D. Williams Aug 2022

Employment Discrimination’S Impact On African American’S Professional And Personal Lives, Trey D. Williams

Information Systems Undergraduate Honors Theses

Title VII of the Civil Rights Act of 1964 makes it illegal to discriminate against a person because of their race, color, religion, sex, or national origin. The law also protects individuals from retaliation if they complain about discrimination, participate in an employment discrimination proceeding, or reasonably oppose discrimination. Although Title VII makes discrimination illegal, it is still present in the workplace. The objective of this thesis is to discuss employee discrimination based on race and sex. Specifically, I will analyze the current workplace discrimination against African American men and women as well as the psychological, physiological, and emotional effects …


The Effects Of Covid-19 On Mental Health And Injury Occurrence Of Division Iii College Football Players, Evan Kennaley Aug 2022

The Effects Of Covid-19 On Mental Health And Injury Occurrence Of Division Iii College Football Players, Evan Kennaley

Masters Theses/Capstone Projects

Objective: The aim of the study was to investigate if with the lockdown of COVID-19 and the reschedule of the Fall 2020 football season caused an increase in injury in a Division Three College football team.

Methods: A 20 question survey was given to the 2022 Spring Otterbein football team. The survey allowed for self reporting of injuries suffered in the 2019,2020, and 2021 football seasons. The survey also looked to examine if there is any anxiety the players suffered from during the lockdown using the Covid Anxiety Scale.

Results: Of the 63 surveys, it was found that the 2021 …


Local Broadcast Reporters Maintaining Social Responsibility And Mental Health While Serving A Community Under Lockdown, Mary-Morgan Ellis Aug 2022

Local Broadcast Reporters Maintaining Social Responsibility And Mental Health While Serving A Community Under Lockdown, Mary-Morgan Ellis

Graduate Theses and Dissertations

This study looks at local broadcast news reporters working in Northwest Arkansas before, at the start, and during the COVID-19 global pandemic. Research for this study includes a content study of the tweets and Twitter accounts of eleven local reporters. This study considers the social responsibility theory and examines how these eleven local reporters use the theory in their everyday work. Research found, though these reporters don’t credit the theory by name, they are still putting its guidelines into effect as a sort of moral compass when creating objective and representative news for their communities. The research also found that …


Impact Of Face Coverings During Covid-19 On Communication: A Look At Development, Disorders, And Mental Health, Elisabeth B. Kerby Jul 2022

Impact Of Face Coverings During Covid-19 On Communication: A Look At Development, Disorders, And Mental Health, Elisabeth B. Kerby

University Honors Program

This research analysis takes a look at the impact of face coverings worn during Covid-19, had on communication. The research questions this thesis analyzes are: What impact did/do face coverings have on communication during COVID-19? Were communication development milestones impacted due to face coverings or other factors during COVID-19? If so, in what ways did they impact these milestones? How did face coverings impact individuals with receptive and/or expressive communication disorders? In what ways was the mental health of individuals who have a communication disorder (or who didn’t) impacted during COVID-19? Was the overall developmental of cognitive processes in children …


A Narrative Review On Yoga: A Potential Intervention For Augmenting Immunomodulation And Mental Health In Covid-19, Indranill Basu-Ray, Kashinath Metri, Dibbendhu Khanra, Rishab Revankar, Kavitha M Chinnaiyan, Nagaratna Raghuram, Mahesh Chandra Mishra, Bhushan Patwardhan, Manjunath Sharma, Ishwar V Basavaraddi, Akshay Anand, Shrinath Reddy, K K Deepak, Marian Levy, Sue Theus, Glenn N Levine, Holger Cramer, Gregory L Fricchione, Nagendra R Hongasandra Jul 2022

