Mindful medicine: New images of an old idea
■ Medical research, using cutting-edge technology, is showing just how the mind can cause health woes for the body.
The link between emotions and health was first detected by Hippocrates and his followers, and it has maintained its staying power over the centuries. For example, a few weeks ago, it caused James Applegate, MD, a family physician in Grand Rapids, Mich., to change the focus of an exam when a patient said she was in the midst of a divorce.
"She had come in for another problem, but we spent the whole visit talking about how she's dealing with the divorce," he said.
He had started with his usual question -- a simple question -- but one tailor-made to elicit a patient's emotional state: "How are things going?" If the response is negative, "You drop your pencil and you focus on that," he said.
"It's hard to get people really well," Dr. Applegate said. "You can improve cholesterol and blood pressure, but you can't get them really, really well until they are in a good place. And that's what you need to focus on."
This quest for a "good place" may be one that is joined by many other physicians as new research findings show just how turmoil in the mind can wreak havoc on the body. Advances in imaging technology and hormone measurements are demonstrating the damage as it occurs.
"The idea that the mind affects the body is a very old one," said William Lovallo, PhD, professor of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center. "And it's also true this has been an enormously difficult proposition to prove scientifically."
But over the past 25 years, evidence of the connection has been building slowly in a positive way, he said. Even more recently, the increased emphasis on brain science in general, using both animals and humans, also has provided insight, he said. Specifically, new understandings of how genes work to affect brain function and new imaging techniques have been able to capture some of the action.
Despite this forward momentum, Dr. Lovallo would draw the line at saying that emotions can cause major illnesses. "I think we are on safer ground saying that emotional states can modify processes that might be going on anyway."
Even less certainty exists that a positive state of mind is going to have a beneficial effect, he cautioned. "But anecdotally, we all know people who tend to be positive, upbeat and happy and appear to be in very good health. But that's more anecdotal than real," Dr. Lovallo said.
On the research front
Meanwhile, science has advanced an impressive trove of data showing that emotions can have an impact on headaches, insomnia, weight gain or loss, cardiovascular disease, asthma and even the effectiveness of cancer treatment.
Dr. Lovallo's research is on the stress hormone cortisol, which, while necessary for life and a core component of the body's response to stress, also can cause harm. "We are learning increasingly large amounts about how cortisol feeds back to the central nervous system and affects brain function," he said. "And we know that cortisol has a long-term effect on memory and that large amounts over long periods of time can actually damage memory structures in the brain."
Additional research is linking stress, depression and cardiovascular health. Elizabeth Bradley, PhD, a professor of public health at Yale University School of Medicine in New Haven, Conn., for 10 years followed a large number of older men and women who had either been fired or laid off from their jobs. She and her colleagues found that involuntary job loss near retirement age more than doubled the risk of heart attack and stroke compared with those who remained employed.
Mary A. Whooley, MD, an associate professor of medicine, epidemiology and biostatistics at the University of California, San Francisco, urged treatment of depression for patients with coronary heart disease in a Grand Rounds article in the June 28 Journal of the American Medical Association. "Evidence from observational studies suggests that depression independently predicts incident coronary heart disease events, congestive heart failure and adverse outcomes among patients with established cardiovascular disease," she writes.
Although the fact that stress leads to health trouble is widely accepted, how that could occur has remained a mystery. But recently, researchers discovered that prolonged stress contributes to cellular aging and could cause the premature development of a variety of diseases.
The mechanism by which this could occur centers on the effect of stress on the length of telomeres, which are DNA-protein complexes that cap the ends of chromosomes and promote genetic stability. Telomeres also play an important role in the number of times a cell divides, as does telomerase, an enzyme that replenishes telomeres with each cell division.
Elissa Epel, PhD, an assistant adjunct professor of psychiatry at the University of California, San Francisco, found that women who cared for chronically ill children were more likely to have shortened telomeres than were women who had healthy children. Women in the study who perceived that they were under a great deal of stress also had the greatest impact on the length of their telomeres and production of telomerase.
Dr. Epel worked with Elizabeth Blackburn, PhD, professor of biology and physiology at UCSF, on the study. Dr. Blackburn was a winner of the 2006 Lasker Award for Basic Medical Research for her work with telomerase.
Although studies have demonstrated a link between chronic psychological stress and impaired health, including cardiovascular disease and weakened immune function, Dr. Epel's finding, published in the Nov. 30, 2004, Proceedings of the National Academy of Sciences, suggested a mechanism for the onset of disease.
Anecdotal and scientific evidence has suggested that chronic stress can take years off your life, and the implications of the study are that this is true, at least at the cellular level, the researchers said. Dr. Epel and colleagues are now conducting a long-term study to see if the findings stand up.
Another mind-body connection was demonstrated by a team of University of Wisconsin-Madison researchers looking at asthma and its connection to stress. They found that the mere mention of certain stressful words activated two brain regions in asthmatics.
Using functional MRI, the researchers scanned the brains of six mildly asthmatic people who were asked to inhale ragweed or dust-mite extracts. Subjects were then shown three types of words: asthma-related, such as wheeze; non-asthma-related but negative words, such as loneliness; and neutral words, such as curtains.
The researchers found that asthma-related terms stimulated responses in the anterior cingulate cortex and the insula that were strongly correlated with measures of lung function and inflammation. The other words did not elicit the same response.
The two brain structures are involved in transmitting information about the physiological condition of the body, such as shortness of breath and pain levels, and they have strong connections with other brain structures essential for processing emotional information, said researcher Richard Davidson, PhD, professor of psychology and psychiatry at the university. The study was published in the Sept. 13, 2005, Proceedings of the National Academy of Sciences.
The university's research team also has delved into meditation and found that, when practiced for many years, it can cause changes in the brain.
From research to practice
As the evidence mounts, primary care physicians could consider their patients' stress levels when offering advice.
"Physicians' input is very powerful for a patient," Dr. Lovallo said. "So a physician could say to a patient, 'I notice you appear to be under a lot of stress. There may be some things you can do about that, and if you'd like, we can talk about it,' " he suggested. "I think that's a terribly important message for patients."
Dr. Bradley and her colleagues have thought a lot about what can be done to offset the effects of job loss on those who are close to retirement. Physicians could caution such patients to take care of themselves, she said. They can tell them: "You need to deal with the stress issue. Even if you are depressed, this is the time to exercise and eat and sleep right."
Companies also could step up at this time and think about the health consequences of laying people off and perhaps form outreach groups and make sure that people are connected to good public health mechanisms, Dr. Bradley said.
The emotional stress of a cancer patient also is being recognized as a powerful element that can, in as many as one-third of patients, interfere with treatment. In recognition of this problem, the American Cancer Society and the National Comprehensive Cancer Network developed Distress Treatment Guidelines for Patients.
The guidelines, released in 2004 and updated in 2005, are designed to address this emotional turmoil and the physical symptoms it causes, such as loss of appetite and sleeplessness. They include a distress thermometer, a screening tool to help patients measure their levels of stress on a scale of one to 10. Patients evaluate their stress levels in several areas from housing needs to quality of life.
"We all get into life situations that really bring the heat up on our tea kettle," Dr. Applegate said. "And we need some way to take the pressure off." The primary care physician doesn't have to do it all, he said. Patients can be referred to massage therapy, yoga or counseling. "You don't have to be the agent of change, but you can direct them to that agent."