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When Descartes uttered his now infamous dictum "Cogito ergo sum (I think, therefore I am)," he created the mind/body dichotomy. With this philosophical stroke, medical research on the body was freed from the constraints of the Church, since the study of anatomy no longer implied dissecting the soul. However, a false distinction arose: the belief that the workings of the mind have no effect on the body. We have now come full circle. The question is no longer whether or not there is a link between mind and body; at issue today are the mechanisms underlying this connection. In this brief article, we review several related studies from our laboratory tying psychosocial stress to health outcomes among women with advanced breast cancer and discuss potential mechanisms underlying the relationship between mental processes and physical health in this stressed population.
A series of investigations based on a prospective evaluation of the efficacy of group psychotherapy for cancer patients suggests that affective and interpersonal factors play a pivotal role in the mind--body connection. In our initial studies, metastatic breast cancer patients randomized to 1 year of supportive-expressive group therapy reported lower mood disturbance, anxiety, maladaptive coping responses, and pain, relative to controls randomized to received educational materials only (Spiegel et al. 1981; Spiegel & Bloom 1983). A 10-year follow-up evaluated the effect of this group intervention on survival (Spiegel et al. 1989). From point of randomization, patients in the intervention group lived an average of 18 months longer (36 months vs 18 months) than those in the control group. Differences in survival were not attributable to differences in prognostic clinical indicators. Further, follow-up analyses indicated that survival differences could not be accounted for by differences in medical treatment received (Kogon et al. 1997). The connection between psychosocial support and slower cancer progression has been supported in 2 other studies (Richardson et al. 1990; Fawzy et al. 1993), but was not confirmed in 3 others (Linn et al. 1982; Ilnyckyj et al. 1994; Cunningham et al. 1998). In 2 of these latter trials, both also involving breast cancer patients, the intervention produced no psychological benefit, so medical effects would be relatively unlikely.
Perhaps the biggest surprise in our ongoing research is that the treatment technique associated with reduced distress and longer survival is not what many who accept the mind--body connection would expect. The approach that was utilized did not emphasize positive over negative feelings, maintaining a uniformly upbeat attitude, or denying the life-threat posed by the disease. Rather, it encouraged a direct confrontation with fears of dying and death, and the expression of all emotions: fear, sadness, anger, joy, and others, in a supportive group setting. Feelings matter, but not just some feelings, all of them. Expressing the so-called "negative" emotions may liberate the positive ones as well. Indeed, we found that cancer patients who directly faced their disease and who did not try to suppress anger, sadness, and anxiety reported better mood (Classen et al. 1996). By openly facing and sharing their thoughts and feelings about their disease and its impact, patients can make the most of the time they have left. Further, such expression invites and intensifies interpersonal support. Supporting others as they explore painful thoughts and feelings helps patients come to better accept their own understandable emotional reactions to the stress of serious illness.
Recent studies from our lab add to mounting evidence implicating the hypothalamic--pituitary --adrenal axis as one factor underlying the mind--body connection. We have focused on cortisol levels and rhythms in particular. Traditionally, stress researchers have thought that elevated cortisol levels are the primary index of stress. Thus, when we found that metastatic breast cancer patients who appraised their social network as more supportive had lower mean salivary cortisol concentrations, this implied that higher quality of interpersonal relationships reduced physiological stress and may be associated with healthier neuroendocrine functioning (Turner-Cobb et al. 2000).
Additional research by our lab and by others has led to a further possibility, that it is not just mean cortisol levels that indexes stress but the pattern of diurnal variation through the day. Even if mean levels are relatively normal, the loss of variation between morning and evening is another index of stress, and we found it predictive of mortality from breast cancer. We found that abnormal diurnal rhythm of salivary cortisol predicted subsequent survival up to 7 years later in women with metastatic disease (Sephton et al. 2000). Earlier mortality was found among patients with "flat" cortisol rhythms, as opposed to those with the healthy diurnal pattern of peaking in the morning and declining over the course of the day. It is noteworthy that greater marital disruption was associated with flatter cortisol rhythms. Links among social support, neuroendocrine function, and mortality suggest possible mechanisms underlying the effect of group therapy on survival. The social support and emotional expression fostered by supportive-expressive group therapy may act as a buffer against the stress of life-threatening illness, influencing physical health by altering stress physiology.
There is growing evidence of rather pronounced medical effects of even fairly limited expression of emotion regarding stressful situations (Spiegel 1999). Smyth and colleagues (Smyth et al. 1999) found that merely writing about a traumatic memory for 20 minutes 3 days in a row resulted in medical improvement among asthmatic and arthritic patients 4 months later. It appears that our emotional systems are pivotal in our management of information and stress response, and that positive and negative emotion can co-occur (Cacioppo 1994). The key seems to be vitality rather than positivity--facing and overcoming adversity rather than ignoring or avoiding it. Indeed, a recent study showed that "fighting spirit" did not predict slower breast cancer progression but the absence of hopelessness and depression did (Watson et al. 1999).
Unfortunately, evidence of a mind--body relationship and its potential mechanisms has at times led to overstated claims that with the right attitude, patients can cure their disease. Patients in our groups have referred to this as the "prison of positive thinking." At a time when discussing thoughts and feelings about practical and existential concerns with supportive others is needed, rigid pleas to "keep a good attitude," however well-intentioned, may constrain disclosure and add to the stress of the situation.
What these studies suggest is that the mind--body connection is real but not simple. Merely fixing a problem in your mind does not repair your body. However, expression of a full range of emotions, obtaining social support, and maintaining emotional resiliency may well contribute to health. Serious illness is a major life stressor that understandably arouses strong emotions, some of them negative. Our challenge as clinicians is to help our patients to both curse the darkness and light a candle.
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