Stress and Health: Biological and Psychological Interactions PDF

Sage Academic Books Stress and Health: Biological and Psychological Interactions For the most optimal reading experience we recommend using our website. A free-to-view version of this content is available by clicking on this link, which includes an easy-to-navigate-...

Sage Academic Books Stress and Health: Biological and Psychological Interactions For the most optimal reading experience we recommend using our website. A free-to-view version of this content is available by clicking on this link, which includes an easy-to-navigate-and-search-entry, and may also include videos, embedded datasets, downloadable datasets, interactive questions, audio content, and downloadable tables and resources. Author: William R. Lovallo Pub. Date: 2020 Product: Sage Academic Books DOI: https://doi.org/10.4135/9781071801390 Keywords: disease, health, emotion, behavioral medicine Disciplines: Psychology, Other Health Specialties, Biological/Physiological Psychology, Clinical/Abnormal Psychology, Health Psychology / Behavioral Medicine, Biological Bases of Stress, Stress Management Access Date: October 3, 2024 Publisher: SAGE Publications, Inc. City: Thousand Oaks Online ISBN: 9781071801390 © 2020 SAGE Publications, Inc. All Rights Reserved. Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Psychosocial Models of Health and Disease Chapter objectives 1. Disease processes should be seen as dynamic interactions between the causative agent and the af- fected organism. 2. The disease and its treatment are embedded in a hierarchy of systemic controls. That is, lower levels of the system are in two-way interaction with higher levels in the system, and each level integrates and regulates the levels below it. 3. The hierarchy of causal influences ultimately includes complex behaviors such as the thoughts and emotions of the affected person and the socioculturally determined environment in which that person lives. 4. Disease and its cure exist in the physical and mental workings of the body, and thoughts and emo- tions play a significant role. What is this book about? It is a short review of how our behaviors, especially ideas and associated emotions, come to have power over our bodies. It is an attempt to create a model of the psychological stress response in relation to its biological consequences and its implications for health. In the following discussion, I hope to provide some useful insights into how psychological theory can contribute to our view of medicine. In 1928, the American physiologist Walter Cannon was addressing the Massachusetts Medical Society on the subject of emotions and disease. He noted that a wife, who was free from any cardiac disorder, saw her husband walking arm in arm with a strange woman and acting in such a way as to rouse jealousy and suspicion. Profoundly stirred by the inci- dent, the wife hastened home and remained there several days. She then began to fear going out lest she might meet her husband with her rival. After days of wretchedness, she was persuaded by a friend to venture forth, “probably in a state of abject terror,”... but she had not gone far when she ran back to her home. Then she noted that her heart was thumping hard, that she had a sense of oppression in her chest and a choking sensation. Later attempts to go outdoors produced the same alarming symptoms. She began to feel that she might die on the street if she went out. There was Stress and Health: Biological and Psychological Interactions Page 2 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. no organic disease of the heart, and yet slight effort as she moved from her home brought on acute distress (Cannon, 1928). It is always impressive to see how the impact of a psychologically meaningful event can change a person’s physical state. Examples like this lead us to ask “How can an idea change the body?” This book is concerned with mental activity and behavioral processes and their relationships to states of health and disease. We specifically take up the question of psychological stress and describe how mental ac- tivity can produce negative effects on the body, perhaps leading to disease or even death. The book will pre- sent research indicating how the effects of psychological stress can be buffered by early experiences, leaving the individual better able to withstand stresses and strains of life. These positive examples are few in number, and they suggest that much more is known about vulnerability to stress than about hardiness or resilience. I mentioned that this book was about mental and behavioral processes. When I say behavior, I mean not only moving and talking but also the neural processes giving rise to thoughts and emotions. Ideas about the rela- tionship between the mind and the body have been debated since the ancient Greeks. In fact, the mind-body problem is one of the fundamental philosophical and scientific issues in human knowledge. The ways of com- bining our thinking about behavior and mental life into our thinking about medicine are essential to developing a truly behavioral medicine. Although the example above is true to life and perfectly understandable as a reaction, we realize that we have little understanding of how this woman’s seeing her husband with his girlfriend led to such extreme fear and to her physical symptoms. Since 1928, researchers have become increasingly familiar with the mechanisms of the brain and how these control the rest of the body. Similarly, psychology has increased our knowledge about how we learn, think, and take in the world. Still, studies of the workings of the body and the processes of the mind tend to exist in separate departments at our universities and in separate compartments of our thinking. This division hinders understanding our woman patient and the relationships between her experience, emo- tions, and her physical state. In considering behavioral influences in health and disease, we need to have a way of thinking about how words can affect the body. We understand how bacteria and viruses can invade our body and how heart disease develops in the arteries of the heart, but we are not yet fully comfortable with the idea that psychological processes such as emotions and personality characteristics can influence these