Essentials of Complementary and Alternative Medicine (June 1999)

CHAPTER 26. B
EHAVIORAL
 M
EDICINE
G. Randolph Schrodt, Jr. and Allan Tasman
Background
 
Definitions
 
History and Development
 
Principal Concepts of the System
Provider-Patient Interaction
Therapy and Outcomes
 
Treatment Options
 
Treatment Evaluation
Organization
Prospects for the Future
Chapter References
BACKGROUND
Definitions
Behavioral medicine is “the application of the theory and practice of modern behavioral sciences to the theory and practice of modern medicine” (
1
). Behavioral 
medicine is deeply rooted in conventional medicine, especially through its emphasis on the scientific method and empirical research. In distinction to conventional 
medical practice, however, health and illness are not conceptualized in either predominantly biological or physical terms. In addition, behavioral medicine is frequently 
not taught in medical schools, not used extensively in hospitals, and not reimbursed by health insurance.
Clinicians who practice in a behavioral medicine model distinguish between a patient's  disease and his or her sickness. Conventional Western medical training and 
clinical practice have focused predominantly on the  objective aspects of tissue/organ pathology and pathophysiology (disease). Behavioral medicine offers a 
paradigm that incorporates the subjective experience, which includes the personal  meaning and cultural and interpersonal  context of illness and healing, as well as 
the associated behavioral responses to physical illness (sickness). Moreover, these attitudes, emotions, and behaviors are also considered to be critical factors in the 
etiology of disease.
Behavioral medicine is a multidisciplinary field concerned with the development and clinical evaluation of interventions that enhance patients' “active, informed and 
responsible roles in understanding the precursors of their illnesses, the disease process itself, the management of recovery, and the subsequent adoption of 
beneficial life routines” (
2
).
History and Development
The origins of behavioral medicine within psychiatry stem from studies of psychosomatic illnesses. After World War II, this research was based on an understanding 
of psychopathology from the psychoanalytic theoretical perspective, which predominated at the time. These studies focused on discerning whether particular physical 
illnesses that had no known etiology at that time, such as rheumatoid arthritis, asthma, and ulcerative colitis, were caused by psychological stress (
3
). This interest in 
the possible relationship between mental functioning and physical illness stimulated a variety of changes in psychiatric practice. One change was the development of 
general hospital-based psychiatric units (
4
). The development of these units allowed for better integration of psychiatry into general medicine and a focus on patients 
whose illnesses appeared to lie at an intersection of psychological and physical etiologies. Coincident with the development of these units was the evolution of 
consultation/liaison programs in psychiatry, which focused on patients whose primary disorder was a physical one, but in whom the stress of the physical illness 
precipitated psychiatric problems (
5
).
These events of the 1940s and 1950s influenced the work of George Engel, who coined the word  biopsychosocial to reflect the importance of understanding the 
multifactorial interactions of biological, psychological, and social influences in a patient's presentation (
6
). The natural evolution of a biopsychosocial approach has 
included a focus on illnesses whose origins are clearly behavioral. Early behavioral medicine programs that developed in the 1960s focused on such issues as 
smoking cessation and weight loss as adjuncts to the treatment of patients who had significant smoking- or obesity-related illness or risk for disease.
In more recent decades, behavioral medicine programs have begun to focus on the importance of self-monitoring, self-care, self-awareness, and compliance with 
treatment for patients who have a wide range of physical problems (
7
). Using predominantly psychosocial treatment methods, which are described later in this 
chapter, modern behavioral medicine programs provide intervention for patients who have severe chronic illnesses such as cancer (
8
, 
9
 and 
10
), cardiovascular 
disease (
11
, 
12
 and 
13
), chronic pain (
14
, 
15
, 
16
, 
17
 and 
18
), diabetes (
19
, 
20
), and rheumatologic diseases (
21
, 
22
 and 
23
). Cognitive-behavioral psychotherapies 
have come to play a more predominant role in behavioral medicine programs than have psychoanalytic-derived therapeutic interventions (
24
).
Principal Concepts of the System
Treatment of sickness is facilitated when both the patient and clinician share a common conceptual model that can provide a guide for treatment interventions. 
Figure 
26.1
 is a graphic representation of a basic cognitive-behavioral medicine model that may be introduced to the patient early in the course of treatment. This model 
emphasizes the interrelationship between stressful life events, cognitive processes, emotional and physiological reactions, and behavior.
F
IGURE
 26.1. The cognitive-behavioral medicine model.
S
TRESSFUL
 L
IFE
 E
VENTS
The initial premise of the cognitive-behavioral model is that emotions, physical reactions, and behaviors are not triggered by events per se, but rather by the 
individual's cognitive appraisal of these events (
25
, 
26
 and 
27
). Therefore, until a life event, symptom, or disease process is perceived, processed, and the meaning is 
established, the person generally does not experience an emotional reaction or behave differently. Any situation (health-related or otherwise) may constitute an event 
in this model. Events may include actual or imagined situations (e.g., visiting the doctor's office or anticipating the results of a diagnostic test), as well as past, 

