Disclosure of traumas and immune function: Health implications for psychotherapy

Spiritual recovery movements and contemporary medical care

When confronted by the threat of illness, general medical and psychiatric patients may turn to treatments that have a spiritual orientation but lack empirical validation. This article examines the nature of contemporary movements that offer these treatments and their impact on medical care. A typology of spiritually oriented recovery movements is presented, including those associated with established religions, holistic medicine, or programs for self-liberation. Possible mechanisms for their behavioral and physiologic impact on health status are discussed. The psychological appeal of these treatments is analyzed in light of the way sick people may attribute meaning to illness and may then become engaged into a spiritual recovery movement, achieve a sense of self-efficacy through affiliation, and finally comply with putative "healing" practices. Although some spiritual recovery movements provide hope in the face of illness and even offer therapeutic benefits, they may also discourage patients from getting appropriate medical treatment and promote harmful regimens. Options are discussed for mental health professionals' response to the spiritual orientation of their patients and options for future research.

Accelerated course of human immunodeficiency virus infection in gay men who conceal their homosexual identity

Research linking psychological inhibition to physical illness led us to examine whether human immunodeficiency virus (HIV) infection might progress more rapidly among gay men who conceal their homosexual identity than among those who do not. We also sought to determine whether any accelerated course of HIV infection among "closeted" gay men might be attributable to differences in health-relevant behavior (e.g., health practices, sexual behavior) or psychosocial characteristics (e.g., depression, anxiety, social support, repressive coping style). Data came from a longitudinal psychosocial study associated with the Los Angeles site of the Multicenter AIDS Cohort Study. Eighty gay men, HIV-seropositive but otherwise healthy at study entry (CD4 T lymphocytes = 30-60% of total lymphocytes), were examined at 6-month intervals for 9 years. Indicators of HIV progression included time to a critically low CD4 T lymphocyte level (15% of total peripheral blood lymphocytes), time to AIDS diagnosis, and time to AIDS mortality. On all measures, HIV infection advanced more rapidly in a dose-response relationship to the degree participants concealed their homosexual identity. Sample characteristics and statistical controls ruled out explanations based on demographic characteristics, health practices, sexual behavior, and antiretroviral therapy. Mediational analyses indicated that observed effects were not attributable to differences in depression, anxiety, social support, or repressive coping style. HIV infection appears to progress more rapidly in gay men who conceal their homosexual identity. These results are consistent with hypotheses about the health effects of psychological inhibition, but further research is required to definitively identify the psychosocial, behavioral, and physiological mechanisms underlying these findings.

Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school

This study was a 19-week prospective conducted to determine the effectiveness of a self-hypnosis/relaxation intervention to relieve symptoms of psychological distress and moderate immune system reactivity to examination stress in 35 first-year medical students. Twenty-one subjects were randomly selected for training in the use of self-hypnosis as a coping skill and were encouraged to practice regularly and to maintain daily diary records related to mood, sleep, physical symptoms, and frequency of relaxation practice. An additional 14 subjects received no explicit training in stress-reduction strategies, but completed similar daily diaries. Self-report psychosocial and symptom measures, as well as blood draws, were obtained at four time points: orientation, late semester, examination period, and postsemester recovery. It was found that significant increases in stress and fatigue occurred during the examination period, paralleled by increases in counts of B lymphocytes and activated T lymphocytes, PHA-induced and PWM-induced blastogenesis, and natural killer cell (NK) cytotoxicity. No immune decreases were observed. Subjects in the self-hypnosis condition reported significantly less distress and anxiety than their nonintervention counterparts, but the two groups did not differ with respect to immune function. Nevertheless, within the self-hypnosis group, the quality of the exercises (ie, relaxation ratings) predicted both the number of NK cells and NK activity. It was concluded that stress associated with academic demands affects immune function, but immune suppression is not inevitable. Practice of self-hypnosis reduces distress, without differential immune effects. However, individual responses to the self-hypnosis intervention appear to predict immune outcomes.

Effect of verbal self-disclosure on natural killer cell activity: moderating influence of cynical hostility

One objective of the present research was to examine the immunological effects of self-disclosing personal information regarding a traumatic or stressful experience. A second objective was to examine the hypothesis that the effect of self-disclosure on immune function is moderated by individual differences in cynical hostility. Forty-three male college undergraduates, classified as high or low on the Cook-Medley Hostility scale were randomly assigned to either a verbal self-disclosure or a nondisclosure discussion condition. Task-induced change in natural killer (NK) cell activity (i.e., cytotoxicity) served as the dependent variable. As predicted, a significant interaction between discussion condition and hostility was obtained. Among subjects in the self-disclosure condition, high hostility subjects exhibited a significantly greater increase in NK cell cytotoxicity than low hostility subjects. The effect of self-disclosure on NK cell activity is moderated by an individual's level of cynical hostility. The greater short term enhancement in NK cell activity observed for hostile persons is a likely correlate of a more pronounced acute arousal response elicited by the self-disclosure task.

