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Alternative Medicine Mind-body medicine
Alternative Medicine: Mind-Body Medicine
Table of Contents
Alternative Medicine: Mind-Body Medicine
II. Mind-Body Medicine Overview
III. Mind-Cure and Mental Healing
IV. Spirituality and Prayer
VI. Relaxation Therapies
B. Progressive muscle relaxation (PMR).
C. Autogenic training.
A. Transcendental meditation (TM).
B. Relaxation response (RR) and respiratory one method (ROM).
C. Moving meditation.
D. Clinically standardized meditation (CSM).
X. Scientific Foundations
A. The Body
B. The Mind
C. Mind-Body Interactions
XI. Scientific Evaluation and MBTs
Health and wellbeing are factors that affect every facet of daily life. This fact is reflected in the 2.2 trillion dollars Americans spent on healthcare in 2007 (National Center for Health Statistics [NCHS], 2010) and the projected 2.6 trillion dollars of expenditures in 2010 (National Health Statistics Group, 2008). Furthermore, government funded medical research exceeds 28 billion dollars per year (National Institutes of Health [NIH], 2007). Conventional medicine improves health and quality of life; however, millions of Americans spend billions of dollars per year on complementary and alternative medicine (CAM) that is not accepted under conventional standards (National Center for Complementary and Alternative Medicine [NCCAM], 2009). Complementary medicine is any unconventional medical practice used in tandem with conventional healthcare and alternative medicine encompasses any unconventional medical practice used in place of conventional medicine. CAM practices do not meet conventional standards because they include untested and unproven practices. Despite this fact, surveys conducted by the National Health Information Survey (NHIS) indicated that 38% of Americans utilize CAM annually (Barnes, Bloom, & Nahin, 2008; Barnes, Powel-Griner, McFann, & Nahin, 2004). CAM practices are also increasingly common in conventional medical education and practice (Fenton & Morris, 2003), with medical schools, nursing schools, and hospitals around the country adapting programs to include CAM (Rhee, Barg, & Hershey, 2004; Saxon, Tunnicliff , Brokaw, & Raess, 2004; Wetzel, Eisenberg, & Kaptchuk, 1998). Additionally, the Nursing Interventions Classification (NIC), a standardized classification of treatments that nurses administer to influence patient health outcomes, includes a variety of CAM interventions (Dochterman & Bulechek, 2004; Frisch, 2001). The reported increase in CAM’s popularity and the frequency of practical application seem apparent.
Popularity does not speak to the medical efficacy of CAM practices; however, popularity and practical application do indicate the need for rigorous evidence based support for the efficacy of practices that receive billions of dollars every year and range from dangerous to benign (Eisenberg, Davis, Ettner, Appel, Wilkey, & Van Rompay, 1998; Eisenberg, Kessler, Foster, Norlock, Calkins, & Delbanco, 1993). In the early 1990’s, CAM’s apparent popularity prompted politicians to petition for the establishment of the Office of Alternative Medicine (OAM) which opened in 1992 (Institute of Medicine, 2004). In 1999, the OAM was renamed the National Center for Complementary and Alternative Medicine (NCCAM) and joined 26 other centers and institutes within the National Institutes of Health (NIH). Despite considerable controversy (Hagen, 2008) and criticisms from prominent medical professionals, NCCAM set out to scientifically research CAM practices. Unlike many other divisions and centers within NIH, NCCAM was established to investigate specific treatment modalities rather than patient populations, biological systems, or disease processes. That is to say, NCCAM research is practitioner centered rather than patient centered. Accordingly, NCCAM recognizes five informal classifications of CAM practices based on practitioner or treatment type (Barnes et al., 2008; NCCAM, 2007): (1) natural products, also called biologically based therapy, (2) mind-body medicine, (3) manipulative and body-based practices, (4) whole medical systems, and (5) energy medicine.
Unconventional mind-body medicine (MBCAM), the primary topic of the present chapter, emphasizes the influence of the mind and mental processes on physical health, behavior, and disease processes. Some examples of unconventional mind-body treatments (MBT) include meditation, relaxation, deep breathing, imagery, and yoga. Almost half of the Americans who reportedly used CAM in 2007 used MBTs; deep breathing, meditation, and yoga were three of the top six CAM treatments (Barnes et al., 2008). There is significant evidence for interactions between the body and the mind within conventional medical research and established scientific disciplines that represent conventional mind-body medicine (MBM). Psychoneuroimmunology, behavioral neuroscience, and behavioral medicine focus on the connection between mental processes, behavior, and health outcomes. Given their popularity and sound scientific basis, it is not surprising that MBTs such as yoga, meditation, and relaxation are considered the most promising and potentially viable treatments researched by NCCAM
MBCAM is popular, it is the focus of research at NCCAM, it is promising from a scientific perspective, and conventional medicine provides a sound scientific basis. Great, it seems as if MBTs are worth the resources (i.e., time, energy, and money) needed for further investigation! Things aren’t always what they seem; but, how can anyone determine whether MBTs are worthwhile without investing more resources than necessary? The current chapter intends walk through the general claims on MBM and the specific claims of MBTs and evaluate those claims without wasting too many resources. First, to familiarize readers with MBCAM, its overall claim will be considered and common MBTs will be described. If the overall claim of MBCAM is unreasonable why waste time evaluating specific treatments? At that point, the second section will pause to discuss what evidence supports MBM and MBCAM’s overall claim and whether it is a reasonable claim. If the claim is reasonable it will make sense to move on the third section to evaluate the basis and specific claims for MBTs. Finally, the conclusions will be discussed, future research directions suggested, and ethical implications considered.
II. Mind-Body Medicine Overview
Throughout recorded history, religious leaders, philosophers, scientists, and politicians have questioned the importance of the intangible mind and physical body as they relate to health and wellbeing. Opinions shift between emphasis on the body, mind, or balance in responsibility between the two. The influence of mind-body dualism, the mechanistic mentality of the industrial revolution, and technological advances in the late 1800s contributed to the development of the biomedical model. This perspective highlighted the role of the physical body and overwhelmingly excluded the role of the mind. However, arguments on both sides of the mind-body debate were strong enough to stand the test of time. Based on a history of human inability to resolve the debate over the influence of the mind on bodily health, it is safe to assume that the overall claim is, at the very least, possible. That is to say, it is possible that the mind and the body both contribute to medical outcomes and that the mind affects bodily health. The next section on scientific foundations considers the support for that overall claim. Meanwhile, MBTs are popular and many people are interested in learning more about them so this section discusses some of the most common MBTs and their specific claims.
