Q J Med 2003; 96: 617-621
© 2003 Association of Physicians
Editorial |
The emotional dimension and the biological paradigm of illness: time for a change
Physicians love numbers and pictures of their patients. They make clinical problems more tangible, and decisions less complex and uncertain. Consider an elderly man with haemoglobin 9 g/dl and mean corpuscular volume 70 fl, a woman who has had a myocardial infarction, and has an ejection fraction of 25%, or a jaundiced patient whose common bile duct is dilated to 13 mm on abdominal ultrasound. Immediately the differential of iron deficiency anaemia, the many therapeutic approaches to ischaemic dilated cardiomyopathy, or the causes of painless common bile duct obstruction, come to mind. However, data that cannot be easily quantified, imaged or brought under the microscope are all too often neglected. Yet psychological factors contribute significantly to the pathogenesis of medical illnesses, affect their course and may be a target for effective intervention.Does the patient suffer from depression, anxiety or stress? Is the patient hopeful, optimistic? Is the patient alone, or supported by family and friends? Even, is the patient a believer in higher being?1 These and other related questions, which may be elicited by the history or by using simple structured questionnaires, are often ignored, disregarded, or given only fleeting consideration. There may be many reasons for this neglect. Assessment of these ‘invisible’ variables is more personally demanding and time-consuming than the mere ordering of a test. Furthermore, since many physicians are not aware of the full significance of psychosocial factors, they are not highly motivated to consider and evaluate them. Since the importance to the patient of empathy, support and hope is not fully appreciated, physicians may fail to adequately provide these essential qualities.2
Almost all of the physician’s education is biologically-oriented, perhaps more so in the current era of spectacular advances in medical technology and capabilities. Indeed, the recent edition of the popular Harrison’s ‘Principles of Internal Medicine’ devotes much less than 1 of its 2960 pages to non-biological effects of medical illness, and hardly anything at all is said on the possible effects of emotions on disease outcomes. When genes can be identified and studied, when almost every nook and cranny of the human body can be visualized by varied imaging techniques and accessed, when minute alterations in biochemical and immunological markers can be exposed and followed, and complex haemodynamic variables easily and accurately monitored, it is hardly surprising, perhaps, that the patient’s feelings, values and beliefs may be downgraded to the bottom of the problem list, or even omitted altogether.
Nevertheless, research interest in the psychosocial and behavioural aspects of medical illness is rapidly growing, particularly over the last decade,3 and extensive data has accumulated, supporting a bi-directional relationship of high clinical significance. Depression, for example, can be found in about 25% of patients who have had unstable angina, myocardial infarction, CABG surgery or stroke.4–7 In these patients, depression inhibits recovery, greatly increases the likelihood of cardiac events (OR 2–5) and is an independent predictor of mortality even years later, with an impact that is equivalent to that of left ventricular failure.4–6 The risk is proportionate to the severity of depression.8,9 In healthy subjects too, depression appears to be a highly significant risk factor for coronary artery disease (CAD).10,11 Yet it is often unrecognized and under-treated.6,7
Other ‘emotional’ factors such as anxiety,12 hostility,13 social isolation14,15 and acute16–19 or chronic20–21 life stress have also been convincingly linked to cardiac morbidity and mortality in CAD patients and healthy subjects alike.22 This association is supported by classical animal studies23 and extensive pathophysiological data. Direct sympathetic nervous system stimulation and hypothalamic-pituitary-adrenal axis activation have central deleterious roles, leading to impaired vagal control, endothelial injury, platelet activation, and myriad immuno-modulatory changes.22–26 Adding to the detrimental effect are unhealthy lifestyle behaviours and poor motivation to seek medical advice and to comply, which can often be found in these patients.27 Several psychosocial variables also tend to ‘cluster’ together, resulting in a substantially increased risk.22 As an example, recent bereavement or severe fright (after an earthquake or terror attack),16–18 as well as minor daily episodes of emotional stress,19,28,29 can cause acute myocardial ischaemia and subsequent cardiac events (OR 2.8).28 When social isolation is added to significant life stress, the risk may be doubled.9,30,31
The impact of psychological and social factors on disease outcomes extends far beyond atherosclerotic cardiovascular disease. Depression and distress are also common in patients with diverse chronic conditions and in caregivers,21,27 and are associated with adverse outcomes in diabetes, collagen diseases, heart failure and even breast cancer.32–38 Earlier reports already indicated that adverse psychological responses to cancer such as helplessness or hopelessness, may predict increased relapses.38–41 Arguably the most intriguing observations linking emotion and survival showed a dip in mortality rates before important meaningful occasions, and a rise in Chinese patients when disease coincides with an ‘ill-fated’ year according to tradition.42 Prospective studies also reveal that stressful life events may increase the likelihood of recurrence of breast cancer,43 and affect susceptibility to varied viral infections44–46 and autoimmune diseases.47–49 These observations may be mediated by modulation of cellular immune responses associated with stress and depression.3,39,50
Thus, feelings may contribute to the pathogenesis of medical illnesses; illness evokes an emotional response, which affects disease outcomes. To ignore this bi-directional relationship today, is to deny a considerable body of evidence. Is it also a missed opportunity to intervene? A landmark study by Spiegel et al. demonstrated a marked survival benefit in metastatic breast cancer patients randomized to weekly supportive group therapy over one year.51,52 Although these findings remain controversial,53,54 the improvement in mood, stress and quality of life associated with psychological interventions is consistent and important in itself.55,56
