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 CHAPTER 7
Psychological Factors Affecting Medical Conditions
1. Case Studies
A. Psychological evaluation revealing distress over physical condition in the case of George.
B. Stress associated illness in the case of Sarah.
C. Diagnosis of a perforated ulcer in the case of Jack.

2. Historical Perspective

3. Diagnostic Issues

4. Psychosocial Mechanisms of Disease

A. The Endocrine System
B. The Autonomic Nervous System
C. The Immune System

5. The Psychology of Stress

6. Focus 7.1 Stress, Marriage, Physiological Changes, and Health

7. Psychosocial Factors That Influence Disease

A. Social Status
B. Social Support
C. Personality

8. Disease States and Psychosocial Factors

A. Infectious Disease
B. Ulcer
C. Cardiovascular Disease

9. Focus 7.2 Inferring Causality in Health Psychology

10. Treatment

11. Canadian Research Centre: Dr. Kim Lavoie

12. Summary

13. Key Terms

14. Lecture Ideas/Activities

A. The hand-warming technique
B. Developing good coping skills
C. Personality and illness
D. Neighborhood effects

Copyright © 2019 Pearson Canada Inc. 7-1

1. Case Studies

A. George, a 32-year old high school teacher, consulted his doctor 37 times about chest
pains, which had caused him great anxiety because he was convinced he was having a
heart attack. Psychological evaluation revealed considerable distress and agitation
extending beyond concerns about physical health. He readily expressed complaints in
many areas of his life, and claimed that his achievements as a teacher gave him no
pleasure. He also reported going “all out” in his day-to-day life and routinely being on
the go from 5am until the evening. Of note, George smokes, abuses alcohol, and is not
physically active. The case suggests that behavioural and psychological factors will need
to be targeted to help George with his physical health.
B. Sarah is a student in her first year of medical school and is also an athlete. She had just
finished a gruelling set of exams when she noticed the first symptoms of what she
recognized as flu. By the start of the next day, she was experiencing full-blown
symptoms: high temperature, aches and pains, a deep cough, and a runny nose. This case
illustrates the role of stressors in infectious diseases, even in physically-fit people like
Sarah.
C. One Sunday morning, Jack awakened with a strange burning sensation in his stomach.
The burning pain came and went and Jack did not seek medical attention for it for some
time. Eventually, he was taken to the nearest hospital after vomiting blood, at which time
he was diagnosed with a perforated ulcer. He reported that at the onset of the burning
pain, he had been going through considerable stress in relation to his upcoming wedding,
about which he was ambivalent. This case illustrates the relationship between stress and
gut health.
D. The actor and comedian John Candy was a smoker and significantly overweight. There
was a history of heart disease in his family, and his father died of heart disease in his
thirties. He tried to lose weight and quit smoking but was unsuccessful, and he lived a
high-pressure life. At the age of 43, John Candy died suddenly from a myocardial
embolism (blood clot in his heart). This case illustrates the combination of biological,
behavioural and likely psychosocial factors in promoting cardiovascular risk.

2. Historical Perspective

The notion that psychological processes have an impact on bodily states, and can even produce
physical disease, has a long history in Western thought, and has also been prominent in other
cultures. Medical and psychological activities and interests converged in a branch of psychology
called psychosomatic medicine. However, there was an issue with this label because it implied a
dualistic view of the mind and of the body. Indeed, during the early to mid-1900s, the thinking
was that some but not all physical disorders were the direct expression of emotion or
psychological conflicts. Over several decades of research and clinical writings it became clear
that psychological factors play a role in all aspects of health and illness. This new understanding
led to a branch of psychology called behavioural medicine, which is contained within the
broader term, health psychology.

Copyright © 2019 Pearson Canada Inc. 7-2

3. Diagnostic Issues

In the DSM-5, there is a new class of disorders called Somatic Symptom and Related Disorders
that has a specific diagnosis called psychological factors affecting a medical condition. An
example of when this would be assigned is in a case wherein it is clear that a psychological or
behavioural factor (e.g., overtly ignoring one’s symptoms) is directly correlated with worsening
or non-recovery from a medical disease. Those who work in the area of behavioural medicine do
not find this DSM diagnosis particularly helpful because it lacks specific information. An
alternative system, Diagnostic Criteria for Psychosomatic Research seems to provide more
information on the type of psychological factors that may adversely impact physical health e.g.,
“Type A Behaviour.”

4. Psychosocial Mechanisms of Disease

One’s body tissues can be affected by certain behaviours, especially when they are recurrent. For
example, the act of smoking regularly exposes body tissues to toxins that in turn confer risk for
disease. In this example, smoking is not the direct cause of disease but rather serves as a vehicle
for transmission of nicotine, which is the more proximal cause of body tissue damage.
Psychosocial variables can also damage body tissues, again indirectly, via their effects on the
endocrine system, the autonomic nervous system, and the immune system.