III. Mind-Cure and Mental Healing
The idea that the mind is primarily responsible for physical health was fostered by American transcendental movements (Wiel, 1983). The basic claim of mind cure and mental healing is that thoughts and patterns of thinking influence health outcomes such that positive thoughts result in good health and negative thoughts, either by commission or omission, result in disease, pain, and poor overall health. Extensions of transcendentalism include the work of authors such as Bernie Siegel (1986; 1989) and Deepak Chopra (1993). Siegel highlighted the connection between disease and the mind (Cassileth, 1999) and introduced the concept of the exceptional patient (Siegel, 1986). Chopra asserted that perception is reality and people can change reality and health outcomes through positivity and focus (Chopra, 1993). He recommends focusing on the source of pain or disease so that the body can heal itself - a type of mental healing intervention similar to imagery. Furthermore, positivity changes the physical body by balancing physical systems on a “quantum” level. Mind cure seeks to make thoughts and thought patterns more positive through interventions such as mental healing techniques to visualize the physical body curing diseases, the use of positive statements to affirm the self and state personal intentions, through meditation and emotional release techniques (Kaptchuk & Eisenberg, 2001). Christian Science is a blend between mind cure and religious or spiritual practices that bridges the gap between philosophical perspective presented by transcendentalism and the theological perspective behind religion. Furthermore, it asserts that thoughts construct reality and that disharmony with God fuels the illusions of pain and disease (Baker-Eddy, 1914),.
IV. Spirituality and Prayer
Other applications of spirituality and prayer as mind-body interventions assume that mental and psychosocial benefits affect general and specific health outcomes. Spirituality, including religious beliefs, represents an individual’s sense of purpose and the associated belief system regarding the meaning of life. In mind-body medicine spirituality, religion, or faith are not implemented as health interventions; however, some researchers attempt to correlate spirituality or religious involvement with specific health outcomes. Prayer refers to specific, health related requests, gratitude, or praise directed toward a higher spiritual power (Haugen, 2008; Rotan & Ospina-Kammerer, 2007). For the purpose of the current discussion on mind-body practices, prayer is limited to prayers by individuals related to the self and personal health issues. Intercessory prayer offered by others on behalf of people with health issues does not fall within the purview MBM but rather under “frontier medicine” or energy medicine. As an active process, prayer is presumed to have a positive influence any type of health outcome.
Imagery is the mental representation of a sensory experience. Simply put, adults typically use imagery in daydreams, to plan their days, and to remember things. Imagining sights, sounds, smells, tastes, touch, and physical movement can elicit physical and emotional reactions. The three primary types of imagery are diagnostic imagery, mental-rehearsal imagery, and end-state imagery (Field, 2009; Freeman, 2009). During diagnostic imagery, an instructor evaluates an individual’s sensory and emotional descriptions of a current condition or state and uses the preliminary information to decide how to guide later imagery sessions for therapeutic benefit. Mental-rehearsal imagery involves imagining a potentially stressful event and imagining or rehearsing the appropriate responses, then initiating the same imagery when the event actually happens. This technique is used to prepare for a variety of stressful or painful events including day-to-day anxiety, medical procedures, surgery, or childbirth. End-state imagery involves specific images to influence specific physical outcomes such as immune response or arousal. In mind-body medicine, imagery is used alone or in conjunction with relaxation, meditation, hypnosis, or biofeedback.
VI. Relaxation Therapies
Relaxation encompasses somatic or muscle relaxation, as well as cognitive relaxation represented by various types of meditation. Relaxation therapies such as breathing exercises, muscle relaxation interventions, and autogenic training seek to teach individuals to decrease muscle tension.
Diaphragmatic breathing (DB) or relaxed deep breathing is an independent intervention for relaxation; however, it is typically included as an integral step in the other relaxation therapies, meditation, hypnosis, biofeedback, and the physically based practices. DB originated from the scientific understanding of anatomy and physiology. Breathing or ventilation includes inspiration, when air and oxygen enter the lungs and expiration, when air and carbon dioxide exit the lungs (Martini, Timmons, & Talltisch, 2003). A flat muscle called the diaphragm separates the chest cavity from the abdominal cavity and is the most important muscle involved in ventilation (see figure 1). During ventilation, the diaphragm contracts to increase the volume of the chest cavity and cause inspiration. When the diaphragm relaxes expiration occurs. The intercostal muscles between the ribs, several chest and rib muscles, neck muscles, and shoulder muscles serve as accessory muscles during ventilation; however, they increase the volume of the chest cavity by lifting the rib cage. Diaphragmatic breathing encourages deep inspiration, slows breathing patterns, allows accessory muscles to relax, and under normal breathing conditions does not require active muscle activity to facilitate expiration. Basically, fewer muscles contract with less frequency but more oxygen enters the bloodstream. Because DB influences the partial pressure of oxygen in the blood, it can heavily influence activation of the autonomic nervous system, all of which will be discussed in the following sections of this chapter. As an intervention based psychological principles, an individual learns how to initiate DB and practices it daily to increase awareness of breathing or establish DB as the primary breathing pattern. Individuals can also intentionally initiate DB in anticipation or response to physically or emotionally stressful events.
Figure 1. Video of the mechanics of respiration.
B. Progressive muscle relaxation (PMR).
PMR is an intervention designed to train individuals to relax specific muscles voluntarily. The first version of PMR was introduced by Edmund Jacobson in the early 1900s based on his observation that states of relaxation diminished startle responses to loud noises and, later, that skeletal muscle tension influenced the size and speed of involuntary reflex responses (Freeman, 2009). He developed Jacobson’s progressive relaxation therapy (JPRT) to systematically train individuals to recognize muscle tension and eliminate it. Individuals lie down, assume a practice position to contract a specific muscle, remain in that position for several minutes, and observe the sensations associated with the tension during that time. Then, the muscle is relaxed and the sensation of relaxation in the muscle is observed. The final goal is to be capable of relaxation of any muscle in the body without initial tension. Individual muscles in each of 9 muscle groups - including each arm and leg, the trunk, neck, eye area, and speech region - receive attention for 6 to 19 days each. In all, JPRT requires up to 100 sessions over the course of 90 days or more. Joseph Wolpe developed a shorter version to use in systematic desensitization, a counter-conditioning method to decrease fear and anxiety (Mazur, 2002; Bouton, 2007). Unlike JPRT, abbreviated progressive relaxation training (APRT) included more direct instructions for relaxation of muscle groups and the use of stronger tension followed by rapid release and relaxation of each muscle. Progressive muscle relaxation (PMR) is an extension of JPRT and APRT developed in the 1970s. It is the method used most frequently today and requires only 10 sessions.
