Mind-Body Interactions

[Music] stanford university well it is uh great to see you on a milestone evening it's amazing to think that we've come to the second quarter and we're about to end it tonight i'm curious how many of you have been here how many of you are here during the first quarter wow it's amazing and how many will so you've done two quarters how many are coming back wow well you know my uh my avocation when i'm not doing this sort of my personal pastime is running marathons and you are on one i would say you're not quite yet at mile 20. that'll come in a few weeks but your endurance is very remarkable and i really appreciate it so tonight's topic is an interesting one and many of you might have wondered why did we select mind-body interactions and i have to tell you just in passing that my own uh interest in this topic began more than four decades ago and dr spiegel our speaker doesn't know this but when i was a medical student i began doing experiments on the impact of social dominance on the risk for infections now this took place in mice but it was in the field that emerged as psychoneuroimmunology a field that has taken place over the last several decades that dr spiegel is one of the world experts in and it connects some of the things that you've learned about already in terms of how our mind works and will serve as a prelude to actually the first topic uh in the third quarter which is the sort of basic fundamentals of immunology the system that protects us from infection and you'll learn tonight more about how our mind influences the outcome of disease and the area that dr spiegel has been most noted is of course in the interactions of the mind in relationship to cancer particularly breast cancer and his seminal work in this area as it has been in many of the other impacts of stress on outcome of health has really been extraordinary he began his journey as others have on the east coast starting out in new haven migrating up to massachusetts so from yale to harvard to medical school training in pskytree and then spending his important professional career here at stanford where he has been really one of the pioneer leaders and one of the areas that he has spent a lot of time working on and i suspect we'll speak about as well tonight as part of mind-body interaction is the field of hypnosis and i've learned more not only about his interest in this but the legacy that began with his own father uh in hypnosis and i'll tell one short story uh that may horrify dr spiegel and it's my own encounter with hypnosis so here's the story as a teenager growing up in new york in an immigrant family but being very curious about learning i decided that i wanted to do away with sleep because it was a waste of time and so i concluded and i was about 16 that if i could just do rem sleep i would be able to you know do away with the wasted hours in bed and i reasoned that the way to do that was to learn self-hypnosis so that i could quickly get to rem sleep probably an artificial way of thinking but i found my way in new york city to a to a hypnotist probably not a very high caliber one certainly not your dad who was quite prescient in one way he tried to teach me took my money for it the art of self-hypnosis but concluded after the second time uh that i was too controlling as a personality and therefore was not a good subject which was probably one of his uh wiser moments and that has turned out to be true in life so tonight we'll have a less controlling person who's actually been an expert in hypnosis and in this exciting area of mind-body interactions dr david [Applause] spiegel so the absence of hypnotizability gives you a hundred per 100 percent prediction that you'll become a dean i can't i can see that actually actually phil told me that there were it was a room full of gluttons for punishment and they needed a psychiatric consult so so here i am um in line with what dean pizo said i want to dedicate this lecture to the memory of my father herbert spiegelmd he died last december 15th at the age of 95. three days before he died he was at lenox hill hospital not as a patient but treating a patient i had referred who had intractable vomiting of pregnancy and she was actually ordering food and starting to eat so he died in the saddle the way he would have wanted to to go and i visited him a few days before he had a shelf full of books on the neurobiology of consciousness and was lecturing me on it telling me what was right in them what was wrong in them telling me what to read and i said dad you know you're 95 why don't you give yourself a break and read a novel or something and he said david there's enough fiction in the non-fiction i read so so uh i also had the great privilege and pleasure of writing a textbook on hypnosis trance and treatment with dad the first edition was in 1978 when i was just starting my career and we've just recently published another addiction and although he was faculty at columbia we had a memorial from there i want you to notice that i got him into a stanford shirt so and much that's in this lecture is are things that i have learned from him and want to pass on to you so what i'd like to talk about is mind and body and medicine and i'd like to set up a kind of a contrast between modern biomedicine and very long traditions of healing because some of the techniques we use are actually very old techniques and i'd like you to just think about the ways you have been learning about the development of medicine and some other traditions so in modern biomedicine one of our major interventions is pharmaceutical agents drugs in traditional healing it's herbs so they're they're less refined uh substances that that have a long tradition many of them don't do anything some of them do interesting things actually and one of the problems is that when an herb becomes effective we redefine it as a drug so the treatment for dropsy which was congestive heart failure in the 17th century was an herb called foxglove and the key element in foxglove is digitalis and so we now use digoxin as a primary treatment for congestive heart failure so there has been some back and forth between traditional and modern biomedical treatments surgery is another major part of biomedical intervention various kinds of manipulation ranging from therapeutic massage to acupuncture to yoga have been a component of traditional healing psychotherapy is a domain that is related to modern biomedicine but the first use of psychotherapy in western culture was hypnosis it's the first time a talking interaction was thought to have therapeutic benefit and hypnosis is as well a part of traditional healing along with mindfulness meditation many other techniques of self-regulating of helping people to manage their own mental and emotional state in modern biomedicine we study disease-related stress in traditional healing we study stress-related disease and so what i hope to do with that context is tell you give you some examples of what we've learned about mind-body interactions now one reason there's a problem is our current health environment i'm sorry mr mcconnell your insurance plan only provides for empathetic nodding and a sad and downward glance there's a 200 copay for any additional words of compassion not to exceed 40 words or three expressions of sympathy or condolence and all i can tell you is i wish this were funny unfortunately it's far too close to the truth and i think one of the reasons that patients have sought mind-body treatments of various kinds is that we've forgotten the oldest adage of medicine which is that our job is to cure rarely relieve suffering often and comfort always and with the flexner era at the beginning of the last century when medicine went from being a trade that you learned by apprenticing yourself to another physician to a science which is a wonderful advance so medical school started to become scientific institutions rather than simply following a doctor around and learning to do what he or she did we redefined medicine in a way that had advantages but disadvantages so the new job definition became that our job was to cure always relieve suffering if you have the time and let someone else do the comforting and i think that's equally wrong you know because no matter how good we get at medicine the death rate will always be one per person you know sooner or later we're all going to die of something and we will need people to help us whether or not they can cure us and i think that's been one of the indictments of modern uh insurance driven health care that we focus too much on cure and not enough on care that has driven people to seek mind-body approaches this is a recent review from the national health statistic reports showing that 38.1 million adults made an average of 10 visits per person to practitioners of complementary and alternative treatments at a total cost of 33.9 billion dollars people are spending more money out of pocket on mind body and other integrative medicine approaches than they are out of pocket on mainstream medical care so there's a tremendous push from patients um who are seeking something that they're not getting despite all of the tremendous advances in high-tech medicine that you've been learning about in these courses so it suggests that something is missing now i think part of what's missing is the fact that we had a much better capitalist system of health care 50 years ago when if you wanted medical care you bought it you paid for it and you chose what you got and the only part of the health care system where that works now is in the alternative medicine system where if you want it you choose it you buy it you pay for it and if you don't like it you don't pay for it people have more control over their alternative health care than they do over their mainstream health care and that's one reason they use it but they're also seeking a kind of support and control in dealing with their illness that we tend not to give them uh in modern health care so what i hope to do is give you some examples of how we can help people better manage themselves manage their bodies and deal with their illnesses and there'll be three examples i'll give you one involves hypnosis um a technique i'll call transformation uh stress support in cancer and then i'll talk a little bit about integrative medicine here at stanford so there has been growing interest in in the role of hypnosis and medical care this is from time magazine a couple years ago um and they point out you know hypnosis itself i think of as something like the oldest profession you know everybody's interested in it but nobody wants to be seen in public with it and it has gone through one rejection after another freud used hypnosis when he first started psychoanalysis and quickly gave it up when a patient became infatuated him and he actually wrote in his autobiography i was relieving this woman of her attacks of pain by using hypnosis to trait them back to their traumatic origins and she threw her arms around my neck he said i was modest enough not to attribute this event to my own irresistible personal attractiveness so freud discovered transference that patients have feelings about their doctors that may have something to do with someone other than them and he abandoned hypnosis another example of the abandonment of hypnosis this very powerful mind-body technique is a young woman suffered from spinal weakness she had to be carried from room to room by her father and this happened through her adolescence through her marriage and only when she became pregnant did she decide she needed treatment so she went to see a follower of mesmers who was the founder of hypnosis named phineas t quinby who used animal magnetism to cure her and she was thrilled she was walking she didn't have the spinal weakness five years later they corresponded some say there was some closer involvement between the two of them she got a letter announcing that he had died suddenly and the next day she slipped on the ice she re-injured her back and she went into a period of mourning and meditation and decided that it was not actually animal magnetism that had cured her it was the word of god does anybody know who this woman is that's right it was mary baker eddie it was the beginning of christian science and to this day you can't mention hypnosis around a christian scientist i was visiting the mother church back in boston which is an amazing place it's like a thousand people can stand up and give testimony to one another and this woman was very nice showing us around until she found out we were there from a hypnosis meeting and she couldn't get us out of there fast enough and the and the the lesson for the day was uh hypnotism alias necromancy denounced loving the dead that's what they call it so you can't mention hypnosis around a christian scientist so the tradition is there but it keeps getting rejected mesmer was an 18th century viennese physician who made quite a name for himself by inducing these altered mental states and if you look at healing ceremonies around the world a key element in the healing ceremony is inducing an altered mental state now the interesting thing is that in the west when we do it we put the patient into the altered mental state in the east it's the healer the shaman who goes into the altered mental state and i actually had a wonderful medical student here years ago ahmateva biswas who went to nepal for the summer and i taught him how to measure hypnotizability and he actually he measured the hypnotizability of hundreds of nepalese and what we found was that the ones who chose to go to the native healers were more hypnotizable than the ones who went to the western medical clinics so they selected themselves for their ability to alter their mental states so mesmer he left he got popular he left his wife and family in vienna and moved to paris where he quickly out-competed the french physicians of the 18th century now i ask you this if you had to um if you had a randomized study in which you've learned about randomized trials in which you sent every other medically ill patient to mesmer to induce an altered mental state or to a french physician how many think mesmer's patients would have done better medically ill