MIND BODY MEDICINE
conditions that require behavioral adjustment.
by Hans Selye in 1936 as “the nonspecific response of the body to any demand.”
is not new in terms of human evolution, but we have many "psychological
stressors" now that primitive men and women did not have, such as
stock market crashes, unemployment, terrorism, urbanization, and the
changing roles of men and women in society.
American Institute of Stress in Yonkers,
New York estimates that
stress-related complaints may be responsible for up to 75% of
symptom-prompted visits to primary care physicians.
has been estimated that 85% of all illnesses are caused or aggravated by
stress (Lewis HR, Martha E. Psychosomatics. 1972).
best sellers have been written about stress, especially the psychology of
stress triggers an involuntary response labeled the fight-or-flight
response, characterized by increased respiratory rate, blood pressure,
pulse, and increased blood flow to the muscles.
same response is triggered whether the stress is real and physical (an
animal attack) or imagined and psychological (dread or fear about the
an evolutionary perspective, the fight-or-flight response was adaptive,
but we are now victims of our past, in that chronic stress which is so
common in this era leads to chronic increases in epinephrine and cortisol
levels in the bloodstream, with resultant chronic hypertension and adrenal
and immune system suppression as well as loss of muscle mass and
deposition of visceral fat, which produces even more cortisol (Selye H. A
Syndrome Produced by Diverse Nocuous Agents. Nature. 1936).
word ‘stress’ was first used in 1926 by Walter Cannon, a Harvard
professor – he used this word to describe adverse events that reduced
homeostasis. Cannon published The
Wisdom of the Body in 1932.
Selye – identified the HPA axis as the mediating stress, and formulated
General Adaptation Syndrome – the 3 stages of stress
– rapid increase in catecholamines, slower increases in cortisol levels.
– sustained increase in catecholamines and cortisol levels, which is
associated with insulin resistance, hypertension, and alterations of
thyroid hormone and sex hormone metabolism.
– low levels of catecholamines and cortisol, associated with
degenerative diseases of aging.
(Hess, 1940's) using electrical stimulation studies in cats, has shown
that a certain part of the hypothalamus in the brain controls the
Stress (chronic) and hormones
causes a rise in cortisol and a loss of the circadian release of
cortisol. Cortisol makes us less
sensitive to leptin, a satiety hormone.
causes a rise in epinephrine and norepinephrine levels.
causes a decrease in testosterone, estrogen, and progesterone.
is associated with lower levels of thyroid hormone.
is associated with lower levels of growth hormone.
stress may lead to insulin resistance.
Stress and the immune system
causes impairment of immune system functioning – specifically decreases in
secretory IgA, decreases in NK activity, and decreases in IL-2.
may enhance humoral immunity at the same time it causes impairment in cell
mediated immunity (Ann N Y Acad Sci. 2002. 966. 290-303).
Stress - men versus women (Self
Healing. May, 2004. Page 8)
show that women across all social and economic categories perceive their
lives as more stressful than men.
show that sources of stress differ - work is the primary source of stress
for men whereas conflict in marriage or problems with other relationships
are the primary sources of stress in women.
women there is data that the fight-or-flight response to stress is
tempered by the tend-and-befriend response, leading women who are more
stressed to be more attentive to their children and to seek out
conversations with friends, whereas men who are more stressed tend to
isolate themselves. There is an evolutionary basis to this model.
hormonal basis of different stress responses in men versus women may be
the release of more oxytocin by women who are stressed, compared with
men. Furthermore, testosterone minimizes the effect of oxytocin on
social bonding, whereas estrogen enhances this effect.
effect of stress on health often differs - women are more likely to suffer
from anxiety, depression, post-traumatic stress disorder, eating
disorders, tension headaches, irritable bowel syndrome, and autoimmune
disorders, whereas men are more likely to suffer from alcohol abuse,
hypertension, or heart disease.
