Psychological Factors and Physical Illness
A. Psychosomatic Medicine
B. Biochemistry and Physiology
C. Behavior Modification
E. Medicine and Public Health
III.A New Paradigm: Behavioral Medicine
IV. Physical Disorders Associated with Psychological Disorders
A. Chronic Pain
There is a third Axis in the DSM-III-R diagnostic system: Axis III
allows the clinician to record the presence of any important physical
disorders and conditions. This in itself is not part of the DSM mental
disorder diagnosis. However, it is clear that certain psychological
factors (eg: one's beliefs, emotions, behavior, etc) may contribute to
the initiation or exacerbation of the physical condition. These
psychological factors, if present, are specified and recorded on Axis I
of the DSM-III-R diagnostic system. In today's lecture we will look at
some of these factors and how they effect physical health.
The physical conditions that have been associated with
psychological factors are numerous indeed: obesity, headache,
menstruation, chronic pain, acne, arthritis, asthma, ulcers, nausea and
vomiting, colitis, hypertension, diabetes, and cancer (APA, 1987; JCCP,
vol 50 (6), 1982). These disorders are also known as "psychosomatic" or
If you recall the beginning of the course, we talked about
something called "dualism": the philosophical position that the mental
and the physical are made up of different "stuffs" - you can't
understand one level in terms of the other. The famous French
philosopher of the 17th century, Rene Descartes, made one of the most
famous proposals for a dualistic view of nature in his Discourse on
Method: "I am a substance the whole nature of which is to think, and
which for its existence does not need any place or depend on any
material thing" (Discourse, part IV). Such a view has had a profound
effect on traditional medicine. Although Descartes recognized that the
mental and physical realms can influence each other, traditional
medicine seemed more often to forget this point. Theirs was an extreme
form of dualism: the mind and body are separate to such an extent that
problems occurring at these levels are dealt with separately. A doctor
for bodily problems, a psychiatrist for mental problems. In large part,
this was because no one knew enough about how the mind and body works
A number of historical events lead to a shift away from this
dualistic view (Blanchard, 1982; Holden, 1980; Pomerleau, 1982):
A. Psychosomatic Medicine
During the 50's and 60's, psychoanalytic theorists attempted
to explain certain physical ailments in terms of psychological
processes rather than physical processes. For example, a number of
physical disorders seemed to have no clear or even possible
physical causes. Eg: Conversion Hysteria: blindness, paralysis,
numbness, etc with no possible physical explanation - does not fit
known neuroanatomy. Instead, the symptoms were hypothesized to be
due to anxiety, repressed guilt, impulses and memories,
intrapsychic conflict...that is, psychological factors.
These theories tended to be crude and mostly correlational in
nature (so it's difficult to talk about causation). Nevertheless,
the important point is that these theorists were arguing that the
mind and body are mutually influencing - they are not separate.
B. Biochemistry and Physiology
In the past 20 - 30 years, there have been important advances
and new findings in biochemistry and physiology. The role that
psychological processes play in health is increasingly being
recognized. EG: Stress and the immune system. We have repeatedly
seen examples of this in our discussions of etiology.
In addition, there have been important technological advances:
Measurement technology has developed to a level undreamed of 50
years ago. Processes once inaccessible are now open to our
scientific gaze. (ie: you can't study something if you can't
measure it). (Note: technology limits our understanding).
Example: Brain imaging.
C. Behavior Modification
During the 60's and 70's, behavior modification demonstrated
its usefulness in treating a wide range of psychological problems.
Behavior modification focused on teaching clients new skills and
placing the ultimate responsibility for the client's "mental
health" on the client. Behavioral oriented therapists eventually
began applying their powerful and reliable behavior change methods
to traditionally "medical" problems: obesity, smoking, etc. As a
result, there was a growing recognition in the medical field of the
role that behavior plays in physical health.
Around the same time, work began on what has been termed
"biofeedback". This is a procedure which allows a person to gain
control over his/her physiological responses - previously thought
to be purely automatic and reflex-like and thus beyond our
The process: immediate feedback on biological processes (body
temperature, heart rate, gastric acid secretion, muscle tension,
etc). The client, with this feedback, is able to learn how to
modify his/her biological responses.
