Mind-Body Connections

Introduction

I am a retired gastroenterologist who practiced at Duke for 35 years. My interest in Mind-Body connections in medicine began early in my practice as I observed my patients and their response to disease. Many of those responses differed from what the medical data suggested should be happening. Some patients got well when this was not expected and others got worse when recovery had been anticipated. Some patients suffered severe pain and disruption of gastrointestinal function, yet all their tests were normal. I gradually realized that my “success” in treating patients with medication or referral to surgery often depended on the patients’ innate healing systems. Those systems, in turn, seemed to depend on the patients’ mental, emotional and spiritual health.

Healers have long appreciated the importance of these human dimensions to health and disease. Biomedical science, our paradigm over the past 400 years, is based on objectivity and measurement. As a result, we have tended to ignore the subjective world of meaning, emotions and values, which cannot be measured and cannot be accommodated by the language of science. Similarly our human subjective world of values and emotions, our psychology and philosophy, are rarely helpful in understanding the physical world. Physicist Fritja Capra and others speak of the “two languages” we must use if we are to understand the objective and the subjective parts of our human reality; each language is complementary to the other and both are necessary if we are to explore how our limbic brain converts the subjective world of meaning into measurable changes in our biology.

Capra says any biologic entity must be seen in three parts: first, as MATTER (the atoms, receptors, organs etc.), second, as FORM (the way matter is organized) and third, as PROCESS (the myriad biochemical reactions and feedback loops by which matter interacts). The second and third levels, FORM and PROCESS, deal with unique relationships and are nonmaterial, and represent the ways human beings differ from one another. As matter, each human body comprises $58-$65 worth of carbon, hydrogen, calcium, chromium, etc. Our value to each other however, our special appearances and personalities (our form and processes) are immeasurably valuable, depending on whether it is our mate, parent, child or stranger to whom we are relating. Form and process represent information about how matter is organized and how it functions.

It is vital that those of us who know that mind-body connections are important in the care of patients develop a language to help us communicate effectively when we encounter scientific fundamentalists, individuals who see the patient and his or her problems as solvable through a mechanical, reductionistic biomedical approach, who view the body as a mere machine with fixable or replaceable parts. It is vital that we help them see the importance of a holistic view, one that takes into account the common knowledge of everyday experience. Take, for example, the response of a person to embarrassment. This involves a thought, an emotion and a neuropeptide-mediated vasodilatation leading to a red face. That is the mind-body connection at work. Other examples include the recall of a major stress event, the memory of which elicits the same cascade of neuropeptides and hormones that accompanied the original event itself. The intentions we bring to illness —such as using mindfulness practice — can have a powerful healing effect on our bodies (see below). Likewise, the messages we send to the patient as health providers when we prescribe a pill or perform a procedure are integral to the healing/curing impact of the drug or procedure. When the patient develops a positive expectation (hope), there is a corresponding shift in their physiology (see placebo below). Using functional MRI scans, investigators can see that the area of the limbic brain that is activated when we experience pain is also activated when we are empathically witnessing pain in someone else. All of these are examples of mind-body interactions.

One of my goals in this paper is to contrast the biomedical and biopsychosocial models of medicine, and to outline the importance of each. We will review the concept of human psychological needs as put forth by Abraham Maslow, and propose that these needs (and values), and whether they are threatened or supported, play a large role in our day-to-day stress level. We will also look at the important role played by our emotional brain,—the limbic system—and its importance in converting our subjective world into objective changes in our biology. We will look at several systems from the viewpoint of the biopsychosocial model to show how mental, emotional, and spiritual life does in fact influence wound healing, blood clotting and the immune response. Finally we will talk briefly about the difference between curing and healing and how we need both in medicine. The healing dimension is too often ignored in today’s biomedical-oriented practice of medicine.

