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Library of Congress Catalog* ng-in-Publicatwn Data

Handbi>ok of mind-body medicine tor primary care / edited by
i>onaid Moss ... feL af].
p> cm.
Includes bibliographical references arid mdejt,
ISBN 0-7619-2323-3 (c : alk paper)
I. Medicine. PsychosomaticHandbooks, manuals, etc, 2. Mind
and body therapiesHandbooks, manuals, etc. 3. Biofeedback
trainingHandbooks, manuals, etc. I. Moss, Donald, Ph. D.
RC49 .H327 2002

6JG.GB~<ic2l
2002008957

This book is printed on acid-free paper. 03 04 05 06 10

98765432

Acquisitions Editor, Editorial

Assistant: Production Editor: Copy

Editor: Typesetter: in doner
C over. Designer:

Jim Brace -Thompson Karen Ehrmann

Suiford Robiasuit Barbara McGowraa C&M
Digitals (P) Dd Terl Greenberg
Michelle Uc

Contents

Foreword: Common Problems in Primary Care:

The Need for a New Biopsychosocial and
Fsychophysio logical Model LX
TERENCE C DAVIES AND FRANK V. DEGRUY, III

Part I. Models and

Concepts for MindBody Medicine 1

1Mind-Body Medicine, Evidence-Based

Medicine, Clinical Psychophysiology, and
Integrative Medicine 3
DONALD MOSS

2The High Risk Model of Threat

Perception and the Trojan Horse
Role Induction: Somatization and
Psychophysiological Disease 19
IAN WlCKRAMASEKERA

3Psychophysiological Foundations of the

Mind-Body Therapies 43
ANGELE MCGRADY

4 Complementary, Alternative, and integrative

Medicine 57
JAMES LAKE

5 The Placebo Effect

Biofeedback Therapy 69
lAN WlCKRAMASEKERA

and

Its

Use

in

6A Comprehensive Approach to Primary Care

Medicine: Mind and Body in the Clinic 83

TERENCE C. DAVIES

Z__Professional Ethics and Practice Standards

in Mind-Body Medicine 93
SEBASTIAN STRIEFEL

Part II. Basic Clinical Tools 107

8 Biofeedback and Biological Monitoring 109

CHRISTOPHE GILBERT AND DONALD MOSS

9 Neurofeedback,
Quantitative EEG 123

Neurotherapy,

and

THEODORE J. LA VAQUE

10 Progressive Relaxation, Autogenic Training,

and Meditation 137
PAUL LEHRER AND PATRICIA CARRINGTON

11 Hypnotherapy 151
lAN WlCKRAMASEKERA

12 Cognitive-Behavioral
Medical Clinic 167

Therapies

MARX A, LAU, ZINDEL V. SEGAL,

ZARETSKY

AND

for

the

Am E.

13 Acupuncture 181

EMANUEL SJLIN

14 Spirituality and Healing 191

STANLEY KRIPPNER

Part III. Applications to Common

Disorders 203

15 The Biobehavioral Treatment of Headache

205
STEVEN M . BASKIN AND RANDALL E.
WEEKS

16 Temporomandibular
Pain 223

Disorders

and

Facial

ALAN G. GLAROS AND LEONARD LAUSTEN

17 Asthma 235

PAUL LEHRER, MAHMOOD SIDDIQIJE,

JONATHAN FELDMAN, AND NICHOLAS
GIARDINO

18 Coronary Disease
Disorder 249

and

Congestive

Heart

NARAS BHAT AND KUSUM BHAT

19 Back Pain: Musculoskeletal Pain Syndrome

259
GABRIEL E, SELLA

20 The Metabolic Syndrome: Obesity, Type

2 Diabetes, Hypertension, and
Hyperlipidemia 275
ANGELE MCGRADY, RAYMOND BOUREY,
BARBARA BAILEY

AND

21 Functional Bowel and Anorectal Disorders

299
OLAFUR S. PALSSON AND ROBERT W. COLUNS

22 Urinary Incontinence 313

OLAFUR $, PALSSON

23 Fibromyalgia 323

C. C STUART DONALDSON AND GABRIEL E.

SELLA

24 Chronic Fatigue Syndrome 333

CHARLES W, LAPP

25 Attention Deficit Hyperactivity Disorder 347

OFL F. LUBAK

26 Anxiety Disorders 359

DONALD MOSS

27 Mood Disorders 377

ELSA BAF.HR AND j. PETER ROSENFELD

28 Sleep and Sleep Disorders 393

SUZANNE WOODWARD

29 Rheumatoid Arthritis 407

CHERYL BOURGUIGNON AND DIANA TAIBI

30 Premenstrual Syndrome
and Premenstrual Dysphoric
Disorder 419
ANNABAKER GARBER

31 Caring for the Person With a Chronic

Condition 429
SHARON WILLIAMS UTZ

Part IV. Education for Mind-Body

Medicine 441

32 Medical Education for Mind-Body Medicine

443
MARGARET DAVIES AND OLAFUR S. PALSSON

33 Nursing Education for Mind-Body Nursing

449
DEBRA E, LYON AND ANN GILL TAYLOR

34 The Professional Role and

Education of Physician Assistants
in Mind-Body Medicine 457
ROBERT W. JARSKI

35 The Behavioral Health Provider in MindBody Medicine 467

RICHARD GEVIRTZ

36 Existential and Spiritual Dimensions of

Primary Care: Healing the Wounded Soul
477
DONALD MOSS

Author Index 489

Subject index 517
About the Editors
535 About the
Contributors 537

Foreword: Common
Problems in Primary
Care
The Need for a New Biopsychosocial and
Psychophysiological Model
Abstract The foreword introduces fhc importance of prim
Ary care in health care a fid rite central place of intibody problems within primary care. The authors* htjth
educator* in primary care medicine, define primary care
and review its scientific and intellectual paradigm. They
describe the role of managed care organizations in
increasing the importance of primary care within
American health tare, enlarging the function of the
primary care physician, and creating incentives that
redirect the priori ries and resources of primary care.
Mental health ts indivisible from physical health,, and the
authors see mental health problems as J major challenge
for primary care. Finally, die authors project their vision
for primary care and the need for a practical, integrated
mind-body approach to health cart withjb the one
undivided house of primary care.

INTRODUCTION

The case for primary care as an obligation of society is

derived from the special vulnerability a EH] the universal
act of illness. This vulnerability' generates A need that
rakes on the substance of a relative right because of
the promises inherent in OUT social and political
structures,
We have, in a sense, all made a set of mutual
promises to guarantee ro each other 3 certain kind of
society, one which is sensitive to and secures those
things closest ro our needs as humans. We would break
our communal promise, tell a communal lie, and live
an inauthentic social life if we neglected to exert every
effort to assure the mimmum security of access to
primary care whenever it is needed. (Peiicgrino &
Thomasma, 1981, 243)

The necessity for sick people to have access to

healers is such a fundamental reality that we
might wonder why
ir was not included within the
7
founding fathers Bill of Rights* In the ongoing
dispute regarding government-provided universal
health care* many people support the viewpoint
of Pellegrino and Thomasma 1981)* who
maintain that primary health care services, at
least, should be the minimum security of access
* * whenever it is needed" (p, 243)* However,
this belief leaves unstated a definition of the
scope and responsibility of primary health care,
and in view of the currently inadequate level of
support for mental health services at a primary
care level (by both practicing clinicians and
third-party payors), one is left to question the
potential sufficiency of a
future response to societal needs for mind-body
treatments, even within a universally insured,
primary care-oriented government health care
system.
The centrality of primary care within a wellfunctioning health care system is by this time
indisputable. Most of the world's countries have
established their health care systems around a
solid core of primary care, and in a comparison
of 12 different Western industrialized nations,
Starfield (1994} demonstrated that countries with
a stronger orientation to primary care w ere
indeed more likely to have better health levels
and lower costs. Sadly, the United States spends
more money on its health care system than any
other country, and yet because of rhe inadequacy
of its primary care services, it is ranked behind
many countries whose overall health care
expenditures are far ess (Starfield, 1994). Even
within rhe British National Health Service, which
has suffered such extremities of financial
shortcoming that rationing of some specialized
services became a necessity, the ready
availability of general practice care has been held
sacrosanct. If primary health care is destined to
become a universal **right,** it is imperative

to

that the human health problems encompassed by

primary care be researched and managed to rhe
highest degree possible so that maximum benefit
can resultfor optimal cost, to the greatest
number. An ever increasing body of research
now reveals that a majority of these health
problems can be defined in terms of mind-body
illness, and Therefore the publication of this
work, at this point in time, becomes a matter of
considerable significance,
This is an ambitious volume. It would be
enough to pull together a coherent inventory of
the common problems that arise at the interface
between mind and body. It would be more than
enough to then create a compendium of the took
that are useful against these problems. The
authors have done all that and more; they have
gone on to describe the use of these methods in
primary care settings* where indeed they are
most needed. They imply that our system of
primary care should be able to accommodate
these methods hut that we may need to develop
a new model of health care to do so. In our
opinion, this is a correct interpretation, although
ir will not be easy. This foreword will describe a
few elements of primary carewhat it is,
where it came from* how if fits uno the larger
house of medicine, what can be accomplished
thereso we can understand how the principles
of psychophysio logical medicine can be
incorporated into the primary health care of
pattents,
Before proceeding further, we want to stare
that we will make no apology for rhe fact that
much of this volume will be construed by many
to be contentious. If the place and relevance of
primary care services in the scheme of things is
a matter of continued debate, then the proper
rofe and significance of many mind-body and
complementary' and alternative medicine (CAM)
therapies is even more con trovers ial. Equally

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vi

MODELS

AND CONCEPTS FOR MIND-BODY MEDICINE

Pruitt, S. FK, Klapow, j, CM Eppfog-Jordafi* j* E,,

& Dre&selhauSj T R. (199$)* Moving
behavioral medicine to the front liner A model
for the integration of behavioral and medical
sciences
in
primary
care*
Professional
Psychology: Research and Practice^ 29(3h 230236*
Regier, D. A,* Narrow, W, E., ftae, D.
Aiandersdieidt* K, W.j Locke* B, Z,s &
Goodwin* R K* (1993). The de facto U*S.
mental and addictive disorders service system.
Archives of General Psycbiatryt SO, 85-93.
Schuyler. D., & Davis, K. (1999)* Primary care and psychiatry;
Anticipating an inrertah marriage. Academic Medicine^ 74(
l )* 27-32,
Sierpina, V. 3. (200 I)* Integrative health care;
Complementary and alternative therapies for the
whole person, Philadelphia; F. A. Davies.
Wdlf A, i.} 995). Spontaneous heating: Him* to
discover and enhance your body's natural ability
to maintain and heal itself New Y ork: Knopf.
Wetback, M. R. (1986). Third hne medicine:
Modern treatment for persistent symptoms, New
York: Routledge & Kegan Paul.
Wickramasekera, L. (19S8J, CUnical behavioral
medicine; Some concepts and procedures, New
York; Plenum*
Yuerij E. Gerdts, J, )L, & Waldforge], 5. (3999)*
Linkages between primary care physicians and
mental health specialists. Families, Systems Cr
llealth* 17(3)# 295-307.

CHAPTER

Professional Ethics and

Practice Standards in MindBody Medicine
SEBASTIAN STRIEFEL

Abstract: This chapter present; a it A me work for ethical professional eotuiu*:: and exemplary
practice that provides the foundation for conventionai ethical principles and practice standards.
The chapter stresses the importance of the practitioners persona! involvement, biases* and values
and introduces rhe concept of jspirattonai ethics. Nine universal ethical principles, which help
clarify many problem situations in mind-body practice, are introduced. The chapter also PC views
core values ant! virtue* to guide the professional Five case studies highlight problem situations in
mind'body practice

INTRODUCTION

Frhitai principles and practice

standards alone arc insufficient tor
resolving the many ethical situations
encountered by ittind~body medicine
practitioners {Jordan Sc Meara*
19^0). It is easy to try to resolve a
situation
without
taking
into
account the human issues involved
that is, one*$ own emotional
involvement* biases, and values, or
the client's pain and affect (Jordan
& Mears, 1990). For example*
Kitchener (2000) reported that
because
of
personal
biases*
practitioners who ire homophobic
are more likely to violate the
confidentiality of a client who is
homosexual and HIV positive than
they are of a client who is
heterosexual and engaged in the
same dangerous practices. Lotting
sight of the context of a problem
situation ts easy* especially if
resolving theproblem is reduced to
art abstract cognitive process by
simply applying ethical principles.
Since
rite
ethical
principles
applicable in specific situations are
often in confict* it takes something
mote to resolve the situation. That
something more is the moral
character
of
the
practitioner
involved. Morally, what kind of

person is involved in making the

necessary decisions?
Someone with good moral villus
JS likely to make better moral
decisions than is someone who
does not have them (Kitchener*
2000}. For example* the ethical
principles for most health care
professions make dear that sexual

intimacies
with
clients
are
prohibited, even if the diene
attempts to initiate A sexual
encounter. Those of sound moral
character are unlikely to get
sexually involved with a dienr*
whereas those who put rheir own
needs ahead of the welfare of the
client are

Fr&gressivi* Relaxation? Autogtmc

Practicing
autogenic
trainee is instructed to
Teaming,
and Meditation 14
5
can
be
praeoce them initially
for exercises
accompanied
by
very brief periods
seconds to I minute) unanticipated and often
side
effects.
several times each day and unpleasant
to increase the practice Although ail methods of
relaxation
trlining
can
time gradually.
The
six
standard produce relaxation-induced
anxiety
on
occasion,
exercises are as follows:
autogenic training tends to
, Heaviness in the limbs. produce these sensations
My right arm is
more
frequently
than
heavy.
progressive
relaxation
My left arm is heavy.
(Heide Borkovec* ), for
My right leg is heavy.
that are unknown.
My left leg is heavy. reasons
Although this experience
* Warmth in the limbs.
even to the most
My right leg is warm. occurs
experienced
autogenic
My left leg is warm.
training ptpetitioners, it is
My right leg is warm.
mostcommon amortg novices to the
My left leg is warm.
(30

6c

1983

3, My heartbeat is calm
and regular.
4H Jr breathes me (automatic
breathing). Although this
phrase sounds awkward in
English, it conveys rhe
meaning ot a pas* sivity
regarding breathing. The
trainee is instructed to
allow breathing to occur
automatically, without any
voluntary effort.
.5. My solar plexus is warm
(warmth in the area
slightly is? front of the
spine, below the sternum).
6. My forehead is. cool.

These formulas are often

interspersed
with
the
formula, \ly mind is at
peace.
Each exercise is followed
by a specific termination
instruction: Squeeze the
fists two times, take a slow
deep breath, slowly let it
out, and then open the
eyes.

method. Schtte described these vents

as 'autogenic discharges,'* caused by a
sudden discharge ot pent-up nervous
energy (Schultz C Luthe, 1969). This
hydraulic model of emotional regulation
is not accepted in modem psychology.
Alternatively, the phenomenon could be
ascribed to disinhibmon and consequent lapses in self-regulation. Other
forms of disinhihition frequently occur
during autogenic training, including a
dream-like
uncritical
stream
of
consciousness, similar to that described
m
psychoanalytic
terminology
as
primary process' thinking/' Physical
sensations are common experiences,
particularly pain or discomfort related
to previous iB- nesses, injuries, ur
surgeries. Intense emotion, fear, and/or
tearfulness are not uncommon. Perhaps
these sensations arc normally inhibited
by higher neural circuitry that is ternporaniy disabled during autogenic
exercises.
Although autogenic discharges can
sometimes cause sufficient discoinfort
to necessitate termination of training,
they also can have beneficial effects.

[iopyrighied
mater

Schultz argued that release of pent-up

energy allows the body to regain its
equilibrium. Alternatively, the beneficial
effects could be interpreted as similar
to those commonly prescribed by
behavior therapists for treating panic
disorder and other conditions involving
fear and avoidance of particular
sensations. Exposure and response
prevention (deliberate experience of the
unpleasant sensations or stimuli and
blocking of the usual methods of
avoiding them) are considered critical
components in treating a variety of
psychological ailments (Lang, Ciaske, &
bjork, 1999k Autogenic discharges may
produce just such an effect. Through
autogenic discharges, the trainee
reexperiences unpleasant sensations,
sometimes repeatedly. Either through
extinction of a classically conditioned
emotional response or by cognitive
restructuring in response to deliberate
thought about rhem, the sensations no
longer produce as great an emotional
response.

Fr&gressivi* Relaxation? Autogtmc

Considering the specific hypnotic areas using organ-specific formulas*

and Meditation
5
aspects of autogenic miningTeaming,
can he and
to produce 14
sclf-hypnotically
helpful to the clinician. In inducing: a induced behavioral changes.
hypnotic
trance,
the
hypnotist
commonly instructs the subject only Clinically Standardized Meditation
to experience what the subject is, in
Among the clinically oriented
fact, experiencing anyway. This is a
techniques,
clinically
well-known method for overcoming meditation
resistance to hyp- node suggestion. standardized meditation, or CSM
In autogenic training, this is done by (Carrington, 1999); the respiratory
avoiding any instructions to experi- one method, or ROM (Benson, i975};
ence anything that will not. in fact, and mindfulness meditation (Kabatoccur. The standardized nature of the Zinn, 1982] have been the most
used
to
date.
These
autogenic training situation allows widely
the experienced practitioner to techniques were devised with clinical
predict the full variety of responses objectives in mind
Optimal use of meditation m a
to die autogenic situation and provide
appropriate instructions. Tims in clinical selling depends on teaching
passive concemrarion instructions, the trainee to manage the technique
the vast majority of trainees can successfullya consideration that
easily
imagine
specific
body can easily be overlooked, Unless
sensations,
although
actually routine problems arising during the
experiencing them may be more practice of meditation are handled
difficult
Hence
the
trainee
is correctly, the likelihood of obtaining
specifically instructed not to try to satisfactory compliance is poor. If the
experience them; and even the technique is adjusted to meet the
unpleasant side effects of autogenic needs of the particular trainee,
compliance
JS
often
training are reinterpreted as a however,
beneficial part of the therapeutic excellent (Carrington ct 1, 1980),
It is doubtful that meditation can
process, Also, thinking about a
particular sensation can, at times, ever be taught effectively through
bring the sensation about. Often a written instructions, because correct
trainee may fed frightened about learning of the technique relies on
communication
of
the
various physical sensations, including the
mood*a
subtle
those associated with relaxation, and meditative
of
tranquility
best
may avoid thinking about them. atmosphere
Autogenic training raises awareness transferred through nuances of voice
of these sensations and allows the and tonal quality (Carrington, 199S).
trainee to habituate to diem. Because Meditation can be taught successfully
fear of ones body can contribute to by means of tape recordings,
anxiety, habituation to physical providing they effectively convey this
sensations can increase rhe sense of elusive meditative mood (Carrington
well-being. This further reinforces the et al., 19$0L In addition, the recorded
hypnotic power of the autogenic teaching system should be thorough
so the trainee learns to handle any
instructions.
After
learning
the
standard minor problems that may arise on the
exercises,
trainees
often
use way to mastery of the technique.
The
CSM
method
(which
autogenic
methods
to
induce
physiological changes in specific incorporates ROM as art alternative

form of meditation) is a total training

program in meditation that can be
learned either through cassette tapes
and a programmed instruction text or
in person with trained instructors.
Because of these advantages, the
following discussion on meditation
method is confined to CSM.

Whatever
the
method
of
instruction (recorded or in person),
dose clinical supervision of the
meditation
practice
is
strongly
recommended, Clinicians arc in a
strategic position to introduce the
idea of learning CSM to patients with
previously identified

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192 RAS
TOOLS
and

CLINICAL

of an organised religious institution

a person's relationship to a
purported
trancen
dent
reality
without regard to religion or cted
(Lukoit* Lu, & Turner, 1996, p. 234).
From this distinction, it follows that
many people are spiritual without
being religious* in the sense o
participating in organized religion.
Likewise* it follows that many people
are religious without being spiritual
that is* they perform the rituals and
accept the creeds of religious
institutions (at least superfr- dally),
hut their ethics* morals, and opportunities for daily practice of their
religion do not match their professed
be Nets {Krippner 6c Welch, 1992),
A significant number of patients,
when asked bow rhty cope with life
stressors and health problems (both
physical and psychological), mention
spiritual and religious attitudes *
beliefs, and practices* In some pans
of the United States* the proportion
reaches between 33 percent and 50
percent, according to some surveys,
especially among African Americans,
women, and the elderly. Furthermore,
a surprisingly large number of
patients would like their physicians to
address religious or spiritual issues in
the context of medical visits (Koenig,
McCullough* & Larson, 2001, p, 94),
In his survey of 47 societies,
Winkdman (1992) studied the records
of
*
religious
and
magical
practitioners* who claimed to have
access to spiritual entities (e.g.T
deities,
ghosts,
pirns).
These
practitioners alleged that they used
special powers (e*g.t casting spells*
bestowing
blessings*
exorcising
demons) to influence rhe course of
human affair* or natural phenomena
in ways not possible by other

members of their sodal group.

