Emotional Intelligence

11

Mind and Medicine

"Who taught you all this, Doctor?"

The reply came promptly:

"Suffering."

—ALBERT CAMUS, The Plague

A vague ache in my groin sent me to my doctor. Nothing seemed unusual until he looked at the results of a urine test. I had traces of blood in my urine.

"I want you to go to the hospital and get some tests . . . kidney function, cytology . . . ," he said in a businesslike tone.

I don't know what he said next. My mind seemed to freeze at the word cytology. Cancer.

I have a foggy memory of his explaining to me when and where to go for diagnostic tests. It was the simplest instruction, but I had to ask him to repeat it three or four times. Cytology —my mind would not leave the word. That one word made me feel as though I had just been mugged at my own front door.

Why should I have reacted so strongly? My doctor was just being thorough and competent, checking the limbs in a diagnostic decision tree. There was a tiny likelihood that cancer was the problem. But this rational analysis was irrelevant at that moment. In the land of the sick, emotions reign supreme; fear is a thought away. We can be so emotionally fragile while we are ailing because our mental well-being is based in part on the illusion of invulnerability. Sickness—especially a severe illness—bursts that illusion, attacking the premise that our private world is safe and secure. Suddenly we feel weak, helpless, and vulnerable.

The problem is when medical personnel ignore how patients are reacting emotionally, even while attending to their physical condition. This inattention to the emotional reality of illness neglects a growing body of evidence showing that people's emotional states can play a sometimes significant role in their vulnerability to disease and in the course of their recovery. Modern medical care too often lacks emotional intelligence.

For the patient, any encounter with a nurse or physician can be a chance for reassuring information, comfort, and solace—or, if handled unfortunately, an invitation to despair. But too often medical caregivers are rushed or indifferent to patients' distress. To be sure, there are compassionate nurses and physicians who take the time to reassure and inform as well as administer medically. But the trend is toward a professional universe in which institutional imperatives can leave medical staff oblivious to the vulnerabilities of patients, or feeling too pressed to do anything about them. With the hard realities of a medical system increasingly timed by accountants, things seem to be getting worse.

Beyond the humanitarian argument for physicians to offer care along with cure, there are other compelling reasons to consider the psychological and social reality of patients as being within the medical realm rather than separate from it. By now a scientific case can be made that there is a margin of medical effectiveness, both in prevention and treatment, that can be gained by treating people's emotional state along with their medical condition. Not in every case or every condition, of course. But looking at data from hundreds and hundreds of cases, there is on average enough increment of medical benefit to suggest that an emotional intervention should be a standard part of medical care for the range of serious disease.

Historically, medicine in modern society has defined its mission in terms of curing disease —the medical disorder—while overlooking illness —the patient's experience of disease. Patients, by going along with this view of their problem, join a quiet conspiracy to ignore how they are reacting emotionally to their medical problems—or to dismiss those reactions as irrelevant to the course of the problem itself. That attitude is reinforced by a medical model that dismisses entirely the idea that mind influences body in any consequential way.

Yet there is an equally unproductive ideology in the other direction: the notion that people can cure themselves of even the most pernicious disease simply by making themselves happy or thinking positive thoughts, or that they are somehow to blame for having gotten sick in the first place. The result of this attitude-will-cure-all rhetoric has been to create widespread confusion and misunderstanding about the extent to which illness can be affected by the mind, and, perhaps worse, sometimes to make people feel guilty for having a disease, as though it were a sign of some moral lapse or spiritual unworthiness.

The truth lies somewhere between these extremes. By sorting through the scientific data, my aim is to clarify the contradictions and replace the nonsense with a clearer understanding of the degree to which our emotions—and emotional intelligence—play a part in health and disease.

THE BODY'S MIND: HOW EMOTIONS MATTER FOR HEALTH

In 1974 a finding in a laboratory at the School of Medicine and Dentistry, University of Rochester, rewrote biology's map of the body: Robert Ader, a psychologist, discovered that the immune system, like the brain, could learn. His result was a shock; the prevailing wisdom in medicine had been that only the brain and central nervous system could respond to experience by changing how they behaved. Ader's finding led to the investigation of what are turning out to be myriad ways the central nervous system and the immune system communicate—biological pathways that make the mind, the emotions, and the body not separate, but intimately entwined.

In his experiment white rats had been given a medication that artificially suppressed the quantity of disease-fighting T cells circulating in their blood. Each time they received the medication, they ate it along with saccharin-laced water. But Ader discovered that giving the rats the saccharin-flavored water alone, without the suppressive medication, still resulted in a lowering of the T-cell count—to the point that some of the rats were getting sick and dying. Their immune system had learned to suppress T cells in response to the flavored water. That just should not have happened, according to the best scientific understanding at the time.

The immune system is the "body's brain," as neuroscientist Francisco Varela, at Paris's Ecole Polytechnique, puts it, defining the body's own sense of self—of what belongs within it and what does not.¹ Immune cells travel in the bloodstream throughout the entire body, contacting virtually every other cell. Those cells they recognize, they leave alone; those they fail to recognize, they attack. The attack either defends us against viruses, bacteria, and cancer or, if the immune cells misidentify some of the body's own cells, creates an autoimmune disease such as allergy or lupus. Until the day Ader made his serendipitous discovery, every anatomist, every physician, and every biologist believed that the brain (along with its extensions throughout the body via the central nervous system) and the immune system were separate entities, neither able to influence the operation of the other. There was no pathway that could connect the brain centers monitoring what the rat tasted with the areas of bone marrow that manufacture T cells. Or so it had been thought for a century.