A Narrative Review On Yoga: A Potential Intervention For Augmenting Immunomodulation And Mental Health In Covid-19, Indranill Basu-Ray, Kashinath Metri, Dibbendhu Khanra, Rishab Revankar, Kavitha M Chinnaiyan, Nagaratna Raghuram, Mahesh Chandra Mishra, Bhushan Patwardhan, Manjunath Sharma, Ishwar V Basavaraddi, Akshay Anand, Shrinath Reddy, K K Deepak, Marian Levy, Sue Theus, Glenn N Levine, Holger Cramer, Gregory L Fricchione, Nagendra R Hongasandra

Faculty, Staff and Students Publications

BACKGROUND: The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has a significant mortality rate of 3-5%. The principal causes of multiorgan failure and death are cytokine release syndrome and immune dysfunction. Stress, anxiety, and depression has been aggravated by the pandemic and its resultant restrictions in day-to-day life which may contribute to immune dysregulation. Thus, immunity strengthening and the prevention of cytokine release syndrome are important for preventing and minimizing mortality in COVID-19 patients. However, despite a few specific remedies that now exist for the SARS-CoV-2virus, the principal modes of prevention include vaccination, masking, and holistic healing methods, such as …


Houseplants As Mental Health Supports For Dorm Occupants During The Lockdown Period At Portland State University, Brittani Wallsten Jun 2022

Houseplants As Mental Health Supports For Dorm Occupants During The Lockdown Period At Portland State University, Brittani Wallsten

Anthós

In this study, students who lived in dorms around the lockdown period of Portland State University, March 2020—September 2021, were interviewed about their experience and how their houseplants affected their mental health. This was done via in-person interviews and an online focus group. Houseplants were found to support students’ mental health by encouraging a regular routine, providing opportunities for responsibility, adding aesthetic value, and serving as a general indicator of mental health. All of the participants recommended houseplants as a mental health support to their fellow students.


The Passive Approach: How Academically Motivated Students Approach Their Mental Health., Megan E. Mccoy Jun 2022

The Passive Approach: How Academically Motivated Students Approach Their Mental Health., Megan E. Mccoy

Anthós

The research utilizes qualitative interviews and focus groups to understand how academically motivated students approach their mental health. Mental health is defined as “emotional, psychological, and social well-being,” by the Center for Disease Control and Prevention and is becoming a more significant concern in collegiate student populations. At Portland State University, the effects of mental health concerns on students are nearly double that of students around the U.S (Community Commons, n.d.). Academically motivated students are a group who seemingly strive for success and likely experience high levels of stress daily. The study found that students often take a passive approach …


Resilience Is Low Among Both Military And Non-Military Populations With Post-Traumatic Stress Disorder, Kelsey Roberts, Janet Wilmoth, Shannon M. Monnat Jun 2022

Resilience Is Low Among Both Military And Non-Military Populations With Post-Traumatic Stress Disorder, Kelsey Roberts, Janet Wilmoth, Shannon M. Monnat

Population Health Research Brief Series

Post-traumatic stress disorder (PTSD) affects the lives of 12 million people in the United States. While commonly thought of in relation to military personnel and veterans, PTSD is also common among the general public. Resilience - the ability to cope with stressful events - is essential for recovering from PTSD. This data slice uses data from the National Wellbeing Survey to examine resilience among U.S. working-age adults with and without PTSD by their relationship to the military. Results show that those with PTSD have less resilience than those who have not experienced PTSD. In addition, those with military experience are …


Mobile Health Applications For Postpartum Depression Management: A Theory-Informed Analysis Of Change-Use-Engagement (Cue) Criteria In The Digital Environment, Alexandra Zingg, Laura Carter, Deevakar Rogith, Sudhakar Selvaraj, Amy Franklin, Sahiti Myneni Jun 2022

Mobile Health Applications For Postpartum Depression Management: A Theory-Informed Analysis Of Change-Use-Engagement (Cue) Criteria In The Digital Environment, Alexandra Zingg, Laura Carter, Deevakar Rogith, Sudhakar Selvaraj, Amy Franklin, Sahiti Myneni