Underlying die procedures of each
practitioner was an explicit or implicit
model of healing that arranged,
structured, and systematized the
practitioner\ beliefs and assumptions.
Many of these models resembled that
proposed by Seaward (2000), who
proposed that stress is a disruption tn
coherence between the layers of
consciousness in the human energy
field" and that stress management
procedures need tO address the
union of mind, bixiy, and spirit (p.
241).

INSTRUMENTATION AND
PROCEDURES OF INDIGENOUS
HEALERS
Indigenous healers, native healers,
traditional
healers
and
similar
practitioners manage the health care
needs, of roughly 70 percent of the
worlds population (Mahler, 5977),
These practitioners often use signs
{concrete
representations
of
something else) and symbols (images
that represent sometluug more
complex) in their work. Numbers*
letters, and directional marks are
signs; mandalas, totem poles, and
abstract
stone
formations
are
symbols. An understanding of a
culture's spiritual signs and symbols
is
essential
to
mental
health
practitioners who intend to relievo
distress and facilitate recovery in settings different from their own.
For example, in the healing
ceremonies of the Navajo and other
tribes in the American Southwest, the
central element is the sand painting,
a symbolic design created in rhe soil
by the tribal shamans. The painting
3

opyrghsd

material

represents ihe spiritual and physical

landscape in which thtr client and her
ur his Mckntss v\isi. as well as the
cause of the problem and the
meaning of the procedure chosen by
the practitioner for its cure, The
practitioner often places stones,
plants, and sacred objects inside the
painting, with colored sand images
symbolizing the relationships among

die various elements. The sand

figures may be clouds, snakes, of
whatever is needed to portray the
path of the sickness as it proceeds
through rime and space. Chanting
and community vigils are typical
procedures that bring the elements of
a sand painting together. The
indisposed person then become!;
aware of the relationship between

Spiritmty and Healing

the sickness and the rest of his or her

life, Usually, friends* neighbors, and
relatives surround the client, singing
and praying for a recovery (Sandner,
1979),
Lvi-Strauss {19.55) proposed that
the kind of logic developed by tribal
people is as rigorous and complete
as that of modem individuals. Both
use signs and symbols in highly
sophisticated ways, but their modes
of expression anti application differ.
example, the cultural myths of
pre'Columbian Mexican and Central
American societies were not only
comprehensive
guides
to
daily
conduct but also explanations for the
mysteries of the universe. Mythic
symbols were manipulated with such
economy that each served a wide
range of philosophical and religions
ideas. QuetzaLcoatl was the *
feathered
serpent'
symbolized the transformation of
matter into spirit), as well as the god
of the winds,
lord of the
the spirit of the sacred
ocelot (a fierce jungle carl, the last
king of the Toltecs, and (following
tht? Spanish conquest) Jesus Christ.
The Christum cross, often used in
healing ceremonies, is a symbol of
Christ's crudfudoCL In Buddhism, a
white elephant often symbolizes the
Buddha. The six'pointed Star of David
is the symbol of Judaism, The
swastika was a sacred symbol in
Hinduism, in the Eastern Orthodox
Church* and among the Maya in
Central America and die Navajos of
the America*! South wi>t* Long
before its use by the Nazis in the
20th century.

For

dawn,

the

For several decades, social and

behavioral scientists have been
collecting data that reflect the wide
variety
of
healing
systems,
Sicknesses and injuries are universal
expert enecs, but each society
implicitly or explicitly classifies them
according to cause and cure. These
explanations include the spiritual
dimension if the social context is
supportive. For example, Mexican
American CMremderos and curanderas
often attribute an illness to an agent
whose existence must lie taken on
faith because it cannot be detected
withmedical
instruments

{Trotter fic Chavieg* 1981).

The mal oj<\ or "evil eye,"
has no place in allopathic
biomedicine, but
enrandemmo practitioners claim it
is caused by a person
(who staring intently at someone
else, usually with envy or
desire.
Treatment
may
include
forming
three
crosses on the victims
body with an egg while the
practitioner

recites the Apostle's Creed.

An
Apache
disease,
mUck^ purportedly results
from the neglect of entities
in nature If an Apache
d*XA not properly salute an
owl, he or she may suffer
from
heart
palpitations,
anxiety*
swearing,
and
shaking* Apache shamans
use spiritual prayers and
songs to treat this illness
that, it is believed, can lead
to suicide if not carefully
managed.
Frank and Frank (199])
conjectured that the first
healing model was built

1
9
3

around the belief that the

etiology of illness was
either supernatural (e,g.,
possession by a malevolent
spirit) or magical [e*g*, the
result of a sorcerer's curse)*
Treatment
consisted
of
appropriate
rituals
that
supposedly
undid
or
neutrair/ed the cause* The
rituals typically required the
active participation of not
only the sufferer but also
family
and
community
members. Both allopathic
and indigenous models of
healing are inclusive, yet
each presents its adherents
with
a
very
different
+
worldview.
Tbe
native
models are spiritual because
they
demonstrate
an
awareness of 3 broader Life
meaning that transcends the
immediacy
of
everyday

physical expediency, as wdl

as
an
"otherworldly"
transcendent reality that
interfaces with ordinary
reality.
The
influence
of
indigenous healers can be
seen in the practices of the
Spiritual
Emergence
Network (Grof & Grof,
1990), The network consists
of practitioners who claim
expertise in working with
such
phenomena
as
purported
spirit
communication
(^channeling," visitations,
eted,
unusual
mental
imagery (visions* voices,
etc*),
shifts
in
body
sensations
(ont-of-body
experiences* stigmata, etc,),
dramatic
religious
experiences

i 94 BASIC CLINICAL
TOOLS

(encounters
with
Jesus
Christ, the Buddha, etc,), and
mystical
experiences
(dissolving" into the cosmos
or into "ineffable love"), llie
network^ purpose is to offer a
process that enables persons
undergoing
spiritual
transformation to find the
support and guidance they
need to work through and then
integrate their fcxperiences.
Spiritual
crises
were
conceptualized quite differently
in the past, especially by
Western
religious
and
psychiatric institutions. The
Roman
Catholic
Church's
manual on exorcism lists many
spiritual crises as symptoms of
possession by sa tunic forces;
for example, "The facility of
divulging future and hidden
events"
is
considered
potentially demonic" (Katptd,
1975). More recently, such
claims have been labeled *
magical thinking or are
considered
symptoms
of
emotional disturbance by many
conventional
psychiatrists
(American
Psychiatric
Association> 1980). Neither
of these stances recognizes the
potential for growth inherent
in a spiritual crisis.
Those who would like to
inform
counselors
arid
psychological therapists that
unusual experiences are not
necessarily pathological might
consult a book published by
the American (psychological
Association titled Varieties of

Anomalous.

Experience

(Gardena, Lynn, ik Krippoer^

2000), which draw's attention
to a number of meaningful

human experiences too long

neglected, ignored, or even
derided, This resource does
not debate the veridicality or
reality of anomalous experiences, focusing instead on the
nature of the descriptive repo
its and how thes*: accounts
can
inform
psychological
therapists*
counselors,
psychiatrists,
and
related
professionals who want ro be
informed alxiur the full range
of the human condition.
The contributors to rhis
book, however, agree with
David Lukoil (1985) that
differentiating psychotic from
spiritual experience is not
easy" (p* 155). The task
requires
familiarity
with
psychopathological
perspectives as well as the

religious, cultural* and

ethnic background of the
client. To facilitate the
process of psychological
therapy in his practice,
Lukoff
used
creative
writing and painting. in
working with a client
(diagnosed as suffering
from manic psychosis)
who claimed that he had
been abducted by 'space
aliens," Lukoif {J 988j
tried to understand the
clients
underlying
personal mythology and
its accompanying meta
phots. Eventually, rhe
client
was
able
no
understand his mythic
framework
as
wdJ,
communicating it in art
and writing that was of
such a high quality that it
was
displayed
and
Copyrighted
material

published. Although the

diene continued to insist
that he actually had been
abducted, he dropped his
preoccupation with the
incident and was able to
get on with his life.
Psychological therapist*
and
counselors,
when
faced with a spiritual
crisis, have several critical
decisions to make. They
need to determine whether
the experience has psychotic components. They
must decide whether the
crisis is basically an
emergency that has little
growth
potential,
a
spiritual emergence in which
the client could gain
something of value if the
crisis is handled well, or
an emergency that can lead
to spin- tuai emergence, A
recurring bsuc is whether
the reported experience
(e,g.t
abduction
by

"aliens/" possession by a
demonic
entity,
or
recollection of a past life
' episode) is a metaphor
for an internal process, a
trauma tlut has been
forgotten, or an account
that should be taken
literally.
The
American
Psychological Association
has abo published two
books on spirituality in
psychological therapy. In
Integrating
Spirituality
into
Treatment (Miller, 1999), the

authors
assert
that
spirituality is of integral
importance to psychology
and offers practitioners
practical
ways
oi
incorporating
spiritual
issues
into
therapy.
Among
the
topics
addressed
are
prayer,
meditation*
forgiveness,
hope, serenity, 12-step
programs, and

Table
20.4

Components of the Medical History

for Diabetes

Initial Vistt
1.

2.

Symptoms* laboratory
results reLued to
dirtTtOS)S

Nutritional
history

assessment

weight

The Metaboik

Syndrome 285

hyperlipidemia, family
history, obesity;

12. ft y chi JSCK: i al/ect

>no m i<J\ i fe style factors
13. Tobacco and alcohol use

3> prenous And present

treatment plan
a. Medications {prescription
and over-the-coimter)
b. Medical
nutrition
therapy
c.Srif-managemem
training
d.Blood glucose
monitoring results
and use of data
4. Current treatment
program 1 Exercise bus
tory
6.Acute complications
{hypoglycemia,
hyperglycemia,
ketoacidosis)
7.History of infection*: dental,
urinary, skin, lower
extremity
8.Chrome complications of
diabetes: eye, renal,
peripheral vascular disease,
gastrointestinal, nervous
system
9.Medication history
Eprescription and o
verthe-co n tf r}
10. Family history: essentia!
hypertension* diabetes,
hyperlipidemia,
cardiovascular disease,
stroke

1. Coronary heart
disease risk factors:
smoking* essential
hypertension*

opyrighied

mater

Ongomg Visiti

l- Frequency, causes,
and severity of hypoand hyperglycemia
2. Biood
glucose
monitoring
3. Patient
regimen
adjustments
4. Adherence

6. Symptom*
complications
7. Other

lrursses

of

medical

8.

Medications
(prescription and overthe -counter)

9. Psychosocial
issuer stresses 10,

problems JP

Tobacco and alcohol

Lifestyle

use

changes

Forms, kept in the

medical record, remind
providers about physical
exams and laboratory
tests,
and
facilitate
documentation of care
(see
Figure
20.1).
Regular use of the
forms signals a need lor
a change in management
and thereby helps health
care providers identify
trends in blood glucose
that
may
predict
increasing severity of
the disease. If symptoms
of mood or anxiety
disorders are noted, the
patient
should
be

evaluated
andeither
medical management or
cognitivebehavioral
therapy ini dated.
Evaluation
of
the
efficacy of the management plan is necessary
before
changes
in
regimen are proposed.
Table 20." summarizes
factors to be considered
in
assessing
the
management plan before
the initial visit with a
new physician (initial
visit) and during visits
for established patients
(ongoing visits).

Tibie
Evaluation of the Diabetes
Management Plan initial Visit
Ongoing
20,7

Visits

1.

Short- and long-term goati

of management

2. Meditations
(prescription and overthe-counter)

* Medical nutrition therapy

4. Lifestyle changes
i, Self-management
education Monitoring;
glucose test results

7.Referral
to
specialists
if
needed
8. Agreement on continuing

support/fbllow-up with
other health care providers
such as dietitian, nurse
educator, exercise
specialist* couiisdor

9.Pneumococcal
vaccines

and

infuenza

1 * ShoiX- and long-term

goals of management 2.

Mediations (prwcriptiGTi
and over-thtcounter)

3. Adequacy
control

of

glycemk

with type 2 diabetes, as shown in a

study of 42 people with scores higher
than 14 on the Beck Depression
Inventory. Patients m the CBT group
showed greater improvement in
depressive symptoms and were more
likely to go into remission compared

4. ftequeiKy/sevecity
of
hypoglycemia
5. Blood glucose monitoring
results
6. Complications; eye, renal,
skin, teet, etc, 7* Contro! of
dyslipidemm
8, Blood pressure

9. Body weight
10, Medical nutrition therapy
11, Exercise regi men
12, Adherence
ro
selfmanagement training
13,

Referral

to

specialists;

annual eye exam

14,

Psychosocial

adjustment

and issues

Knowledge and .skills

regarding diabetes self-

15,

management

J6. Smoking
indicated)

cessation

{if

1?. Annual influenza vaccine

with patients in the control group.

Failures in the CBT group were those
with lower eompJjartce to seifmonitoring of blood glucose and more
complications (Lustman, Freedland,
Griffith, Si Clouse, 1948). GBI also
was associated with lessening of

diabetes-related anxiety in adotescents with type 2 diabetes i Ha ins*

Davies, Pan on, "forks, Ac Ainoi
oso*Camanjta, 2000).
Mind-body therapies used to treat
persons with diabetes have shown
variable results. Thirty-two patients
with type 2 diabetes com- pitied a
Mlidy ill width F.MCr feudhiiik uml
progressive relaxatton training were
prov tiled, ha rhe group as a whole,

relaxation training wa>s no mote

effective than intensive1 conventional
treatment. However, patients in the
relaxation group who evidenced high
trait anxiety levels showed improved
glucose tolerance and decreased
plasma cortisol (Lane, McCaskill,
Ross, F&nglos, Ac Surwit, 1993). In
another study, anxiety, tension, and
skin conductance decreased with
relaxation,

indicating that the subjects

bad learned the relaxation
response, bar no changes in
blood
glucose
were
documented (jablon, Nalibafi
Gilmore,
&
Rosenthal
1997).

In type l diabetes, several studies

suggested
positive
effects
of
biofeedback-assisted
relaxation
therapy on blood glucose {McGrady,
Bailey, & Good, 1991; McGrady,
Graham, Si Bailey, 1996)* In contrast,
patients who showed symptoms of
depression w ere not able to lower
blood glucose lifter A similar behavioral treatment regimen (McGrady &c
Homer, 1999), A small study of 15
adolescents with type 1 diabetes
found
that
stress
management
{cognitive restructuring and problem
solving) decreased anxiety levels and
improved coping abilities but did not
change blood glucose iHains jet al*t
2000}. At tiris rime, the differential
effects of relaxation therapy in type I
and type 2 diabetes require further
study*

Thermal
biofeedbackassisted relaxation has tieen
useful for people with
diabetes- related circular ion
problems* Forty subjects
with diabetes were given
biofeedback
training
to
increase toe temperature anti
blood volume pulse; results
showed improvements m
circulation in the feet, which
could decrease complications
of diabetes iRice and
Schindler, 1992)*
Yoga
reduced
blood
glucose and decreased the
need for oral hypoglycemic

The Metabolic
drugs in a group of 149
1125
people w ithSyndrom?
type 2 diabetes
who practiced yi>ga ior 4f)
days.
Yoga
training
consisted of one and onehalf hours a day of
relaxation,
breathing
training, and postum while
patients were hospitalised*
Two thirds of the patients
demonstrated a fair to good
response in blood glucose
(Jain, Uppal, Bhatnagar, fit
Talukdar, 1993)*
Essential Hypertension

fwo stress management

education
approaches,
transcendental
meditation
anti
progressive
muscle
relaxation, were compared

with lifestyle modification education

in 100 addt Africao Americans with
mild EHT Transcendental meditation
decreased systolic blood pressure by
10.7 mm Hgand diastolic blood
pressure by 6,4 mm Hg, and the
relaxation group decreased systolic
blood pressure by 4,7 nun Hg and
diastolic blood pressure by 3*3 mm
Hg. Only small changes were
observed in the education group*
These results compare favorably with
other nonpharmacological therapies
of EHT such as sodium reduction and
exercise (Schneider etal, 1995V
The effects of transcendental
meditation
on
total
peripheral
resistance were analysed in 32
healthy long-term practitioners of the
technique compared with a group o
controls* Systolic blood pressure and
total peripheral resistance decreased
and
correlated
with
decreased

Copyrighted
material

cortisol and sympathetic activity

(Barnes, Tmber, Turner, Davis, Sc
Strong, 1999 '. Elderly blacks caught
the
transcendental
meditation
technique were able to decrease
blood pressure more than the educa*
non
and
progressive
muscle
relaxation groups (Alexander et ah,
1996).
Exercise, weight management, and
the two combined were compared
with
wait-list
control
in
133
sedentary, overweight, un medicated
persons with high normal blood
pressure, stage 1 and 2 EHT. Patients
in the treatment groups decreased
systolic and diastolic blood pressure
as well as TPR, while cardiac output
increased. The weight management
group demonstrated lower fasting
and postprandial blood glucose* The
best effects were those found in the
group that received the combinado
of exercise and weight management
(Blumcnthal et a fa 2000). A program
of weight lews and low sodium diet w
as tested in odo1 obese persons with
EHT, while the reduced sodium diet
was abo given to elderly persons with
EHT who were not obese* Both
interventions were effective for up to
36 months (Wheleon ct al* 1998).
Several types of feedbackdirect
KOCH] pressure feedback as we1! as
EMG* thermal, skin conductance, and
heart rate variability Hofeedback
have been tested in persons with
EHT. Direct blood pressure feedback
svas used without relaxation therapy
in early studies by Engel, Glasgow*
and
Gaarder
(1983),
The
experimental
group
showed
a
decrease in systolic blood pressure of
73 mm Hg compared with 4.4 mm Hg
in the control group. Glasgow* Engd.

and DLugoff i 1989> proposed that

feedback and relaxation therapy
should l?e offered in a specific
sequence and not initially combined.
Blood pressure feedback followed by
relaxation training with daily home
practice was suggested to be the
most effective in lowering blood
pressure, Direct blood pressure
feedback* using a device that
measures bkxx] pressure from the
finger, has aiso been applied EO
white-coat hypertension, a type of
hypertension identified when an mdividual manifests elevated blood
pressure in the doctors office or
clinic but maintains normal blood
pressure at home. After a two-week
monitoring
period,
subjects
participated in four sessions of bio
feed back. Significant decreases in
systolic and diastolic blood pressure
were
recorded
in
addition
to
decreased blood pressure responses
to mental stress challenge iNakao,
Nomura, Shimosawa, Fufita, &c
Kuboki, 2000),
Forehead EMC biofeedback with
adjunctive
relaxation
has
been
studied extensively in EHT, An early
study of 22 trained subjects and )6
controls showed statistically significant decreases in both systolic ( J L 2
mm Hgi and diastolic {5.7 mm Hg)
blood pressure (McGrady, Yonker* I
an, Fine, fit Woemer, 1981). jurek,
Higgins,
and
McGrady
(1992)
combined EMG feedback and diuretic
medication to produce an additive
effect, Goebel, Viol, and Ore ha ugh
(1993) also reported small but
consistent
decreases
in
blood
pressure and anti hypertensive
medication compared to a believable
control group,

The
application
of
thermal
biofeedback to EHT is reviewed in
Blanchard (1990), An advantage in
lowering
blood
pressure
was
observed in those patients trained to
increase the temperature of their
hands compared to the group
receiving
progressive
relaxation
(Blanchard et al, 1986), Over a threeyear
period*
108
individuals
participated in a study of autogenic
training with thermal feedback taught
in a group setting. Home practice was
recommended.
The
experimental
group showed significant decreases
in systolic and diastolic blood
pressure,
increases
in
finger
temperature* and decreases in trait
anxiety and plasma aldosterone
(McGrady, 1994).
Persons with ambulatory blood
pressure of at least 140/90 mm Hg
participated in 10 hours of stress
management ( = 27) or were wait
listed i*r * 33) until after rhe control
period.
The
intervention
was
customized to patients1 psychological
risk, factors, Bloiid decreased in the
immediate treatment group (6,1 mm
Hg systolic and 43 mm Hg diastolic).
Similar reductions were observed in
the waitlist group eventually treated.
The extent of the systolic blood
pressure decrease was related to
reduced psychological stress and
change in anger coping style*.
Starting levels of hhxxi pressure were
strongly related with degree of
change (linden, Lenz^ Con* 2001),
Stress management plus exercise
was compared with exercise alone in
patients with heart disease. At the
end of treatment, patients m the
combined treatment group decreased
their global distress score and blood