Example: Control over blood flow (and thus body temperature)
via temperature probe attached to finger tips. When blood flow
increases above some predetermined threshold, a tone will sound.
The client is instructed to decrease blood flow in the hand.
He/she does this by learning to keep the tone from sounding (the
tone indicating increased blood flow).
Demonstration: Ask for volunteer; hookup with EMG biofeedback
equipment (if available).
People are able to learn this control, although the mechanism
is unclear as to how this works. Biofeedback may simply be having
the same effect as relaxation training - reduced physiological
arousal (eg: Silver & Blanchard, 1978).
This technique was soon applied to a whole host of medical
problems, especially those problems that were being linked to
psychological factors (eg: headaches, hypertension, ulcers).
[Note: the reliability of this technique has come under question in
recent years - it is not the "cure-all" it is sometimes claimed to
be. Much more research is needed (Agras, 1984)]
E. Medicine and Public Health
During the late 60's and early 70's, infectious diseases (the
focus of the medical field) were essentially conquered. The
interest shifted to heart disease, cancer (now the 2 main killers)
and other chronic health problems (eg: smoking). It was recognized
that psychological factors are important in the etiology and
maintenance of these disorders.
III. A New Paradigm: Behavioral Medicine
Out of these developments, a "new paradigm" (Gentry, 1984; Holden,
1980) or approach to medical disorders arose: This new paradigm is
referred to as Behavioral Medicine. This approach emphasizes the
importance of a "systems theory" perspective when trying to understand
and deal with medical problems. (The biopsychosocial model we discussed
earlier is an example of a systems approach). An individual's health
must be understood in the context of a system. This system includes
complex, ongoing feedback loops between many subsystems: physiology,
neurochemistry, behavior, psychology, the environment, and so on.
Illness is potentially a quite complex experience. A division between
the Mind and the Body becomes difficult to maintain; the two are not
different stuffs, but are part of a complex psycho-physiological system.
This approach necessitates an interdisciplinary effort: knowledge
from various fields must be integrated if we are to fully understand and
treat "medical" problems (Gentry, 1984, Weiss, 1982 -see Handout 19-1:
illustrates the numerous fields that will play a role in behavioral
Some of the key etiological factors and mechanisms that have been
identified (Pomerleau, 1982; Weiss, 1982) include:
1. Biological processes per se.
2. The role of biological and psychological processes as part of a
3. The behavior of health-care providers (delivery of services)
4. Adherence to treatment ("compliance"). (eg: taking
medications, following a diet)
5. Behaviors that are risk factors (eg: life style).
6. The effect of interpersonal relationships on health.
Likewise, intervention will address these various levels.
It is clear from this perspective that in many cases physical
health and psychological processes can not be separated.
IV. Physical Disorders Associated with Psychological Factors
Numerous physical disorders are associated with psychological
factors. Your book reviews some of these disorders: Coronary heart
disease, anorexia/bulimia, essential hypertension, peptic ulcers, and
tension and migraine headaches. In today's lecture, we will examine
A. Chronic Pain
Chronic pain is one of the most prevalent and difficult
problems physicians treat; it is one of the leading medical
problems. The typical drug treatments used for acute pain are
usually ineffective, and carry with them a whole host of negative
side effects when used long-term (Keefe, 1982).
Physicians are increasingly recognizing the role that
behavioral, psychological and environmental factors play in chronic
pain. An assessment of these factors may be as important as a
medical exam (Fordyce, 1976). No longer is pain (esp. chronic
pain) seen as simply the experience of tissue damage. While this
may account for acute pain, it does not explain the continuation of
pain after tissue damage heals (Melzack & Wall, 1982; Philips,
1. Overt Behavior: Well behaviors (eg: activity, exercise)
and Pain behaviors (eg: med. intake, time spent in bed,
guarded movements). In many cases of chronic pain, the Pain
behaviors are being reinforced by other people. When the
individual exhibits pain behavior, s/he receives sympathy,
attention, or other so called "secondary gains". That is,
there are pay-offs for being in pain.
Those patients who cope with their pain by engaging in "well-
behaviors" report less pain than those who do not engage in
those behaviors (Keefe, 1982).