What about interventions in cardiovascular diseases, an area where mind-body interactions have been particularly well studied? Several quite impressive results have been reported. Hypertensive patients assigned to a stress management program achieve a significant reduction in both blood pressure and carotid artery intimal-medial thickness, a measure of atherosclerosis57,58 that increased in controls. Furthermore, four long-term controlled studies that randomized 1478 CAD patients to a program of lifestyle changes centered on stress management (or alteration of type A behaviour) in addition to usual care, demonstrated remarkable benefits: about 50% reductions in cardiac recurrences were observed, associated with a similar decrease in ambulatory myocardial ischaemia and ~8% regression in coronary diameter.59–62 Controls, who received usual medical care alone, had significantly more events and showed a 28% increase in coronary diameter. The intervention group also had a concurrent improvement in psychological indices. Interestingly, in two randomized studies where psychological improvement was not achieved, no cardiac benefits were observed.63 Thus, emotional factors are increasingly recognized as established cardiovascular risk factors, which interact synergistically with conventional CAD risk factors.22 Psychosocial evaluation and interventions have already been incorporated into the American Heart Association Core Components of Cardiac Rehabilitation/Secondary Prevention programs,64 its effect extending to an improvement of glycaemic control in diabetes.65
Cognitive behavioural stress management or exercise programs also seem to improve immune status.66 An unusual study was recently reported: asthma or rheumatoid arthritis patients were randomized to write briefly about their most stressful life experience or an emotionally neutral subject. The intervention group had objective and clinically significant improvements in disease markers (lung function, or overall rheumatic disease activity, respectively), whereas control patients remained unchanged.67 Many other advantages may ensue, pending further verification. A program of active social engagements may prevent or delay cognitive decline in old age,68 and behavioural treatments decrease disability in patients with chronic low back pain.69 Impressive reductions in medical costs may add a dimension to the use of psychosocial interventions.62 When 952 patients with chronic diseases were randomized to receive a handbook and several group sessions focusing on developing skills to cope with symptoms and emotions, they showed significant improvement in exercise time, fatigue, disability and self-reported health distress, compared with wait-list controls. They even achieved fewer hospital admissions and shorter time at hospital at 6 months, saving more than 10 times the cost of the program per participant.70
On the whole, these results strongly reaffirm the significance of emotional factors in diverse medical illnesses, and suggest a promising approach that complements current treatment modalities. Providing empathy, hope and support, treating depression and initiating behavioural medicine interventions are all relatively simple to administer, brief, inexpensive and safe.71 Above all, they have proven efficacy and power to improve patient’s health. It is intriguing to discover in randomized controlled trials that this improvement often extends beyond the subjective, even though the attainment of less distress, better mood and better function is in itself an admirable goal, affording a substantially better quality of life for the patient. Compliance and adherence to medical recommendations will often follow, and moreover, improved autonomic nervous system function and neuroimmunological mechanisms can be expected.3 Thus, ‘hard’ biological end points can be achieved by ‘low tech’ behavioural interventions. This should be further studied in large-scale controlled trials, but the time has come to move evidence-based health and behaviour research into practice.72
Three significant limitations of the outlined premise need to be considered. First, the scope of this editorial does not allow for a discussion of the methods used in the studies reported on. However, only data that are based on well-controlled (mostly randomized) trials are cited. Second, it should be noted that some studies failed to show significant positive results. This is particularly true of the effect of psychosocial support on cancer progression, especially breast cancer.53,54,73 Even in the field of atherosclerotic cardiovascular disease, where most of the evidence favours the impact of non-biological variables on the pathophysiology of disease and of behavioural interventions on the outcomes of care, a few studies yielded negative findings.22,63 Nevertheless, the overall data showing positive findings is substantial and impressive enough to warrant at least a change in attitude and further research effort. Third, it is doubtful whether these few negative studies are the reason why the growing body of literature that connects psychosocial factors with biological and functional outcomes is ignored by mainstream medicine. One explanation may have little to do with the scientific evidence. It is a simple fact that insurers in the US still do not pay for the majority of cognitive services, inexpensive as they may be. Another explanation is that health care professionals are so captivated by the prevailing biological paradigm that little room is left for any alternative thought, even when it is supposed to take its place side by side with the current paradigm, not replace it. A change in this paradigm and better-informed economics of medical care, is the hope behind this editorial. Lack of time may be another reason. However, our preliminary results suggest that patients' demands on physicians’ time are very reasonable, and that a lot of meaningful contact and empathy can be accomplished in very little time. In fact, incorporating the psychosocial paradigm into patient care may prove to be cost-effective,71 and its economic aspects need to be investigated.
In conclusion, mind-body interactions are too important to be disregarded. Emotional problems are common components of medical illness, have a substantial adverse effect on its course and outcome, and may be modified to the patient’s advantage. The purely biological paradigm of disease must be reformed to recognize, admit and emphasize the ubiquitous impact of emotional factors. Psychosocial aspects should be carefully considered during each patient-physician encounter. More research should be devoted to define practical methods of assessing patient’s feelings, and identify effective interventions. Meanwhile, all physicians should be well aware that medical illness has another side to it, and consider ‘invisible’ psychological factors as an inseparable, important and modifiable part of their patient’s illness.
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Hadassah Medical School Jerusalem e-mail: amimd{at}clalit.org.il
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