Chronic Stress: A Case of Mind Over Matter?
There is increasing scientific understanding and acceptance that chronic stress and its effects on the brain can lead to a host of health issues. But there has been less research into the mind’s potential to heal. A new book by journalist and scientist Jo Marchant, Cure: A Journey into the Science of Mind over Body, looks at the scientific evidence supporting the mind’s ability to heal and explains what is needed to better study and learn from the mind’s potential and limitations with regard to our health.
Marchant recently appeared on the Knowledge@Wharton show on Wharton Business Radio on SiriusXM channel 111 to talk about the book and what she learned in her research.
An edited transcript of the conversation follows.
Jo Marchant: Yes, that’s right. I looked at everything from placebo effects where people take a medicine that turns out to be fake and feel better [to] looking at some of the biochemical mechanisms behind that … to stress, for example, and how that influences disease risk over time. There are all sorts of different mechanisms by which the mind can influence our physical health.
Knowledge@Wharton: A lot of people now understand that if you can manage stress fairly well, that’s certainly a big positive to the overall makeup of your medical health.
Marchant: Definitely. We’re all starting to realize now that chronic stress is bad for us. We know that it’s bad for blood pressure and heart health. But what really surprised me with chronic stress is just how broad the impact is on health. For example, being stressed switches on a branch of the immune system called inflammation. It’s the body’s first line of defense against infections and injury, which is great in an emergency. But if that’s switched on long term, that plays a role in all sorts of conditions from autoimmune disease to allergies to atherosclerosis to dementia. Most of the chronic diseases that we’re suffering from in modern life are impacted in some way or another by stress.
Knowledge@Wharton: Yet we still have this division — the old-fashioned Western-style medicine, compared to some of the other options that are out there. Is it possible that at some point down the road those two sides will be able to meld?
Marchant: I hope so. That’s what I was hoping to do with this book: bring these two sides together. We all know from experience that our mental state influences the physical body. If you step out, and you’re almost hit by a car, you feel your heart racing. We know if we’re nervous about something, and that can have real effects on our guts sometimes. If you think about biting into a lemon, you often feel that tingling at the back of your mouth where the salivary glands are. So we know that there are these effects.
When that comes to health, the question becomes so polarized. You’ve got claims of miracle cures on one side and then skeptics deny any role for the mind in health on the other. I hope that by treating this in an evidenced-based way and really looking at the scientific research, we can make sense of this topic and bring the two sides together.
Knowledge@Wharton: You start the book with a very interesting conversation you had with a lady at a park one day about homeopathic medicine. I wanted you to tell that story because … in some respects it really does set up the book.
Marchant: I’m a scientist by trade and a science journalist. I’m used to that worldview, if you like.
But I have young kids now, and I mix with other moms. I was in the park talking to another mom.
Our kids are playing, building sandcastles. She’s talking about how wonderful she found homeopathy. I felt that I had to say, “Yeah, but there’s nothing in homeopathy. The ingredients are so diluted it’s just effectively water. That’s the scientific perspective, right? There’s nothing in it.” She just looked at me, and she was like, “Well, nothing measurable.” I felt that this really summed up the difference between these two perspectives. The Western scientific perspective looks at physical, measurable objects. That’s true in medicine as well. We want to see some structural things wrong with the body, and we treat things with physical drugs and interventions. Then [there is] the kind of alternative perspective where it’s more the immeasurable, our beliefs and emotions and individual experiences that are seen as more important….
Knowledge@Wharton: Is there a little bit of a shift going on? Maybe some of this is generational as well?…
Marchant: There are a lot of people who are becoming a little bit disillusioned with the scientific approach. It has been so effective. Conventional Western medicine has saved so many lives. We take these physical drugs and treatments for granted, but there are a lot of conditions like chronic pain, for example, where the conventional treatments aren’t that great actually.
People are starting to look for alternatives and be almost like, “I don’t care why it works as long as it does.” This is where the scientific approach as it has been so far is maybe letting people down a little bit.
[For example,] we have these placebo-controlled trials. We test these drugs and treatments against fake medicines — placebos — to make sure that it’s a real, direct, biochemical action of the drug that’s working. That’s really important for knowing where the drugs work. But it means that we’ve sidelined all of these other aspects of care, everything to do with how care is delivered, the interaction with the medical practitioner for example, the hopes and expectations and beliefs of the individual.
What some of the placebo research is doing now is showing us that those things, which alternative medicines often incorporate very well, are important and do make a difference. I’d love to see us treating those in a more evidenced-based way so we can incorporate some of those elements back into conventional care.
