Is illness a purely physical condition? Does a person’s mind play a role in becoming ill and getting well? People have wondered about these questions for thousands of years, and the answers they have arrived at have changed over time.
Although we do not know for certain, it appears that the best-educated people thousands of years ago believed physical and mental illness were caused by mystical forces, such as evil spirits.
ANCIENT GREECE AND ROME
The philosophers of ancient Greece produced the earliest written ideas about physiology, disease processes, and the mind between 500 and 300 B.C. Hippocrates, often called ‘‘the Father of Medicine,’’ proposed a humoral theory of illness. According to this theory, the body contains four fluids called humor (in biology, the term humor refers to any plant or animal fluid). When the mixture of these humor is harmonious or balanced, we are in a state of health. The disease occurs when the mixture is faulty.
Greek philosophers, especially Plato, were among the first to propose that the mind and the body are separate entities. The mind was considered to have little or no relationship to the body and its state of health. This remained the dominant view of writers and philosophers for more than a thousand years, and the body and the mind are conceptually separate today. The body refers to our physical being, including our skin, muscles, bones, heart and brain. The mind refers to an abstract process that includes our thoughts, perceptions and feelings. Although we can separate the mind and body conceptually, an important issue is whether they function independently. The question of their relationship is called the mind/body problem.
THE MIDDLE AGES
After the collapse of the Roman Empire in the 5th century A.D., much of the Western world was in disarray. The advancement of knowledge and culture slowed sharply in Europe and remained stunted during the Middle Ages, which lasted almost a thousand years. Sickness was seen as God’s punishment for doing evil things. As a result, the Church came to control the practice of medicine, and priests became increasingly involved in treating the ill, often by torturing the body to drive out evil spirits. It was not until the 13th century that new ideas about the mind/body problem began to emerge. The Italian philosopher St. Thomas Aquinas rejected the view that the mind and body are separate and saw them as interrelated. Although his position did not have as great an impact as others had had, it renewed interest in the issue and influenced later philosophers.
THE RENAISSANCE AND AFTER
The word renaissance means rebirth—a fitting name for the 14th and 15th centuries. During this period in history, Europe saw a rebirth of inquiry, culture, and politics. Scholars became more ‘‘human-centered’’ than ‘‘God centered’’ in their search for truth and ‘‘believed that truth can be seen in many ways, from many individual perspectives’’. These ideas set the stage for important changes in philosophy once the scientific revolution began after 1600.
The 17th-century French philosopher and mathematician Rene´ Descartes probably had the greatest influence on scientific thought of any philosopher in history. Like the Greeks, he regarded the mind and body as separate entities, but he introduced three important innovations. First, he conceived of the body as a machine and described the mechanics of how action and sensation occurred. Second, he proposed that the mind and body, although separate, could communicate through the pineal gland, an organ in the brain. Third, he believed that animals have no soul and that the soul in humans leaves the body at death .
In the 18th and 19th centuries, knowledge in science and medicine grew quickly, helped greatly by improvements in the microscope and the use of dissection in autopsies. Once scientists learned the basics of how the body functioned and discovered that micro- organisms cause certain diseases, they rejected the humoral theory of illness and proposed new theories.
The field of surgery flourished after antiseptic techniques and anesthesia were introduced in the mid-19th century. Before then, hospitals were ‘‘notorious places, more likely to spread diseases than cure them’’. Over time, the reputation of physicians and hospitals began to improve, and people’s trust in the ability of doctors to heal increased.
These advances, coupled with the continuing belief that the mind and body are separate, laid the foundation for a new approach, or ‘‘model,’’ for conceptualizing health and illness. This approach called the biomedical model proposes that all diseases or physical disorders can be explained by disturbances in physiological processes, which result from injury, biochemical imbalances, bacterial or viral infection, and the like. The biomedical model assumes that disease is an affliction of the body and is separate from the psychological and social processes of the mind. This viewpoint became widely accepted during the 19th and 20th centuries and still represents the dominant view in medicine today.
