|Ahead of print publication
Presidential address: Mind–Body medicine
Shraddha Nursing Home, Aurangabad, Maharashtra, India
|Date of Submission||28-Jan-2022|
|Date of Decision||05-Feb-2022|
|Date of Acceptance||24-Mar-2022|
|Date of Web Publication||17-Jun-2022|
Shraddha Nursing Home, 10-B, Opp. Brotherhood Church, Near Water Tank, Samta Nagar, Aurangabad - 431 001, Maharashtra
Source of Support: None, Conflict of Interest: None
| Introduction|| |
There can be no two opinions that it is a challenging time for the health-care sector, in general, and mental health, in particular. As you are aware, not only do we need to address the large gap in availability and accessibility of mental healthcare, but also as highlighted by Prof. Norman Sartorius, former Director of WHO and President of WPA, with whom I have had the great pleasure of extended personal interaction in recent times, comorbidity, i.e., simultaneous presence/overlap of psychological and physical illness, is the new challenge for health-care system, which makes us think how best to re-orient our efforts to unify mind and body, which were historically separated in modern medicine.
The mind–body (MB) divide has led not only to compartmentalization of healthcare but has also influenced medical education and thereafter our clinical practice. Considering the large overlap between psychological and physical morbidity and the etiological role of highly prevalent psychological stress in causation of both psychiatric and medical morbidity, considering composite MB approach is no longer utopian ideal but an imperative which should guide our vision about medical training and practice, about which Prof. B. N. Gangadhar has also been vocal recently. The MB approach may additionally be beneficial to reduce the stigma. Paying heed to the guidance of these stalwarts, it is my proposal to consider serious steps as to how best to translate into practice composite MB approach so as to improve outcomes and quality of life for our clients and communities to whom we serve. The benefits could extend well beyond helping others – in recent times, it is a global trend to learn MB techniques for the wellness and resilience of health professions themselves.
I am going to take stock of the conceptual development in the field, and it will be my endeavor to formulate practical programs for systematic training for professionals at different stages of career, both within and outside of the mental health-care fold.
“Health is a state of complete physical, mental, and social well-being and is not merely the absence of disease or infirmity” (WHO). This idealistic view may not be possible to achieve as it requires holistic approach. Further, the definition involves physical, mental, and socio-cultural well-being, but modern medicine mainly focuses on physical illnesses for diagnosis and management. Many a times, the outcome is not satisfactory. There are only few medical conditions that can be cured; rest can be controlled or comforted.
A worldwide rise in noncommunicable diseases (NCDs) and concurrent emergence of COVID-19 pandemic in the past 2 years has imposed unprecedented pressure on healthcare. In addition, the understanding of associated background inflammation in NCDs and limitations of the pharmacotherapy to effectively control them once again call for moving beyond conventional pharmacotherapy. It is in this context that the need for incorporating mind–body medicine (MBM) into conventional western medical management system is growing and receiving considerable global attention among the health-care community.
In 1964, Stoeckle et al. concluded that 60%–80% of visits to primary care physicians have a stress-related component. The factor to become ill lies in the brain and stress plays an important role in human illness and wellness. As mentioned above, for most of noncommunicable disorders, stress remains a major causative factor.
| Dynamic Concept of Mind|| |
Stress tries to destabilize the rhythm/order homeostasis and pushes system toward disease. Normally, an individual is resilient and his/her systems are in order. During stress, this is disturbed and there is a building of allostatic load which is the accumulation of wear and tear. If the stress is taken off, the bodily state recovers to normal state; however, if stress continues, then it progresses to disease state and later complications, as shown in [Figure 1].
MBM emphasizes communication among the mind, body, and behavior. MBM focuses on the significant ways in which behavioral, social, mental, spiritual, and emotional factors affect an individual's health. MB interventions form a significant subset of complementary and alternative medicine.
MBM is an evidence-based participatory pragmatic self-care approach that combines the power of traditional knowledge of Yoga and Meditation with modern psychology and medicine.
Behavioral medicine or MBM is concerned with ways with which mind and emotions influence body and physical health.
Hippocrates wrote, “The natural healing force within each one of us is the greatest force in getting well.” This is MBM in a nutshell.
A 16th-century surgeon, Ambroise Pare said, “I dress the wound, but God healed it,” pointing toward the healing force is lying within.
| The Mind|| |
The word mind originally comes from a Proto-Indo-European verbal root: *men-, meaning “to think, remember,” whence also Latin mens “mind,” and Sanskrit manas “mind.” It is a concept.