how many think the french physicians patients would have done better well the first group is right you know why sorry bloodlighting the major treatment was bloodletting voltaire wrote to his brother we did everything we could to save father's life we even sent the doctors away and unless you happen to have congestive heart failure or polycythemia vera you are more likely to be killed and helped by going to a doctor this did not endear mesmer to his colleagues in medicine so he was investigated by a french panel of experts that included our own benjamin franklin who was having a great time in paris the the the famous chemist lavoisier and a doctor well known for his work in pain control his name was guitar he kind of created the mind body problem and they concluded that what mesmer was doing was nothing but he did imagination which actually was probably true but he did imagination as a powerful thing and one sad footnote is that every member of that commission except franklin actually died on the guillotine so it was a dangerous time mesmer would have these pacquias in which they would have magnetic weak magnetic fields and try to influence people's thinking and induce a hypnotic trance you don't need any of this to do it there are risks to animal magnetism though so don't say i didn't warn you [Music] so what is hypnosis well how many of you have been hypnotized any of you okay so correct me if i'm wrong there's a substantial amount of experience here i think of hypnosis as a state of aroused attentive focal concentration with a relative constriction of peripheral awareness so hypnosis is to consciousness what looking through a telephoto lens is to a camera you see what you see with great detail but you're less aware of the context of the surroundings so this profound absorption is a part of hypnotizability and the people who are more hypnotizable tend to use it all the time so how many of you've had the experience in a movie of getting so caught up in the movie that you forget you're watching the movie you enter the imagine world how many of you have that how many of you have never had that experience you don't know what i'm talking about okay so it's about half and half and you guys can leave now um in fact that's a that's associated with a trait called absorption the tendency to lose yourself to have self-altering experiences and the first group of you are more hypnotizable than the second and hypnotizability is a very stable trait people have it as it's as stable as iq throughout adult life so those people who have it get fully absorbed in what they're attending to and then there are two other things that go along with it one is what we call dissociation so it means that you put out of consciousness things that would ordinarily be in consciousness now there's a are we our brains process vast amounts of information automatically the brain is a huge information processor but the things we're aware of when we're thinking reflecting making choices that system is a much more energetically expensive system and it can manage only about seven plus or minus two things at a time the famous experimental psychologist george miller wrote a paper called the magical number seven plus or minus two and he didn't like magic so the fact that he used that word would caught people's attention and what he was saying is that in every study of working memory and attention you can remember between five and nine things which was actually how bell labs came up with a number of digits and a phone number that you could remember about seven ten is kind of pushing it for us and that's why we all have them recorded on cell phones and don't know our own home number anymore um so in hypnosis you're down at the lower end you're focusing on fewer things you put out of consciousness things that would be in consciousness and do we is this a kind of weird thing well let's do a little experiment right now you're having sensations in your bottoms touching these wonderful chairs the school has provided for you hopefully those sensations were not foremost in your mind at the time i brought it up or if they were you could you could leave now so all the time we're deciding to pay attention to some things and put out of conscious awareness others hypnosis is a more extreme form of doing that now the third thing that happens with hypnosis is what's been called suggestibility the idea that you will just rotately go ahead and do anything anyone tells you to do when you're in this altered state and when my patients used to anxiously ask my father he was a psychiatrist who practiced hypnosis since world war ii he they'd ask him nervously can you hypnotize me and make me do anything you want and he would say to them if i had that much power do you think i'd be wasting my time sitting here talking to you so he converted anxiety into anger that way [Music] and on the one hand no you can't people can refuse to do something suggested to them on the other hand i think we've all had that it seemed like a good idea at the time experience where you thought what was i thinking when i went along with that so in order to make judgments you have to compare and contrast you have to be in a in a frame of mind where you're thinking about the implications a.a calls it thinking through that next drink think through what it means if you do it and if you're in a kind of frame of mind where you're less likely to critically judge and evaluate you're more likely to do it and worry about it later and that does happen in hypnosis so while anybody can refuse to do something it is the case that people who are hypnotized are more likely to go along now there are sort of dark implications of that if it's misused on the other hand there are positive therapeutic applications a lot of people have a million ways of defeating the cleverest therapeutic strategy you've just cooked up and if they're in a state in which they're less likely to do that they're more likely to go along with and act upon the the instruction you give so this altered mental state can get people to focus intently on a good therapeutic strategy to put outside of awareness things like pain that they just assume not pay so much attention to and to give up their habitual ways of defeating efforts to get them better so i want to show you some examples of that in a sense hypnosis gets us to reverse the way in which we usually use our brain and i'll give you an example of this typically in ordinary consciousness for example we respond to perceptions and manipulate language and we're doing that right now i'm manipulating language you're responding to perception so i'm in a more active mode you're in a more passive mode if you look at the brain one really simplistic way of thinking about the brain is just divide it front and back okay and in the pre-central area here you have most of the parts of the brain that enable us to enact things upon the world you have the motor cortex here you have the frontal lobes where we make decisions and plan what we're going to do and you have the anterior part of the temporal lobe which is where the speech centers are the back part of the brain is the sensory receptive part of the brain so you have the this huge occipital cortex where we process visual information somatosensory cortex here and auditory cortex here in the posterior part of the temporal lobe so the back part of the brain is where we respond to the world the front part is where we act on the world and what you do in hypnosis is you invert that a bit because in hypnosis we respond to language rather than use it to change the world and we can manipulate perception so we take a more active stance about parts of our experience in which we're usually pretty passive and that's one of the things that i think makes hypnosis such an interesting phenomenon now you may wonder why on earth would humans be evolved to do that well think about the fact from an evolutionary point of view that as physical creatures we're pathetic you know we're not very big we're not very fast eagles see better than we do dogs hear and smell better than we do um and about the only sort of physical advantage we have on the animal kingdom is the opposing thumb which is a good thing but you know it's got its limits so what that means is that we're more often creatures of prey and the way prey detect their victims is motion so if you've evolved in such a way that even if you're scared or hurt you can put out of awareness things that would tend to stir you up and keep yourself still you have a better chance of surviving so there's a lot of evolutionary theory that thinks we have evolved these states of consciousness to help ourselves survive in situations where we otherwise might not so this is another example of of exactly that so how can you get through uh get through your medical care being treated like saint sebastian and still have a smiley face well i'll give you a number of examples of that how we've used hypnosis to do this so you know we tend to think in a very bottom-up way about things like pain perception for example have you ever had the experience of stubbing your toe on a door frame or something and you think oh god this is going to hurt and it takes about you know two or three seconds and then it hurts well now why the delay the reason is that there are there are two peripheral neural systems that transmit information and one of these large alpha fibers that are well myelinated you've heard about myelinated neurons and things like that well anyhow they they speed conduction of impulses and they detect position and vibration and so when you juxtapose your toe with a hard object you know right away you've done it because the position sense gets to your brain quickly the fibers that carry pain perception are smaller they're not well myelinated and they conduct impulses more slowly and they go by a different path what's called the lateral spinal thalamic tract up to the thalamus and the periacriductal gray in the brain and so that's the second signal that gets to you we tend to think that the amount of pain we feel is just the product of all of this noxious input that comes up but for decades there has been research that shows that in fact pain is a bi-directional experience and that we can alter our perception of pain even pavlov noted this that after a while you give the same shock to a dog and they stop reacting to it that the downward input from the cortex can actually modulate the amount of pain you feel the way i you can remember that is that the strain in pain lies mainly in the brain you have to pay attention to pain for it to hurt and here's an example of that see here's the pain stimulus little mary here looks kind of interested actually and her father is in terrible pain so yeah and you know many of us know athletes who broke their ankle in the second quarter of a football game and didn't know they were hurt until you know half time or something when somebody said what's wrong with your ankle pain is a combination of the physical input and the amount of attention you pay to it but pain can hijack attention so let me give you some examples of how we can use hypnosis to help people deal with it and i'll just tell you one case example before i tell you the study i was called by a famous oncologist here to see a young man who was a world-class swimmer who nearly died one night he bled out he had a great food food-sized lymphoma that's a a white blood cell tumor in his gut and he nearly died they brought him in the hospital and started him on chemotherapy and he was literally climbing the walls i mean literally he was in so much pain he couldn't stand it his parents were afraid he was becoming a drug addict and so they when they run out of things to do that's when they call me so the drugs weren't working so get spiegel in here so uh the i told the parents i'm not worried about drug addiction that's low on my list let me deal with them so i go in the room this huge strapping guy is is struggling on the bed moaning and screaming and i said to him trying to establish rapport we learned that in psychiatry i said i said um you don't really want to be here do you and he said how many years of medical training did it take you to figure that out so i could see we were getting along very well and i said well where would you rather be and he said well you know i'm a great swimmer but i've never surfed and i said okay we're going to hawaii so i got him hypnotized and i told him to imagine that he was surfing and he kept groaning but the groan changed a little bit and i said what happened and he said well i fell off the surfboard and i said good well get on it and do it right so i got him practicing surfing just don't be here go somewhere else where you'd rather be 48 hours later i was back on the unit he was in the hall in bear claw slippers chasing the nurses up and down the hall he was off his pain meds and i got to the note from this famous oncologist who wrote patient off of pain meds tumor must be regressing so you know we're sort of the rodney danger field of medicine we don't get no respect this is a paper that we published in the lancet uh in 2000. elvira lang who was a radiologist here is now at harvard and i built up a collaboration over a number of years and it's one of the wonderful things at stanford where there's just terrific people around that you can build research collaborations with and um she had been she she came to me to learn to use hypnosis which she called alodine imagery but with his hypnosis to help patients who were going through invasive radiological procedures now these are procedures where they do arterial cut downs they thread little cameras to visualize the constriction in the renal artery or to do embolization of tumors in the liver and elsewhere and you don't use general anesthesia it's a lengthy procedure two to three hours often there is substantial pain and anxiety involved with it so we randomized patients to three conditions one standard care all the patients had ivs and they could push a button and get what's called patient-controlled analgesia so they could give themselves a dose of opiates another third had that plus structured attention so they had a kindly nurse who was there just kind