HOW THE ROLE OF PSYCHOLOGY EMERGED
The idea that medicine and psychology are somehow connected has a long history, dating back at least to ancient Greece. It became somewhat more formalized early in the 20th century in the work of Sigmund Freud, who was trained as a physician. He noticed that some patients showed physical symptoms with no detectable organic disorder. Using his psychoanalytic theory, Freud proposed that these symptoms were ‘‘converted’’ from unconscious emotional conflicts. He called this condition conversion hysteria. Symptoms like these occur less often in urban than in backwoods areas, perhaps because urbanites realize that medical tests can generally determine if an organic disorder exists. The need to understand conditions such as conversion hysteria led to the development of psychosomatic medicine, the first field dedicated to studying the interplay between emotional life and bodily processes.
The field called psychosomatic medicine was formed in the 1930s and began publishing the journal Psychosomatic Medicine. Its founders were mainly trained in medicine, and their leaders included psychoanalysts and psychiatrists. The field was soon organized as a society now called the American Psychosomatic Society.
The term psychosomatic does not mean a person’s symptoms are ‘‘imaginary’’; it means that the mind and body are both involved. Early research in psychosomatic medicine focused on psychoanalytic interpretations for specific, real health problems, including ulcers, high blood pressure, asthma, migraine headaches, and rheumatoid arthritis. For example, Alexander (1950) described the case of a 23-year-old man with a bleeding ulcer and proposed that the man’s relationship with his mother created feelings of insecurity and dependency that caused the ulcer. The man’s stomach problems later decreased, presumably because he overcame these feelings through therapy. Over the years, the field’s approaches and theories evolved. It is currently a broader field concerned with interrelationships among psychological and social factors, biological and physiological functions, and the development and course of illness.
Health psychology, a field that is principally within the discipline of psychology.
- To promote and maintain health. Health psychologists study such topics as why people do and do not smoke cigarettes, exercise, drink alcohol, and eat particular diets. As a result, these professionals can help in the design of school health education programs and media campaigns to encourage healthful lifestyles and behaviors.
- To prevent and treat illness. Psychological principles have been applied effectively in preventing illness, such as in reducing high blood pressure. For people who become seriously ill, psychologists with clinical training can help them adjust to their current condition, rehabilitation program, and future prospects, such as reduced work or sexual activity.
- To identify the causes and diagnostic correlates of health, illness, and related dysfunction. Health psychologists study the causes of disease; the research we saw earlier showing the importance of personality factors in the development of illness is an example of the work toward this goal. Psychologists also study physiological and perceptual processes, which affect people’s experience of physical symptoms.
- To analyze and improve health care systems and health policy.
Health psychologists contribute toward this goal by studying and advising medical professionals on ways by which characteristics or functions of hospitals, nursing homes, medical personnel, and medical costs affect patients and their likelihood of following medical advice.
CURRENT PERSPECTIVES ON HEALTH AND ILLNESS
In 1977, George Engel at the University of Rochester published a seminal paper that described the biopsychosocial model of disease, which stressed an integrated systems approach to human behavior and disease. The biopsychosocial model is derived from general systems theory. The biological system emphasizes the anatomical, structural, and molecular substrate of disease and its effects on the patient’s biological functioning; the psychological system emphasizes the effects of psychodynamic factors, motivation, and personality on the experience of illness and the reaction to it; and the social system emphasizes cultural, environmental, and familial influences on the expression and the experience of illness. Engel postulated that each system affects, and is affected by, every other system. Engel’s model does not assert that medical illness is a direct result of a person’s psychological or sociocultural makeup but, rather, encourages a comprehensive understanding of disease and treatment.
A dramatic example of Engel’s conception of the biopsychosocial model was a 1971 study of the relation between sudden death and psychological factors. After investigating 170 sudden deaths over about 6 years, he observed that serious illness or even death can be associated with psychological stress or trauma. Among the potential triggering events Engel listed are the following: the death of a close friend, grief, anniversary reactions, loss of self-esteem, personal danger or threat and the letdown after the threat has passed, and reunion or triumphs.
THE BIOPSYCHOSOCIAL PERSPECTIVE
The Role of Biological Factors
What is included in the term biological factors? This term includes the genetic materials and processes by which we inherit characteristics from our parents. It also includes the function and structure of the person’s physiology. For example, does the body contain structural defects, such as a malformed heart valve or damage in the brain, that impair the operation of these organs? Does the body respond effectively in protecting itself, such as by fighting infection? Does the body overreact sometimes in the protective function, as happens in many allergic reactions to harmless substances, such as pollen or dust?