According to Merriam-Webster dictionary, the element or complex of elements in an individual who feels, perceives, thinks, wills, and especially reasons. The mind is an abstract concept used to characterize thoughts, feelings, subjective states, and self-awareness that presumably arise from the brain. In simple words and for practical purpose, mind is the functional capacity of brain.
| The Body|| |
The body can be defined as “physical whole of a live or dead person or animal the human body.” In other words, it is “the organized physical substance of an animal or plant either living or dead.”
| History of Mind–Body Medicine|| |
There were opposing views about whether mind and body function separately or their function is interdependent. The first one is MB dualism whereas the second is MB interaction.
The concept of MB dualism of health depended solely on the physical mechanisms of the body and the mind and the body live in separate compartments. Gnostics and some sects of medieval Christianity believed in concept of MB separation.
Rene Descartes, a 17th-century French philosopher, a strong proponent of MB dualism – put forth a scientific version of MB split. According to him, human beings consisted of two quite unlike substances which could not exist in unity. Mind was unextended, immaterial but thinking substance, while body was an extended, material but unthinking substance. The body was subject to mechanical laws; however, the mind was not.
The concept is that the mind is important in the treatment of illness and is integral to the healing approaches of traditional Chinese as well as Ayurvedic medicine and dating back more than 2000 years. That is how wisdom that mind and body interact is quite old. Some physical illnesses are secondary to grief or anger is seen in the ancient Hebrews. Hippocrates believed that health depends upon a balance of the body, mind, and environment and that disease is caused by imbalances in these areas (400 B.C.).
| Later Developments|| |
Claude Bernard gave the concept of the “milieu intérieur.” He wrote, “The stability of the internal environment [the milieu intérieur] is the condition for the free and independent life.” This state was later labeled as “homeostasis” by Harvard physiologist Walter Bradford Cannon. In 1911, Cannon found out disturbances in homeostasis due to threat. He observed that the body response caused increase in heart rate, blood pressure, blood sugar, muscle tension, and respiration during the threat, i.e., Autonomic Nervous System (ANS) response. He termed it “fight-or-flight response” or “the stress response.” It is all because of sympathetic nervous system hyperactivity during times of stress. In 1920, the concept of psychosomatic medicine was introduced by Franz Alexander.
John Haygarth, an English physician, for the first time, investigated the efficacy of the placebo effect in the 18th century, but it was Henry Beecher who found that 35% the wounded soldiers reported pain relief with saline injections. He did 15 such trials and officially labeled this effect as “placebo effect,” showing that there are internal forces which takes care of illness.
Later, in 1950, Hans Selye described the “general adaptation syndrome” in relation to stress and described the deleterious effects of stress and distress on physical health. He highlighted the role of yet another brain–body link, the hypothalamo–pituitary–adrenal axis). The first stage of this response is the “stress reaction” or “fight–flight response” (alarm). After this link was obvious, in 1964, George F. olomon et al. (University of California in Los Angeles) coined the term “psychoimmunology” after demonstrating through a series of experiments that mental state affects body immunity and vice versa.
Later, personality typologies and their connection as contributory factors with disorders were established. For instance, “Type A” personality's proneness to heart disease, hypertension, and stress-related disorders (traits - aggressive, ambitious, and always rushed, tend to cope with stress by getting angry and upset).
“Type B” personalities cope with stressful situations with communication and balance instead of anger and aggression and have been found to be less prone to stress-related conditions.
“Type C” personality is one who tends to suppress emotions and has trouble with self-expression are prone to the development of cancer.
Recently added Type D personality demonstrates the correlation with Coronary Artery Disease (CAD), and 52% of patients were anxious. This group is distressed and worrisome. The risk seemed independent of traditional risk factors and depression.
The psychologists Robert Ader and Nicholas Cohen (1975) demonstrated impact of mental and emotional cues on immune system and subsequently coined the term “psychoneuroimmunology (PNI).” In 1970s, Hugo Besedovsky, Adriana del Rey, and Ernst Sorkin, working in Switzerland, reported multi-directional immune–neuroendocrine interactions. They founded the new discipline popularly known as Psycho-Neuro-Immuno-Endocrinology (PNIE) that features moment-to-moment bi-directional interaction between mind and body. It is the integration of Central Nervous System (CNS) and Peripheral Nervous System (PNS), hormone, and immune system. The PNIE constitutes the theoretical foundation of MBM.