Mind-Body Connections

Biomedical vs. Biopsychosocial model

The biomedical model, our paradigm in medicine for 400 years, is based on two principles. The first states that all complex biological phenomena are derived from a single primary principle or cause, and the goal of medicine is to find that principle or cause; it is reductionistic. The second principle is that of mind-body dualism, which separates (and tends to belittle or dismiss) the subjective aspects of humans (emotions, thinking and spirituality) from the objective or measurable biology of the human body. The biomedical model has successfully led to discoveries in molecular biology, but this approach often leads to seeing the sick body as only a disordered machine whose parts need to be fixed. The biomedical approach looks to find a single, simple explanation, but is not up to the task of explaining complex, interdependent systems in a living organism (patient). We don’t want to abandon the biomedical model, but we need the more holistic biopsychosocial model proposed by George Engel.

Engel set forth the biopsychosocial model in the 1970s, borrowing from the systems approach that proposes to link all levels of organization in biology or medicine in a hierarchy of relationships. Change on one level effects changes in the levels above and below in the hierarchy. In 2004, the Proceedings of the Mayo Clinic put it this way: “Systems biology is the science of integrating genetic, genomic, biochemical, cellular, physiological and clinical data (including psychosocial) to create a systems approach that can be used to predicatively model a biological event. Many diseases, such as atherosclerosis, cannot be explained by a single defect. It is necessary to use a more holistic, multidimensional, system-level approach”. The biopsychosocial model emphasizes that the whole is greater than the simple sum of its parts.

Healers outside biomedical medicine have appreciated the mind-body connection for centuries. This connection was largely ignored by conventional medicine because the mind was subjective and not easily measurable. Now biomedical research is providing ways to measure “informational molecules” present in the central nervous system (CNS), and the endocrine, immune and other systems that change in response to the mental, emotional and spiritual dimensions of who we are. One example is the field of psychoneuroimmunology and endocrinology, where the brain and immune and hormonal systems communicate with each other in a multi-directional manner. Another is the clinical studies that have used a system level approach to show the harmful effects of psychosocial stressors as diverse as social isolation or type A personality with hostility on mortality in heart disease. Patients with either of these two psychosocial stressors who have a heart attack experience 30-40% increase in mortality during the following year. The increased mortality is reversible when the stressor conditions are modified, even though we do not completely understand the molecular mechanisms that produce the increase mortality. We will explore both examples in more detail later.

We will use the system approach to look at some of the connections between the different layers, which will help us appreciate the importance of mind-body connections. I start with Abraham Maslow’s proposal that in addition to our biological needs for air, water and food, humans have psychological needs for love, empowerment and meaning/purpose. Meaning is essential because it lets us make sense of our outer and inner world, and helps us to generate values, beliefs, goals, and intentions. These needs (for love, empowerment, meaning/purpose) usually operate outside our awareness and yet are important in terms of our stress level. When we perceive these needs and values to be threatened by our environment, we activate the fight/flight response, mediated through the limbic brain’s connections to the hypothalamic pituitary adrenal (HPA) axis and the sympathetic nervous system. When we perceive that our needs/values are to be nurtured and supported, we move toward contentment and the relaxation response described by Benson. The need for love, empowerment and meaning can also lead us to question whether we are loveable or whether we “measure up.” The human processes of growing, relating and creating seek fulfillment of these needs. When our needs are threatened, we use coping skills (see below); when these work to resolve the threat with little cost to the individual, there is minimal stress. But when we perceive that our internal or external environment demands change that exceeds our ability to cope, our needs and values are threatened. Stress then increases and the fight/flight response may be activated, depending on the rate, magnitude, or type of change demanded.

The coping skills we develop depend on our genetic make-up, our pre-existing personality (the way we filter and perceive our world), on education and socioeconomic factors, our ability to re-frame threat as challenge, our relaxation skills (meditation, yoga, Tai Chi, etc), our social supports and exercise habits, as well as the use of numbing activities like television, the internet, tobacco, alcohol, drugs, etc. When coping skills are adequate, there is minimal activation of fight/flight response and we may be said to be in allostatic balance. When demand is high, we may still be in balance but under heavy allostatic load. When demands exceed our ability to cope, we experience the full fight /flight response.

Experiencing some degree of stress can be a positive event, stimulating us to change, create, adapt, and grow. This is particularly true when the stress is followed by a period of recovery, and is not sustained over long periods. On the other hand, chronic stress with the prolonged activation of the fight/flight response appears to cost us in terms of wear and tear in our body (depressed immune responses, cardiovascular reactivity with elevated blood pressure, increase blood coagulability, etc).