C. Autogenic training.
A German neurologist introduced autogenic training to induce muscle relaxation through the autonomic nervous system. Unlike PMR, autogenic training does not require an instructor or therapist and is recommended as a self-administered process. People completing autogenic training use imagery to systematically increase awareness of and subsequently address sensations associated with autonomic functions. For instance, people use imagery of heaviness throughout the body to relax muscles and warmth to induce vasodilation. Other types of imagery address heart rate, deep breathing, organ regulation, and blood flow to the brain.
In contrast to relaxation therapies, the various types of meditation utilize cognitive mechanisms to increase parasympathetic activity. Meditation is a calm state achieved through intentional self awareness or self regulation. Meditators let go of thoughts and emotions through concentration, mindfulness, or postures (NCCAM, 2010). Concentrative meditation includes techniques such as transcendental meditation (TM), Herbert Benson’s respiratory one method (ROM), and moving meditation techniques including yoga, tai chi, and qi gong. The objective of concentrative meditation is to focus attention on a repeated sound, image, or activity. Meditators use the object of meditation to refocus when distractions, such as thoughts or external sensations, interrupt their concentration. Conversely, mindfulness meditation involves open consideration of the thoughts and sensations that present themselves at a given moment. Consideration and subsequent release of the thought or sensation occurs without dedicated time or effort and meditators pass nonjudgementally from one observation to the next.
A. Transcendental meditation (TM).
Maharishi Mehesh Yogi separated the meditative aspects of yoga and developed TM which gained popularity in the US in the 1960s (Field, 2009; Freeman, 2009). Robert Wallace, a Maharishi follower, wrote the first peer-reviewed article on TM in 1970 (Freeman, 2009) and initiated academic interest in the technique. The goal of TM is to evaluate consciousness in order to experience progressively higher levels of consciousness and, eventually, experience pure consciousness - the source of all thought. TM involves silent repetition of a mantra, a word or a sound, to free the mind from activity and move beyond thoughts (Maharishi Foundation USA, 2010). Certified instructors lead seven-step courses for beginners followed by weekly sessions, and later monthly sessions. Practice of TM is encouraged twice a day for 20 minutes.
B. Relaxation response (RR) and respiratory one method (ROM).
While studying the interaction between behavior and blood pressure in animals, Herbert Benson developed an interest in TM and started to research the topic with Wallace (Wallace, Benson, & Wilson, 1971). Benson’s later research led him to define the relaxation response as a decrease in the activity of the sympathetic nervous system. Furthermore, he articulated two steps to induce the RR: (1) repetition of a word or sound and (2) passive disregard for interrupting thoughts (Benson, 1997). The ROM is a more detailed technique to achieve the RR. For the ROM, individuals find a comfortable position in a quiet location, close their eyes, relax their muscles, and repeat the word “one” each time they exhale.
C. Moving meditation.
Yoga, tai chi, and qi gong represent forms of moving meditation. Yoga is based on Indian philosophies and seeks to facilitate wellness by balancing the mind, body, and spirit (Taylor, 2009). Such balance involves postures (asanas) and breath control (pranayama) which are the Hatha or physical components of yoga (Yoga Alliance, 2010). Hatha is thought to facilitate meditation and allow individuals to transcend thought. Tai chi originated in China as a martial art adaptation of qi gong (Bottomley, 2009a; 2009b). Both are based on Taoist meditation and seek to balance vital energy (chi or qi) with the principles of Yin and Yang. Like yoga, tai chi and qi gong emphasize concentrative meditation through movements and breathing.
D. Clinically standardized meditation (CSM).
Unlike concentrative or mindfulness techniques, CSM was designed specifically as a clinical intervention for physical or psychological health. Patricia Carrington developed CSM to provide individuals with an easy to learn, unstructured form of meditation with no religious connotations (Freeman, 2009). During CSM, meditators silently repeat a soothing sound but do not connect the repetition to breathing or any other rhythmic pattern. CSM includes a structured system for personal instruction and clinical supervision.
In the late 1770s, Franz Mesmer introduced animal magnetism, the precursor to hypnosis (Dingfelder, 2010; Field, 2009). Mesmer claimed that “an invisible magnetic fluid filled the universe and triggered psychological nervous illnesses when it became imbalanced” (Lilienfeld, Lynn, Ruscio, and Beyerstein, 2010, pp. 100). Relaxation techniques and imagery are presumed to put people in an altered state of consciousness or a hypnotic state. A hypnotic state is further presumed to heighten suggestibility and expectancy associated with healing, allow contact with otherwise inaccessible unconscious perceptions, and allow mental influence over involuntary biological functions (Weil, 1983).
In the 1960s, advances in learning theory, behavioral psychology, and psychophysiology lead researchers to question whether individuals could voluntarily control the automatic and involuntary physiological functions associated with the autonomic nervous system. Research on biofeedback began with the work of Neal Miller, a psychologist at Yale University (Miller, 1969). Biofeedback represents the use of electronic devices to monitor specific physiological parameters and provide patients with informational feedback, typically auditory or visual, with the intent to teach them to control physiological responses (Field, 2009; Rotan & Ospina-Kammerer, 2007; Snyder & Lindquist, 2010; Freeman, 2009). The major types of biofeedback include heart rate variability (HRV), biofeedback, electromyography (EMG) biofeedback, thermal biofeedback, galvanic skin response (GSR) biofeedback, and electroencephalogram (EEG)biofeedback. EMG biofeedback monitors muscle tension as evidenced by the electrical activity in muscles and presumably treats musculoskeletal pain, headaches, incontinence, and respiratory disorders. The redistribution of blood flow is inferred from changes in skin temperature in thermal biofeedback and presumably addresses headaches, hypertension, and other circulatory issues. GSR biofeedback monitors perspiration, an autonomic response associated with anxiety and phobias. Finally, EEG biofeedback seeks to alter brainwaves to address a range of issues from brain injury to attention deficit hyperactivity disorder (ADHD).