Stress and Health: Biological and Psychological Interactions Page 3 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. same disease processes. We know, or at least most of us believe, that we can’t use our minds directly to influence outside objects. We can’t levitate things. We can’t transport ourselves to another place by means of thought. And yet, the exam- ple demonstrates that the mind influences the body, sometimes in dramatic ways. Before we discuss specific psychological contributions to stress responses in later chapters, we should give thought to a more gener- al conceptual model of how mental processes can affect the health of the body, interacting with processes of health and disease. This brief consideration will allow us to place the topic of psychological stress into a behavioral medicine framework. In addition, it helps us gain an appreciation for how the behavioral medicine approach may complement and enrich a more traditional medical model. We will start here by analyzing the infectious disease process using a very restricted biomedical model. We will see how this model can be usefully expanded to include the behaviors of the patient. A second exam- ple will describe how behavioral medicine can be useful in coming to understand the ways in which placebo effects operate. Finally, we will consider how a behavioral medicine approach is especially helpful in concep- tualizing cause and treatment in complex diseases such as coronary artery disease. The Standard Biomedical Model and New Approaches to Medicine We begin here with a short comment on the enormous influence of the writings of the great French philoso- pher René Descartes, who argued that we could study the workings of the body as if we were studying a machine that we had seen for the first time and that to do so, we did not need to inquire into the workings of the soul, as he called the mind, which he saw as the seat of our consciousness (Descartes, 1637/1956). Although Descartes was most likely finding a path to discussing physiology without offending officials of the Catholic Church, he is credited with the dubious distinction of putting a dualistic stamp on our thinking about ourselves. This stamp made it easier to talk about the mechanisms of the body while ignoring the processes we now associate with thoughts and emotions. Indeed, he put these into fundamentally separate categories that were not compatible with each other. Stress and Health: Biological and Psychological Interactions Page 4 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. In line with the Cartesian idea, the standard biomedical model goes like this: Disease is a linearly causal process, “a condition of the living animal... or one of its parts that impairs the performance of a vital func- tion.” In other words, disease is disorder in an otherwise smooth-running machine. The cure is to disrupt the causative agent at the physical level to help the machine repair itself, restore order, and regain normal func- tion. Finally, in the strong form of this model, following our Western tradition, the workings of the mind are not relevant to the disease or its cure. Figure 1.1 is a conceptual diagram of this strong form of the biomedical model. The diagram illustrates a normally functioning person being acted on by some pathogenic stimulus such as an infection, a cancer, or coronary heart disease. The mode of therapy is a direct physical intervention to restore the person’s healthy, well-ordered state. Such therapies may be the administration of an antibiotic to cure a bacterial infection, the application of chemotherapy for a cancer, or coronary bypass grafts for coronary heart disease. All of these treatments have known restorative, if not curative, properties. Their application in individual cases results in one of the three outcomes on the right. We hope that the patient gets better. However, other outcomes also occur, including continued illness or even death. Figure 1.1 Traditional medical model of the disease process. The disease process and the treatment are shown acting on a passive organism, and the treatment and disease do not interact. This depicts a restrictive view of the traditional medical model. A key feature of this model is that the cure works with or without the knowledge or assistance of the patient. The cure is purely physical and not affected by the thoughts or emotional state of the person being treated. Stress and Health: Biological and Psychological Interactions Page 5 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. This traditional model has the following characteristics: 1. The model has one-way causation. The pathogen acts on the host and not the other way around. 2. The disease is a physiological process, and treatment operates on the physiology of the person to alter the disease state. 3. Therefore, the model is nonhierarchical, meaning that different levels of complexity in the system, particularly higher nervous system controls related to thoughts and emotions, do not interact with each other. 4. As a result, the model is dualistic. The mental status of the person is incidental to the cause of the disease and its cure. The mind and the body exist in different realms in this framework, and there is no strong basis for considering how they might work together for the person’s well-being. In considering the contrasting features of the biomedical model and the behavioral medicine model presented here, the following points should be kept in mind: 1. The traditional biomedical model has proven to be very effective at treating disease. When speaking of the shortcomings of the model, I simply mean that it is limited because it has no way to incorporate the knowledge that thoughts and emotions can enhance development of diseases or promote their cures. 2. Although we may consider emotions to be important in the health equation, and while we talk about the power of thoughts, we should recognize that these rarely are, if ever, the sole cause of disease. Instead, we think that such mental processes may aggravate, alleviate, and otherwise modify existing disease processes. 3. We are only just beginning to understand how interactions between psychological processes and dis- ease pathophysiology may occur. The information in this chapter is primarily a formal description of how such interactions may operate. Later chapters will deal with these interactions in more mecha- nistic fashion. 