Lecture 19
      
                     Psychological Factors and Physical Illness
      
      
      Lecture Outline
      
      I.  Introduction
      II. Background
           A. Psychosomatic Medicine
           B. Biochemistry and Physiology
           C. Behavior Modification
           D. Biofeedback
           E. Medicine and Public Health
      III.A New Paradigm: Behavioral Medicine
      IV. Physical Disorders Associated with Psychological Disorders
           A. Chronic Pain
           B. Cancer
      V.  Conclusion
      
                     -------------------------------------------
      
      I.  Introduction
      
           There is a third Axis in the DSM-III-R diagnostic system:  Axis III
      allows the clinician to record the presence of any important physical
      disorders and conditions.  This in itself is not part of the DSM mental
      disorder diagnosis.  However, it is clear that certain psychological
      factors (eg: one's beliefs, emotions, behavior, etc) may contribute to
      the initiation or exacerbation of the physical condition.  These
      psychological factors, if present, are specified and recorded on Axis I
      of the DSM-III-R diagnostic system.  In today's lecture we will look at
      some of these factors and how they effect physical health.  
           The physical conditions that have been associated with
      psychological factors are numerous indeed:  obesity, headache,
      menstruation, chronic pain, acne, arthritis, asthma, ulcers, nausea and
      vomiting, colitis, hypertension, diabetes, and cancer (APA, 1987; JCCP,
      vol 50 (6), 1982).  These disorders are also known as "psychosomatic" or
      "psychophysiological" disorders.
      
      II. Background
      
           If you recall the beginning of the course, we talked about
      something called "dualism": the philosophical position that the mental
      and the physical are made up of different "stuffs" - you can't
      understand one level in terms of the other.  The famous French
      philosopher of the 17th century, Rene Descartes, made one of the most
      famous proposals for a dualistic view of nature in his Discourse on
      Method:  "I am a substance the whole nature of which is to think, and
      which for its existence does not need any place or depend on any
      material thing" (Discourse, part IV).  Such a view has had a profound
      effect on traditional medicine.  Although Descartes recognized that the
      mental and physical realms can influence each other, traditional
      medicine seemed more often to forget this point.  Theirs was an extreme
      form of dualism:  the mind and body are separate to such an extent that
      problems occurring at these levels are dealt with separately.  A doctor
      for bodily problems, a psychiatrist for mental problems.  In large part,
      this was because no one knew enough about how the mind and body works
      (Holden, 1980).
      
      A number of historical events lead to a shift away from this
      dualistic view (Blanchard, 1982; Holden, 1980; Pomerleau, 1982):
      
      A. Psychosomatic Medicine
      
           During the 50's and 60's, psychoanalytic theorists attempted
      to explain certain physical ailments in terms of psychological
      processes rather than physical processes.  For example, a number of
      physical disorders seemed to have no clear or even possible
      physical causes.  Eg: Conversion Hysteria: blindness, paralysis,
      numbness, etc with no possible physical explanation - does not fit
      known neuroanatomy.  Instead, the symptoms were hypothesized to be
      due to anxiety, repressed guilt, impulses and memories,
      intrapsychic conflict...that is, psychological factors.  
           These theories tended to be crude and mostly correlational in
      nature (so it's difficult to talk about causation).  Nevertheless,
      the important point is that these theorists were arguing that the
      mind and body are mutually influencing - they are not separate.
      
      B. Biochemistry and Physiology
      
           In the past 20 - 30 years, there have been important advances
      and new findings in biochemistry and physiology.  The role that
      psychological processes play in health is increasingly being
      recognized.  EG: Stress and the immune system.  We have repeatedly
      seen examples of this in our discussions of etiology.  
           In addition, there have been important technological advances: 
      Measurement technology has developed to a level undreamed of 50
      years ago.  Processes once inaccessible are now open to our
      scientific gaze.  (ie:  you can't study something if you can't
      measure it).  (Note: technology limits our understanding). 
      Example:  Brain imaging.
      
      C. Behavior Modification
      
           During the 60's and 70's, behavior modification demonstrated
      its usefulness in treating a wide range of psychological problems. 
      Behavior modification focused on teaching clients new skills and
      placing the ultimate responsibility for the client's "mental
      health" on the client.  Behavioral oriented therapists eventually
      began applying their powerful and reliable behavior change methods
      to traditionally "medical" problems: obesity, smoking, etc.  As a
      result, there was a growing recognition in the medical field of the
      role that behavior plays in physical health.
      
