STEP PERSPECTIVE, Volume 7, No. 2 -Summer/1995; A Publication

The majority of writings in this and other publications focus on biochemical medical treatment for those infected with HIV or resultant opportunistic infections. What is often overlooked are the psychological aspects of HIV infection, or for that matter, the psychological perception of illness and disease. The emerging field of psycho-neuroimmunology examines the interaction between physiological functioning and memory, behavior, or thoughts. Psychoneuroimmunology was founded upon the work of George Solomon, MD who suggested that when evaluating health and disease more than physiological symptoms needed to be considered. His initial work in the mid 1960s centered around behavior and personality patterns in patients with chronic rheumatoid arthritis. Since that time numerous studies have been conducted researching the specific biological influences mood, thought, and behavior may exert upon the body.

One of the most important and influential researchers to document the psychological parameters of health has been Suzanne Kobassa. Her work is paramount for its introduction of the term "hardiness." Hardiness consists of three main parameters. These are: commitment, control, and challenge.2 Commitment involves one's feelings toward work, family, social encounters and self. Those with a sense of commitment experience a sense of purpose within themselves and in what they do; they perceive themselves to be a vital and active participant in their own lives. In opposition to commitment lies alienation; a sense of isolation from the world and in interactions.

Control refers to a sense of power. Those with a high profile of control are able to take an active role in and possess a sense of responsibility for their lives. The attitude of those who possess high levels of control is one of influence; they perceive they can influence the outcome of events affecting them. When control is low, individuals suffer from a sense of helplessness and hopelessness, consumed by a feeling that they are powerless to meet the situation.

Challenge is the ability to view all situations as potentially positive with successful outcomes. Individuals who experience low levels of challenge often perceive any given situation as a threat to their health and well-being. Kobassa examined how stressful life events affect one's health and the frequency of disease. She argues against a direct cause-and-effect relationship between stress and illness. She rejects the notion that stress is to be avoided for one to lead a healthy life. What Kobassa's studies demonstrate is how an individual's personality and coping mechanism directly influence health. She discovered that individuals who possessed high levels of hardiness (having high profiles of these three parameters) suffered fewer illnesses.3 The conclusion here is that events, in and of themselves, cannot be identified as stressful or illness provoking; it is the interpretation the person makes regarding the event that is significant. Those with high hardiness profiles will interpret events as positive, engaging, and challenging. Operating from this vantage point, Kobassa believes, one can greatly impact one's own health.

Kobassa measured and evaluated the individuals in her studies based on patient report, psychoemotional scales, and symptoms. Therefore, the patient's assessment of events and health status could easily be gauged. The frequency of office visits during and following the studies was also assessed. However, direct physiological parameters, blood pressure, cell counts, etc., were not measured.

Keicolt - Glaser and Glaser were instrumental in measuring the direct physiological effects of stress. They evaluated the immune functioning of medical students.4,5,6 Their findings suggested that during periods of stress, in this case examination periods, students had a decrease in NK cell activity. NK cells are involved in non-specific immune surveillance against tumor cells and viruses. Additionally, gamma interferon levels (which aid in the body's ability to produce cells to help fight infection) and blastogenesis (ability of cells to transform to larger, more potent forms upon contact with foreign material) were lower during exam periods. These levels all returned to normal after the stressful event was concluded. However, regardless of the familiarity of the stressful event, that is, no matter how many times the students had taken exams, they continued to have a decrease in immune functioning. Finally, Glaser found that students with a sense of isolation and loneliness (a control parameter) had lower NK cell activity than those students who did not report such feelings. This may be interpreted as suggesting that those who viewed the examination process as threatening and stressful experienced a greater decrease in immune functioning as measured by NK cell activity.