The Metabolic

pressure reactivity to psychological

1127
challenge, theSyndrom?
latter particularly
important for lowering risk {Turner,
Linden, van der Wal, & ScbambtrgiT,
1995). An important metA-iinalysri of
trials of relaxation-based therapies
showed that the starting blood
pressure is predictive for the amount
of decrease in blood pressure. When
adjustments are made for differing
starring blood pressure, the best non
drug treatments were as efficacious
as several drug regimens {Linden &
Chambers, 1994)*
One study compared respiratory
sums arrhythmia (RSA) feedback with
thermal biofeedbaefc in EHT. Both
<ype^ of feedback were effective in
towering blood pressure, despite
differences
in
media
ring
mechanisms, it was suggested that
RSA feedback lowers blood pressure
through an increase in parasympathetic function, while both EMCr and
thermal feedback areeffective due to
a decrease in sympathetic function i
Herbs, 1994).
Efforts to define the long-term
maintenance of decreased blood
pressure in persons with EHT trained
with biofmlback-assisted relaxation
have proven ro be com plicated. The
nar- vjral progression of hypertension
and changes in medication must be
factored into the analysis of longterm
biofeedback
effects.
Nonetheless, some patients are able
ro maintain lower blood pressure
years after die end of therapy
(Blanchard et at., 1986; Leserman et
al.+1989; McGmdy, Nadsady, be
Schuimnn-Bntednski, 1991),

HypeHipuietnui
Copyrighted
material

lietailed descriptions of weight

management programs are beyond
die scope of this chapter, but the
primary care practitioner treating the
metabolic syndrome should lx: aware
of the significant influence of
psychological Actors in obesity. In
addition to the medical adverse
effects of long-term ovmvt ight are
the psychological concomitants. in a
society where a targe body results m
negative attitudes and overt hostility
directed toward the overweight
person, it becumes dear diat
treatment
must
consider
the
multifaceted nature of the problem.
Approaches
therapy need to
include
behavioral
and
social
components ((Nth, Fontaine, Cheskin*
Sf Allison, 2000).
Behavioral programs comprising
exercise, bertt-T eating habits, and
psychological support are considered
to be ideal ;Devlin et al., 2000).
However, most people crying to lose
weight do not use the recommended
combination of weight management
and physical activity. Conclusions
based on a survey of 100,000 adults
were that ar least one third of the
men
and
women
who
were
attempting to lose or maintain weight
were engaged in one or the other,
but not both (Serdula ct al, 1999).
Diet without exercise dtxrs not lower
LDL levels in men ot women with
high-risk
lipoprotein
levels
fStefemek*
Mackey,
Sheehan,
Ellsworth. Haskell, & Wood, 1993).

to

PREDICTION OF
TREATMENT RESPONSE
A success rate of 50 percent to 65
percent based on a enter ion
decrease in blood pressure of 5 mm
Hg mean arterial pressure in studies
of bio feedback in RHT fostered
interest in trying to determine if
blood pressure response could be
predicted. In a study of 40 individuals
with EHT, 25 were classified as
successful while 10 failed. Treatment
was most successful for patients with
the highest levels
anxiety, muscle
tension, urinary cortisol, and heart
tare
and
the
coolest
hand
temperatures. In addition, high
normal stimulated plasma rerun
activity predicted success in contrast
to low renin activity {McGrady is;
Higgins,
1989;
McGrady,
Utz,
Woemer, Bernal, Sc Higgins, 19S6;
Weaver & McGrady, 1995).
There have been variable results in
studies of patients with diabetes
contenting
which
patient
characteristics might predict betrer
response.
External
barriers
to
adherence
seemed
easier
to
overcome than feelings of deprivation
(Schlundt et aL, 1994). Depression
has been suggested to interfere with
a positive response to bio feed backassisted relaxation iMcGrady &
Homer, 1999); and poorer adherence
to self-monitoring of blood glucose
predicted a poorer response to
cognitive-behavioral
rlierapy
for
depression

oi

APPLICATIONS TO
protective treatment effect in the West of Scotland
COMMON DISORDERS
Coronary Prevention Study. Circulation, 103, 357362.
Gavard, J, A., Lusimjn, P+ & Clouse, R. E.
f1993), Prevalence of depression in adults with
diabetes. Diabetes Gire, I6t 1167-1 178,
f
Glasgow, M* S.* Engel, B, T,, ic D Lugoffr B. C.
(1989). A controlled study of & standardized
behavioral stepped treatment for hypertension.
Psychosomatic Medicine, 51, Hl-26.
Glasgow, R, E,, &c Anderson, R. M. {1999>* in
dixibeiw care, moving from compliance to
adherents is not enough. Diabetes Care, 22(12}
2090-2091,
Glasgow, it ET Fisher, E. B Anderson, B, J.,
i^aGnsou A*, Marrero, D#, Johnson* S- B.t et ai.
(1999). Behavioral science in diabetes. Diabetes
Car** 22, 32-843. Goebel, Mt Viol, G. W,, &
Orebaugh, C. {1993}* An incremental model to
isolate specific effects of behavioral treatments in
essential hypervasion. Biofeedback & Setf.Ragidatkm,
11(4), 25J-28QL
GoodalJ, T.A. t & Halford, W. K, (1991). Selfmanagement of diabetes mdlmis: A critical review.
Health Psychology, 10, i^S,
Cioodnkk, R J., Henry-, J, H,r & BuJti, V. M. (1995).
Treatment of depression in patienrs with diabetes
mellrttts. Jiutmal of Clinical Psychiatry, 56,128-136.
Gump, l . ( ffUJ. Gent-OvS uf the metabolic
syndrome, British Journal of Sntrition . SJfSnppL 1), S39-S48.
Haffncr, $. M. f 19981. The importance of
hyperglycemia m the nonfasting state to the
development of cardiovascular disease, Endocrine
Reviews J 9, 583-592, Hams, A, A,, Davies, W, H.,
Parton, E^, Totki J43c Amoroso-Cama-rata, J, {2000}.
A stress management intervention for adolescents with
type 2 diabetes. The Diabetes Educator, 26, 417-424.
Herbs, I). (1994}. The effects of heart rate partem
biofeedback versus skin temperature biofeedback for
the treatment of essential hypertension. Unpublished
doctoral dissertation> California School of Professional
Psychology San Diego, Howorks, K., Pumpria,
Wagner*N(Misk&* 0* GrtilmayF, Schhtsche, C-,
Schabiminn, A. {2000). Empowering dijbfta outpfltktifi with structured education; Shortterm ait d
bog-term effects of hmetionai insulin treatment on percehred control over diabetes, journal of Psychosomatic
Research, 4$t 37-44. Hu, F, BH, Sigal, R, J.*
RkhTklward^J. Goldit^ G, A,, Sotomon, C. G.p
Willett, W, C Spc&ef, F, E., Sc Manson, J. E,
(1999}. Walking compared with vigorous physical
activity and risk of type 2 diabetes in women.
Journal of the American Medical Association, 282p 14331439,
294

20

op-tightil
mater

APPLICATIONS TO
Hu I then, LL L,T Entire, T., Mattiasson, l.T Si
COMMON DISORDERS
Bcrgfund, G. (1995}, Insulin and forearm vasodilation
in hyperten^ion-proue men, Hypertension, 25, 2 34-21
ft. jablon, 5. 1.., Naltboff, B. IXt Gilmore, S. L<* Sf
Rosenthal, \1, f. (1997). Effects of relaxation training
on glucose tolerance and diabetic control in type ll
diabetes. Applied Psychophysiology attd Biofeedback, 22,
155-69,
Jain, S. C., Uppal, A.. Hhatnagar, S. O, D., &:
Talukdar. R (1993). A study <>f response pattern of
non-insulin dependent diabetics to yoga therapy.
Diabetes Research and Clinical Practice, 19, 69-74. joint
National Committee, (1997), The sixth report of the
Joint National Committee on prevention* detech on*
evaluation and treatment of high blood pressure.
Archives of Internal Medicine, 157, 24132446,
Jonas, B. S., Franks, F-, &: Ingram, D. D, (1997^,
Are symptoms of anxiety and depression rink factors
for hypertension: Archives of Family Medicine, 6, 43-49.
Jonas, B. S,, & Latuio* J. F. (2000). Negative affect
as a prospective risk factor for hypertension.
Psychosomatic Medicine, 62, 168-196.
Jurck, L L Higgins, J. T-, Jr.t & McGrady, A.
(1992). interaction of bk>feedbackassisted relaxation and diuretic in treatment of
essential hypertension. Biofeedback & SelfRcgniarion, 37(2), 125-14L
295

between
these
categories*
These
disorders are generally
more
prevalent
in
women than in men, and
women seek health care
for these problems more
readily
than
males
(Thompson et aL, 2000;
Whitehead,
Wald,
Diamant, er al., 2000).
By virtue of their
classification as function
al disorders, both these
disorders presumably do
not involve biological or
structural pathology, and
abnormal physiological
functioning is central to
their nature. The first

assumption has generally

been bonM: out by
research n but the
evidence has been mixed
in regard to the latter.
Abnormalities in physiological functioning are
sufficiently
predomi^
nant and well defined in
some of titese disorders
TO serve as diagnostic
criteria for the disorder,
in
pelvic
floor
dyssynergia>
for
example,
paradoxical
muscle tension during
elimination is used to
diagnose the condition.
In other disorders,
evidence has been reliop-

tightil
mater

APPLICATIONS TO
ably detected in groupCOMMON DISORDERS
based
studies
of
abnormal physiological
responses or patterns.
However, the abnormal
physiological responses
are nor evident in all (or
nearly all) patients and
therefore
are
not
diagnostically
useful.
This is the case for
irritable bowel syndrome,
in
which
excessive
physiological response to
intestinal
stimulation,
hypermotility,
and
heightened intestinal pain
sensitivity are seen tu a
substantial proportion of
patients in many studies,
but not in nearly all
individuals (Whitehead^
1996;
Whitehead
&
falsson, 1998). In still
other disorders irt this
category
such
as
functional
abdominal
pain (Ktngham, Sown,
Colson, 6c Clark, 1984),
there h little evidence or
data
on
abnormal
physiological findings.
Research
on
psychological functioning
m
patients
with
functional bowel and
anorectal disorders has
generally found patients
to
show
high
psychological
distress
compared with healthy
controls
and
other
medical
patients
(Pressman, 1999; Jarre It
er aL, \ 998 L Anxiety,
291

depression,
and
rotoatization rest scores
are
commonly
Significantly
elevated
{Whitehead,
1996).
Many patients (in some
studies the majority of
patients assessed) meet
the formal criteria for
comorbid
affective
(mood)
disordersa
diagnosis
sometimes
identified as a negative
prog nostic indicator for
behavioral treatment app
roadies
(Drossm&tt,
1999; Dykes, Smilght
Humphreys
Sc
Bass,
2001; Neh/a* Bruce,
Ratfi-Harvey, Pemberton,
Sc
CamHleri,
2000;
WhorweH,
Prior,
&
Cotgan,
1987).
Neuroticism,
a
personality
trait
associated with excess
negative affect over time
and threat perception,
has
repeatedly
been
found to be elevated in
these
disorders
(Whitehead,
1996).
Other
psychological
personality
profile
disturbances have also
been
found
to
characterize some of
these disorders (Heymen,
Wexner, 8c Gulledge^
1993).
Psychological
and
social factors associated
with childhood bowel
and anorectal disorders
are
very
poorly
op-tightil
mater

APPLICATIONS TO
understood
compared
COMMON DISORDERS
wixh those associated with
adult disorders. It is hard
to say whether it is the
parent, the child, both,
or an overly busy, twoworkingparents
or
divorced-parents culture
(War of the Diapers, ^
1999)
that
is
contributing most
to
toileting delays and other
childhood
elimination
problems.
Adult patients with
functional bowel and
anorectal disorders often
report high life stress
and past traumatic life
experiences (Grossman,
Gotmuri, et al., 2000;
Whitehead, 1996). in
particular, a history of
sexual abuse is reported
by
as many as 40
percent to 50 percent of
these patients, more than
is reported by patients
with any other medical
disorder
{Drossman,
1995;
Leroi,
Rerkelmans,
Denis,
Hemotid, Sc Devroede, 3
995; Lcroi, Bernier, et
at, 1995}.
Psychological distress
contributes significantly
to
the
severity
of
functional bowel and
anorectal
symptoms
{Drossman,
1999;
Drossman-, Whitehead,
et d., 2000; Jarrett et al.,
1998}. It xs at present
unclear,
however,
292

whether the impact of

psychological functioning
on symptoms occurs
through
physiological

effects
or
though
amplifying
somatization and i
Uness
behavior.
Empirical research has
shown only a modest
or
no
relationship
between the magnitude
of
physiological
abnormalities and that
of
psychological
distress (Whi to head.
1996).
Not
only
do
psychological
factors
contribute
to
the
manifestation
of
functional bowel and
anorectal disorders, but
these disorders often
have severe irrigative
impacts
on
the
psychological
wellbeing and social and
occupational
functioning of patients.
Fecal
incontinence,
which occurs in about
2 percent of children
(by definition after age
foun and mostly (about
95 percent) takes the
form of a constipated,
overflow incontinence,
can become a source
of very great conflict
within the family and
in child care settings
beyond
the
home
(American
Gastroenterological
op-

tightil
mater

293

APPLICATIONS TO

Association.
1999;
COMMON DISORDERS
Collins.
19S0;
Whitehead,
Wald,
Norton,
2001).
Adults who continue
to U* incontinent or
who
develop
incontinence
(approximately
2
percent overall) will
likely suffer just as
greatly, fear leaving
home, and miss our on
being
active
and
having a normal life
(Whitehead, Wald, &
Norton, 2001 j* The
overall incidence of
fecal
incontinence
approaches 15 percent
after the age of 50 and
finally
becomes
a
major factor in nursing
home placements for
the elderly, where it
approaches 50 percent
among the residents
(Jorge &C Wexner,
1993;
Whitehead,
Wald,
Sc
Norton,
2001). Irritable bowel
syndrome,
which
affects 10 percent ro
20 percent of die
general population and
most commonly begins
in early adulthfiod, is
ejne of the leading
caufses
of
work
absenteeism in the
United States and can
severely disrupt normal
social and intimate
relationship
functioning.

TYPICAL
SYMPTOM
PROFILE
AND
ASSESSMENT

Until the early 1990s,

functional bowel and
anorectal
disorders
were generally loosely

and
inconsistently
diagnosed.
An
international effort in
gastroenterology
began
in 198S to develop
consensus criteria for
these
and
other
functional GI disorders.
The product of that
effort
was
the
establishment of specific
consensus criteria for
functional GI disorders,
the
so-caUed
Rome
enteria,
which
have
gradually won broad
acceptance in die field,
both In research and
clinical practice. The
current version of these
criteria is the Rome Q
criteria
published
in
2000
(Drossman,
Cora^iari, et al., 2000).
The bowel and anorectal
disorder
criteria
are
summarized in Table 2
U.
A definite diagnosis
typically requires both
irtflf+sron ot A set of
characteristic symptoms
of one of the disorders
and the exclusion of
op-tightil
mater

APPLICATIONS TO
likely
competing
COMMON DISORDERS
biological or structural
explanations
for
the
patient's symptoms. In
addition
to
physical
examination,
one
or
more rests may he
appropriate for the latter
purpose. Depending on
the
nature
of
the
symptoms and the health
risk profile of the
patient, these may be
endoscopy
or
radiological studies, anal
manometry>
blood
samples, stool tests to
rule our infection or
parasites,
or
breath
hydrogen
tests,
Constipation
and
incontinence,
in
particular,
warrant
a
thorough
diagnostic
evaluation to search tor
possible structural and
physiological causes. An
authoritative
set
of
294

lUfre are numerous

factors to attend TO in
the clinical assessment
interview of patients
with
lower
Gf
functional complaints*
and many of these will
influence
treatment
decisions. Some of the
factors are matters that
good clinicians attend
to in general behavioral
medicine practice, such
as the history of the
presenting problems and

guidelines may be found

in the * Consensus
Conference
Rcpom
Treatment Options for
Fecal
Incontinence
(Whitehead, Wald, &
Norton, 2001),
Mental
health
professionals
working
with
these
patients
should collaborate with
physicians and be well
acquainted with the common
resrs
and
assessment procedures to
ensure that other* and
often more dangerous,
conditions
involving
pathophysiology
are
properly ruled out. They
should not under' take
treatment until this has
been
done,
as
identification
of
biological
pathology
might
otherwise
be
delayed or obscured.
They

a
general
medical,
psychiatric, and social
history'. Because a host
of
pharmacological
agents
influence
gastrointestinal
functioning*
special
attention also needs to
he paid to use of
prescription, over-thecounter,
and
recreational drugs, and
vise
of
tobacco*
caffeine* alcohol, and
herbal
supplements.
optightil
mater

APPLICATIONS TO
Dietary habits should
COMMON DISORDERS
also be examined, as
fiber intake, specific
food sensitivities, anti
lactose intolerance may
have a contributory role
in symptoms. Cutrem
life stress, symptoms of
anxiety and depression,
and any relationship of
these with the presenting symptoms are
always
inipqrrani
considerations*
295

CONVENTION
AL MEDICAL
TREATMENTS
AND THEIR
SHORTCOMIN
GS
Due to the fact that
anxiety,
heightened
somatic
focus,
and
worry about potential
harm
from
these
functional GI problems
are more common than
not, patient education,
reassurance,
and
establishment of a good
therapeutic relationship
ate considered standard
and
important
components of good
conventional
medical
management
[Drossman* 1999),
Beyond those general
therapeutic
measures,
which arc sufficient to
ameliorate
the
symptoms
of
some
patients,
conventional

medical
treatment
typically
is
largely
limned
to
pharmacological
interventions
for
individual
symptoms.
Such
symptomatic
treatment varies greatly
in success, depending
on
che
disorder*
individual patients, and
symptoms
targeted
(Drossman, Corazziari*
et ai., 2000),
Treatment of the pain
that is central to
irritable
bowel
syndrome*
and
fimetkmai
abdominal
and anorectal pain has
met
with
limited
success.
Common
analgesics are: largely
ineffective
for
that
purpose* as they are
designed
to
target
peripheral pain rather
than
pain
in
the
gastrointestinal
tract.
Concerns
about
addiction potential and
overdosing limit the use
of
narcotics.
Antidepressant medications, on the other
hand, have been found
to act as ^central
analgesics^ Thompson
et aL, 2000) and can
reduce
abdominal
discomfort* which can
interfere with daily
activity, and have an
impact
on
the
depression of patients w
op-tightil
mater

APPLICATIONS TO
ho
luve
significant
COMMON DISORDERS
vegetative
depressive
symptoms
(e*g**
sleep*
appetite*
or
libido
impairment).
Anxiolytic medication
is often used to treat
the prevalent anxiety of
functional GI patients,
bur the value of these
dmgs
for
gas*
trointestinal
disorders
remains ro be proven,
and
their
sedative
effects and addiction
potential limit their
utility {Thompson et
aL, 2000), Bran and
oiher sources of fiber,
such as whole-grain
foods or fiber bulk
laxatives, have long
been recommended to
patients
for
management
of
constipation.
Fiber
supplementation has the
advantages of being
benign,
inexpensive,
and readily available to
all patients. In sufficient
doses {optima 11 y ar
least 30 grams per
day), fiber added to the
304 ' APPUCATiON'S TO
296

used iti the general population

(Heaton &t Cripps, 1993) and
by patients with functional
bowel disorders, and chronic
use can do more Harm than
good*
Dietary approaches to the
management of rhe functional
bowel and anorectal disorders

diet
can
improve
constipation,
hard
stools, and attaining.
Some patients report
improvement
in
diarrhea and pain AS
well, Jt should be
noted, however* that
some patients either
receive no benefit or
experience
significant
worsening
of
their
bowel symptoms from
increased fiber intake,
Furthermore, up to half
of patients may fail to
comply
due
to
flatulence, distention, or
abdominal discomfort.
Among
those
who
continue tr ear merit*
however, improvement
is seen in up ro 80
percent
of
cases
(Thompson
er
aL,
2000).
Laxatives other than
fiber are commonly
available and widely
used
by
patients,
Although they can help
constipation, they arc
often
inappropriately
and excessively