X. Scientific Foundations
It is important to establish whether MBM’s major claim is adequate to justify spending time, energy, and, eventually, money on further evaluation of MBTs. The major claim underlying MBM, and thus MBTs, is that the body and the mind both contribute to medical outcomes. Specifically, the psychological or mental processes of the mind can influence the biological structures and processes of the body to contribute to bodily medical outcomes. Based on historical persistence and the wisdom of the ages the claim was deemed possible; however, plenty of things are possible! It is possible that an apocalypse will occur in 12 hours and end civilization, but, as chapter 21 reveals, that is not a likely, reasonable, or plausible. To establish plausibility, it is important to determine whether MBM is consistent with the existing body of scientific knowledge (Sagan, 1996; Shermer, 2002; Kida, 2006). Conventional medicine is based on scientific knowledge so the discussion will begin there.
The larger portion of conventional medicine is concerned with body-body and body-mind medicine. Medical doctors in a wide range of specialties operate on the assumption that biology, expressed through human anatomical structures and physiological processes, is the basis for addressing biological health issues. In the case of psychiatry, body-mind medicine, biology is considered the primary basis for psychological or mental health issues. The role of the mind has traditionally been limited to its influence on mental factors. Psychology, for instance, is the area of conventional medicine associated with mind-mind medicine and it constitutes a very small portion of conventional medicine overall. The claim that the mind can contribute to biological outcomes seems to contradict the scientifically founded assumptions of conventional medicine. Although the overwhelming emphasis on biological factors is apparent in conventional medicine, it does not preclude the contribution of psychological or mental factors, it simply ignores them. In fact, recent synthesis of psychological principles and emerging physiological research provides a strong scientific basis for the mind’s influence on bodily health. The discussion will begin with pertinent body-body and mind-mind principles to provide an adequate foundation for mind-body principles and the larger issue in question - the plausibility of the claim that the mind influences bodily health.
A. The Body
From a physiological perspective, humans are complex organisms made up of many types of cells with many forms and functions. Likewise, groups of similar cells collectively combine to form many types of tissues. Different tissues combine to form organs and groups of organs, or organ systems, are each responsible for specific functions. The respiratory, cardiovascular, musculoskeletal, digestive, urinary, integumentary, reproductive, immune, nervous, and endocrine systems interact to keep the human body alive and healthy. However, if cells fail to function normally, then tissues, organs, organ systems, and the body will also fail. Even complex organ systems depend on the ability of individual cells to function normally and cells require a stable environment to do so. Walter Cannon, the father of American physiology, was the first to describe homeostasis as regulation of the internal environment to maintain stability (Silverthorn, William, Garison, & Silverthorn, 2004). All of the body systems work to maintain homeostasis; and, accordingly protect the body against disease states that arise from disruptions in physiological processes and prepare the body to defend or repair itself from external threats. Although each physiological system contributes to homeostasis, the nervous and endocrine systems monitor and coordinate the functions of the other systems.
The nervous system utilizes an organized network of nerve cells, or neurons, to receive and send electrical and chemical signals (Silverthorn, et al., 2004). The central nervous system is comprised of the brain and spinal cord which receive information from the sensory neurons of the peripheral nervous system and send responses through the efferent neurons of the peripheral nervous system. The efferent division of the peripheral nervous system consists of the autonomic nervous system, responsible for involuntary responses, and the somatic nervous system, responsible for voluntary skeletal muscle control. Homeostasis is primarily mediated through the antagonistic control of the sympathetic and parasympathetic branches of the autonomic nervous system. That is to say, the sympathetic and parasympathetic branches have opposite effects on physiological parameters. In addition to maintaining homeostasis on the cellular level, the autonomic nervous system is responsible for defending against large scale disruptions in normal function such as physical trauma. Sympathetic activity is most frequently associated with the fight-or-flight response, a term that originated with Walter Cannon (Neylan, 1998). The fight-or-flight response is characterized by rapid shallow breathing, increased heart rate, dilation of blood vessels to the heart, arms, and legs, and restriction of blood flow to the digestive system. As the name implies, the fight-or-flight response mobilizes the body to defend again immanent threats or run away. Conversely, parasympathetic activity is associated with the opposite responses - rest and digestion. The limbic system, the brain region associated with emotions, is also involved in autonomic responses on multiple levels.
Aside from maintaining homeostasis, the autonomic nervous system synchronizes its activity with the endocrine system; and, in some cases regulates endocrine activity (Silverthorn, et al., 2004). The endocrine system is comprised of the glands and cells that synthesize and excrete chemical signals, or hormones. Unlike neurotransmitters, the fast-acting chemical signals of the nervous system, hormones are released into the bloodstream to communicate with distant cells and organs. The endocrine glands most important to the present discussion include the hypothalamus, pituitary, and adrenal glands. Another function of the endocrine system includes close coordination with the body’s defense system. The immune system identifies foreign materials or microbes, communicates the need for response, and coordinates the effort to eliminate the intruder. Different types of white blood cells, or leukocytes, are responsible for the activity of the immune system and use chemical signals, cytokines, to communicate.
Structural and functional overlap between the nervous, endocrine, and immune systems are well documented (Silverthorn, et al., 2004). The systems communicate with each other through the same chemical signals and receptors. The nervous system initiates endocrine activity and hormone release, and hormones mediate neural integration. Likewise, neurons and leukocytes release hormones. Some neurons have receptors for cytokines and leukocytes have receptors for neurotransmitters. These common chemicals and receptors allow hormones and regulatory neurochemicals to modify immune responses and the immune system can directly stimulate nervous and endocrine activity. Interactions between the nervous, endocrine, and immune systems are particularly apparent in relation to the body’s stress response.