4. The possibility that behavioral influences may alter disease processes should be approached with the same scientific caution used in understanding diseases and cures within the standard biomedical model. This description of the traditional biomedical model and ways that it can be expanded is presented deliber- ately in stark terms. This strong distinction allows us to sharpen the contrast between approaches and to illustrate the potential contributions of a behavioral medicine. As individuals, doctors understand that the mind affects the body. Practicing physicians are well aware of the power of thoughts and emotions to affect health, Stress and Health: Biological and Psychological Interactions Page 6 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. and that worry, grief, and anxiety are obstacles to effective treatment. The problem for the physician is that the standard model by its nature does not provide a path for putting this intuitive knowledge into practice or for turning these mind-body relationships to the patient’s advantage. Knowing that the mental state of the patient may affect the disease and response to treatment therefore becomes part of the art, rather than the science, of medicine even in the hands of an insightful and empathetic practitioner. Important areas of medical practice, such as family medicine, have a strong commitment to a biopsychosocial model of health. That is, they recognize the importance of the doctor-patient relationship, and treatment ac- knowledges that physical health is affected by psychological processes and by social conditions. Here, the physician has a philosophical commitment to appreciating the impact of social and psychological causes in health and disease and to bringing this understanding into the clinic. Unfortunately, there is little in standard medical training that provides skills and knowledge in applying a biopsychosocial model. The other side of this problem is that the emerging science of behavioral medicine is a promise yet to be fulfilled. There is a great deal of work to be done. Disciplines like psychology need to contribute to a base of theory and rigorously acquired knowledge that can lead to practical applications. This book will not solve the problem, but it will attempt to lay out what we know about the impact of psychological stress on the body, using an approach grounded in the neurosciences. A Biobehavioral Model of Disease and Treatment The model of disease outlined above is narrow. It restricts our view of the range of processes acting on our bodies, and this limits our thoughts about the causes and therapeutic interventions possible in a behavioral medicine. We can expand our view of the disease process by embedding our first model in one that includes the person’s learning history and sociocultural environment as shown in Figure 1.2. This enlarged model of disease and treatment shows three important interactions between the person and the environment: 1. The person’s psychosocial processes, meaning his or her thoughts, emotions, and spoken words, interact with the social and cultural environments. These informational interchanges, for example, in- formation concerning the nature of the disease and its cure, can affect its outcome. 2. The pathogen not only affects the person’s physiology, but the actions of the person’s immune system Stress and Health: Biological and Psychological Interactions Page 7 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. also alter the pathogen. This two-way interaction represents an exchange of information between host and pathogen, if we consider that each is learning something from the other. 3. The treatment still acts to alter the disease state, as it did in the first example. However, the model includes interactions among the treatment, pathogen, and host, and the social environment and psy- chosocial functioning as processes that affect treatment outcome. Figure 1.2 Expanded model of the disease process. The disease process interacts with the person, and psychological processes are shown interacting with physiological processes. In turn, the person interacts with the sociocultural environment. The treatment, disease, and environment are all capable of interacting as well. Pathogen-Host Interactions To illustrate the informational and behavioral elements incorporated into Figure 1.2, we might think about pathogen-host interactions based on current knowledge in immunology. In this framework, the pathogen pro- vides information about itself to the host. This signals the immune system that a foreign organism is present and that the organism has certain foreign proteins on its outer membrane, and the immune system learns how to recognize these proteins for future reference. The immune system then seeks the foreign cells and attacks them with one or more defenses. In turn, the invader may have evolved counterdefenses to evade or trick the immune cells, allowing it to survive longer in the host. Stress and Health: Biological and Psychological Interactions Page 8 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. The pathogen-immune interaction illustrates how a wide range of behaviors, in this case at the cellular level, may play a role in the processes of disease and treatment. First, the host is involved in a dynamic, interactive relationship with the pathogen. Second, this interaction is characterized by the exchange of information about the nature of the invader and the form of the host’s defensive response. Third, the virulence of the infection is the outcome of the interaction between the host and the pathogen. These interactions, exchanges of information, and virulence of the disease are behavioral interchanges. We normally think of behaviors as the overt actions of others and ourselves; it was noted earlier that the term behavior should also include our inner thoughts and feelings. The idea that cellular interactions also have the characteristics of behaviors should not be surprising, because behavior is a good description of the interac- tive sequence of invasion, identification, cellular attack, and counterattack involved in the infectious disease process. This expanded