Guido Grassi, in his theory, “Neuroadrenergic theory of hypertension” states that it is the progressive increase in sympathetic overdrive which affects the course of disease (from its inception to complication), further reflects inseparable connect between body and mind in illness.
Dr. Herbert Benson at Harvard Medical School in 1970 observed that trained Yoga specialists (yogis) could control bodily functions that had previously been believed to be autonomic. The yogis could reduce their heart rate, blood pressure, metabolism, body temperature, and other physiological processes to surprisingly low levels during meditation. Other people who were then taught meditation were able to reach deep states of relaxation and calmness as well. This relaxation response, as Benson termed it, is essentially the opposite of the fight-or-flight response. The relaxation response reduces blood pressure, respiration, heart rate, oxygen consumption, muscle tension, and other bodily processes caused by stress. Researchers soon began to theorize that if stress could have harmful effects on health, then the relaxation response might have the opposite effect. Later, the Harvard Mind/Body Medical Institute was founded and started integrating MB practices and studies into their health programs.
Thus, a new field opened up in academic medicine called PNI, which is the study of how the mind and nervous system affect the immune system. Studies have since shown that the mind and emotions play roles in many diseases, including cancer, diabetes, heart disease, gastrointestinal problems, and asthma.
Mindfulness meditation was introduced in the West in the 1970s and became familiarized in the 1980s. In the late 20th century, James focused on studying the science of the mind, which is responsible for health concerns and healing.
| Mind-Body Medicine: Fundamentals|| |
In addition, to interview, examine, and investigate a case for diagnosis, the MBM involves behavioral and psychosocial interventions as the first-line interventions. The fundamental aspects included are as follows:
The MBM approach requires a partnership among specialists in the medical and mental specialties, including physicians, nurse, and psychologists, as well as MB specialists, such as biofeedback practitioners, chiropractors, nutritionists, and yoga teachers. The result is an integrated team of caregivers who address mind and body in each health-care visit.
Active participation of patient in treatment
The patient is given an active role from the beginning in developing a treatment plan and takes more responsibility for directing the psychosocial and lifestyle aspects of that plan. MBM emphasizes patient education and patient self-management as an integral part of clinical practice, from the 1st day of treatment initiation.
Mind–body techniques (mind–body interventions or mind–body therapies or mind–body training)
The National Institutes of Health define mind–body techniques (MBTs) as “interventions that use a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms.”
- Those which affect mental and physical fitness, listing activities such as yoga, tai chi, pilates, guided imagery, guided meditation and forms of meditative practices, hypnosis, hypnotherapy, and prayer, as well as art therapy, music therapy, and dance therapy
- Those focusing more on the mind: Biofeedback, mindfulness, autogenic training, hypnotherapy, imagery, meditation, and prayer.
Following are some commonly practiced MBTs.
- Guided imagery
- Hypnotherapy (hypnosis)
- Meditation (including mindfulness)
- Progressive muscle relaxation techniques
- Cognitive-behavioral therapy (CBT)
- Autogenic therapy
- Support groups
- Movement to express thoughts/feelings
- Enjoying nature
- Moderate exercise
In addition to these techniques, inputs from western psychotherapy, viz.
- Psychodynamic therapy
- Dialectical behavior therapy
- Humanistic/experiential therapy is integral part of MBM.
These techniques improve attention process, self-awareness at physical, emotional, and cognitive level, and optimization of behavioral response (action), which also help in reflection and problem-solving, meaningfulness in life, and resilience building. The clients have freedom to choose MBT method.
Monitoring progress with mind–body techniques through biofeedback
With the help of biofeedback, the physiological arousal can be monitored at will of subject. The parameters used commonly are electromyograph, Galvanic skin response, temperature, heart rate variability, and electroencephalograph.
Individualized treatment approach (tailor-made)
It is fine-tuning of MB practices as per the need of patients and not just the pharmacotherapy. It is the key to better treatment outcomes. Assessment of patients at physical and psychological level is must for this tailor-made treatment.
| Implications in Clinical Practice|| |
Arthritis (osteoarthritis, rheumatoid arthritis, and fibromyalgia)
The treatments include combinations of relaxation, biofeedback therapy, cognitive strategies (e.g., for coping with pain), and education.
Some weak evidence exists in the management of chronic and acute pain management using “progressive muscle relaxation.” The MB interventions have small-to-moderate effects for depressive symptoms in a variety of chronic pain conditions.