COMMON DSORDRS

have often been tried. There

have been some reports of
success with elimination dim
in controlling diarrhea* but
these remain largely unproven
{Thompson et al., 2000),
Anndiarrheal
medications
often help to control functional
diarrhea
and
diarrhea

op-

tightil
mater

297

COMMON

APPLICATIONS TO

associated with irritable bowel

DISORDERS
syndrome, but the common
antidiarrheal drugs frequently
have troublesome side effects
(Whitehead, Wald* Dtamaot,
et at, 2000),
Surgical interventions arc
generally not called for in the
treatment of time dona I bowd
and anorectal disorders but
are sometimes used to relieve
constipation associated with
severe
colonic
inertia.
Although
constipation
improves in at least half of
these patients after surgerys
serious and lasting side effects
such as diarrhea or incontinence are common (Pfeiffer,
Agachan, &c Wexner* 1996),
Conventional management
of
childhood
fecal
incontinence and constipation
is problematic And deserves a
special mention here, Ihe
predominant
method
for
treating thiJd- hood encoprcsis
has been habit training that is
highly reliant on oral laxatives,
which has resulted in longterm remission rates of only
around
60
percent
in
extensive reviews (Fdf et aL,
1999;
Lowery,
Srour,
Whitehead, & Schuster, 1985;
Whitehead, Wald, 0 Norton,
2001), This approach can
require months of treatment*
and
most
parents
and
pediatricians
use
harsh
stimulant vegetable laxatives
and problematic mineral oils.
Presenters
at
the
1999
Consensus
Conference
on
Fecal Incontinence advised

against the use of such harsh

agents, A very dear bias
emerged
among
pediatric
authors and practitioners in
the 1970s and 19S0s for using
oral laxatives to the exclusion
of more immediately acting

suppositories or enemas
(Levine, 1.982; Levine &
Bakow, 1976}.
Cultural concerns over
sexual connotations of
using the anal route may
prevent ihe more benign,
and often more helpful,
use of suppositories and
enemas and may inappro
priately
discourage
adequate examination of
children with anorectal
disorders. Gold, Levine,
Weinstein, Kessler, and
IVtiei {1999) found that
77
percent
of
128
children
referred
for
chronic constipation had
not
had
a
rectal
examination, a basic and
critical medical procedure
for diagnosis before referral, Fifty-four percent of
these children were found
ro have fecal impaction.
Fifty-two percent of the
children in this study had
received
stimulant
7
laxative therapy* and 1
percent of that subset had
not had prior digital rectal
examination, While abuse
of children can be a valid
concern, a legitimate and
important
medical
procedure such as a rectal
op-tightil
mater

APPLICATIONS TO
exam
must
nor
be
COMMON DISORDERS
ignored.
In
summary*
conventional
medical
management of functional
bowel
and
anorectal
disorders
consists
of
education,
reassurance,
and
drug
therapy,
sometimes supplemented
by diet adjustment and
increased fiber intake.
Such management helps
the majority of patients.
However, 25 percent to
40 percent of patients
{Felt, cr alr, 1999;
Lowery, et ah, 1985;
Whitehead* Wald, dc
Norton* 2001; Whorwell,
Prior, & Golgail, 1987)
will continue to suffer
from
chronic,
and
sometimes
debilitating*
symptoms without any
lasting
relief
from
standard
medical
management
These
treatment
refractory patients, as;
well
as
those
with
prominent chronic psychological distress or dear
association between stress
and GI symptoms, are
proper
candidates
for
psychological and psych
physiologiesI
interventions.
Furthermore, some mindbody
treatment
approaches, detailed in
the next section, have
shown such high and
reliable success rates to
298

research that they rival or

outperform
standard
medical treatment and
might be considered as the
first
choice
for
rrearing
incontinence*
pelvic
floor
dyssynergia,
and
irritable
bowel Syndrome*

BEHAVIORAL AND
F5Y CHOPHYSIGLOGIC AL
INTERVENTIONS

Broad-ranging
psychological
and psych ophysio logical
interventions
have
been

nested
trowel

for functional
and anorectal

disorders.
B to feedback
is
the
therapeutic
modality
that
most directly addresses die
essence of functionsE G1
disorders, because it aims to
directly
normalize
the
abnormalities in physiological
functioning that are thought to
underlie symptom production.
Biofecdback
has
been
demonstrated to be effective
n the treatment of pelvic floor
dyssynergia (nck, 1993; Rao,
Lock 8c Loenig-Baucke, 1997)
and fecal incontinence (Stick,
1993) in adults and children
and has been uwd as a
component
in
multimodal
treatment of irritable bowel
syndrome i Schwartz* Taylor,
Scharff, Ck Blanchard, 1990}*
Cognitive and cognitivebehavioral theta pies identify
maladaptive thoughts and
perceptual
biases
that
exacerbate
or optrigger

tightil
mater

299

COMMON

APPLICATIONS TO

symptoms or cause excess

DISORDERS
emotional
distress.
The
treatment aims at giving
patients control over both
their symptoms and the
impact of die symptoms ort
their lives. This approach has
been demonstrated to be
effective in the treatment of
irritable
bowel
syndrome
(Toner er a!., 1998)*
Behavioral
interventions
aim at (i) changing specific
behaviors directly related to
symptoms, such as voiding
behavior, that can influence
bowel functioning directlys or
(2) correcting maladaptive
behavioral
responses
that
produce psychological distress
(Coraey,
Stanton,
Newell,
Clare, &f Fairclough, 1991).
These interventions have been
used successfully in habit
training for fecal incontinence
(Lowery et alt 1985} and are
often
a
complementary
component
to
other
approaches to treatment*
Hypnotherapy has been
mostly used in the treatment
of irritable bowel syndrome,
where a therapeutic approach
centering
on
gut-directed
imagery
and
physiological
relaxation has l>een found to
help
many
patients
{Gonsalkorak; rt al., 1999;
WhorwdL Prior, &: Coigan,
1987)*
Psychodynamic
and
interpersonal
therapy
approaches have been used
only in a limited way in
reported work on functional

bowel and anorectal disorders

and are reported co have a
beneficial
impact
on
symptoms of irei* cable bowel
syndrome (Guthrie, Creed*
Dawson, & Tonienson, 1991;
Svedlund,
19831.
These
treatments
aim
at
ameliorating the effect that
difficulties in interpersonal
relationships have on the
symptoms ami welbbeing of
patients.
Stress management training, such
as progressive muscle relaxation or
autogenic training, makes good sense
in light of the ubiquitous findings of
heightened distress in patients with
these disorders. Stress management
training has hetn

iotmd

to reduce the

symptoms of irritable bowel syndrome

(Blanchard, Greene, Scharifi & SchwarzMcMocris,

199 3 ;

Shaw et ah,
with

Lynch & Zambie,

1 991 )

another

1 98 9 ;

and is often combined

specific

psychological

intervention, such as cognitive therapy,

hypnosis, or bofredbatk,

he rationale

ior rbis approach is TO neutralize the

sympathetic arousal that may amplify
or trigger gastrom testina! symptoms,
as well as to improve patients* wellbeing. Biofeedback (typically thermal or
EMG biofeedback training) has also
been used for general relaxation*

The
cognitive
and
cognitive-behavioral
treatment modalities are often
combined in various ways in
the treatment of functional
bowel and anorectal disorders.
For example, A treatment
package for irritable bowel
syndrome
consisting
of
progressive muscle

op-tightil
mater

300

APPLICATIONS TO

Cognithte-Behi&ri6ra/
bowel
syndrome
has
COMMON DISORDERS
been reported ro be Therapy for Irn table
successful in more Bowel Syndrome, The success
than a dozen studies, rate of this treatment is as
It has been tested in high as 80 percent, and the
a
randomized efficacy of this therapy has
been established in several
placebocontrolled
trial fWhorwdl, Prior, studies (Greene & Blanchard,
& Faragher, 1984)., 1994; Payne Sc Blanchard,
and a Urge case 1995; Toner et al., 1998; Yart
Fennis,
Sc
series (205 patients) Dolmen,
has been reported Bleijenberg, 1996), including
(Gonsalkoxak et ah, controlled trials (Payne Si
1999). Improvement Blanchard;, 1995). The
is typically seen in treatment can be conducted
SO percent or more in structured forma u and
of patients treated scripts arc available for
with a course of 7 to handling common therapy
12
session^ situations (Toner et aL, 1998).
Unfortunately,
no
remarkably, this high
validated
success rate is also empirically
seen
in
studies psychological or mind-body
involving
only treatment proto cols currently
for functional abdominal
patients with severe exist
functional diarrhea*
problems who have bloating,
functional abdominal or
failed
conventional and
anorectal pain.
management
(Palsson, Turner, &
Johnson.
2000; Long-Term Outcome
WhorwdL Prior, Si Studies
Colgan,
1987;
Functional bo we! and
Whorwfti, Prior, 6c
Faragher,
1984). anorectal disorders are
Fully
standardized generally chronic in nature,
protocols have been although many have an
tested
tPabson, intermittent course, and sponBurnett, Meyer, Si taneous recovery sometimes
Whitehead,
1997; occurs. Many studies of
and
Palsson, Turner, Si behavioral
Johnson, 2000) and psychophystological
are
available
to
clinicians with proper interventions for functional Gl
training
and disorders only include three to
experience in clinical six months of followup.

hypnosis,

op-

tightil
mater

301

COMMON

APPLICATIONS TO

Several
studies,
however,
DISORDERS
have demonstrated that foe
clinical improvement effected
by these treatments can last
at bast one to four years.
Examples
include
die
following:
* Gains
from
hypnosis
treatment for irritable bowel
syndrome have proven to be
well maintained at one-year
sod
two-year
followup
(WhofWeU, Prior, & Colgan,
1987; Palsson, Turner, Si
Johnson, 2000)*
* A follow-up (ChiotakakouFaliaknu, Kamm, Roy, Storrie,
& Turner, 1998) of 100 adults
treated with biofeedback for
constipation
refractory
to
conventional
treatment
showed that 57 percent of
patiems improved after two
years.
* Habit training for focal
incontinence
in
children
showed the therapeutic gam
to be well maintained at
three-year follow-up, with 61
percent
of
patients
experiencing excellent results
after that time (Lowery aL,
1985).

* A four-year foilow-up of
patients with multicomponent
treatment
Involving
progressive muscle relaxation,
thermal
hiofeedback,
cognitive
therapyt
and
education found that the
majority
of
patients
still
showed at least a 50 percent
reduction in primary symptom
scores for irritable bowel
syndrome (Schwartz et aLt
1990),
Such long-term benefits
from mind-body therapies for
functional
bowel
and
anorectal disorders support
the cost-effectiveness of these
treatments and the value of
considering these approaches
in the management of tum>
tional Gl disorders.
FUTURE DIRECTIONS

The Need for

Further Research

With
the
exception
of
biofoedback studies, the bulk
research
therapies for functional bow-el

of

on mind-body

and anorectal disorders

Copyrighted maleria!

op-tightil
mater

-OS I APPUq^TIONS TO

has focused
op irritable This manna] is currently
COMMON
DISORDERS
bowel
syndrome.
Psychological
and
psychophysiological Therapies for other disorders
need to be developed and
empirically tested*
Investigations of better
alternatives to the current
conventional treatment of
functional
lower
GJ
disorders in children have
especially been neglected.
Promising
alternatives
have
repeatedly
been
identified, bur adequate
efforts have not been made
to produce the research
data
necessary
for
systematic
empirical
validation
of
these
alternatives*
Psychologist
Logan
Wright (1973, 1975), for
example, introduced a
pnKetiure a quarter of a
century ago that rapidly
overcame unis- ntus and
guaranteed
daily
defecation using the anal
route.
His
procedure
dramatically reduced the
average number of soilings
from 17,14 in the first
week ro 2A6 for week wo
and 0*50 for week four.
This dramatic and rapid
response is much better
than that observed with
the oral route*
Another example of a
promising
treatment
alternative for children is
provided in the Clean Kid
Manual (Collins, 2002},

used by several pediatricians across the country in

creating their patients, and
parents are ordering the
manual directly after many
months of frustration with
the traditional pediatric
method.

Broadening the
Standard Medical
Approach to
Functional Lower
G1 Disorders

The realities of todays

dominant
health
care
environment
arc
rhat
primary care clinicians are
the principal caretakers of
patients with functional
bowel and anorectal disorders.
Qjnveotional
management
of
these
disorders could become
more
effective
by
integrating
successful
elements of mind-body
therapies into standard
medical care. Structured
procedures for primary
care
clinicians
that
incorporate
both
the
psychological,
physiological,
and
biomedical
aspects
of
these problems could be
developed and taught in
medical settings. Judging
from what has been found
effective for functional Gl
disorders
ro
date,
relaxation,
cognitive
restructuring,
education,
and empathy would likely
be important dements in
Copyrighted
materia!

such
corapreheiisivc
biopsychosoctaJ
interventions*
Additionally, physicians
who manage the health
care of functional Gl
patients should form dose

collaborations
with
behavioral clinicians with
expertise in the psychokigied

and
psychophysiologidai
therapies that have been
empirically validated for
these problems.

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Clinical factice and Practice Economics
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B., Scharff, L.f C khwara-MtMoiris, S. P.
(1993), Relaxation training as a treatment
for irritable bowel syndrome. Biofeedback &
Self-RzguLitian, , 125-132.

Chiottkakou-FaUkcni, E>> Kamm, M, A., Roy, A.

j Storne, J, B., &; Turner, i, C. (1998).
Biofcedbaek provides long-term benefit for patients
with intractable, slow and normal transit
constipation- GuU 42(4}. 517-521 r Collins, R, W.
(19801. Enuresis and encopresi, in R. H. Woody
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286-294). San Francisco: jossey-Bass. Colkm, R.
W. (2002, Much 0). The dean kid manual
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LeroL A. M., Bermcr, C., Waticr, A., Hemtmd, M,,
Goupih G., Black, R., et ai. jl995j* Prevalence of
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International Journal of Colorectal Disease^ 30(4}, 200-206.
Levinc, M D. (1982). Encopitsiai Its potentiation,
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Pediatric Climes of North America, 29(2), 315-330,
Levine, M. D., Sc iiakuw, H. (1976), Children with
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Lowery, S+ P., Srour, J. Wr> Whitehead, W* .,
Schuster, M. M, (19S5). Habit training as
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Lynch, P, M., St Zamble, E. (1959), A controlled
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Psychological disorders in patients with evacuation
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American journal of Gastroenterology, 95(7), 1755-1758.
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Patanar, S. R., Ferrara. A*, Levy, Jr R,T i^trach, S,
W., Williamson, P. R., &. FettttO S. E. (1997).
Biofeedback in colorectal practice: A multi-center,
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Payne, A,, Si Blanchard, E. B. (1995). A controlled
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Pfri/fcr, J., Agachan, F., & Wntficr, . D. (1996)Surgery for constipation: A review. Diseases of the
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Rao, S. S., Enck, P., St Loemg-Baucke* V. (1997).
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Schwam, S- P., Taylor, A. E-, Scharff, L, Sc
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irritable bowd syndrome patients: A four-year
follow-up, Behavior Research and Therapy, 25(4), 331-335.
Shaw, G., Srivastava, E. D.t Sadlier, M, Swann, P.,
Janies, J, Y., St Rhodes, J. (1991), Stress
management for irritable bowel syndrome; A
controlled trial. Digestion, 50, 3642.
Svedlund, j, (1983). Psychotherapy in irritable bowel
syndrome: A controlled outcome >tudy. Acta
Psychiatric Samdinavica, TfSuppL), 1-86*
Thompson* W. G., Longstteth, G., Drossman, D. A.,
Heaton, K.., Irvine, E* j*, St Mdler-Lisner, S.
(2000)* C, Functional bowef disorders, and D,
Functional abdominal pain, in f). A. Drosstnan, EL
CorazzUri, N. J* Talley, W+ G. Thompson* & W,
E. Whitehead f Ed^h Rome f; The functional
gastrointestinal disorders
(2nd cd,T pp. 351-432).
Mcljran, VA: Degnon Associates.
Toiler^ B. B,, Sega), Z. V,, Emmort, Myran, D., All,
A., DiGasbarro, I., et aL (1998), Cognitive-behavioral
group therapy for patients with irritable bowd
syndrome. International journal of Group Psychotherapy, 4#(2)*
215-243, Van Dulmen, A. R, Feunts, J. F., 3c
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Bletjetibcfg, G. (1996). Cognitive-behavioral group

therapy for irritable bowel syndrome: Effects and
long-term Mow-up. Psychosomatic Medicine, S8i 5), 508-514,
War of the diapers. (1999, January 25), Time, p. 64,

-OS I APPUq^TIONS TO
W. E. (1996)* Psychosocial aspect of
COMMON Whitehead*
DISORDERS
functional
gastrointestinal
disorders.
Gastroenterology Clinics of North America, 25{lj* 2134,
Whitehead* W* E,, & Palsson, O. 5. (1998b Is rectal
sensitivity a biological marker for irritable lx>wd
syndrome: Psychological influenti* on pain
perception
n
irritable
bowel
syndrome*
Gastroenterology* J5(Jh !2t3-ll7li
Whitehead, W. t# Wald, A*, Diamant, N. E.T Erick,
P., Pemberton* J. li, &C Rao, S. 5. (2000),
Functional dividers of the anus and ree tuoi, fo D.
A* Dro&smjm, W* Conaziari, R J. Tattey, W, G.
Thompson, Si W. E, Whitehead (Eds*), Rome //;
The function^ gastrointestinal disorders (2nd c&. pp.
483-5321* McLean* VA: Degnon Associates,
Whitehead, W, F., Wald* A.. & Norton, N* J.
(2001}. Consensus conference report: Treatment
options for tecal incontinence, Dis^d^s of the Coion
and Retti*ws 441}, 131-144,
WhorwdL P. J+> Prior, A* &; Colgati, S. M, {1987}*
Hypnotherapy in severe irritable bowel syndrome:
Further experience, Gat, 28{4), 423-425,
WhorwdL P* j,, Prior, A,, & Faragfrer, , B. (1984).
Controlled trial of hypnotherapy in the treatment of
severe refractory irrite bieTwwd syndrome*
Lancet* 2. 1232-1234*
Professional Psychology*
137-144.
Wright, L (1975J. Outcome of a standardised
program for treating psychogenic encopresi*.
Professional Psychology, 6( U ), 4J3-456*
Wright, L. (1 97 3 ). Handl i ng t he encopr et i c chil d.