Faculty, Staff and Student Publications

Postpartum Depression (PPD) is the most common childbirth complication, with approximately 15% of postpartum women experiencing depression symptoms. Mobile applications have potential to expand delivery of mental health interventions. However, our understanding of how these tools engage women with PPD and facilitate positive behavioral changes is limited. In our paper, we analyze 15 commercial PPD applications to understand their role as facilitators of change, engagement, and sustained use. Applications reviewed contained an average of four theory-based behavioral change techniques, and highest patient engagement level reached was to empower patients through patient-generated data. Heuristic violations were identified in areas including user …


Implementing Adverse Childhood Experience Screening In An Intensive Outpatient Mental Health Program, Bryan Amaro May 2022

Implementing Adverse Childhood Experience Screening In An Intensive Outpatient Mental Health Program, Bryan Amaro

Doctor of Nursing Practice Final Manuscripts

Adverse Childhood Experiences (ACES) are linked to damaging events which happen to people when we are young (0-18). ACEs are connected to a phenomenon known as the toxic stress response which can later become the root etiology for many mental health, substance abuse and chronic medical health complications our society faces. ACEs affect all populations and do not discriminate across socioeconomic, racial, ethnic, gender, or geographic lines. Roughly two thirds of Americans have experienced at least one ACE. This project seeks to perform ACE screening at an Intensive Outpatient behavioral health center by screening for ACEs upon all admissions into …


Family-Centered Training And Therapy As Substance Abuse Intervention In Adolescents, Ryan St. John, Cam'ron Klotz, Muskaan Bibi, Archana Salek May 2022

Family-Centered Training And Therapy As Substance Abuse Intervention In Adolescents, Ryan St. John, Cam'ron Klotz, Muskaan Bibi, Archana Salek

Rowan-Virtua Research Day

We hypothesized that providing mental health resources for adolescents and educating their parents and families would decrease the prevalence of substance abuse in the Camden, NJ community given that overdose death had risen 138% from 2014-2018. Educating parents and families on the importance of adolescents dealing with mental disorders may help evaluate the mental stability of their child and prevent them from turning to illicit substance to cope. Increasing the communication and the availability of resources for adolescents to turn to before resorting to illicit substances can have beneficial effects.


The Need For Depression And Anxiety Screenings At A Student-Run Clinic, Shayna Peterzell, Sahil Parikh, Alicia Podwojniak, Vibha Chauhan, Riya Tandra, Emily Forester, Saumil Parikh, Jessica-Sophie Horoschak, Patrick Pearce, Roma Padalkar, Sobiah Khan, Tara Pellegrino May 2022

The Need For Depression And Anxiety Screenings At A Student-Run Clinic, Shayna Peterzell, Sahil Parikh, Alicia Podwojniak, Vibha Chauhan, Riya Tandra, Emily Forester, Saumil Parikh, Jessica-Sophie Horoschak, Patrick Pearce, Roma Padalkar, Sobiah Khan, Tara Pellegrino

Rowan-Virtua Research Day

General anxiety and major depressive disorder are common and treatable mental health disorders. The US Preventive Services Task Force provides strong evidence that early screening helps identify depression in primary care settings, promotes intervention and facilitates treatment. Many medical offices use validated screening tools, GAD-7 and PHQ-9, to measure symptom severities and further help guide treatment modalities for patients with anxiety and depression, respectively. The Rowan Community Health Clinic (RCHC) in Lindenwold, NJ is a student-run free clinic that serves patients regardless of patient gender, race, income, or insurance status. This study aims to determine if there is a need …


The Impact On Adolescent Mental Health In South Jersey Due To The Cancelation And Return Of Sports, Tara Pellegrino, Tara Young May 2022

The Impact On Adolescent Mental Health In South Jersey Due To The Cancelation And Return Of Sports, Tara Pellegrino, Tara Young

Rowan-Virtua Research Day

Due to the Covid-19 pandemic, many organized sports programs have been canceled or limited in participation. While research prior to the pandemic has strongly suggested that participation in organized sports has benefits for mental and physical health, especially in adolescence, there have been minimal studies on how the removal of organized sports affects mental health outcomes. Additionally, studies have found that the stress of the pandemic and its associated life changes has greatly decreased mental health outcomes in our target population. These findings may indicate the importance of return to organized sports in a time where mental health outcomes are …


