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
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
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,
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
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
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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