Knowledge@Wharton: Were you someone who really, for a while, believed in the scientific method, and then seeing the data presented it changed your philosophy a little bit to be more middle of the road in this situation?
Marchant: I’ve always been very much from a scientific perspective. I want to see the trials and the evidence. I want to know how things work and why things work. But I think where this has taken me in writing this book is realizing that the way you design your trials, who’s paying for those trials, all these aspects are so important in determining what questions get asked and what answers you get. I still believe in the scientific approach, but I don’t think scientists are necessarily always asking the right questions in the right way. Instead of just dismissing the role of the mind in health we need to start looking at it more seriously and designing trials with that in mind.
Newer scientists are finding now that when you respond to a placebo, for example, if it eases your pain, that’s not an imaginary effect. You didn’t just think that your pain has disappeared.
There are real measurable biological changes going on in the brain and the body that are very similar to the changes that you get that are caused by drugs. So these placebo effects are just as real as any effect from a chemical drug. That really has to start shifting our perspective on this to realize that mental changes have very physical effects on the body that can impact our health.
Knowledge@Wharton: You talk about how randomized trials are such an important part to this whole process, probably as big as anything we’ve seen in the last 50-60 years, but how do you go about adding that component of the mind in there? It has to be a little bit of a sea change with the people who are thinking about putting these trials together and running them, correct?
Marchant: Yes, absolutely, because the sort of dogma up till now is that if you test something against placebo, and there’s no difference, then that treatment is worthless, right? It doesn’t work. We throw it out. But there’s some very interesting trials suggesting that that isn’t necessarily always true.
One trial in more than a thousand patients with chronic back pain, for example, testing acupuncture against fake acupuncture where you put the needles in the wrong places and they don’t fully penetrate the skin. There’s no difference between those groups as usual with acupuncture. So it’s not working through the needles and the energy fields that the therapist is saying. Placebo acupuncture is just as good.
But there was a third group in this trial that got conventional treatment, pain killers, also physiotherapy and exercise. Both acupuncture groups did twice as well as the group that got the drugs. So even though the acupuncture doesn’t work by the normal definition, it’s actually much better than the conventional treatment and the pain killers. Obviously we still need physical drugs and treatment, but we do have to be thinking about when there are conditions where the drugs aren’t so great, and there are quite significant downsides to those drugs. Should we be looking at what makes placebo acupuncture so effective if it’s not the needles? What are those components?
Then there are also some quite interesting trials coming out of Harvard, for example, where they are trying to tease that out. So giving people placebo acupuncture, but one group would have a warm, emphatic practitioner and one would have a cold but polite practitioner. The people with the warm, emphatic practitioner have much better relief from their symptoms. Or comparing long consultations with lots of personal questions to sort of a shorter, standard consultation for example. Again, having that longer consultation matters for the symptoms. That trial was in acid reflux disease. So you can start to take a scientific approach to teasing out what are these different ingredients and how are they working.
Knowledge@Wharton: The other interesting thing … is the fact that what is considered to be a therapy in one country may not even been used in another. There are so many countries that can probably learn from one another?
Marchant: I’m sure there are lots of different perspectives. You have a lot of good research on alternative medicines coming out of Germany, for example, because they have traditionally taken that more seriously. That acupuncture trial I just mentioned with 1,000 back pain patients was done in Germany. There are definite different perspectives that can come in. But another interesting about this is that cultural and societal beliefs and attitudes make a difference as well. So you see different responses to placebos, for example, depending on what country you’re in. So it’s not just an individual thing; it depends on the culture that you’re embedded in. So there will be things that we can learn, but there will also be differences between different countries as well.
Knowledge@Wharton: So then is this an issue that realistically needs to be tackled at the level of the World Health Organization, an organization that has tentacles in a variety of different locations around the globe? If you start there and continue to push from there, you may be able to see even greater change in the United States or in China, Australia?
Marchant: We are going to need to tackle this from a lot of different perspectives because at the moment there is barely any funding there for this research. Our medicine is based on clinical trial results, but the vast majority of those clinical trials are funded by drug companies. Even the ones that are funded with public money, from the NIH [National Institutes of Health], for example, are overwhelmingly focused toward physical drugs and treatments. By definition, that’s where our medicine is focused because those are the results that we’re getting out of the trials. Until we can find a way of shifting that perspective and getting more funds looking at some of these other aspects of care, which in the long run I think could end up actually saving money, until we can do that, yeah, it’s hard to see sort of how much progress there’s going to be.