Assessing The Impact Of The Covid-19 Pandemic On Adolescent Mental Health, Vanessa Pizutelli, Yanil Morales, Christina Copeland, Archana Salek May 2022

Assessing The Impact Of The Covid-19 Pandemic On Adolescent Mental Health, Vanessa Pizutelli, Yanil Morales, Christina Copeland, Archana Salek

Rowan-Virtua Research Day

Adolescence is a crucial period in which adverse childhood experiences, social relationships, and habits can influence mental wellbeing. According to the CDC, the onset of mental illness is 14.5 years old, which is why it is imperative that individuals with mental health conditions receive early intervention. Since the start of the Covid-19 pandemic, research has shown a dramatic decline in adolescent mental health. Specifically in New Jersey, it has been reported that individuals ages 18-23 have the highest levels of stress and depressive symptoms since the start of the pandemic. In light of these findings, it is vital that more …


The Effects Of The Transition From Pre-Nursing To Nursing On Mental Health, Andrew J. Davis, Paige R. Mullins, Kimberly A. Sell May 2022

The Effects Of The Transition From Pre-Nursing To Nursing On Mental Health, Andrew J. Davis, Paige R. Mullins, Kimberly A. Sell

Undergraduate Honors Theses

Mental health is an ever-growing crisis among adolescents and young adults, with suicide as second leading cause of death and the number of those negatively affected continually on the rise. Transitions are one of the major stressors prevalent among these age groups, placing individuals at risk for mental health deficits. This quantitative voluntary response comparative study assesses the transitional mental health of pre-nursing students and students in the nursing program at East Tennessee State University. Emailed to all with a declared major of pre-nursing or nursing, this study measured mental health using evidenced based assessment tools. The PHQ-9 for depression …


Beyond "Restoration Of Honor": Compensating Veterans For The Psychological Injuries Of The Gay And Transgender Bans, Evan R. Seamone May 2022

Beyond "Restoration Of Honor": Compensating Veterans For The Psychological Injuries Of The Gay And Transgender Bans, Evan R. Seamone

William & Mary Journal of Race, Gender, and Social Justice

This Article is titled “Beyond Restoration of Honor” specifically to introduce the policy priority of ensuring that all Sexual and Gender Identity Minority (SGIM) veterans who were harmed by...discriminatory policies [like Don't Ask, Don't Tell] can obtain and use Veterans Affairs (VA) disability benefits for injuries resulting from discrimination while in the military. While this Article highlights the value of codifying a series of specific SGIM stressor markers for PTSD in the VA’s regulations concerning personal assault and creating presumptions of service-connection for specific military experiences, existing laws and regulations permit service-connection for these injuries without further regulatory changes.

In …


Identifying Risk Factors For Hospitalization With Mental Illness And/Or Behavioral Disorders And Concurrent Temperature-Related Illness In New York State : A Cross-Sectional Study, Heather Aydin-Ghormoz May 2022

Identifying Risk Factors For Hospitalization With Mental Illness And/Or Behavioral Disorders And Concurrent Temperature-Related Illness In New York State : A Cross-Sectional Study, Heather Aydin-Ghormoz

Legacy Theses & Dissertations (2009 - 2024)

Background: In New York State (NYS), extreme heat events in the warm months (May – September) are expected to increase over the next 60 years. Additionally, NYS experiences extremely low temperatures in the colder months (October – April). Extreme temperature events are linked to increased emergency department visits, hospitalizations, and mortality for individuals with mental and behavioral disorders. This research aims to characterize individual and regional risk factors for mental and behavioral disorder hospitalizations with concurrent temperature-related illness in NYS. Methods: Using data from the NYS Statewide and Planning Research and Cooperative System between 2005 – 2019, multivariate log binomial …