A. The Endocrine System

The endocrine system consists of a number of organs (e.g., pituitary gland, adrenal
glands) that manufacture and secrete hormones directly into the blood stream, which then
exert influences on other organs like the heart or the liver. The hypothalamic-pituitary-
adrenal (HPA) axis and the hormone it secretes, cortisol (i.e., the “stress” hormone) are
very well studied. Cortisol is of particular interest because prolonged dysregulation in its
actions can have several damaging effects. For example, it can increase fat storage in the
abdomen, which in turn promotes cardiovascular risk. There is also evidence that
dysregulation of cortisol activity can lead to neuronal damage.

B. The Autonomic Nervous System

The autonomic nervous system (ANS) consists of two distinct parts: the sympathetic
branch and the parasympathetic branch. The ANS is responsible for bodily changes like
racing heart, dry mouth and sweating that occur in response to stress. ANS effects are
based on nervous conduction; whereas the effects of endocrine systems rely on the blood
stream. However, the sympathetic system is also part of the sympathetic-adrenal
medullary axis, an endocrine system, which is responsible for secretion of the hormones
epinephrine and norepinephrine. These hormones produce the feeling known colloquially
as the “adrenaline rush.”

Copyright © 2019 Pearson Canada Inc. 7-3

C. The Immune System
The immune system is a network of cells and organs that defend against external and
internal disease-causing agents. White blood cells are involved. There are three general
categories of immune responses: non-specific immune responses, cellular immunity,
and humoral immunity. In the 1980s, a field called psychoneuroimmunology emerged
as the outgrowth of research showing that the immune system can be affected by learning
experiences, emotional states, and personal characteristics.

5. The Psychology of Stress

The study of stress has provided answers to important questions regarding the pathways by
which psychosocial variables lead to, exacerbate, or maintain physical illness and disease. The
term “stress” has been interpreted and studied in three ways: (1) as a response (2) as a stimulus,
or a property of the external world, or (3) as a transaction that intervenes between stimulus and
response.

Selye proposed the first formal theory of stress called the general adaptation syndrome (GAS).
The first phase is alarm (adaptation challenge). If the challenge persists, then resistance
(fighting or coping) follows. With continued challenge comes exhaustion (resistance fails), and
the organism may succumb to disease.

The stress-as-response and the stress-as-stimulus approaches have proven to be unsatisfactory

and of limited value for a couple of reasons. For one, the physiological responses that constitute
the so-called “stress response” can be observed under vastly different situations. Presumably,
when heart rates goes up while running on the treadmill this is not the same as when heart rates
goes up during a panic attack. The study of stress as a stimulus suffers from the same issue –
what is stressful for one person may not be stressful for another. So both approaches discount the
roles of context and individual differences. The transactional model of stress is a departure
from these approaches in that it views stress as a dynamic series of transactions between a person
and their environment. The role of appraisals (i.e., evaluations) is crucial to this model.
According to Lazarus, these appraisals occur quite automatically. Primary and secondary
appraisals are evaluations of the threat value of a situation. Appraisals then lead to problem-
solving coping (adaptive) or emotion-focused coping (maladaptive). A person’s coping style
influences their subsequent appraisals of threat.

6. Focus 7.1 Stress, Marriage, Physiological Changes, and Health

This focus box highlights the usefulness of studying the way couples interact under stress.
Research has shown for example that hostile interactions are associated with greater release of
stress-relevant hormones.

Copyright © 2019 Pearson Canada Inc. 7-4

7. Psychosocial Factors That Influence Disease

A. Social Status
Social status “refers to an individual's relative position within a social hierarchy.” What
appears to be important is the extent to which individuals hold a more dominant versus a
more submissive position in their hierarchy. Individuals in a dominant position (like
bosses) show stress responses that are similar to those in a less dominant position,
however they appear to recover more quickly from stressors– that is, they do not show a
sustained stress response whereas those lower in dominance do.

B. Social Support
One of the most pervasive and consistent psychosocial variables that has been related to
health status is social support. Individuals who feel less connected to others are at higher
risk of mortality. Good social support is a potent protective factor in health; however the
exact mechanisms remain unclear.

C. Personality
Alexythymia refers to difficulty identifying and labeling internal experiences such as
emotions. Individuals high in alexithymia also do not view internal experiences as
important. Type A personality also plays a role in medical conditions.

8. Disease States and Psychosocial Factors

A. Infectious Disease
The onset of infectious diseases such as colds or the flu has been shown to be associated
with the stressors and strains of daily life. The symptoms of some infectious diseases,
often seem to onset or become exacerbated during periods of emotional stress. Exam
stress, employment stress and marital difficulties have been linked to infectious disease
risk in some studies. It is likely that immune system mechanisms are involved, but these
are unclear at the moment.

