Excerpted from Mind-Brain-Gene: Toward Psychotherapy Integration © 2019 by John B. Arden. The following is from Chapter 4, “The Body-Mind and Health.” Used with the permission of the publisher, W. W. Norton & Company.
“Think with your whole body.” —Taisen Deshimaru
Anna and Michael had been married for seventeen years when both began to complain that the other no longer focused on the rest of the family. They spent an inordinate amount of time ruminating resentments about each other. Meanwhile, their two children were entering the first few years of high school and presenting new challenges for their parents. Both Anna and Michael felt they didn’t have the energy to keep up with the constant attention needed to maintain clear limits and expectations for the kids. Though they did not want to admit it, they felt relieved when their kids began to spend more time on their computers, playing video games and on social media. This meant less monitoring was necessary because the kids left the house less, and they began to match their parents in obesity, fatigue, and dysphoric moods.
Perplexed by everyone’s loss of energy, Anna asked their physician whether the entire family had contracted Lyme disease. They felt ill and did not know why. He ordered blood tests for each of the family members. Though there was no evidence of Lyme disease, he expressed concern that they all had become significantly overweight. He also reported that both Anna and Michael had high levels of C-reactive protein (a measure of inflammation), blood glucose, and LDL (bad) cholesterol. Anna had developed type 2 diabetes, and Michael had metabolic syndrome (a cluster of conditions—increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels that includes that occur together, increasing the risk of heart disease, stroke and diabetes). Anna responded by saying, “We were already very depressed! Now you are telling us we have bad genes? That makes me even feel worse.” Michael agreed. In response, their physician prescribed Prozac for both of them. With this medication Band-Aid their physician missed the opportunity to offer comprehensive health care and refer them to therapists to avert disastrous long-term mental and physical health. Though he started the consultation constructively by warning the entire family about their weight and both parents of their looming illnesses, the integrative approach they needed was compromised by the quick fix of “mismanaged” care.
What role should psychotherapy play in helping this family? Psychotherapy in the twenty-first century could be renamed “behavioral health,” because self- care behaviors have major effects on the immune system, the brain, and the body in general. These interactions have a profound effect on mental health. It is this relationship that is explored in this chapter.
Anna and Michael’s family has become the new norm. There are now overwhelming numbers of people like them throughout the developed world. Plagued with health problems brought on by poor physical and emotional self-care, they suffer bidirectional causal pathways between acquired physical and psychological impairments.
The Centers for Disease Control estimates that health behaviors account for 50 percent of adverse health outcomes in the United States— as much as genetics (20 percent), the environment (20 percent), and access to health care (10 percent) combined. These statistics suggest that half of all health conditions are preventable by changes in self-care behavior (Amara et al., 2003). Research has found that 40 percent of medical patients have a comorbid psychological disorder, while 75 percent of patients with a psychological disorder also suffer with a comorbid physical disorder (Kessler, Ormel, Demler, & Stang, 2003). Essentially, health behaviors represent the interwoven natures of physical and mental health.
The number of Americans suffering at least one physical illness is predicted to increase to 157 million by the year 2020. This is a mental health crisis that can no longer be overlooked. Though these statistics are ominous, integrated health care providers, including psychotherapists, can work to avert disaster to the health of millions of people through a better understanding of the bidirectional causal interactions among the mind, brain, and the immune system found in the field of psychoneuroimmunology, and providing approaches consistent with it. Since its emergence as a rigorous field of research, psychoneuroimmunology has identified many interrelated mental and physical health dysregulations. Not so coincidentally, this field of inquiry the emerged with the surge in numbers of people, like Anna and Michael, with chronic and acquired illnesses that dysregulate the immune system who also suffer from psychological disorders.
Because over half the population of the United States unknowingly suffers from self-inflicted immune system dysregulation, psychotherapy in the twenty-first century must promote lifestyle and behavioral health changes. Not doing so is like building a house on a sandbar by a hurricane-swept beach.
