It's All in Your Head
by Dennis Meredith
Photo: Chris Hildreth
As researchers at Duke and other medical centers are discovering, the shortest path to healing the body may be through the mind.
ou felt as if you'd been abducted by aliens. You lay chilled and woozy in an icy, cavernous chamber beneath glaring saucer-shaped lights. You were vulnerably naked, except for a flimsy, inadequate garment. Faceless creatures loomed over you wielding gleaming metal instruments of unknown purpose. They peered intently at a display screen that seemed to reveal important information about you. But you could not see the screen, and they did not tell you what it showed. You heard only the abrupt rattle of anonymous machines and the creatures' muffled voices as they mumbled terse, arcane phrases to one another. They clustered around your lower body, still conferring among themselves. Then they sliced into your groin, performing an intricate procedure beyond your sight. A hot flush suddenly enveloped your chest, quickly rising toward an unbearable heat. You moaned in alarm.
This cardiac catheterization, as was typical years ago, was no alien encounter. It was like countless other surgeries, scans, samplings, and traditional medical indignities that had been visited upon patients over centuries of modern medicine. The procedure was merely another example of medicine as performed by self- possessed technicians for whom the patient is little more than a large sack of organic matter to be probed and analyzed.
Such a mechanistic approach to treatment is changing rapidly, as the medical profession has come to realize that the mind can be as powerful a healing tool as the scalpel and the pill. Doctors are learning that fear, anger, and depression can be as dangerous as any microbe; and conversely, that serenity, love, and faith can reach as deeply into the body's physiology to heal as any drug. This power of mind was dramatized in a Duke Medical Center symposium last October on "Integrating Mind, Body, and Spirit in Medical Practice." At the conference, a cadre of Duke physicians and other health-care providers described an arsenal of healing techniques--including imagery, support groups, hypnosis, and old-time religion--for making the mind an ally in treatment and, in fact, making the entire healing process more humane.
Duke Medical Center is particularly committed to using mind-body approaches to broaden the meaning and practice of health care, said Chancellor for Health Affairs Ralph Snyderman. "My guess is that pure molecular science or technical intervention probably addresses only about 20 percent of the totality of patients' needs," he told the conference. "We must go beyond what science can do and ask, 'Isn't there more?' We have to return to our role as healers and find a better way to integrate spirituality and the art of practice with the science of medicine."
Major research on mind-body medicine is under way at Duke Medical Center, including the $6 million in behavioral psychiatry studies the National Institutes of Health supported last year. Such research efforts led NIH behavioral medicine research group leader Peter Kaufmann to comment that "There's no question that Duke is a world leader in research in this area."
As an example of such methods, the Duke conference heard practitioners of "anodyne therapy" describe how they change the cold-hearted cardiac catheterization into a much more humane procedure. Imagine that, instead of encountering mumbling alien medical creatures, you are greeted by a soothing nurse who sits beside you teaching a relaxation breathing technique to exhale your tensions. The nurse has you mentally visualize your discomfort as an object--say a flaming, red ball--that you mentally push away to make vanish over the horizon. And to help you escape the clinical unpleasantness to come, the nurse coaches you with "guided imagery" to transport your mind to a favorite place--perhaps a sun-soaked summer beach or a crisp fall mountain afternoon. Ensconced in this mental sanctuary, you are "safe" from the pain and anxiety of the medical procedure.
Basically, anodyne therapy is bedside manner with brains, says John Pateros, co-director of the Anodyne Training Center in California. "It's a whole new approach to rapport that involves being conscious of what we're doing in the rapport process." Pateros and center co-director Donna Hamilton teach the techniques to medical practitioners nationwide, including a large contingent at Duke.
Using words and body language, the anodyne therapist aims to relax the patient undergoing biopsies, angiographies, endoscopies, mammographies, and other anxiety-producing procedures. Sometimes little gestures mean a lot. According to Hamilton, the anodyne therapist maintains her head at the patient's level, to avoid presenting an ominous looming presence. The anodynist also mirrors the patient's gestures, voice, and even breathing to establish rapport. The right words also help. "When giving an injection, instead of telling the patient, 'You're going to feel a little bee sting and then it's going to burn,' the therapist says, 'We're going to give you some numbing medication; just notice how quickly it becomes numb.' We're still informing the patient of what's going to happen, and yet we're reframing the outcome they're going to have. We're making them curious rather than tense."
Duke radiologist Larry Burk, who has championed the technique at the university, says that it takes little time and adds proven medical benefits. "We normally give patients anti-anxiety medications as well as pain medication. But with anodyne imagery, we can reduce or eliminate the sedatives."