Stress and disease
has established that people under chronic stress have weak immune systems
and have an increased risk of cardiovascular disease.
study in 58 women aged 20-50, with 39 experiencing chronic stress as
caregivers of chronically ill children and 19 healthy showed that the
women reporting the highest stress levels had changes in blood mononuclear
cells (shorter telomeres, less telomerase, higher levels of free radicals)
associated with premature aging (Proceedings
of the National Academy of Sciences. 2004).
Relaxation Response (Herbert Benson, MD)
relaxation response is defined physiologically as a state characterized by
decreased oxygen consumption, decreased metabolic rate, alpha waves on EEG
brainwave tracings, decreased blood lactate levels, decreased respiratory
rate, decreased heart rate and decreased blood pressure in those people
in the 1940's, using his electrical stimulation studies in cats, showed
that the state which Benson labels as the Relaxation Response is mediated
by a specific part of the hypothalamus in the brain. This is an
involuntary response with physiology opposite to that of the
is the term that is used for the practice which invokes the relaxation
may be defined broadly as any activity that keeps attention pleasantly
anchored in the present moment (i.e. intentional self-regulation of
allows us through training to activate an involuntary response (i.e. the
major classes of meditation:
meditation - Focus attention to a single aspect such as breathing, a
visual object, or a sound. TM is an example. TM is derived
from a Hindu-influenced practice of meditation.
meditation - emphasizes detached observation of oneself engaged in a
practice such as breathing. Uses a detached observational state to
experience all physical and mental events as they occur. Developed
as a contemporary system by Jon Kabat-Zinn,
PhD. Mindfulness is defined as moment to moment nonjudgemental
awareness. Mindfulness meditation
is derived from a form of Buddhist meditation known as Vipassana.
analysis of ancient religious practices such as dovening
in Orthodox Jews and chanting in Buddhism shows that these practices
elicit the Relaxation Response.
now understand scientifically what our ancestors understood intuitively
(i.e. we can learn to activate an "involuntary response"
through the practice of a specific technique which is generally labeled
is consistent with the finding of Skinner that we can control behavior by
altering the environment, and the finding of Miller that we can control
involuntary processes through biofeedback - meditation allows us to skip
the biofeedback and control involuntary processes through breath
that breathing is unique in that it is an involuntary process which can
also be easily controlled voluntarily.
basic elements are necessary in order for one to elicit the Relaxation
Response - they are a quiet environment, a mental device such as a sound or
a word, a passive attitude, and a comfortable position
allows one to develop the ability to become aware of the Inner Self, which
in terms of psychological constructs used to explain the mind, is beyond
the ego, and is connected to a larger wholeness
is very safe - the only risks to be aware of include a correlation between
prolonged meditation and hallucinations, and a conflict between the
passive attitude required to meditate and the free association method used
when an individual is undergoing psychoanalysis.
physiological arousal and psychological anxiety.
changes – reduction in habitual responses (Altern Ther Health Med. 2005. 11. 42-58).
effects- long-term meditators self-induce high-amplitude gamma-band
synchrony on EEG tracings (Proc Natl Acad Sci U S A. 2004. 10. 16369-16373).
of the sympathetic nervous system via the fight-or-flight response is only
one aspect of the effect of stress on our bodies; another is tightening of
muscles and resultant muscle tension.
stretches help to alleviate the muscle tension, and also prepare one
mentally for meditation.
is some evidence that yoga lowers blood pressure and offers protection
from cardiovascular disease (Alt Med
Alert. 2005. 8. 92-95).
- Ashtanga – fast-paced series of postures done in a
continual flow, similar to tai chi.
– vigorous series of 26 poses that are performed in a room heated to 85
to 100 degrees Fahrenheit.
– uses body postures or poses (asanas) and
mindful breathing to develop muscular control, relaxation, and a feeling
– control of breath, sound vibration, and meditation are emphasized along
with the postures; used as a lifestyle intervention by Dean Ornish.
- Iyengar – uses props to help less flexible students
attain the postures and properly flex the spine.