B. Ulcer
Ulcers have long been considered a symptom of stress. Psychoanalysis was once the
treatment of choice for ulcers. Evidently, the conceptualization of ulcers has changed
over time and has become more complex. It is understood that exposure to stressors is
linked with increased secretion of gastric acids (i.e., digestive juices), which erodes the
stomach’s lining, giving way to the formation of ulcers. The unpredictability of the
stressor is a moderating factor. However, questions remain as to how chronic,
unpredictable stress creates these changes in the gut. Considerable excitement has been
aroused in the medical community by the discovery of a bacterium, H. pylori, that is
believed to play a primary role in the development of ulcers. However, it likely does not
act in isolation to cause ulcers. Some preliminary work indicates that exposure to stress
intensifies the harmful actions of this bacterium, possibly via cortisol relevant
mechanisms.

Copyright © 2019 Pearson Canada Inc. 7-5

C. Cardiovascular Disease
Diseases of the cardiovascular system, such as ischemic heart disease and myocardial
infarction, are the leading causes of death and disability in Western societies.
Cardiovascular diseases are responsible for more potential years of life lost (PYLL)
than any other cause of death except cancer and injuries. The vasculature is the
extensive network of arteries, arterioles, capillaries, venules and veins. The pressure of
the blood flowing through the vasculature. Blood pressure is a consequence of two
major variables: cardiac output (the amount of blood pumped by the heart) and total
peripheral resistance (the diameter of the blood vessels). Deaths due to myocardial
infarction can result from arrhythmias or atherosclerosis. High blood cholesterol and
cigarette smoking are considered significant modifiable risk factors for cardiovascular
diseases. There are protective factors, such as exercise, which are thought to reduce the
risk. Yet another factor that contributes to risk of cardiovascular disease is hypertension,
or high blood pressure at rest.

Numerous studies using the stress reactivity paradigm have shown that cardiovascular
functions are responsive to changing psychological conditions. It has been argued that the
risk of cardiovascular disease increases with heightened or exaggerated cardiovascular
reactivity. However, it has been shown that blunted or attenuated cardiovascular
reactivity is also associated with health risks, so over- and under-reactivity are both
problematic. In addition to reactivity, there also has been interest in the role of
cardiovascular recovery in health and illness—delayed return to a baseline state after a
stressor is over is indicative of poor adaptation.

Some psychological factors have been implicated in cardiovascular disease. In one study,
people identified as Type A (aggressively ambitious) were approximately twice as likely
to die from heart disease as those identified as Type B (calm and relaxed), and this was
independent of behaviours like smoking. Some studies found that hostility was the main
characteristic accounting for increased risk of heart disease. The Type A versus B
characterisations do not shed light on the specific features that confer risk for heart
disease. It turn out hostility is a key factor. It features prominently in at least five
theories: the psychophysiological reactivity model, the psychosocial vulnerability
model, the transactional model, the health behaviour model, and the constitutional
vulnerability model. Individuals who are high in hostility engage in more unhealthy,
heart-disease promoting behaviours and have difficulty regulating anger. Finally,
evidence has emerged for a connection between depression and cardiovascular risk and
mortality. Several explanations have been offered. One is reduced physical activity,
which coincides with depression and confers risk for cardiovascular events. A massive
Canadian study examining a large range of risk factors for a recurrence of heart attack
showed that psychosocial variables placed third in a list of 9 risk factors.

Copyright © 2019 Pearson Canada Inc. 7-6

9. Focus 7.2 Inferring Causality in Health Psychology

The longitudinal study, in which a large group of people are evaluated with respect to the
existence of psychological features and are then followed up to determine whether they have
developed the disease, can shed light on possible cause-effect relationships especially when they
span many years.

10. Treatment

There are two classes of intervention that are prescribed to manage/target psychosocial factors
within the context of physical illness. “Generic” approaches include basic stress management
principles and various type of relaxation. The more targeted interventions directly focus on
modifying known psychosocial factors. For example, programs have been developed to reduce
Type A behaviour and encourage social connection.

11. Canadian Research Centre: Dr. Kim Lavoie

Dr. Lavoie is a health psychologist who studies the role of behavioural and psychological factors
in chronic diseases including asthma and cardiovascular diseases. She has developed and tested a
number of interventions designed to reduce health-compromising behaviours (e.g., increase
physical activity and reduce medication non-adherence). She also trains health professionals in
the use of motivational interviewing to help patients make positive health related changes.

12. Summary

1. There is a long tradition of attempting to understand the role of psychosocial factors in

physical disease.
2. The role of psychological factors in physical disease is recognized in DSM-5.
3. Stress affects bodily tissues via effects on the autonomic nervous system, the endocrine
systems and the immune system.
4. Cognitive, personality and interpersonal factors play a role in the relationship between
stress and physical disease.
5. Psychological factors are involved in diseases ranging from the common cold to ulcers to
heart disease.
6. Theories have led to the development of promising psychological treatments for medical
conditions (e.g., to reduce health-compromising behaviours).