The Immune System
To get a better idea how chronic health conditions develop and cause psychological disorders, it is useful to put the immune system in perspective. Just as we are optimally endowed with a stress response system to deal with external danger, such as fighting off or fleeing from a predator, our bodies are protected from pathogens by a dynamic immune system. Whether the threat is from foreign bacteria, a contagious virus, or simply a cut on the finger, your body marshals internal resources to protect its cells and maintain homeostasis. Like the police, fire, and ambulance services combined, the immune system protects the body from external and internal threat. When working optimally it can save your life. When activated inappropriately it can cripple your life.
As a diffuse sense organ scattered throughout the body, the immune system communicates to the brain by both neural (fast) and hormone (slower) subsystems, influencing mood, cognition, and behavior. It comprises two main components: specialized cells that carry out protective functions and chemical messengers that allow those cells to communicate with one another and the rest of the body. The cells and the chemical messengers interact to mediate the location and intensity of inflammatory responses to protect the body from harm.
Chronic stress combined with poor self-care, such as inadequate sleep, impoverished diet, lack of exercise, and extra weight, inappropriately activates the immune system, with damaging effects. Anna and Michael, like millions of other people, acquired chronic conditions that turned their dysregulated immune systems into threats. Their immune systems switched from protectors to overactive enemies triggering autoimmune disorders and a downward spiral of significantly compromised physical and emotional health. Whether in response to adverse childhood experiences or chronic stress, or simply because of poor self-care, autoimmune disorders result in a variety psychological disorders, which then further exacerbate existing autoimmune disorders. To understand how this occurs and how psychotherapists can intervene, it is useful to highlight the multiple feedback systems that make up the immune system.
Specialized cells that carry out protective functions include the lymphocytes, which come in a wide variety of cell types, including B and T cells, produced in the bone marrow and thymus gland, respectively. Macrophages are the general foot soldiers that gobble up threatening bacteria, memory B cells are the snipers trained to attack specific targets, and helper T cells are communication officers, alerting other troops to an invasion. To maintain homeostasis in the body, these cells work together in a precise and coordinated dance choreographed by chemokines and cytokines, chemical messengers that allow those cells to communicate with one another and the rest of the body.
After lymphocytes are born they are tested in the bone marrow and thymus to be exposed to molecules of your body so that they will not attack the body. The ones that bind strongly to “self” molecules are killed off or undergo “editing” in the genes that give rise to receptors. Autoimmune disorders develop when this process fails. Facilitated through cytokines, pathogens are killed while avoiding harm to the body.
When harmful substances enter our body, cells in our immune system called macrophages (big eaters) serve as an immediate defense. These Pac-Men of the immune system detect, destroy, and clear foreign substances from the body. This first response system also includes neutrophils (40–75 percent of white blood cells), which aid the macrophages in killing foreign substances while initiating the inflammatory response. The term inflammation comes from a Latin term meaning “set on fire”; inflammation serves as a protective mechanism so that the healing processes of tissue repair can begin. For local responses, like a bruise on the knee, inflammation also produces a physical barrier that prevents the spread of infection into the blood stream.
While short-term inflammation that responds to injury or illness rep-resents a healthy process, chronic inflammation is not. Chronic inflammation represents a common factor among many psychological disorders and poor health. Because it is such a dominant feature, a better under-standing of chronic inflammation will help our efforts to put it under control. In other words, to understand how a healthy system becomes unhealthy so that we can shift it back to healthy again, we need to understand how chronic inflammation gets turned on and off.
Normally, as part of the inflammatory response, infected or damaged cells send out alarm signals via chemical messengers called cytokines that attract and guide specific immune cells to the site of infection or damage. Cytokines (cyto means “cell” in Greek, and kinos means “movement between cells”) are communication substances, proteins released by immune cells that act on target cells to regulate immunity. Cytokines include the interleukins (meaning “between the white blood cells”) and tumor necrosis factor alpha. There are pro-inflammatory and anti-inflammatory cytokines. The pro-inflammatory cytokines (PICs) coordinate inflammatory responses. Anti-inflammatory cytokines, as their name implies, work to dampen the inflammatory response. With chronic inflammation the PICs dominate. Inadequate diet, poor-quality sleep, and lack of exercise as well as stress, depression, autoimmune disorders, and obesity, are associated with excess release of PICs, and thus chronic inflammation. As a common marker of inflammation, a fluid produced by the liver called C-reactive protein (CRP) can be measured in a standard blood panel. One of the findings from Anna’s and Michael’s blood panels was moderately high levels of CRP. While very high levels of CRP are caused by infections, moderately high levels are associated with autoimmune diseases, obesity, and depression (Kendall-Tackett, 2010). Chronic inflammation represents one of the common factors associated with autoimmune disorders, such as rheumatoid arthritis, lupus, type 2 diabetes, Addison’s disease, Crohn’s disease, and ulcerative colitis. Chronic inflammation is also associated with neurodegenerative diseases such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease, and with psychological disorders.