- Viniyoga – flows from pose to pose like ashtanga but is performed at a slower pace.
of cognitive behavioral interventions such as biofeedback, meditation,
progressive relaxation techniques, and education on stress management in
order to treat conditions such as hypertension and insomnia.
research is required to determine whether techniques known to alter
physiology acutely in highly trained individuals in a laboratory study can
in fact induce chronic physiologic changes in selected patient groups.
hypertension, an article published by David Eisenberg, et al. in 1993 in
the Annals of Internal Medicine, based upon a review of existing
literature, found no significant evidence for benefit of cognitive
interventions beyond that of sham techniques or self-monitoring of blood
the other hand, in 1995 a NIH panel concluded based upon a review of
published studies that hypnosis and biofeedback are effective in
alleviating chronic pain associated with certain cancers, as well as
tension headaches, and that relaxation techniques are effective in
treating insomnia. Many also consider biofeedback useful in the treatment
of Raynaud's, asthma, and stress urinary incontinence.
Placebo Effect (Self-Healing Effect) - Belief alone elicits
placebo effect is based upon the mind affecting the body (in a positive
of the history of medicine is the history of the placebo effect.
than simply regarding the placebo effect as a nuisance which interferes
with and confounds modern scientific study, practitioners should use the
placebo effect as a therapeutic ally (Dr. Andrew Weil). This is part of
the art of medicine.
study of the role of faith and belief in healing requires researchers to
bridge the gap between the social sciences and the natural sciences.
Cousins reminds us that the placebo effect begins with patient confidence
in the practitioner, and that the belief of the practitioner is an
important factor. When a trusted physician enthusiastically offers a
patient a new treatment, the placebo rate may be as high as 70%.
Ader, a University of Rochester
psychologist, showed in 1974 that the immune system of rats can be
classically conditioned. He paired saccharin with cyclophosphamide (an
immune depressant drug) and showed that eventually the mere provision of
saccharin flavored drinking water to rats led to measurably diminished
functioning of the immune system.
at the Ontario Cancer Institute showed that mice conditioned with camphor
and an immune stimulant drug called polyinosinicpolycystidilic
acid showed increased activity of killer cells, the cells responsible for
immune surveillance, in response to mere exposure to camphor.
researchers in the 1980's demonstrated anatomic evidence of connections
between the brain and the immune system, showing that nerve fibers go to
the spleen, thymus, lymph nodes, and bone marrow.
hypothalamus in the brain governs the pituitary gland, the master
endocrine gland in the body, which is located at the base of the brain,
via various neurochemicals.
endocrine system can in turn affect the immune system via endocrine
hormones which bind to receptors on the surface of the immune system
as the study of the interactions between beliefs, behavioral states, the
nervous system, and the immune system.
- Superimmunity can be defined as the capacity to think
and feel in ways that can protect us from disease, heal us, and allow us
to attain wellness.
now know that feelings, thoughts, and beliefs can lead to increased or
decreased disease susceptibility.
As per a review article with 192 references,
current empirical data for the psychological benefits associated with laughter
is than the data for physiological benefits (Altern Ther Health Med. 2010. 16 . 56-64).
laughter, induced by watching 30 minutes of a comedy was associated with
changes in arterial compliance, whereas arterial compliance did not change
after watching a documentary for 30 minutes, in a crossover trial design
in 17 apparently healthy adults (Am
J Cardiol. 2010. 106. 856-859).
laughter in association with the emotion which arises when watching a
funny movie or hearing a funny joke has been shown to improve blood flow,
lower cortisol levels, and boost immune system function (Time. 9/13/10).
laughter is assumed to be associated with the same benefits, but as of
2010, there is no published literature on fake laughter (Time. 9/13/10).
Intriguing Examples of Mind-Body Interactions
creates brain matter - intellectual activity increases dendrite formation
in neurons, which may offset loss of neurons with aging.
subjects trained to smile showed increased levels of endorphins.
watching a film showing sexual love have increased salivary IgA levels.
stress impairs the function of natural killer cells in humans.
lymphocyte response to mitogens becomes sluggish in a person who has lost
a spouse, and the death rate for widows and widowers in the first year is
ten times that of matched controls.