use of the term behavior readily allows us to incorporate the basic disease mecha- nism into a larger model including psychosocial and sociocultural processes, as shown in Figure 1.2. As we will see in Chapter 7, the dynamic properties of immune system behavior also provide abundant pathways for the study of interactions with higher nervous system processes, such as emotions. For this reason, it is emphasized at several points the importance of seeing disease and treatment as events in a hierarchically integrated system of behaviors, and not simply as isolated at the cellular or organ level. Psychosocial-Sociocultural Interactions Considering sociocultural processes, it is not hard to imagine that the outcome of this pathogen’s invasion will surely be different for a person whose learning history includes the knowledge of antibiotics, or for one whose sociocultural background calls for praying but not visiting a physician. Knowledge of disease and choices of treatment are fundamentally informational and behavioral processes, just as the interactions between host and invader are informational and behavioral interactions at the cellular level. These learned and culturally conditioned information exchanges and behaviors determine the course and outcome of the disease, as do the interactions at the immune system level. Another important feature of our expanded view of disease is that the model is not linearly causal. It is re- cursive and interactive. In Figure 1.1, the arrows all point in one direction, suggesting that the causal events work in only one direction. In Figure 1.2, the two-way arrows invite us to think about the course of the disease Stress and Health: Biological and Psychological Interactions Page 9 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. and its treatment as repeated, or recursive, interactions. Disease and treatment become behavioral process- es unfolding over time as an ongoing interchange between host and pathogen. This model implies that treatment of an infectious disorder could have significant psychological, behavioral, and cultural elements. By considering a model as in Figure 1.2, we begin to see that what we call the physical aspects of the disease and the psychosocial and cultural processes are no longer clearly different. Note that two-way arrows are included between psychosocial processes and physiological processes. That is, we are acknowledging that thoughts and emotions are intimately connected to the workings of our bodies. However, a clearer discussion of the mechanisms involved will be provided in Chapters 5–8. In a model such as this, the concepts of somatic disease, psychosomatic disease, or psychological disease are no longer categori- cally different terms. They merely call our attention to different facets of the same process. In this sense, the story told at the beginning of the first chapter and the dualistic sense of mind and body that the initial ques- tion implied begin to look fuzzy. Some additional examples should further serve to break down the distinction. Also, our view of treatment, and even prevention, changes when we take such an expanded view of disease. Placebo Effects For our second example, we will discuss placebo effects. In using a placebo, the patient takes a preparation that has no known biological activity, and yet the patient responds and perhaps improves. We call this a place- bo effect from the Latin phrase for I shall please. This implies that the medical effect has to do with a mental process associated with thoughts and emotions. In fact, for the placebo to work, the patient has to think that he or she is taking a medicine to cure a specific disease. To understand placebo effects, we have to examine the information processes, including the beliefs and cultural norms of the patient and physician. When we consider the dynamics of placebo effects, we come to the realization that all of the interactions outlined in Figure 1.2 may accompany any form of treatment. That is, we may entertain the idea that every form of treat- ment, placebo or otherwise, can have elements of psychological causation at work. This topic is discussed at length in engaging works by Benson and McCallie, Kirsch, and Harrington (Benson & McCallie, 1979; Har- rington, 1997; Kirsch, 1990). The case of the placebo effect illustrates the difficulties inherent in our tradition of mind-body dualism, and the controversy over the cause of placebo effects illustrates the difficulties of bio- medical approach in coming to terms with processes that start out in the psychological realm and end up in Stress and Health: Biological and Psychological Interactions Page 10 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. the body. Current thinking is that placebo effects operate either because of the expectancies of the person receiving them or because of conditioned associations that may accompany the treatment situation. In both models, the initiating event is acknowledged to be psychological. Expectancies and conditioned associations, in turn, both develop in a certain sociocultural environment and in persons with a certain learning history. We learn to ex- pect things about the world from our culture and from our own experience. We have learned responses to the world we live in. A patient taking pills in a drug study, but who is unknowingly assigned to the placebo control group, may say explicitly or implicitly, “Doctors give people medicines that make them well. The pills I’m taking are designed to cure my illness. I have taken pills in the past that cured me of other illnesses, and perhaps these will work as well.” These words describe the patient’s expectations about what the pills might be able to do. In some cases, these ideas result in outright cures or therapeutic effects as large as those caused by the active drug (Benson & McCallie, 1979). For example, in various studies of medications for coronary heart disease, up to 33%–37% of patients given placebos improved subjectively and objectively for up to a year or more—impressive results for an inactive compound. This kind of outcome does not fit a traditional physicalist model of medicine. Placebo effects can only be un- derstood as being mediated informationally by way of the central nervous system. Figure 1.3 illustrates that