4 (5 ),

Copyrighted
Copy rig
materia!
hied materici

307 APPLICATIONS TO COMMON

DISORDERS
micturition)* Stretch sensors
in the bladder wall send in
formation via the spine to the
brain* enabling the brain to
monitor
the
degree
of
fullness in the bladder.
Normal filling and emptying
of the bladder are largely
under the control of the
autonomic nervous system
(ANS), based on information
from the stretch sensors.
When there is little fluid in
the bladder* the sympathetic
branch of the A NS is
srinmUted. which causes the
smooth muscles of the
detrusor to relax and stretch
so
the
bladder
can
accommodate more fluid.
Simultaneously*
the
parasympathetic branch of
the ANS is inhibited* which
keeps the internal sphincter
contracted, holding the urine
securely in the bladder.
When the bladder volume
reaches approximately 300
cc, the brain normally
recognizes fullness. When
bladder emptying is desired,
tht brain stimulates the
parasympathetic nerves to the
bladder
and
inhibits
sympathetic nerve activity.
This results in contraction of
the detrusor smooth muscles
and relaxation of the internal
bladder sphincter. allowing
urine to escape. The wall
contraction continues during
that process, pushing the
urine out to overcome
resistance in the urethra.
Once the bladder is empty*
parasympathetic
inhibition

and sympathetic stimulation

resume, allowing filling to
begin again. The external
bladder sphincter usually
plays little role in continence
but can help to block
urination
briefly
when
needed, both in deliberate
withholding and to prevent
urine loss durmg transient
pressure increases in the
abdomen, such as during
coughing,
sneezing*
or
laughing.
Factors that increase risk
for
incontinence
include
diabetes mdlims. forge body
mass index, hearing children
(with the risk increasing after
each birch), and increasing
age (MacLeiman et ,iL*
2000;
Persson,
WolnerHanssen* & Rydhstroem,
2000k Regarding the last
factor, it is important to
recognize that normal aging
docs not cause Ul. However,
aging ..suits in biological
changes (such as pelvic
muscle
atrophy,
reduced
venation,
and
decreased
bladder
size)
and
accumulating events (such as
urinary tract infections, fecal
impaction, obstetric trauma*
prostate
problems,
immobility]
that
make
incontinence more likely to
occur*
TYPICAL SYMPTOM PROFILES

Most cases of UI fail into

one of four categories:
2

opyfightecl

material

308 APPLICATIONS TO COMMON

DISORDERS
1* Urge incontinence, or
detrusor interactivity (also
called
uninhibited
or
overactive bladder, detrusor
instability,
or
detrusor
hyperreflexia), is marked by
a recurrent* sudden urge to
urinate and frequent voiding*
The symptoms are produced
by
inappropriate
early
contractions of the muscles
in the bladder wall due to
defective ANS inhibition or
by excessive afferent sensory
stimulation from the bladder.
This can result from several
diseases and physiological
changes and becomes more
likely with aging. Urge
incontinence is not associated
with
any
consistent
pathophysiological evidence
detectable
by
rests
or
physical exam; therefore,
diagnosis is primarily based
on history.
2. Overflow incontinence is
chatterer wed by markedly
reduced
urinary
stream,
incomplete or unsuccessful
voiding, and frequent or
continuous dribbling of urine.
The causes are either a
bladder with lessened or
absent
contractile
ability
(hypotonic or atonic bladder)
or obstruction in the urine
outflow.
Either
cause
produces biglser than normal
bladder
volumes
with
pressure that exceeds the
resistance of the urethra,
causing dribbling, whereas
the obstruction or muscle
dysfunction causes voiding

difficulty. In men, bladder

outlet obstruction is usually
due to prostate enlargement.
Physical examination of urge
incontinence patients often
reveals a distended bladder
and LR men* prostate

opyfightecl

material

You
have

You
have

APPLICATIONS TO

incontinence
(Fanrl*
COMMON
DISORDERS
Wyman;
McGliah,
et af.*
1991), Patient education
and positive reinforcement
arc important components
of such training (Faml,
Wyman,
Harkins,
&
Hadley, 19901
Bipfeedback,
often
requiring no more than
four to six sessions, has
proven effective in several
studies
(e.gi$
Burgio,
Whitehead,
5c
Engel,
1985;
Bums,
Pnniko^
Nochasjski, Desottlle, Sc
Harwood, 1990; Barton*
Pearce, Burgio, Engel, $i
Whitehead,
19&8;
Ceresoli et al, 1993;
Glavind, Nohr, Sc Walter,
1996; Susset, Galea, Sc
Read,
1990),
with
significant
therapeutic
effects on both urge and
stress incontinence- HI
hiofeedback uses feedback
from
electromyographic
and pressure sensors to
correct
incontinence*
related
physiological
activity. Because of the
complexity of the voiding
process and the various
reasons
for
problems,
several
measuring
channels should be used
(Tries & Eistnan, 1995).
The (raining aims at reinforcing bladder inhibition,
strengthening
pelvic
muscle
tone
and
contractions,
or
maintaining stable bladder
pressure while contracting

pelvic
floor
muscles.
Although clearly effective,
it is unclear whether
bipfeedbadfc has distinct
advantages over other
methods. Several studies
have typically failed to
demonstrate dear outcome
differences of biofeedback
and comparison methods
(Bums et ah, 1990; Burton
et al, 1988; Ceresoli et
ah,
1993).
However,
Glavind et al (1996)
found biofeedback to lead
to more improvement than
pelvic
floor
exercises
alone in a study of 40
women (91 percent versus
22 percent on an objective
test at three-month followup). Many research protocols
and
clinical
treatment programs use
biofeedback
in
combination with pelvic
floor
exercises
and/or
bladder training. Apart
from biofeedback effects
alone,
biofeedback
instruments can also be
used
to
significantly
enhance teaching of pelvic
floor exercises (Burgio,
Robinson,
Sc
Engel,
1986).
EFFECTIVE PROTOCOLS
AND INTERVENTIONS

The many ways in which

interventions are combined
in the treatment of urinary
incontinence make it hard
to assess which single
interventions are effective
copyrighted
materia!

APPLICATIONS TO

and how much different

COMMON DISORDERS
components
add to the
outcome.
Surgery,
biofecdback,
bladder
training, and pdvic floor
exercises, however, have
been
demonsirated
individually to have m 80
percent or better success
rate in select UI patient
groups. Some examples of
such
effective
interventions are described
in
the
following
paragraphs.
Retropubic urethropexies
and suburethral slings are
surgical procedures that
have reportedly corrected
genuine stress incontinence successfully in 80
percent to 96 percent of
cases (Leach et aL, 1997;
Ulmsten et at, 1996).
However* since surgery,
unlike other inventions,
can sometimes result m
serious and lasting side
effects,
other
options
should be explored first.
in a study of 15 women
with stress and urge
incontinence, Susset et al.
(1990) reported that 87
percent
of
patients
improved on an objective
measure (pad weights) and
80 percent of patients
reported
KJ0
percent
symptom
improvement
from imravaginal pressure
biofeedback
combined
with use of home training
devices.

jams and Millar (1980)

conducted a randomised
and controlled trial of
inpatient bladder training
with 60 women. After
treatment, 83 percent were
continent and symptom
feet compared with 23
percent of controls.
In a comparison of
pelvic
floor
exercises
alone or combined with
biofeedback, Ceresoh et ah
(1993) found that 82
percent of patients using
the exercise*, alone and
89 percent also receiving
biofeedback had at least
60 percent improvement
in urinary loss (group
differences
were
not
statistically significant),

copyrighted
materia!

999i, new medications, and

minimally invasive surgical
Follow-up
in
studies
of solutions, keep emerging and
tahavioral
and
p*y- are likely to add to the arsenal
chophysiological treatments, as of currently effective treatments
well as other conservative for UL Behavioral and psychomanagement
methods,
has physiological methods have
unfortunately been 1 txmrevl in been amply demonstrated to be
most cases to a period of less useful in the treatment of Ul,
than a year after treatment. bur further research work
Empirical literature on the long- remains in the field to refine
term success of conservative and demonstrate which protomanagement
methods
for cols and combinations are most
urinary incontinence is therefore effecting
especially
for
almosi nonexistent and what biofeedback, which is practiced
little there is tends to rely on in a bewildering number of
small samples or the effects of ways*
I^ong-term
outcome
heterogenous
interventions, studies of significant siie are
However, there are indications sorely needed for ail of the
that
some
conservative conservative
management
approaches such as bladder methods.
training
and
pelvic
floor
Lack of reimbursement has
exercises have beneficial effects hindered many UI patients from
lasting a number of years benefiting from *ome of the
{Hahn, MiUom, et aL, 1993; benign and effective treatment
Lagro-Janssen &c van Wee!, altema- dves. The mounting
199%; Weinberger, Goodman, body of research evidence on
& Games, 1999). Surgical these methods is gradually
interventions for stress incon- removing such obstacles, and
tinence show excellent long- much wider access to options
term outcomes beyond 48 other than medications and
months with an SO percent or surgery is foreseeable* For
better success rate, {Leach et example, based on review of
aL, 1997; Richter et aL, 2001; the research and clinician expen
Ulmsten et aL, 1996)
testimonies, the Health Care
Financing
Administration
(2000a, 2000bi has recently
FUTURE DIRECTIONS
established a national policy
coverage
for
New and promising treatments mandating
stimulation
and
tor urinary incontinence, such as electrical
extracorporeal
magnetic biofeed- back for Medicare
innervation (Galloway et aL, ] beneficiaries with UI, when
certain conditions arc met.
LONG TERM OUTCOME STUDIES

Urinary Incontinence
307

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material

Urinary Incontinence

Copy
rig hied material
\
$21

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Alternative Treatments

Relaxation training of
any type serves to reduce
the generalized arousal of
the system, Hypnosis,
seif-hypnosis, autogenics*
and
visualization
techniques can all be
used,
depending
on
individual
tastes
and
needs, Progressive muscle
relaxation has the advantage of reducing the
muscle's resting levels but
runs the risk of irritating
any
existing
muscle
imbalances
and
cocontractions so should be
applied carefully. Surface
EMG techniques can be
used to monitor and com
ttol the muscle activity.
Numerous
forms
of
physical rherapy (e,g.?
Feldenkms,
Sahrmann
muscle work, and cranial
sacral therapy) are also
available, These particular
techniques are recommended
because
they
involve gentle manipulation of the muscles and
joints while not muting
the nervous system. Ice
and heat applied with
massage therapy also work
well,
Transcutaneous
nerve
stimulation
and
other variations of jt are
not recommended, as the
long-term effect is poor.
Some of the newer
microcurrent
techniques
(e,g,, Alpha Stim*j appear

82

to have promise, bur 1

further research is needed.
OUTCOME STUDIES
A more recent trend in
the literature is to view
the
treatment
of
fibromyalgia
from
a
multidisciplinary approach.
The overall effectiveness
of cofnbining treatment
modalities focused on both
the central and peripl^
era! nervous systems in
alleviating the complex
psychohigical and somatic
complaints associated with
fibromyalgia
is
demonstrated by a recent
clinical outcomes study by
Donaldson, Sella, arid
Mueller
U99S)
and
Mueller et aL (2001).
Both these retrospective
studies demonstrated that
a
multidisciplinary
approach to the treatment
of fibromyalgia shows a
high success rate with
positive long-renn results.
Donaldson, Sella, and
Mueller {1998) studied
252 consecutive referrals
to
a
chronic
pain
treatment center over a
period of one year. All
subjects were physician
referred, with 157 meeting
the criteria for fibromyalgia as defined by the
American
College
of
Rheumatology
{Wolfe,
Smyrhe, et aL 1990). All
subjects
received
a

Copy-righted
materia!

four'point evaluation that

iadtided U) trigger-point
evaluation, (2) SEMG
evaluation,
(3)
physiotherapy evaluation,
and (4) an EEC evaluation
as designed by Ochs
{1996a* 1996 b). This
evaluation
was
then
repeated
posttreatment,
whenever possible. All
subjects
received
a
comprehensive treatment
program that Included (1)
trigger-point therapy, (2)
physiotherapy, (3) SEMG
neuromuscular retraining
as outlined in Donaldson,
Sella*
and
Mueller
(199S), and (4) EEG
neurotherapy as designed
by Ochs {1996a, 1996b),
These subjects were on
average 44,2 years old
[range 14 to SJ), 80
percent female, in pain for
an average of seven years,
with a total score of 29.3
on the McGill Pain
Questionnaire.
Surface
IMG evaluation showed
significant
muscle
dysfunctions
primarily
affecting
the
upper
trapezius {47.2 percent of
the sample) and other
muscles in the neck, The
EEG evaluation indicated
the presence of elevated
theta activity 28 J percent
of the time, alpha activity
14.3 percent of the time,
and tbeta/alpha activity
17.3 percent of the rime.
This
dominance
was
evident at 8 of 13 sites

examined, including EP,

F3, Fz, C3, Cz, C4, and
Pi.
A combined therapy
progrant
of
SEMG
biofeedback,
massage
therapy,
physiotherapy,
and EEG neurotherapy
$howeda after one year,
that out of 44 who had
completed treatment, 4
reported
increased
symptoms, 10 reported
virtually a 100 percent
decrease in symptoms, and
the remaining 30 all
improved
to
varying
degrees. Tliere was a
marked pattern to the
improvement with the
cognitive
dysfunctions
clearing up in two to three
weeks, the pain decreasing
and becoming localized in
two to three months, and the

sleep
improving
in
approximately* three months.
Long-term follow-up of the
subjects that improved showed
they
maintained
the
improvement over a further
one-year follow-up,
Mueller et aL {2001)
reported on a series of 30
consecutive
fibromyalgia
referrals, treated using a
multidisciplinary
approach.
Although there was some
individual variation T patients
were generally treated three to
five times per week with
EEG-Driven Stimulation (EDS
was a precursor to FNS)
exclusively until changes in
their cognitive and emotional
stares and improvement in

their sleep was reported. Once

this shift became apparent
{mean of 16 6 weeks), the
number of EDS sessions per
week was reduced, and weekly
sessions of physical therapies
were added. Physical therapies
included some combination of
trigger-point
massage,
myofascial
and
positional
release, stretch and spray,
SRMG-assisted neuromuscular
retrainings prescribed muscle
stretching, and strengthening
exercises, depending on each
patient's needs. As a group,
these patients averaged 37.3
(15.6) hours of EDS and
14.7 {8.0} hours of physical
therapies over the course of
approximately three ro four
months of treatment.
Significant
decreases
in
average levels of cortical delta
{1t6 4 Hz), theta (4 to 3 Hz),
and alpha (8 to 12 Hz)
activity' as measured in preand posttreatmem brain maps
(313 percent * 28.9 percent,
and 18.7 percent reductions,
respectively)
were
noted.
Concurrently
significant
differences
(preto
posttreatmenc) were obtained
on the Symptom Check list9G^R (Derogate, 1994), the
Fibromyalgia
Impact
Questionnaire
(Burckbardt,
Clark, 6c Bennett, 1991), and
repeated patient self-reports of
selected key symptoms usmg a
visual analog scale (VM).
Patients rated themselves as an
average of 62.2 percent
{21.6 percent) improved
overall at the time of their

82

follow-up an average of 8.2

(4.3) months after treatment 3
was terminated. Similarly,
patients reported a significant
reduction
m
number
of
positive tender points from 15
(2) at intake to H ( 3} at
discharge.

7"he data just presented

and clinical data generated
by Donaldson and at
various dinks throughout
North
America
are
consistent in that they
suggest that change in the
CMS activity is necessary
before change in the
remainder
of
the
symptomatology
may
occur.
These
findings
point to a centrally
mediated
control
mechanism at a key component
to
change.
Presently, it is not known
if just creating the CNS
will result in longterm
symptom
reduction.
Treating the peripheral
musculature and peripheral
nervous system is still
needed to ensure longterm
and/or permanent change,
CONCLUSION

Fibromyalgia represents a
complex
and
puzzling
problem for the health
care professionaL The
ACR criteria for diagnosis
of this dysfunction is
based on the presence of
11 of 18 tender points
recurring throughout the

Copy-righted
materia!

body, emphasizing the

diffuse nature of the pain
component
to
this
problem.
In
addition,
various
cognitive,
emotional,
and
other
health problems (e.g.,
headaches) are reported,
and sleep problems are
well documented, Further
compounding the problem
is rhe variety of reported
causes of this dysfunction,
it is difficult to make
sense of how trauma,
virus, stress, and neck
pain all can produce the
same dysfunction!
Today there is no easy
answerno silver bullet
m the treatment of
fibromyalgia.
Current
research that is showing
some success with this
problem is muinfaceted in

To make some sense of

these seemingly unrelated
problems,
much
investigation has occurred
involving
biochemical
markers tn the blood,
brain, ant! other systems in
the body. These results
are not dear or have not
been replicated. Recently,
researchers have begun
examining the role of the
brain in chrome benign
pain and, in particular,
fibromyalgia. Presently *
this
work
is
very
preliminary and needs
further investigation.
nature,
treating
the
problem
with
sevtra!
therapies. While there is
hope for the future, let us
remain critical in the
present and do no harm/'

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Burckhardt, . (1992), low levels of
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Bkbaumer, N.T F lor, H., Lurzenbcrgtr, W\3 Sc
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(1991),
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C: Hexyx Publications.
Older, S,, Batiatarano* X, Damiing, C., Ward,
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pain
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fibromyalgia-like
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Russell, Qnr, M*, rnnan* B*, Vipriio, G*

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Elevated cerebrospinal fluid levels of

substance P in patients with the fibromyalgia
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B.
(1993).
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Wilkins,

Westmorland* B. (1993). The EEG in cerebral

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(pp. 291-304). Baltimore: Williams &;

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Whitt* K,* Speechtey* M,* Marth, M., &

Ostbye, T, (1999), The Loudon fibromy&L

gia epidemiology study: The prevalence of

fibromyalgia syndrome in London, Ontario.

Journal of Rheumatology 26(7), 1570-1576,

Wolfe, F,, Ross, K*, Anderson, J,> Russell, Lt
Sc Hebert, L (1995). The prevalence and
characteristics of fibromyalgia in the general
population. Arthritis and Rheumatism, 38(1),
9-2L
Wolfe, F., Smythe, H* A~* Yunus, M, B*,
Bcrmctt,
R,
M.,
Bombardtacc,
CL,
GoUcitivrg, D* L, etal. (1990), The
American Gollege of Rheumatology 1990
criteria for the damnification of fibromyalgia:
Report of the multiccmer criteria committee.
Arthritis and Rheumatism* 33, I6i>-172.
Yunus, M., Ahtis, T*, Aldag, J*, & Masi, A. T.
(1991). Relationship of dinkal features with
psychological status in primary fibromyalgia*
Arthritis and Rheumatism. 34(1), 15-21.
Yunus M., Dailey, J., Aldag, j., Masi, A* T.,
& Jobe, P. ( 1992). Plasma tryptophan and
other ammo acids in primary fibromyalgia; A
cfmmilled study. Journal of Rheumatology'. 19,
90-94.

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materia!

Box 24A 1994 International Case Definition Criteria

for Chronic Fatigue
Syndrome
Chronic fatigue syndrome is a syndrome
characterized by fatigue that is:
* Medically unexplained
* New in onset
* Of at least b months duration
* Not the result of ongoing exertion or relieved
by rest* and
*Causes a substantia] reduction in previous levels
of occupational, educational, social, or personal
activities
In addition, there must be tour or more of the
following symptoms:
Impaired memory or concentration
* Poctexertiona] malaise lasting more than 24 hours
* Un refreshing sleep
* Myalgias
Migratory multi joint pain without swelling,
heat, or redness (arthralgia}
Headaches of new type, pattern, or severity
* Recurrent nonsuppurative pharyngitis
* Cervical or axillary lymph node tenderness
CFS is excluded for the purposes of research,
however, by other currently active medical
that syndrome
are known
TO cause
significant
forconditions
chronic fatigue
but that
The next
step is to encourage regular
fatigue,
major
depressive
or
psychotic
illnesses
treatment can improve many symptomsi activity. Prolonged bed rest should be
andavoided
schizophrenia),
A (including
major* Lty bipolar
of personsdisorder
with CFS
due to problems with physical
dementia,
morbid
obesity
(BMI
45),
current
rerum to near normal activity, but this dectmdkkming.
The patient should be
eatingmay
disorders,
andThe
alcohol
or substance
process
take years.
physician
advised toabuse,
balance light activity with
should
assureFuku&t
the patient
of continued
SOURCE:
tt ah (19S*4)
+
care and suggest that psychological
counseling may help to cope with such
a long-term illness.
Activity

frequent rest periods. Althoughpatients

will resist exercise at first for fear of
triggering a relapse, they can be
coached to do interval exercise safely.
Two to five niiii utes of activity
(walking, biking, swimming, light
weights, aerobics, etc.) at a self-selected
pace should be alternated with 5
minutes of rest, and then repeated as
tolerated. With interval exercise, all but
the sickest patients can achieve several
minutes of activity daily.

Nutrition

The next priority is to optimize the

patients health with good nutrition,

vitamins, and supplements. A prudent

carbohydrate- based diet with lots of
fruits and vegetables,

318

APPLICATIONS TO

potato* rice* pasta, and

COMMON
Light DISORDERS
meats (chicken,
turkey, and scaly fish)
seems roierared best in
CFSt while heavy meals
with red meat and fried
or greasy foods are more
difficult m digest* cause
slow peristalsis, and are
innately
fatiguing*
Patients with irritable
bowel symptoms and
diarrhea
may
benefit
from a diet low in dairy
and
gluten
(wheat)
products.
Empirically,
many patients do not
tolerate refuted sugar,
excess
caffeine,
and
alcohol*
Symptomatic Therapies

The next step in

traditional patient man*
agement is to address
specific symptoms.
Sleeps
Sleep
U
probably the most important symptom to address
because without adequate
step* anyone would be
irritable, moody, achy,
and miserable* Sedatives
or hypnotics of lesser or
greater potency may be
necessary* with vigilant
awareness
of
the
potential development of
habituation or tolerance*
Relaxation therapies can
also be helpful (set
Chapccr 2S for further
behavioral strategies to
enhance sleep)*

Pain, Pain may arise

from muscles* joints, or
headaches* The usual
cautions
in
using
analgesic
medications
have to be observed,
although the risk of
habituation to narcotics
is remarkably low in
persons with chronic,
ponmalignant pain, anti
pain relief should not be
withheld 1for fear of
addiction* unless* of
course, the patient has a
past history of drug or
alcohol abuse {Pottenoy,
1990);
Central
activation
(reduction of fatigue and
cognitive
dysfunction).
Fatigue and cognitive
dysfunction are the two
most common concerns
in CPS patients. Fatigue
can be managed by
resting frequently, bur
additional
cognitive
dysfunction {brain fog*)
makes
the
illness
dreadful,
leading
to
discouragement,
frustration,
depressed
mood, and anxiousness.
Some of these feelings
may lx: attributed to
reduced serotonin levels m
the
blood
and
cerebrospinal fluid (Russell
et
aL,
1992)*
Accordingly,
serotonin
agonists, such as the
tricyclic
antidepressants
and selective serotonin
muptake inhibitors, are
frequently prescribed* The
fopy.righted
materia!