Harvard Alumni Study has shown that mental health is the most important
determinant of physical health.
speed of healing of surgical wounds in the immediate post-operative period
is much more rapid in patients who showed faith, trust, and confidence in
their doctors, their nurses, and themselves.
who are more assertive in the hospital heal faster.
recover more quickly in hospital rooms with a view of trees and bushes.
suggestion can obliterate the vascular manifestation (induration and
erythema) of a positive Manteaux test for tuberculosis, which is a
function of cell-mediated immunity. (Hypnosis is an altered state of
consciousness characterized by an increased receptiveness to suggestion.)
shows that determination to overcome illness correlates with greater
tolerance to severe pain (Pain is initiated by a physical stimulus and is
a protective mechanism; ones emotional response to pain determines how
intensively the pain is experienced.).
laughter provided increased analgesia for Norman Cousins, a writer
stricken with ankylosing spondylitis.
levels rose 100% in 28 people who practiced "Cut Thru"
(recognize insecurity, then consciously choose a more hopeful perspective)
for 1 month.
- In a
small study (14 couples), amongst those who went through a two session
program to learn about stress management and relaxation techniques, 28%
conceived in their first attempt at in vitro fertilization, compared to a 6%
rate in "historic controls."
- In Roseto,
Pa, the only explanation
that could be found for the unusually low heart disease death rate was the
strong sense of community.
with low testosterone levels show a 30% increase following crying. It is
fascinating that while tears induced by onions contain only salt and
water, tears induced by watching a sad movie contain leftover chemicals
secreted when we are under stress. Thus, like our urine and sweat, tears
are another "limb" of our excretory system.
published studies of women desiring larger breasts indicate that imagining
larger breasts results in an average increase in circumference over a 12
week period of 1 1/4 inches, and 80% of the increase persists for an
additional 12 weeks.
of joy and exhilaration are associated with production of interleukin-2,
which costs up to $40,000 per treatment course when used to treat cancer.
- In a
study of 498 older men who completed the MMPI, there was a linear,
dose-response relationship between negative emotions and the risk of
ischemic heart disease (Am J Card. 2003. 92. 901-906).
In a study in 41 rheumatoid arthritis patients
and 23 controls, laughter (mirthful laughter) is associated beneficial changes
in pro-inflammatory cytokine levels in those with rheumatoid arthritis (Rheumatology. 2006. 45. 182-186).
Personality Type (trait) and Disease
personality types (traits) are associated with physiologic states which
predispose to certain disease.
and Rosenman, in the 1950's, found that Type A behavior, characterized by the fierce struggle to do
more things in less time against keen competition, is associated with
increased risk of heart disease.
analysis of trait anger and trait forgiveness in 308 healthy young female
volunteers found “divergent cardiovascular effects of anger and
forgiveness, such that anger is associated with a more cardiotoxic
and hemodynamic profile, whereas TF (trait forgiveness) is associated with
a more cardioprotective profile (Am J Cardiol.
2014. 114. 47-52).
the 1960's, Andrew Weil, MD, writes that the entire medical community
acknowledged asthma, rheumatoid arthritis, peptic ulcer disease, and
ulcerative colitis to be psychosomatic diseases, but that there has been a
shift away from this way of thinking, at least in conventional medical
there is a cancer personality remains debatable.
Mind-Body Interactions Which Alter Disease Outcome
Adherence to placebo and health outcomes - in
several large placebo controlled studies, in which adherence to placebo was
measured, those subjects with a high adherence to taking placebo had better
outcomes than those non-adherent with placebo.
the Coronary Drug Project (CDP), a multicenter trial of the cholesterol
lowering drugs niacin and clofibrate, clofibrate was no better than placebo with regard to
cardiovascular mortality rate; subgroup analysis of those administered clofibrate showed that those who took 80% or more of their
pills had only half the death rate of those who did not take their pills.
the BHAT study in 1990, adherence to treatment was associated with a lower
the CHARM study looking at candesartan (Atacand) for
CHF, placebo adherence was therapeutically more valuable than the overall
statistical treatment difference between placebo and active drug (Lancet.