the traditional model of disease does not have a mechanism that permits physiologically inactive substances to have a measurable effect on the patient. There is no direct means by which the substance can intervene in the disease process. Stress and Health: Biological and Psychological Interactions Page 11 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Figure 1.3 Placebo effects in the context of a traditional medical model. In a medical model that ignores psychological processes, there are no adequate mechanisms to explain the op- eration of placebo effects. This is not to say that traditional medicine ignores placebo effects, only that it has no metaphysical and episte- mological basis for understanding them. This uneasy recognition that something occurs, but that we have no means for conceptualizing or controlling it, is an uncomfortable place to be, and it illustrates the advantages of expanding our traditional biomedical models. An expanded model, such as the one in Figure 1.2, is more inclusive and opens up possibilities for incorporating placebo effects into our thinking. We can now begin to consider how experience, beliefs, and cultural norms might set the stage for physical changes to occur fol- lowing ingestion of an otherwise inert substance in a treatment context. Psychoneuroimmunology In considering placebo effects, we should also give a brief mention to important developments in our under- standing of how psychological events may alter the functions of the immune system. Ader and his colleagues (Ader & Cohen, 1993) performed ingenious experiments to study how conditioned stimuli can alter immune function. In a prototype experiment, a group of rats was given a drug known to suppress the function of the immune system. Simultaneous with the drug, the animals were given saccharine in their water. At a later time, after their immune systems had recovered, the animals were again exposed to the saccharine water, but this Stress and Health: Biological and Psychological Interactions Page 12 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. time without the immunosuppressive drug. This resulted in a resuppression of immune function, even though no active drug was present. It so happens that to a rat, saccharine tastes different from sugar, and so saccha- rine provided a novel taste sensation for these animals. It is also the case that novel tastes are very salient stimuli for rats. Ader and his coworkers suggested that this phenomenon of saccharine-induced immunosuppression could be accounted for by a process of classical conditioning. In classical conditioning, we present a stimulus that has automatic effects on the body (such as food, which will lead to salivation in a dog), and we also present a stimulus unconnected with the original response (such as a bell or tone). Eventually the bell comes to elicit salivation, and so we say the salivation has become conditioned to the sound. Figure 1.4 provides a diagram of the typical series of events in a classical conditioning experiment. In Ader’s studies, we can think of the immunosuppressive drug as an unconditioned stimulus (UCS), one that automatically produces an uncondi- tioned immunosuppressive response (UCR) due to its direct action on the system. We can also think of the saccharine as a conditioned stimulus (CS), one that has no effect on its own. Finally, we can see how the response to the saccharine alone became a conditioned response (CR) developed from the original UCR as- sociated with the CS-UCS pairing. These observations stand as a watershed in the science of immunology because they open up the possibly that there could be unsuspected behavioral and cognitive sources of in- fluence on immune function, and therefore on health. In a famous paper, Robert Rescorla (Rescorla, 1988) described how animals learn anticipatory responses during classical conditioning. After all, what was Pavlov’s dog doing when he salivated to the sound of the bell, if not anticipating food? The conditioning explanation for placebos has the advantage of a parallel neuro- physiological mechanism that gets us from symbols and ideas to physiological responses that affect the body. This is a powerful explanatory tool in favor of the conditioning model. The work by Ader, as well as the discovery of the role of classical conditioning in immune system processes, illustrates three points that are central to this book. First, the fact that classical conditioning can exert immuno- suppressive effects means that an individual’s personal life history may place a definite stamp on the state of the body, both deleterious and beneficial. Second, this example not only helps us understand psychological effects on immune function but it also provides a clue as to the nature of some if not all placebo responses. In fact, we can think of the saccharine in Ader’s studies as a kind of placebo, an inactive substance that ac- quired its powers through conditioning. Third, we should note that the taste of saccharine to the rat is really an informational stimulus. It had no power of its own, but it became a piece of information, a symbol, that some- Stress and Health: Biological and Psychological Interactions Page 13 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. thing else may also happen––such as the administration of the immunosuppressive drug. Fourth, this kind of conditioning is not a special type of experience confined to the lab. Our entire lives are constantly emerg- ing patterns of relationships with information from the environment. This pattern of relationships defines the meaning that events have for us, and conditioning provides a scientifically credible mechanism for how the world “gets under our skin,” in the words of Anne Harrington. The inactive saccharine, in other words, gained meaning because of the unique pairing with the drug, and the workings of the body were therefore altered. In this way, we can begin to think about how ideas may come to have power over our bodies. Figure 1.4 Classical conditioning. An unconditioned stimulus (UCS), such as food or shock, evokes an innate unconditioned response (UCR), such as salivation or freezing. The condi- tioned stimulus (CS) is usually a sight or sound that has little or no innate effect or one that rapidly dissipates because the