319

APPLICATIONS TO

increase in serotonin not

COMMON
DISORDERS
only improves
mood but
also improves sleep quality and motivation. Agents
with
norepinephrine
agonism (for example,
amitriptyline
and
venkfasrine)
have
the
added benefit of raising
the pain threshold.
Drugs*
Recently,
amphetamine-like
drugs
have been used to activate
the
central
nervous
system. While the exact
mechanism of action is
undefined, this class of
drug may work by (1)
direct
stimulation,
(2)
improving the aEtemional
deficits typical of CFS*
{3}
reducing
daytime
somnolence*
{4}
enhancing
die
antidepressant drugs* or
l5) raising the blood
pressure.
Long-acting
sftmufanrs
such
AS
phentertmoe or sustainedrelease
Dexedrmc
are
convenient for once-a-day
use, but methylphenidate

is
equally
effective.
Modafinil was introduced
specifically
for
the
treatment of daytime hyper
somnolence but has been
shown effective in treating
the fatigue associated with
multiple
sclerosis
and
fibromyalgia {Rammohan
et al*t 2 0 0 2 a s well as
chronic fatigue syndrome*
Orthostatic intolerance is
treated
with
volume
expansion, beta blockade*
and alpha agonism*
BEHAVIORAL AND
NEUROPSYCHIATRIC
ASPECTS OF CFS; A NEW
PARADIGM FOR DISEASE

For the past century, the

dominant
medical
paradigm has been that
illness or disease is
defined by a physical
injury* infection, or some
other specific* etiologic
factor* There is now
large and growing body of
evidence that CFS is not a
disease 1 of
simple
causation '
3

fopy.righted
materia!

but a disorder that

involves profound and
multiple
physiological
changes that resdt in [he
syioptomatology
that
characterizes
the
condition. The autonomic
dysfunction referred to
earlier (Bo^Hoelaigah et
aL, 1995) is likely to be
a refection of chronic
hypoactivation of the
stress
system
as
described by Habib et al.
(2001)*
Thus
a
gradually
increasing
understanding
of
the
mtimate and interactive
relationships between the
neurological* endocrine*
and
immunological
systems is leading us
toward defining a new
disease paradigm*
Depression and
Chronic Fatigue
Syndrome
Many physicians and
lay people still believe
that CFS is due to
depression alone. This
misunderstanding
is
perpetuated
by
uninformed practitioners
who either equate *
fatigue" with depression
or who have achieved
some success treating
persons
secondarily
depressed by debilitating
CFS, Scientific evidence,
however* shows that
depression
is
physiologically
and
clinically quite different

Chrome Fatigue

from
CFS
(Bakheit,
SyndromeCray, Sc 19
Behan* Dtnan*
O'Keane, 1992; BouHoulaigah er ah, 1995;
Demitrack et ah, 1991;
Farrar.
Locke*
fic
Kantrowitz*
1995;
Mountz et al.* 1995;
Schondorf
et
a!**
1999)*
Table
24,2
summarizes
the
differences
between
major depression and
CFS.
EFFECTIVE ALTERNATIVE AND
BEHAVIORAL TREATMENT
INTERVENTIONS

Alternative Therapies
Many persons with
CFS rum to complementary and alternative
therapies as a consequence of poor general
and informational support
from thei r physicians
and rhe absence of
effective
allopathic
treatments (Ax, Gregg,
Sc Jones, 1997), A
recent surveillance study
by the Centers for
Disease
Control
and
Prevention (NUenbauro,
Reyes, Jones, Sc Reeves,
2001) identified various
forms of treatment used
to treat chronic fatigue.
Seventy-nine
percent
used tradtional medical
therapies, bur a majority
also relied on vitamins
(79 percent), exercise
(64
percent),
dietary
changes (54 percent). In

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material

addition*
36
percent
reported using herbal
remedies, acupuncture, or
homeopathy.
Good scientific studies
of complementary and
alternative therapies in
CFS
are
few.
The
strongest body of support
seems
to
he
for
acupuncture, which is
adVseated mostly for the
management of chronic
pain. Some results have
been equivocal because
of design, sample size* a
nd difficulties in blinding
both
operators
and
subjects* The National
institutes
of
Health
promulgated
a
comprehensive
cotiiiensus statement in 1997,
concluding
that
acupuncture showed good
efficacy as an adjunctive
treatment
for
fibromyalgia
and
myofascial pain as well
as more traditional pain
syndromes
such
as
postoperative
and
postdenta!
pain*
osteoarthritis,
low-back

Chrome Fatigue

pain, andSyndrome
carpal ttttmti 19
syndrome.

Meditation, Hypnosis,
Biofeedbackt
and
Neurofeedback
Stress may exacerbate
CFS and fibromyalgia, so
it is not surprising that a
number of papers support
mind-body interventions,
including muscle bio
feedback, hypnosis, and
relaxation training, for
stress reduction in CFS
{National Institutes of
Health, 1997). Kaplan
demonstrated the positive
impact that meditation
and visual imagery can
have on fibromyalgia
patients
(Kaplan,
Goldenberg, & GalvinNadean, 1993), Likewise,
muscle
biofeedback,
hypnosis, and relaxation
training
arc
widely
recommended for stress
reduction in CFS.
Electroencephalograph
(EEC) biofeedback [also
called neurofeedhack) has
been used by our group
and others (James Sc

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material

322 APPLICATIONS

TO COMMON

Table 24-2 Dl&jfflicq Between Mijor Depression atitl Chronic Fatigue Syndrome
DISORDERS

Feature

Major Depression

CFS

Fatigue
Posiexerrionaf
malaise
Sleep disorder

2 8% of C*ISK
19% of cases
Early awakening, light
sktp

Exercise
HPG axis

E idp$
Excess cortisol
Hyper-response to ACTH
No response to
busptrone
Cortical abnormalities

100% of cases
79-fl7% of cases
Early onset f REM
Alpha-intrusion
Myoclonus, resrlc** leg;*
intolerant
Low cortisol output
Poor response to ACTH*
CRH
Hyper^oi^dnemia
with
busptrooe challenge
Low CBF m thalamus,
caudate, and temporal
Proactive
lobes and vocal
lend to overexert
Abrupt
Clusters and epidemics
occur unresponsive
Usually

SPEC! scan
Mnud
Onset
incidence
Rtsprin-ic to therapy

Hopeless, helpless
Vegetative
Insidious
Sporadic
Usually positive

Fried berg* er a!. I397fc fic Goodruek {199?); Mounts et JJ.

(199J)*
SOURCES? iVjLbdt

(1992); Dtfmirratk |iLp99l); Farrar, Locke & iUnTrowiti (19SJ); laaoft, Rjchnum,

NOTE: EiPCiA = hypodulani^pituitaiygQfUdai axis, GBF n* cettbni blood flow, REM = rapid eyt tent
Foleiij 1996)* Neurofeedback can facilitate relaxation effects, or it cui

Cognitive-behavioral therapy (CBT) is a biopsychosocial approach to

increase conical activation and sharpen anentkm, depending on the training

CFS management*. Cognitive therapy assumes that somatic symptoms are

protocol. Hence ncurofeed- hack can improve sleep and quality of life as

perpetuated by errant illness beliefs and maladaptive coping* Tiiat is, certain

well as produce measurable improvements in cognitive and functional

cognitions and behaviors may perpetuate symptoms and impairments*

abilities* The drawback to thi* therapy, however* is the large number of

Cognitive therapists believe thar abnormalemotions and physiology are

visits required for success* The number of skilled neurofeedback practitioners

perpetuated by ^catastrophic interpretations" that lead to excessive emotion

is small but growing (see Chapter 9 for an introduction to neurofeedback and

and beliefs that somatic symptoms are beyond the control of the individual*

Chapter 23 for a discussion of the application of neurofeedback to

Intensive cognitive-behavioral treatment, administered by skilled therapists, is

fibromyalgia}*

directive and emphasises sell-help, education, correction of inaccurate beliefs*

Cognitive-Behavioral
Therapy

and the application of appropriate coping skills (See Chapter 12 for an

overview of CBT*)
Numerous studies have applied CBT to chronic fatigue syndrome.

Rearm studies in the United Kingdom {Deale, Chalder, Masks, & Wesstey*

1997

Sharpe et a!*, 1996) have demonstrated a reasonable improve- mem

{return to work or school activity or a 10-pomt increase h rhe Kamofsky

score} for approximately 70 percent of those who coin- pieted the pre^ram.
This suggests that when both cognitive and behavioral components arc
addressed by expen therapists, CBT can be an effective long-term treatment
for CFS {Price & Couper, 2000)*
As encouraging as this research may sound, there are numerous
problems with

Copyrighted
materia!

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meditation-based stress reduction program on fibromyalgia. General
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Journal of Medicine, 108f 169-171.
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Lapp, C W, (1996, October}. Nettratty mediated hypotension and
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3441.
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Pam Symptom Management, 5(Suppb 1), 546-562.
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fatigue syndrome. Cochrane Database Systematic Retuew, 2,
CD001027.
Ramtnohan, K. W., Rosenberg,, J. H., Poliak* C f1., Lynn* D. j.t Blumenfdd, A.* 6c
Nagaraja, H. N, (2002, February). Efficacy and safety of modafinil (Pmvigil) for the
treatment of fatigue in multiple sclerosis. Journal of Neurology,
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ah (1998). One-carbon meraboEistn and CFS. In T. K. Roberts (Ed.),

Proceedings of the international conference on the

clmical and scientific basis of chronic fatigue
syndrome ip. 142). Sydney, Australia! T. K. Roberta.

Rjgden, S. (1998). Functional medtcineadfunt&fae nutritional

support for chrome fatigue syndrome* Gig Harbor, WA:
HealthComin ImematumaL
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ifram
serotonin
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with
fibromyaJgii/fibrositis syndrome. Journal of Rheumatology.
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Schondorf, R.. Benoit, J., Wein, T., tfc Phaneuf, D.
(1999). Orthostatic intolerance in the chronic fatigue
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Schondorf, R., Sc Low, P. A. (1993), Idiopathic
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43(1), J 32-137,
Schwarts R* B,, Garada, B. ML, Kormiroff, A, L.,
Tice, R M, Gfeic, M., jolts?,, F. A., er a!, (1994).
Detection of intracranial abnormalities in patients
With chronic fatigue syndrome: comparison of MR
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J62(4], 935-943.
Sharpe. M., Hawton, K., Simkin, S., Surawy, CT
Hackman, A., Klimts, L, et al. (1996). Cognitive
behavior therapy for the chronic fatigue syndrome: A
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312(7012), 22-26.
Straus, S, (1988). The chronic mononucleosis
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Streeten, D., J Bell, D, S+ (1998). Circulating blood
volume in chronic fatigue syndrome, Journal of Chronic
Fattgtte Syndrome, 4( I), 3-15.
Wigers, S. R, Stiles, T. C, &. Vogel, P, A, (1996).
Effects of aerobic extras versus stress management
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Wilke, Wt S,, Fouad-Tarazi, R M,f Cash, J. M,, &
Calabrese, L H, (1998). The connection between
CFS and neuraily mediated hypotension. Cleveland
Clinic Journal of Medicine, 65(5), 261-266.

CH A P T
ER

Attention
Deficit
Hyperactivity
Disorder
JOEL F. LUBAR
Abstract: Attention deficit hyperactivity disorder is a
lifelong disorder with a genetic basis and lingering
effects into aduh years. The author describes the
profile of attention deficit hyperactivity disorder a ad
tts basis in neurophysiology* He provides guidelines
for assessment using clinical interviews^ behavior
checklists continuous performance
tests, and baseline
1
electroencephalograph (EEG) tut AS u re men ES. He
propos a protocol of EE G biofredhack training
(ttenrofeedbackl to alter cerebral activity and correct
the neural dysfunction underlying attention problems.
He recommends a comprehensive treatment program
integrating academic training and neuroftedhacii. The
author cites die growing number of Outcome studies
implicating his original research and documenting the
effectiveness of neurofeedback for artemion disorders.
The research indicates that neorofcedback produces
positive bog-tain modifications in cortical activity and
cognitive function.

MEDICAL,
PHYSIOLOGICAL,
AND
BEHAVIORAL
PROFILES OK
THE DISORDER

Attention
deficit
hyperactivity
disorder
(ADDfifflJ),
as currently
characterized
in
the
Diagnostic and Statistical
Manual
of
Mental
Disorders
(DSM-IV),
consists of three main
forms:
inattentive*
hyperactive-impulsive,
and combined (American
Psychiatric Association*
1994).
These
terms

3
4
7

replace
older
idasvifications such as
hyperkinetic disorder of
childhood,
a
term
popular in the 1970s,
md
minimal
brain
dysfunction
syndrome,
popular from 1940 to
1%0
iWhakn
&
Herckcr, 1991). The
disorder is regarded as
neurological!y
based,
primarily
involvingdysfunction in

the prefrontal lobes

and in the associated
dopaminergic and,, to
some
extent,
noradrenergic systems
of the brain {jh R
Lubar & ]* CX Lubar,
1999).
Research over the
last five decades has
begun to crystallize
our understanding of
the prefrontal lobe in
much more derail.
Foster ft 997) has
cited
considerable
evidence
indicating
that che frontal lobe
can be thought of as
three
interconnected
systems. First, the lateral prefrontal cortex is
extremely
important
for
planning
and
organizing behavior. It
is involved in the
formulation
and
execution of different
behavioral
schemas,
Bartley (1997) refers
to this function as
reconstitution.
It

involves the ability to

reformulate new plans
and new schemes of
action when previous

ones have not been effective,

Clearly
individuals
with
attention deficit hyperactivity
disorder
have
significant
difficulties
in
planning,
oipuiizing,
understanding
consequences of behavior,
and reformulating behavioral
plans when things have not
worked in die past, which
often leads to ^giving up."
The dorsal lateral prefrontal
cortex is extremely important
for
working
or
recent
memory function and for
holding information during
periods
of
delay
or
interference*
The second portion of the
frontal lobe is the anterior
cingulate
and
medial
prefrontal cortex, These areas
have been referred to as
regions
of
"executive
attention" by Posner and
R&ichle (1997) and involve
planning in terms of carrying
out a task that involves
integration
of
sensory
information leading to motor
responses.
An
example
would be the intention to
begin a project such as
homework.
The
third
system
is
primarily
involved
in
inhibitory
control
and
involves the orbitalfrontal
cortex (more on the right
side than the left side) and
portions of the medial cortex. Tbest: areas project
heavily through the amygdala
and other limbic structures
and ultimately down to the
hypothalamus, vvirh outputs

to the autonomic nervous

system as well as brain-stem
motor nuclei.
Deficits
in
inhibitory
control are very often seen
in individuals with the
hyperactive form of attention
deficit disorder. These individuals
often
exhibit
inappropriate social behavior
and behaviors associated with
oppositions! defiant disorder,
conduct disorders, and, for
the more severe cases, antisocial personality disorder.
Taken

together,

the

three

components of frontal lobe function

clearly underlie the importance of the
frontal lobe as the organizing structure
in the brain for all the systems and
lower systems in terms of sensory
integration,
autonomic

motor

outflow,

organization.

and

Halstead

(1947} characterized the frontal lobes

^organs
of civilizarion*^thar is,
the portion of the brain
that
differentiates
complex
human
behavior,
planning,
judgment, and social
behaviors and is not as
developed
in
less
complex species, What
is
characterized
as
attention deficit today
was
previously
characterized
as
a
"deficit
in
moral
behavior associated with
wanton destructiveness"
(Still, 1902), which
summarizes in part the
constellation
of
probleins seen tn some
individuals
with
very weIJ in his phrase the

attention deficit disorder

or with prefrontal lobe
injury.
There is considerable
evidence
from
the
work of Kenneth Blum
and colleagues (Miller
C
Blum,
1995;
Nobd, Blum, Ritchie,
Montgomery,
&
Sheridan, 1991} that
there
are
specific
generic
alleles
ass
existed
with
metaholism
of
dopamine
rhat
are
abnormal in nearly 50
percent of hidividuah
that
experience
AD/HD, particularly
the hyperactive form.
Another
important
recent finding is that
ADD/HD is a lifelong,
pervasive disorder that
docs not dimimsh in
adolescence
or
adulthood
but
undergoes
a
transiormarion. Many
people
who
experienced
the
hyperactive typ^ of
attention
deficit
disorder as children
experience
the
inattentive or combined
form as adolescents
and adults, On the
other hand, children
with the inattentive
form are likely to
continue to experience
that form. Estimates of
the
proportion
of
individuals
who

experienced ADD/HD
as
children
and
Continued
ro
experience
it
AS
adolescents and adults
have ranged as high as
90 percent. Findings
by
Zametkinet
al.
{1990)
employing
PET technology and
Amen and Carmichael
(1997) using SPECT
imaging confirm the
pervasiveness of this
disorder
from
childhood through late
adulthood,
Behaviorally,
ADD/HD
is
duiraeterized
by
ia&trentivcrtess,
inability
tt>
stay
focused on tasks that
are perceived as tx*rtng
or irrelevant to the
individual, difficulty in
meeting
deadlines,
generalized difficulty in
concentration, focusing
and task completion of
homework
or
assignments in class,
poor

25A Screening Questions for ADD/HD

1* Do you ffod it difficult to keep your mind on
tasks?
2. Arc you easily distracted from what you arc doing?
Box

3. Do

you frequently fail to complete tasks you have

begun?
4. Arc you frequently disorganized* losing things*
forgetting p\m$, or neglecting details?
5. Are you restless, over active, and fidgety?
6. Do you do things impulsively,

Without thinking

about the consequences?

If the individual or a family member responds
positively to more than one of these screening
questions* a more complete assessment should be
conducted.
performance academically for
reasons not associated with
learning disabilities or menral
retardation. In the case of the
hyperactive
of
combined
component,, there is also
restlessness,
excessive
activity, and often inappropriate
behavior
in
social
situations.
Health
professionals who suspect
rhar
a
pattern
has
an
attention problem should ask
the questions shown in Box
25,t as a brief screen for
ADD/HD,

TYPICAL SYMPTOM
PROFILE AND
ASSESSMENT

ADD/HD rarely occurs in

isolation
but
is
often
associated with a variety of
comorbiditks,
including
obsessive-compulsive
disorder, oppositional-defiant
disorder, conduct disorder,
and
in
extreme
cases,
antisocial personality disorder
and learning disabilities. For
this reason, it is important to
determine
the
relative
contribution of each of these
combinations of comorbidities
with the central core of
symptoms related to attention
deficit
disorder.
There
h
considerable and increasing
evidence that individuals with
ADD/HD show7 a different
pattern of G activity than
uondinical controls. Studies by
Mann, Lubor, Zimmerman,
Miller, and Muenchcn (1992)
showed
that
individuals
experiencing the inattentive
form
of
ADD/HD
have

moreslow activity in the rht-ta

anti low alpha range in the
frontal portion of the cortex
and decreased high-frequency
activity in the Ix^ta range in
the posterior portion of the
cortex. This is particularly
evident
during
academic
challenges such as reading
an;! drawing tasks. Studies by
Rtceio, Hynd, Cohen, and
Gonzalez
(1993)
at
the
University of Georgia also
reported decreased frontal
lobe
derivation
in
these
individuals,
A
recent
mnhkenter study involved the
contributions of eight clinics
and a total of more than 4R0
cases both with uui without
attention
deficit
disorder
(Monastra et aL* 1999)* This
study showed that individuals
with ADD/HD between the
ages at 6 and 30 differed

significantly from nonclinkal

controls in the mea' sure of
the percentage of theta power
divided by the percentage of
beta power recorded at the
vertex location on the scalp.
These differences were highly
significant and correlated very
well
with
behavioral,
psychometric, and continuous
performance
measures.
A
second paper involved 469
additional cases aged b co 20
(Monastra, Lobar, & Linden,
2001). This study, using the
theta/beta
ratio
and
Ca
(vertex) location, obtained
reliabilities greater chan 0T90
with rating scale and continuous
performance
measures.
Groups
with
ADD/HD could be differentia
red from non- dinical controls
with at least 90 percent
accuracy by KEG measures.

