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to Menu PageBiological scientists have long been aware of the importance of social relationships on health. As the evolutionary biologist George Gaylord Simpson observed, "No animal or plant lives alone or is self-sustaining. All live in communities including other members of their own species and also a number, usually a large variety, of other sorts of animals and plants. The quest to be alone is indeed a futile one, never successfully followed in the history of life" (emphasis added) (Simpson, 1953, p. 53).
This observation is nowhere truer than in the human domain, where perceptions of social isolation and aloneness may set in motion mind-body events of life-or-death importance. This point has been demonstrated in research on many dimensions of human experience, among them the following:
~Bereavement. The idea that a person can die from being separated suddenly from a loved one is rooted in history and spans all cultures--the "broken heart" syndrome. In the United States, 700,000 people aged 50 or older lose their spouses annually. Of these, 35,000 die during the first year after the spouse's death. Researcher Steven Schleifer of Mount Sinai Hospital, New York, calculates that 20 percent, or 7,000, of these deaths are directly caused by the loss of the spouse. The physiological processes responsible for increased mortality during bereavement have been the subject of extensive investigations and include profound alterations in cardiovascular and immunological responses. In study after study, the mortality of the surviving spouse during the first year of bereavement has been found to be 2 to 12 times that of married people the same age (Dimsdale, 1977; Engel, 1971; Holmes and Rahe, 1967; Lown et al., 1980; Lynch, 1977; Schleifer et al., 1983; Stoddard and Henry, 1985). These studies have far-reaching therapeutic implications as well. Individual and group support can--and have been shown to--help mitigate the devastating effects of loss.
Poor education and illiteracy. A more general and pervasive form of isolation results from poor education and illiteracy, which are in turn associated with increased incidence of ~disease and death. As Thomas B. Graboys of Harvard Medical School has stated, poor education is "an Orwellian recipe in which the estranged worker, besieged from above and below, mixes internal rage and incessant frustration into a fatal brew" (Graboys, 1984).
Many believe that the common factor in poor education, poor health, and higher mortality is simply that the poorly educated take worse care of themselves. However, research shows that smoking, exercise, diet, and accessibility to health care, while important, do not explain the poorer health and earlier death of these people; the influence of social isolation and poor education is more powerful. Moreover, poor education appears to be only a stand-in or proxy for stress and loneliness--that is, low education actually does its damage through the stress and social isolation to which it leads (Berkman and Syme, 1982; House et al., 1982, 1988; Ruberman et al., 1984; Sagan, 1987).
The underlying pathophysiological processes by which social isolation may bring about poor health have been illuminated by studies of primates in the wild. Low-ranking baboons, whose entire life is spent in constant danger with little control, demonstrate high circulating ~levels of hydrocortisone, which remain elevated even when the stressful event has passed. In addition, chronic psychological stress and isolation have been associated with decreased concentrations of high-density lipoproteins, which protect against heart disease, and weaker immune systems with fewer circulating disease-fighting lymphocytes (Sapolsky, 1990).
Attitude toward work and work status may also be intimately related to health and well-being. Several lines of evidence point to these correlations:
• When researcher Peter L. Schnall and his colleagues examined the relationship between "job strain," blood pressure, and the mass of the heart's left ventricle, they found--after adjusting for age, race, body-mass index, type A behavior, alcohol intake, smoking, the nature of the work site, sodium excretion, education, and the physical demand level of the job--that job strain was significantly related to hypertension. They concluded that "job strain may be a risk factor for both hypertension and structural changes of the heart in working ~men" (Schnall et al., 1990; Williams, 1990).
• Epidemiologist C. David Jenkins demonstrated in 1971 that most people in the United States who experience their first heart attack when they are under the age of 50 have no major risk factors. Although Jenkins's findings must be tempered by the more recent redefinition of what constitutes "normal" cholesterol and blood pressure, the point remains: a purely physical approach may be inadequate for understanding the origins of coronary artery disease in our culture (Jenkins, 1971).
• In a 1973 survey in Massachusetts, a special Department of Health, Education, and Welfare task force reported that the best predictor for heart attack was none of the classic risk factors, but the level of one's job dissatisfaction (Work in America: Report of a Special Task Force to the Secretary of Health, Education, and Welfare, 1973). It is possible that this finding may be related to the observation that heart attacks in the United States, as well as in other Western industrialized nations, cluster on Monday mornings from 8 to 9 a.m., the beginning of the work week (Kolata, 1986; Muller et al., 1987; Rabkin et al., 1980; ~Thompson et al., 1992).