Hans Selye began to study stress in the 1930s when he noticed that rats had a relatively uniform symptomatic response to a wide variety of traumatic events (Selye, 1936; Neylan, 1998). That is, regardless of the type of trauma - extreme temperatures, physical exertion, poison, surgery, or spinal cord injury - rats developed a common pattern of symptoms. Selye articulated three stages in the progression of the syndrome and later named it General Adaptation Syndrome (GAD)(Barlow & Durand, 2005). An initial alarm reaction occurs as a response to “nonspecific nocuous agents” (Selye, 1936, p32), later referred to as stress. During the second stage, resistance occurs, followed by exhaustion in the third stage. On a physiological level, the hypothalamic-pituitary-adrenocortical axis (HPA axis) is where the structural and functional overlaps between the nervous, endocrine, and immune system are most important (Silverthorn, et al., 2004). When a perceived stressor is detected the sympathetic division of the autonomic nervous system activates the hypothalamus and, to a lesser degree, the adrenal glands of the endocrine system. The hypothalmus is part of the nervous system; specifically it is part of the limbic system, the brain region associated with emotion, learning, and memory. Once activated the hypothalamus releases a neurohormone to stimulate the pituitary gland, which in turn releases a hormone targeted at the adrenal glands. Finally, the adrenal glands release cortisol, a stress hormone. The stress response ends when cortisol reaches the hypothalamus and other structures in the limbic system (e.g., the hippocampus) which inhibit further release of hormones.
B. The Mind
Classical conditioning involves learned involuntary responses or conditioned reflexes similar to the reflexive, involuntary actions of the nervous and endocrine systems. In classical conditioning, an organism learns that a sensory experience (i.e., an object or event) is associated with a particular outcome and responds to the sensory experience in the same way it previously responded to the outcome. In the early 1900s, the work of physiologist Ivan Pavlov provided the most familiar example of classical conditioning. Pavlov’s interest in the digestive system lead him to conduct a series of experiments in which he measured the amount of saliva that dogs produced while they ate. He noticed that after several meals under experimental conditions dogs began salivating before the food arrived. In the case of Pavlov’s dogs, salivation was their involuntary physiological response to the presence of food. After they became familiar with the events that preceded the presence of food, those events elicited the same involuntary physiological response of salivation before the food arrived. In humans, internal physiological events that precede a particular outcome can later elicit an involuntary response. For instance, when increased heart rate or dizziness frequently precede panic attacks a person will come to respond to increased heart rate or dizziness in the same way they respond to panic attacks. Likewise, classical conditioning occurs with emotions, immune responses, and homeostasis. Unlike classical conditioning, operant conditioning acts on voluntary behaviors. An organism learns that a voluntary action is associated with a particular outcome or reinforcer. For instance, people learn to voluntarily put money into a vending machine to get food, a reinforcer. If a vending machine stops dispensing food people stop putting money into the machine.
C. Mind-Body Interactions
The longest standing examples of the mind’s influence on the body include the existence of somatic illnesses. There are numerous cases of spontaneous physiological illnesses that occur in the absence of disease pathology or physical damage. The Diagnostic and statistical manual of mental disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) provides diagnostic criteria for 7 somatoform disorders. Although it is a recent phenomena, the placebo effect probably represents the most powerful example of the link between the mind and the body. The term was coined by a physician named Henry Beecher (NCCAM, 2007). Morphine shortages during World War II lead Beecher to inject soldiers with saline. To his surprise, the saline injections controlled a substantial amount of the soldiers’ pain. Beecher’s later research revealed that belief in a treatment accounted for up to 35% of the therapeutic effects. The influence of the mind and beliefs on treatment outcomes is so pervasive that medical research requires placebo controlled trials to establish the efficacy of treatments such as drugs therapy and surgery. In some cases, it is possible for people to develop placebo addictions and in other cases the effect of the placebo is equal to the effect of the active treatment (Stanovich, 2010). One study demonstrated that participants who paid more money for a placebo pill experienced more pain relief than participants who paid less money.
Beyond the belief and expectancy of the placebo effect, physical changes in the nervous system provide an important link between the mind and body. Anatomical structures and physiological functions that makeup the nervous system can predispose individuals to psychological disorders such as obsessive compulsive disorder (OCD), depression, and anxiety. Likewise, psychopathology and treatment can lead to changes in brain structure and function. In a landmark study researchers found that cognitive behavioral therapy for OCD affected brain function (Baxter, Schwartz, Bergman, Szuba, Guze, & Mazziotta, 1992). Later research found similar therapeutic effects on brain function with depression and phobias (Barlow & Durand, 2005). Psychological experiences and psychosocial factors also influence neurotransmitter activity and the number of neurotransmitter receptors. On a larger structural scale, stress, post traumatic stress disorder (PTSD), and depression are associated with decreases in the size of the hippocampus (McEwen, 1999; Duman, 2004; Heim, Plotsky & Nemeroff, 2004). As mentioned earlier, the hippocampus is instrumental in ending the stress response; however, damage after long term exposure to stress hormones also causes decreased sensitivity and diminishes hippocampal control of hormone secretion. Furthermore, studies conducted on monkeys indicate psychological factors such as sense of control and predictability of events moderate the secretion of stress hormones and alleviate some of the more negative long term effects (Barlow & Durand, 2005).
Psychological and social factors not only influence the structure and function of the nervous system but also physical health and disease processes. Research in health psychology indicates that psychological factors such as sense of control, coping ability, personality type, and stress influence hypertension, heart disease, and chronic pain. Still, the primary focus of recent research revolves around the interaction between the stress response, psychological factors, and the immune system. In the 1970s researchers gave rats sweetened water followed by an injection of an immunosuppressant drug (Ader & Cohen, 1975). Days later they gave half of the rats regular water, half of the rats sweetened water and exposed all of the rats to foreign cells to elicit an immune response. The rats that received the sweetened water along with the foreign cells experienced diminished immune activity similar to the effects of the immunosuppressant drug; but, the rats who received the regular water experienced normal immune responses to the foreign cells. The results indicated that the rats’ immune systems were susceptible to classical conditioning. Since then, a mounting body of research indicates that classical conditioning can cause increases and decreases in immune responses (Bouton, 2007; Barlow & Durand, 2005; Silverthorn, et al., 2004). Cognitive behavioral stress-management programs are associated with changes in immune responses to and HIV and AIDS (Barlow & Durand, 2005). Psychotherapy and stress management programs can influence the progression cancer and immune responses to chemotherapy.