Inflammation and Associated Psychological Disorders
- Bipolar disorder
- Posttraumatic stress disorder
- Cognitive decline
In addition, in children inflammation has been linked to:
- Tourette’s syndrome
- Obsessive compulsive disorder
- Attention deficit hyperactivity disorder
Anna and Michael, along with their kids, were unknowingly stoking up the amount of PICs and offering themselves few opportunities to generate anti-inflammatory cytokines through lifestyle changes. As a result, they were all suffering from chronic inflammation, with its associated fatigue, cognitive deficits, and depression.
When Anna returned to her family doctor for follow-up, complaining that she felt too little improvement, she was referred to me. Initially, she was quite perturbed that I addressed her poor self-care behaviors and associated them with her depression. Her resistance to these factors began to dissipate when I noted that both of her children began developing some of the same symptoms when their self-care matched hers.
The Brain’s Immune System
Chronic inflammation can lead to depression, cognitive impairments, fatigue, and achiness. Brain systems are affected by inflammation that can also perpetuate inflammation. These systems directly affect energy levels, pain, coping responses, and sense of self. So when Anna and Michael complained about lethargy, difficulty generating positive thoughts, depression, and cognitive deficits, inflammation likely played a significant role.
The brain has specialized cells with immune-like functions. Chief among them are the glial cells. Initially glial cells were thought of as the substance that holds neurons together (glia means “glue”) and were erroneously thought to function only as support cells. Glial cells include microglia and astrocytes, which are considered part of the brain’s resident immune cells.
Microglia make up 6–12 percent of all the cells in the central nervous system, where they constantly monitor for potential immune problems. They have many of the same receptors as peripheral macrophages and so can recognize bacteria and viruses. When they detect danger microglia release PICs such as interleukin-1 (IL- 1) (Maier & Watkins, 2009). Chronic stress and compromised health “prime” microglia so that they make and release PICs more easily when they encounter danger again. In other words, once the immune cells in the brain have been activated, it is more likely that activation will occur in the future.
Astrocytes play a significant role in the immune system by providing a point of interaction between cytokines and neurons via genetic transcription and synaptic plasticity. Astrocytes exchange signals with neurons, detect and react to immune signals, and release PICs, which influence peripheral immune cells. Through this process of monitoring, reaction, and learning, astrocytes can play significant roles in the perpetuation of the inflammatory spiral.
Activation of the inflammatory pathways in the brain adversely affect memory and mood. The excessive release of PICs from microglia and astrocytes in the brain, as well as in the rest of the body, including from fat cells, causes wide-ranging detrimental psychological effects. Overexpressed PICs cause cognitive deficits that involve disturbances in synaptic strength. High concentrations of receptors for PICs are located in the prefrontal cortex and hippocampus, potentiating cognitive impairments, including poorer working memory, episodic memory, and executive functions (Lim & Marsland, 2014). This is why Annie and Michael had an executive network “brownout.” For example, excessive IL-1 in the hippocampus has been shown to impair memory by interfering with brain- derived neurotrophic factor (BDNF), which is involved in neural plasticity, neurogenesis, memory, energy balance, and mood.
Because chronic inflammation deteriorates overall health and contributes to cognitive deficits and mood disorders, promoting lifestyle changes that lower inflammation should be a major goal of therapy. For example, given that extra fat cells contribute to chronic inflammation, weight loss should be a major goal—but this also represents a major challenge to building the therapeutic alliance![Content protected for subscribers only]