• Robert A. Karasek and colleagues have shown that the job characteristics of high demand and low decision latitude have predictive value for myocardial infarction. Occupational groups embodying these personality traits--waiters in busy restaurants, assembly line workers, and gas station attendants, for example--are at increased risk for heart attack. Their hypothesis is that increasing job demands are harmful when environmental constraints prevent optimal coping or when coping does not increase possibilities for personal and professional growth and development (Bergrugge, 1982; Bruhn et al., 1974; Karasek et al., 1982, 1988; Palmore, 1969; Sales and House, 1971; Syme, 1991).
• Psychologist Suzanne C. Kobasa and colleagues have identified job qualities that offer protection against cardiovascular morbidity and mortality, even in psychologically stressful job settings. They refer to the "three Cs": (1) control--a sense of personal decisionmaking; (2) challenge--the sense of personal growth and wisdom; becoming a better person; and (3) commitment to life on and off the job--to work, community, family, and self. Persons ~experiencing these qualities are said to possess "hardiness" and are relatively immune to job-induced illness or death (Kobasa et al., 1982).
Perceived meaning--how one perceives an event or issue, what something symbolizes or represents in one's mind--has direct consequences to health.3 The annals of medicine are replete with anecdotes illustrating the power of perceived meaning--for example, accounts of sudden death after receiving bad news. Moreover, perceived meanings affect not just health, they also influence the types of therapies that are chosen. For example, if "body" means "machine," as it has tended to for people since the Industrial Revolution, illness is likely to be seen as a breakdown or malfunction, and the tendency is to prefer mechanically oriented approaches to treating illness.
Therapies, therefore, are likely to be designed to repair the machine when it malfunctions--surgery, drugs, irradiation, and so on. Or, if illness symbolizes an attack from ~the outside by "invading" pathogens or foreign substances, as it does to many people, people are apt to look for magic bullets in the form of antibiotics or other substances to protect them from these threats. Society may even declare counterattacks, such as the "wars" on acquired immunodeficiency syndrome (AIDS), heart disease, cancer, high blood pressure, or cholesterol. Perceived meanings, therefore, can be translated into the body as potent influences, and they can strongly influence the design of medical interventions.
More recently, careful studies have indicated the pivotal role of perceived meaning in health. Sociologists Ellen Idler of Rutgers University and Stanislav Kasl of the Department of Epidemiology and Public Health at Yale Medical School studied the impact of people's opinions on their health--what their health meant to them. The study involved more than 2,800 men and women, and the findings were consistent with the results of five other large studies involving more than 23,000 people. All these studies lead to the same conclusion: One's own opinion about his or her state of health is a better predictor than objective factors, such as physical symptoms, extensive exams, and laboratory tests, or behaviors such as cigarette smoking. For instance, people who smoked were twice as likely to die ~during the next 12 years as people who did not, whereas those who said their health was "poor" were seven times more likely to die than those who said their health was "excellent" (Idler and Kasl, 1991).
Dorland's Illustrated Medical Dictionary, twenty-fifth edition, defines the word placebo (in Latin, "I will please") as an inactive substance or preparation given to satisfy the patient's symbolic need for drug therapy and used in controlled studies to determine the efficacy of medicinal substances. It is also a procedure with no intrinsic therapeutic value, performed for such purposes. Although the placebo response is perhaps the most widely known example of mind-body interaction in contemporary scientific medicine,4 it is at the same time one of the most undervalued and neglected assets in today's medical practice (Benson and Epstein, 1975). Even the definition from the medical dictionary suggests the term's uselessness apart from its narrow role in testing drugs. However, throughout most of medical history--in the centuries before antibiotics and other "wonder drugs"--the placebo effect was the central ~treatment physicians offered their patients (Benson and Epstein, 1975). Doctors hoped that their reassuring attention and their belief in their treatments would mobilize powers within their patients to fight their illnesses.
Today the placebo response is considered primarily a way of testing new drugs: if patients who have been given a placebo improve as much as those who took the new medication, the drug is dismissed as ineffective and with it the placebo. "Since a beneficial effect is the desired result," say cardiologist Herbert Benson and psychiatrist Mark Epstein, "should not the placebo effect be further investigated so that we might better explain its worthwhile consequences?" (Benson and Epstein, 1975).