Copyright © 2019 Pearson Canada Inc. 7-7

13. Key Terms

alarm (p. 152)

alexithymia (p. 156)
appraisals (p. 154)
arrhythmias (p. 162)
atherogenesis (p. 163)
atherosclerosis (p. 162)
behavioural medicine (p. 147)
cardiac output (p. 162)
cardiovascular reactivity (p. 163)
cellular immunity (p.151)
constitutional vulnerability (p. 165)
dualistic (p. 146)
exhaustion (p. 152)
general adaptation syndrome (GAS) (pp. 152-153)
health behaviour model (p. 165)
health psychology (p. 147)
humoral immunity (p. 151)
hypertension (p. 163)
ischemic heart disease (p. 161)
longitudinal study (p. 160)
modifiable risk factors (p. 163)
myocardial infarction (p. 161)
nonspecific immune responses (p. 151)
potential years of life lost (PYLL) (p. 161)
primary appraisals (p. 154)
protective factor (p. 163)
psychoneuroimmunology (p. 152)
psychophysiological reactivity model (p. 165)
psychosocial vulnerability model (p. 165)
resistance (p. 152)
secondary appraisals (p. 154)
stress reactivity paradigm (p. 163)
stroke (p. 161)
systolic blood pressure/diastolic blood pressure (p. 162)
total peripheral resistance (p. 162)
transactional model (p. 165)
Type A (p. 164)
vasculature (p. 162)

Copyright © 2019 Pearson Canada Inc. 7-8

14. Lecture Ideas/Activities

A. The hand-warming technique.

Norman Cousins uses this simple technique to demonstrate that each of us has greater
power of the mind over the body than we realize. It is described in detail in his book
Head First. The technique was developed by Dr. Elmer Green at the Menninger Clinic in
Kansas to help migraine sufferers. Students can do this exercise at home and report their
results in class, or you can conduct the demonstration in class if each student has access
to a fever thermometer. Have students grasp the bulb of the thermometer in one hand
while you conduct the exercise. You can begin by asking students to do deep breathing
exercises accompanied by mental imagery of some pleasant experiences in their lives.
After several minutes of relaxation, move to the heart of the procedure. Instruct students
to concentrate on a specific place in the body, just behind the eyes or in the center of the
scalp. Ask if students experience a slight warm or tingling sensation in these places. Now
have students visualize their heart pumping blood to the shoulders, now across the
shoulders, now down the arm, past the wrist and into their hands. Now have them open
their eyes and look at the thermometer. Average skin temperature runs from about 76 to
82 degrees. Many individuals can increase temperature to their hands by 10 degrees or
more. Demonstrating that we have the ability to move our blood around suggests we have
greater control over our bodies than we realize.

B. Developing good coping skills.

When discussing stress management, students often want to know what they can do to
help manage stress in their own lives. It is important to emphasize that long-term stress
management involves more than a “quick fix,” such as popping a pill. It involves
developing a stress-resistant lifestyle. While experts debate many of the specifics
involved in this lifestyle, most agree on some general principles which can be helpful.
These are as follows:

1. Self-Awareness. Learning about your stressors and how the things you do affect
your stress levels. Learning what your strengths and weaknesses are and how to
cope with or improve upon those weaknesses.

2. Time Management. Learning to schedule your time efficiently and build

relaxation/personal time into your schedule. Much of the stress experienced by
people today is directly related to trying to constantly cram 26 hours of work into
a 24-hour day. Good time management can free up time so that you do not feel
the need to constantly watch the clock.

Copyright © 2019 Pearson Canada Inc. 7-9

3. A Support System. Having a network of close friends with whom you can be
open and honest, and on whom you can lean when you are having problems is a
crucial part of managing stress. This is particularly important for males as
researchers have found that men tend to not maintain previous friendships as they
get older. In addition, they do not build new friendships. Hence, a major
complaint among middle-aged and older men is loneliness.
4. Regular Exercise. Regular, noncompetitive, aerobic exercise is good
for overall fitness because it burns off much of the physical tension that
accompanies stress and helps in stress management. Feeling more relaxed
physically may also help you feel more relaxed mentally.

5. Diet. While experts disagree on the exact role of diet in stress, eating a well-
balanced diet, as with exercise, is not only good for your overall health, but may
help you manage stress as well. In particular, avoiding excess caffeine and excess
sugar is important because they can make stressed people feel more “jittery” and
anxious.

6. Relaxing/Pleasurable Activities. Developing hobbies or personal activities that

you enjoy and are relaxing can provide a sense of well-being that is useful in
combating stress. What the activities are doesn’t matter as long as you enjoy
them. Such activities can be important stress-fighting tools if you make regular
time in your schedule for them so you can pursue them without feeling guilty.
Writing these activities into your calendar makes them harder to cancel.

7. Attitude. None of the above techniques will be very effective if you fill your head
with negative thoughts and regularly view the world with a pessimistic, fatalistic
attitude. Focusing on what you can do and on what you can control, and trying to
find the best in each situation, will make each of the above techniques work much
more effectively.