A Research Derived Bereavement Support Group Technique for the Hiv-1 Infected

A brief, semi-structured, bereavement support group for HIV seropositive and at risk homosexual men suffering a recent loss of a close friend or lover is described. The intervention employed a set of topics to stimulate group discussion. These topics were organized into three phases: making contact, venting of emotion, and “moving on.” Our predictive theoretical model integrating life stressor appraisal, social support availability, and active coping was incorporated. Therapeutic foci are active monitoring of stressor load; accurate stressor appraisal; extending, using and evaluating one's social support network; and selection of adaptive coping strategies. Three vignettes illustrate the integration of the research protocol with clinical issues. Implications for clinical care are discussed.

Wellness and HIV: developing a model for progression from theoretical knowledge about psychosocial factors to application

Psychosocial factors and immunological markers have been associated not only with progression from HIV to AIDS and AIDS survival, but also with wellness. Not yet identified, and therefore not yet formalized into a system for clinical decision-making, are those individual differences that moderate both the impact of psychosocial factors and the potential benefit of interventions. Therefore the link between theoretical knowledge and application has not yet been established in a manner that would predict the outcome of recommended interventions. Presented here are background considerations to a combination of short-term and longitudinal studies which investigate these issues. The decision process devised here would be suitable for use with individuals with any physical disorder that has a psychosocial component.

The significance of belief and expectancy within the spiritual healing encounter

Historically, traditional cultures recognized the importance of belief and expectancy within the healing encounter and created complex rituals and ceremonies designed to elicit or foster the expectancy and participation of both the healer and patient, as well as the community as a whole. This holistic approach to health care was a fundamental component in the spiritual healing rituals of virtually all traditional native cultures. The focus of the current study was to assess the impact of healer and patient expectations on mental and physical health parameters following a spiritual healing session. A pre-post methodological design which incorporated extensive psychophysiological health outcome measures along with independent medical diagnoses was utilized. The study was conducted in a northern California suburb of Marin County utilizing an American-born spiritual healer trained in the Philippines. The results indicated that there was a statistically significant difference between the pre-treatment and post-treatment scores for all fourteen dependent variables examined. The data also demonstrated a significant difference between the high versus low expectancy subjects for both patient and healer groups, as well as a significant relationship between high expectancy in patients and healer and the effectiveness of the spiritual healing encounter. The results of the study therefore suggest that high healer and patient expectancy may be important elements which can serve as both predictors as well as facilitators of the healing process. The degree of bonding or communication between the healer and patient was postulated as an important factor in this regard. Due to the fact that a majority of the conditions reported (75%) were organic disorders that would not commonly disappear within the 3 week time frame of the study, the significant results obtained suggest that spiritual healing in combination with traditional allopathic medicine may have the potential to be an effective treatment protocol for severe or long-term disorders. An important contributing feature of this study was that an independent means of assessing the patients' self-reports, i.e. an allopathic medical examination, was included in the experiment. There was a significant correlation between the patient's expectation level and their assessment of improvement, as well as a significant relationship between the patient's assessment of their condition and the objective evaluations provided by independent medical examinations.

Implications of mind-body theory for integration in psychiatry

Recently, several authors have called for an integration of philosophy, psychology, and neuroscience regarding the mind-brain problem (Brothers 1989; Cooper 1985; Hundert 1989). In this essay I review two philosophical theories of mind that lead to very different conclusions regarding integration. Reductionist materialism is the theory that currently has the widest acceptance. Unity theory, a less familiar theory, may present the most plausible alternative to reductionism currently available. Numerous examples from the psychiatric literature are used to illustrate the challenge that faces each of these theories. Critical evaluation of how they meet the challenge, particularly in accounting for apparent psychosomatic causation, shows the strengths and weaknesses of each theory, particularly regarding their clinical utility in psychiatry.