      D. Biofeedback
      
           Around the same time, work began on what has been termed
      "biofeedback".  This is a procedure which allows a person to gain
      control over his/her physiological responses - previously thought
      to be purely automatic and reflex-like and thus beyond our
      conscious control.  
           The process:  immediate feedback on biological processes (body
      temperature, heart rate, gastric acid secretion, muscle tension,
      etc).  The client, with this feedback, is able to learn how to
      modify his/her biological responses.  
           Example:  Control over blood flow (and thus body temperature)
      via temperature probe attached to finger tips.  When blood flow
      increases above some predetermined threshold, a tone will sound. 
      The client is instructed to decrease blood flow in the hand. 
      He/she does this by learning to keep the tone from sounding (the
      tone indicating increased blood flow).  
           Demonstration:  Ask for volunteer; hookup with EMG biofeedback
      equipment (if available).
           People are able to learn this control, although the mechanism
      is unclear as to how this works.  Biofeedback may simply be having
      the same effect as relaxation training - reduced physiological
      arousal (eg: Silver & Blanchard, 1978).  
           This technique was soon applied to a whole host of medical
      problems, especially those problems that were being linked to
      psychological factors (eg: headaches, hypertension, ulcers).
      [Note: the reliability of this technique has come under question in
      recent years - it is not the "cure-all" it is sometimes claimed to
      be.  Much more research is needed  (Agras, 1984)]
      
      E. Medicine and Public Health
      
           During the late 60's and early 70's, infectious diseases (the
      focus of the medical field) were essentially conquered.  The
      interest shifted to heart disease, cancer (now the 2 main killers)
      and other chronic health problems (eg: smoking).  It was recognized
      that psychological factors are important in the etiology and
      maintenance of these disorders.
      
      III. A New Paradigm: Behavioral Medicine
      
           Out of these developments, a "new paradigm" (Gentry, 1984; Holden,
      1980) or approach to medical disorders arose:  This new paradigm is
      referred to as Behavioral Medicine.  This approach emphasizes the
      importance of a "systems theory" perspective when trying to understand
      and deal with medical problems.  (The biopsychosocial model we discussed
      earlier is an example of a systems approach).  An individual's health
      must be understood in the context of a system.  This system includes
      complex, ongoing feedback loops between many subsystems: physiology,
      neurochemistry, behavior, psychology, the environment, and so on. 
      Illness is potentially a quite complex experience.  A division between
      the Mind and the Body becomes difficult to maintain; the two are not
      different stuffs, but are part of a complex psycho-physiological system.
           This approach necessitates an interdisciplinary effort: knowledge
      from various fields must be integrated if we are to fully understand and
      treat "medical" problems (Gentry, 1984, Weiss, 1982 -see Handout 19-1:
      illustrates the numerous fields that will play a role in behavioral
      medicine).
           Some of the key etiological factors and mechanisms that have been
      identified (Pomerleau, 1982; Weiss, 1982) include:
      1. Biological processes per se.
      2. The role of biological and psychological processes as part of a  
         single system.
      3. The behavior of health-care providers (delivery of services)
      4. Adherence to treatment ("compliance").  (eg: taking              
         medications, following a diet)
      5. Behaviors that are risk factors (eg: life style).
      6. The effect of interpersonal relationships on health.
      
      Likewise, intervention will address these various levels.
      
           It is clear from this perspective that in many cases physical
      health and psychological processes can not be separated.
      
      IV. Physical Disorders Associated with Psychological Factors     
      
           Numerous physical disorders are associated with psychological
      factors.  Your book reviews some of these disorders: Coronary heart
      disease, anorexia/bulimia, essential hypertension, peptic ulcers, and
      tension and migraine headaches.  In today's lecture, we will examine
      additional disorders.
      
      A. Chronic Pain
      
           Chronic pain is one of the most prevalent and difficult
      problems physicians treat; it is one of the leading medical
      problems.  The typical drug treatments used for acute pain are
      usually ineffective, and carry with them a whole host of negative
      side effects when used long-term (Keefe, 1982).  
           Physicians are increasingly recognizing the role that
      behavioral, psychological and environmental factors play in chronic
      pain.  An assessment of these factors may be as important as a
      medical exam (Fordyce, 1976).  No longer is pain (esp. chronic
      pain) seen as simply the experience of tissue damage.  While this
      may account for acute pain, it does not explain the continuation of
      pain after tissue damage heals (Melzack & Wall, 1982; Philips,
      1988).
      
      Etiological factors
      
      1. Overt Behavior:  Well behaviors (eg: activity, exercise)
      and Pain behaviors (eg: med. intake, time spent in bed,
      guarded movements).  In many cases of chronic pain, the Pain
      behaviors are being reinforced by other people.  When the
      individual exhibits pain behavior, s/he receives sympathy,
      attention, or other so called "secondary gains".  That is,
      there are pay-offs for being in pain.  
      
      Those patients who cope with their pain by engaging in "well-
      behaviors" report less pain than those who do not engage in
      those behaviors (Keefe, 1982).
      