stimulus is not behaviorally or biologically significant. Con- ditioning in the laboratory is established and tested in three stages: (a) habituation—pre- senting the CS alone to remove any general attentional responses to the stimulus; (b) con- ditioning—CS–UCS pairings to form a new, conditioned response (CR), to the CS; and (c) extinction—testing the strength and durability of the new CR by presenting the CS alone. The conditioned response now mimics or anticipates the original unconditioned response. Stress and Health: Biological and Psychological Interactions Page 14 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Cultural, Intrapersonal, and Physiological Influences in Coronary Heart Disease As a last example, consider what happens in the diagnosis and treatment of a complex, chronic disease like coronary heart disease. We will find that in this example there are even richer sources of behavioral input to the disease process and to its alleviation than there were in the case of infectious disease. What we call coro- nary heart disease, or coronary artery disease, is the result of the gradual accumulation of cholesterol-rich fatty plaques and thickened areas in the walls of the blood vessels that supply blood to the heart. This ulti- mately leads to an attenuated blood supply to the continually working heart muscle. The muscle receives too little oxygen, often causing the oppressive chest pain of angina pectoris. Occasionally a blood clot may form at the site of a thickened atherosclerotic lesion and completely block blood flow to the heart muscle down- stream, resulting in a heart attack, referred to by cardiologists as a myocardial infarction, or just an MI. Current treatments for this disease involve using bypass grafts that circumvent the lesioned areas of coronary artery by attachment of new vessels borrowed from other parts of the body, placing an expandable mesh stent in lesioned areas to increase blood flow past the blockage, and also putting the patient on a low cholesterol diet supplemented by cholesterol-lowering drugs. Coronary artery bypass grafts and angioplasties were per- formed on over 1.7 million men and women in the U.S. in 2009. All of these treatments are strictly within the traditional framework—they intervene in the pathogenic process at the tissue level. Figure 1.5a shows a restricted, physicalist view of coronary artery disease and its treatment. In this view, the cause is a diet too high in cholesterol and saturated fats, perhaps helped along by a genetic predisposition to atherosclerosis. The cure is some combination of the therapies above. However, we also know that personal behaviors and cultural practices have much to do with the development of coronary heart disease. In the Unit- ed States, we have a cultural practice of eating a diet high in animal fat and total calories. Furthermore, some persons may aggravate the development of heart disease by regularly engaging in vigorous competitive be- haviors accompanied by a hostile attitude. This constellation of extreme activity and hostile emotions, known as Type A behavior, may be associated with frequent elevations of blood pressure along with stress hormone secretion and the release of stored fat molecules into the blood stream. These physiological processes may accelerate lesion formation and growth. With an expanded view of the disorder, depicted in Figure 1.5b, we can see the interplay of sociocultural, Stress and Health: Biological and Psychological Interactions Page 15 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. genetic, and personal habits in the etiology of the disease. The expanded model allows us to consider that coronary heart disease does not have a simple unitary cause. Instead, a genetic heritage, in combination with a constellation of overt behaviors and emotional predispositions, occurring in a certain cultural environment, all act to increase or decrease disease risk. Furthermore, this expanded disease model not only allows for a more thorough view of the development of coronary heart disease but also begins to give us insights into possible modes of therapy not possible under our more restricted model in Figure 1.5a. For example, it may be possible to provide cognitive and behavioral training to persons subject to frequent, emotionally intense, hostile interactions, thus lessening the destructive effects of blood pressure and catecholamine rises on the atherosclerotic vessels. In fact, such treatment in men who had experienced a first heart attack resulted in a significantly lower rate of second attacks compared with men who received only standard care (Friedman et al., 1986). Stress and Health: Biological and Psychological Interactions Page 16 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Figure 1.5 Traditional model of coronary artery disease (a) and an expanded model (b). Tra- ditional treatments for coronary disease are shown as addressing the acute effects of the illness without addressing behavioral sources of the disorder. The expanded model indi- cates the potential for psychosocial causes, thereby indicating behavioral means of treat- ment. This chapter has stated that we inherited a dualistic view of ourselves via the Cartesian tradition. This leaves us with the problem of how psychosocial and sociocultural processes, which are by nature nonphysical, can act as causes of disease or as modes of treatment. Psychosocial and cultural processes are, at their root, informational. These processes shape our view of the world, our interpretations of social interactions, and ul- timately our bodily responses. At the end of the book, we will consider an approach to this question that may help us dispense with the distinction between terms such as physical, psychological, and sociocultural. Stress and Health: Biological and Psychological Interactions Page 17 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Psychosocial Theories of Disease and Treatment The previous examples tell us that to understand all the causes of disease, and to consider the greatest pos- sible range of treatments, we should recognize that a simple linear model adequately describes neither the causes nor the cures. An expanded definition of disease might look like this: a disorder of body functions or systems arising from malfunction at the level of physiological, psychophysiological, or sociocultural function- ing. We noted that our expanded biobehavioral model of disease not only helps us think about causes, but it also provides insights into elements critical to treatment. Several authors have considered the role of psycholog- ical and sociocultural processes in treatment (Elstein & Bordage, 1979). We may consider a revised view of treatment, taking into account some traditional and nontraditional questions: 1. Who is being treated? The patient’s psychological makeup, learning history, and cultural background may be important elements in developing a plan of treatment. 