Mood disorders, depression, brain chemistry relationship to weight loss and sleep disorders – Psychotherapist Review and Commentary
Robert A. Anderson
Low back pain-hypnosis
Fifteen adults 18-43 years of age with chronic low back pain (mean duration 4 years) were found to be moderately/highly hypnotizable based on the modified 11-point Stanford Hypnotic Susceptibility Scale. Somatosensory event-related potential correlates of noxious electrical stimulation were evaluated during attend (control) and hypnotic analgesia conditions at anterior frontal, midfrontal, central, and parietal brain regions. Significant brain inhibitory processing was evidenced in different brain locations (p<.05 – p<.001) compared to the control condition. Hypnotic analgesia led to highly significant mean reductions in perceived sensory pain and distress (p<.001). Participants were then shown to develop self-efficacy through the successful transfer of newly learned skills of experimental pain reduction to reduction of their own chronic pain; within 3 sessions, they reported chronic pain reduction, increased psychological well-being, and increased sleep quality. In 60% the pain was totally gone and in 80% the distress was totally gone by the end of the 3rd session. Hypnotic analgesia is an active process that requires inhibitory effort, dissociated from conscious awareness, in which the anterior frontal cortex participates in a topographically specific inhibitory feedback circuit that cooperates in the allocation of thalamocortical activities. The development of "neurosignatures of pain" can influence subsequent pain experiences, and may be expanded in size and easily reactivated.
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Crawford HJ et al. Hypnotic analgesia: 1. Somatosensory event-related potential changes to noxious stimuli and 2. Transfer learning to reduce chronic low back pain. Int J Clin Exp Hypn 1998 Jan; 46(1):92-132.
Comment: This study suggests that hypnosis and other psychological interventions need to be introduced early as adjuncts in medical treatments for onset pain before the development of chronic pain. Pain control and sleep quality were significantly improved. Chronic pain is one of the leading reasons why patients seek medical care. The commonest conventional medical responses are prescriptions for analgesics and psychotropics. The disadvantages of these classes of drugs are the potential for addiction with analgesics and for undesirable alteration of mood and mental clarity with psychotropic medicines. Use of behavioral approaches such as hypnosis used here bypasses these hazards and empowers patients to be more fully in charge of their own awarenesses and internal voluntary controls. My own personal coping with chronic low back pain from a congenital spondylolisthesis has been enhanced most of all with regular meditation and associated programmable imagery. While some mystery about these “soft” processes remains, they are far more powerful than most practitioners would think, and these approaches are grossly underused in medical care.
Insomnia/stress
Fifteen adult insomniacs <40 were studied for activity of the "stress system" (hypothalamic-pituitary-adrenal axis and the sympathetic nervous system). A baseline night of measurements showed mean sleep latency to be 41 minutes. Mean disturbances were 7% in stage 1 sleep, 66% in stage 2 sleep, 23% in REM sleep and 3% in slow-wave sleep. Each subject then spent 3 nights in the sleep lab. 24-hour urinary free cortisol values were correlated with total wake time (p=.05). Catecholamine metabolites (DHPG–dihydroxyphenylglycol, and DOPAC–dihydroxyphenylacetic acid) were positively correlated with the percentage of stage 1 sleep disturbance (p<.05) and wake time after sleep onset (p<.05). Growth hormone was not significantly correlated.
Vgontzas AN et al. Chronic Insomnia and Activity of the Stress System: A Preliminary Study. J Psychosom Res 1998 Jul; 45(1):21-31
Comment: Stress, as evidenced by cortisol and catecholamine output, was significantly correlated with aspects of insomnia. Cortisol levels appear to be throttled back at night in healthy individuals. Perception of stress, elevated night-time cortisol output, blunted immune responses and poor sleep are associated phenomena which tend to move together. Poor sleep then becomes an additional stress and the cycle is ratcheted up one notch. So, better handling of stress, and behavioral approaches for enhancement of sleep can both interrupt this vicious cycle. The behavioral approaches which improve stress handling and efficacious sleep also are markedly successful in favorably modulating serious illnesses such as heart disease (see below).
Myocardial ischemia/stress management
One hundred seven patients with coronary artery disease and myocardial ischemia documented during mental stress testing or ambulatory electrocardiographic monitoring, were randomly assigned to a 38-month program of stress management training with patients living at a distance from the facility forming a nonrandom, usual care control group. The training consisted of sixteen 1.5-hour weekly sessions of cognitive education with graded task assignments of monitoring irrational internal autonomic thoughts, generating alternative interpretations of situations and unrealistic thoughts, progressive relaxation and >2 sessions of EMG biofeedback. Myocardial ischemia was reassessed following treatment, and patients were contacted annually for up to five years to document cardiac events, including death, nonfatal MI, and cardiac revascularization procedures. Twenty-two patients (21%) experienced at least one cardiac event during a mean follow-up period of 38 months. Stress management was associated with a relative risk of 0.26 v. usual care controls (p=0.04). The stress management subjects experienced weight loss (p=.02), decreased severe ventricular wall movement (p<.004), reduced ischemia induced by mental stress and less ambulatory ischemia.