Coping with Bereavement: A Review of the Grief Work Hypothesis

The article challenges the longstanding belief in the importance of “grief work” for adjustment to bereavement (the grief work hypothesis). It examines claims made in theoretical formulations and principles of grief counseling and therapy concerning the necessity of working through loss. Empirical evidence is reviewed, and cross-cultural findings are described to document alternative patterns of coping with grief. It is argued that there are grounds for questioning the hypothesis: 1) existing definitions and operationalizations are problematic; 2) the few empirical studies that have examined the impact of grief work have yielded equivocal results; 3) grief work is not a universal concept. Limitations of the grief work hypothesis as an explanation of coping with bereavement are identified and a differential approach is suggested. Implications for counseling and therapy are discussed.

Psychosocial counseling to improve quality of life in HIV infection

Psychosocial interventions such as cognitive behavioral stress management (CBSM), may enhance coping and social support which contribute to an improvement of quality of life factors such as emotional functioning, social functioning, and sense of well-being, for HIV-infected men during several phases of HIV spectrum disease. These phases include the acutely stressful period immediately following notification of HIV+ status, the adjustment period following this news, and the process of dealing with chronic symptomatic HIV infection. Normalization of some aspects of immunological status were found to accompany some of these psychosocial changes in the short-run. Longer-term follow-up indicated relationships between psychosocial factors and improved immunological status and physical functioning up to 2 years later. Factors such as an increased use of active coping strategies, including relaxation exercises, use of more functional appraisals and elicitation of social support, and decreased use of denial/avoidance coping strategies, may be key predictors of longer-term emotional well-being, social functioning, and physical functioning in HIV-infected populations. Special issues need to be addressed in emerging models of quality of life assessment in HIV populations. For example, the way resurgence of stigmatization and self-doubt affects sense of identity and well-being need to be addressed in quality of life research as well as in psychosocial interventions. Loss of employment and its financial and existential consequences are also factors which impact sense of self and well-being, and need to be addressed both in research as well as in interventions. The effect of repeated HIV-related bereavements upon an individual's social network and the emotional, social, and physical sequelae of bereavement have implications for HIV quality of life research as well. Quality of survival time has become a paramount issue in the context of HIV spectrum disease. Examining the relationships among coping strategies, social support, emotional well-being, realistic appraisals of one's functioning in comparison to their aspirations, and the influence of psychosocial functioning on disease course are central missions of our research program.

Hierarchical cortical control of neuroimmunomodulatory pathways

The central nervous system and the immune system are both stimulus response systems with sophisticated memories mediating defence and adaptation to external and internal threats. There is mounting evidence that these two systems share their information in a bidirectional flow of cytokines, steroids, and neuropeptides. This review examines the influence of higher cognitive centres on immunity and highlights the central role played by the hypothalamus in enabling these two systems to function as an integrated unit to maintain homeostasis. The search for novel compounds that are capable of enhancing immunity by regulating these brain-immune feedback loops offers one of the most exciting areas for future neurobiological research.

Immunology and exercise. Physiology, pathophysiology, and implications for HIV infection

This article covers the latest information on the immunologic changes of exercise as well as the effects of regular exercise on persons infected with HIV and the exercise recommendations for HIV-infected athletes. Included are discussions about psychoneuroimmunology and exercise-associated changes in immunity.

Changes in cognitive coping strategies predict EBV-antibody titre change following a stressor disclosure induction

Previous research has shown that emotional disclosure of traumatic or stressful events is associated with facilitating insight into the experience, improving mood, and modulating some aspects of the immune system. The current study examined how cognitive changes and experiential involvement during an emotional disclosure induction protocol relate to immune functioning, as measured by IgG antibody titres to the Epstein-Barr virus viral capsid antigen (EBV-VCA). Seventy-six college undergraduates were randomly assigned to either a disclosure induction or an assessment-only control condition. Experimental subjects met with an experimenter for three weekly 20-min individual sessions during which time they were asked to discuss a stressful or traumatic topic which they had previously discussed only minimally with others. Blood was drawn a week prior to the first session and at one week following the third session. Subjects completed the Impact of Event Scale (IES) after session 1 and at followup, and the extent of experiential involvement in disclosure during each session was assessed by means of the Experiencing Scale. Mood was assessed before and after each disclosure using the Nowlis Mood Adjective Checklist. Although the disclosure induction did not directly affect EBV-VCA antibody titres, individual differences in subjects' ability to involve themselves in the disclosure process and abandon their avoidance of the stressful tropic during the course of the 3-wk period were predictive of antibody decrements. These associations were more pronounced for individuals who disclosed older and more troublesome events.

