Embracing the powerful link between our minds and our physical health can help alleviate chronic conditions and improve overall wellness, research reveals.
If you were experiencing abdominal pain, diarrhoea and bloating, would you go to see a psychologist?
My guess is that you would tend to visit your general practitioner for such symptoms. However, if you meet the criteria for irritable bowel syndrome (IBS), which includes persistent abdominal pain, altered bowel habits and abdominal bloating and distention that can’t be explained by traditional medicine, evidence suggests you are as likely to get benefit from psychological intervention as from your doctor, who may prescribe muscle relaxants and possibly an antidepressant.
How can physical symptoms respond to psychological treatment? Welcome to the world of mind-body medicine, in which it is believed there is an interaction between what occurs in the body and what goes on in the mind, and that each is capable of affecting the other. Although obvious to some (practitioners of traditional Chinese medicine come to mind), Western medicine has been slow to accept this interaction.
You will probably be familiar with elements of this field: a common example of the mind influencing the body is when people are nervous or anxious and their body responds with physical symptoms. Anxiety is a psychological issue with a powerful physical component.
Think about the last time you were anxious. It might have been before a big presentation at work; a date; a party where you didn’t know many people; or a job interview. What did you notice in your body? Butterflies in your stomach? Tension in your neck or jaw? A pounding heart? Clammy hands?
Most people can identify signals from their body that tell them they are nervous or anxious, although the symptoms differ from person to person. These are common and are a normal response to stress, and are to some degree adaptive: research tells us that some anxiety boosts performance, whereas too much anxiety undermines performance. If a person experiencing anxiety focuses on abdominal breathing, they can change their physiology, including slowing their heart rate, metabolism, breathing and even brainwaves.
An inverse example, where the body influences the mind, is seen in people who are lacking in vitamin B12. These people may seem to be depressed (a strong psychological component) but in fact, if you give them vitamin B12 (a physical treatment), their depression lifts.
Probably the most commonly experienced mind-body interaction occurs when we exercise. Decades of research has shown that exercise affects learning, stress, anxiety, hormonal changes and ageing.
Thus the mind-body link goes both ways: one can have a psychological issue that presents partly as a physical issue, or a physical issue that has a partly psychological component.
When you’re sick, you go to the doctor, who diagnoses what is wrong and – in an ideal world – explains how you can be cured. According to Robert Woolfolk and Lesley Allen, authors of Treating Somatization: A Cognitive Behavioural Approach, doctors typically have a dualistic view of health: either you are physically unwell, as in a general medical condition, or you are mentally unwell, meeting the criteria for a mental disorder. For the past 300 years, doctors have followed the lead of French philosopher and mathematician René Descartes, who in 1637 stated his view that the body did not need the mind to work. Medicine has typically relied on physical evidence of abnormality, which is known as the biomedical model of illness.
This can be extremely useful, especially in acute conditions (e.g., you have a broken leg), but it starts becoming less useful when dealing with longstanding disorders such as chronic fatigue syndrome, also known as myalgic encephalomyelitis, which is defined by persistent fatigue unrelated to exertion; fibromyalgia, which is characterised by widespread pain in muscles, ligaments and tendons as well as fatigue and multiple tender points; and the aforementioned irritable bowel syndrome. This is because many chronic conditions are influenced by a range of factors that may or may not bear much relation to the underlying biology.
What if you have a pain, which after exhaustive tests can’t be traced to anything? What if you have extreme fatigue, but you haven’t done anything particularly onerous? What if you have regular cramping and diarrhoea but the tests all come back normal?
One of the most puzzling and frustrating aspects of life for many people is when medical knowledge can’t explain their symptoms, leaving them with the original problem plus uncertainty, which may lead to distress. People commonly find they are much less productive than they once were, and they and their doctors experience their illness as difficult to treat.
People tend to feel insulted or dismissed if their problems don’t fit neatly into one of the categories of physical or mental disorder. This is understandable as most of us like things to be simple and easily fixed – but many conditions have physical and mental components.
For the sake of simplicity, let’s take a look at the common chronic disorder IBS, with the understanding that chronic fatigue syndrome and fibromyalgia may also benefit from a psychological approach.
Take the example of Sarah, a professional 31-year-old who has two preschool-aged children and was diagnosed with IBS at age 12, after examinations that found no organic pathology. Her symptoms are severe abdominal pain and diarrhoea. When she has ‘an episode’, she frequents the bathroom regularly and finds it disrupts her life (although much less now than in previous years).
She sees a strong association between her temperament and her symptoms, describing herself as stressed and worried as a child, due to conflict between her parents. “My parents didn’t get along … my dad was a heavy drinker and you never knew how he would be when he got home.”
IBS is a common condition, affecting 10-22 per cent of the global population. According to a study reported in the Journal of Anxiety Disorders last year, patients with IBS are more likely to suffer from panic, anxiety and depression compared with healthy controls or individuals with biological markers of illness (e.g., people with Crohn’s disease).