Low back pain
A Cochrane review examined the efficacy of MBTs in chronic low back pain. Interventions were categorized as operant (using reinforcement to modify behavior), cognitive (modification of cognitive responses to pain), or respondent (modification of the physiologic response system, e.g., progressive muscle relaxation).
Relaxation and biofeedback with drug therapy were found to be effective 43% of cases compared to 14% in the placebo group in a meta-analysis.
Evidence from multiple studies in heterogeneous groups of cancer patients suggests that various MBTs can improve mood, quality of life, coping, and functioning, as well as ameliorate disease and treatment-related symptoms, such as chemotherapy-induced nausea and vomiting and physical pain.
Biofeedback-assisted muscle re-training is effective in the treatment of incontinence disorders; it is an effective treatment for patients with passive and urge fecal incontinence and also for impaired fecal continence after obstetric trauma and constipation.
Cardiovascular disease and hypertension
Both acute and chronic forms of psychosocial stress contribute to the pathogenesis of coronary atherosclerosis. The MBTs can be effective in the treatment of coronary artery disease (e.g., relaxation, group and individual psychotherapy, type A behavior modification, and stress management).
Stimulus control, progressive muscle relaxation, and paradoxical intention are “empirically supported” treatments, whereas three additional approaches such as sleep restriction, biofeedback, and multifaceted CBT are “probably efficacious” treatments as suggested by American Psychiatric Association (APA).
The MBTs, such as relaxation, guided imagery, hypnosis, and instructional interventions (e.g., providing information about the procedure), before surgery, proved to be efficacious on postsurgical outcomes.
Other clinical areas
The MBTs may be beneficial in many conditions, including asthma, tinnitus, diabetes, chronic obstructive pulmonary disease, recovery after stroke (muscle re-education using biofeedback), many dermatologic conditions, e.g., psoriasis, allergies, irritable bowel syndrome, peptic ulcer, pregnancy outcomes (presence of a doula for emotional support, has beneficial effects), and human immunodeficiency virus infection.
There is evidence to suggest that MB therapies are effective for treating common multiple sclerosis (MS) symptoms, including fatigue, anxiety, depression, incontinence, and quality of life. It is safe therapy in patients with MS.
An randomized controlled trial (RCT) of 18 patients with drug-refractory epilepsy revealed a reduction in seizure frequency in those treated with electrodermal activity biofeedback compared to subjects treated with sham biofeedback.
Effect on immunity
Following systematic exposure to a respiratory virus in the laboratory, individuals who report higher levels of stress or negative moods have been shown to develop more severe illness than those who report less stress or more positive moods.
The PNIE constitutes the theoretical foundation of MBM. Complex interplay of neurocardiac axis, psycho-neuro-endocrine axis, and psycho-immunology axis is involved in causation and management of many disorders mentioned previously.
| Vision of Indian Psychiatric Society Ahead|| |
At present, there is no proper implementation of MB practices even though physicians know the importance. There should be a radical system change, and this is already initiated by Indian Psychiatric Society (IPS) by making a task force at national on MBM 2 years back. It has organized two international conferences in collaboration with diabetic association of India and national and local workshops.
The IPS WZB has started a subcommittee on MBM for achieving the tasks ahead.
In the near future, IPS will take workshops for junior residents for stress management through MBTs.
Soon, it will be arranging trainers training for medical teachers.
Thanks one and all.
Jai Hind, Jai Maharashtra, Long live IPS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stoeckle JD, Zola IK, Davidson GE. The quantity and significance of psychological distress in medical patients. Some preliminary observations about the decision to seek medical aid. J Chronic Dis 1964;17:959-70.
Phadke L. Mind – Body medicine in conventional healthcare system: A need of the hour. Med J Basic Appl Res 2021;2:4-7.
Kerna NA, Holets HM, Hafid H, Pruitt KD, Carsrud ND, Ndhlovu S, et al. A practical review of Mind-Body Medicine (MBM): Descriptions of prevalent MBM therapies, indications, contraindications, and efficacy May 2021. EC Psychol Psychiatr 2021;10:86-98.
Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: State of the science, implications for practice. J Am Board Fam Pract 2003;16:131-47.
Senders A, Wahbeh H, Spain R, Shinto L. Mind-body medicine for multiple sclerosis: A systematic review. Autoimmune Dis 2012;2012:567324.
Vitetta L, Anton B, Cortizo F, Sali A. Mind-body medicine: Stress and its impact on overall health and longevity. Ann N Y Acad Sci 2005;1057:492-505.