of holding their hand and helping them and the third group got was taught self-hypnosis to do the kinds of things i'm talking about here where you imagine that the part of your body that hurts is cooler or warmer or you just go somewhere else or you focus on sensations in another part of your body but you use this constriction of attention to focus on something else and filter the hurt out of the pain so these were the three conditions and here's what happened you see here the pain scores on a zero to ten scale and one of the things it's very important if you're in pain make sure your doctor asks you to rate your pain on a 0-10 scale it's very hard to communicate how much pain you're in and either people over-modulate and say i'm fine when i'm not or they under-modulate and they rant and rave and then people don't take them seriously either so using a numerical scale like this is very helpful so these patients rated their pain and you can see that by the second hour the the standard care patients were starting to lose it their pain was going up and up it was six out of ten point scale by the third hour it was seven and a half so they're getting worse and worse despite giving themselves considerable amount of analgesic medication the ones who were getting the supportive care were staying about the same they were doing okay the hypnosis patients were actually reporting less and less pain as time went on so it was down to one by two and a half hours after the study had begun the anxiety scores actually started to worry me because again the standard care patients are getting more and more anxious the the ones with the nurse paying attention to them we're staying about the same and i was afraid the hypnosis patients had all died because they had no anxiety at all by the other two hours they were doing fine so you see dramatic differences over time in the pain and anxieties patients felt all undergoing the same kinds of medical procedures and the interesting thing is that the hypnosis patients were using half as much medication half as much pain medication as the other groups were so they had less pain less anxiety and used less medication and the procedures on average took 17 minutes less time so and and part of it was less wear and tear on the medical staff who didn't feel that they were causing all kinds of pain to the patients uh it turns out actually that even adding the extra personnel to do the study you saved an average of 348 dollars of procedure because there were fewer complications and it took less time to do the procedure the there was far less problems with over sedation with problems with blood pressure in the hypnosis group than there were in the other two groups so this was a this was a situation in which a very simple straightforward intervention helped people get through the procedure quicker more safely and with less pain and anxiety now when i said the rodney dangerfield of medicine if if you had a drug that did this i can assure you that by now every hospital in the world would be using it this wasn't a drug this was teaching patient self-hypnosis published in one of the best medical journals people are starting to use it there's more use of it but it is anything but standard care i'll give you another example this is uh my daughter julia drew this when she was a good deal younger she said my dad hypnotizes people and makes them want to live longer and you see a particularly successful clinical example here and julia who's now a student in law school says dad are you still showing that thing and i said so i have to tell you that this doesn't represent her current level of artistic ability um i was getting calls from packard hospital that they were having physical struggles with eight-year-old girls in the radiology suite uh and and could i help them deal with it so um i thought well yes this is worth looking into and it involved what's called avoiding cystourethrograms and these are studies where you have to stick a catheter in through the penis or the urethra to into the bladder instill it with radio opaque dye and then have the child void to see whether there's backflow up into the kidneys because the the bladder and the ureters that go into the bladder are actually very cleverly designed most of the time and that is your if your bladder is like this nice and round your ureter goes in like this and what that means is that when you start to urinate it naturally closes the ureter it's a natural valve so that you don't get pushback of the urine into the kidney but some children are born with it perpendicular and that means there is pushback and you can lose your kidneys so you have to you have to image them every year and see whether they're going to grow out of it naturally or you have to do major surgery the kids remember this and sometimes the parents lie to the kids and say we're going out for an ice cream and the next thing you know they're in the hospital with strangers doing this to them it isn't good so we got them i would see the child and the mother a week before the procedure i'd hypnotize the child and have them i'd say where would you rather be and so they would be disneyland or playing with a friend or in a park and we'd make a list and the mother would practice with the child every night and when we got to the suite the mother would be behind the head i'd be by the right shoulder and between us we would keep the child distracted doing self-hypnosis we now have developed some dvds that we give to parents to help them do it um and so what the we had a randomized study where half the kids got routine care and half got this self-hypnosis training and you can see that there was significantly less crying during the procedure and we had them rate how uncomfortable and happy they were they reported the children reported less distress particularly during the catheter preparation which is the worst time and inserting the catheter the techs who were there the whole time thought it was twice as easy to do the procedures and again that's 17 minutes it took 17 minutes less time per procedure to do it and that's a long 17 minutes with an eight-year-old in a radiology suite so again we were able to show and publish in pediatrics that simple self-hypnosis can make a huge difference in how comfortable it is for children to go through these procedures now i'll give you a third example of how we've learned to use hypnosis this is the smoking gun and we know that that smoking is a major public health problem i think it's really remarkable that there are whole industries devoted to getting people hooked on substances that have no real virtue except to kill you with emphysema or lung cancer not to mention the effects on your children and so we developed a technique and my dad was a pioneer in this area it was a very simple self-hypnosis technique a lot of people say you know i want to start you know smoking at least gives me an opportunity to take a few minutes for myself now of course you're putting poison in your lungs while you're doing it but you know so i say well you know what you can feel good take a few deep breaths teach your body to float without poisoning yourself at the same time that's called self-hypnosis so we teach them to do self-hypnosis and concentrate on three points for my body smoking's a poison i need my body to live i owe my body respect and protection so you focus on what you're for i'm thinking of your body as if it were a trusting innocent child um and protecting it from damage rather than than being against smoking you know and one thing that people who use hypnosis are pretty good at is figuring out what not to say to patients you know try this try not thinking about purple elephants you know don't think about purple elephants well what are you doing you know you're thinking about it if you tell somebody don't do something you're actually forcing them to be tempted to do it and instead we're saying focus on what you're for not what you're against and hook in your behavior about smoking to all the other sensible things you do like buckle your seat belts and look both way when you cross the street and eat carefully and all that so you connect it with a network of associations that help people uh to focus on this and i have to tell you one other story about my dad i he there was an article in the times about him in the wall street journal in a blog people started collecting stories about him and one guy said i went to see herbert spiegel um 20 years ago and i'd been smoking for eight years i couldn't stop and he put some headphones on and he said some things to me and i left his office and i lit up a cigarette and it tasted just as good as it had before and i thought i just wasted 200 bucks he said that was the last cigarette i smoked in 20 years he said i don't know what he did to me but it but it stopped and as a matter of fact we get half of the people we see for just one session to stop and half of them will not touch a cigarette in two years so if they have a single cigarette it's classed as a failure so it's not bad i figure that's the best use of my clinical time that i make if i get one out of four people never to smoke again teaching them self-hypnosis i'm happy so these are some examples of how hypnosis can help people how you can use the mind to influence our brain and behavior change the way we process pain and change some of our behavior and there are lots of other examples of this too i want to take a few minutes to talk about what's going on in the brain when people are hypnotized and that's an area where we're doing active research now one region of the brain that our studies and others have shown seems to be heavily involved in hypnosis is the anterior cingulate cortex so here's a cerebellum back here this person is looking to the right so the cingulate cortex lies between the limbic system the emotional and memory basal part of the brain and the frontal cortex here where we think and plan so it kind of translates information from our thinking to our feeling and it also helps us to focus attention it's a context generator so when you're on the horns of a dilemma when you're trying to detect where the road is to turn on a dark night your anterior cingulate gyrus is working very hard and so it seems to be involved in hypnosis where you're focusing attention um and it is also a place where we process pain and i'm going to show you some interesting data about hypnosis and pain in the brain in just a minute um there's another part of the brain that we're finding is involved and that's called the ventrolateral prefrontal cortex that's right up about here it's a part of the brain that causes us to stop and think so when you inhibit activity and you say what's going on your ventrolateral prefrontal cortex is involved and that seems to be involved in hypnosis as well now for many decades we've been doing experiments looking at the relationship between hypnosis and perception and one of the lessons we've learned you would tend to think that since hypnosis is just this sort of talky treatment that you wouldn't actually change the way the brain processes information but you might change the way people react to the information and our research and that of others shows that that's not the case so one of the studies i was able to do quite a while ago with carl priebur when he was here at stanford and he was very welcoming and helped me use his laboratory and use eeg is we we measured what's called an evoked response now this is just an eeg that is time locked to a series of stimuli so you're recording electrical activity from the brain on the scalp on the surface of the scalp time lock to giving stimuli in this case it was a an electric shock to the wrist and you record how the brain responds to this series of 50 or 70 shocks and the red line is a normal response so you see here this is called p 100 p 200 p 300 and this is the classical response of the brain to a sensory perception the p300 is mostly influenced by surprise if you're surprised by a stimulus the p300 will get bigger the p100 is largely a reaction to just the strength of the stimulus itself it's just a tenth of a second very fast brain reaction in the yellow line represents people receiving the same people receiving the same shock only they were hypnotized and i told them your hand is cold and numb it's in ice water cool tingling numbness you won't feel anything and what you see are some really marked changes in the evoked response the p100 disappeared which is really still surprising to me that it was that powerful the brain just acted as though it was not sensing that stimulus and the p300 was only half as big so the brain reset the gain and decided it wasn't feeling what in fact it was being presented with uh i was talking with a colleague of mine and i know you had a lecture with the dr schatz uh on on believing is seeing as believing well i'm gonna do the other the flip side of that which is believing is seeing that if you think something intensely enough you will see it differently and i was talking with a colleague of mine at harvard steve costlin who is a very tough experimental psychologist and who said well you know this this uh stuff you've been doing is interesting but maybe people are just shutting down and they're not responding so i said okay well what would be an experiment you would believe and he was very much into visual imagery so he said i want people to have to look at things but change what they're seeing and let's see if there's a difference so um we did a uh we we got a series of highly hypnotizable subjects and we put them in a pet scanner and you can detect either glucose metabolism or blood flow we were looking at blood flow here and this shows the regions of the brain that respond to color perception so we took them this is the difference between looking at color and looking at black and white and these were the regions that do that processing so then we hypnotized them and we told them in one condition to drain the color out of the color grid and then the other to add color to a black and white grid so they were doing in hypnosis kind of what you're doing now seeing it change from one to the other and in those conditions when they were looking at black