328
APPLICATIONS TO
use
of
stimulant
and
COMMON
DISORDERS
antidepressant
medications
(Rcsnick.
2000),
The
remainder of this chapter
discusses neurofeedbock as an
alternative therapy that is
producing substantial benefit
for the majority of children
and adults who complete a
course of treatment.

BEHAVIORAL AND
PSYCHOPHYSIOLOGICAL
INTERVENTIONS:
NEUROFEEDBACK

Roughly 1,200 practitioners

m the United States and
many in Asia* Australia,
Canada, Europe, Israel* and
South America currently use
EEC
biofeedback
(neuTofeedback)
to
help
overcome
symptoms
of
AJDDfHD, This approach has
grown
rapidly
beeatiise
studies have shown it to be
extremely effective not only
for symptomatic relief but
also
for
altering
the
underlying
cerebral
dysfunction associated with
the disorder by changing
EEG activity and perhaps die
underlying neuromata balk
abnormalities, The first controlled
study
of
neurofeedback
intervention
was published by Lubar and
Shouse (1976) with a single
cast\
Additional
aiscs
published by Shouse and
Lubar 1979) were blind
crossover
studies
with
independent evaluations in

classroom settings* These

studies showed that training
children to increase the sensorimotor rhythm {5MR}a
brain rhythm associated with
inhibition of motor outflow
from the motor cortexand
to inhibit 4-ro- 8-Hta theta
activity
associated
with
inattention showed significant
improvements
in
the
classroom.
This
original
series of studies involved an
ABA crossover design so that
during part of the study, the
conditions were reversed,
leading to worsening of
symptoms, and then reversed
again to the original condition,
leading
to
an
improvement in symptoms
both at home and in
classroom settings The study
ended
with
the
slow
withdrawal of medication and
maintenance of the positive
results that were obtained
during the feedback training.
In 1934, J* O. Lubar and J*
F, Lubar published case
studies
showing
the
effectiveness
of
neurofeedback
training.
Later, a controlled study f
Lubar,
Swartwood,
Swartwood, & O'Don&eD,
1995)
correlated
the
improvement
on
TOVA
scores with decreased slow
activity in the EEG over the
course of ncurofeedbatk
training. There was an
improvement
in
TOVA
scores and increased scores
on the WISC-ft measure of
IQ+ The hill-scale IQ
Copyrighted
materia!

improvement
was
approximately .12 points,
Several
groups
have
replicated
this
research,
induding Linden* Habib*
and Radojcvic (1996} and,
most recently* Thompson
and
Thompson
(1998)*
whose study included lit
subjects98 children and
13 adultsranging from 5
TO 63 years old. Tanscy
1991) showed changes in
WISC-R scores following
EEG biofeedback training*
Rosstter and La Va<jue
(1995) showed that EEG
biofeedback training was at
least
as
effective
as
psychoso mu ferns for
individuals with ADD/HD.
Altogether,
approximately
45
published
studies
employing
neurofeedback
have replicated the original
work (Lubar fc Shoss,
1976) and extended it to
larger populations, including
those with several subtypes
of attention deficit disorder.
Several studies also replicated that original work in
individuals with comorbid
attention deficit disorder and
learning
disabilities,
in
addition*
numerous
presentations at meetings of
professional societies have
described replications of die
original findings.
It is important, however,
to emphasize that the use of
neurofeedback by itself is
m>t an appropriate complete
treatment, I use cognitive
strategies
that
combine

neurofeedhack
with
academic training {see Box
25,3k I have used this
model since the 1970s> and
several other groups employ
the same model.

330

APPLICATIONS TO

COMMON
DISORDERS
Box 253
Patient and Family Education

Intervention with the individual with attention

problems is more effective when
patients and their families are educated about the
nature of attention problems and
about behavioral strategies to compensate for impaired
attention. Patients and families
should be given the following information:
1. Attention deficits are real neuro logically based
disorders* which significantly impair academic
learning, social learning, and vocational functioning.
2. Attention deficits can cause problems beyond the
classroom, including physical d unis mess, frequent
accidents, poor time management, and careless
mistakes on the job,
3. Failure to address attention problems commonly
results in lifelong patterns of underachievemait* low
self-esteem, and impaired social functioning,
4. Neither lecturing nor punishing rhe individual with
an attention problem will correct the inattention or
personal disorganization.
5. Attention deficits rarely disappear after adolescence,
and many adults require continued intervention,
6. Many individuals will continue to show some
impairment in attention even after the best medical,
behavioral, and psychophystoiogjcal interventions.
7. Behavioral methods can assist rhe individual to
organize tasks, manage time, and otherwise
compensate for inattention and disorganization.
Although studies involving The protocol that Lubar and
neurofeedback alone a bo Shouse U976) developed
show positive results, these originaly involved training
are more appropriate in an increase in SMR (12 to
validating research protocols 15 Hz) over the motor
as opposed to clinical cortex and ai the same time
inhibiting slow activity in
interventions,
the range of 4 Co % Hi for
children and 6 to 10 Hz for
adolescents
and
adults.
EFFECTIVE PROTOCOLS
Determining
die
best
AND INTERVENTIONS
locations
for
training
requires
referential
or
bipolar measurements from
individual locations on die
Copyrighted
materia!

scalp or a multichannel
quantitative EEG involving
19 electrodes and examining
locations that show the
greatest
amount
of
slowactivity compared with
fast
activity
measured
Through
thera/beca
or
alpWbcta ratios. Recently,
Chabot, Orgill, Crawford,
Harrisj and Serfontdn 0999}
described at least half a
dozen subtypes of ADD/HD
based on quantitative EEG
measurements in over 400
cases.
Some
of
these
subtypes involved excessive
frontal beta activity rather
than deficient beta activity in
posterior locations. These

subtypes may he associated

with
individual
that
experience a combination of
attention deficit disorder and
alcoholism. The reasons for
tins are findings by John,
Prichep,
Friedman,
and
Easton (198$) and Penision
and
Kulkosky
(1990}
indicating that in alcoholics
there is excessive beta
activity and deficit alpha and
theta activity. However, in
individuals that have both
Attention deficit disorder arid
addictive disorders, a pattern
appears to be emerging consisting
of
a
bimodal
distribution of

some of the studies have

employed only neurofeedback
approaches.
Basically,
the
majority of ttctfV neurui red
back
studies
have
been
observation ai studies submitted
by clinicians working in dmica
1 settings, as opposed to
controlled research in laboratory
settings. Recently, however, rhe
New England Journal of Medicine
has published two important
papers (Benson &. Ham, 2000;
Conea to, Shah, &c Horowitz,
2000) that show that the results
of observational Studies are
very similar to those obtained in
controlled clinical trials with
random
assignment*
These
papers deal with large mmanalyses
of
medical
interventions and provide the
first and clearest evidence that
observational
studies
not
employing random assignment,
double-blind approaches and
ABA crossover designs may be
just as valuable the more
traditional court of science**
approach* Clearly, both kinds
of smdies are necessary at this
point The controlled studies

Af-iffjp Deficit Hyperactivity Disorder

3SS

with random assignment of

individuals imo different groups
to
compare
outcome
are
important to show, as clearly as
possible,
the
strength
of
neurofeedback in and of itself*
In the clinical context, however,
ir is preferable tn combine
neurofeedback
with
other
approaches*
Managed care and insurance
carriers
are
beginning
to
recognize neurofeed back as a
viable intervention and are
beginning to cover the cost of
neurofeedback framing far many
of their clients, There is a grow
ing
real
ration
that
neurofeedback is aimed at the
underlying neurological and
neurochemical basis for the
disorder rather than at the
symptoms, and it appears from
the data collected so far that the
effects are long lasting, ITie
growth curve of neurofeedback
tor the evaluation and treatment
of ADD/HP is still in its early
stages, but rapid, continued
development of this technology
can be expected over the next
decade.
REFERENCES

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hran 5PECT imaging in ADHD, Amtals of plmkal
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statistical manual of mental disorders :4th id., P5A-JV).
Washington, DC: Author.
Berkley, It. A. (1990)* Attention deficit hyperactivity disorder:
A handbook for diagnosis and treatment. New York:
Guilford.

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Barkley, H. A. (1997). Behavioral inhibition, streamed

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121, 65-94t

'

Benwn, KH, & Haru, A. Jt (2000). A comparison of

obitrtitbnaJ studies and randomized controlled trials.
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Scrfntein, G- (IWf.

Behavioral nnd elcctrophyriologica) predictors of

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ConcaK^jq Shah, N\, Si Horowitz, R. (2000),

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Conners, C. K, (1990), Conners rating Modes manual* North Totrui

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Eustcr, J. M> (199 K The prefrontal cortex: Anatomy,
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Ha Howell, H, M., fc Ratey, ]. J, (1994). Driven

fo distraction: Recognizing and coping tmth
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H atacad W. G 1947). Brain and intelligence: A
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Intermediate
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John* E* K.y Pricbep, L. S., Friedman, J*3 & Easton,
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Lubu\ J* F. f 1995), Neurofeed back for the
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Lobar, j. R, A; Lub&r, |. O. (1999)* Neurofeedbatk assessment and

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in TOVA scores* behavioral ratings, and WISC-R
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Mann* C* A.? Lubar, J* F., Zimmerman A, W,,
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McCamey* S* B. {19S9)* The attention deficit disorders
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Miller, LT K*, & Blum, K. (1995). Overloadt Attention

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MoDHtni, V* J., Luhar, J, F., 6c Linden, M, K.
(2001), The development of a quait- rmrtve
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P. Green G- Wing, W., Phillips A,, & Fengcr,
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Adolescent Psychiatry, 39, 1 >>2-143

Nobel, E*f Blum, K,* Ritchie, T, Montgomery, A*, 6c

Sheridan, P* (1991)* Allelic asCKijnon o the
1>2 dopamine receptor pene with receptor-binding
characteristics in alcoholism* Archives of General
Psychiatry, 4S, &4S~654*

Copyrighted
m ater si

Threat
Neurotr
Percepti
ansi
360 APPLICATIONS TO COMMON
on
Imbalan
DISORDERS
ces
Cogniti
ve Avoidant
Escalati
on
Behavior
Stimulus

Neurophysiol
ogical
External
Stress
Generalization

Figure 26.1 Comprehensive Model of Anxiety

biochemical vulnerability, Biochemical

physiological
activation,
cognitive fears* behavioral Vulnerability
avoidance patterns, and a
stressful environment (see
Figure 26.1). As Peter
Lang and S. J. Rachman
observed, distinct aspects
of anxi- ery do not covary
reliably {Rachman, 1982,
1999), They are loosely
coupled, or discordant. An
individual can overcome
avoidance behavior yet
remain cognitively afraid
and
neurophysiologkally
activated. Similarly, an
individual can relax his or
her body yet continue to
label a situation as a
threat. This is critical
because treatment should
target each aspect of
anxiety distinctly, as the
patients
presentation
demands.
Copyrighted
material

361 APPLICATIONS TO COMMON DISORDERS

Biological
psychiatry
has identified a number of
neurotransmitters
implicated
in
anxiety
disorders.
The
unavailability of serotonin
in the synaptic deft, the
gap
betweenneurons,
appears to play a role in
obsessivecompulsive
disorder and at least an
accessory role in the rest
of the anxiety disorders.
Serotonin serves as a
chemical
messenger
across the synapse. Both
anxiety and depressive
symptoms decrease when
medication blocks the
uptake of serotonin into
receptors on the neuronal
dendrites and increases the
availability of serotonin,
There are also probable
abnormalities at gamma-

aminobutyric
acid
(GABA)
receptors
in
anxiety disorders. GABA
is
an
inhibitory
neurotransmitter
that
reduces
efferent
and
afferent activity to and
from the limbic brain (the
emotional brain, including
the amygdala and the
hippocampus).
When
GABA levels are low,
there is a heightening of
subjective
distress,
including both anxiety and
depression.
The
benzodiazepine
medications, widely used
in
anxiety
disorders,
modulate the activity of
GABA in the brain
(Bernstein, 1995; Nutt Sc
Malizia, 2001).

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material

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Table 26.2 Medical Illnesses and Factors Causing Anxiety-Like

Symptoms
Specific Disorder
Symptorm
Angina, myocardial
Tachycardia,
Cardiovascular
infarction,
palpitations,
arrhythmias,
ischemia, chest pam
Abdominal
pain,
Gastrointestina
Peptic ulcer, Oohu**
diarrhea, upset
l
disease
stomachshortness of
Fatigue,
Hematological
Anemia
breath, palpitations
Metabolic
Cushing's syndrome*
Insomnia, irritability*
hy p (?th yroiJ ism,
rrtrimilcmsncss,
menopause, porphyria
faintness >
Neurological
Encephalopathies,
Headache, dizziness,
disorders
headedne&s,
Shortness of breath*
Respiratory
Asthma
suffocation, fears

a faulty cognitive schema

underlying anxiety serves as a
basis
for
more
strategic
cognitive therapy. Similarly, a
p^ychophyriological assessment
of dysfunctional respiratory
activity, and of the resultant
abnormalities in respiratory CG;,
can be helpful in treating panic
disorder and other anxiety
disorders. Exhaustive diagnosis
includes m assessment of all
dimensions of anxiety disorders
shown in Figure 26.1,
Medical Screening

Evaluation
of
anxiety
disorders
begins
with
a
screening for medical conditions
that
trigger
symptoms
mimicking anxiety disorders
(Gold, 1989), The initial exam
should include a history, a
physical, and lab work as
indicated by symptoms and
history. Family history should

include special attention to

cardiac
disease,
thyroid
conditions,
depression,
and
anxiety disorders in the past
three generations* A family
history of cardiac disorder, for
example, can play a twofold
role:
(})
genetically
by
increasing the risk for cardiac
illness that may have triggered
current symptoms, and (2)
psychologically by raising die
fear of the patient for any heart
irregularities, even those due to
exertion or anxiety.
Table
26.2
lists
medical
illnesses that cause symptoms
similar to anxiety. Careful
screening for these conditions
will
accomplish
three
interrelated ends: to identify
(and manage) any medical
condition* contributing to anxiety symptoms, to medically
reassure the patient in any
unfounded fears of illness, and
to
reinforce
the
patient's

acceptance of the anxiety

diagnosis by emphasizing the
physiological
link
between
anxiety and the patient's current
symptoms.
Psychopfrysiolagical Assessment
The
Psychophysioiogicul
Stress Profile (PSP) is a tool
used to identify the profile of
an individual's personal stress
response
{Wickramasekera,
1988) and to demonstrate
convincingly for the patient the

mind-body linkage.
The PSP
r
uses a vartcf} of physiology cal
sensors ro monitor the body,
first in a baseline condition,
second in relaxation, third under
stress conditions, and fourth on
recovery. Table 263 shows a
typical PSP format, using
mental math to creare the first
stress Erial and a visualization
qf a stressful situation to create
the second stress trial The
third stress trial consists of
hyperventilation
or any another
1
'challenge' activity that can

366

APPLICATIONS

TO COMMON

DISORDERS

Table 263 Formar for Psychophvri alogica J Stress Profile

Duration
Step
Condition
(minutes)
Accommodation to room
Baseline
3
conditionswithout
Relaxation
3
Relaxation
Serial 7s, multiplication,
Mental math
2
division on demand
Recovery
3
Relaxation
Persona! stressot
2
Visualization of stressful
Recovery
3
Relaxation
Therapist-guided activity
\
Challenge mais
to evoke anxiety
symptoms
\
Recovery
Relaxation
Debriefing
Discussion of patterns in
psvchophysiokvgicat stress

trigger .mxiety in the patient.

For example, a patient with
exertion-triggered panic might
use a step-exem$c machine for
the challenge trial, or an
individual who panics when
Ught- headed might spin on a
stool an a physiological
challenge,
in
each
case
evoking
the
typical
physiological accompaniments
of an actual anxiety arcade
For
anxiety,
several
physiological measures ane
relevant for the PS1\ The electromyograph (EMG) measures
muscle
tension
patterns
accompanying fear and worry.
The muscles of the upper
torso, shoulders and neck, and
the face are mosr likely to
show the effects of anxiety.
The skin conductance meter
shows an immediate dectroderma]
increase
when
anxious
thoughts
occur.
Temperature feedback units
detect abnormally low skin
temperatures,
reflecting

vasoconstriction as a measure
of
anxiety,
fear,
or
hypemgilance.
The
pneumograph
measures
patterns in respiration, and
provides a measure of the rate
of breathing and a graphic
picture showing how fiiD or
limited and how even or
uneven each individual breath
is. The pneumograph also
shows whether the individual
is relying on the muscles of
the chest or the diaphragm for
respiration.
The
electrocardiogram fFJKG) and
photoplethy&mograph (PPG}
measure heart rare and patterns
in
heart
rhythms
that
frequently are affected by
anxiety. When breathing is
relaxed, slow, and full and (he
individual feels peaceful in
both thoughts and feelings,
then the respiratory and
cardiovascular systems enter
into a balance called the
respiratory sinus arrhythmia
{R$A)t involving a parallel
Copyrighted
materia!

367

APPLICATIONS

DISORDERS

TO COMMON

sinusoidal rise and tall in

breathing and heart rate i
Forges, 1986; Forges 5c
Byrne,
1992}/
This
synchronous partem
also produces a coherent
organization in the heart
rhythms, evident in spectral
analyses of the frequency
distribution of heart rate
changes. The patient can
observe both the smooth RSA
pattern and the heart rate variability patterns in the PSP if
he or she can relax adequately
either in the relaxation or
recovery trials. (See Chapter 8
for a more detailed explanation
of biofeedback moduli ties J

After the patient has seen

hand
temperature
drop,
respiration and heart rates
increase, and muscle Tension
rise each rime she or he
directs
attention
to
job
problems or marital strain, the
involvement of psychosocial
factors in physical symptoms
becomes more pbusible. Such
a profile a ho indicates to the
patient and the practitioner the
physiologic
systems
most
involved
in
symptom
production and most relevant
to symptom reduction* Litter,
relaxation and biofeedback

Copyrighted
materia!

Cinefili identification of specific

individuai cognitive distortions is an
important part of the assessment
process. The patient is invited to
voice specific fears accompanying
the anxiety symptoms, to mentally
relive that same fear in the interview
room, ami to report any physiological
activation
or
recurrence
of
physiological tensions as the fear is
experienced.
The
interviewer
identifies typical cognitive schemas
that frequently involve such fears,
The
interviewer
need
not
aggressively confront the fears in the
initial interview bur should emphasize
that similar thoughts and fears often
keep individuals anxious and that
treatment
includes
exploring
thoughts further and giving up or
modifying many of them.