2. Mental factors: How the individual responds to his/her
pain can have a profound impact on the subjective experience
of that pain (Keefe, 1982; Melzack & Wall, 1982). Possible
-catastrophizing: "blowing the pain out of
-feeling out of control, helpless.
-anger, fear etc
[these can all intensify the pain, lead to
-reinterpretation of sensations
-saying positive, reassuring things to yourself
A person with chronic pain will do things to try to tolerate,
minimize or reduce his/her pain. Sometimes, however, the
person's responses to pain may exacerbate the pain. Eg: If I
keep telling myself the pain is unbearable, then it probably
3. Self-report: What someone says to others about his/her
pain may play a role in the development and maintenance of the
pain. As his/her overt behaviors may engender "secondary
gains", so too might his/her self-report lead to reinforcement
(Fordyce, 1976, Keefe, 1982).
Sum: We can see that behavioral, psychological and
environmental factors come into play in the experience of
Psychological factors have been found to be associated with
both the etiology of cancer and its treatment.
a) Personality factors: Some studies have linked certain
personality traits with cancer (Krantz & Glass, 1984). These
traits include helplessness, moodiness, emotional repression
("bottling up" strong feelings). These findings, however, are
far from certain. While there may be an association between
personality and cancer, there is presently little convincing
evidence of a causal relationship (Krantz & Glass, 1984).
b) Stress: Stress has been shown to disrupt the immune
system, making the body more vulnerable to a wide range of
viruses and other disease agents. To the extent that certain
cancers are virally caused, stress may play an important role
it the etiology of these cancers. Animal studies have
supported this relationship - stress does interfere with the
immune system. Eg: rats implanted with tumor cells were less
likely to be able to fight off the disease when experiencing
inescapable shocks (a stressor) than were rats without shocks
or with escapable shocks (Ader & Cohen, 1984; Visintainer,
Volpicelli & Seligman, 1982). Similar patterns have been
found with humans: In general, high stress or numerous
stressors are associated with depressed immune defenses (Ader
& Cohen, 1984).
Psychological factors also play a role in the treatment
of cancer - or more accurately, these factors can interfere
Chemotherapy is one of the most widely prescribed methods of
treating cancer (Redd & Andrykowski, 1982). Such treatment
involves adminstration of chemicals that are toxic to the
cancer cells. Such treatment often requires a long time to be
effective - repeated treatments are necessary. Unfortunately,
these chemicals are toxic to much more than the cancer cells.
They also attack the intestinal tract, the tissue of the bone
marrow, and the reproductive system, to name but a few (Redd &
Andrykowski, 1982). These effects lead to various aversive
reactions in the patient: nausea, vomiting and diarrhea.
These side effects can last anywhere from 2 to 24 hours after
the chemotherapy session.
As a result, approximately 25% of the patients develop
aversion reactions prior to subsequent treatment sessions
(Redd & Andrykowski, 1982): nausea, etc occurs before
receiving the drugs. This has been termed "anticipatory
What is occurring in these situations is the patient comes to
associate reactions to the drugs with the sights, sounds,
smells, thoughts, etc that accompany the treatment.
Eventually, mere exposure to these things (sights, sounds,
etc) elicit the aversion reactions. This is a case of
Classical Conditioning (the basic process of which we have
discussed in earlier lectures):
It is increasingly being recognized by medical practitioners that
the most effective treatment for certain physical disorders will need to
take into account psychological factors. In the disorders we discussed
today, this was very clearly the case:
1. Alter consequences of pain behaviors. Eg: withhold
reinforcement for pain behaviors while simultaneously reinforcing
2. Teach new methods of coping and self-management. Eg:
relaxation training, biofeedback, even assertion training (learn
how to state your needs directly rather than passively by being
sick) (Keefe, 1982).
1. Relaxation training to counter the effects of stress.
Learning better ways to cope with and gain control of life stress.
2. Learn responses that are incompatible with the anticipatory
nausea. Some of the techniques to aid in the learning of these
responses include relaxation training, systematic desensitization,
biofeedback (Redd & Andrykowski, 1982).
US ---> UR chemicals ---> nausea
US + CS ---> UR chem's + sights, etc ---> nausea
CS ---> CR sights, etc ---> nausea