The placebo response relies heavily on the interrelationship between doctor and patient. Patients bring with them to the doctor's office their attitudes, expectations, hopes, and fears. Doctors, in turn, have their own biases, attitudes, expectations, and methods of communication, which have a profound effect on patients. Doctors who believe in the efficacy of their treatment communicate that enthusiasm to their patients; those who have ~strong expectations of specific effects and are self-confident and attentive are the most successful at eliciting a positive placebo response (Wheatley, 1967). It is the interrelationship between the doctor and patient and the congruence of their expectations that bring about a positive placebo response. If the congruence is lacking, a favorable response rarely occurs (Hankoff et al., 1960).
The placebo response says a great deal about the importance of the doctor-patient relationship and the need to pay greater attention to it--and to provide further medical training on how that relationship can be heightened. It is particularly important in this highly technological era of medicine, when doctor-patient contacts are diminishing.
Although the literature of mind-body interaction documenting the placebo response is too vast to be reviewed here, several additional mind-body issues raised by this research deserve emphasis:
• The placebo response is almost ubiquitous. Studies show that in virtually any disease, ~roughly one-third of all symptoms improve when patients are given a placebo treatment without drugs (Goleman and Gurin, 1993).
• Placebo responses can be extraordinarily dramatic and offer valuable insights into the extent of the "powers of the mind" (Levoy, 1989).
• The nocebo response, a toxic or negative placebo event, raises serious questions about what is meant by "the natural course" or "the inherent biology" of any particular disease and suggests the great degree to which attitudes and expectations can affect one's state of health and the course of an illness.
• Nocebo effects can also be dramatic, are very common, and should be more widely acknowledged. Even anaphylactoid reactions (Wolf and Pinsky, 1954) and addictions to placebos (Rhein, 1980)--reactions not commonly thought to be "mental" in origin--have been reported, along with a variety of other noxious reactions. In one controlled study by the British Stomach Cancer Group, 30 percent of the control (placebo-treated) group lost their ~hair, and 56 percent of the same group had "drug-related" nausea or vomiting (Fielding et al., 1983).
"Spirituality" is, generally speaking, one's inward sense of something greater than the individual self or the meaning one perceives that transcends the immediate circumstances. "Religion" may be described as the outward, concrete expression of such feelings.
The therapeutic potential of spirituality and religion have generally been neglected in the teaching and practice of medicine. However, epidemiologists Jeffrey S. Levin and Harold Y. Vanderpool have assembled what they term an "epidemiology of religion"--a large body of empirical findings "lying forgotten at the margins of medical research . . . specifically . . . nearly 250 published studies dating back over 150 years which [present] the results of epidemiologic, sociomedical, and biomedical investigations into the effects of religion. Nearly all of these investigations were large-scale studies" (Levin, 1989; Levin and Schiller, 1987; ~Levin and Vanderpool, 1991; Vanderpool and Levin, 1990).
Reviewing this immense database, Schiller and Levin found significant associations with variables such as religious attendance and subjective religiosity for a wide assortment of health outcomes, including cardiovascular disease, hypertension and stroke, uterine and other cancers, colitis and enteritis, general mortality, and overall health status (Schiller and Levin, 1988). These data are so consistent that Levin and Vanderpool suggest that infrequent religious attendance or observance should be regarded as a consistent risk factor for morbidity and mortality of various types (Levin and Vanderpool, 1987).
These findings are consistent with those of David B. Larson and Susan S. Larson, who surveyed 12 years of issues of the American Journal of Psychiatry and the Archives of General Psychiatry. They found that 92 percent of the studies that measured participation in religious ceremony, social support, prayer, and relationship with God showed benefit for mental health, whereas 4 percent were neutral, and 4 percent showed harm (Larson and Larson, 1991). Craigie and colleagues, in a 1990 review of 10 years of issues of the Journal ~of Family Practice, reported similar findings: 83 percent of studies showed benefit for physical health, 17 percent were neutral, and 0 percent showed harm (Craigie et al., 1990).