Blumenthal JA et al. Stress management and exercise training in cardiac patients with myocardial ischemia. Effects on prognosis and evaluation of mechanisms. Arch Intern Med 1997 Oct 27; 157(19):2213-23
Comment: These data suggest that behavioral interventions offer additional benefit well beyond usual medical care in cardiac patients with evidence of myocardial ischemia. The amazing 75% reduction in cardiac “events,” (heart attack, death, need for heart revascularization surgery) over a mean followup of three-plus years was achieved after an investment of 24 total hours of stress management training. These behavioral methods have advantages over conventional medical management in that they change the patient in a holistic way rather than simply modifying certain single biochemical parameters such as cholesterol metabolism. And from a societal point of view, the cost of the 24 hours of training is outweighed many times over by the cost savings in 75% reduction in care required for subsequent cardiac complications. And for the record of the theme this month, significant weight loss was also achieved compared to “usual care” controls.
Hypertension/hypnosis
The effect of nine hypnosis sessions at one-half-day intervals on six non-medicated hypertensive patients and nine on medications was compared to six controls. Baseline mean blood pressures were established by five separated readings before treatment. Jacobsen’s Progressive Relaxation was used, followed by a hypnotic exercise in which the subjects were asked to close their eyes, imagine being in their own bed in their own home at night, relaxing their mind and about to drop off to sleep
in a deep inner relaxation. They were then presented a picture of breathing slowly and deeply, and slowly walking down a long stairway. “You are learning how muscle and inner relaxation are achieved. You will be able from now on to bring about the relaxation yourself.” Blood pressure was recorded post-session. Controls reported at the same intervals to sit quietly for comparable lengths of time. In the no-drug group, post-session mean systolic blood pressure fell 17% vs. baseline by the eighth session (p<.01); post-session mean diastolic BP fell 20% vs. baseline by session 9 (p<.01). In the drug-treated group, SBP fell a mean of 16% by session 3 (p<.01) and DBP by 14% by sessions 6-9 (p<.01). Controls showed no change.
Deabler HL et al. The use of relaxation and hypnosis in lowering high blood pressure. Am J Clin Hypn 1973 Oct; 16(2):75-83
Comment: Critics maintain that any study showing post-session improvements in blood pressures which does not record blood pressures days, weeks or months later, lacks validity. While this criticism holds some validity, my experience would confirm that post-session changes, given sufficient practice, will generalize to waking experiences far beyond the minutes after a relaxation session. While “one case doth not a study make,” my personal waking blood pressures at age 35 were 150/92; after sessions of meditation I recorded pressures as low as 90/50. After six months my waking pressures were no higher than 110/70 at any time they were recorded. They are only slightly elevated from this level 35 years later. It appears that this is almost a conditioning experience; the association between relaxed feelings and lower blood pressures is established by a routine (e.g. Progressive Relaxation, Meditation, Self-Suggestion) consistent practice reinforces the experience and conscious awareness about the decreased pressure; the practiced behavior(s) gradually change the physiological responses to stresses and challenges and make their way into the lexicon of preferred responses, which then become permanent.
Mood/music
One hundred forty-four volunteer subjects completed a psychological profile before and after listening to 15 minutes of grunge rock, classical, new age and designer music. Classical music reduced tension (p<.01); new age decreased tension and hostility (p<.001) and increased relaxation, but decreased vigor (p<.001) and mental clarity (p<.01); grunge rock increased hostility, sadness tension (p<.001) and fatigue (p<.01), and decreased caring, relaxation, vigor and mental clarity (p<.001). Designer music increased caring, relaxation, mental clarity (p<.001) and vigor (p<.01) and decreased hostility (p<.05), fatigue and tension (p<.001).
McCraty R et al. The Effects of Different Types of Music on Mood, Tension and Mental Clarity. Alt Ther Health Med 1998 Jan; 4(1):75-84
Comment: We are surrounded by music at nearly every turn. Radio, television, elevators, waiting on the telephone, shopping in stores. As this study shows, the effects on emotional states and mood are not equal. I like this study because it agrees with my own, perhaps prejudicial but at least partially intuitive hit: namely that grunge music has undesirable effects. That is, if you think that decreased caring, relaxation, vigor and mental clarity are undesirable effects. In one sense, this is environmental medicine. We are affected by our surroundings, including social, physical, atmospheric, visual, and auditory influences among others. And, while this does not deal with sleep or weight loss, it is helpful as part of complete history taking to know the kind(s) of music to which a given patient is attracted.