We can also look at this from an individual level as well because [when we understand] how our brains influence our symptoms and our physiology, [we] can’t just say a blanket, “Oh the mind heals everything.” That’s not true. But by understanding what the mechanisms are and how we can use our mental state to help us in different situations, that’s something that individuals can start to take responsibility for as well….
Knowledge@Wharton: The other interesting point to bring up is just the fact that the mind is such a powerful tool to begin with…. It’s a little bit disappointing that the medical field hasn’t looked at it as a greater tool. How do you feel about that?
Marchant: In the past, it was taken for granted that the mind and the body are kind of inseparable, and that the care that you received from your doctor is important. There are just various things that feed into the mind having been sidelined more recently, and that’s everything from [the philosopher René] Descartes and the 17th century splitting of the mind and the body and saying that physical, measurable objects are more real and more suitable for scientific inquiries and subjective elements like thoughts and beliefs, to things like the invention of the autopsy, for example, which shifted doctors toward diagnosing conditions based on structural changes in the body rather than the patient’s subjective report, to randomized controlled trials in the 1950s where we started to test drugs against placebos. All of these things have come together to mean that we don’t take the mind as seriously in medicine. It is just seen as less scientific. When you have a trial and the outcome is subjective, like self report of pain, that’s dismissed as not a very rigorous study. I’ve had colleagues roll their eyes a bit when they heard what subject I was going to write about because it’s just not seen as very scientific. It’s too important to be left to alternative therapies and pseudo-scientific theories. There’s nothing pseudo-scientific or magical or mystical about the mind’s effect on the body. It’s just biology.
We can reclaim that for science and study it in an evidence-based way.
Knowledge@Wharton: The people who are feeling this level of pain are probably a part of the cure as well. You talk a little bit about being able to, in some respects I guess, rewire our brains to help this process out, correct?
Marchant: I talk about that in relation to stress, certainly, because you can’t rewire your brain overnight. In terms of chronic stress, we know that it changes people’s brains over time. Parts of the brain, such as the amygdala, [which is] involved in an emotional response to fear and threats, will grow larger and better connected if you’re chronically stressed, and parts of the brain like the prefrontal cortex, which is involved in high order thinking, [such as] rational planning, motivation, decision making, will shrink and become less well connected. There are various techniques — mindfulness meditation is one that’s quite well studied — showing that you can reverse those brain changes caused by stress and actually make the amygdala become smaller again over time, and the prefrontal cortex, the gray matter there to become larger. We can do things that will change how our brains respond to threats, and therefore, the physiological [changes] follow from that. But it’s not a quick fix just like diet or exercise. You can’t just decide one day that you’re going to do it, and everything will be different. You have to put in the hours and really work at it over time….
Knowledge@Wharton: What do you see as maybe the most important thing that needs to be addressed going forward … to try and get the mind used more as a tool in this whole process?
Marchant: There is a prejudice, a bias against the idea that the mind might be helpful. We just about accept the idea that things like stress can be bad for us. But when you turn that around and start talking about healing thoughts, people really get turned off by that. One of the main messages that I want to get across is that this isn’t mystical, magical thing. There are really evolutionary reasons why our mindset is important for our health. So when you look at symptoms such as pain, for example, that’s a warning signal. It’s there to get us to change our behavior. There are benefits to that and also costs. You don’t want to feel too little pain in a certain situation. That could be dangerous. But you don’t want to feel too much pain either. All the time the brain is looking at the physical state of our body in our surroundings to determine the level of that warning signal. But it’s also incorporating our psychological perceptions. So the more under threat, stressed, alone, afraid you feel, it’s going to ramp up that warning signal. And this is through biochemical changes, a release of neurotransmitters and so on that causes that. It’s not just an imaginary thing.
If we feel safe, supported, cared for, that we’ve received effective medical treatment, that tells the brain that the crisis is over, it doesn’t need the warning signals so much anymore. You get the release of endorphins. You’ll have the pain eased and again, through these biochemical mechanisms. So understanding why these changes occur, the placebo effect isn’t just some weird, mysterious thing. We’ve evolved that way for a reason. It starts to just make a lot more sense that we can realize that, oh, actually we do have some control over the symptoms that we feel. Our mental state is important. We don’t need to leave this to see the scientific alternative therapist. Once we can start seeing it in a scientific way then I hope that the changes in attitude will then follow.