2. What is the specific disease state? Accurate diagnosis is crucial to successful treatment. 3. What factors limit treatment alternatives? Not all treatments are feasible at all times. 4. What is the social environment? This may facilitate some treatments and limit the uses of others. 5. What is the specific form of treatment? Clearly, all other considerations aside, the treatment must ul- timately interact appropriately with the disease process at a physical level. 6. What is the therapist’s psychological makeup? The success of treatment may be influenced by the attitudes of the practitioner. 7. What is the mode of therapy? The form of therapy must be tailored to meet the restrictions imposed by 1–6 above. 8. What is the goal of treatment? Given any disease state, the goals of treatment will be conditioned based on realistic considerations of 1–7 above. Each of the above questions relies on considering modifications of a traditional biomedical model that are de- termined by the patient, the doctor-patient relationship, and the context, including the cultural environment. A contemporary approach to behavioral medicine may be useful in comprehending these issues and applying appropriate modifications to practice in individual cases. Stress and Health: Biological and Psychological Interactions Page 18 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. The Foundation of Behavioral Medicine Behavioral medicine involves the study of how sociocultural and mind-brain processes can influence the health of an individual. It seeks to identify ways that maladaptive behaviors, states of mind, or cultural prac- tices may impair health and how these same processes can be used to improve it. In an influential chapter on behavioral medicine titled “The Brain as a Health Care System,” Gary Schwartz (Schwartz, 1979) argued that general systems theory offers a way to conceptualize the role of the mind-brain in health and disease. Systems theory describes how simple and complex systems are regulated and how they maintain that regulation when threatened with disruption. Schwartz pointed out that the brain is engaged constantly in hierarchically integrating information to regulate bodily functions, such as respiration. By hier- archical, we mean that bodily functions have several layers of control, each layer being modified by the one above. The layered control concept provides a way of thinking about how our higher brain activities such as thoughts and emotions can act on lower centers to alter bodily functions. In calling the brain a health care system, Schwartz acknowledged that the brain ultimately plays the topmost role in regulating physiological systems, recognizing that the brain is essential in maintaining the health of the body, not only through phys- iological regulation but also through emotions, thoughts, and behaviors. Finally, the brain is capable of inter- preting and assimilating social and cultural information and reflecting these influences on the workings of the body. Schwartz proposed a five-stage model to illustrate these processes: 1. The organism and the environment are involved in a two-way dialogue. We receive information from our external environment and continuously modify that environment by our actions. For example, you might get up and raise the thermostat if the room is cold. Or put on a sweater. 2. The mind-brain integrates information from the external and internal environments and makes use of these two sources of information to determine regulation of the somatic organs. When you are cold, you might shiver to increase your body temperature. 3. The somatic organs alter their function to adapt to external and internal demands according to activity determined by the brain. In this way, they function to maintain an optimal balance for the body’s inter- nal environment. This topic will receive primary attention in Chapters 3–7, where we deal with the concept of stress, physiological regulation, and responses to challenges of a physical and a psycho- logical nature. 4. In carrying out its regulatory role, the brain makes heavy use of interoceptive information. For exam- Stress and Health: Biological and Psychological Interactions Page 19 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. ple, in the short-term regulation of blood pressure, the brainstem receives constant input from the baroreceptors located in the aorta and carotid arteries. Deviations from normal pressure lead to rapid changes in the heart’s rate and force of contraction. This allows sudden pressure changes to be com- pensated for almost instantly and automatically. These processes happen automatically and out of our awareness. 5. Finally, it is possible for the brain to use external sources of information to regulate the body. An everyday example is that we may look at the temperature setting on a thermostat to adjust it to ensure a comfortable environment in our home or office. A more subtle and striking example of such information-based regulation uses the process of biofeedback. In biofeedback, a bodily function normally not accessible to our awareness, such as blood pressure, is displayed visually or auditorally to allow us conscious access to the momentary state of our pressure. By this means, it becomes possible with practice to raise or lower pressure for short periods by altering processes control- ling pressure, such as heart rate. Biofeedback therefore provides another information channel for the brain to have access to and alter processes in the body, at least temporarily. It also should be noted that biofeedback is probably unable to permanently lower blood pressure in a person