Matthews, Larson, and Barry made a major contribution in bringing together the research in this field--a two-volume report that compiles hundreds of studies, titled The Faith Factor: An Annotated Bibliography of Clinical Research on Spiritual Subjects (Matthews et al., 1993). Because research indicates that religious and spiritual meanings are correlated with increased physical and mental health and a lower incidence of a variety of diseases, and because religious and spiritual issues also affect profoundly how physicians regard death and treat the elderly, the quarantine against bringing up these matters in the doctor-patient relationship must be lifted. Becoming sensitive to these delicate issues does not require physicians to advocate any particular religious point of view. It does imply, however, that they should honor the salutary effects of spiritual meanings in their patients' lives, and inquire about spiritual and religious issues as assiduously as any physical factor.5
Spontaneous Remission of Cancer~The belief that life-threatening diseases such as cancer may disappear suddenly and completely is universal. This idea is usually coupled with the conviction that radical healing is somehow connected with one's state of mind.
Opinions vary as to how often cancer regresses spontaneously, leaving the person healthy. In their 1966 book on spontaneous regression of cancer, Everson and Cole collected 176 case reports from various countries around the world and concluded that spontaneous regression occurs in one of 100,000 cases of cancer. Other authorities believe the incidence may be much higher. Everson and Cole found that almost any therapy to induce remission seems to work some of the time. Regression of cancer follows such diverse measures as intercessory prayer, conversion to Christian Science, mud packs, vitamin therapy, and force-feeding. They found that spontaneous regression occurs after both insulin and electroshock treatments. Since almost any treatment seems to work occasionally but not consistently, many have concluded that these measures are equally worthless and that spontaneous regression of cancer is purely a random event (Everson and Cole, 1966).
~This point of view is a historical oddity. Prior to the 20th century, both physicians and patients believed the mind was a major factor in the development and course of cancer. In the years since Everson and Cole's review, this perspective has been recovered and reexamined. Many investigators--including psychologist Lawrence LeShan (1977) of New York and psychiatrist Steven Greer (1985) of King's College Hospital, London--have produced studies that suggest that emotions, attitudes, and personality traits may affect the onset of cancer as well as its course and outcome.
The Institute of Noetic Sciences has just published the most comprehensive investigation of spontaneous remission ever done--Spontaneous Remission: An Annotated Bibliography (O'Regan and Hirshberg, 1993).6 This 15-year project was the work of biochemist Caryle Hirshberg and researcher Brendan O'Regan, who combed 3,500 references from more than 800 journals in 20 languages. The report deals not only with cancer but also with the spontaneous remission of a wide spectrum of diseases. It is the largest database of medically reported cases of spontaneous remission in the world. Key findings are as follows:
~ • Remission is a widely documented phenomenon, almost certainly more common than generally believed.
• Remission is an extremely promising area of research. Studying the psychobiological processes involved may provide important clues to understanding the body's self-regulatory processes and the breakdowns that precede the onset of many diseases.
• Data on remissions can have an important influence on how patients are treated and handled when diagnosed with a terminal illness. Restoring hope may help instill a "fighting spirit," an important factor in recovery from illness.
This interest in the possible role of the mind in the causation and course of cancer has been significantly stimulated by the discovery of the complex interactions among the mind and the neurological and immune systems, the subject of the rapidly expanding discipline of psychoneuroimmunology.
~The relationship between psychological strategies and the regression of cancer is immensely complex and cannot be fully reviewed here. Two salient points should be made, however, that contradict popular belief and illustrate the complexity of these events: (1) Although an aggressive, fighting stance is generally advocated in stimulating spontaneous regression of cancer, University of California-Los Angeles psychologist Shelley E. Taylor has shown that (a) psychological denial following the diagnosis of breast cancer and (b) openly facing the disease and its implications are associated with near-equal survival statistics (Taylor, 1989). (2) Sometimes a mode of psychological acceptance, not aggressiveness, toward the diagnosis seems to set the stage for spontaneous remission. This point is particularly obvious in a series of spontaneous cancer remissions reported from Japan by Y. Ikemi and colleagues (Ikemi et al., 1975).
The profound differences in the psychological stances taken by people who survive cancer suggest that not only is there extreme variation between cultures, there are profound differences in the psychology of cancer survivors within cultures as well. Because the causal mechanisms involved are not known, and in view of the sheer variety of the psychological ~states that are apparently involved in spontaneous regression of cancer, physicians are currently unjustified in recommending uniformly that patients with cancer adopt a specific psychological stance in hopes of getting well. Still, spontaneous remission of cancer is a fact. Far more knowledge is needed about when and why it happens and what can be done to promote it.