      2. Mental factors:  How the individual responds to his/her
      pain can have a profound impact on the subjective experience
      of that pain (Keefe, 1982; Melzack & Wall, 1982).  Possible
      responses:
              Distortions:
                      -catastrophizing: "blowing the pain out of
                       proportion".
                      -feeling out of control, helpless.
                      -anger, fear etc
      
                      [these can all intensify the pain, lead to
                      depression].
      
              Coping Strategies:
                      -reinterpretation of sensations
                      -ignoring
                      -saying positive, reassuring things to yourself
      
      A person with chronic pain will do things to try to tolerate,
      minimize or reduce his/her pain.  Sometimes, however, the
      person's responses to pain may exacerbate the pain.  Eg: If I
      keep telling myself the pain is unbearable, then it probably
      will be.
      
      3. Self-report:  What someone says to others about his/her
      pain may play a role in the development and maintenance of the
      pain.  As his/her overt behaviors may engender "secondary
      gains", so too might his/her self-report lead to reinforcement
      (Fordyce, 1976, Keefe, 1982).  
      
      Sum:  We can see that behavioral, psychological and
      environmental factors come into play in the experience of
      pain.
      
      B. Cancer
      
           Psychological factors have been found to be associated with
      both the etiology of cancer and its treatment.
      
      1. Etiology:  
           a) Personality factors: Some studies have linked certain
      personality traits with cancer (Krantz & Glass, 1984).  These
      traits include helplessness, moodiness, emotional repression
      ("bottling up" strong feelings).  These findings, however, are
      far from certain.  While there may be an association between
      personality and cancer, there is presently little convincing
      evidence of a causal relationship (Krantz & Glass, 1984).
           b) Stress: Stress has been shown to disrupt the immune
      system, making the body more vulnerable to a wide range of
      viruses and other disease agents.  To the extent that certain
      cancers are virally caused, stress may play an important role
      it the etiology of these cancers.  Animal studies have
      supported this relationship - stress does interfere with the
      immune system.  Eg: rats implanted with tumor cells were less
      likely to be able to fight off the disease when experiencing
      inescapable shocks (a stressor) than were rats without shocks
      or with escapable shocks (Ader & Cohen, 1984; Visintainer,
      Volpicelli & Seligman, 1982).  Similar patterns have been
      found with humans:  In general, high stress or numerous
      stressors are associated with depressed immune defenses (Ader
      & Cohen, 1984).  
      
      2. Treatment:
           Psychological factors also play a role in the treatment
      of cancer - or more accurately, these factors can interfere
      with treatment.
      
      Chemotherapy is one of the most widely prescribed methods of
      treating cancer (Redd & Andrykowski, 1982).  Such treatment
      involves adminstration of chemicals that are toxic to the
      cancer cells.  Such treatment often requires a long time to be
      effective - repeated treatments are necessary.  Unfortunately,
      these chemicals are toxic to much more than the cancer cells. 
      They also attack the intestinal tract, the tissue of the bone
      marrow, and the reproductive system, to name but a few (Redd &
      Andrykowski, 1982).  These effects lead to various aversive
      reactions in the patient: nausea, vomiting and diarrhea. 
      These side effects can last anywhere from 2 to 24 hours after
      the chemotherapy session. 
      
      As a result, approximately 25% of the patients develop
      aversion reactions prior to subsequent treatment sessions
      (Redd & Andrykowski, 1982): nausea, etc occurs before
      receiving the drugs.  This has been termed "anticipatory
      nausea". 
      
      What is occurring in these situations is the patient comes to
      associate reactions to the drugs with the sights, sounds,
      smells, thoughts, etc that accompany the treatment. 
      Eventually, mere exposure to these things (sights, sounds,
      etc) elicit the aversion reactions.  This is a case of
      Classical Conditioning (the basic process of which we have
      discussed in earlier lectures):
      
      
          US ---> UR chemicals ---> nausea US + CS ---> UR chem's + sights, etc ---> nausea CS ---> CR sights, etc ---> nausea
      V. Conclusion It is increasingly being recognized by medical practitioners that the most effective treatment for certain physical disorders will need to take into account psychological factors. In the disorders we discussed today, this was very clearly the case: Chronic Pain: 1. Alter consequences of pain behaviors. Eg: withhold reinforcement for pain behaviors while simultaneously reinforcing well behaviors. 2. Teach new methods of coping and self-management. Eg: relaxation training, biofeedback, even assertion training (learn how to state your needs directly rather than passively by being sick) (Keefe, 1982). Cancer: 1. Relaxation training to counter the effects of stress. Learning better ways to cope with and gain control of life stress. 2. Learn responses that are incompatible with the anticipatory nausea. Some of the techniques to aid in the learning of these responses include relaxation training, systematic desensitization, biofeedback (Redd & Andrykowski, 1982).