present, or future experiences (e.g., the memory of a painful examination, shortness of breath, or expectations of future impact on one's family after being diagnosed 
with cancer).
Mind–body research has focused on a variety of stressful life events that appear to have particular relevance to health and illness. Studies have shown that 
disruptions of interpersonal relationships, such as the death or serious illness of a spouse or child, are often associated with a strong negative impact on health and 
well-being (
28
). Other stressful events, including divorce or separation, social isolation, loss of a job, financial problems, or  role strain—that is, the competition 
between various life demands—may also lead to adverse health effects (
29
, 
30
). However, regardless of the pathogenic potential of stressful life events, individuals 
vary considerably in host  susceptibility. A growing body of research suggests that an individual's thinking style may be the critical mediating factor in the stress 
response.
C
OGNITIVE
 A
PPRAISAL
: Y
OUR
 T
HINKING
 M
AY
 B
E
 K
ILLING
 Y
OU
Several factors can influence an individual's cognitive appraisal of an event. First,  awareness of an event is required. In some situations, the early stages of disease 
processes are relatively asymptomatic (e.g., heart disease or cancer) and do not trigger cognitive/emotional/behavioral reactions because the illness is not perceived. 
Likewise, some behaviors (e.g., a diet high in saturated fats or unprotected sex) do not intuitively suggest potential adverse health effects. Unless an individual is 
informed of the potential negative implications of a situation or behavior, change is unlikely. This is the fundamental principle of personal and public health education 
efforts.
Unfortunately, information alone is often insufficient to change ingrained attitudes, beliefs, and behaviors. In some cases, psychological defense mechanisms, such as 
denial or repression, may diminish an individual's awareness of a potentially dangerous situation. However, these defense mechanisms may not always be 
maladaptive. For example, women undergoing chemotherapy for breast cancer tolerate the procedure best if they are able to employ distraction and other cognitive 
avoidance techniques (
31
). Likewise, patients who have chronic pain disorders often find relief if they can employ these same approaches (
16
, 
17
). Nevertheless, 
even patients who have breast cancer or chronic pain need to be aware of and informed about their illness and treatment options to be effective partners in the 
healing process.
The conscious awareness of an event usually triggers  automatic thoughts. Automatic thoughts and mental images occur rapidly and are often not subjected to close 
scrutiny or logical analysis (
25
, 
26
 and 
27
). These thoughts and images often appear to be a totally plausible and accurate representation of reality, although they 
may in fact be distorted or incorrect. For example, some individuals misinterpret epigastric pain as indigestion when in fact they are having a myocardial infarction. In 
contrast, patients who have somatization and anxiety disorders may catastrophize the significance of relatively minor somatic sensations. In each case, the subjective 
reality of the symptom is different than the objective evidence indicates, and this subjective perception will trigger emotional and behavioral responses that are 
markedly different from those based on an objective evaluation.
Changing Health-Related Behaviors
Behavioral medicine researchers have begun to elucidate the complex cognitive processes that are involved in the establishment, maintenance, and change of 
health-related behaviors (
32
, 
33
 and 
34
). The process of changing a behavior (e.g., stopping smoking or drinking) or initiating a new behavior (e.g., exercise, 
measuring blood sugar levels each day, learning to meditate) involves a series of cognitive assessments and decisions that ultimately determine behavioral intent and 
motivation. Readiness to change behavior can be seen to involve movement through various stages:
1. Precontemplation (not thinking of change)
2. Contemplation (considering change but not actively trying)
3. Preparation (early steps are taken and trial efforts to change are made)
4. Action (initiation of behavioral change)
5. Maintenance (continued change for more than 6 months) (
32
)
Some of the cognitive processes involved in these transitions include personal risk assessment, perception of costs versus benefits of change, expectations of 
outcome, and compatibility with sociocultural norms. Positive or negative feedback from others after initiating new behaviors also can be a powerful influence in this 