and white but thought it was color there was a significant increase in blood flow in the color processing regions of their brains and when they were looking at color and thought it was black and white there was a significant decrease in blood flow in those regions so that's why i call it believing is seeing that in fact if they thought they were looking at color their brain responded as if it were color so we have much more ability to alter perception in our brains than we give ourselves credit for um this is another example done by our wonderful group in montreal pierre rainville and colleagues and what's cool about this study was that he hypnotized two groups of subjects and gave them analgesia instructions reduced pain but he just changed the language that he used and he got very different results so in one condition he did what i did in the evoque potential study he just said your hand is cool and numb and you just you'll feel very little of sensation they got reduced pain and the reduction um here was in the um in the somatosensory cortex so it's the back just in the in the post central gyrus area where we tend to process sensation and that's where the big difference was so here you see the difference between increased and decreased pain if he did the same thing except now he said the pain is there but it won't bother you that's the only difference was the words he used they also got a reduction in pain but now it was that anterior cingulate gyrus where you saw the difference and there were no differences in somatosensory cortex so just changing the language you used changes the parts of the brain that people used in developing hypnotic analgesia so the parts of the brain that we think are involved are this anterior cingulate here which helps us to focus attention frontal cortex as well you see here the limbic system and the the amygdala and hippocampus where we process memory and emotion and it's a region of the brain that mediates between our emotion system and our thinking system and seems to be powerfully involved in hypnosis and with a group of colleagues here now fomiko heft allen reese and psychiatry two colleagues who were at stanford and are now at mit susan whitfield gabrielle john gabrielli mike grishas in neurology vinod menon in psychiatry and i have been looking at the neural basis of hypnotizability so what distinguishes people who are high and low in hypnotizability we know it's a stable trait so if you're hypnotized if you're a nine on a ten point scale when you're 21 you're going to be a nine when you're 54. it's it's as stable as iq it's a very stable trait and so we looked at differences in what we call functional connectivity which parts of the brain co-activate during certain tasks in high and low hypnotizables and i won't go into great detail but i'll just tell you that in a condition where we're looking at a network that's involved in trying to figure out what to do next so you're concerned about the next task that you have to engage in we found that the anterior cingulate cortex functional connectivity was higher in high hypnotizables than in lows so i'll show it to you here in a simpler diagram so basically there's growing evidence that this part of the brain that helps us focus attention is activated in hypnosis and now with members of this group we've got new funding and i'm here to tell you the stimulus grants were a great thing thank you president obama we got funding and we're we're now examining the the neural signature of the hypnotic trance which is something that so far has eluded researchers but we think we've got a chance to get it so that's what we're working on now many people think of placebos when they think of hypnosis and the word placebo actually is from the latin i will please that's what it means uh many people are sort of contemptuous of placebos but actually they're very powerful in fact i was at a meeting on the placebo at nih and and people from big pharma were there and they were tearing their hair out because what you may have seen an article in newsweek a couple of weeks ago about how there's a there's a researcher in england named kirsch who thinks that the effects of antidepressants are really all placebo effects now they're not but what has happened is this 10 15 years ago when the newer antidepressants started to be used about two-thirds of patients would get better right but half of those would get better with a placebo so it was about 30 placebo 30 percent antidepressant and 30 no response what's happened is as people get more and more convinced that antidepressants really work the placebo rate is going up and the pharmacologic rate is not so it's now like 45 or 50 are responding to placebos and only 10 to 15 are responding to pharmacologic effects now it tends to be people with the most severe depression and it doesn't mean antidepressants don't work but it means actually that the placebo is a powerful thing and we ought to think more about the words we say to patients because they have a tremendous influence on what happens to them that can be a good thing is that you have a question in the back yeah go ahead i guess showing progress because those people really have a desire to get better as opposed to the people who are on pharmacological medicines who may not have that same desire well no in those studies everybody is in what's called a randomized trial so it's the same population of people they're all saying i want treatment they don't know whether they're getting a placebo or the real drug but what in your question what i think you're right about is that what's happened is people's general conviction that taking these drugs is going to get me better has strengthened and so that means more of them are responding just to the expectation and less to the pharmacology is what i think is happening now in there were a lot of articles in medical journals in the late 19th century about tomato poisoning and there were many admissions to hospitals and emergency rooms for the results of tomato poisoning because it was widely believed that tomatoes were a poisonous fruit and so people got sick they would eat a tomato they'd start to throw up they feel terrible that's a negative placebo effect or what's called a no sibo effect and and so expectation can work in either way you know it can make you feel better but it can also make you feel worse and there are times you know as a physician i have to warn patients about all of the serious side effects of medications and also most of the common side effects even if they're not so serious i'm sure that in a certain proportion of my patients i'm giving them a nocebo message that they're going to get sick and some people actually think the drug is more effective if it actually if they feel the effect in some way but the placebo is a powerful thing there are groups now that are able to show what's going on in the brain frontal cortex to periaqueductal grey activation in in pain control with placebo which is the best established use of placebos but words and suggestion and even in a non-hypnotic context are powerful therapeutic tool but can also cause mischief this phil yes comment about placebos and nuns um psychological effects they can affect physiological yes what dr pisa is saying is that they can have physiological effects not just psychological effects that's absolutely right and i'll show some examples of that but this isn't just a matter of feeling worse or feeling more pain it can change heart rate blood pressure it can change gastrointestinal motility there are all kinds of real fit you know think about it we our body is complicated but our brain is very complicated and it runs the show and so there's no reason why the information we process shouldn't have effects through the nervous system on the way the rest of our body functions and placebos are a powerful example of exactly that so they have medical consequences i mean the extreme example of the nocebo effect you may have seen these there's a phenomenon among some uh tribes called boning when they when they choose somebody who's considered an unacceptable person for having transgressed some social norm they'll just stand them over there and take this sacred bone and point it at them and he falls over dead i've seen films of this you know it's probably a cardiac arrhythmia but that is a the extreme of the nocebo effect where you just say i think you're going to die and they do so it can have powerful medical consequences this is from a study in which they basically looked at placebo versus hypnotic analgesia in high and low hypnotizable subjects and the bottom line here is that what they found was oh here we go i'm using the wrong thing that that high hypnotizables got much here's the here's the placebo level of effect um here this is the placebo analgesia and here you see among the low hypnotizables the level of analgesia sorry the level of analgesia was the same for hypnosis as it was for placebo here for the low hypnotizables but for the high hypnotizables they got much more analgesia much more pain reduction in hypnosis than they did placebo so placebo is a part of hypnosis but hypnosis is a much more powerful way of controlling pain and here's an example of what dean piezo was talking about this involves hypnosis we hypnotized people and had them eat an imaginary meal and this was like at seven in the morning they had to be npo you know no food to eat to so we could measure their gastric acid secretion and i hadn't had breakfast either i was hungry and they were they were taking for an hour in hypnosis an imaginary gastronomic tour of the bay area one woman after 40 minutes said let's stop i'm full and i wasn't so the first hour was their baseline gastric acid secretion the second hour was post hypno eating the imaginary meals 89 increase in gastric acid secretion no food then in the next condition we hypnotized him and said relax and do anything you want except food or drink and here we got a 40 decrease in gastric acid secretion so we could change it in either direction so then ken klein the gastroenterologist who's working with me says well i want to try the ultimate thing i want to inject them with pentegastrin which is a hormone that stimulates gastric acid secretion in the stomach and so we injected them with penegaster and had them relaxed and despite that we got a significant 19 decrease in gastric acid secretion in the relaxation conditions so we could override the effect of the hormone as well so the brain has powerful effects on the way the body works and we don't begin to understand the extent to which the brain can control various body functions and one final example this is such a nice visual uh that helps me to illustrate something a couple of things one is that people tend to think of hypnosis as doing something to somebody but actually hypnosis is an occasion to teach people how much more control they can have over their own body so this gentleman came to see me he was referred by bob chase wonderful professor of hand surgery here and he'd been sent to bob this was his hand in maximal extension three and a half years two and a half years after an industrial accident he was a contractor he was down in monterey making more money than i was as an assistant professor and a defective ladder collapsed on his hand he had a compound fracture of his index finger and he had terrible pain it healed very badly and this was his hand two and a half years later and the insurance company was secretly filming him to prove that he could actually use the hand and he was faking it now i wouldn't believe that from a patient despite the fact that i don't like insurance companies however it was in his medical record they were trying to prove that he could really use the hand he wasn't he had lost his job his wife had left him he lost his home he was in terrible shape he was depressed he went to a psychologist who thought that this was a what you call a conversion symptom and convergent symptoms happen there are times when what you think in your mind causes a dysfunction in the body examples are what are called pseudo seizures where you're stressed and suddenly you start to act as though you have epilepsy even though there's not a seizure focus in the brain but any medical problem is always a combination of what's going on in the mind and what's going on in the body and the dumbest thing you can say to a patient is it's all in your head you know because number one it's never entirely true you know i mean even people with spinal cord injuries rehabilitate differently depending on their attitude and how hard they work at rehabilitation so there's always a mental component to it but what's the other reason why telling a patient it's all in their head is a really bad idea put yourself in the position of the patient why would you not like them right right that's part of it that you're not taking them seriously there's another reason to yes i think you may start feeling low and disappointed and so your brain will work in the opposite direction of not inspiring you okay good so you're teaching them a failure experience instead of a success experience that's right there's another part too yes what's the patient's fault right i mean the problem itself right right it's the patience for you're blaming the victim which we're very good at yes there's another reason those yes right right so so your your the interpersonal interaction is to get sicker rather than to get better because what happens if you get better exactly so you humiliate the patient for getting better that's a really bad thing to do so i said to him so he said to me you know what this wasn't a fist he said i knew i was angry at my employer this was not news to me i didn't have to have a conversion symptom so i said to him so so the the insurance company sent him to bob chase and said amputate the index finger they said you'll never have a usable hand if we don't do it and like all good surgeons bob said this is a last resort not a first he said are you willing to try anything and the guy said yeah he said even going to a psychiatrist and he hesitated he said well maybe he said even one who said even one who uses hypnosis and he said well i'll try anything so he came to