The body is made up of enormously complex physical systems. For instance, it has organs, bones, and nerves, and these are composed of tissues, which in turn consist of cells, molecules, and atoms. The efficient, effective, and healthful functioning of these systems depends on the way these components operate and interact with each other.
The Role of Psychological Factors
When we discussed the role of lifestyle and personality in health and illness earlier, we were describing behavior and mental processes. Behavior and mental processes are the focus of psychology, and they involve cognition, emotion, and motivation.
Cognition is a mental activity that encompasses perceiving, learning, remembering, thinking, interpreting, believing, and problem-solving. How do these cognitive factors affect health and illness? Suppose, for instance, you strongly believe, ‘‘Life is not worth living without the things I enjoy.’’ If you enjoy smoking cigarettes, would you quit to reduce your risk of getting cancer or heart disease? Probably not. Or suppose you develop a pain in your abdomen and you remember having had a similar symptom in the past that disappeared in a couple of days. Would you seek treatment? Again, probably not. These examples are just two of the countless ways cognition plays a role in health and illness.
Emotion is a subjective feeling that affects and is affected by our thoughts, behavior, and physiology. Some emotions are positive or pleasant, such as joy and affection, and others are negative, such as anger, fear, and sadness. Emotions relate to health and illness in many ways. For instance, people whose emotions are relatively positive are less disease-prone and more likely to take good care of their health and to recover quickly from an illness than are people whose emotions are relatively negative. We considered these relationships when we discussed the role of personality in illness. Emotions can also be important in people’s decisions about seeking treatment. People who are frightened of doctors and dentists may avoid getting the health care they need.
Motivation is the process within individuals that gets them to start some activity, choose its direction, and persist in it. A person who is motivated to feel and look better might begin an exercise program, choose the goals to be reached, and stick with it. Many people are motivated to do what important people in their lives want them to do. Parents who quit smoking because their child pleads with them to protect their health are an example.
The Role of Social Factors
People live in a social world. We have relationships with individual people—a family member, a friend, or an acquaintance—and with groups. As we interact with people, we affect them, and they affect us. For example, adolescents often start smoking cigarettes and drinking alcohol as a result of peer pressure. They want very much to be popular and to look ‘‘cool’’ or ‘‘tough’’ to schoolmates and others. These social processes provide clear and powerful motivational forces. But our social world is larger than just the people we know or meet.
On a fairly broad level, our society affects the health of individuals by promoting certain values of our culture, such as that being fit and healthy is good. The mass media—television, newspapers, and so on—often reflect these values by setting good examples and urging us to eat well, not to use drugs, and not to drink and drive. The media can do much to promote health, but sometimes they encourage unhealthful behavior, such as when children see jazzy TV commercials for sweet, nutrient-poor foods. Can individuals affect society’s values? Yes, by writing our opinions to the mass media and lawmakers, selecting which television shows and movies to watch, and buying healthful products, for example.
Our community consists of individuals who live fairly near one another, such as in the same town or county, and organizations, such as government. The influence of communities is suggested in the research finding that they differ in the extent to which their members practice certain health-related behaviors, such as smoking cigarettes or consuming fatty foods (Diehr et al., 1993). There are many reasons for these differences. For instance, a community’s environmental characteristics seem to influence residents’ physical activity and diets (Sallis et al., 2006; Story et al., 2008). Residents tend to be more physically active and have healthier diets in communities that have parks, are safe, and have stores and restaurants with large selections of high-quality fruits, vegetables, and low-fat products.
The closest and most continuous social relationships for most people occur within the family, which can include nonrelatives who live together and share a strong emotional bond. As individuals grow and develop in childhood, the family has an especially strong influence. Children learn many health-related behaviors and ideas from their parents, brothers, and sisters. Parents can set good examples for healthful behavior by using seat belts, serving and eating nutritious meals, exercising, not smoking, and so on. Families can also encourage children to perform healthful behaviors and praise them when they do. And as we have said, an individual can influence the larger social unit. A family may stop eating certain nutritious foods, such as broccoli or fish because one member has a tantrum when these foods are served.
The role of biological, psychological, and social factors in health and illness is not hard to see. What is more difficult to understand is how health is affected by the interplay of these components, as the biopsychosocial model proposes.