Over the years since then, Ader's modest discovery has forced a new look at the links between the immune system and the central nervous system. The field that studies this, psychoneuroimmunology, or PNI, is now a leading-edge medical science. Its very name acknowledges the links: psycho, or "mind"; neuro, for the neuroendocrine system (which subsumes the nervous system and hormone systems); and immunology, for the immune system.

A network of researchers is finding that the chemical messengers that operate most extensively in both brain and immune system are those that are most dense in neural areas that regulate emotion.² Some of the strongest evidence for a direct physical pathway allowing emotions to impact the immune system has come from David Felten, a colleague of Ader's. Felten began by noting that emotions have a powerful effect on the autonomic nervous system, which regulates everything from how much insulin is secreted to blood-pressure levels. Felten, working with his wife, Suzanne, and other colleagues, then detected a meeting point where the autonomic nervous system directly talks to lymphocytes and macrophages, cells of the immune system.³

In electron-microscope studies, they found synapse like contacts where the nerve terminals of the autonomic system have endings that directly abut these immune cells. This physical contact point allows the nerve cells to release neurotransmitters to regulate the immune cells; indeed, they signal back and forth. The finding is revolutionary. No one had suspected that immune cells could be targets of messages from the nerves.

To test how important these nerve endings were in the workings of the immune system, Felten went a step further. In experiments with animals he removed some nerves from lymph nodes and spleen—where immune cells are stored or made—and then used viruses to challenge the immune system. The result: a huge drop in immune response to the virus. His conclusion is that without those nerve endings the immune system simply does not respond as it should to the challenge of an invading virus or bacterium. In short, the nervous system not only connects to the immune system, but is essential for proper immune function.

Another key pathway linking emotions and the immune system is via the influence of the hormones released under stress. The catecholamines (epinephrine and norepinephrine—otherwise known as adrenaline and nor-adrenaline), cortisol and prolactin, and the natural opiates beta-endorphin and enkephalin are all released during stress arousal. Each has a strong impact on immune cells. While the relationships are complex, the main influence is that while these hormones surge through the body, the immune cells are hampered in their function: stress suppresses immune resistance, at least temporarily, presumably in a conservation of energy that puts a priority on the more immediate emergency, which is more pressing for survival. But if stress is constant and intense, that suppression may become long-lasting.⁴

Microbiologists and other scientists are finding more and more such connections between the brain and the cardiovascular and immune systems—having first had to accept the once-radical notion that they exist at all.⁵

TOXIC EMOTIONS: THE CLINICAL DATA

Despite such evidence, many or most physicians are still skeptical that emotions matter clinically. One reason is that while many studies have found stress and negative emotions to weaken the effectiveness of various immune cells, it is not always clear that the range of these changes is great enough to make a medical difference.

Even so, an increasing number of physicians acknowledge the place of emotions in medicine. For instance, Dr. Camran Nezhat, an eminent gynecological laparoscopic surgeon at Stanford University, says, "If someone scheduled for surgery tells me she's panicked that day and does not want to go through with it, I cancel the surgery." Nezhat explains, "Every surgeon knows that people who are extremely scared do terribly in surgery. They bleed too much, they have more infections and complications. They have a harder time recovering. It's much better if they are calm."

The reason is straightforward: panic and anxiety hike blood pressure, and veins distended by pressure bleed more profusely when cut by the surgeon's knife. Excess bleeding is one of the most troublesome surgical complications, one that can sometimes lead to death.

Beyond such medical anecdotes, evidence for the clinical importance of emotions has been mounting steadily. Perhaps the most compelling data on the medical significance of emotion come from a mass analysis combining results from 101 smaller studies into a single larger one of several thousand men and women. The study confirms that perturbing emotions are bad for health—to a degree.⁶ People who experienced chronic anxiety, long periods of sadness and pessimism, unremitting tension or incessant hostility, relentless cynicism or suspiciousness, were found to have double the risk of disease—including asthma, arthritis, headaches, peptic ulcers, and heart disease (each representative of major, broad categories of disease). This order of magnitude makes distressing emotions as toxic a risk factor as, say, smoking or high cholesterol are for heart disease—in other words, a major threat to health.

To be sure, this is a broad statistical link, and by no means indicates that everyone who has such chronic feelings will thus more easily fall prey to a disease. But the evidence for a potent role for emotion in disease is far more extensive than this one study of studies indicates. Taking a more detailed look at the data for specific emotions, especially the big three—anger, anxiety, and depression—makes clearer some specific ways that feelings have medical significance, even if the biological mechanisms by which such emotions have their effect are yet to be fully understood.⁷

When Anger Is Suicidal

A while back, the man said, a bump on the side of his car led to a fruitless and frustrating journey. After endless insurance company red tape and auto body shops that did more damage, he still owed $800. And it wasn't even his fault. He was so fed up that whenever he got into the car he was overcome with disgust. He finally sold the car in frustration. Years later the memories still made the man livid with outrage.