Like the other mind-body techniques presented at the conference, anodyne therapy marshals hard scientific evidence to back its claims. One confirming study compared two groups of patients undergoing cardiac catheterization--a group receiving anodyne ther-apy, and a control group that was not. All the patients were given push-button devices to self-administer pain medication. During the procedure, the control group stabbed away at the button, dosing themselves to fight the pain. But most patients in the mellow anodyned group didn't push the button even once.
Unlike anodyne therapy, most other mind-body treatments help patients cope with chronic disease. Duke cardiologist and conference organizer Martin Sullivan described the Center for Living's "Healing the Heart" program, a two-week retreat for coronary artery disease patients. Besides teaching the nuts-and-bolts of good diet and exercise, the retreats feature support groups, meditation, mindfulness, and yoga to reduce stress and increase coping. "People who have an illness often want to get away from their bodies, because the body has been damaged," says Sullivan, who is the program's director. "We want to help them make a reconnection with the body." The techniques have worked. In a study of 200 patients who participated in the program, angina episodes were reduced from six per week to one.
To answer the life-or-death question of whether such treatments increase survival among heart attack victims, Duke is participating in a three-year study sponsored by the National Heart, Lung, and Blood Institute. In the $30-million study, known as ENRICHD, for Enhancing Recovery in Coronary Heart Disease Patients, Duke and seven other medical centers will study 3,000 coronary patients who test high on depression and social isolation. Half will be given counseling and group therapy; the others will receive standard cardiac care as researchers follow their progress.
Mind-body techniques have reached beyond the hospital. At the conference, Redford and Virginia Williams described their workshop for people whose anger could prove hazardous to their health. Drawing on their 1993 book, Anger Kills: 17 Strategies for Controlling the Hostility that Can Harm Your Health (Times Books/Random House), the husband-and-wife team teach "lifeskills" that reduce angry reactions to everyday frustrations. Participants learn to determine whether an anger-producing situation is really important, whether their feelings are appropriate to the situation, whether it can be changed, and whether it's worth changing. "If they get a 'no' to any of those questions, that tells them they don't want to have this anger," says Redford Williams. They should be able to talk themselves out of the anger, knowing what that anger is doing to their body.
"Anger kills, whether you let it all hang out or whether you keep it to yourself," says Williams, who directs Duke's Behavioral Medicine Research Center. As proof, he cites studies of both cardiac and cancer patients. Those who were provided social support and were trained to manage their anger and other negative emotions had about half the heart attack recurrence and mortality as those who were not.
Perhaps the most surprising revelation of the conference was that the palpable physical symptom of pain can be controlled by force of mind. The surprise comes because the most popular beliefs about pain are, well, painfully outdated, says Francis Keefe, director of the Duke Pain Management Program. Pain is not a simple nerve signal traveling from injury to the perceiving brain, he says. Rather, pain travels many parallel routes to many brain centers, including emotional centers. And the brain has the power to open and shut the pain gateways along nerve pathways. Thus, insists Keefe, "Your thoughts, feelings and behaviors--your physiological responses to pain--can alter that fundamental pain experience."
To give suffering patients control over their pain, the center teaches relaxation and imagery techniques and counsels patients on overcoming pain-intensifying feelings of hopelessness. And, the center helps patients break out of a vicious cycle of pain they've become trapped in. "Most people I see spend one-half or more of their time in bed," Keefe says. "Then, they will get up, work until their pain is extreme, then rest and take heavy doses of pain medication. Over time, their tolerance for activity decreases, their focus on pain increases, and use of rest and pain medication increases." Instead, the center teaches patients to begin with short periods of activity, resting well before pain sets in. They gain confidence that they are masters of their pain, and they gradually reenter a more normal activity cycle.
"The old sayings 'Let pain be your guide' and 'No pain, no gain' are really embedded in our cultural views of how we respond to our own pain. But paradoxically those very strategies and that very outlook works against the person rather than for them," says Keefe.
Hypnosis was also on stage at the conference, but not as an entertainment device. Instead, says Duke physician Janet Lehr, hypnosis has also become accepted as another powerful tool for chronic pain and a wide variety of other problems. She described how, in only a few sessions of fifteen minutes each, she takes patients into a hypnotic state, helping them control pain, stop smoking, relieve anxiety and phobias, improve post-operative healing, alleviate skin disorders, and treat tooth-grinding. The hypnotic trance, which patients can easily achieve for themselves, is one of three states of consciousness, explains Lehr, of the Department of Community and Family Medicine. The other states are sleep and waking. Evidence of the trance state's reality can be dramatic, she says, recalling a six-year-old girl in the emergency room who had suffered a badly lacerated scalp. "I could tell she was in a trance," says Lehr. "She was wide-eyed, staring straight ahead, not moving a muscle. I told the nurse I wasn't going to use lidocaine, and she looked at me like I was nuts! But I talked to the little girl, gave her suggestions of coolness and comfort, and sewed her up." The little girl remained pain-free, as have countless other patients undergoing surgery under hypnosis.