The limbic brain includes the hippocampus, which stores our memories of past events with their associated emotions, and the amygdala, which assigns emotion, and the corresponding intensity of the emotion, to an event. From an evolutionary perspective, the limbic brain is first found in mammals, whose offspring are helpless at birth and require extended periods of care. This region of the brain is central to our understanding of how subjective human experience (meaning), and the status of our needs and values, produce measurable changes in our biology. When we compare a current perception to similar past events, we calculate the threatening or nurturing potential of the perception: does the black dog running out of the yard remind us of the pet Labrador retriever we had as a child—or the neighborhood dog that bit us? Emotions are generated as the limbic brain evaluates the status of our needs/values. Lewis and Lanon describe the limbic brain as a social sense organ, sensing the inner state of other people and evaluating whether our immediate environment is likely to threaten or support our needs/values. They consider the limbic brain the “heart” of the CNS.

The prefrontal lobe reacts more slowly than the limbic brain, and as it monitors perceptions and adds new information, it can override emotional output of the limbic brain (some of the time). In addition to generating emotions, the limbic brain also prepares the body for any physical response required. This is carried out through the limbic brain’s multiple connections to the hypothalamus and the autonomic nervous system, which together produce a visceral response. If threat is perceived, then the fight/flight response elicits increased secretion of cortisol, adrenaline, and noradrenalin, with concomitantly increased blood pressure and pulse, altered blood flow patterns (fear, for example, increases blood flow to leg muscles, and anger, blood flow to the hands), increased respiratory rate, blood sugar, and blood coagulability, etc. Even when our emotions are suppressed or produce only minimal conscious awareness, the visceral response is measurable in terms of hormone output, pulse rate, etc.

When our needs are supported and nurtured, we move toward joy and contentment—that is, the “relaxation response” studied by Herbert Benson at Harvard. I would like to now describe several systems using the biopsychosocial model, emphasizing how the different layers or systems interact with each other .We will look first at the relaxation response.

System Level Model

Relaxation/Placebo Response

Benson studied the “relaxation response” that occurs during meditation, yoga, and Tai Chi. He has postulated that the body has a naturally healing system that counterbalances the fight/flight response when allostatic balance is lost (stress overload). He has shown that the relaxation response and the placebo response (a positive expectation or belief that a pill, procedure, or person will help them) provoke similar responses in subjects studied under laboratory conditions. The hallmarks of the relaxation response are increased parasympathetic activity (slowed pulse, decreased blood pressure and lowered oxygen consumption) as well as increased endorphin and dopamine release. Nitric oxide appears to mediate these physiological changes. During the relaxation response there are decreases in the activation of the HPA axis and in sympathetic outflow. According to Benson and others, regular elicitation of the relaxation response produces short- and long-term physiologic changes that lower blood pressure and reduce heart irregularity. Note that mindfulness practice requires intention on the part of the practitioner, while the placebo response involves a belief or positive expectation. The quality of the relationship between the patient and health care person appears to be important in eliciting a placebo response in a patient.

Studies of Relaxation Response

I want to review two studies of the relation of mindfulness meditation to health. Jon Kabat-Zinn divided a group of 25 volunteers so that half spent 8 weeks in mindfulness meditation. EEG recordings made at the beginning, after 8 weeks and again at 4 months, revealed that the meditating group showed the increased left frontal lobe activity associated with positive affect in meditating subjects. Influenza vaccine was administered at the end of 8 weeks of training, and the meditation group had a higher antibody response to the vaccine. Importantly, the magnitude of the antibody response correlated with the degree of increase in left frontal lobe activity and the number of classes attended during the 8 weeks. A second study, at UCLA, provided a subset of HIV-positive patients with 8 weeks of meditation. The group given mindfulness training maintained their CD-4 T-lymphocyte cell count, while the control group showed continued loss of CD-4 cells. These studies support the idea that stress has a negative impact on the immune system in HIV infected individuals.