This bitter memory was brought to mind purposely, as part of a study of anger in heart patients at Stanford University Medical School. All the patients in the study had, like this embittered man, suffered a first heart attack, and the question was whether anger might have a significant impact of some kind on their heart function. The effect was striking: while the patients recounted incidents that made them mad, the pumping efficiency of their hearts dropped by five percentage points.⁸ Some of the patients showed a drop in pumping efficiency of 7 percent or greater—a range that cardiologists regard as a sign of a myocardial ischemia, a dangerous drop in blood flow to the heart itself.

The drop in pumping efficiency was not seen with other distressing feelings, such as anxiety, nor during physical exertion; anger seems to be the one emotion that does most harm to the heart. While recalling the upsetting incident, the patients said they were only about half as mad as they had been while it was happening, suggesting that their hearts would have been even more greatly hampered during an actual angry encounter.

This finding is part of a larger network of evidence emerging from dozens of studies pointing to the power of anger to damage the heart.⁹ The old idea has not held up that a hurried, high-pressure Type-A personality is at great risk from heart disease, but from that failed theory has emerged a new finding: it is hostility that puts people at risk.

Much of the data on hostility has come from research by Dr. Redford Williams at Duke University.¹⁰ For example, Williams found that those physicians who had had the highest scores on a test of hostility while still in medical school were seven times as likely to have died by the age of fifty as were those with low hostility scores—being prone to anger was a stronger predictor of dying young than were other risk factors such as smoking, high blood pressure, and high cholesterol. And findings by a colleague, Dr. John Barefoot at the University of North Carolina, show that in heart patients undergoing angiography, in which a tube is inserted into the coronary artery to measure lesions, scores on a test of hostility correlate with the extent and severity of coronary artery disease.

Of course, no one is saying that anger alone causes coronary artery disease; it is one of several interacting factors. As Peter Kaufman, acting chief of the Behavioral Medicine Branch of the National Heart, Lung, and Blood Institute, explained to me, "We can't yet sort out whether anger and hostility play a causal role in the early development of coronary artery disease, or whether it intensifies the problem once heart disease has begun, or both. But take a twenty-year-old who repeatedly gets angry. Each episode of anger adds an additional stress to the heart by increasing his heart rate and blood pressure. When that is repeated over and over again, it can do damage," especially because the turbulence of blood flowing through the coronary artery with each heartbeat "can cause microtears in the vessel, where plaque develops. If your heart rate is faster and blood pressure is higher because you're habitually angry, then over thirty years that may lead to a faster buildup of plaque, and so lead to coronary artery disease."¹¹

Once heart disease develops, the mechanisms triggered by anger affect the very efficiency of the heart as a pump, as was shown in the study of angry memories in heart patients. The net effect is to make anger particularly lethal in those who already have heart disease. For instance, a Stanford University Medical School study of 1,012 men and women who suffered from a first heart attack and then were followed for up to eight years showed that those men who were most aggressive and hostile at the outset suffered the highest rate of second heart attacks.¹² There were similar results in a Yale School of Medicine study of 929 men who had survived heart attacks and were tracked for up to ten years.¹³ Those who had been rated as easily roused to anger were three times more likely to die of cardiac arrest than those who were more even-tempered. If they also had high cholesterol levels, the added risk from anger was five times higher.

The Yale researchers point out that it may not be anger alone that heightens the risk of death from heart disease, but rather intense negative emotionality of any kind that regularly sends surges of stress hormones through the body. But overall, the strongest scientific links between emotions and heart disease are to anger: a Harvard Medical School study asked more than fifteen hundred men and women who had suffered heart attacks to describe their emotional state in the hours before the attack. Being angry more than doubled the risk of cardiac arrest in people who already had heart disease; the heightened risk lasted for about two hours after the anger was aroused.¹⁴

These findings do not mean that people should try to suppress anger when it is appropriate. Indeed, there is evidence that trying to completely suppress such feelings in the heat of the moment actually results in magnifying the body's agitation and may raise blood pressure.¹⁵ On the other hand, as we saw in Chapter 5, the net effect of ventilating anger every time it is felt is simply to feed it, making it a more likely response to any annoying situation. Williams resolves this paradox by concluding that whether anger is expressed or not is less important than whether it is chronic. An occasional display of hostility is not dangerous to health; the problem arises when hostility becomes so constant as to define an antagonistic personal style—one marked by repeated feelings of mistrust and cynicism and the propensity to snide comments and put-downs, as well as more obvious bouts of temper and rage.¹⁶

The hopeful news is that chronic anger need not be a death sentence: hostility is a habit that can change. One group of heart-attack patients at Stanford University Medical School was enrolled in a program designed to help them soften the attitudes that gave them a short temper. This anger-control training resulted in a second-heart-attack rate 44 percent lower than for those who had not tried to change their hostility.¹⁷ A program designed by Williams has had similar beneficial results.¹⁸ Like the Stanford program, it teaches basic elements of emotional intelligence, particularly mindfulness of anger as it begins to stir, the ability to regulate it once it has begun, and empathy. Patients are asked to jot down cynical or hostile thoughts as they notice them. If the thoughts persist, they try to short-circuit them by saying (or thinking), "Stop!" And they are encouraged to purposely substitute reasonable thoughts for cynical, mistrustful ones during trying situations—for instance, if an elevator is delayed, to search for a benign reason rather than harbor anger against some imagined thoughtless person who may be responsible for the delay. For frustrating encounters, they learn the ability to see things from the other person's perspective—empathy is a balm for anger.