Unfortunately, Lehr says, while hypnosis is accepted by such groups as the American Medical Association, it is not embraced, and not taught widely to nurses or physicians. And insurance companies balk at covering it. "I see hypnosis as a useful tool, but the insurance companies don't see it like that. They'd rather not pay for a patient to get traditional hypnosis."
If hypnosis receives little respect as a medical treatment, religion is downright attacked by many psychiatrists, says Harold Koenig, director of the medical center's Program on Religion, Aging, and Health. He cites famed psychiatrist Albert Ellis, who wrote that "Devout orthodox dogmatic religion, or what might be called religiosity, is significantly correlated with emotional disturbance." Ellis charged that religion "can be seen as promoting pathology." Similarly, psychiatrist Wendell Waters of McMasters University wrote, "Simply put, Christian indoctrination is a form of mental and emotional abuse that can adversely affect bodily health in the same way a drug can."
Despite such attitudes, says Koenig, research studies have shown clearly that religion--which the huge majority of medical patients say they depend on to help them through a crisis--is good for people's health. He mentions a survey of 1,000 men admitted to the Durham VA Hospital, which revealed an association between higher use of religion to cope with health problems and lower rates of health-sapping depression. Even more dramatic were the results of an Israeli study that followed 10,000 people for twenty-six years, documenting their death from coronary artery disease. The analysis--which controlled for differences in diet and healthy behaviors--showed significantly higher death rates from heart disease in non-believers than in orthodox Jewish believers.
"We're not talking about miracles or some type of supernatural phenomena," says Koenig. "We're just looking at basic social, psy-chological, and physiological parameters. That's all." Religious faith reduces stress, anxiety, and depression, says Koenig. Such serenity means lower adrenalin and in turn may enhance the immune system to better fight infections, cancer, heart disease, stroke, and stomach and bowel problems. What's more, says Koenig, religion offers critical social support. "If you've got people in your church checking up on you, calling you if you don't show up at church, bugging you if you don't take your medication or go to your doctor's visit, you'll be more likely to take your medication and see your doctor. And your diseases will be detected sooner and perhaps treated quicker."
Research has clearly shown the clinical benefits of such mind-body treatments as anodyne therapy, hypnosis, and religious belief. But hard-nosed scientists demand laboratory proof of the mind-body connection itself if they are to give it credence. They seek a clear trail of scientific evidence linking evanescent thought with the biochemical malfunctions of disease. So, over the last decade, molecular biologists have scouted that trail, piecing together its path using surveys and lab experiments.
Survey studies by Duke Medical Center's John Barefoot and Redford Williams have revealed the medical hazards of stress. In one long-term study of graduates of UNC Medical School, those who scored high in stress on a personality test were more likely to die of heart attack over the next decades. Only 2 percent of those scoring low on stress died over the following twenty-five years, while 14 percent of high-stress scorers died.
What's more, monkey studies have offered firm evidence that it's the stress itself, and not poor health habits, that kills people, says Duke cardiologist Martin Sullivan. He cites a Bowman Gray Medical Center study in which monkeys fed a high-fat diet were divided into two groups. One group was put into a stable social environment, "a sort of monkey Club Med," says Sullivan. For eighteen months, the other group was stressed by subjecting the animals to constant rearrangement of groups into new cages. After suffering such constant social upheaval, the dominant monkeys--who found themselves constantly sorting out their rank in new cages--showed twice as many fatty deposits in their coronary arteries as their less dominant cage mates or the "Club Med" monkeys.
Besides convicting stress as a killer, researchers have implicated social isolation and depression with health problems in both human and animal studies. Studies of thousands of people have revealed that those with fewer social ties--such as membership in social clubs and family support--were several times more likely to have cancer or heart disease, or to die from all causes.
The deepest scientific mystery has been how the killers stress and depression invade from the world of thought and emotion into the immune system, where they weaken the body's resistance. Researchers in a new field with the mouth-filling name of psychoneuroimmunology are mapping those biological invasion pathways. And their discoveries have been startling. Duke clinical psychologist Ruth Quillian told the conference that scientists now understand generally how the brain talks to the immune system. It continually peppers the immune system with instructions, both through the hard-wiring of the autonomic nervous system and via transmitted chemical messages of hormones such as cortisol and adrenalin. The autonomic nervous system regulates involuntary actions, such as those of the intestines, heart, and glands.