see me and i said to him you know i don't know why your hand is like this and i don't care do you want to get better and he said yes and i said well we're going to embark on a rehabilitation program so that meant he could get better without being dishonored and i said you have two obvious problems here you have horrible circulation in your hand and frankly if you just held your hand like this for two and a half years the circulation wouldn't be good and he had muscle wasting in his forearm it was four centimeters skinnier than in his right arm so he lost muscle mass and he lost circulation so i said you're going to develop some tremors in your hand and they're going to build up the blood flow and the muscle mass and so he sat there for a half an hour in my office with his hand shaking like this sweat pouring off his forehead and i thought this is not somebody who's not motivated to get better so in three months half an hour a day twice a day he would do this exercise he had full extension of all the fingers except the originally fractured one and he actually we gave him a tennis ball to kind of do some exercise with he actually ruptured some ligaments he was trying too hard we had to tell them to slow down not so fast and bob put a dynamic splint on the original injured finger and so now 11 months later he had virtually full extension of the hand and he came into the clinic carrying a 35-pound brick and the secretary was afraid he was going to throw it through the window or something he said doc i can hold a brick again i can go back to work and so he put his union card on top of the brick and i signed it he had to sue the insurance company to take him off disability they would not believe now that his hand was actually working and he could actually make a real fist this time and i have a publication with bob chase in the journal of hand surgery that i'm proud of he he um he actually is now back at work making more money again than i am and i used to bring him in to teach the medical students and he would get impatient listening to me explain all this stuff and he would say doc when do i get to show them what i did so he didn't feel that i had put the whammy on him he felt that he had earned his way out of this which he did and so he's he's back at work so here's the problem of saying it's all in your head here lies harold gordon mexiville see it wasn't psychosomatic so that's what you were suggesting before so i'd like to turn now to the other thing that dean piso mentioned which is my work with um stress support and cancer yes you have a question yeah that's fine go ahead sure i've got nitrous oxide i i think it is the most wonderful thing for uh when i have oral surgery i'm like sure bring it on but and i thought of that when you said you talked about the difference between pain and between hurting and feels like you're here maybe that's not how you said it yeah sensation and suffering yeah i i know it hurt i mean there's pain that it doesn't hurt right people me that's impossible that you feel the pain that it doesn't hurt so i thought maybe you could address which part of the brain used it or whether yeah and why won't they use it for other procedures like thyroid biopsies well you know there's always a risk benefit ratio and any time you you mess with consciousness bad things can happen you know people can uh can for example get nauseated and throw up and then inhale some of the food if they're not fully conscious so um we tend to avoid reducing consciousness except for really serious situations where you have to prepare more you have to have more emergency equipment available nitrous is you know is pretty good it tends to to give you exactly that sense it's like opiates do this too well you know the pain is there but it just doesn't bother you very much and so there are times typically with thyroid biopsies you know a little local injection is usually enough to avoid the discomfort but not for some people but frankly what i would like to see is more use of teaching people self-hypnosis to manage the pain because as i showed you earlier it is very effective it doesn't take long to do and it can really help with the discomfort yes i'm here to tell you it does my wife helen blough is a professor of molecular micro immunology here at stanford runs the baxter laboratory does stem cell research we have two children and we decided that we would use self-hypnosis rather than epidurals for the delivery and daniel was ten pounds when he was born he was the first child he's now six foot four he's very large and halfway through her eight hour labor she said to me david you know i'm a pharmacologist too there are drugs for this and i said deep breath you're floating in lake tahoe cool tingling and uh daniel was born fine and i had no pain at all so and our daughter our daughter julia was born in four four hours of labor very little pain all self-hypnosis so the answer is yes it works yes in the background about language yeah do we process language in the same parts of the brain independent of the language we are speaking yes pretty much that's the case we have one language center wernicke's in broca's area usually in the left temporal lobe some on the right as well but yes it does it doesn't depend on the language yes two things one uh i read in uh i guess it was newsweek or time where where medical records got switched and someone who was told that he had cancer that was inaudible and had two weeks to live and in two weeks he passed away and then the doctor realized that that he was given the wrong diagnosis so talk about mind body but my question really is uh when you're talking about hypnosis it also sounded like meditation to me you know going to another spot and you know feeling better in that area so i'm wondering if you see much difference in that well i've asked this a lot and i have colleagues who are experienced meditators and i think probably the mental state you get into particularly if you're highly hypnotizable when you're meditating is pretty similar but the ceremony surrounding it is very different hypnosis is much more western oriented it's problem focused you use it to focus on a problem and alter your perception almost by design the eastern approaches are non-problem focused so the ceremony involves doing your mantra doing a body scan or something i think you're in an altered mental state that isn't too different but you're not trying to solve a problem you're trying to just live in the moment and focus on your breathing and then let the problems kind of take care of themselves so the ceremony is rather different i suspect that the mental state and we're actually starting to do some research on that is pretty similar yes i was told by a professor at an unknown medical school about 20 miles north of here then what could that be children under 10 can't receive placebos or placebos are infected when a child under 10. is that correct that's absolutely incorrect and in fact the peak period of hypnotizability in the human lifespan is from like six to twelve all eight-year-olds are in trances all the time you know you you know you call them in for dinner they don't hear you so that's that's a wonderful time actually to to take advantage of the placebo effect yeah so that's why they're 20 miles to the north yeah two years ago i've been reading about a psychiatrist who used hypnosis and he put people into hypnosis into an earlier life that they had experienced yeah and somebody who had a problem with the throat and quick wear necklace was hung in an earlier life which accounted for that decision yeah this is past life regression my dad used to say i have enough trouble figuring out what's going on in this life um if you can have vivid fantasies there's hypnotic age progression too and so you can have a very vivid fantasy about what you were who you were in a past life it has nothing to do with the reality of it so so i don't put much uh much stock in it i was there was one of these trans channelers years ago and one of the local tv stations asked me if i could explain it and i said well bring me a high hypnotizable and i'll give you a trans channeler so wendy tokuda came down from from channel 4 with a camera crew and brought one of her crewmen who was highly hypnotized by hypnotized him and said there's a spirit inside you let it speak and he said i am zafra and i bring a message of peace and he goes on and on and i and i pointed to his boss and i said who's that and he said [Music] he couldn't say her name and i brought him out i showed him the tape he thought it was incredible he couldn't believe he'd said all this stuff and wendy dakuta looked at me and she said doctor i'm glad that you do what you do and i do what i do and i'm getting out of here so yeah it's fantasy yeah is there any work done on how uh hypnosis and people who are hypnotizable and how that works with their sleep and sleep patterns um it's an interesting question uh i don't oh yes i should repeat uh has there been any work on uh the relationship between hypnotizability and sleep patterns you know despite the name hypnos the common root which means sleep in greek hypnosis is not sleep it's actually a form of highly focused attention i don't know of many studies on sleep patterns of high versus low hypnotizable it's a very interesting question my impression is that highs sleep better than low slows tend to be more anxious and they have trouble turning off their thoughts and we actually treat people with sleep disturbance by having them just be a traffic director to their thoughts to project them onto an imaginary screen rather than experiencing them inside their bodies where they tend to get the sympathetic arousal that keeps them awake but it's a good question i don't know of any studies on actual sleep history of high versus low hypnotizables yes um all these wonderful benefits for the medical setting for being hypnotized self-esteem hypnosis is that available at all to the people who are low income uh it's a good question uh in general there's less of it available i wouldn't say none and when i find somebody who isn't hypnotizable i always test them first i say well let's do something else so i'll do progressive muscle relaxation or i'll be more likely to prescribe a medication but interestingly in this study of the in the radiology study i mentioned we measured hypnotizability and it was uncorrelated with results and we think that in really high stress situations like that whatever ability people have they use it so i'd say the more pressure they're under to perform the more they'll make use of whatever they've got but there's about a third of the adult population that just aren't meaningfully hypnotizable yes yep lady in green are people who uh follow uh like charismatic who might be mesmerizing leaders yeah uh yeah i think so i i i thought for the jim jones catastrophe for example that a lot of those people probably were i mean if you look at these situations you know they they focus on one thing the more irrational it is the better they suspend critical awareness they don't focus on contradictory information that might scare them so it wouldn't surprise me if a substance not everyone but a substantial proportion are pretty hypnotizable so it's a vulnerability as well as an asset okay so i think i will now go on and talk some about cancer and if there are other questions we can have them so this lady here raised a very interesting question about this woman who got the wrong diagnosis and was dead in two weeks it's not it's not simply that if you think it's bad in your mind it'll get bad in your body or if you if you wish away your cancer cells or see your white blood cells killing your cancer cells the cancer will go away there was a there was a guy named simonton who wrote a book called getting well again in which he wrote that you could just teach people to do that and they cured their cancer which irritated me and i'll show you what effect it had on my own research what we're looking at is what are the factors that can influence not just quality of life but potentially quantity of life with cancer we think they involve stress history because then subsequent stressors are more stressful depression complicates cancer certain genetic vulnerabilities may also make people more vulnerable to the stress-induced effects of cancer and we think some of the systems dean piso mentioned one the immune system also the stress hormone system cortisol and other stress hormones are factors that may influence the progression of cancer cancer is a stressor this is a dressmaker's maquette that was made by one of my breast cancer patients who brought it in one day to a group to demonstrate the effects of the cancer on her body and it is unforgettable so she had had a modified radical mastectomy a tram flap reconstruction of her left breast she had radiation burns she had a biopsy incision on the other side and her name she gave me permission to use her name maurice was a silicon valley engineer when she started when she got metastatic disease she said you know all my life i wanted to be an artist so she quit her job she went to art school and she was teaching art by the time she died and had a beautiful body of art that she'd created and this is her way of reminding us what it's like to be a cancer patient so it isn't one big stress it's a series of stressors that involve existential issues you know half of all people diagnosed with cancer will live to die of something else but i'm here to tell you that everybody diagnosed with cancer thinks it's going to kill them so it's an existential challenge for everybody they have important decisions to make about treatment reduced physical abilities they're a change in family roles so it's an ongoing series of daily stressors that they live with and there are more and more people living with it our success in treating cancer means that while in 1971 there were three million cancer survivors there are now 11 million cancer survivors so more and more people are living with rather than dying of cancer it's being converted from what used to be thought of as a terminal illness to a chronic illness like diabetes you have to live with it it's serious but it's not necessarily fatal now