Copyright © 2019 Pearson Canada Inc. 7-10

C. Personality and illness.
Theories asserting that certain personality types can be risk factors for the development
of disease are often controversial in both the medical and psychological communities.
However, the idea that certain personalities are more likely to develop heart disease has
been around for 2,000 years, since the time of Hippocrates. This debate was rekindled by
Ronald Grossarth-Meticek, a Yugoslavian psychologist who has conducted extensive
experiments on this subject for over twenty years. His work was summarized by Hans
Eysenck in his article "Health's Character," in Psychology Today, 1988, 28-35.
Grossarth-Meticek claims he has devised tests that can identify cancer-prone and heart-
disease prone personalities. Cancer-prone personalities are characterized by an inability
to express emotions such as anger, fear, and anxiety. Also, their inability to cope with
stress results in high levels of hopelessness, helplessness, and depression. Although not
all the components of the Type A personality predict heart disease, the ones that stand up
best are the tendencies toward anger, hostility, and aggression. Extensive longitudinal
studies by Grossarth-Meticek and his colleagues have shown that among type 1 (cancer-
prone) personalities, 1/2 died from cancer, whereas fewer than 1/10 died of heart disease.
Among type 2 (heart disease) personalities, 1/3 died of heart disease, but only 1/5 from
cancer. Types 3 and 4 personalities who can handle stress better have much lower rates of
death. Luckily, there is hope. Death rates among people with cancer-prone and heart
disease-prone personalities decrease after therapeutic intervention targeting those
personality patterns related to cancer and heart disease.

D. The effects of neighborhood on health.

The neighborhood you live in can have important effects on your health. Ask your
students what they think the connection is between neighborhood and risk of diabetes,
obesity, and cardiovascular disease, for example. See what they come up with and share
the following study:

Dr. Gillian Booth at St. Michael’s Hospital in Toronto conducted a 5-year longitudinal
study with residents of Toronto. She identified 1.2 million Torontonians aged 30-64 who
did not have diabetes. The neighborhoods where these people lived were rated on the
degree to which they are conducive to walking. “Walkable” neighborhoods are highly
populated, have streets that connect to other streets, and are in close proximity to stores,
schools, and other destinations. The risk of developing diabetes in the 5 year follow-up
period was 32% higher for those living in the least walkable areas compared to those who
lived in the most walkable areas in Toronto. In a similar study conducted in Utah with a
sample of 650,000 residents, people who lived in older, more walkable neighborhoods
had lower BMIs (Body Mass Index), placing them at lower risk for obesity related
disorders. Some of these benefits are likely due to greater levels of physical activity, but
other factors, such as more interaction with neighbors and higher levels of community
involvement may also make people less susceptible to weight-related illnesses.

Copyright © 2019 Pearson Canada Inc. 7-11

Another random document with
no related content on Scribd:
beckoned the Indian discoverers of these mountains hundreds of
years ago.
 Rail Fences
“Something there is that does not love a wall,” poet Robert Frost
once wrote. Likewise, many mountain people felt something there is
that does not love a fence. Fences were built for the purpose of
keeping certain creatures out—and keeping other creatures in.
During early days of settlement there were no stock-laws in the
mountains. Cattle, mules, horses, hogs, sheep, and fowls ranged
freely over the countryside. Each farmer had to build fences to
protect his garden and crops from these domestic foragers as well
as some of the wild “varmint” marauders. Rail fences had several
distinct merits: they provided a practical use for some of the trees
felled to clear crop and pasture land; they required little repair; they
blended esthetically into the surroundings and landscape. Mountain
fences have been described as “horse-high, bull-strong, and pig-
tight.” W. Clark Medford, of North Carolina, has told us how worm
fences (right) were built:
H. Woodbridge Williams
 Charles S. Grossman
“There was no way to build a fence in those days except with rails—
just like there was no way to cover a house except with boards. First,
they went into the woods, cut a good ‘rail tree’ and, with axes, wedge
and gluts, split the cuts (of six-, eight- and ten-foot lengths as
desired) into the rail. After being hauled to location, they were placed
along the fence-way, which had already been cut out and made
ready. Next, the ‘worm’ was laid. That is, the ground-rails were put
down, end-on-end, alternating the lengths—first a long rail, then a
short one—and so on through. Anyone who has seen a rail fence
knows that the rails were laid end-on-end at angles—not at right
angles, but nearly so. One course of rails after another would be laid
up on the fence until it had reached the desired height (most fences
were about eight rails high, some ten). Then, at intervals, the corners
(where the rails lapped) would be propped with poles, and
sometimes a stake would be driven. Such fences, when built of good
chestnut or chestnut-oak rails, lasted for many years if kept from
falling down.”
One of the most valuable fences ever constructed in the Smoky
Mountains was surely that of Abraham Mingus. When “Uncle Abe,”
one-time postmaster and miller, needed rails for fencing, he “cut into
a field thick with walnut timber, split the tree bodies, and fenced his
land with black walnut rails.”
The variety of fences was nearly infinite. Sherman Myers leans
against a sturdy post and rider (below) near Primitive Baptist Church.
Other kinds of fences are shown on the next two pages.