Medical Laboratory Science Students At The University Of Southern Mississippi Response To The Covid-19 Pandemic, Kaitlyn Mcginnis May 2022

Medical Laboratory Science Students At The University Of Southern Mississippi Response To The Covid-19 Pandemic, Kaitlyn Mcginnis

Honors Theses

The COVID-19 pandemic has changed educators’ and students’ perspectives on virtual teaching of the laboratory sciences. This study aims to determine the perceived effects of the COVID-19 pandemic on Medical Laboratory Science (MLS) students at the University of Southern Mississippi. This study will evaluate how the changes to the instruction of the MLS curriculum and overall student mental health affected their grades and retention of academic content during and post-pandemic. The goal is to determine students’ perception of the effectiveness of virtual learning during the COVID-19 quarantine period, and whether it is a sustainable learning resource. Five students enrolled in …


Family Disruptions And Maternal Health In Covid Times, Donna Maldonado May 2022

Family Disruptions And Maternal Health In Covid Times, Donna Maldonado

Open Access Theses & Dissertations

AbstractPrenatal and postpartum women of the border region of El Paso-Ciudad Juarez have been experiencing multiple forms of family disruption due to the twenty-month border closure in an attempt to contain the COVID pandemic, partners having to find jobs far away from home because of economic concerns, and fear of familial disruption due to the threat of deportation of partners or family members. The purpose of the study is to explore the perceived effects of these types of family disruptions and how they are shaping maternal health in COVID times. This project included the analysis of fifteen interviews with pregnant …


The Physician Suicide Crisis, Christian J. Leonardo Apr 2022

The Physician Suicide Crisis, Christian J. Leonardo

The Review: A Journal of Undergraduate Student Research

Abstract

Background: Mental health has been a serious issue among physicians over the past century. It is clear if we do not address this issue, the doctor shortage in America will continue to rise and the quality of care that patients receive will continue to deteriorate.

Methods: Literary research was conducted using both primary and secondary sources in order to find historical evidence of the mental health crisis among physicians.

Findings: It is clear that there is a mental health crisis among physicians by the staggering statistics that will be discussed throughout the paper. It is also evident that more …


Emerging Viral Diseases: Generation Z'S Outlook, Ian Mcwhorter Apr 2022

Emerging Viral Diseases: Generation Z'S Outlook, Ian Mcwhorter

Honors Projects

Generation Z differs notably from previous generations like Baby Boomers or Generation X. In recent years, young adults have been persisting through the COVID-19 pandemic, though not unscathed. This paper seeks to answer the following question: How does Generation Z differ in its outlook on Viral diseases compared to previous generations? Using a series of three surveys conducted on three seperate Viral diseases (HIV, Zika, and COVID 19), it was found that while Generation Z has improved in its ability to combat Viral outbreaks due to factors like high digital literacy, other factors such as poorer mental health show that …


Improving Mental Health After Sci: An Occupation-Based Program, Kerston Ring Apr 2022

Improving Mental Health After Sci: An Occupation-Based Program, Kerston Ring

Spring 2022 Virtual OTD Capstone Symposium

The purpose of this project was to assess the effectiveness of occupational therapy in promoting positive mental health in those with SCI. Formal conversations related to mental health as well as various leisure activities took place throughout the program. The leisure activities were determined prior to initiating the program during the needs assessment. These were activities that the participants were either familiar with or novel. The activities were client-centered and modified as necessary to meet the client’s needs for full participation. The objectives of this capstone were to conduct a needs assessment to understand what factors could be changed to …


Mental Health After Injury: How Neighborhoods Impact Recovery, Bryce Hruska, Maria Pacella-Labarbara, Ivan E. Castro, Richard L. George, Douglas L. Delahanty Apr 2022

Mental Health After Injury: How Neighborhoods Impact Recovery, Bryce Hruska, Maria Pacella-Labarbara, Ivan E. Castro, Richard L. George, Douglas L. Delahanty

Population Health Research Brief Series

Each year in the United States, there are over 90 million injury-related emergency department visits, resulting in $4.2 trillion in costs related to medical care, loss of work, and reduced quality of life. Nearly a quarter of injury survivors are diagnosed with a new mental health disorder within the first year of injury. This brief examines several aspects of neighborhood context and their relationship to PTSD symptom severity following an injury. Results show that survivors living in neighborhoods with higher racial segregation and lower socioeconomic status report higher PTSD symptom severity.