one of the mind-body interactions that is dangerous for cancer is depression and as you as your level of medical illness increases um the rate of depression increases so in the general population in this room three or four percent may be or have been depressed at some time among medical outpatients it's six percent 12 percent among medical inpatients about a quarter of cancer patients have significant depression it's worth noting that those who request assisted suicide two-thirds of them are depressed and the thing to do when they're requesting assisted suicide is not kill them but diagnose and treat their depression because people get suicidal when they're depressed depression can be a very difficult situation because you feel sad you have negative thoughts about yourself you remember selectively things you've done wrong when somebody's depressed if you tell them nine good things and one bad thing guess what they're going to remember they'll remember the one bad thing and one little clinical trick i give the medical students is if you find yourself getting angry with someone and you don't know why ask yourself whether they're depressed because depressed people are irritating you know they they don't give anything back you want to shake them by the neck and say it's not that bad you know get a grip they can't or they would so depression damages interpersonal relationships it tends to get you stuck in this cycle of feeling bad thinking bad things that only reinforce the bad affect on top of that we now have evidence that there are certain genetic differences that make people vulnerable to getting depressed when they're stressed so this is a paper by caspian colleagues published in science showing that if you have one variant of a gene that codes for what's called the serotonin transporter the transport serotonin a neurotransmitter in the nerve synapse if you have the short allele of that gene you're significantly more likely to get depressed when you're stressed two or more times and of course cancer is a stressor so there are people with specific genetic vulnerabilities to get depressed when they're stressed and on top of that other things start to go wrong they don't sleep as well they have they don't tolerate pain as well and pain makes them more depressed so it becomes this reciprocating cycle that can lead them not to cooperate with treatment to withdraw and as well have effects on the biology of the disease so in a recent review we did we found that depression doesn't have a lot to do with getting cancer but it seems to have a lot to do with the progression of cancer so 15 of 24 studies showed that those who were depressed all other things being equal would die sooner of cancer it would progress more rapidly than those who were not depressed and this is similar to the power of depression in heart disease we know that people who have heart disease and are depressed are going to die sooner but somehow cancer seems more mysterious to us than heart disease this is a drawing of a french breast cancer patient who said the treatment is long and hard to undergo and and the treatments themselves often seem like punishment to patients you know if you if you want patients to love you be a cardiologist you know because you go into the er you've got crushing chest pain you think you're gonna die and five minutes later the pain is gone you think you're gonna live with oncology it's exactly the opposite you know dr piso knows as well you think you're fine and there's a lump or a little bleeding or something and the doctor transforms that into a life threat and then the treatments make you feel worse than the disease you know slash poison and burn tends to be the treatment for cancer so the treatment feels like a punishment to many cancer patients we find that depression actually predicts poor outcomes so this is a study we did here um in which we looked at changes in depression over the first year and we found that those who were getting more depressed lived an average of three years those who were getting less depressed lived an average of five years and this isn't like getting depressed two weeks before you die this is years before so depression actually predicts poor outcome and many other studies have shown this and one of the things we're actively investigating is why would that be what is it about depression that seems to facilitate the more rapid progression of cancer this was a dutch breast cancer patient making a painting about how she was facing her illness itself and one lesson in this painting is notice that she's got an umbrella but it's not open she's not shielding herself from the confrontation and that's something i recommend for cancer patients and i'll show you some examples of that another stress-related mind-body interaction is that patients who have suffered significant life reverses are more likely to get breast cancer now this is a complex literature some studies show it some don't but this is an example in a particularly good one involving more than 10 000 patients in finland and they found that any any single adverse life event increased the risk of getting breast cancer seven percent a major event 35 percent divorce or separation more than two-fold and death of a close relative about 36 percent so these adverse events can have an effect on the body as well as the mind and so when you're suffering emotionally you may also be suffering physically um oksana polish in our group did a study in a recent sample of ours in which we looked at the relationship between early life traumatic stress or stress and the rapidity with which these women went from an initial diagnosis of breast cancer to a recurrence to metastatic disease and we found that those who had a traumatic stress history sexual or physical abuse for example had only half the time between the initial diagnosis and recurrence than did those who had no stress history and those with milder stress were in the middle so it suggests that traumatic stress does things to our stress response systems that endanger us when we have cancer so what can we do to treat depression and stress this sculpture by the way was done by a dutch breast cancer patient and one of the remarkable things is not only does it depict her despair but it's the only work of art she did in her life and i think it's just a remarkable sculpture so there are of course pharmacologic treatments that i mentioned for depression they're very helpful although we're now learning that certain antidepressants interfere with some of the hormonal treatments so the antidepressant paroxetine and sertraline compete for metabolism with tamoxifen which is a an estrogen receptor blocker it's a tamoxifen is what's called a pro-drug it's it's not the drug itself but it's metabolized to the active drug and the anti-depressant competes with it uh at this this cytochrome 450 system such that you have less active tamoxifen and it actually can shorten survival so we're having to get more careful about what kinds of depression treatment we use and there are many psychotherapies here's one example of psychotherapy for california is here the therapeutic highway here i'm going to focus on some psychotherapy to give you a feeling for how we try to help cancer patients cope with the disease related stress that they suffer there are many individual as well as group forms of psychotherapy for those who are psychoanalytically oriented he's saying i'm beginning to have second thoughts about group therapy so there are seven themes that we discuss in these groups making new social connections learning to express rather than suppress emotion detoxify fears of dying and death reorder life priorities strengthen families clarify communications with physicians and we teach them self-hypnosis for pain and anxiety control we've written a number of articles and also a book on group therapy for cancer patients thomas jefferson said when angry count 10 before you speak a very angry count 100 mark twain said when angry count 41 very angry swear i'm on the mark twain side of this one because many many cancer patients feel that if they're controlling how bad they feel about the disease they're actually controlling the disease and one of the real burdens of the simon and wish away your cancer approach is that they feel that they're letting their bodies down they're letting their families down if they feel sad or scared about the cancer and if i've learned one thing in 30 years of doing this research it's that dealing with the real emotions that come with it doesn't hurt your body it doesn't hurt you it helps you and so pretending that you don't have you're not afraid or sad is a way of alienating yourself from your loved ones and adding more stress to your body not less so the and and in in one of the studies we did in our lab we found that cancer patients who are high in emotional control were actually more anxious and depressed than those who were low in emotional control so it doesn't work but one of my breast cancer patients said i was crying and my husband walked in and said stop crying you'll make the cancer spread and we we call that the prison of positive thinking you know if if you're not scared and sad and angry sometimes when you have cancer you really do need a psychiatrist you know that it's a kind of situation that triggers those natural emotional responses and the thing is to use them and work with them so what we taught women in this group is actually how to reduce their control of emotion and we this was a randomized psychotherapy trial and we were able to show that we significantly reduced their tendency to suppress their emotion that's the yellow line here compared to the controls who didn't get the psychotherapy so they learn to be less suppressive of their own emotions and at the same time al bandura here at stanford develop self-efficacy theory it's it's our ability to think we're managing things well and we developed a scale along those lines and the cancer patients who learned this felt that they were managing their emotions better even though they were far less controlling of their emotions so so it worked we also teach patients to deal with their fears of dying and death now it may seem strange there's nothing we can do about the fact that we die but there's a lot we can do about the way we die and in general because we isolate people who are dying we don't talk with them we make them feel as if they're already dead you know how do we conceptualize death it's it's you know being removed from loved ones there's an old african-american spiritual you got to walk that lonesome valley by yourself if we isolate people socially when they're sick we make them feel as if they're already dead and we worsen their death anxiety so paradoxically talking about death grieving death in these groups when we started these groups irv yalum my mentor who recruited me to stanford many years ago started one of these groups with breast cancer and we were warned by oncologists that we'd make patients worse because they would see one another die and get demoralized well we followed that very carefully we studied them very closely to make sure we weren't making them worse in fact we were making them better and i'll show you evidence for that and if you think about it death is not a novel concept to a cancer patient you know it has occurred to them that the illness could kill them so watching people die in close company actually helps them learn to deal with dying and death one of our patients when another one died made these little cards dear eva whenever the wind is from the sea salty and strong you are here remembering your zest for hilltops and the sturdy surf of your laughter gentles my grief at your going and tempers the thought of my own so these patients gain from it and what i'd like to another example is a woman emily who said being in the group is like standing at the top of a tall building or the edge of the grand canyon i don't like heights but gradually you learn to look and you feel better about yourself because you're able to look that's how i feel about death in the group i'm able to look at it now i can't say i feel serene but i can look at it so they gained a sense of strength by being able to face one another's death they also saw that they shouldn't be marginalized somebody mentioned that earlier that just because you're dying doesn't mean you're failing doesn't mean you're letting people down and if you can't see your own self-worth you can see it in the eight other women who are sitting around the room we had one woman who came in she was an elegantly dressed woman matched accessories everything even when she was very sick losing weight and she came in one day and she said my husband is a banker but he's not a teller he doesn't like to talk and i think he's kind of i think i think he's had it and i should just find a way to shorten my life and we could have speculated about the husband but it wasn't in the room i said i think you're asking us a question have we had it with you would we be better off without you and she got very powerful feedback about how much she meant what a role model she was to the other women in the group and in her will when she died they sent a limousine to the building where the group meets over at 401 quarry and took us all to her memorial service where we spoke about her so that kind of being together in the face of death is a powerful thing so i want to show you an example of how the group faced one of its deaths to give you a feeling for what we do if we could each take a minute to think about what would i want to get from the group before it's over today test the waters a little more what do i want because if it's hard in here i can imagine it's really hard outside my main objective was to come in and help someone else regain hope because you can get through it i'd like to make sure that what i do what i decide to do with treatment and things for cancer uh is the best thing to do daryl called me after i didn't show up last week i thought somebody cares that i wasn't feeling well okay how much you called yourself yeah and i think that that's what i want from this group is to find people who are supportive and caring about me and what do you want i