with hypertension. In another example, biofeedback can allow patients who suffer from muscle tension to develop conscious awareness of the onset of episodes of tension and to recognize which muscles are tensing up. After several sessions of feedback, the person may become able to do this outside the clinic and take steps to relax the appropriate muscle groups before they become painful. This is a simple but effective technique for gaining awareness to regulate the state of our bodies. In considering Schwartz’s ideas on the regulation of body processes by the brain and the expanded disease model described in Figure 1.2, we can see that both place a significant emphasis on the role of information received by the brain to alter the functions of the body. Schwartz makes the important point that there is no fundamental difference in the interoceptive information the brain uses in its normal regulation of the body, or in the information it receives from outside as determined by the behaviors of the individual or by the cultural environment. We will return to the concept of hierarchical control by the brain in considering autonomic regu- lation in Chapter 3 and in our description of central nervous integrations of psychological stress responses in Chapters 5–7. Stress and Health: Biological and Psychological Interactions Page 20 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. Summary This chapter described how the mind-body dualism of Descartes affected the Western view of physiology and medicine. In turn, this has led to an unnecessarily narrow view of disease and treatment. It has described a revised model of disease in which thoughts and emotions can be major elements in treatment. By acknowl- edging the role of psychosocial and sociocultural processes, behavioral medicine expands our ways of think- ing about the influences on health and disease. To return to our starting point, our metaphysical case of split personality leaves us few conceptual tools to help us understand and explain how the mind alters the body. As a result, we do not yet have a generally accepted, scientifically grounded model for appreciating how thoughts and emotions affect health. In order to take this abstract discussion of behavioral medicine closer to reality, we need to do two things. First, we have to confront the obstacles to our thinking that are conditioned by our intellectual heritage. For this reason, I have sketched the history of our dualistic model of ourselves. If we continue to think of physical processes and mental or psychological functions as being in separate realms, then we will have a much more difficult time envisioning how our state of health and disease are conditioned by our thoughts, feelings, and actions. We will return to this topic in our last chapter and consider some ways of further dispelling the gaps in our understanding. Second, we need to address the mechanisms by which the brain, in fact, controls our bodies and find the linkages between ideas and regulatory processes. In a sense, we need to follow the steps be- tween the idea and the bodily function if we are to answer our primary question of how an idea can come to have power over our bodies—how mental stress can affect our health. Fortunately, we are gaining a better understanding of how our state of mind affects the state of our body. Chapters 9–11 will present recent mod- els of chronic stress that have been advanced to allow us to think about the products of negative emotions and persistent feelings of distress as causes of changes in the body and brain that may be health impairing. There are also recent models showing how early nurturing and beneficial environments may improve stress reactivity and long-term health in adulthood. These advances in research point toward future areas of study that will have a considerable impact on our thinking about the mind and the body. Further Reading Toulmin, S. (1967). Neuroscience and human understanding. In G. C. Quarton, T. Melnechuk, & F. O. Schmitt Stress and Health: Biological and Psychological Interactions Page 21 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. (Eds.), The neurosciences: A study program (pp. 822–832). New York, NY: Rockefeller University Press. This is a rich, powerfully informative, and concise discussion of the relationship between the study of the brain and the emerging reconceptualization of consciousness. These topics are fundamental to our understanding of how the mind can influence the body. Foss, L., & Rothenberg, K. (1988). The second medical revolution. Boston, MA: Shambhala. Schwartz, G. (1979). The brain as a health care system. In G. C. Stone, F. Cohen, & N. E. Adler, (Eds.), Health psychology: A handbook (pp. 549–571). San Francisco, CA: Jossey-Bass Publishers. Two primary sources for material covered in this chapter. Together they provide a broad view of the relation- ship of behavioral medicine to traditional medicine. Sarafino, E. P. (2001). Health psychology: Biopsychosocial interactions (4th ed.). New York, NY: John Wiley & Sons. An excellent standard text that describes the biopsychosocial model from a behavioral medicine perspective. Harrington, A. (1997). The placebo effect: An interdisciplinary exploration. Cambridge MA: Harvard University Press. An important work on the placebo phenomenon, viewed broadly from the perspective of several disciplines. Wozniak, R. H. (1992). Mind and body: René Descartes to William James. Bethesda, MD: National Library of Medicine. Our discussion of the mind-body problem is very selective. Wozniak provides a thorough historical commen- tary on the major lines of thought related to this paradox during the development of modern psychology. Discussion points 1. How can thoughts and emotions become connected with physiological outputs to the body? 2. How can the cultural environment affect thought processes and interpretations in the world in a way that can affect the processes in the first question? 3. Discuss the placebo effect and classical conditioning. Stress and Health: Biological and Psychological Interactions Page 22 of 23 Sage Sage Academic Books © 2016 by SAGE Publications, Inc. disease health emotion behavioral medicine https://doi.org/10.4135/9781071801390 Stress and Health: Biological and Psychological Interactions Page 23 of 23