In this post and rider variation, rails are fastened to a single

post with wire and staples.
National Park Service
Mary Birchfield of Cades Cove had an unusual fence with wire
wound around crude pickets.
Charles S. Grossman

The Allisons of Cataloochee built a picket fence around their

garden.
Charles S. Grossman
In the summer, farmers enclosed haystacks to keep grazing
cattle away.
Charles S. Grossman

Ki Cable’s worm, or snake, fence in Cades Cove is one of the

most common kinds of fencing.
Charles S. Grossman
Poles were used at John Oliver’s Cades Cove farm to line up
the wall as it was built.
Charles S. Grossman
 The plight of their Cherokee ancestors is revealed in
the faces of Kweti and child in this photograph taken
by James Mooney.
Smithsonian Institution
 Land of the Cherokees
The Cherokees were among the first. They were the first to inhabit
the Smokies, the first to leave them and yet remain behind. By the
1600s these Indians had built in the Southern Appalachians a Nation
hundreds of years old, a way of life in harmony with the surrounding
natural world, a culture richly varied and satisfying. But barely two
centuries later, the newly formed government of the United States
was pushing the Cherokees ever farther west. In the struggle for
homeland, a new era had arrived: a time for the pioneer and for the
settler from Europe and the eastern seaboard to stake claims to
what seemed to them mere wilderness but which to the Cherokees
was a physical and spiritual abode.
Perhaps it was during the last Ice Age that Indians drifted from Asia
to this continent across what was then a land passage through
Alaska’s Bering Strait. Finding and settling various regions of North
America, this ancient people fragmented after thousands of years
into different tribal and linguistic stocks. The Iroquois, inhabitants of
what are now the North Central and Atlantic states, became one of
the most distinctive of these stocks.
By the year 1000, the Cherokees, a tribe of Iroquoian origin, had
broken off the main line and turned south. Whether wanting to or
being pressured to, they slowly followed the mountain leads of the
Blue Ridge and the Alleghenies until they reached the security and
peace of the mist-shrouded Southern Appalachians. These
“Mountaineers,” as other Iroquois called them, claimed an empire of
roughly 104,000 square kilometers (40,000 square miles). Bounded
on the north by the mighty Ohio River, it stretched southward in a
great circle through eight states, including half of South Carolina and
almost all of Kentucky and Tennessee.
Cherokee settlements dotted much of this territory, particularly in
eastern Tennessee, western North Carolina, and northern Georgia.
These state regions are the rough outlines of what came to be the
three main divisions of the Cherokee Nation: the Lower settlements
on the headwaters of the Savannah River in Georgia and South
Carolina; the Middle Towns on the Little Tennessee and Tuckasegee
rivers in North Carolina; and the Overhill Towns with a capital on the
Tellico River in Tennessee.
Between the Middle and the Overhill Cherokee, straddling what is
now the North Carolina-Tennessee line, lay the imposing range of
the Great Smoky Mountains. Except for Mt. Mitchell in the nearby
Blue Ridge, these were the highest mountains east of the Black Hills
in South Dakota and the Rockies in Colorado. They formed the heart
of the territorial Cherokee Nation. The Oconaluftee River, rushing
down to the Tuckasegee from the North Carolina side of the
Smokies, watered the homesites and fields of many Cherokees.
Kituwah, a Middle Town near the present-day Deep Creek
campground, may have been in the first Cherokee village.
For the most part, however, the Cherokees settled only in the
foothills of the Smokies. Like the later pioneers, the Cherokees were
content with the fertile lands along the rivers and creeks. But more
than contentment was involved. Awed by this tangled wilderness, the
Indians looked upon these heights as something both sacred and
dangerous. One of the strongest of the old Cherokee myths tells of a
race of spirits living there in mountain caves. These handsome “Little
People” were usually helpful and kind, but they could make the
