The mind’s role comes into focus
Dr. Marc Feldman thought he could help sick people get better -- if he could only get them into his office. But patients often canceled their appointments upon arriving at his Duke University clinic, and Feldman soon figured out why. It was the sign on his office door: “Psychosomatic medicine.”
“They were convinced that I was going to tell them, ‘It’s all in your head,’ ” said Feldman, a psychiatrist now practicing in Birmingham, Ala.
That was the late 1980s. Since then, patients and doctors alike have come to better understand how the mind and emotions affect physical illness, a field known as psychosomatic medicine. In March, the American Board of Medical Specialties will decide whether to create a medical subspecialty in it. The designation would lead to more specific training, easier identification of experts and improved insurance reimbursement.
Hundreds of psychiatrists have asked for the designation, which they say is a first step in helping patients get appropriate treatment. “When you make a specialty official, you increase the likelihood of people finding you,” said Dr. Nina Stotland, a professor of psychiatry and obstetrics-gynecology at Rush Medical College in Chicago.
And Kaiser Permanente, the state’s largest HMO with millions of members, has launched a program that uses mind-body techniques to help people with chronic health conditions. It has proved so effective it will be made available free to Kaiser members and some nonmembers beginning in spring.
“I’m surprised it has taken medicine so long to recognize what is obvious; how single-minded and relentless we’ve been in reducing and separating mind and body in medicine,” said Dr. David S. Sobel, director of patient education at Kaiser Permanente.
The barriers separating the treatment of physical illness from thoughts, feelings and attitudes haven’t fallen entirely, however. Many people still don’t understand psychosomatic medicine, often mistaking it for imaginary illnesses; few hospitals and doctors know where to send patients who may need it; insurers often don’t pay for it; and even experts aren’t sure what methods work best for specific illnesses.
But scientists now have proof that the mind-body connection exists. Studies have revealed that around 20% of people with heart disease also have depression, that stress exacerbates gastrointestinal disorders and that attitude can influence survival time for people with terminal illnesses. Experimental programs have demonstrated that techniques such as relaxation, group support, imagery, meditation, even prayer, can alter the course of some illnesses, decrease symptoms and reduce hospital stays and medication. High-tech equipment, such as brain imaging studies and other body scans, have shown that relaxation can slow blood flow and that frightening emotions can trigger spasms in the gut.
“This is cool stuff that you can’t argue against anymore,” said Marc Schoen, an assistant clinical professor of medicine at UCLA. “We can now say, arguably, that almost everything becomes psychosomatic.”
Psychosomatic conditions are real disorders that are caused or exacerbated by one’s mental or emotional state. They can include:
Body symptoms caused by psychological distress, such as stomachaches that occur in a child who doesn’t want to go to school.
Disease that results from -- and whose course is influenced by -- unhealthy behavior.
Medical diseases, such as arthritis, heart disease, cancer and AIDS, that are affected by stress, coping skills and social support.
After years of battling severe asthma, Mary Ann Marcuzzi, a 44-year-old human resources executive in San Diego, found that the most effective treatments used both traditional medicines and psychological techniques. Diagnosed at 19, Marcuzzi came upon a doctor who prescribed biofeedback and stress management in addition to medication. Later, Marcuzzi learned to use self-hypnosis and guided imagery when she felt her lungs beginning to spasm.
“My asthma tends to kick up when I’m frustrated or angry,” she says. “I go to my office, close the door and go to a special place in my head. I picture myself in a meadow, sitting in the grass, breathing in the healing air.”
The need to use psychosomatic medical principles in everyday health care is greater now than ever, experts say. More emphasis on the psychological impact of illness might help patients comply better with treatments and reduce hospitalizations and other services that fuel rising health-care costs.
About 25% of people who visit the doctor have physical symptoms most likely caused by their emotional state, Sobel says. And as many as 80% show signs of significant psychological distress resulting from physical ailments.
The Kaiser program, for example, will address the growing costs of chronic conditions. The six-week class teaches mind-body strategies to control symptoms and improve health.
It was previously offered to only a few patients, such as those with two serious, but related, disorders, who then paid a fee to attend the workshops. But emotional and psychological elements affect so many ill people that the health plan decided it might be able to save money -- and improve care -- by making the program open to anyone, free of charge.
The program is an outgrowth of a 1999 study developed by Kaiser and Stanford University in which patients with chronic conditions met for seven weeks in a two-hour group session with a trained lay leader. Participants had fewer hospitalizations, shorter hospital stays, spent more time exercising, communicated better with doctors and had less fatigue, disability and other limitations than those who didn’t participate in such a program.
Some doctors, however, bungle their attempts to apply mind-body medicine by appearing to blame the patient for his or her symptoms, says Stotland. This can be especially true in disorders that are poorly understood and difficult to diagnose, such as chronic fatigue syndrome or fibromyalgia.
“The minute you say, ‘You have an anxiety disorder on top of your cardiac disorder,’ it becomes a stigma,” says Stotland. “We all know perfectly well that emotions affect the body. But there is a way to make it make sense to people and take away the stigma.”
The efforts to bring mind-body medicine to the masses has also been hampered by the lack of insurance coverage.
Despite the fact that half of his patients are referred to him by other doctors, UCLA’s Schoen says that he often has to battle insurance companies to obtain coverage for patients.
“There is no coverage for stress management unless there is some sort of definable mental disorder you can attach to it,” says Schoen.
Psychiatrists say they hope that approval of a new specialty -- they would be called psychosomatic doctors -- will lead to better reimbursement rates by insurers and more inclusion of psychosomatic doctors on hospital and clinic staffs.
Although psychosomatic medicine addresses both physical and mental health, many insurance plans have separate reimbursement systems for physical and mental care, which can create problems for patients and their doctors.
Insurers may also be reluctant to cover psychosomatic treatments because of a lack of evidence on which approaches work best for particular conditions and because not all therapies work for every patient, Sobel says.
But that position, he adds, ignores the now-overwhelming evidence that people frequently get better faster and spend fewer health-care dollars when their treatment encompasses their behavior, thoughts and feelings. “I use this metaphor: If this were a drug that produced these kinds of effects ... wouldn’t we be using it?”
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Powerful proof
Several studies over the last two decades have demonstrated how strong the link can be between the body and the mind.
In 61 patients with osteoarthritis in the knee, Italian researchers writing in the Journal of Rheumatology found that depression levels better predicted the patients’ disability and pain than did the extent of their knee damage.
In 198 patients with heart disease, University of Washington researchers found that measures of anxiety and depression better predicted patients’ health status one year after cardiac catheterization than did the severity of narrowing in the coronary arteries.
A Duke University study of 107 heart disease patients found that relaxation, cognitive therapy and a lowering of hostility reduced the risk of further heart problems by 75% compared to people given the usual medical care and medications.
In a UC Davis study, 335 patients about to undergo surgery were randomly assigned to listen to one of four different audiotapes before and after surgery. The group that listened to a tape with guided imagery, music and specific suggestions of diminished blood loss and rapid healing had 43% less blood loss and spent one less day in the hospital compared to people who listened to other kinds of tapes.
A landmark 1991 study in the Journal of the American Medical Assn. found that women who were assisted by a trained support person (a doula) during childbirth had greatly reduced rates of caesarean section and anesthesia use.