Snyder concluded that not only is the individual's hardiness a factor, but the form stressful events take is of equal relevance.7 In her study, Snyder assessed patient response to a novel antigen--a substance that induces an immune response (along the lines of an allergic reaction)--in the context of stressful events. She reports differences for patients experiencing and defining stress in terms of good versus bad. The group with bad stress, those with repeated daily hassles as opposed to brief and infrequent major stress, had decreased immune function as measured by the proliferation of lymphocytes (B and T cells). The intensity of these daily hassles was of key significance. Like the previous studies, stress levels were measured by patient self report and a variety of mental health scales. Not only is the individual's ability to cope with situations a factor now, but the intensity and frequency of the stressful event is of importance. The works of those studying HIV infection and AIDS in context with Kobassa's hardiness scale has contributed further insights. Although not mentioned in her work, others believe a fourth "C" should be added to the scale, namely community, also classified as social support.8, 9, 10 Community plays a large role for those in a medically challenging situation. This last factor can help foster and maintain the individual's control, commitment and challenge. Support involves the patient's ability to access help in both the emotional and the problem-solving realms. Such behavior would include expression of feelings, emotions, and thoughts, and accessing information from others; such as advice or explanations. Those who demonstrated such behavior were reported to have a longer survival rate after exposure to Pneumocystis Carinii Penumonia (PCP).8 What is now added to the equation is specific behavioral traits, namely the process of accessing and expressing personal information.

At the Center for Biopsychosocial Study of AIDS at the University of Miami, researchers set out to further evaluate the behavioral changes that may affect immunological functioning. They conducted a variety of studies following groups of asymptomatic, healthy gay males for 5-10 weeks prior to and following notification of their HIV-1 antibody status.11, 12, 13 Subjects were divided into intervention and control groups. Measured biological outcomes were evaluated by immunological, endocrinological, and neuropeptide levels for the duration of intervention prior to notification, and immediately after notification as well as follow-up intervals throughout 1 year post notification. Some 24 measures were assessed, including total T cells, B cells, T-helper cell subsets, NK cells subsets, serum IgG, IgA, and IgM, Epstein - Barr virus antibodies, plasma cortisol and beta-endorphin levels. The psychological measures involved hardiness parameters, sexual and health behaviors, affect inventories, etc. The authors admit that controlling for confounding factors (factors not considered or evaluated such as sleep and physical activity levels) and compliance remains problematic. However, their research again yields support for the concepts offered by Kobassa. The individual's ability to cope with a situation, the person's hardiness, and belief system affect immunological, endocrine, and neuropeptide levels.

In all the studies conducted by the Miami group, cognitive or behavioral modification was the main intervention offered. However, in a few studies, the effects of aerobic exercise were also examined. The results strongly indicated that at the time of notification of HIV antibody status, those who participated in the cognitive or behavioral modification or the aerobic exercise protocols experienced less or minimal decrease in immunological parameters. As opposed to control groups, psychological measures for depression post notification were less affected. The authors hypothesize that both the cognitive or behavioral intervention and the aerobic exercise facilitate better coping skills for the individual by acting as a buffer system to anxiety and depression. By offering individuals a method for coping and reframing the situation, the individual can view the information at notification as controllable and as a challenge. Furthermore, by engaging in aerobic conditioning or behavioral restructuring, the individual has been supposedly gaining a sense of commitment to his or her health. These interventions provide the individual with a sense of control, self-esteem, and power. Without these, the authors suggests, a cascade of events occurs which decreases the immunological, endocrine, and neuropeptide functioning of the individual.

Their theory is as follows : control subjects showed anxiety, depression, and isolation leading to activation of the sympathetic nervous system (commonly viewed as the flight or fight system) and CRH (cortisol releasing hormone). This then leads to the increase of peripheral catecholamines and/or cortisol levels. When these levels are elevated, a decrease of positive immune enhancing hormones, peptides and cells occurs by way of negative feedback. These include interleukin-1, interleukin-2, and gamma-interferon to name a few. Once the decrease of positive hormones takes place, what has been found is a decrease in the ability of NK cells to attack foreign material, a decrease in the ratio of CD4 to CD8, and the decline in blastogenesis. The authors propose that when a person has undergone some form of stress management, this cascade fails to become engaged at such an intense level. The parasympathetic nervous system (that system responsible for general relaxation and calmness) then predominates. Thus, no increase in cortisol, peripheral catecholamines, and CRH occurs. An increase in the interleukin and interferon levels follows, as well as an increase in beta-endorphins and met-enkephalin. The final result is immune enhancement with an increase in NK cell activity, increase in CD4 and CD8, and increase in blastogenesis. This, they suggest, may decelerate possible disease progression.