When the brain transmits the alarm calls of stress, the body's immune system responds by lowering its effectiveness. Stress studies of those popular campus lab rats, students, showed that exam stress or the assignment to perform heavy mental arithmetic lowers immune system function, says Quillian. And conversely, when students were asked to write about traumatic events for twenty minutes a day for four days, their immune system increased in function, compared to students who had written about benign subjects. And, the study found, the students who had poured out their traumas onto paper visited the student clinic less over the following six months.
"There is really the beginning of some physiological data to support good bedside manner and psychotherapy," says Quillian. Although such research is preliminary, she emphasizes, the future may see mind-body techniques that could, for example, reduce the transplant patient's need for immune-suppressive drugs.
Hostility causes the brain to launch health-damaging signals to the immune system, says Redford Williams. He terms the nervous system and hormone responses of hostile people "really a pathway to disease and death." For anybody who has ever been cut off in traffic by a foul-tempered driver, it's some comfort to know that their road leads to an early end in the cemetery. According to Williams, physiological studies have revealed that highly hostile people show decreased activity in the protective parasympathetic nervous system, which normally acts to slow heart rate and dilate blood vessels.
Researchers have also begun to trace the hormonal effects of stress in increasing levels of cholesterol and the stress hormones cortisol and adrenalin. These body chemicals can damage critical immune cells called macrophages, the disease-fighting "battle-tanks" of the immune system. Such macrophage damage allows the development of fatty deposits in coronary arteries and inhibits the body's cancer-fighting ability.
All this hard, cold evidence means that our society needs a softer, warmer approach to a more humane healing, says physician Elliott Dacher, author of the book Whole Healing (E.P. Dutton, 1996). This new world view harks back to the ancient Greek view of healing as a holistic process of body and spirit, he says. "The individual was a large thing at one time," he told the conference. "There was a great deal of the imagination, the poetic, the romantic, the mythical. Human life was not simply a collection of anatomical parts. We have deconstructed the largeness, the beauty, the sacredness, and the significance of human life to what it is today."
Dacher argues that it's particularly important we change our basic concept of healing, given the change in the nature of medical problems. "We've shifted the burden of disease from infectious disease during the industrial revolution to diseases of living in an urban environment with stress. Seventy percent of disease causation right now is lifestyle and environment." Dacher sees this postmodern view of healing centering on the individual and recognizing four very different routes to healing--the body's self-healing "homeostatic" system, external medical treatment, mind-body healing, and spiritual healing.
Although such a medical revolution is clearly upon us, conference organizer Martin Sullivan warns that our society also needs a compassion revolution in how we relate to one another. "I saw an interview with Mother Teresa, in which she was asked, 'You've been in India dealing with illnesses like cholera and AIDS. What is the worst illness you've ever seen?'" Sullivan told the conference. "And she said without blinking an eye, 'The worst illness I have ever seen is the loneliness and isolation in the West.'"
Being poor is also hazardous to your health, Duke Medical Center physician Redford Williams told a Duke conference on mind-body medicine. Researchers have found that heart disease and general health problems--besides being linked with hostility, depression, social isolation, and high-strain jobs--are firmly linked to poverty.
While the heavier smoking and drinking and greater tendency to obesity among the poor may cause some of these health effects, "these physical risk factors only explain about a quarter or less of increased morbidity and mortality attributed to low socio-economic status," says Williams.
The real key to poverty's toxicity, he says, is that being poor itself breeds stress, depression, and isolation. As evidence, Williams cites a personality survey of a national sample of people by colleague John Barefoot. The study shows that as income dropped, hostility and depression grew. Barefoot also found that lower-income non-whites showed a larger increase in hostility than did whites--reflecting the harsher environment in which poorer non-whites live.
In fact, smoking, alcoholism, and overeating among the poor are no more than a natural reaction to the poverty-caused violence, parental neglect, and stress that surrounds them, says Williams. "They're using substances like alcohol and food and cigarettes as a self-medication to reduce the distress of living in this kind of situation."
The stress of poverty is in a sense hereditary, because it poi- sons the family environment into which a child is born. Williams cites a three-year study in which observers charted parent-child interactions among middle-class and welfare parents. "The average child of professional-level parents by age three had heard over 500,000 encouragements. The average child of welfare parents, fewer than 100,000."
Such findings have persuaded scientists that poverty generates stress and depression. And, they have mapped the tragic biochemical pathways by which stress and depression affect the body to cause physical disease. Williams says he hopes that these findings will be taken into account by those who determine policies about programs aimed at the poor.