process. In many cases, an individual's conclusion regarding a health behavior may appear illogical, even ridiculous to the health care professional or others. In fact, 
research suggests that most people evaluate risk predominantly from an emotional rather than logical point of view (
35
). This may partly explain how an individual 
could insist on drinking bottled spring water but not wear a car seat belt, despite the fact that he or she is more likely to die from a motor vehicle accident than from 
drinking contaminated tap water.
As the patient and clinician explore thinking processes through the course of treatment, basic organizing themes or  schemas begin to emerge (
25
, 
26
 and 
27
). 
Schemas are deeper cognitive structures, which may operate outside of one's usual conscious awareness. They include the fundamental rules or assumptions that 
act as templates for screening, filtering, processing, and evaluating the significance of experiences. Stressful situations and life events, particularly health-or 
illness-related events, may activate latent maladaptive schemas, such as, “I don't function well under stress,” “I'm not a real man if I can't work,” or, “It's a sign of 
weakness to ask for help.” These basic beliefs and assumptions influence the perception of events and increase the frequency of distorted automatic thoughts.
Chronic Illness
Chronic illness is commonly associated with a pervasive sense of  helplessness (
7
, 
34
). Even patients who demonstrate effective coping during acute illnesses may be 
overwhelmed by unrelenting pain or other symptoms; the need for ongoing medical care; uncertainty of outcome, relief, or cure of symptoms; and the disruption of 
normal lifestyle patterns and relationships resulting from chronic illness.
Not all patients who have chronic illness, however, adopt this posture of helplessness. Seligman (
36
) has focused on the value of optimism in effectively dealing with 
illness. In his and other researchers' studies of attributional style (how people explain the causes of events), they have identified a distinct difference in how optimistic 
individuals think about stressful life events compared with pessimists (
36
, 
37
 and 
38
).
Pessimists tend to interpret negative events in global (“I'm useless to my family.... I can't do anything anymore”), personalized (“I'm weak”), and persistent (“It'll never 
get better”) terms. This outlook is associated with a diminished sense of  self-efficacy (
20
), decreased effort when confronted with problems, and a hopeless outlook for 
the future. In contrast, optimistic individuals view negative life events as more specific (“This illness will require that I make some modifications in my work load”), 
externalized (“I am not my illness”), and variable (“I can influence the outcome of this illness”). Compared with their more optimistic peers, persons who have a 
pessimistic explanatory style at age 25 are predicted to have poorer health status in later life (
38
).
Stress Hardiness
Certain attitudes appear to convey a type of immunity to the negative impact of stressful life events and situations. Kobasa and her colleagues (
39
) have identified 
three characteristic attitudes of  stress hardiness: control, challenge, and commitment. An increased sense of personal control is generally associated with improved 
tolerance of stressful events. Some events, however, such as undergoing surgery, are not under direct personal control. However, even in these cases, an ability to 
discriminate between events that can be controlled and those that cannot be controlled, and to focus one's efforts on the former, appears to be the most effective (and 
least distressing) problem-solving strategy (
40
). Stress-hardy individuals also perceive problems as challenges rather than burdens or overwhelming obstacles. As 
demands increase, they exhibit greater effort toward the identification of possible solutions and alternatives as well as the design of problem-solving strategies. 
Finally, a deep sense of commitment to a personal or higher purpose provides meaning and coherence in the midst of chaos and uncertainty (
41
).
Although it is difficult to compartmentalize the mechanism of action of most alternative and complementary therapeutic techniques, it is apparent that many involve the 
modification of cognitive processes. The basic doctor-patient relationship, psychotherapy, educational efforts, and even the healing aspects of visualization, ritual, 
and spirituality may all be understood as powerful tools that modify an individual's perception of reality and basic belief systems.
E
MOTIONAL AND
 N
EUROBEHAVIORAL
 R
EACTIONS
: T
HE
 B
ODY'S
 I
NNER
 D
IALOGUE
When an individual interprets an event or situation as dangerous, the  stress response is activated (
42
, 
43
). The stress response is a complex, coordinated cascade of 