Placebo Response

Benson concluded that the placebo response produces physiologic and biochemical changes similar to the relaxation response described above. For example, endorphins can be released when individuals are given a sugar pill for pain, thus demonstrating the body’s ability to ameliorate pain intensity by release of this “internal opiate.” The analgesic response can be blocked when volunteer subjects are given the narcotic antagonist Narcan along with the placebo. This further supports the idea that the placebo response involves endorphin-mediated relief of pain.

In the early 1970s bronchial reactivity was studied in asthma patients using isoproterenol as bronchodilator and methacholine as a bronchoconstrictor. Spirometry was used to measure the degree of bronchial constriction or dilatation. When asthma patients were told they were receiving a bronchodilator and given isoproterenol, there was maximum dilation of the airways; if told they were receiving a bronchoconstrictor and given methacholine, there was maximum constriction. However, if told they were receiving a bronchodilator and given methacholine, there was still a bronchodilator effect, and constriction occurred when told they were receiving a bronchoconstictor but given isoproterenol. The individual’s expectation produced a bodily response that exceeded the pharmacologic effect of the administered drug!

Finally, a group of patients with Parkinson’s disease were studied during PET scans to determine the effect of a dopamine-releasing drug vs placebo. The normal blue color assigned to the basal ganglia on PET scan turned orange as the dopamine-releasing drug was administered, and physical therapists detected significant improvement in functional status after the drug was given. Interestingly, when patients were told they were receiving active drug but were given saline, over 50% of patients demonstrated the same shift to orange in the basal ganglia, and their functional status improved as much as when the dopamine releasing drug was given.

Psychoneuroimmunology and Endocrinology

Our CNS receives sensory information from our primary sense organs (vision, taste, smell, touch), as well as from internal images and sensations (memories, dreams and imagination). The CNS correlates these images and sensations with memories and their associated emotions in the limbic brain. This allows us to form perceptions as to whether our human needs and values are being threatened or supported. When we perceive threat but lack adequate coping skills, the fight/flight response is activated; when there is support/nurture of our needs and values, we move toward contentment and the relaxation response. In 1985, Blalock proposed that, like the CNS, the immune system was also a sensing organ that monitors our internal molecular environment to distinguish self from non-self. When viruses, bacteria, fungi, cancer cells are seen as non-self, the immune system recognizes this and attempts to eliminate them.

The CNS, endocrine and immune systems used to be thought of as independently functioning systems (particularly the immune system). The CNS was thought to carry out its functions by secreting biogenic amines like acetylcholine and noradrenalin at synapses between neurons. Beginning in late 1970s, work by Candace Pert and others revealed that, in addition to biogenic amines, CNS neurons secreted many neuropeptides, which convey information to cells that carry specific receptors for these neuropeptides. These neuropeptide signals do not necessarily involve synaptic transmission: neuropeptides may act as neurotransmitters, may produce local, paracrine effects on adjacent cells or act at distance like hormones. More than 80 such peptides have been described and, interestingly, many of the same peptides are also produced by endocrine, immune and gastrointestinal tract cells. Receptors for many of these neuropeptides are found on immune system cells like the monocyte, and are also synthesized by these same cells. The cortex of the limbic brain, including the hippocampus and amygdala, contains some of the highest concentrations of both neuropeptides and their receptors. Most of these peptides are capable of altering emotional states as well as conveying information and eliciting physiological responses. Pert has described them as the “molecules of emotion,” while others describe them as “informational molecules.” Examples include endorphins, cholecystokinin, bombesin, vasoactive intestinal polypeptide (VIP), and oxytocin. To emphasize, these peptides can act locally by diffusion (paracrine effects), at a distance (hormonal effects) or as neurotransmitters. These molecules and other hormones and neurotransmitters provide a way for the CNS, endocrine and immune systems to communicate with each other.

The mobile cells of the immune system can synthesize cytokines, protein molecules that direct immune cells to stimulate proliferation of other immune cells and help amplify the immune response. Tumor Necrosis Factor (TNF), Interleukin 1(IL-1), and Interleukin 6 (IL-6) are typical examples. Cytokines released by the immune system can affect the CNS, producing the lassitude and depressed mood experienced during infections. Cytokines also stimulate the HPA axis to produce cortisol, which down-regulates the inflammatory response to prevent an exaggerated reaction that could damage local normal tissue.