All the above mentioned works have focused upon the individual's personality traits or hardiness. Behavior and emotion have been the means by which these traits are assessed. However, the belief system of the individual plays an integral role in directly impacting one's hardiness and health as defined by Kobassa's challenge parameter. This entails the diagnosis and the meaning it carries. Each individual makes an assessment about their diagnosis, thus giving it power to effect their health. This can best demonstrated by the studies involving "medical hexing" and "voodoo death." The concept of voodoo death comes from the accounts of individuals who have been cursed by a person or persons they deem to have power over them (such as a witch doctor, tribal leader, or spiritual guide). In these accounts, the process was as follows: an individual presented to a hospital or clinic in the final stages of death. The body was responding as if it was dying, yet no causative agent was found. All that was known was that someone had cursed or accused them, for which the prognosis was death. In one case, the tribal doctor who had "pointed the bone" at one such individual was reluctantly brought to the clinic where the MDs pleaded with him to remove the curse.14 Disgruntled, the tribal doctor revoked the curse. A day later, the man who was dying recovered to his previous full state of health. Other individuals were not as fortunate. Such stories help bring into focus the concept of psychoneuroimmunology or psycho-biological interactions.

As Sanford I. Cohen has discussed in his study of the concept of medical "hexing," voodoo deaths occur daily in our medical profession without much forethought. He describes voodoo death as follows: "So called voodoo or hex death is a classic example of biopsychological interaction. It is a dramatic demise that occurs when a person feels cursed by another believed powerful enough to kill or powerful enough to create a feeling of hopelessness. The victim has to believe that the hex works and that he cannot control it."14 This hexing occurs today in our modern medical practices. The hexing occurs the moment, and possibly before, a patient is given a diagnosis. In order for such a process to happen, the following factors are involved: 1. A message must be communicated from the external world (the diagnosis) 2. A personal belief system must be in place (belief that the doctor is expert and the medical system valid) -- Kobassa's parameter of control 3. A perception of one's own power is made (the disease is fatal and uncontrollable) -- Kobassa's parameter of control and challenge 4. A particular behavior of the victim occurs (withdrawal from family and friends, non-communicative) -- Kobassa's parameter of commitment 5. A behavior from the community and family occurs (isolating and fearful treatment further propagating helplessness) 6. A psychological reaction occurs (depression, shame, remorse, guilt) 7. A biological reaction occurs (CNS and endocrine changes) So what does all this mean for the individual? Again we return to the connections defined by the field of psychoneuroimmunology, the belief in the connection between psyche and soma. In this model, we are no longer individuals who have a mind or a body; we are mind and body. The thoughts we generate directly affect physiological processes. As discussed previously, if the individual holds to the concept that their diagnosis is fatal, a mood is then generated within. No longer can we hold the view that mood is some ephemeral, esoteric entity that is stored in the psyche. Moods are generated by the assertions one makes about the action. The action here is the diagnosis. If one assesses that this diagnosis is equal to fatality, a mood will then be created. The mood occurs in the body as well as in the psyche. By changing the assessments, asserting control, challenge or commitment, the mood borne from such a place would alter the physiology.

The suggestion here is that the individual and medical profession question their assumptions about the individual's ability to take an active role in the process of health. This involves generating a new approach to diagnosis; one that does not stimulate "hexing" behavior. If one is to view patients in a static, materialistic, Cartesian plane, then a diagnosis is something a patient IS. They ARE cancer. They ARE asthma. They ARE HIV. No other reality exists. If this is in the minds of the physician and patient, what impact does this carry? How does this translate into the patient's view of themselves? If the patient is to dissolve themselves into the diagnosis ("I can no longer perform in this way because I have 'X'"), then from where will the healing come? As we can clearly infer from the work of the Miami group, those who were taught coping mechanisms were better able to deal with notification of their HIV antibody status. What coping and behavioral strategies offered the individual was the means by which to reframe and re-assess the meaning of the notification. What is being proposed here is that one examine one's belief systems and how one reacts to all situations. For stress is not a concrete and identifiable entity. Yet often we find that we speak as if something that occurred was stressful; "My day was stressful," "That meeting was stressful," etc. However, as Kobassa attempted to demonstrate, the day or meeting itself was not stressful. The belief or perception one holds regarding the meeting or day will elicit a biopsychoemotional reaction in the individual. Therefore, if one can learn ways in which to develop hardiness (commitment, challenge and control), foster community, and reframe one's beliefs about illness, diagnosis, and the infallibility of the medical system one may learn ways in which to create wellness and health at any given moment regardless of one's diagnosis.