2005. 366. 2005-2011). The accompanying editorial noted that “high adherence to
placebo had a 3.5 times greater effect on reducing mortality than the overall
treatment effect of candesartan” (Lancet. 2005. 366. 1989-1991).
groups and health outcomes
a randomized study involving 86 women with metastatic breast cancer, Dr.
David Spiegel, a Stanford psychiatrist, showed that those who
participated in weekly discussion groups in which they shared their
feelings and learned simple techniques to reduce stress not only had a
better quality of life, but nearly doubled their survival to a mean
survival of 37 months (Spiegel D, Bloom, JR, Kraemer HC, et al. Effect of
psychosocial treatment on survival of patients with metastatic breast
cancer. Lancet. 1989. 2. 888-891). If new chemotherapy
had performed this well, it would have been big news. However, a
larger study designed to test the same hypothesis showed only
improvements in quality of life, not mortality. This study included
235 patients with metastatic breast cancer and fifty-two 90 minute group
sessions of emotional expression, coping, and psychological
support. At 6 years, survival in the treatment group was 17.9
months, survival in the control group was 17.6 months (N
Engl J Med. 2001. 345.
study in patients following surgical removal of a malignant melanoma
showed that after 5 years, there were only 7 recurrences and 3 deaths in
those in a 6 week support group, whereas there were 13 recurrences and 10
deaths in the control group (Arch
Gen Psychiat. 1993. 50. 681-689).
to increase the capacity for emotional expression, especially anger, may
slow the progress of cancer.
that reduce the sense of helplessness/hopelessness may extend life in
people with cancer.
Simonton’s have found better outcomes in cancer patients who are able to
visualize a strong immune system overcoming weaker cancer.
Clinical Application of Mind-Body Therapies (biofeedback, meditation,
relaxation, stress management)
is strong evidence of efficacy for mind-body therapies in the areas of
chronic low back pain, headache disorders, insomnia, cardiac
rehabilitation, management and treatment of disease-related symptoms in
cancer, osteoarthritis, rheumatoid arthritis, and postsurgical outcomes,
with moderate evidence of efficacy in the treatment of hypertension (Astin JA et al. Mind-body medicine: state of the
science, implications for practice. J
Am Board Fam Pract. 2003.
study in which four focus groups were conducted, two with medical students
and residents, one with primary care doctors, and one with specialists
found that barriers to integration of mind-body medicine in clinical
practice include inadequate attention to these modalities in medical
training, lack of time, inadequate monetary incentives, and a cultural
ethos which favors a “quick fix” (Explore.
2005. 1. 278-283).
Mind/Body Institute www.mbmi.org or
1-866-509-0732. Founded in 1988, currently under the direction of Herbert
- Heartmath Institute www.heartmath.com
Software to display heart rate variability (and demonstrate improvements
associated with meditation)
clubs www.laughterclubs.com or
Based Stress Reduction Program www.umassmed.edu/cfm/srp
or 508-856-2656. Established in 1979, currently under the direction of Jon
- The Relaxation and Stress Reduction
Workbook, 6th Edition. Davis M et al.
Herbert. The Relaxation Response. 1975
Herbert. Beyond the Relaxation Response. 1984
- Borysenko, Joan. Minding the Body, Mending the
Bruce. The Biology of Belief.
Paul. Superimmunity. 1987
- MindBody Medicine. Consumer Reports
Books. Edited by Daniel Goleman and Joel Gurin.
H and Miller FG. Commentary: Lessons from Recent Research about the
Placebo Effect – From Art to Science. JAMA.
2011; 306 :2612-1613.
- Ludwig DS and Kabat-Zinn
J. Mindfulness in Medicine. JAMA. 2008; 300 :1350-1352.
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