The HPA axis is activated during the fight/flight response to stress, leading to increased cortisol production with its potential to down-regulate the immune system. Increased cortisol release is thought to play a major role in the suppression of immune system seen in patients under chronic stress. In addition, the sympathetic nervous system innervates the organs of the immune system (thymus, lymph nodes, and bone marrow); it, too, predominantly down-regulates the immune system. Candace Pert describes the neuropeptides and their receptors as the link between emotions and the physiological response to the meaning of the information we receive—they help us translate information about our physical and emotional reality. In summary, the CNS, the immune system and the endocrine system talk to each other using neurotransmitters, hormones and neuropeptides. These “informational molecules” provide multi-directional communication between the three systems.

Our immune system must carry out four major functions to ensure our survival: 1) Recognize what is foreign (distinguish non-self from self). 2) Remember what is foreign in order to facilitate rapid response when re-exposure occurs. 3) Mobilize effector systems to destroy the invading organisms or cancer cells. 4) Modulate the inflammatory reaction to avoid excessive response (avoid damage to normal tissue cells). I want to mention briefly four cell types that subserve the immune response: 1) The monocyte, which is transformed into the tissue macrophage and engulfs organisms, processes their antigens into small peptides (9-15 amino acids), and releases TNF, IL-1, and IL-6 to induce proliferation of the T-lymphocytes. The antigens are then presented to the T-helper lymphocyte, which, in turn, releases cytokines to induce proliferation of other immune cells. 2) T-helper lymphocytes amplify the immune response through additional cytokine release. These are the CD-4 cells that are considered the “brains” of the immune system. There are also T-suppressor lymphocytes, which can be cytotoxic. 3) Natural Killer lymphocytes (NK cells) can kill cancer cells and cells containing intracellular viruses and mycobacterium. 4) B-lymphocytes that mature into antibody-producing plasma cells (humoral response). Like the cells of the CNS and endocrine systems, immune system cells can communicate at a distance (endocrine), locally via diffusion to adjacent cells (paracrine) or through neuropeptide release. Hormones from the HPA axis and the sympathetic nervous system down-regulate the immune system, but growth hormone and prolactin can enhance the immune system response under certain conditions.

Events that produce chronic stress in humans (bereavement, exam stress, hostile marriage relationships, chronic caretaking, etc) produce immune suppression through activating our fight/flight response. The following are examples of studies supporting this notion:

1. Alzheimers caregivers have a reduced humoral (antibody) and cellular responses to flu vaccine. In addition, standardized biopsy site wounds heal more slowly in these caretakers than in age-matched controls.
2. Experimentally induced rhinovirus infections increase symptomatic illness in volunteers who were under increased stress compared to less stressed controls.
3. Antibody responses to Hepatitis B, Pneumococcus, and Influenza vaccines are depressed in subjects with high levels of perceived stress. This was associated with elevated salivary cortisol levels in one study.
4. Dental students under exam stress had reduced rates of healing of controlled biopsy sites compared to biopsies carried out during the summer vacation.
5. Salivary IgA secretion was reduced for several days in college students after they had watched a scary movie (Omen), but IgA secretion was increased for several days after students watched a movie that portrayed the compassion of Mother Teresa.
6. Infections with herpes viruses 1 and 2 and Epstein Barr virus, and outbreaks of herpes zoster (shingles) are more likely to occur, last longer, and to relapse in subjects under chronic stress conditions.

Psychosocial Factors in Coronary Heart Disease

There is clear and convincing evidence that psychosocial factors contribute to the decades-long pathogenesis and eventual expression of coronary heart disease (plaque rupture, thrombosis, malignant arrhythmia). Hostility, characterized by unresolved anger and resentment, is a strong risk factor, and recurrent depression is a moderate risk factor for but powerful predictor of mortality from myocardial infarction (MI). Chronic anxiety disorders (panic, obsessive-compulsive, phobic disorders) also seem to be risk factors, but less information is available. Social isolation contributes significantly to post-MI mortality (socially isolated patients have a 30-40% increase in mortality in the first year after MI).