Bulimia/guided imagery
Fifty participants meeting DSM-III-R criteria for bulimia nervosa completed baseline assessment of eating disorder symptoms and psychological functioning and were randomized to be routinely treated controls, or to routine treatment plus guided imagery for 6 weeks, evaluated in double-blind fashion. Guided imagery treatment had substantial effects, with 74% reduction of bingeing and 73% reduction in purging episodes. The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight compared to the control group. In addition, the guided imagery demonstrated improvement on psychological measures of aloneness and the ability for self-comforting.
Esplen MJ et al. A randomized controlled trial of guided imagery in bulimia nervosa. Psychol Med 1998 Nov; 28(6):1347-57
Comment: Evidence from this study suggests that guided imagery was an effective treatment for bulimia nervosa, at least in the short-term. While the background and predisposing circumstances for bulimia are not completely understood, behavioral methods are of substantial help. And deficient zinc levels are almost universally found in bulimic patients; many authorities believe that these low levels may precede rather than follow the illness. Positron emission tomography (PET scans) and single-photon emission computed tomography (SPECT scans) show decreased mid-brain 5-hydroxytryptophan transporter binding in bingeing patients (Psychopharmacol [Berl] 2001; 155:310) and deficient parietal brain glucose turnover has been noted in both bulimic and anorexic patients (Int J Eat Disord 1999; 25: 29). Awaited are studies in which brain function assessed by tomography during and after behavioral treatment are compared to baseline. Many sources report 50 to 75% marked to moderate improvement in binge eating with adequate exposure to behavioral methods.
Blood pressure/mood
One hundred ninety-seven healthy college students were evaluated with psychological test instruments, ascertaining levels of primary moods including anger, sadness and happiness. Nighttime blood pressures were determined with automatic periodic recordings; those with high anger scores had significantly higher diastolic pressures at night (p<0.01) and those with high happiness and pleasantness scores had significantly lower diastolic BPs (p<0.001). Cardiac rates were not significantly different.
Shapiro D et al. Daily Mood States and Ambulatory Blood Pressure. Psychophysiology Jul 1997; 34(4):399-405
Comment: Mood and blood pressure are inextricably related. While it probably sounds plausible that happy and more pleasant people would have more normal blood pressures, confirmation through controlled studies should be a motivation to do something about it. Thinking and mood (emotional) states follow our perceptions of the external world and inner awarenesses. Numerous published studies from the Heartmath Institute and elsewhere document the feasibility of using experiential methods to teach modification of attitudes which shift perceptions. This has been described as “getting our shift together.” I look forward to the time when the teaching of these approaches in our schools of allopathic medicine is given equivalent emphasis compared to, say, our teaching of cholesterol metabolism. Then again, perhaps not in my lifetime?
Cardiovascular response/mood
In 32 subjects studied while seated and during physical standing exercise, imagery clearly affected cardiovascular patterns (p<.001). Self-rated emotional levels were chosen from an analogue scale. Subjects engaged in one trial each, using imagery from the past to induce the desired emotional state and reproduce it in imagery for 2 minutes. Anger significantly increased diastolic blood pressure (p=.005), exceeding changes with happiness, sadness and fear. Anger was distinctly the opposite of relaxation. Sadness, happiness and fear exercise responses were similar to those in seated control circumstances. All four emotions raised exercise systolic pressures above the two control readings (p<.001) and systolic BP was significantly higher in anger than the other three emotional states (p<.001). Increases in heart rate were greater than in both the control and relaxation states (p<.001). Fear and anger had significantly greater increases than sadness and especially happiness. Sadness interfered with normal cardiovascular adjustments during exercise but other emotional states did not. Exercise SBP recovered faster during fear than during anger. Anger and fear increased SBP and heart rate significantly during exercise (p<.001), anger greater than fear.
Schwartz GE et al. Cardiovascular Differentiation of Happiness, Sadness, Anger and Fear Following Imagery and Exercise. Psychosom Med 1981 Aug; 43(4):343-64
Comment: This older study reinforces conclusions about the relationship of mood states to blood pressures. In addition this study also showed changes in pulse rate. The three negative powerful emotions (anger, sadness, fear-anxiety) engender powerful neurotransmitter and hormonal responses. They are triggered not only by “real” events but also by imaginary and symbolic ones. The optimal handling of these powerful events appears to be a middle path of allowing the experience to have its emotional effect, but letting go the feelings as soon as possible. This has been best demonstrated with numerous studies which demonstrate a significant cardiovascular downside to both excessive expression of anger as well as holding it in. Someone probably has said it well: “Adopt moderation in all things.”
