William Collinge MPH PhDRecent years have seen a growing body of research documenting the benefits of behavioral medicine in chronic illnesses. Many findings are relevant to CFIDS because they suggest that behavioral methods may help ameliorate some of its most difficult symptoms. While no such research with PWC’s has yet been published, there is sufficient scientific rationale to argue that behavioral medicine should be included as part of a comprehensive treatment approach.
“Complementary,” Not “Alternative”
One potential source of confusion about the role of behavioral medicine, which can lead to unnecessary bias against it, is the use of the term “alternative.” Particularly in the case of CFIDS, it should not be construed as an “alternative treatment” because it does not treat disease. Rather, it is complementary or adjunctive to appropriate medical treatment. Its goal is to support and enhance the person’s host resistance and help reduce the severity of symptoms.
Methods
The repertoire of behavioral medicine includes behavioral or psychological strategies which directly influence physiological states. The methods are applied in structured group programs, in individual therapy, and in daily practice at home.
The most fundamental and empirically supported of these strategies is induction of “the relaxation response.”‘ This is a physiological state with beneficial effects for a wide array of symptoms including pain (arthralgias and myalgias), insomnia, gastrointestinal disturbances, anxiety and depression.1Other common techniques include the use of mental imagery, hypnosis, biofeedback, and various breath therapy methods.
Relevant Research Findings
Following is a sample of demonstrated effects which appear to have important implications for the symptoms and disease process of CFIDS.
A controlled study measured the effects of a behavioral medicine program on symptoms of AIDS. The treatment group received training in biofeedback, guided imagery, and hypnosis. Results included significant decreases in fever, fatigue, pain, headache, nausea, and insomnia; and increased vigor and hardiness.2
A study of 48 patients with HIV who took a group behavioral medicine program found significantly reduced tension, anxiety, fatigue, depression, and total mood disturbance.3
A controlled study of immunological and psychological outcomes of a group program was conducted with malignant melanoma patients. Results included significant increases in large granular lymphocytes (defined as CD57 withLeu-7) and NK cells (defined as CD16 with Leu-II and CD56 with NKHI), along with indications of increased NK cytotoxic activity. There were also significantly lower levels of psychological distress, and higher levels of positive coping methods in comparison to patients who did not have the group.4
In another controlled study, subjects who were trained to induce the relaxation response showed a significant improvement in NK cell activity, as well as lower antibody titers to a herpes simplex type I antigen. In addition, there were significant decreases in symptoms of emotional distress.5
For another study, researchers examined the impact of regular induction of the relaxation response in ameliorating the effects of stress in healthy subjects. The frequency of practice of the technique was significantly and positively associated with the percentage of T-helper cells circulating in the blood.6
A controlled study of healthy adults measured the effects of relaxation and guided imagery on cellular immune functioning. Over a ten-day period, subjects practiced the techniques for an hour per day. A significant increase in NK cell function was demonstrated.7
A hypnosis/relaxation/imagery process was found in a controlled study to result in significant improvements in neutrophil adherence. (Neutrophils are important immune cells in defense against bacterial and fungal infection, and in mediating tissue damage in conditions such as inflammatory arthritis in autoimmune diseases.)8
Another study examined immune effects of a single 45 minute intervention using relaxation with imagery. Results included a significant increase in a mitogen measure and a marginally significant increase in white blood count.9
A study of metastatic cancer patients using a weekly group program and daily imagery processes for a year found significant improvements in NK cell activity, interleukin 11 levels, Rozet formation (total proliferating lymphocytes), IgA, IgG, mixed lymphocyte response, and other measures.10
A study examined the effect of a guided breath therapy experience on salivary immunoglobulin A (S-IgA). Forty-five participants in a group program gave samples before and immediately after the process, which involves abdominal breathing accompanied by post-hypnotic suggestion. A 46% increase in S-IgAlevels was found.11 (S-IgA is the body’s first line of defense against pathogens entering through the mouth and nose which produce, among other illnesses, respiratory tract infections [colds, flu, sinusitis, etc.]12)
A controlled study of a group program for metastatic breast cancer patients found a near doubling of survival time compared with controls receiving only conventional treatment.13 It may be presumed, if the immune system is the main defense against cancer progression, that improved immune functioning was probably a factor.
The effects reported on NK cells in some of the above studies are especially important for CFIDS in that depressed NK cell activity is one of the features of this syndrome.
It should be understood that statistically significant findings do not necessarily translate into tangible clinical benefits for patients. Such findings do, however, support the notion that potentially beneficial physiological effects are possible. One can only imagine the demand if a drug were developed which could achieve the above results at no cost, with no side effects, and no toxicity.
Learning from Other Illnesses
CFIDS is obviously an organic disease, probably of an infectious origin. However, while its etiology is clearly not psychogenic, this does not mean that clinically significant benefits cannot be gained by the incorporation of psychotherapeutic and behavioral approaches. Cancer, heart disease, and AIDS have all gone through stages of evolution in which behavioral interventions were first considered irrelevant, then shunned as irresponsible or “unproven,” and finally, in the face of convincing data, embraced as essential to comprehensive care.