As Williams told me, "The antidote to hostility is to develop a more trusting heart. All it takes is the right motivation. When people see that their hostility can lead to an early grave, they are ready to try."

Stress: Anxiety Out of Proportion and Out of Place

I just feel anxious and tense all the time. It all started in high school. I was a straight-A student, and I worried constantly about my grades, whether the other kids and the teachers liked me, being prompt for classes—things like that. There was a lot of pressure from my parents to do well in school and to be a good role model. . . . I guess I just caved in to all that pressure, because my stomach problems began in my sophomore year of high school. Since that time, I've had to be really careful about drinking caffeine and eating spicy meals. I notice that when I'm feeling worried or tense my stomach will flare up, and since I'm usually worried about something, I'm always nauseous.¹⁹

Anxiety—the distress evoked by life's pressures—is perhaps the emotion with the greatest weight of scientific evidence connecting it to the onset of sickness and course of recovery. When anxiety helps us prepare to deal with some danger (a presumed utility in evolution), then it has served us well. But in modern life anxiety is more often out of proportion and out of place—distress comes in the face of situations that we must live with or that are conjured by the mind, not real dangers we need to confront. Repeated bouts of anxiety signal high levels of stress. The woman whose constant worrying primes her gastrointestinal trouble is a textbook example of how anxiety and stress exacerbate medical problems.

In a 1993 review in the Archives of Internal Medicine of extensive research on the stress-disease link, Yale psychologist Bruce McEwen noted a broad spectrum of effects: compromising immune function to the point that it can speed the metastasis of cancer; increasing vulnerability to viral infections; exacerbating plaque formation leading to atherosclerosis and blood clotting leading to myocardial infarction; accelerating the onset of Type I diabetes and the course of Type II diabetes; and worsening or triggering an asthma attack.²⁰ Stress can also lead to ulceration of the gastrointestinal tract, triggering symptoms in ulcerative colitis and in inflammatory bowel disease. The brain itself is susceptible to the long-term effects of sustained stress, including damage to the hippocampus, and so to memory. In general, says McEwen, "evidence is mounting that the nervous system is subject to 'wear and tear' as a result of stressful experiences."²¹

Particularly compelling evidence for the medical impact from distress has come from studies with infectious diseases such as colds, the flu, and herpes. We are continually exposed to such viruses, but ordinarily our immune system fights them off—except that under emotional stress those defenses more often fail. In experiments in which the robustness of the immune system has been assayed directly, stress and anxiety have been found to weaken it, but in most such results it is unclear whether the range of immune weakening is of clinical significance—that is, great enough to open the way to disease.²² For that reason stronger scientific links of stress and anxiety to medical vulnerability come from prospective studies: those that start with healthy people and monitor first a heightening of distress followed by a weakening of the immune system and the onset of illness.

In one of the most scientifically compelling studies, Sheldon Cohen, a psychologist at Carnegie-Mellon University, working with scientists at a specialized colds research unit in Sheffield, England, carefully assessed how much stress people were feeling in their lives, and then systematically exposed them to a cold virus. Not everyone so exposed actually comes down with a cold; a robust immune system can—and constantly does—resist the cold virus. Cohen found that the more stress in their lives, the more likely people were to catch cold. Among those with little stress, 27 percent came down with a cold after being exposed to the virus; among those with the most stressful lives, 47 percent got the cold—direct evidence that stress itself weakens the immune system.²³ (While this may be one of those scientific results that confirms what everyone has observed or suspected all along, it is considered a landmark finding because of its scientific rigor.)

Likewise, married couples who for three months kept daily checklists of hassles and upsetting events such as marital fights showed a strong pattern: three or four days after an especially intense batch of upsets, they came down with a cold or upper-respiratory infection. That lag period is precisely the incubation time for many common cold viruses, suggesting that being exposed while they were most worried and upset made them especially vulnerable.²⁴

The same stress-infection pattern holds for the herpes virus—both the type that causes cold sores on the lip and the type that causes genital lesions. Once people have been exposed to the herpes virus, it stays latent in the body, flaring up from time to time. The activity of the herpes virus can be tracked by levels of antibodies to it in the blood. Using this measure, reactivation of the herpes virus has been found in medical students undergoing year-end exams, in recently separated women, and among people under constant pressure from caring for a family member with Alzheimer's disease.²⁵

The toll of anxiety is not just that it lowers the immune response; other research is showing adverse effects on the cardiovascular system. While chronic hostility and repeated episodes of anger seem to put men at greatest risk for heart disease, the more deadly emotion in women may be anxiety and fear. In research at Stanford University School of Medicine with more than a thousand men and women who had suffered a first heart attack, those women who went on to suffer a second heart attack were marked by high levels of fearfulness and anxiety. In many cases the fearfulness took the form of crippling phobias: after their first heart attack the patients stopped driving, quit their jobs, or avoided going out.²⁶

The insidious physical effects of mental stress and anxiety—the kind produced by high-pressure jobs, or high-pressure lives such as that of a single mother juggling day care and a job—are being pinpointed at an anatomically fine-grained level. For example, Stephen Manuck, a University of Pittsburgh psychologist, put thirty volunteers through a rigorous, anxiety-riddled ordeal in a laboratory while he monitored the men's blood, assaying a substance secreted by blood platelets called adenosine triphosphate, or ATP, which can trigger blood-vessel changes that may lead to heart attacks and strokes. While the volunteers were under the intense stress, their ATP levels rose sharply, as did their heart rate and blood pressure.