How are we to understand the mechanisms by which psychological stress impairs heart function? Lewis et al point to the limbic system, which regulates emotions and social bonding or failure to bond. In a sense, the limbic system is the “heart” of the brain. Perceived threat to our needs and values results in the fight /flight response with its increased sympathetic nervous system activity and catecholamine and cortisol release, and the accompanying emotions of anxiety, fear, or anger. On the other hand, support for our needs and values moves us toward the relaxation response with its release of endorphins, dopamine, oxytocin and parasympathetic outflow, and the associated emotions of pleasure, contentment, joy. In our day-to-day lives, we fluctuate between these polar opposites. Even when the emotional responses are outside conscious awareness, the biological footprints (hormone response, etc) are there and can be measured. There is evidence to suggest that the pathophysiology of coronary heart disease is related to sustained periods of fight/flight response, which increases blood pressure, cardiac irritability, blood coagulability, cholesterol and inflammatory markers (C-reactive protein, IL-1, IL-6). Compared to controls, patients with type A personality, and with accompanying hostility, cynicism, and time pressure, have an exaggerated sympathetic response to experimentally induced stress.

Not only is stress a risk factor but psychosocial intervention can help patients with coronary heart disease. In one meta-analysis of 24 studies (a total of 2,024 patients), control patients received education about diet, exercise and medications, but intervention subjects received health education plus some form of behavior modification (mindfulness meditation; visualization for stress management; cognitive and group therapy). The goal was to reduce stress by helping patients to reach out for support, to learn to trust, and to express emotions in a healthy way. Emphasis was placed on helping patients express anger through resolution of conflict instead of resentment and seething. Over the ensuing two years, those in the behavior therapy group had a significant reduction in anxiety and depression, and a 41% reduction in mortality compared to controls.

Most people look at heart attack as a bad thing, and in the experiential sense, it is. However, not everything that follows a heart attack has to be bad. Health professionals can help make some good of the bad by asking: do patients use the event of myocardial infarction to reappraise their health status, change their diet, improve their exercise, lower their cholesterol and examine their life coping skills? Can they learn to seek social support, express emotions in a supportive setting, express anger in a constructive manner that leads to resolution of conflicts? We know that patients who have less post-MI depression and social isolation have a significantly lower mortality.

In addition to studies of the impact of Type A personality with hostility, depression, and social isolation on heart disease, there are additional examples of how psychosocial factors affect health. One is the so called “status syndrome.” Studies of civil service employees in England and in Sweden have shown that individual health status becomes worse as you progress from the top (level one) of the social hierarchy to the bottom (level six). Workers in level six have high demands imposed, but little or no control over their work environment (quite the opposite of those at level one). Level one individuals were often highly educated (PhD), but even those at level two (often with master’s degree or more) manifested more health issues than people at level one. Lack of a high school diploma is a major health risk factor in any disease studied. Does lack of control, lack of empowerment in the work environment (level six) mean more stress and potential fight/flight? If so, is this a cost to the person long-term in regards to their health?

The “Broken Heart” syndrome has been described by a group from John Hopkins. They reported on 19 patients who presented with chest pain, left heart failure and pulmonary edema, and varying degrees of hypotension. Cardiac catheterization revealed only one patient had coronary heart disease and none had myocardial infarction. All 19 patients recovered over 5-7 days. It turned out that each patient had received “bad news,” often of an unexpected death, 4-6 hours before the onset of symptoms. Plasma catecholamine levels in the 19 patients were 3-4 times higher than patients admitted with typical myocardial infarction and the authors postulated that left ventricular failure in their patients was due to a “stunning” of the myocardium by excess catecholamine levels. This would account for the reversibility of symptoms and the absence of reoccurrence over the next two years.