Immunity/compassion, anger
In 30 healthy volunteers, salivary IgA, heart rate and mood were measured before and after experiencing loving care or anger which were induced in two ways: by self-induction and by viewing video tapes. Anger produced a significant increase in heart rate (p<.01) and total mood disturbance (p<.05) and an insignificant immediate increase in sIgA followed by significant decreases in sIgA at 1,2,3 and 6 hours (p<.01), and 4 and 5 hours (p<.05). Positive emotions (care and compassion), however, produced a significant immediate increase in salivary IgA of 41% (p<.05). Thus, in contrast to care and compassion, anger produced a significant inhibition of sIgA at one to five hours after the experience. The care and compassion group experienced dramatic decreases in tension/anxiety, anger/hostility, fatigue, confusion and an increase in vigor (p<.05). Self-induction techniques were more potent than external methods in induction of sIgA changes.
Rein G, Atkinson M, McCraty R. The physiological and psychological effects of compassion and anger. J Adv Med 1985 Sum; 8(2):87-105
Comment: I have referred to this study before in reemphasizing the name of this column: psychoneuroimmunoendocrinology. Mood and attitude, even that induced by imaginary recall, have definitive effects on the immune system. The easily measured salivary immunoglobulin A was markedly decreased at hours 1-6 after induction of a state of anger, whereas it was markedly increased following induction of care and compassion. Critics will attack the study on the premise that these changes may not be clinically significant. That is an unanswered question. That said, I would rather that my own salivary IgA be higher than lower.
Negative emotions/Proinflammatory cytokines
Negative affect and lack of supportive interpersonal relationships loom large in the picture of modulation of immune dysregulation. Immune dysregulation may be one core mechanism for a spectrum of conditions associated with aging, including cardiovascular disease, osteoporosis, arthritis, type II diabetes, certain cancers, and frailty and functional decline; production of proinflammatory cytokines that influence these and other conditions can be stimulated directly by negative emotions and indirectly by prolonged infection. The ability to unwind after stressful encounters down-regulates the total stress burden. Prolonged intrusive ruminations following a stressful trauma appear to provide one avenue for persistent immune downregulation including reduced NK cell activity. Higher salivary immune responses are associated with days of more positive mood. Higher social support is robustly associated with higher NK cell activity and mitogenic leucocyte responsiveness in those under stress, whereas chronically abrasive close personal relationships are seen to provoke persistent immune downregulation. Differences in perceptions to the same event provoke different endocrine and immune responses. Benefits of disclosure-based interventions vary depending on the degree to which subjects become emotionally and cognitively involved in the process, reorganize the meaning of the traumatic event, and reduce avoidance of the issue.
Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Psychoneuro-immunology: psychological influences on immune function and health. J Consult Clin Psychol 2002 Jun; 70(3):537-47
Comment: This summary from the Glaser group at Ohio State is documented by scores of their excellent controlled clinical studies. Each sentence in this abstract of their summary contains a kernel of knowledge that holistic practitioners need. Superb stress management and healthy social support are quintessential ingredients in a plan for optimum health and being fully alive. Allowing oneself to generate intense prolonged negative feeling states entrains health decline. The current intense 50/50 political polarization in the United States often appears to be powerfully fueled by intense anger on both sides. This is an environmental concern and practitioners should be cognizant of potential health implications.
614 Daniels Drive NE East Wenatchee, Washington 98802 USA
by Robert A. Anderson, MD
Robert Anderson is a retired family physician. In mid-career, his practice took on a more holistic nature as decades passed. He has authored five major books, Stress Power! (1978), Wellness Medicine (1987), The Complete Self-Care Guide to Holistic Medicine (1999) (co-author), The Scientific Basis for Holistic Medicine, (6th edition), newly available from American Health Press, nhf@msn.com, and Clinician’s Guide to Holistic Medicine (McGraw Hill, 2001). Anderson was the founding president of the American Board of Holistic Medicine, past president of the American Holistic Medical Association, former Assistant Clinical Professor of Family Medicine at the University of Washington and currently Adjunct Instructor in Family Medicine at Bastyr University.
Psychoneuroimmunoendocrinology describes the unity of mental, neurological, hormonal and immunological functions with its many potential applications. PNIE addresses the impact of cognitive images of the mind (whatever its elusive definition) on the central nervous system and consequent interactions with endocrine and immune systems. It encompasses many arenas, including biofeedback and voluntary controls, impact of thought and belief on physiology, past and present effects of stress on mental, emotional and physical function, placebo effects, effects of social relationships on health and disease, and impacts of “energy medicine” on personal function and that of others. This column highlights the impact of cogent studies from these arenas on the understanding of holistic medicine in the new millennium.
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