Emphasis on the biomedical model is softening based on converging evidence for interactions between the mind and the body. Anatomical structures and physiological processes combine to form and animate the human body. The structures and processes responsible for psychological factors influence the anatomy of brain regions and the biochemical processes in those regions. Likewise, the systemic activity associated with general bodily functions influences the rate and occurrence of the biochemical reactions required to initiate thoughts or cognitions, emotions, and personality trait dimensions of cognitions. Conventional medical wisdom acknowledges that damage to physical processes and structures of the body alters the expressions of the mind and mental life. Likewise, psychological trauma alters the physical processes and structures of the body. The mind and body necessarily operate as two parts of a whole and the mind is a causal factor in bodily health. MBM’s overall claim is plausible but is it plausible to claim that specific MBTs contribute to medically significant outcomes?
XI. Scientific Evaluation and MBTs
The majority of the interactions between physiological systems came to light because of scientific research generated in light of mind-body phenomena. Research in psychoneuroimmunology led to an evolving conception of nervous and endocrine processes as a continuum rather than separate systems (Silverthorn, et al., 2004). Furthermore, it was primarily responsible for much of the physiological body of knowledge pertaining to structural and functional interactions between the nervous, endocrine, and immune systems, particularly the HPA axis. Active, serious research in MBM is evident in multiple disciplines within the scientific community and virtually all medical research includes controls for the placebo effect, another mind-body phenomena. Still, the specific mechanisms behind the MB relationship are a mystery and science has more questions than answers.
Prior to this point in the chapter MBM and MBCAM were not used synonymously; however, little was done to highlight the distinction between the two. At this point, it is important to do so because the evidence provided in the previous section was all valid, theory driven research and fell well within conventional standards. Although the content of the previous section provides a strong theoretical basis for MBCAM and the MBTs discussed previously, it is not always used to generate MBCAM research. That is to say, MBM is associated with conventional medicine and with scientific evaluation but MBCAM is not. As such, MBM research attempts to unravel the mysteries and answer the questions that current theory and knowledge do not address pertaining to the relationship between the mind and the body. To accomplish that goal, MBM research uses valid, well documented theories to make predictions about the mechanisms that underlie MB phenomena. Furthermore, MBM research is designed to isolate the components of MBTs that contribute to specific medical outcomes. There is significant confusion regarding the whether some MBT’s are conventional or unconventional. Of those MBTs with strong theoretical basis for a given purpose, there is weak to no theoretical basis for use of the same MBT for the purposes investigated by MBCAM. Therefore, much of MBCAM research is counter-theoretical, atheoretical, or loosely based on theory. For instance, biofeedback was born out of sound theory driven research, and has demonstrated replicable effects for conditions such as urinary and fecal incontinence, migraine headachs (Wahbeh, Elsas & Oken, 2008), and a number of stress-related ailments. For these purposes, biofeedback falls within MBM. However, regarding asthma, temporomandibular joint disorder, or circulatory syndromes. In those instances, theory fails to support the use of biofeedback, as does the resulting research. Confusion between proven and unproven applications may be misleading researchers and consumers but why is theory driven research important in the first place?
It is important that well established theories drive research and an instance within conventional body-body medicine provides an excellent example to illustrate this point. By the early 1870s, scientists had stumbled upon successful treatments for diseases and even a vaccine for smallpox before they had any idea what caused disease (“Bloodletting”, 1871; Tortora, Funke, & Case, 2003). Scientists knew that microscopic organisms existed but most people believed that gods and demons caused diseases to punish people for their sins. It would have been absurd to think that tiny organism, undetectable to human eyes, caused diseases. Despite popular beliefs, the German doctor Robert Koch suspected that the microorganisms caused a fatal disease in the cows when he observed rod-shaped organisms in the blood of sick cows but not in the blood of healthy cows (Tortora, Funke, & Case, 2003). Koch knew that his outrageous claim would be difficult to prove without careful planning so he devised a series of experimental procedures, later known as Koch’s postulates, to test his suspicions. He identified and cultured bacteria from the blood of a dead cow and injected the live bacterial culture into a healthy cow. When the cow died, he isolated the bacteria and compared the second culture to the first. Koch replaced gods and demons with a method that isolated the cause of the disease. Koch’s germ theory of disease provided a theoretical basis for scientists to systematically isolate and investigate infectious diseases. Knowledge of the actual cause of disease exponentially expanded medical horizons and allowed for inferences that were not possible otherwise. Theory tells researchers what direction to shoot in and it illuminates the likely target. If the research results miss the target, researchers know that they need to rethink their shooting skills (i.e., research design and methodology) or they know something is wrong with the theory.
When MBCAM treatments are founded on unscientific theory the associated research shoots haphazardly in all directions. To avoid wasting resources on research or further evaluation of MBTs that lack theoretical merit the discussion will turn to example from the MBTs discussed earlier. Deepak Chopra and Bernie Siegel are proponents of mind-cure and mental healing. As mentioned previously there theoretical basis lies in philosophical and theological theory rather than scientific theory. Deepak Chopra’s scientific jargon seems to claim that quantum theory is the basis for his mind-cure and mental healing (1993). Physics is complicated and quantum physics in particular is incredibly complex. Chopra provides relatively simplistic explanations of complex aspects of quantum physics that the uninformed observer can easily misinterpret. In an interview with Richard Dawkins (2007; also see figure 2), Chopra claims that changes in consciousness cause changes in biology on a quantum level and that quantum physics proves that we construct our own reality. Later in the interview, he admits that quantum theory actually provides a metaphor rather that a theoretical basis for his ideas. Bernie Siegel began as a surgical oncologist who noticed some exceptional cancer patients (E-Caps) took responsibility for their own health and their outlooks on life remained positive despite adverse circumstances (Siegel, 1986; 1989). Later research failed to substantiate Siegel’s observations (Cassileth, 1999), likely because his claims were based on inaccurate personal observations rather than theory. Transcendental meditation, moving meditations (e.g., yoga, tai chi, and qu gong) and hypnosis follow similar patterns with theoretical origins based in religious, philosophical, and cultural perspectives rather than scientific theory. CSM and ROM are other forms of meditation adapted from sound theoretical perspectives; however, these along with relaxation therapies suffer from another problem that seems to plague MBCAM research compared to MBM research.