Narrative Wirting with Emotional Expression

James Pennebaker has spent most of his career studying the health benefits of narrative writing with emotional expression. In one study, Glaser from Ohio State was able to demonstrate both psychosocial and immune system benefits to participants who wrote with emotional expression. In this study of over 400 engineers at one company who were terminated after 20-25 years of work experience, Pennebaker divided the group in half, asking one group to write 30 minutes each day for five days, describing in detail what had happened and how it had affected their lives. In particular, they were to explore the feelings and emotions they were experiencing. The control group wrote about activities unrelated to work. Pennebaker found that the group who wrote about their work not only experienced an emotional catharsis, but also began to develop insights about and find new meaning in their experiences. Four months later, over 50% of the experimental subjects had found new jobs, but only 7% of the controls had. In addition, immune system (both natural killer cell and T lymphocyte) function was significantly improved compared to controls. Unresolved emotional issues can to affect our biology, weeks, months and even years after the stressful events.

Stress Overload and Psychosomatic Illness

As long as we see the world as a friendly place, as long as we have reasonable coping skills and our stress load or demand level can be met, we are in allostatic balance. When stress demands increase, or we lose coping skills or social support, we become vulnerable to what can be called “overload.” We all have some way such overload is expressed by the body. Some responses do not reach consciousness (we can detect elevated stress hormone levels even though the subject has no emotional awareness or physical symptoms). At other times, stress overload is expressed as severe abdominal cramping and diarrhea with irritable bowel syndrome, or we get tension headache. Once symptoms develop, we suffer (eg pain), our lives are disrupted and we have questions about why this is happening. Each of these responses (suffering, loss of roles, lack of known cause) adds to the stress overload and can create a downward spiral. The challenge for the health provider is to understand the mechanism of the symptoms, know how psychosocial factors contribute to the overload, and interpret these for the patient. When the patient understands the symptoms are not caused by cancer, for example (appropriate tests having been done to exclude cancer, of course), and they are not “imaginary,” then the patient’s fears about the cause of the problem are reduced and the downward spiral of stress can be reversed. It may be helpful to point out that chronic contraction of muscles causes pain—try holding a 5 lb weight in hand, arm extended, for 15 minutes. When patients understand that most back pains (without evidence of nerve root compression, tumor or infection) are muscular in origin, they respond better to conservative treatment. The issue is to address the psychosocial factors that caused the “overload” and precipitated the physiological response in the body.

Healing vs. Curing

“Curing” refers to removal of disease through the use of surgical procedures or medication. It is generally viewed as an externally applied treatment of which the patient is a passive recipient. “Healing,” on the other hand, refers to an internal process that depends on the body’s innate physiological systems to maintain or restore homeostasis. The immune system response to infection, wound healing, blood clotting or lysis of clots are examples of those physiological systems. As we have seen earlier, the optimal functioning of these systems depends on the mental, emotional and spiritual condition of the patient. When the patient is undergoing the fight/flight response to chronic stress, the limbic brain activates the HPA axis and the sympathetic nervous system, which can suppress the immune system, slow wound healing and increase coagulability of blood. This response can also raise blood pressure and contribute to cardiac irritability. Healing can occur through mental reframing (seeing life events as challenge rather than as victimization). Healing also has emotional (resolving grief over a loss) or spiritual (finding a new or deeper connection to what gives meaning to our life) roots. Mental, emotional and spiritual healing may occur even as the patient is dying

The word heal comes from the Anglo-Saxon hal, which means whole or wholeness. Healing means integrating all aspects of who we are. If we learn that it is proper to be nice and cooperative under all social conditions, we may repress our fierceness/assertiveness into our unconscious. There are times in life when we need fierceness or assertiveness to protect our values, beliefs or needs; and at those times, if we are “nice” or “cooperative,” that necessary fierceness may be unavailable to us. Healing is about integrating all parts of who we are; it is about gaining the wisdom to know when each part is called for in a situation.

“Doctoring” means more than making a diagnosis and giving a prescription. It means establishing relationships that help patients optimize their sense of mental, emotional and spiritual wellbeing. This happens when the patient feels cared about, when both doctor and patient understand each other’s perspective, when the patient gains a sense of mastery (empowerment), and the patient is helped to establish goals for the future (hope).

 

Mike McLeod is a retired Gastroenterologist, Professor of Medicine emeritus at Duke University Medical Center and associate director for the Practice Course for first and second year medical students.

 

 

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References

 

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