don't really come wanting anything i just volunteered with steady and here i am [Music] our october 2nd meeting was sweet and sad the members were doing in a more palpable way than they had previously with fears of dying debbie talked about planning her trip to hawaii and how much she was looking forward to it and at the same time she knew that this would likely be her very last trip um this is october 30th 1991. it was a pivotal meeting for the group because it was the first meeting after debbie had died um clearly the group was challenged to face what they most feared and emerge either feeling closer and more supported or demoralized i mean do we know anything that's what i was gonna say what happened what happened i'd like to know what happened what do we know my understanding is that she got some fluid in her lungs and that a decision was made not to be extremely aggressive in trying to um to treat that that they felt that the prognosis was good i'm angry that i don't have a chance to say goodbye i mean it just feels so abrupt and we weren't able to do anything not knowing yes how does that you would have wanted to be able to yeah well at least i would yeah sound like that something yeah the issue that i hear everyone talking about was the lack of predictability in the sense that here was debbie talking about her trip to hawaii and now she's not with us there was a big bubble there of of euphoria for her and it was gone and it wasn't a bubble it was a big deep hole better wish i had known her before cancer i keep thinking what was she like before you know because we never really knew the real demi because she said that that wasn't the real deadly i invested in her i had feelings for her i just wish i could yeah i would like to think about something well what would you say not to worry and not fear to have somebody there to tell you that and just share it with her and it's okay and um so that her family will be okay they will be all right and not for her to feel guilty for being sick and guilty for dying on them and they'll they they will continue what you're doing in that group is marching back right there in the center of that circle and forcing those women to look at it that's right they can't turn their eyes away from it you're rubbing their nose in it well that was uh bill moyers he has such a gentle way of asking he told me that journalists are people who explain things they don't understand which sort of like but he was right we were rubbing their nose in it and that is the essence of what's different about what we do with cancer patients and the pop psychology idea that you just wish it away you know one of my patients got got a call from her oncologist that she'd had a recurrence of her disease and she was at one of these new agey retreats somewhere in marin county they have them all the time and and he leans in the window of her car and says you caused your cancer you can cure it and she tried to roll the window up on his head which i thought was a pretty good idea but there is this sort of you know this sort of fantasy idea that you control everything so and the problem is that the other the opposite mistake is to say the mind has nothing to do with the illness at all it isn't by wishing it away but by handling stress better we think you can make a difference now what aspect of of debbie's death was the group focused on what what part of it suddenness of it okay and how was that why were they focused on that what did that mean to them it could happen any of them it was so there was a certain amount of anxiety that's right but then what did they go on to discuss they didn't get to say goodbye so what are they starting to do now this was the first death in this group they're certainly starting to bond they've been through a common terrible experience and what else are they doing right on what they might feel but something else and that is right what they might do that is they're defining terms for a better death and not that they're blaming debbie it was very sudden but they're saying well when i go or when you go we want to prepare for it we want to be able to say goodbye so they can't control the fact of death but they can do a lot about the way they die there's actually a wonderful new book out by irv volume who helped me start all this called staring at the sun about helping people to deal with and face their own dying and it's very clear to me if i haven't learned anything else it's helping people face this death together face their own mortality together helps them it certainly doesn't hurt them and let me show you some of the evidence so we also encourage people if they have limited time to face those limitations and make decisions about how they want to live the rest of their lives although not everybody gets it i'm sorry mr rainey our test show you have two weeks to live and he says can i take them in august [Music] not clear on the concept so what we try to do is convert anxiety into fear and depression into sadness to convert a kind of general clout of misery into something you can face and do something about and we think that helps people manage the stress of this illness much better so what are the results he's saying do you remember what you were feeling before you ate the other members of the group it's it's a rare side effect that so we we looked at standard scales of mood disturbance in the women who were randomized to the support groups that's the yellow line and the ones in the control condition and you see that there was a significantly greater reduction in distress in the treatment group despite the fact that they were facing these kinds of deaths they were watching one another die of the same illness they wound up less anxious and depressed and that replicates a finding we had 20 years earlier in another randomized trial of psychotherapy for breast cancer patients the control group got worse the treatment group got better so we have solid data that shows that helping them confront these illnesses together deal with their fears of dying and death expressing emotion reduces distress it doesn't increase it and this is from what's called a cochrane database review these are very tough-minded statistical reviews of outcomes of psychotherapy and what it shows is there's significant evidence that even in cancer patients with very advanced disease treatment psychotherapy reduces depression and can help them look better and i'm glad to say that our study was one of the studies that they cited in this review shakespeare of course knew that all long before he said give sorrow words the grief that does not speak whispers the off-road heart and visit break when you're i mean people are bonding to you they're bonding to each other they care about this group a lot the group means something to them one thing is being measured wouldn't their natural inclination be to say that that gets better because they would feel disloyal or saying anything else so how accurate is the measure in that situation well uh yes yes i'll repeat the question so she's saying that well these women are in the group and isn't there some sort of social pressure for them to report that they're they're doing better um and we of course we don't just ask them did the groups help you we give them standard scales that ask them to rate on 80 items from a zero to five scale how anxious or frightened or depressed or sad are you they do know why they're doing it um and it's a reasonable question but on the other hand um i'd have to say that when you're dealing with breast cancer that's shortening your life you probably care more about that than whether i'm happy and get to publish a paper and so my general sense is that they told us the truth and you know things could have turned out better than they did too so i think they were appreciative thank you of having the opportunity but i don't think um they were so appreciative that they would markedly alter their their responses it's a it's a reasonable question but i think the answer is probably no yes yeah exactly you know the the i think uh who was it boswell said the gallows concentrates a man's mind wonderfully you know you just there are other things you focus on yes um well the interesting thing is while isn't a natural response to death to be depressed oddly enough no it's certainly natural to be sad or frightened or angry but depression is this kind of reverberating cycle where you feel hopeless helpless and worthless and i have to tell you i went to the mayo clinic once to give grand rounds and they had me go on work rounds with some patients and i saw a woman who was dying that day and she had scheduled a series of interviews with all of her family half an hour each to tell them what she thought of them and what she thought they better do with their lives and you know she was the most hopeful woman i think i've ever met so so i not sadness yes depression no and not you know it's it's a minority of people who are dying who are depressed and there are good treatments for that depression right until the last hours of life so it's very important that if they are depressed we deal with it and not dismiss it as a natural consequence of of dying uh yes one more yes the question is does acupuncture alleviate depression i've not seen so much data on that it's certainly very good for pain and pain exacerbates depression so if you have a patient who has both depression and pain and you treat the pain with acupuncture you probably would have a positive effect on depression as well in fact one of the other effects of this group was to reduce pain so we had a significant reduction in pain among the women randomized to the group compared to controls on the same and very low amounts of medication and this replicated a finding we had 20 years ago in another randomized trial so we can significantly reduce pain and that in turn should have an effect on depression as well so the idea is to help these women convert themselves from feeling damaged and stressed to transcending to facing and dealing with what they're dealing with this is the wing victory of samothrace in the louvre you don't look at that and say my god there's a woman missing her arms and her head you see it as an image of female power of transcendence and that's what we try to help these women do [Music] he's got three types of cards one says congratulations one says get well and one says good luck with the american health care system by the way you know the definition of a canadian a canadian is an american without a gun and with health insurance yes so in the last few minutes um we've lost a little time but i'll try and present some of the data we're gathering on what we think is going on in the body when these women manage their stress better this was a paper we published in the lancet in 1989. we were shocked to discover i because i mentioned simonton and this wish away your cancer thing we had this randomized psychotherapy trial we knew we'd help the women emotionally and it suddenly occurred to me i ought to find out what happened to them so we went to state death records and we got the survival time for all of the women in the study 83 of the 86 had died and it turned out that there was a significant difference in survival time the women randomized to group therapy lived an average of 18 months longer than the control patients by 48 months all the controls had died and a third of the treaty that's down here and a third of the treatment group were still alive so much to our surprise helping them face death and dying live better seemed to help them live longer now this aroused a fair amount of attention there was an article in the new england journal by a group in canada showing that there was a significant reduction in depression using a similar kind of psychotherapy but no difference in survival time so we repli we attempted to replicate the study we recruited a new sample of 125 women with metastatic breast cancer randomized them to group therapy or a control condition we found no overall survival difference but an interaction with the type of cancer they had so the ones who had a more serious kind what's called estrogen receptor negative cancer which is a more aggressive kind of breast cancer that does not respond to hormonal treatments lived longer if they were randomized to the treatment group than the controls and we think the difference may be because the hormonal treatments have gotten so much better with breast cancer that breast cancer mortality is going down and we think that may have influenced the er positive women but not affected the er negative women who still showed the treatment effect and this is data from an epidemiologist named pedo showing this improvement in survival now that they've started to use more effective hormonal as well as chemotherapeutic agents as well the other problem was we were haunted by our prior study most of our control patients were in support groups in fact i had a control patient in my office saying to me i want the name of all the other controls in the study so i can start a support group with them you know i said i don't think so you know this is a recently published study by barbara anderson at ohio state university randomized trial with women who had primary breast cancer they got group therapy or standard care and she also found a significant improvement in survival in the women who got the group therapy so there are several studies now independent studies showing uh such an effect and this was thomas kuchler in germany published in the journal of clinical oncology showing that gi cancer patients who got immediate intensive psychotherapy right after their surgical treatment lived longer over a 10-year follow-up than those who didn't so there are studies that show it all in all six studies randomized trials showing effective psychotherapy on cancer survival six others show no difference i'm glad to say there are no studies showing that psychotherapy kills patients we don't shorten life so it's still i think an important and an open question but there is at least some evidence suggesting that living better with cancer may help you live longer and there is plenty of evidence that social isolation is bad for your health this is from a review by james