Figure 2. Dawkins interviews Chopra
Although mind-cure and mental healing catch the attention of few professionals, MBTs such as hypnosis rely on an inadequate theoretical basis but have received significant attention within conventional medicine. As mentioned previously, hypnosis was founded on the idea that imbalanced magnetic fields cause poor health. In what was arguably the first psychological study (Dingfelder, 2010), Benjamin Franklin conducted studies on animal magnetism in which some participants were unknowingly exposed to Mesmer’s treatment while others believed they were exposed but received an active control or placebo treatment. The patients who believed they were treated responded as such while those who were unaware of the treatment showed no signs of treatment. The only active element of Mesmer’s treatment was the placebo effect. Likewise, later claims suggested that hypnotic states were the result of altered consciousness, heighten suggestibility, allow access to unconscious perceptions, or contribute to mental influence over involuntary biological. Beyond the effects of the active relaxation techniques and imagery used to induce hypnotic states, research indicates that the only remaining therapeutic value is derived from the placebo effect (Lilienfeld et al., 2010).
Researchers concluded that an altered state of consciousness did not cause the other outcomes associated with hypnosis because relaxation and imagery, combined with placebo effects, accounted for all but an insignificant portion of the effects. As mentioned earlier and illustrated by Koch’s example, conventional research is designed to isolate the causes of specific medical outcomes. Additionally, the goal of MBM is to treat and cure diseases while MBCAM seems to focus more on “healing” rather than “curing”. This highlights an important distinction between conventional (i.e., MBM) and unconventional (i.e., MBCAM) (Achterberg et al., 1992). That is to say, MBCAM focuses on improving how patients feel rather than improving overall health by eliminating diseases and pathological states. MBM seeks to determine the aspects of specific treatments significantly contribute to outcomes and analyze how much of the outcome each aspect accounts for. With this view in mind, it is important in conventional research to determine a baseline for how often an outcome occurs naturally in the population. This can be achieved with the inclusion of an inactive or waitlist control group that does not receive any treatment whatsoever. Furthermore, research that is internally valid and controls for any other foreseeable contributions to the treatment outcome other than the treatment itself. That is to say, it includes an active control group or a control group that receives a believable but inert placebo that is comparable to the treatment itself. This ensures that any significant outcome can be traced to the treatment only. Although the definitions for MBTs seems straight forward, significant overlap exists between them. For instance, relaxation is a major theme underlying the majority of the practices outlined below and relaxation interventions are used in the practice of meditation, hypnosis, biofeedback, and yoga. Furthermore, many of the practices are actually combinations of other mind-body practices. Imagery is an excellent example of this type of overlap because it is a foundational part of relaxation interventions, several types of meditation, hypnosis, and is instrumental for biofeedback. It is difficult to determine, for example, if treatment outcomes associated with biofeedback are the result of deep breathing, imagery, or the actual biofeedback intervention itself because biofeedback as a whole includes more than one treatment.
With few exceptions, MBTs include deep breathing in some capacity. Deep breathing is the most parsimonious alternate explanation for the perceived success of many MBTs. As mentioned earlier, tissues, organs, organ systems, and the body fail to function normally when cells fail to function normally. Oxygen is essential to every cellular process. Cells die quickly if they are unable to exchange oxygen and carbon dioxide with the blood. Therefore, cellular respiration is of primary importance to homeostasis; and, the autonomic nervous system is highly sensitive to factors that threaten cellular respiration. Accordingly, much of the balance between sympathetic and parasympathetic activation depends on changes in ventilation, as well as the amount of oxygen and carbon dioxide in the blood. DB may independently account for a variety of autonomic responses because it addresses a number of regulatory markers used by the autonomic nervous system (Jerath, Barnes, & Jerath, 2006). For instance, increase in oxygen levels in the blood is known to account for drops in blood pressure, heart rate, and other autonomic responses. Therefore, the autonomic responses attributed to imagery, relaxation therapies, meditation, or hypnosis may simply be the result of inclusion of DB in those treatments.
The emphasis on healing vs. curing distinguishes MBCAM from MBM in that it leads them to use different criteria to determine what type of outcomes indicate that a treatment was successful. MBCAM stresses the healthcare process and outcomes that indicate that patients feel like they are better. MBM stresses outcomes that are measurable, objective, and account for a significant portion of the overall therapeutic effect, outcomes that indicate that patients are in fact better. This is an important distinction between the two because it predisposes MBCAM to pay less attention to differentiation between effective and ineffective aspects of a treatment and, more importantly, to the magnitude of placebo effects. So, MBCAM research frequently fails to randomly assign participants to experimental and control groups, favors waitlist or inactive control groups over active control groups. If participants showed significant improvement compared to the population baseline (i.e., an inactive control group), then they achieved successful outcomes because they feel like they are better. As a result, none of the many of MBCAM research reviewed in the present chapter included a DB control group to determine whether the effects of a given treatment were caused or significantly mediated by DB. Additionally, many MBCAM studies omitted adequate controls for the placebo effect so it is unclear whether the treatment worked or whether the placebo effect worked.
Given that the overall claim of MBCAM treatments are reasonable, why have conventional methods consistently produced a larger quantity of higher quality results? One possibility is that conventional medicine adopted a formal method of inquiry to question informal observations, common sense, and traditional practices. MB phenomena provide valuable contributions to the scientific body of theory and knowledge. Failure to apply conventional approaches to seemingly trivial treatments, such as deep breathing or imagery, may not seem to limit future research as much its application in epidemiology. Advances in fields such as psychoneuroimmunology contradict that perception in that conventional approaches to MB phenomena led to important contributions to scientific theory and knowledge. The unconventional research methods utilized by MBCAM limit the potential for MBTs to make meaningful contributions to theory and knowledge. More importantly, failure to identify the factors that underlie disease or treatment processes can not only discourage productive research but also inadvertently harm patients.