Psychoneuroimmunology researcher Alastair Cunningham articulates this point well with regard to cancer: “Although epidemiological considerations suggest that the contribution of psychological factors to cancer onset is small… no upper limit to what can be achieved (by psychological intervention) is necessarily thereby set: the relative influence of the psyche on outcome may be greatly expanded by such therapy, overriding the usual progression of disease.”14 Might this reasoning apply to CFIDS as well?
Risks and Limitations
All forms of medicine carry risks. The main risk in behavioral medicine is its potential for psychosocial morbidity, usually in the form of self-blame. If the patient has unrealistic expectations about what they believe should happen in using such techniques, and they don’t get the results they expect, they may conclude, “I must be doing it wrong,” and perhaps have a sense of failure or inadequacy.
The fact is that one can do everything right and still have symptoms. These techniques are a contribution to a comprehensive treatment approach overtime, but are not curative in themselves. The degree of the contribution will vary from one person to the next, but there are no guarantees. Care providers need to address this fact directly with PWC’s who are using such approaches, to assure that they have a realistic perspective.
Another risk is over-reliance on these approaches at the exclusion of other forms of medicine. It bears repeating that behavioral medicine is complementary to other effective forms of treatment, not exclusive.
One limitation is that many methods require an ability to sit quietly and, in some cases, focus the mind on the process. Some patients suffering from extremes of agitation, cognitive dysfunction, or debilitating fatigue may at times have difficulty following through with a routine of regular practice. Those who do best are able to sustain a regular practice and achieve cumulative benefits over time.
Conclusions
Clinical experience indicates that PWC’s who use behavioral self help strategies in this complementary way have better medical outcomes, and improved self-efficacy in managing many symptoms, than those who rely solely on medical intervention alone.
The challenge of living with a serious illness for which there is no medical cure provokes us to explore all options. There is a real danger in “false despair” if one believes oneself to be powerless.
Until a medical cure is discovered, there is a great deal PWC’s can do to help themselves manage symptoms, improve their quality of life, and promote their well-being. Kept in proper perspective, behavioral medicine can make a significant contribution to a comprehensive approach.
References
1. Benson H. The Relaxation Response, New York: Avon Books, 1975,and Beyond the Relaxation Response, New York: Berkley Books, 1985.
2. Auerbach JE, Oleson TD, Solomon GF. A behavioral medicine intervention as an adjunctive treatment for HIV related illness. Psychology and Health1992; 6:325-34.
3. Collinge, W. (1989). H.I.V. and quality of life: Outcomes of a psychosocial intervention program. Tenth Annual Proceedings, Society of Behavioral Medicine, p. 41.
4. Fawzy FI, Kemeny ME, Fawzy NW, Elashoff R, Morton D, Cousins N, FaheyJL. A structured psychiatric intervention for cancer patients. II. Changesover time in immunological measures. Archives of General Psychiatry1990; 47:729-35.
5. Kiecolt-Glaser J, Glaser R, Williger D, Stout J. Psychosocial enhancement of immunocompetence in a geriatric population. Health Psychology1985; 4:25-41.
6. Kiecolt-Glaser J, Glaser R, Strain E. Modulation of cellular immunity in medical students. Journal of Behavioral Medicine 1986; 9:311-20.
7. Zachariae R, Kristensen JS, Hockland P, Ellegaard J, Metze E, HoklandM. Effect of psychological intervention in the form of relaxation and guided imagery on cellular immune function in normal healthy subjects. Psychotherapyand Psychosomatics 1990; 54:32-9.
8. Hall HR, Minnes L, Tosi M, Olness K. Voluntary modulation of neutrophil adhesiveness using a cyberphysiologic strategy. International Journal of Neuroscience 1992; 63:287-97.
9. Hall HR, Mumma GH, Longo S, Dixon R. Voluntary immunomodulation: A preliminary study. International Journal of Neuroscience 1992; 63:275-85.
10. Gruber B, Hall N. Immune system and psychological changes in metastatic cancer patients using relaxation and guided imagery: A pilot study. ScandinavianJournal of Behavior Therapy 1988; 17:25-45.
11. Collinge W, Kabbal J. Evocative breath therapy and immunoenhancement: a pilot study. Manuscript submitted for review.
12. Tomasi TB. The Immune System of Secretions. Englewood Cliffs: Prentice Hall, 1976.
13. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effects of psychosocial treatment on survival of patients with metastatic breast cancer. TheLancet October 14, 1989, 888-91.
14. Cunningham AJ. The influence of mind on cancer. Canadian Psychologist1985; 26:13-19.
Dr Jacob Teitelbaum MD
Daniel Redwood DC
Tom Ferguson MD