Research indicates that how people view their illness can have important consequences for them. A study reported last year in the Journal of Psychosomatic Research found that patients who see their illnesses as entirely physiological (biological) have more severe IBS symptoms, compared with those who saw stress, internal conflicts and internal anxiety as playing a role.
Another study last year, reported in the Journal of Cognitive Psychotherapy found that patients with IBS tend to catastrophise – see the worst-case scenario as most likely – the way their symptoms would impact their lives. This is in contrast to people who see symptoms as just a normal reaction and tell themselves to keep on going.
In addition to this type of catastrophic thought process, studies have found that patients with IBS are sensitive to physical sensations in their stomach, endorsing statements such as “I worry that whenever I eat during the day, bloating and distention in my belly will get worse” or “I have a difficult time enjoying myself because I cannot get my mind off discomfort in my belly”. The hyper-awareness that patients experience can contribute to the pain they feel.
Because of these findings, it has been suggested that there be a therapeutic focus on reducing sensitivity to body symptoms and correcting catastrophic beliefs about the social and everyday implications of gastro-intestinal symptoms.
Sarah agrees with this. “Previous to learning these [cognitive] skills, I would panic when the symptoms would come on,” she says. “The episodes are so sore and I’d feel so overwhelmed. It didn’t help that the episodes would occur at night, when there are few distractions. I would feel like I would die. It was awful, and I’d ask myself: ‘When will this end?’
“Now I find that I can say to myself: ‘I can, have and will get through this.’ I have more perspective, knowing that in two hours this will be over. I have learned to manage better and now the episodes are far less frequent. It’s interesting that I can see in retrospect that there was a stressor that triggered it, but it’s hard to see at the time.”
The domain of health psychology has been developed to help people adjust to changes in their physical health, learn ways to manage their condition, and cope with the emotional impact of illness.
Lisa Reynolds, a health psychologist, says the potential downside of the mind-body connection is that people could blame themselves for their illnesses. “Some might think they have a flaw in their personality; others might think they have brought it on themselves by thinking negatively. These kinds of beliefs can be extremely unhelpful.
“One of the roles of a health psychologist is to unravel the perceptions that people may have about their condition, address any unhelpful thinking that adds to a feeling of self-blame, and support people to take an active role in the management of their condition.”
Health psychologists work to support people in making the changes required to better manage their condition. “People can play an important part in managing their illness, lessening the impact of physical symptoms and reducing the emotional turmoil that medically unexplained conditions can generate,” says Reynolds. behaviour therapy
A 2009 Cochrane review (the most stringent international review of scientific evidence about health care) reviewed 25 studies in a consideration of psychological treatments for the management of IBS. Although it was difficult to draw conclusions from the studies due to big differences between them, results suggest that cognitive behavioural therapy and interpersonal psychotherapy may be effective.
The cognitive behaviour model proposes that the way we think and the way we behave can heighten or minimise physical symptoms.
A second review of previous studies, conducted last year and reported in Gut – an international journal of gastroenterology and hepatology – investigated the effectiveness of antidepressants and psychological therapies on IBS symptoms compared with placebo across 32 studies. It found both treatments to be effective, with the most convincing evidence for cognitive behaviour therapy (CBT). Since these reviews were printed, further evidence has been published that highlights less intensive interventions for IBS patients, including internet-based CBT therapy and a CBT self-management program.
Reynolds is keen to impart a hopeful message based on the clients she has seen and the literature she has read: “The good news is that there are a number of ways of approaching these conditions. We can focus on body sensations by using relaxation techniques to reduce muscle tension; we can focus on behaviour, like gradually increasing exercise and finding meaningful activity; and we can focus on thoughts to find balanced ways of thinking.”
By acknowledging the connection between physical health and what is in our minds, we can harness our thoughts and behaviours as important tools in the process towards overall physical and emotional wellbeing.
Bodily distress syndrome
Psychologists are fond of using a fairly unwieldy word to describe how they understand illnesses. The ‘biopsychosocial’ model was proposed by George Engel in 1977, and it sees illness as a complex entity with interaction between physical (genetic/neurochemical); psychological (thoughts, feelings, attitudes, beliefs) and social (interpersonal relationships/cultural) factors. Three examples of syndromes best understood using the biopsychosocial model are chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. There is considerable overlap between these three disorders and there is currently a debate in the research literature (for example in the May 2010 edition of the Journal of Psychosomatic Research) about whether each disorder is a separate entity or whether they can best be understood as a single diagnosis: ‘bodily distress syndrome’. A Dutch researcher said classifying the disorders as such “may help unify research efforts across medical disciplines and facilitate delivery of evidence-based care”. Interestingly, these conditions are most commonly seen in females, which – according to experts – may be due to the male stereotype of unwillingness to admit discomfort. They also suggest that doctors may not be so alert to these diagnoses in males and may treat them differently.