Understandably, health risks seem greatest for those whose jobs are high in "strain": having high-pressure performance demands while having little or no control over how to get the job done (a predicament that gives bus drivers, for instance, a high rate of hypertension). For example, in a study of 569 patients with colorectal cancer and a matched comparison group, those who said that in the previous ten years they had experienced severe on-the-job aggravation were five and a half times more likely to have developed the cancer compared to those with no such stress in their lives.²⁷

Because the medical toll of distress is so broad, relaxation techniques—which directly counter the physiological arousal of stress—are being used clinically to ease the symptoms of a wide variety of chronic illnesses. These include cardiovascular disease, some types of diabetes, arthritis, asthma, gastrointestinal disorders, and chronic pain, to name a few. To the degree any symptoms are worsened by stress and emotional distress, helping patients become more relaxed and able to handle their turbulent feelings can often offer some reprieve.²⁸

The Medical Costs of Depression

She had been diagnosed with metastatic breast cancer, a return and spread of the malignancy several years after what she had thought was successful surgery for the disease. Her doctor could no longer talk of a cure, and the chemotherapy, at best, might offer just a few more months of life. Understandably, she was depressed—so much so that whenever she went to her oncologist, she found herself at some point bursting out into tears. Her oncologist's response each time: asking her to leave the office immediately.

Apart from the hurtfulness of the oncologist's coldness, did it matter medically that he would not deal with his patient's constant sadness? By the time a disease has become so virulent, it would be unlikely that any emotion would have an appreciable effect on its progress. While the woman's depression most certainly dimmed the quality of her final months, the medical evidence that melancholy might affect the course of cancer is as yet mixed.²⁹ But cancer aside, a smattering of studies suggest a role for depression in many other medical conditions, especially in worsening a sickness once it has begun. The evidence is mounting that for patients with serious disease who are depressed, it would pay medically to treat their depression too.

One complication in treating depression in medical patients is that its symptoms, including loss of appetite and lethargy, are easily mistaken for signs of other diseases, particularly by physicians with little training in psychiatric diagnosis. That inability to diagnose depression may itself add to the problem, since it means that a patient's depression—like that of the weepy breast-cancer patient—goes unnoticed and untreated. And that failure to diagnose and treat may add to the risk of death in severe disease.

For instance, of 100 patients who received bone marrow transplants, 12 of the 13 who had been depressed died within the first year of the transplant, while 34 of the remaining 87 were still alive two years later.³⁰ And in patients with chronic kidney failure who were receiving dialysis, those who were diagnosed with major depression were most likely to die within the following two years; depression was a stronger predictor of death than any medical sign.³¹ Here the route connecting emotion to medical status was not biological but attitudinal: The depressed patients were much worse about complying with their medical regimens—cheating on their diets, for example, which put them at higher risk.

Heart disease too seems to be exacerbated by depression. In a study of 2,832 middle-aged men and women tracked for twelve years, those who felt a sense of nagging despair and hopelessness had a heightened rate of death from heart disease.³² And for the 3 percent or so who were most severely depressed, the death rate from heart disease, compared to the rate for those with no feelings of depression, was four times greater.

Depression seems to pose a particularly grave medical risk for heart attack survivors.³³ In a study of patients in a Montreal hospital who were discharged after being treated for a first heart attack, depressed patients had a sharply higher risk of dying within the following six months. Among the one in eight patients who were seriously depressed, the death rate was five times higher than for others with comparable disease—an effect as great as that of major medical risks for cardiac death, such as left ventricular dysfunction or a history of previous heart attacks. Among the possible mechanisms that might explain why depression so greatly increases the odds of a later heart attack are its effects on heart rate variability, increasing the risk of fatal arrhythmias.

Depression has also been found to complicate recovery from hip fracture. In a study of elderly women with hip fracture, several thousand were given psychiatric evaluations on their admission to the hospital. Those who were depressed on admission stayed an average of eight days longer than those with comparable injury but no depression, and were only a third as likely ever to walk again. But depressed women who had psychiatric help for their depression along with other medical care needed less physical therapy to walk again and had fewer rehospitalizations over the three months after their return home from the hospital.

Likewise, in a study of patients whose condition was so dire that they were among the top 10 percent of those using medical services—often because of having multiple illnesses, such as both heart disease and diabetes—about one in six had serious depression. When these patients were treated for the problem, the number of days per year that they were disabled dropped from 79 to 51 for those who had major depression, and from 62 days per year to just 18 in those who had been treated for mild depression.³⁴

THE MEDICAL BENEFITS OF POSITIVE FEELINGS

The cumulative evidence for adverse medical effects from anger, anxiety, and depression, then, is compelling. Both anger and anxiety, when chronic, can make people more susceptible to a range of disease. And while depression may not make people more vulnerable to becoming ill, it does seem to impede medical recovery and heighten the risk of death, especially with more frail patients with severe conditions.