One way in which people can begin to address these issues is to seek out trusted support opportunities. This may be in the guise of support groups, friends, or even finding a qualified mental health professional. In an atmosphere of trust, one can learn and practice how to be assertive and expressive. Control is one of the parameters for which many find themselves longing. While control had been defined as a sense of power, by applying all the concepts listed here, the meaning of control is far more specific. Control refers to one's ability to effectively impact one's belief system. The only controllable factor in our lives is the perceptions and meanings we assign to any given situation. By attempting to control HIV, one is making judgments about what HIV is and how it will affect one's life. People live in a place of powerlessness, hopelessness and helplessness. The question arises as to whether or not HIV is something one can actually control. However, by exerting control over one's perception about HIV, one can live in a place of power.

A caveat needs to be offered on the issue of guilt. In no way is the information given here an implication of fault or guilt. One need not read this and decide that one's emotions or ways of thinking are the cause of one's illness. Rather, what is being offered is a way to learn how to better assist the body in healing. This is not a panacea -- a cure-all. Psychoneuroimmunolgy stresses the connection between mind and body. Therefore, working on the body will affect the mind as well. What one believes regarding one's treatment has a significant impact upon one's health. By obtaining insight into one's hardiness level, community, and belief or value system, the possibility for experiencing greater health is offered.

Dr. Lichtenstein is a recent graduate of John Bastyr University now in private practice in Seattle. He can be reached at 206/994-8361 Bibliography 1. Freedman, M. (1969) Pathogenesis of Coronary Artery Disease. McGraw-Hill, New York.

2. Kobassa, S. C. et. al. (1983) Type A and Hardiness. Journal of Behavioral Medicine, Vol. 6.

3. Kobassa, S.C. (1979) Personality and Resistance to Illness. American Journal of Community Psychology, Vol. 7.

4. Glaser, R. et. al. (1985) Stress-related impairments in cellular Immunity. Psychiatry Research, 16.

5. Glaser, R. et. al. (1987) Stress-Related Immune Suppression: Health Implications. Brain, Behavior, and Immunity, Vol. 1.

6. Glaser, R. et. al. (1986) Stress Depresses Interferon Production by Leukocytes Concomitant with a Decrease in Natural Killer Cell Activity. Behavioral Neuroscience, Vol. 100.

7. Snyder, B.K. et. al. (1993) Stress and Psychological Factors: Effects on Primary Cellular Immune Response. Journal of Behavioral Medicine. Vol. 16.

8. Temoshok, L. (1983-1988). A Longitudinal Psychosocial (Psychoimmunological) Study of AIDS (ARC). National Institute of Mental Health.

9. Solomon G. F., et. al. (1987). An Intensive Psychoimmunological Study of Long-Surviving Persons with AIDS: Pilot work, background studies, hypotheses and methods. Annals New York Academy of Science, 496.

10. Temoshok, L. (1988). Psychoimmunology and AIDS. Psychological, Neuropsychiatric and Substance Abuse Aspects of AIDS.

11. Antoni, M.H., et. al. (1990). Psychoneuroimmunology and HIV-1. Journal of Consulting and Clinical Psychology, 58.

12. Antoni, M.H. et. al. (1991). Cognitive-Behavioral Stress Management Intervention Buffers Distress Responses and Immunologic Changes Following Notification of HIV-1 Seropositivity. Journal of Consulting and Clinical Psychology, 59.

13. Antoni, M.H., et. al. (1991). Disparities in Psychological, Neuroendocrine, and Immunological Pattens in Asymptomatic HIV-1 Seropositive and Seronegative Gay Men. Biological Psychiatry, 29.

14. Cohen, S. I. (1988). Voodoo Death, the Stress Response, and AIDS. Psychological, Neuropsychiatric, and Substance Abuse Aspects of AIDS.

These articles were provided by the Seattle Treatment Education Project - Copyright (c) 1997 - Seattle Treatment Education Project. Noncommercial reproduction encouraged. Distributed by AEGIS - http://www.aegis.com