What we have learnt from the experience of the last few years is, that a great number of cases which our predecessors thought and taught would die without blood-letting, may be spared the operation and yet live; and also, that many of the severe symptoms and risks in these cases were in reality the symptoms and risks arising out of loss of blood. The value of such knowledge is inestimable - greater than has been contributed by an experience of the last two centuries; but, like all good things, it is capable of being misapplied…. And it is a still worse misapplication to condemn a treatment as doing no good because it does some harm or to assume that the harm outbalances the good. (“Bloodletting”, 1871, pp. 283)
Doctors administered bloodletting as a therapeutic intervention for thousands of years. Its familiarity as a conventional medical practice was so well established that doctors continued to use the treatment even when evidence indicated that it was harmful. The author of the above quote proceeded to defend the continued use of bloodletting despite his own acknowledgement of the risk to patients. Furthermore, he later reassured the reader that the procedure was the most convenient, fast-acting, and measurable; and, to the trained professional, the benefits were consistently and definitely apparent. As in the case of bloodletting, the distinction between scientific evidence-based practice and unproven, untested practices can be the difference between life and death. Although it is difficult to imagine meditation or relaxation therapies as life and death decisions, they could have unanticipated negative effects.
Various types of psychotherapy, for instance, are generally considered beneficial or at worst ineffective (Lilienfeld, 2007). However, psychotherapy can have harmful effects such as exacerbation of existing symptoms, further unnecessary deterioration, emergence of new symptoms, and physical injury (Barlow, 2010; Lilienfeld, 2007). For instance, critical incident stress debriefing (CISD) is a therapeutic technique administered one to three days after a traumatic event that puts individuals at risk for post traumatic stress disorder (PTSD) (Lilienfeld, 2007). A therapist encourages traumatized individuals to share their negative emotions and PTSD symptoms. It seems like a harmless and intuitively valid treatment; however, CISD following traumatic events can actually cause increases in later symptoms PTSD symptoms (Barlow, 2010; Lilienfeld, 2007). Similarly, in certain populations, grief counseling and behavioral interventions for troubled adolescents can actually cause more long term problems. Potential harm is not limited to those receiving psychotherapy but to their loved ones as well. More along the lines of MBM therapists used hypnosis to access traumatic memories that were presumed to be inaccessible during conscious states. As mentioned earlier, a hypnotic state is not actually an altered state of consciousness. Despite controversy over that piece of information, therapists used hypnosis to recover “repressed” memories. Use of hypnosis, a treatment with inadequate theoretical basis and questionable support, led to recovery of false memories in many patients (Lilienfeld, 2007). Family and friends were falsely accused and some falsely imprisoned. Likewise, some populations experience increased anxiety and even panic attacks during progressive muscle relaxation and meditation (Lilienfeld, 2007). Regardless of how harmless a treatment may seem, these examples demonstrate that scientific evaluation is necessary to objectively determine the safety, usefulness, and the circumstances under which they are most or least effective. Even seemingly innocuous treatments can have terrible consequences. Which leads to the next point regarding the placebo effect. By omitting adequate controls for the placebo effect MBCAM seems to condone its inclusion as part of a therapeutic outcome; however, there may be unexpected harmful effects associated with the placebo effect as well (see Box 1)
Should the placebo effect be prescribed?
Some people benefit from placebo effects and the perceived beneficial effects of many medical treatments are mediated by placebo effects. A treatment is ineffective when placebo effects account for all but an insignificant portion of overall treatment effect. Ineffective treatments should not be used or endorsed in conventional medicine or CAM. Some people argue that the placebo benefits from ineffective treatments justify their acceptance (i.e., use or endorsement) when there are no associated health risks. That argument is based on the inaccurate assumption that we are aware of the entire range of potential effects of the placebo effect. Furthermore, the absence of health risk is not sufficient to justify acceptance because there are a number of risks and ethical considerations that do not directly relate to the health of those who utilize ineffective treatments.
Acceptance of ineffective treatments can lead people to forego effective preventative treatments and miss opportunities to take advantage of effective cures. Reduction of obvious symptoms without addressing the underlying cause can give people a false sense of security that they are cured. Such placebo mediated reductions may obscure the severity or progression of a disease until permanent damage occurs or invasive procedures are required. Placebo induced relief of back pain following chiropractic care and inaccurate causal explanations of residual pain from a chiropractic rather than medical perspective can hide the progression of degenerative disk disease until surgical procedures are necessary. More importantly, the placebo effect is actually a complex phenomena that science does not fully understand. Reactions to similar placebo conditions vary due to characteristics of the placebo, situational factors, and individual differences. For example, cost and context of administration are situational factors that influence the type and magnitude of placebo reactions. Differential reactions and underlying physiological mechanisms have been observed in response to the same type of placebo and the differences appear to depend on the individual perceptions of the patient regarding the purpose of the treatment.
Popular acceptance of a number of ineffective CAM treatments is evidenced in America by prevalence of use within the general population, inclusion in education programs for healthcare professionals, and amount of revenue generated by CAM practitioners and CAM products. Populations with insufficient education and poor critical thinking skills are particularly susceptible to confusion over the difference between popular acceptance and efficacy. Familiarity and popular acceptance obscures the distinction between effective and ineffective treatments and leads to unwarranted reallocation of public and private resources to ineffective treatments. Popular misconceptions about the potential efficacy of CAM led politicians to open the national center for complementary and alternative medicine (NCCAM). After more than a decade and millions of taxpayer dollars, there is still no scientific support for the CAM practices under investigation at the NCCAM. The public funds allocated to the NCCAM to research ineffective treatments could go toward research to improve effective treatments, investigate underfunded rare diseases, or any number of worthy programs. Likewise, individuals who lack the education to distinguish efficacy from popularity are susceptible to spend their own money on ineffective treatments rather than useful goods and services. Perceived success of such treatments from placebo effects may encourage them to take financial risks on future scams and fraud.
Box 1. Excerpt from Wiegman, 2010
Theory driven scientific research on MB phenomena like psychoneuroimmunology led to drastic changes in recent understanding of research methodology and physiological processes that are changing the face of medicine. Good support exists for several MBTs and those that lack support are becoming more apparent. Still MBCAM treatments under research at the NCCAM suffer from weak methodology and poor design. Because of these factors, there no firm conclusions can be drawn from the results of the NCCAM’s research. furthermore, When approached scientifically, well directed future research on MBTs has tremendous potential; however, tapping into that potential requires careful consideration of the ethical implications and cost to benefit analysis.
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