Social Media’S Impact On One’S Mental, Physical, And Emotional Well-Being, Alexandria J. Shearer Apr 2022

Social Media’S Impact On One’S Mental, Physical, And Emotional Well-Being, Alexandria J. Shearer

Honors College Theses

Social media is widely used in users’ daily lives and is deeply embedded in the world of technology. Cellular devices and their applications have shown primarily negative effects on individuals’ lives. Studies have shown a lower self-esteem in young adults addicted to their smartphone (Aznar-Díaz, et al., et al. 2020). Another study highlighted the reactions to creating one’s own content versus the implications of consuming content. Individuals who created more than they consumed reported a higher level of self-esteem (Hygen, et al., 2021). While there were many studies regarding social media and wellness of young adults, there were gaps in …


Mental Health In Massachusetts Prisons, Jeffrey Yung Apr 2022

Mental Health In Massachusetts Prisons, Jeffrey Yung

Undergraduate Theses and Capstone Projects

In November of last year, former Massachusetts U.S. Attorney Andrew Lelling and the Department of Justice’s Civil Rights Division released the findings of an investigation of the Massachusetts Department of Corrections (MDOC). They found several violations of prisoner’ constitutionals rights for mental health cases under the Eighth Amendment. The Eighth Amendment prohibits cruel and unusual punishments for criminal defendants. The findings reveal a lack of structured mental health care for MDOC prisoners, untrained employees, and unnecessary abuse of restrictive housing for prisoners designated under a mental health watch program.


Eco Yoga Therapy For Mental Health Related To The Covid-19 Pandemic, Karyn Stein Apr 2022

Eco Yoga Therapy For Mental Health Related To The Covid-19 Pandemic, Karyn Stein

LMU Theses and Dissertations

Recently the magnitude of the mental health crisis due to the COVID-19 pandemic has been emerging. Reports of anxiety or depression related to COVID-19 have been on the rise globally. Individuals have been living in a perpetual state of the unknown for over two years. Fear of the virus, sickness of oneself or family/friends and social isolation have taken a toll. According to the WHO, anxiety and depression have gone up 25% in the last year (2022). The effects of a rising mental health crisis will be drastic on top of the deaths and sickness related to COVID-19. While governments …


Covid-19 & Mental Health: The Impact On The Future Of Younger Generations, Greyson A. Fox Tran Apr 2022

Covid-19 & Mental Health: The Impact On The Future Of Younger Generations, Greyson A. Fox Tran

Senior Theses

The aim of this research is to identify any existing correlations between the COVID-19 pandemic and negative mental health outcomes in younger populations. This paper examines the impact of the COVID-19 pandemic on the mental health of those younger than 25 years of age, specifically focusing on students. It will investigate how various factors of the pandemic have affected people and how they have coped with psychological distress induced by the pandemic. Through a review of scientific data and scholarly literature, the impacts of the pandemic on mental health will be assessed. Coping mechanisms and the effects of physical activity …


Unhealthy Workplace Conditions Contribute To Physician Suicide, Mariah Brennan Nanni, Alexandra Punch Mar 2022

Unhealthy Workplace Conditions Contribute To Physician Suicide, Mariah Brennan Nanni, Alexandra Punch

Population Health Research Brief Series

Physicians have the highest suicide rate of all professions. High-stress working environments, long hours, burnout, substance use, and financial stress all contribute to high physician suicide rates. Adding fuel to the fire, COVID-19 has intensified this long-term problem. This issue brief describes the unhealthy workplace conditions that contribute to poor mental health among physicians and calls for policies that encourage physicians to seek help and rest without the fear of punishment.