Cardiovascular consequences of expressing, experiencing, and repressing anger

Psychoanalytic theory's pathogenic view of repression gave rise to the widely held belief that the expression of anger is beneficial to mental and physical health. The present paper reviews a number of experimental and correlational studies which demonstrate that the full expression of anger, with its vocal manifestations, is associated with significant cardiovascular hyperreactivity. Furthermore, epidemiological studies indicate that such expression of anger are also related to coronary heart disease (CHD) and to some physiological and hormonal changes that have been implicated in the pathophysiology of CHD. On the other hand, neither the mere experience of anger nor its repression has any of the above negative cardiovascular consequences, although the repression of anger seems to have other untoward health consequences.

Construct validity of a self-report measure of alexithymia in a psychiatric inpatient sample

This study examined the construct validity of a widely used self-report measure of alexithymia in a mixed-sex sample of 101 psychiatric inpatients (62 women and 39 men). Contrary to expectations, scores on Shipko and Noviello's (1984) alexithymia scale (SNALEX) were: (1) correlated positively with a Rorschach index of verbal productivity; (2) unrelated to a Rorschach index of adaptive use of fantasy; (3) correlated negatively with scores on the MMPI L and K scales and correlated positively with scores on the MMPI F scale; and (4) correlated negatively with subject age. In addition, SNALEX scores were correlated negatively with scores on Klieger and Kinsman's (1980) alexithymia scale (KKALEX) in subjects of both sexes. These results do not support the construct validity of the SNALEX as a measure of alexithymia is psychiatric inpatients.

Basics in psychoneuroimmunology

Central nervous, endocrine and immune systems (IS) are all considered to be important regulators of psychological and physical wellbeing. Research into psychoneuroimmunology became relatively widespread in the 1970s. More and more studies considered these systems to be interactive units. Disciplines ranging from anatomy to psychology revealed the IS as the target of brain and endocrine signals. Findings also suggest that the IS is active even in a bidirectional feedback loop. Today the IS is no longer regarded as autonomous and scientists begin to see the emergence of a new psychosomatic paradigm. So far, evidence for the mind-body interaction paradigm has been collected with regard to the role of nerve fibres in lymphatic tissues, the effects of brain lesions on the IS, the interplay of neurotransmitters, hormones and immunotransmitters in a network of bidirectional feedback loops between the brain and the IS, the effects of ontogeny, learning and conditioning on the development of the IS, the impact of experimental and naturally occurring stressors on the IS, the possible immune modulating effects of personality characteristics, life style and psychodynamic processes and the role of the IS in disease. Research findings in most of the mentioned topics are presented.

Putting stress into words: health, linguistic, and therapeutic implications

When individuals are asked to write or talk about personally upsetting experiences, significant improvements in physical health are found. Analyses of subjects' writing about traumas indicate that those whose health improves most tend to use a higher proportion of negative emotion words than positive emotion words. Independent of verbal emotion expression, the increasing use of insight, causal, and associated cognitive words over several days of writing is linked to health improvement. That is, the construction of a coherent story together with the expression of negative emotions work together in therapeutic writing. Evidence of these processes are also seen in specific links between word production and immediate autonomic nervous system activity. Implications for therapy and for considering the mind and body as fluid, dynamic systems are discussed.

Immunological responses of breast cancer patients to behavioral interventions

This article reports the results of an 18-month study of immune system and psychological changes in stage 1 breast cancer patients provided with relaxation, guided imagery, and biofeedback training. Thirteen lymph node negative patients who had recovered from a modified radical mastectomy were randomly assigned to either an immediate treatment or a delayed treatment control group. Multiple pre-post psychological measures were performed. Significant effects were found in natural killer cell (NK) activity (p < .017), mixed lymphocyte responsiveness (MLR) (p < .001), concanavalin A (Con-A) responsiveness (p < .001), and the number of peripheral blood lymphocytes (PBL) (p < .01). No significant psychological changes were detected; however, reductions were seen in psychological inventory scales measuring anxiety. The results show that behavioral interventions can be correlated with immune system measures, thereby replicating the results of an earlier pilot study from our Center. Discussion is provided on differential T-cell and B-cell responsiveness to behavioral interventions.

Putting stress into words: the impact of writing on physiological, absentee, and self-reported emotional well-being measures

BACKGROUND AND PURPOSE

Inhibiting or holding back one's thoughts, feelings, or behaviors is associated with long-term stress and disease. Actively confronting upsetting experiences can reduce the negative effects of inhibition. The present study describes a unique approach to aid individuals in dealing with psychological and emotional issues that they must often face.

METHODS

Forty-one of the 81 university employees who were participating in a wellness program agreed to participate in the present study. Subjects were randomly assigned to write about either personal traumatic experiences (n = 23) or non-traumatic topics (n = 18) for 20 minutes once a week for four consecutive weeks.