house in science showing that people who were low in social isolation had about a two-fold increase in their all-cause mortality rate and this is true for cancer as well than people who are well integrated socially it might interest you to know that the kind of social integration that's good for your health if you're a man is being married if you're a woman it's not being married it's relationships with other women which leads me to the unhappy conclusion that having a relationship with a man does your health no good at all regardless of your own gender and having a relationship with a woman does your health a great deal of good regardless of your own gender but social isolation is as bad a risk factor for mortality as smoking or high serum cholesterol levels but we pay no attention to that and we focus all our efforts on statins that's very good it's very important but it's not the only way to improve health so we're looking at dysregulation in various physiological systems that we think may have an effect on cancer progression and because time is running short i'll go through this fairly quickly but we think that the way people respond to stress affects their endocrine and immune systems in ways that can affect the progression of cancer and so we've been studying this with national cancer institute and national institute of aging support the stress response system that's primary is what's called the hypothalamic pituitary adrenal axis and it helps us secrete cortisol which is a stress hormone from the adrenal cortex that elevates glucose in the blood so it prepares you to fight or flee but in the interest of maintaining overall metabolism when cortisol levels go up the system starts to shut itself off so that you don't waste energy once the threat is over but there's a concept called allostatic load that repeated stressors repeated hits on the system will tend to disregulate it so it isn't the big stress it's the series of little stressors that we've talked about that can disregulate this stress response system so normally it should turn itself on and then turn itself off but it's sort of like breaking a light switch if you keep flicking it enough it'll either get stuck in the on position or stuck in the off position and we examined the pattern of cortisol throughout the day and night of women with metastatic breast cancer your cortisol levels were now in the night time should be down about here they should be a quarter as high as they were when you woke up in the morning waking up as a daily stress test so your court level should be high but people who are depressed tend to have high and relatively flat cortisol levels throughout the day and we looked at this stress hormone in women with metastatic breast cancer and found that only about a quarter of them had nice normal patterns like this and that those who had the abnormal patterns where this stress hormone went up later in the day wound up dying significantly sooner so we could predict years ahead who was going to die sooner based just on their diurnal pattern of cortisol we published this in the journal the national cancer institute and it's independent of all the other risk factors for breast cancer progression so disrupted stress hormones are a factor in predicting early mortality and somebody asked a question about sleep you had a question yeah so all these studies obviously are on women those medicines right sir and it seems like most of the studies in general have been done with women right are there reasons why the same studies haven't been done with prostate cancer you know lymphoma male populations and would you predict that the results would be the same there are studies that have been done with male populations some of those studies that looked at in psychotherapy and survival were for example in people with melanoma both men and women there are a lot of women with breast cancer sadly it's the most prevalent cancer among women and the second leading killer second to lung cancer so it is more common to do it we think that the story is pretty much the same with men as well but it just happens that it's a common cancer that has been heavily studied um it turns out that sleep disruption is associated with these abnormal cortisol patterns and so we've been studying now sleep patterns and disruption in sleep and one of the things that oxana polish from our group has found is that people who sleep better at night are better able to self-soothe during the day we call it vagal tone it's the activity of the parasympathetic nervous system when you really calm yourself down you have better vagal tone and it's associated with better sleep at night now we all feel that you know if you had a bad night's sleep you just feel crummy the next day and you can't calm yourself as well and it turns out that there is parasympathetic nervous system activity that's different when people sleep well and the parasympathetic system is in control of your body at night too so it's a way of turning down the sympathetic system turning up the parasympathetic system and that can affect the stress response as well in fact our breast cancer patients whose sleep got worse in the initial year died significantly sooner and again it wasn't just two months before they died losing sleep about the proximity of death this was months or years before so sleep disruption is another independent risk factor for cancer and we've been i think asleep at the switch and not recognizing that circadian rhythms are a very important part of stress and health helping people live better and potentially live longer we're now doing a study sponsored by the national cancer institute measuring sleep of metastatic breast cancer patients and if you know of anyone with that disease we can pay them to come into the hospital and have their sleep monitored for 36 hours measure their hormones and we're trying to learn more about these hormonal systems so please give beta or myself a call and we'd welcome them yes what about certain countries where people take naps oh you mean italy kind of thing um we we haven't studied that italy and spain they have very different circadian patterns but we think probably their stress hormones are normalized by it and actually the afternoon nap we all have a nadir about three o'clock in the afternoon and that's a time when your cortisol should be declining more and we think the sleep may actually help it to decline more it probably doesn't trigger another increase in cortisol but it's an interesting question we haven't we haven't studied that yes if sleep is a problem for cancer patients or for anyone why not let them use sleep aids does that have the same effect as well if sleep is a problem why not let them use sleep aids they can help the problem is most of the pharmacologic sleep aids work for a short time but but you tend to get habituated you need more to get the same effect or they just stop working there are some there's an old antidepressant called deserel which is sedating and is used and people don't habituate to that we use sometimes sleep hygiene is important too you know one trick is don't have your clock facing your bed because if you wake up and you see oh my god it's four in the morning that's an arousal cue you know your heart rate goes up your blood pressure goes up you're waking yourself up so there are things you can learn to do we think normalizing sleep and people just don't get enough sleep they don't go to bed early enough you know we so it's an important thing but the medication is not the the whole story unfortunately so uh i see we're at 8 20. we lost can we go a little bit longer what do you what do you think we've got a few more minutes okay so we've been looking at other measures particularly the other aspects of the endocrine and the immune system try to understand how stress and sleep disruption may influence cancer progression and there are a couple of really interesting findings you may have heard of the gene brca one it's one it's a an oncogene that if it is if you have an abnormal form of it your risk of lifetime breast cancer goes from uh seven or eight percent to 85 percent so it's a it's a gene it's a gene that is designed to destroy transformed cells to help them in their own lives when they change too much and if that gene is damaged you're at much greater risk for getting breast cancer well it turns out if you put cortisol on mammary cells you can inhibit the expression of this gene so it may be that abnormal levels of this stress hormone which we see in these women with the disrupted circadian patterns are actually inhibiting expression of genes that tend to regulate tumor cells and down regulate their growth we found also that patients with the abnormal cortisol patterns had lower numbers of natural killer cells these are these are lymphocytes that don't look for antigens like a bacterial antigen they look for transformed and dying cells and they kill them so they're part of the body's natural tumor surveillance network and fewer numbers of those cells are associated with more rapid cancer progression and we're also associated with the sleep disruption so we've recruited with dean piezo's help frodos de barr who is a national authority on psychoneuro immunology and he and i are working together to understand the relationship between endocrine and immune dysfunction that can affect cancer progression yes you had it um there are the problem are there drugs is the question that could change cortisol levels um the problem is that most of the ones that do are themselves cortisol-like so you could lower the endogenous cortisol but you would be exposing the body with drugs like dexamethasone to similar cortisol effects we were looking there was a drug that's called a crh antagonist that would tell the body to stop producing or releasing cortisol but it turned out to be toxic to the liver and it was taken off the market so we're looking for drugs that that will do that but we haven't found the right one yet this is a study that dr dubar and i did in which we found that depression actually inhibits our measures of cell-mediated immunity and so we think there's a direct connection between depression higher cortisol levels and lower aspects of immune function that we just published so that's the trail that we're on now looking at these hormonal endocrine links and this is a study by another group that shows that stress hormones like norepinephrine can trigger the growth of blood vessels that support tumors so there are a number of pathways by which stress can directly facilitate tumor growth or inhibit the body's immune and other mechanisms for surveillance against cancer so that's how we think stress affects psychological response hormonal and circadian responses that can have an effect on tumor growth in summary stresses are best handled with the acronym faces face rather than flea from stressors alter your perception of your situation learn to cope actively find some aspect of the stress you can do something about express rather than suppress emotion and enhance social support in that way feeling may lead to healing this is our center on stress and health they're a wonderful group of people this is oksana polish who is in our group heather abercrombie janine dc davis they're wonderful people who have been working for decades to help us understand what we've learned and i want to thank our patients as well who have given very generously of their time and sometimes answered our questionnaires honestly i hope i want to acknowledge our funding from the national institute on aging the national cancer institute national institute of mental health the california breast cancer research program your tobacco tax dollars at work the charles a dana foundation and the john d and catherine t macarthur foundation i want to briefly mention our center for integrative medicine here at stanford she's saying chicken soup bile 4 alternative medicines the the center was started in 1998 we have physicians psychologists acupuncturists massage therapists and instructors we do hypnosis biofeedback supportive care program now at the cancer center a variety of treatments to help people cope with serious illness we have classes on forgiveness journaling love yourself for everyone else's sake and a very popular class on mindfulness-based trust reduction taught by mark abramson we're available on the web and this is the contact information here's one of our successful patients shakespeare said when we are better see bearing our woes we scarcely think our miseries are foes the mind much suffers death or skip when grief hath mates and bearing fellowship but i want to remind you finally that dealing with a mind-body situation is a tricky business he's saying what happened here sergeant he says it's a placebo overdose we're pretty sure he only thinks he's dead thank you for your attention well we've gone over the time but it's just in your mind um and uh i want to thank dr spiegel for a wonderful presentation i know you enjoyed it and and of course as we complete this quarter um we'll be putting up all of the uh quarters uh lectures up on stanford youtube uh and itunes so you'll be able to see this all again and think about it one more time so this ends our time together for those who are leaving this quarter and not returning uh re-examine your reasons for doing that still time to come in we have a few more places left until your friends in the next quarter and we'll look forward to seeing everybody back who's coming and i want to thank all of you who did come to this last quarter for doing so it's been a joyous activity for all of us and i think if you have lingering questions about your mind and your body and whether they're connected or not dr spiegel will be here for a few moments thanks again and good night for more please visit us at stanford.edu

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Keywords: science, biology, medicine, biomedicine, physician, doctor, radiology, technology, mind, body, hypnosis, Doctor Herbert Spiegel, neurobiology, consciousness, healing, therapy, treatment, suggestibility, perception, pain, brain, cortex, drug, placebo, phar

Id: PlFaIxTv1_w

Length: 113min 56sec (6836 seconds)

Published: Wed Jun 09 2010