neurobehavioral activation that has evolved as a basic survival mechanism. The most basic threat is to one's life or health. However,  danger thoughts may also 
extend to other vital interests, such as the welfare of loved ones, self-esteem, or financial security (
26
). In this respect, the use of the stress response for survival and 
well-being is straightforward. The capacity to predict and detect danger enhances the likelihood of success in negotiating the complexities of daily life. In fact, the 
absence of automatic thoughts of danger can be of great clinical significance. For instance, some adolescents display a distorted sense of invulnerability and 
omnipotence, and as a result, the actual dangers of drug use, reckless driving, and unprotected sex are not recognized.
The main neurophysiological components of the stress response involve increased release of corticotropin-releasing factor (CRF) from the hypothalamus, the 
activation of the sympathetic nervous system via the locus ceruleus/noradrenergic system in the brainstem, and the release of neuropeptides from various areas of 
the brain (
42
, 
43
). Increased CRF release activates the pituitary-adrenal axis and has other peripheral effects, including a major role in immunosuppression. The 
immune system and the brain communicate via hormones, neurotransmitters, and peptides such as cytokines, which results in reciprocal modulation of activity (
28
, 
44
, 
45
).
Specific Responses
Physiological features of the stress response include increased energy production (gluconeogenesis and lipolysis), increased muscle tension, increased respiratory 
rate, and increased cardiovascular tone (elevated blood pressure and heart rate). Neurobehavioral reactions include increased arousal, alertness, scanning, and 
vigilance. Emotional tone is altered, with increased subjective anxiety and apprehension. As suggested in 
Figure 26.1
, even the cognitive functions of perception, 
retrieval, and analysis of information regarding the environment are altered (
26
). Essentially, the individual is prepared to  fight, flee, freeze, or faint. Physiological 
activity that is relatively insignificant to immediate survival, such as feeding or reproduction, is suppressed so that all resources can be redirected toward coping with 
the threat.
In many circumstances, this stress response has positive adaptive value. Increased apprehension and an impulse to flee would probably be a rational reaction to 
turning a corner and walking into an unfamiliar dark alley in a major city. Likewise, when the  threat is time-limited, such as engaging in a sporting competition or 
driving on a busy interstate highway, the increased alertness and neuroendocrine and autonomic arousal may be beneficial.
Unfortunately, the characteristics of this innate alarm system evolved within an environment very distinct from that of contemporary culture. The instinct to run when 
threatened may enhance the likelihood of survival if one is being chased by a saber-toothed tiger, but this instinct is clearly maladaptive if the threat is a physician 
who wants to discuss a health problem. The freeze reaction may protect a deer in the forest from hunters, but it is a poor adaptive response if its paralyzing effect 
prevents a diabetic person from testing blood sugar levels or self-injecting insulin. Furthermore, chronic activation of the stress response system appears to be a 
major etiological factor in many chronic illnesses, such as cardiovascular disease; immune system disorders; and psychiatric illnesses, including depression, panic 
disorder, and addictions (
7
, 
42
, 
43
, 
44
 and 
45
). When the chronic stress is a chronic illness, neurobehavioral stress reactions may exacerbate the initial medical 
problem and impair adaptive coping behavior (
13
, 
22
, 
46
, 
47
).
Relaxation Response
The relaxation response is characterized by decreased arousal of the autonomic and central nervous system, lowered musculoskeletal and cardiovascular tone, and 
altered neuroendocrine function associated with restoration and repair of tissues (
48
). The relaxation response is elicited by a variety of mental states and techniques 
that are described in more detail later in this chapter and in other sections of this volume. In general, the relaxation response is associated with a general quieting of 
the usual flood of thoughts, daydreams, inner conversations, judgments, sensations, and emotions that characterize the waking consciousness. This state of 
consciousness is typically first elicited by focusing attention on a repetitive word or sound (e.g., mantra); stimulus (e.g., staring at a mandala or a flame); or behavior 
(e.g., one's breathing). Second, when intrusive thoughts, sensations, or feelings enter into awareness, the individual adopts a passive,  observer attitude and gently 
redirects focus back to the meditative word or sound (
41
).
Mind–Body Interaction
Although the concepts of stress and the relaxation response are well characterized and useful for patient education and clinical practice, it is an oversimplification to 
suggest that states of consciousness and associated neurobehavioral responses fit neatly into these two discrete categories. Walsh (
49
) has emphasized the need for 
researchers to take a more discriminating approach to defining, mapping, and comparing altered states of consciousness. For example, different forms of meditation 
are associated with variations in the level of arousal, concentration, awareness of the environment, and emotional responsiveness (
49
). Other researchers have 
identified differential effects of stress management strategies (e.g., biofeedback, hypnosis, meditation) with different medical disorders (
14
, 
50
, 
51
). Nevertheless, the 
intimate relationship between mental processes and physiological responses is well established and remains a fundamental principle of behavioral medicine theory 
and practice.