intruder lose his way.
If the Cherokees looked up to the Smokies, they aimed at life around
them with a level eye. Although the Spanish explorer Hernando
DeSoto and his soldiers ventured through Cherokee country in 1540
and chronicled generally primitive conditions, a Spanish missionary
noted 17 years later that the Cherokees appeared “sedate and
thoughtful, dwelling in peace in their native mountains; they
cultivated their fields and lived in prosperity and plenty.”
They were moderately tall and rather slender with long black hair
and sometimes very light complexions. They wore animal skin
loincloths and robes, moccasins and a knee-length buckskin hunting
 shirt. A
Cherokee man
might dress
more gaudily
than a woman,
but both
enjoyed
decorating their
bodies
extravagantly,
covering
themselves with
paint and, as
trade with
whites grew
and flourished,
jewelry.
The tepee of
Indian lore did
not exist here.
The Cherokee
house was a
rough log
structure with
one door and
no windows. A
small hole in
the bark roof
National Park Service allowed smoke
from a central
Adventurers were drawn to the Great fire to escape.
Smoky Mountains and the surrounding Furniture and
area in the 18th century. In 1760 a decorations
young British agent from Virginia, Lt. included cane
Henry Timberlake, journeyed far into seats and
Cherokee country. He observed Indian painted hemp
life and even sketched a map of the rugs. A good-
 Overhill territory, complete with Fort sized village
Loudoun, “Chote” or Echota, and the might number
“Enemy Mountains.” 40 or 50
houses.
Chota, in the Overhill country on the Little Tennessee River, was a
center of civil and religious authority; it was also known as a “Town of
Refuge,” a place of asylum for Indian criminals, especially
murderers. The Smokies settlement of Kituwah served as a “Mother
Town,” or a headquarters, for one of the seven Cherokee clans.
These clans—Wolf, Blue, Paint, Bird, Deer, Long Hair, and Wild
Potato—were basic to the social structure of the tribe. The
Cherokees traced their kinship by clan; marriage within clans was
forbidden. And whereas the broad divisions of Lower, Middle, and
Overhill followed natural differences in geography and dialect, the
clans assumed great political significance. Each clan selected its
own chiefs and its own “Mother Town.” Although one or two persons
in Chota might be considered symbolic leaders, any chief’s powers
were limited to advice and persuasion.
The Cherokees extended this democratic tone to all their towns.
Each village, whether built along or near a stream or surrounded by
protective log palisades, would have as its center a Town House and
Square. The Square, a level field in front, was used for celebrations
and dancing. The Town House itself sheltered the town council, plus
the entire village, during their frequent meetings. In times of
decision-making, as many as 500 people crowded into the smoky,
earth-domed building where they sat in elevated rows around the
council and heard debates on issues from war to the public granary.
Democracy was the keynote of the Cherokee Nation. “White” chiefs
served during peacetime; “Red” chiefs served in time of war. Priests
once formed a special class, but after an episode in which one of the
priests attempted to “take” the wife of the leading chief’s brother, all
such privileged persons were made to take their place alongside—
not in front of—the other members of the community.
Women enjoyed the same status in Cherokee society as men. Clan
kinship, land included, followed the mother’s side of the family.
Although the men hunted much of the time, they helped with some
household duties, such as sewing. Marriages were solemnly
negotiated. And it was possible for women to sit in the councils as
equals to men. Indeed, Nancy Ward, one of those equals who
enjoyed the rank of Beloved Woman, did much to strengthen bonds
of friendship between Cherokee and white during the turbulent years
of the mid-18th century. The Irishman James Adair, who traded with
the Cherokees during the years 1736 to 1743, even accused these
Indians of “petticoat government.” Yet he must have found certain
attractions in this arrangement, for he himself married a Cherokee
woman of the Deer Clan.