But if chronic emotional distress in its many forms is toxic, the opposite range of emotion can be tonic—to a degree. This by no means says that positive emotion is curative, or that laughter or happiness alone will turn the course of a serious disease. The edge positive emotions offer seems subtle, but, by using studies with large numbers of people, can be teased out of the mass of complex variables that affect the course of disease.

The Price of Pessimism—and Advantages of Optimism

As with depression, there are medical costs to pessimism—and corresponding benefits from optimism. For example, 122 men who had their first heart attack were evaluated on their degree of optimism or pessimism. Eight years later, of the 25 most pessimistic men, 21 had died; of the 25 most optimistic, just 6 had died. Their mental outlook proved a better predictor of survival than any medical risk factor, including the amount of damage to the heart in the first attack, artery blockage, cholesterol level, or blood pressure. And in other research, patients going into artery bypass surgery who were more optimistic had a much faster recovery and fewer medical complications during and after surgery than did more pessimistic patients.³⁵

Like its near cousin optimism, hope has healing power. People who have a great deal of hopefulness are, understandably, better able to bear up under trying circumstances, including medical difficulties. In a study of people paralyzed from spinal injuries, those who had more hope were able to gain greater levels of physical mobility compared to other patients with similar degrees of injury, but who felt less hopeful. Hope is especially telling in paralysis from spinal injury, since this medical tragedy typically involves a man who is paralyzed in his twenties by an accident and will remain so for the rest of his life. How he reacts emotionally will have broad consequences for the degree to which he will make the efforts that might bring him greater physical and social functioning.³⁶

Just why an optimistic or pessimistic outlook should have health consequences is open to any of several explanations. One theory proposes that pessimism leads to depression, which in turn interferes with the resistance of the immune system to tumors and infection—an unproven speculation at present. Or it may be that pessimists neglect themselves—some studies have found that pessimists smoke and drink more, and exercise less, than optimists, and are generally much more careless about their health habits. Or it may one day turn out that the physiology of hopefulness is itself somehow helpful biologically to the body's fight against disease.

With a Little Help From My Friends:

The Medical Value of Relationships

Add the sounds of silence to the list of emotional risks to health—and close emotional ties to the list of protective factors. Studies done over two decades involving more than thirty-seven thousand people show that social isolation—the sense that you have nobody with whom you can share your private feelings or have close contact—doubles the chances of sickness or death. ³⁷ Isolation itself, a 1987 report in Science concluded, "is as significant to mortality rates as smoking, high blood pressure, high cholesterol, obesity, and lack of physical exercise." Indeed, smoking increases mortality risk by a factor of just 1.6, while social isolation does so by a factor of 2.0, making it a greater health risk.³⁸

Isolation is harder on men than on women. Isolated men were two to three times more likely to die as were men with close social ties; for isolated women, the risk was one and a half times greater than for more socially connected women. The difference between men and women in the impact of isolation may be because women's relationships tend to be emotionally closer than men's; a few strands of such social ties for a woman may be more comforting than the same small number of friendships for a man.

Of course, solitude is not the same as isolation; many people who live on their own or see few friends are content and healthy. Rather, it is the subjective sense of being cut off from people and having no one to turn to that is the medical risk. This finding is ominous in light of the increasing isolation bred by solitary TV-watching and the falling away of social habits such as clubs and visits in modern urban societies, and suggests an added value to self-help groups such as Alcoholics Anonymous as surrogate communities.

The power of isolation as a mortality risk factor—and the healing power of close ties—can be seen in the study of one hundred bone marrow transplant patients.³⁹ Among patients who felt they had strong emotional support from their spouse, family, or friends, 54 percent survived the transplants after two years, versus just 20 percent among those who reported little such support. Similarly, elderly people who suffer heart attacks, but have two or more people in their lives they can rely on for emotional support, are more than twice as likely to survive longer than a year after an attack than are those people with no such support.⁴⁰

Perhaps the most telling testimony to the healing potency of emotional ties is a Swedish study published in 1993.⁴¹ All the men living in the Swedish city of Goteborg who were born in 1933 were offered a free medical exam; seven years later the 752 men who had come for the exam were contacted again. Of these, 41 had died in the intervening years.

Men who had originally reported being under intense emotional stress had a death rate three times greater than those who said their lives were calm and placid. The emotional distress was due to events such as serious financial trouble, feeling insecure at work or being forced out of a job, being the object of a legal action, or going through a divorce. Having had three or more of these troubles within the year before the exam was a stronger predictor of dying within the ensuing seven years than were medical indicators such as high blood pressure, high concentrations of blood triglycerides, or high serum cholesterol levels.

Yet among men who said they had a dependable web of intimacy—a wife, close friends, and the like—there was no relationship whatever between high stress levels and death rate. Having people to turn to and talk with, people who could offer solace, help, and suggestions, protected them from the deadly impact of life's rigors and trauma.