RESULTS

Results indicate that individuals who wrote about upsetting personal experiences evidenced significant drops in selected blood measures compared to those who wrote about non-traumatic topics (e.g., for SGOT: 4.0% drop among traumatic topic group versus 13.1% increase among non-traumatic topic group, ANOVA p = .029; for SGPT: 24.5% drop versus 7.7% increase, p = .001). During the month of writing, traumatic topic group subjects evidenced a 28.6% reduction in absentee rates from work relative to the eight months before the experiment compared with a 48.5% increase in absentee rates among non-traumatic topic subjects (p = .04). Subjects low in emotional inhibition evidenced the greatest reductions in absentee rates following personal disclosure compared to those high in emotional inhibition (p = .011).

DISCUSSION

The proposed writing strategy offers a unique tool for health promotion practitioners.(ABSTRACT TRUNCATED AT 250 WORDS)

A controlled study of sensation awareness and verbal disclosure for regulation of arousal and anxiety

Interactions of attention and verbalization were investigated for effects of self-reported arousal and state-anxiety. Levels of verbalization from silence through talking-without-a-listener to disclosure were compared while self-directed attention was manipulated for sensation versus general thoughts and feelings. Following a stimulus, disclosure of sensations was expected to reduce state anxiety and increase energetic arousal significantly more than disclosure of thoughts. Based on a randomly assigned sample of 120 men, a 3 x 2 x 2 multivariate analysis of variance indicated a significant interaction in the predicted directions. A significant interaction was also found for the 3 x 2 interaction for energetic arousal. For state anxiety means were in the predicted direction. Results indicate that verbalization of sensations is more energizing and calming than silence, while for general thought, silence is more energizing and calming than verbalization. The results suggest efficacy in reframing self-talk to quiet awareness and in communicating sensed distinctions as they emerge.

Self-regulation of the immune system through biobehavioral strategies

Increasing scientific study and attention is being directed to mind-body interactions, particularly to the interrelationships between the brain and the immune system. This effort has created a new interdisciplinary field, psychoneuroimmunology. An overview of this new field is provided, followed by a comprehensive survey of the growing evidence suggesting that measurable immune system parameters can be influenced by biobehavioral strategies involving self-regulation. Modalities included are relaxation and imagery techniques, biofeedback-assisted strategies, the use of humor, and affiliation to influence emotional states, hypnosis, and conditioning paradigms. The majority of studies have reported significant immune parameter changes. Additional well-designed research is needed to clarify and confirm these initial findings. Future research would benefit from investigating the clinical implications of these immune parameter changes. Knowledge of effects of the mind on the body is rapidly expanding and may be important for achieving improved immune system functioning and health.

Social psychology of the immune system: a conceptual framework and review of the literature

The literature on psychosocial factors affecting the immune system is reviewed. The literature is summarized in terms of a provisional model accounting for immunosuppression in terms of four mutually influential explanatory constructs (dysphoric responses; immunosuppressive behaviors; adverse life experiences; and vulnerability) and the relationships among the diverse manifestations of the constructs. The literature and the summary provisional model point to directions for future research that should establish the intervening role of immunosuppression in the relationships between psychosocial factors and the disease process.

Expanding theoretical conceptualizations of self-help groups

Self-help groups, a prevalent and significant source of social support, manifest the public-participation premise of primary health care. Yet, self-help studies have typically lacked theoretical grounding. Psychoneuroimmunological and social-learning theories could contribute to the theoretical understanding of self-help groups. As self-help groups can mitigate the impact of natural social-network losses, they could help prevent health disorders via an immunocompetence-maintenance function. Health professionals could consider this possibility in assessment, planning, intervention and evaluation. Furthermore, health professionals could take steps to enhance self-efficacy and collective efficacy, derivative concepts of social-learning theory germane to self-help groups. Therefore, pertinent concepts and creative linkages are proposed in a preliminary attempt to initiate a self-help group theoretical framework for health professionals.

Effect of psychosocial treatment on survival of patients with metastatic breast cancer

The effect of psychosocial intervention on time of survival of 86 patients with metastatic breast cancer was studied prospectively. The 1 year intervention consisted of weekly supportive group therapy with self-hypnosis for pain. Both the treatment (n = 50) and control groups (n = 36) had routine oncological care. At 10 year follow-up, only 3 of the patients were alive, and death records were obtained for the other 83. Survival from time of randomisation and onset of intervention was a mean 36.6 (SD 37.6) months in the intervention group compared with 18.9 (10.8) months in the control group, a significant difference. Survival plots indicated that divergence in survival began at 20 months after entry, or 8 months after intervention ended.