Smithsonian Institution
A Cherokee fishes in the Oconaluftee River.
Charles S. Grossman
A team of oxen hauls a sled full of corn stalks for a
Cherokee farmer near Ravensford, North Carolina.
Oxen were more common beasts of burden in the
mountains than horses mainly because they were less
expensive.
Adair, an intent observer of Indian life, marveled at the Cherokees’
knowledge of nature’s medicines: “I do not remember to have seen
or heard of an Indian dying by the bite of a snake, when out at war,
or a hunting ... they, as well as all other Indian nations, have a great
knowledge of specific virtues in simples: applying herbs and plants,
on the most dangerous occasions, and seldom if ever, fail to effect a
thorough cure, from the natural bush.... For my own part, I would
prefer an old Indian before any surgeon whatsoever....”
 Pages 40-41: At Ayunini’s house a woman pounds
corn into meal with a mortar and pestle. The simple,
log house is typical of Cherokee homes at the turn of
the century. This one has stone chimneys, whereas
many merely had a hole in the roof.
The Indians marveled at nature itself. A Civil War veteran remarked
that the Cherokees “possess a keen and delicate appreciation of the
beautiful in nature.” Most of their elaborate mythology bore a direct
relation to rock and plant, animal and tree, river and sky. One myth
told of a tortoise and a hare. The tortoise won the race, but not by
steady plodding. He placed his relatives at intervals along the
course; the hare, thinking the tortoise was outrunning him at every
turn, wore himself out before the finish.
The Cherokees’ many myths and their obedience to nature required
frequent performance of rituals. There were many nature
celebrations, including three each corn season: the first at the
planting of this staple crop, the second at the very beginning of the
harvest, the third and last and largest at the moment of the fullest
ripening. One of the most important rites, the changing of the fire,
inaugurated each new year. All flames were extinguished and the
hearths were swept clean of ashes. The sacred fire at the center of
the Town House was then rekindled.
One ritual aroused particular enthusiasm: war. Battles drew the tribe
together, providing an arena for fresh exploits and a common
purpose and source of inspiration for the children. The Cherokees,
with their spears, bows and arrows, and mallet-shaped clubs, met
any challenger: Shawnee, Tuscarora, Creek, English, or American.
In 1730, Cherokee chiefs told English emissaries: “Should we make
peace with the Tuscaroras ... we must immediately look for some
other with whom we can be engaged in our beloved occupation.”
Even in peacetime, the Cherokees might invade settlements just for
practice.
But when the white man came, the struggle was for larger stakes. In
1775 William Bartram, the first able native-born American botanist,
could explore the dangerous Cherokee country and find artistry
there, perfected even in the minor arts of weaving and of carving
stone tobacco pipes. He could meet and exchange respects with the
famous Cherokee statesman Attakullakulla, also known as the Little
Carpenter. And yet, a year later, other white men would destroy more
than two-thirds of the settled Cherokee Nation.
Who were these fateful newcomers? Most of them were Scotch-Irish,
a distinctive and adventuresome blend of people transplanted chiefly
from the Scottish Lowlands to Northern Ireland during the reign of
James I. Subsequently they flocked to the American frontier in
search of religious freedom, economic opportunity, and new land
they could call their own.
In the late 1600s, while the English colonized the Atlantic seaboard
in North and South Carolina and Virginia, while the French settled
Alabama, Mississippi, and Louisiana ports on the Gulf of Mexico,
and while the Spanish pushed into Florida, 5,000 Presbyterian Scots
left England for “the Plantation” in Northern Ireland. But as they
settled and prospered, England passed laws prohibiting certain
articles of Irish trade, excluding Presbyterians from civil and military
offices, even declaring their ministers liable to prosecution for
performing marriages.
The Scotch-Irish, as they were then called, found such repression
unbearable and fled in the early 18th century to ports in Delaware
and Pennsylvania. With their influx, Pennsylvania land prices
skyrocketed. Poor, rocky soil to the immediate west turned great
numbers of these Scotch-Irish southward down Virginia’s
Shenandoah Valley and along North Carolina’s Piedmont plateau.
From 1732 to 1754, the population of North Carolina more than
doubled. Extravagant stories of this new and fertile land also drew
many from the German Palatinate to America; during the middle
1700s these hardworking “Pennsylvania Dutch” poured into the
southern colonies.
Virginia, the Carolinas, and Georgia were colonies of the crown, and
the Scotch-Irish and Germans intermarried with the already settled
British. These Englishmen, of course, had their own reasons for
leaving their more conservative countrymen in the mother country
and starting a whole new life. Some were adventurers eager to
explore a different land, some sought religious freedom, not a few
were second sons—victims of the law of primogeniture—who arrived
with hopes of building new financial empires of their own. They all
confronted the frontier.
They encountered the Cherokee Nation and its vast territory. Earliest
relations between the Cherokees and the pioneers were, to say the
least, marked by paradox. Traders like James Adair formed
economic ties and carried on a heavy commerce of guns for furs,
whisky for blankets, jewelry for horses. But there was also deep
resentment. The English colonies, especially South Carolina, even
took Indian prisoners and sold them into slavery.
The Spanish had practiced this kind of slavery, arguing that thus the
Indians would be exposed to the boon of Christianity. The English
colonies employed what were known as “indentured servants,”
persons who paid off the cost of their passage to America by working
often as hard as slaves. And in later years both the white man and
some of the more prosperous Cherokees kept Negro slaves. Such
instances in the Nation were more rare than not, however, and a
Cherokee might work side by side with any slave he owned;
marriage between them was not infrequent. Be that as it may, the
deplorable colonial policy of enforced servitude at any level, which
continued into the late 1700s, sowed seeds of bitterness that ended
in a bloody harvest.
Like the pioneers, the Cherokees cherished liberty above all else
and distrusted government. Both left religion to the family and
refused to institute any orthodox system of belief. Even the forms of
humor were often parallel; the Cherokee could be as sarcastic as the
pioneer and used irony to correct behavior. As one historian put it:
“The coward was praised for his valor; the liar for his veracity; and
the thief for his honesty.” But through the ironies of history, the
Scotch-Irish-English-German pioneers of the highlands, who were
similar to the Cherokees in a multitude of ways and quite different
from the lowland aristocrats, became the Indians’ worst enemy.
Their conflict was, in a sense, inevitable. The countries of England
and France and their representatives in America both battled and
befriended the Cherokees during the 18th century. Their main
concern lay in their own rivalry, not in any deep-founded argument
with the Indians. As they expanded the American frontier and
immersed themselves in the process of building a country, the
colonists inevitably encroached upon the Cherokee Nation.
In 1730, in a burst of freewheeling diplomacy, the British sent a
flamboyant and remarkable representative, Sir Alexander Cuming,
into remote Cherokee country on a mission of goodwill. After
meeting with the Indians on their own terms and terrain, Cuming
arranged a massive public relations campaign and escorted
Attakullakulla and six other Cherokee leaders to London, where they
were showered with gifts and presented at court to King George II.
The Cherokees allied themselves with Britain, but this did not
discourage the French from trying to win their allegiance. When the
English in 1743 captured a persuasive visionary named Christian
Priber who sought to transform the Cherokee Nation into a socialist
utopia, they suspected him of being a French agent and took him to