The quality of relationships as well as their sheer number seems key to buffering stress. Negative relationships take their own toll. Marital arguments, for example, have a negative impact on the immune system.⁴² One study of college roommates found that the more they disliked each other, the more susceptible they were to colds and the flu, and the more frequently they went to doctors. John Cacioppo, the Ohio State University psychologist who did the roommate study, told me, "It's the most important relationships in your life, the people you see day in and day out, that seem to be crucial for your health. And the more significant the relationship is in your life, the more it matters for your health."⁴³

The Healing Power of Emotional Support

In The Merry Adventures of Robin Hood, Robin advises a young follower: "Tell us thy troubles and speak freely. A flow of words doth ever ease the heart of sorrows; it is like opening the waste where the mill dam is overfull." This bit of folk wisdom has great merit; unburdening a troubled heart appears to be good medicine. The scientific corroboration of Robin's advice comes from James Pennebaker, a Southern Methodist University psychologist, who has shown in a series of experiments that getting people to talk about the thoughts that trouble them most has a beneficial medical effect.⁴⁴ His method is remarkably simple: he asks people to write, for fifteen to twenty minutes a day over five or so days, about, for example, "the most traumatic experience of your entire life," or some pressing worry of the moment. What people write can be kept entirely to themselves if they like.

The net effect of this confessional is striking: enhanced immune function, significant drops in health-center visits in the following six months, fewer days missed from work, and even improved liver enzyme function. Moreover, those whose writing showed most evidence of turbulent feelings had the greatest improvements in their immune function. A specific pattern emerged as the "healthiest" way to ventilate troubling feelings: at first expressing a high level of sadness, anxiety, anger—whatever troubling feelings the topic brought up; then, over the course of the next several days weaving a narrative, finding some meaning in the trauma or travail.

That process, of course, seems akin to what happens when people explore such troubles in psychotherapy. Indeed, Pennebaker's findings suggest one reason why other studies show medical patients given psychotherapy in addition to surgery or medical treatment often fare better medically than do those who receive medical treatment alone.⁴⁵

Perhaps the most powerful demonstration of the clinical power of emotional support was in groups at Stanford University Medical School for women with advanced metastatic breast cancer. After an initial treatment, often including surgery, these women's cancer had returned and was spreading through their bodies. It was only a matter of time, clinically speaking, until the spreading cancer killed them. Dr. David Spiegel, who conducted the study, was himself stunned by the findings, as was the medical community: women with advanced breast cancer who went to weekly meetings with others survived twice as long as did women with the same disease who faced it on their own.⁴⁶

All the women received standard medical care; the only difference was that some also went to the groups, where they were able to unburden themselves with others who understood what they faced and were willing to listen to their fears, their pain, and their anger. Often this was the only place where the women could be open about these emotions, because other people in their lives dreaded talking with them about the cancer and their imminent death. Women who attended the groups lived for thirty-seven additional months, on average, while those with the disease who did not go to the groups died, on average, in nineteen months—a gain in life expectancy for such patients beyond the reach of any medication or other medical treatment. As Dr. Jimmie Holland, the chief psychiatric oncologist at Sloan-Kettering Memorial Hospital, a cancer treatment center in New York City, put it to me, "Every cancer patient should be in a group like this." Indeed, if it had been a new drug that produced the extended life expectancy, pharmaceutical companies would be battling to produce it.

BRINGING EMOTIONAL INTELLIGENCE TO MEDICAL CARE

The day a routine checkup spotted some blood in my urine, my doctor sent me for a diagnostic test in which I was injected with a radioactive dye. I lay on a table while an overhead X-ray machine took successive images of the dye's progression through my kidneys and bladder. I had company for the test: a close friend, a physician himself, happened to be visiting for a few days and offered to come to the hospital with me. He sat in the room while the X-ray machine, on an automated track, rotated for new camera angles, whirred and clicked; rotated, whirred, clicked.

The test took an hour and a half. At the very end a kidney specialist hurried into the room, quickly introduced himself, and disappeared to scan the X-rays. He didn't return to tell me what they showed.

As we were leaving the exam room my friend and I passed the nephrologist. Feeling shaken and somewhat dazed by the test, I did not have the presence of mind to ask the one question that had been on my mind all morning. But my companion, the physician, did: "Doctor," he said, "my friend's father died of bladder cancer. He's anxious to know if you saw any signs of cancer in the X-rays."

"No abnormalities," was the curt reply as the nephrologist hurried on to his next appointment.

My inability to ask the single question I cared about most is repeated a thousand times each day in hospitals and clinics everywhere. A study of patients in physicians' waiting rooms found that each had an average of three or more questions in mind to ask the physician they were about to see. But when the patients left the physician's office, an average of only one and a half of those questions had been answered.⁴⁷ This finding speaks to one of the many ways patients' emotional needs are unmet by today's medicine. Unanswered questions feed uncertainty, fear, catastrophizing. And they lead patients to balk at going along with treatment regimes they don't fully understand.

There are many ways medicine can expand its view of health to include the emotional realities of illness. For one, patients could routinely be offered fuller information essential to the decisions they must make about their own medical care; some services now offer any caller a state-of-the-art computer search of the medical literature on what ails them, so that patients can be more equal partners with their physicians in making informed decisions.⁴⁸ Another approach is programs that, in a few minutes' time, teach patients to be effective questioners with their physicians, so that when they have three questions in mind as they wait for the doctor, they will come out of the office with three answers.⁴⁹

Moments when patients face surgery or invasive and painful tests are fraught with anxiety—and are a prime opportunity to deal with the emotional dimension. Some hospitals have developed presurgery instruction for patients that help them assuage their fears and handle their discomforts—for example, by teaching patients relaxation techniques, answering their questions well in advance of surgery, and telling them several days ahead of surgery precisely what they are likely to experience during their recovery. The result: patients recover from surgery an average of two to three days sooner.⁵⁰

Being a hospital patient can be a tremendously lonely, helpless experience. But some hospitals have begun to design rooms so that family members can stay with patients, cooking and caring for them as they would at home—a progressive step that, ironically, is routine throughout the Third World.⁵¹

Relaxation training can help patients deal with some of the distress their symptoms bring, as well as with the emotions that may be triggering or exacerbating their symptoms. An exemplary model is Jon Kabat-Zinn's Stress Reduction Clinic at the University of Massachusetts Medical Center, which offers a ten-week course in mindfulness and yoga to patients; the emphasis is on being mindful of emotional episodes as they are happening, and on cultivating a daily practice that offers deep relaxation. Hospitals have made instructional tapes from the course available over patients' television sets—a far better emotional diet for the bedridden than the usual fare, soap operas.⁵²

Relaxation and yoga are also at the core of the innovative program for treating heart disease developed by Dr. Dean Ornish. ⁵³ After a year of this program, which included a low-fat diet, patients whose heart disease was severe enough to warrant a coronary bypass actually reversed the buildup of artery-clogging plaque. Ornish tells me that relaxation training is one of the most important parts of the program. Like Kabat-Zinn's, it takes advantage of what Dr. Herbert Benson calls the "relaxation response," the physiological opposite of the stress arousal that contributes to such a wide spectrum of medical problems.

Finally, there is the added medical value of an empathic physician or nurse, attuned to patients, able to listen and be heard. This means fostering "relationship-centered care," recognizing that the relationship between physician and patient is itself a factor of significance. Such relationships would be fostered more readily if medical education included some basic tools of emotional intelligence, especially self-awareness and the arts of empathy and listening.⁵⁴

TOWARD A MEDICINE THAT CARES

Such steps are a beginning. But for medicine to enlarge its vision to embrace the impact of emotions, two large implications of the scientific findings must be taken to heart:

1. Helping people better manage their upsetting feelings —anger, anxiety, depression, pessimism, and loneliness —is a form of disease prevention. Since the data show that the toxicity of these emotions, when chronic, is on a par with smoking cigarettes, helping people handle them better could potentially have a medical payoff as great as getting heavy smokers to quit. One way to do this that could have broad public-health effects would be to impart most basic emotional intelligence skills to children, so that they become lifelong habits. Another high-payoff preventive strategy would be to teach emotion management to people reaching retirement age, since emotional well-being is one factor that determines whether an older person declines rapidly or thrives. A third target group might be so-called at-risk populations—the very poor, single working mothers, residents of high-crime neighborhoods, and the like—who live under extraordinary pressure day in and day out, and so might do better medically with help in handling the emotional toll of these stresses.

2. Many patients can benefit measurably when their psychological needs are attended to along with their purely medical ones. While it is a step toward more humane care when a physician or nurse offers a distressed patient comfort and consolation, more can be done. But emotional care is an opportunity too often lost in the way medicine is practiced today; it is a blind spot for medicine. Despite mounting data on the medical usefulness of attending to emotional needs, as well as supporting evidence for connections between the brain's emotional center and the immune system, many physicians remain skeptical that their patients' emotions matter clinically, dismissing the evidence for this as trivial and anecdotal, as "fringe," or, worse, as the exaggerations of a self-promoting few.

Though more and more patients seek a more humane medicine, it is becoming endangered. Of course, there remain dedicated nurses and physicians who give their patients tender, sensitive care. But the changing culture of medicine itself, as it becomes more responsive to the imperatives of business, is making such care increasingly difficult to find.

On the other hand, there may be a business advantage to humane medicine: treating emotional distress in patients, early evidence suggests, can save money—especially to the extent that it prevents or delays the onset of sickness, or helps patients heal more quickly. In a study of elderly patients with hip fracture at Mt. Sinai School of Medicine in New York City and at Northwestern University, patients who received therapy for depression in addition to normal orthopedic care left the hospital an average of two days earlier; total savings for the hundred or so patients was $97,361 in medical costs.⁵⁵

Such care also makes patients more satisfied with their physicians and medical treatment. In the emerging medical marketplace, where patients often have the option to choose between competing health plans, satisfaction levels will no doubt enter the equation of these very personal decisions—souring experiences can lead patients to go elsewhere for care, while pleasing ones translate into loyalty.

Finally, medical ethics may demand such an approach. An editorial in the Journal of the American Medical Association, commenting on a report that depression increases five fold the likelihood of dying after being treated for a heart attack, notes: "[T]he clear demonstration that psychological factors like depression and social isolation distinguish the coronary heart disease patients at highest risk means it would be unethical not to start trying to treat these factors."⁵⁶

If the findings on emotions and health mean anything, it is that medical care that neglects how people feel as they battle a chronic or severe disease is no longer adequate. It is time for medicine to take more methodical advantage of the link between emotion and health. What is now the exception could—and should—be part of the mainstream, so that a more caring medicine is available to us all. At the least it would make medicine more humane. And, for some, it could speed the course of recovery. "Compassion," as one patient put it in an open letter to his surgeon, "is not mere hand holding. It is good medicine."⁵⁷