Behavioral Assessment

Behavioral assessment focuses on

identifying
avoidance
behaviors,
safety (defensive) behaviors, and
superstitious
or
symptomatic:
behaviors
related
to
specific
anxieties* The patient is invited to
describe any behaviors or actions
accompanying fears. Is the patient
avoiding going anywhere chat he or
she used to go freely? s the patient
engaging
in
any
Superstitious
behaviors or behaviors that don't
make sense but that she or he cannot
seem to stop?
In addition, behavioral assessment
identifies
patterns
of
stimulus
generalization and environmental
reinforcement of anxious behavior.
The patient is asked whether bis or
her fears or anxious behaviors seem
to be spreading to new situations and
places. Does she or he fed any
control over this spreading of

symptoms? Does the patient think

she or he can reverse the spread and
resume entering situations recently
avoided? What actions by other
people might be enabling or encouraging the spread of avoidance
behavior? Well- intentioned family
members may be doing tasks for the
patient, enabling her to become more
helplessly crapped in scif-isufaiion md
inactivity.
Conceptualizing the
Patient s Anxiety Disorder

The multimodal assessment of

anxiety
culminates
in
a
formulation that should integrate
the several strands of the
assessinent and lead lgica Uy
into a strategic treatment plan.
For example, one might arrive
at the following formulation:

J 68

APPLICATIONS TO
A 31 -year old worn A a
presents
with a recurrence
COMMON
DISORDERS
of an obsessivt-compulsivi
disorder
(GCD).
The
1
patient * mother and two
sisters have experienced
similar OCD episodes, and
she had a previous episode
that focused on fear of
germs and contamination.
She is now afraid that she
might see a sharp object
and cut her young child.
She becomes temhed of
this possibility and begin*
to panic* with racing heart
and hypervermistiotL She
has begun to avoid her
child, avoids being home
alone, and seeks farmfy
members to do child care.
She ha* no desire to harm
the dnld, only the intrusive
obsessional thoughts that
somehow she might do this.
She has no history of
violence, anger nuibums*
or impulses toward abuse.
Her assessment emphasizes
the psychiatric diagnosis
and family history
of OCD, the cognitive schema
that her impulses are our of
control and she might do
anything, behavior patterns of
avoidance,
and
the
physiological
process
of
hypermitilation and autonomic
arousal. The treatment plan

emphasize* medication
(SSR1), reassurance that
the obsessional ideas are
symptoms of OCD, training
in thought stopping and
redirecting of her thoughts*
and reassurance that she is
a gixx) mother and can
resume care of the child.
She is encouraged ro
practice her diaphragm
m?itk
breathing
.and
relaxation exercises that she
has previously mastered.
The
patient
is
also
informed of neurofeedback
protocols to minify cortical
and subcortical pattern*
relevant
m
OCD*

especially
excessive
activation in ami over tire
anterior CVEV guiare gyrus*
She is a candidate for A
QEEG
assessment
and
nctirofeedhadi training. She
delays medication, rtMimeti
diaphragmatic
breathing*
and begins to redirect and
talk
hack
to
her
obsessional
thoughts.
With
reassurance
and
encouragement, her Primitive ideas remit within less
dian
a
week
after
oatnmencinp treatment.

Relaxation
Training and
General Bio
feedback

Relaxation (raining is useful

m
overcoming
anxiety*
tensions* and worry tAmar,
1995). Chapter 10 provides an
introduction
to
progressive
muscle relaxation* autogenic
training*
ami
clinically
standardised mcdira- non. T
hermal biofeedback helps the
patient learn general autonomic
relaxation, EMG ( musclej
biofecdback
guides
the
individual
to
relax
the
expressive muscles of the face
and upper torso. Anxiety*
worry, and frustration typically
produce ttnsc muscles around
the eyes and in the jaw* neck*
shoulders* and arms. Skin
conductance
(electrodermali
biofeedback is useful in training
the imh vidua 1 to decrease
worrisome thinking and to quicr
anxious thoughts.

Respiratory ami
Heart Rate
Variability
Biofeedback

Copyrighted
materia!

Breath retraining, respiratory

biofeedback, and heart rare
variability jHRV) biofeedback
are useful took in reducing anxiety disorders, especially panic
disorder,
and
producing
subjective calming (Berger 6c
Gevittz*
2001;
Clark
&
Hinschman* 1990; von Schede,
1998). Paced diaphragmatic
breathing restores synchrony
between the respiratory and
cardiovascular systems (GeVirtz,
1999).
Paced
breathing
produces RSA, in which lowfrequency rhythms prevail in
heart function at a frequency of
about 0.1 Hz* or 6 cycles per
minute, The heart rate gently
increases with each in-breath
and decreases with each outbreath at a rate of about 6
cycles of breathing and heart
rate changes pet minute. This
RSA pattern produces greater
homeostasiN in the autonomic
nervous
system,
reducing
anxiety
symptoms
(Poises*
1995; Tiller, McCrary* &
Atkinson, 199b). New software
has been introduced to enable
direct biofeedback training of
heart r^te variability, providing
an additional tool to address
the respiratory and cardiac
dysfunction accompanying anxiety
states (McCrary & Singer* in press).
Many patients report spontaneous
reductions in their anxiety symptoms
in everyday life once they have
begun
respiratory
and
HRV
biofeedback. Others report that they
are able to use their new breathing
patterns when anxiety hits and
quickly manage anxiety.

Meurofeedhitck
A number of case studies and
small research investigations have
applied neurofeedback to generalized
anxiety disorder, phobic disorders,
obsessive-compulsive disorder, and
posttrauimtic stress disorder {Moore,
2000). The neurometric (QEEC)
assessment
identifies
abnormal
cortical activation patterns, and
neurofeedback guides the patient to
correct abnormal activation patterns.
Typical cortical patterns m anxiety
disorders include the following:

1, Excessive

fast-wave
activity that is high In rhe beta
frequency range {24 to 32 Hz),
often m combination with
deficient amounts of slow-wave
activation. This pattern calls tor
neorofecdback
training
to
increase slow- wave (alpha)
activity and suppress fast-wave

activity.
2, Excessive

slow-wave

activity that is often in combination

with deficient fast-wave activity. This
pattern calls for a suppression ot slow
-w ave activity and training to
enhance
fast-wave
activity
(Satdberger Sc Thomas, 2000,
Thomas Sc Satdberger, 1997).

3, Excessive
activity
along the midline in
centrai and frontal areas,
reflecting
probable
subcorneal overactivation
in the anterior cingulate
gyrus, driving obsessional
thinking. This pattern calls
tor neurofeedback training
to suppress the *hot spot"'
along the midline.

J 68

In

APPLICATIONS TO

each

case, well as the implied

normalization
of
patterns*; as subcortical processes,

COMMON
DISORDERS
normalization
of cortical

activation

Copyrighted
materia!

Neurot
ransi

imbalan
Perceptio
ces
n
Cogniti
Neurophysioli
>gical
ve
Escalat
ion
Avoidant
Behavior

Stimulus

Generalizat iim
ion p ior
Figure 26.2 Comprehensive Treatment Model iera
py

serves to reduce anxiety, nervousness,

and agitation and to enhance subjective
feelings of relaxation and calming.

Summary: Integrating Treatments

nacothe
rapy
iwmeciha

rk
NfiYtn
feedbac
k
External
Relaxatio
Stressn

The various available medical and

mind- body therapies for anxiety have
been discussed separately, as though
each were an entirely distinct path for
treatment. However, both research and
clinical experience show that therapies
can have an interactive and synergistic
effect (see Figure 26,2)* For example,
the combination of medication and
cognitive-behavioral therapy produces
faster recovery than therapy alone and
lower relapse rates than medication
alone (Gorman, 1997)* Relaxation
therapy, biofeedback, and neurofeedback
can also facilitate the success of
cognitive-behavioral
therapy.
For
example, learning to reliably create a
physiologically relaxed state makes it
easier for patients to undertake
exposuretherapy, which requires patients
to enter anxiety-producing situations. On
the other hand, research also shows that
mind-body therapies can produce
relatively positive results in isolation*
For example, Berger and Gevirtz (2001)

reported that breathing retraining alone

produced as much improvement as
cognitive-behavioral therapy alone.
CONCLUSION: SELECTION
OF CONVENTIONAL AND
ALTERNATIVE TREATMENTS

The most critical task of the primary

care provider is to identify anxiety

disorders and distinguish them from

their frequently somatic presentation.
Next, the health care provider must
educate the patient that anxiety disorders
are troubling but common and
manageable disorders* Patient education
is critical in dispelling patient shame
and denial, and in countering the
common disposition to

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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have

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444 HANDBOOK OF MIND-BODY

Appell, R. A., 317, UJL
115 Appels,
A..
254
MEDICINE
FOR
PRIMARY
7
Applegate, Vi . B., 289
Arbanel, A., 65 Arbis),
P.t 3S9 Arena, J. G,, 74
Arendi'Nielsen, L, 1 51,
154 Arien, S., 378
ArJcin, A. M., 400 Amm,
F. C, 409, 410 Arnold. L.
M, 6 Arnold, M, S.,
28,1, 436 Aronne, L J,*
2?5 Arthur, M, W.,41J
Asai, M 2SI Ashtna,
M,, 114 Askanazi, J.,
361 Asset, S, M., 197

Association for Applied Psychophysiology

and Biofwdback, 66, 128, 46S, 472, 473,
474 Association o Physician Assisi ant
Proprams, 4.57, 458 Astin, J., 60
Atkinson, G, 29, 75T
154 Atkinson, M., 254,
370 At kin soil, R.p
21,22, 153 Aun, B.,
408 Austin, B. icriii
Avants, S. K., 184 Ax,
S., 339

Babyak, M., 289

Biicchmi, P*j 59 Badr, S.,
404 Baehr, E,, 384, 388,
424 Baehf, R., 384, 388
Baer, L., 155 Barrwald,
C. G., 408 BagbyF 342
Bagidla, E,, 484
Bagtiom, A. J., Jr., 413
BaharW Lt 229 Bailey.
B. K.h 2S9 Bakal, D+ A+l
209, 217 Baker, D,, 254
Baker, J., 317 Baker,
5 243 Bakhcit, A.
M 339, M0 Bakcnr, R,
304 Bahnt, E., 5
Balmr. M.h 5 Ball weg,
R 463 Biudstra, E., 453
Bandura, A 411,412,
430, 431,432
bangdiwala, . [., 300
Ranhamou, S., 84 R
prista, M. A,, 73, 76
Barabasz, A. F,, 153,
154, 155, 157 Barabasi,
M 153, 154, 155, 157

CARE

Barale, A 364
Barber, J,, 154
Barber, T. X., 72, 73, 76, 151
Bargh, J. A,, 28
Bark ham, M 386, 3S7
Barkley, G., 206
Barkley, R, 347,3JQ, 351

Barlow, D. F., 369

Barlow, D. H., 8, 176,218, 369

Barlow, W, 226
Barnes, V, A.,51,29

Barnhart, R X 14

Barr, P. A,, 436

BdrrrtT'Connqr, E,, 276, 278

Barron, F. X 196
Barsky, A S5

barsky, A- J,, 45, 51

Barton, KH A., 208
Bartsnkis, T,, 253
Basham, R, S,T 30 Baskin, S 206, 209,212
Baskin, 5 NE, 116
BasmaiianJ. V., 110, US, 265 Bass, C., 44, 300
Bass, F B,, 20 Bassett, M T, 280 Bass man, L.,
59t 65 Basra, R., 6 Bar**, D, W 336 BatituccL,
E,, 228 Rattafarann, D., 323> 324 Bartie, M. C,t
259 Beary, J. F 461 Beaupr, P.h 411, 412
Bcchara, A,, 383
Beck, A>T 138, 68, 171, 176,218, 363, 369,
382
Beck, J. 5 168, 169, I72v 174, 176
Beck, L, 420
Beck, W S 342
Beclecr, D. j>, 281

Basmajian, j., 32S

Beckerman, A., 437

Heckles Wilson, N. R., 214

Beckman, R. J., 221

Beecher, H, K,, 70, 76

Behan, P. ., 339, MQ
Hckkclund, 5, L, 408
Bclickl D+, 22, 153,

155 Bclicki, 22,

153. 155 Bell, D. 5., 335 Bell, R.
A., 2H1 Belles, D. ft., 231 Belyca,
M., 436 bemporad. J., 378 Benca,
R. M., 401 Bendtsen, L,, 114
Benness. C, 317 Bennett, A L,
151 Bennett, P, H,, 276

Copyrighted
material

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have

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have

Carlsson, G. E.p 225 Carlsson, S. G,, 126

Carmichael, B. D., 348 Carnes M -, 319
Carney, R- M,, 387 Carol, M. P<, 461
Carr, R.
E., 242, 243, 244 Carrington, P., 138,
146, 147 Carrol], B. J., 420 Case, A. M.,
421 Cash. J, M, 335 Cass, H., 386
Cassano, G., 382 Cassell, E, J,, 4, 89
Cassidy, C A., 433, 437 Gain, J. E_, 231,
265 Castes, M.T 241 Castillo, J,, 205
Cavagnini, F,n 2S2 Cavallo-Perin, P., 283
Cawley, J, F-, 458, 459 Cedercreutz, C.,
155 Celentano, D. D,, 205
Centers for Disease Control and
Prevention, 237, 276, 278, 279, 334,
335, 336, 132 Ceresoti, A*, 317, 318
Cha, G., 131 Chabor, R. J+T 127, Ml
Chabriat, H., 210 Chaffin, 1)., 261
ChaJder, T., 340 Chalks, G. B., 24, 73. 15J
Chamberlin, j., 43 Chambers, L. A., 291
Chamblfss, D. L., 128 Chang, P., 184
Chang, R. W., 410 Charest, J., 75
Chatterton. B, E,* 342 Chatterton, R. T.T
408 Chaturvedi, N.t 280 Chavira, J. A.,
193 Chenard, J. R,, 75
Cheney, P, R., 333, 334, 335, 336, 341

Carpenter ML E, 26

Collette* P., 276

Author ndex

411

Collings, G, H., 146. 147

Collins, j. F., 169
Collins,), K 154
Collins, R. W., 301. 3B
Collbon, D. A.t 155
Colson, R., 300
Compas, B, E., 168
Con, A. H., 290

Concalo, J., 355

Conners, C. K,, 350
Conroy, A, M, 24, 153

Consensus Trial Study Group,

250
Constantin!, S., 26

Comrades, 5., 452

Conway, A., 367

Conway, C, 343
Coogltr, C., 14
Cook, M. R., 71, 74

Cooper, N. S., 409, 410

Chernigovskaya,, V,, 243

Chesfcin, L J,, 291
Chesney, bC, 253
Chester, T. D., 24, 153
Chestnut, TCr. N., 1S4
Chevalier, H., 404
Chila, A. G., 74

Chskrat, H,, 6

Child, C, 59
Chiotakaku-Faliakou, E., 307 Chi vertun,
5. G,, 184 Christensen, J, F-, 49 ChristieSly, J., siiii Chrousos, G. P,, 46. 333,
335, 339
Chung, D. G., 335, 336 Cigada,
M., 26
Clapp, A. U 34 J, 343 Clapp, L, L., 341,
343 Clare, A,, 305 Clark, D. A., 168 Clark,
D. M, 363 Clark, L. A., 30 Clark, M,
B 483 Clark, M. E.t 32 Clark, M. L., 3
Clark, M. M., 44 Clark, R 12 Clark, 324
Dark, S. C, 335 Garke, L, 214 Clams, .
C-, 229 Clavel-Chapelon, F., 184 Clay, R.,
473 Clayborne, B. M.> 289 ClcmcnCe, C.,
184 Gemmey, P., 411 Giver, S. P.p 319
Clouse, R. E., 282, 288, 292 Guff, L. E.,
27 Cobb, L A., 70, 76 Cob be, 5. M., 236,
287 Coderre, T, 325 Coffey, P., 50 Cohen,
H. D.p 71, 74 Cohen, H. j 484 Cohen, M,
59, 60, 63, 64 Cohen, M, jr, 349 Cohen,
N,, 9, 46,72, 114 Cohen, S., 46, 48, 51
Cohn, N 250 Colditi, G. A., 283
Coleman, G,p 72, 76
Cogan, S. M** 151, 156, 300,

304, 305, 307

Copyrighted
material

Cooper* P.* 305* 307

Cooper, R., 276 Coran,
A., 304 Coran, A., 241
Curazziari,. E., 299, 300,
301, 303
Corcoran, C., 47
Cordmgley, G., 205, 211
CorJingley, G. E., 207,
209, 212, 215
Cordinglcy, G. R>215
Cordray, D. S.* 411
Corry, G., 94, 95, 97,
9, 99
Corey, M. S.* 94, 95,
97, 98* 99
Comey, K. H,f 305
Corning, W. C, 123, 127
Cornwell, N,h 2H
Corry, D. B., 235
Coryell. W,, 382
Cosire, R* 22, 153, 155
Costa, P. T., Jn, 75
Coulter. A., 284
Coulter, L, 187
Coulthard'Moms, L, 155
Council, J- RTT 154, 265
Couper,]., 163, 340, 341
Cowan, M, 408
CoxT 1. Mr, 342
Coyne, ],* 6
Cram, J, EC, 212
Craske, M. G., H5* 176*
369
Crawford, G 127, 353
Crawford, H, ],, 154
Crawford, S>, 59
Creed, F., 305
Crer, T, LT 242, 244
Creighton, J.p 452
Crider, . B., 230
Cripps, H. A., 34
Cnqui* M.1 H., 276, 27
tritel, J. ., 140
Crits-Christoph. P.h 68
Croci, M, 282
Croekerr, J. E., 70, 76
Crouch, M., xiii
Crowne, D. P-, 2l
Crowson, J, J., 24, 153
Cruikshanks, P,, 305,
307
Csikszentmihalyi, M+, 24
Culbertson, A, L, 411
Culligan, P. J., 315* 3 Jb
Cullitcm, P. D., 184
Cuker,]. A.*277
Cummings,]., 11
Cummings, J, L,, 3ti4
Cummings, N.* 11
Cummings, N. A., 364
Curais, G, C., 362
Cutcomb. S.T 154
Cutncr, A,, 317
Cutulo, M., 40S

Cyt, M* G, 444 Cyr-Provost,

M*, 207, 212 Czcbler, G A.,

399

Dafter, R, E., 29
Dahlstrom, L, 226
Dahme, B., 242, 243T 244
Dailey, J 324
Dike, J, A., 459
Paie, E KH> 335, 339. 340
Dalessio* D, j.* 116, 206
Damasio, A. R.* 28, 29, S3,
84, 152, 383* 384
Damasio* H,, 383* 384
Dams, P,-C.* 8
Damskcr, J. L* 444
Danthot, J.* 210
DAndrea, G,, 206
Danning* C, 323, 324
Damon, W. G,* 6
Dantzer, R,* 45
D'Aquili, E. G., 481
Das, J. P.* 23* 27,72, 73, 76
Da Silva,]. A, R, 407,408
Davenport* T. L,* 127
Davert, E. C., 155
David* S, V,* 128
Davidson, M, xii, 341
Davidson, R. ].* 138, 382*
383, 384, 388
Davi, M.* 10* 21* 25, 28*
30* 33
Davi* S. M., 445* 446
Davi, T., 10, 21, 25, 30, 33*
2U
Davi, T. C, 84* 90* 444
Davi* W, H., 288* 232
Davis* A.* 452
Davis* G. C** 211
Davis, K* 51*239
Davis* K.* 83
Davis, M, K**218
Davis* R. B., 13, 14* 53* 60,
37* 430* 431, 437, 459* 462
Dawson* A. A.* 156 Dawson*
D,* 305 Dawson* G., 378
Dawson* P.* 399 Day, A,* 425
DCosta, A., 241 Deale, A.,
340 De Becker* P., 341
DeBenedims, G.,26,
153*210*211 de Blic* ]*, 364
De Chanr, H., 20h 49

Deckro, J, P 221 de Cdurten,

M, P., 275 DeGood, D^ 452
DcGruy, R V., HI* xv, 6* 20,
21* 43, 88 Dejoscph, J. F.,
403 de KJoet, R 324
DeLaCruz, M 51

de la
FuentfFem
andei, R,
^0
Detbartco,
T. L,, 58, 60

DeLeeu
w, U
341,34
2 De
Lorgenl,
M*, 283 De
Luca.
C 328
DeLuea, C
J 265
DeLuca, J.,
34]
DeMarco.
G., 51
Dembroskt,
T., 253
DcMdricir,
K., 341
Demitrack,
M. A., 335,
339. 34Q
Dempsey.
! , 404
Denis, 300
Dennerstei
n, Lv 425
426
Dennttt
D., 29
Dennis C
253
Dennllet,
J, 49
Dendngcr,
M*
P 116,208,
2l1
Departmen
t gl Health
and Human
Services,
434
DePascalis.
V., 153
DePa&jna.
V. 207,
212 212
Depur, R.,
389 Dcriu,
F, 139 dc
Rivera,]. L.
G.h 241
Derman,

S.. 323, 324

Dcrogaris, L,
350
Derogatis, L
R. 20
DeRnbeis, K.
j., 168, 169,
171, n
Descartes,
ft., 59
Deshieldv T.
L, 225
Desotelli, P,,
318 Deuscr,
W. E.T 343
[>euster, P.
A., 419, 420
Dcvalos, M+,
378 Devid, ft.
A,, 27
Devine DA^, 153
Devlin M, J.,
44, 281,291
DeVries, H.
281, 282 de
Vnes, R R.
407
Dcvrocdc, G.,
300 Deyo, R.
A,, 8, 70, 71
Diabetes
Research
Working
Group, 278
Duma nr, N.
ET 300,104
Diamond
5 214
Didcmcnte,
C. C., 50
434, 435t 436
Diener, H. C,
209, 210
Dierrich, A.
47
Diez-ftouz, A.
V,, 280
DiGasbarro,
L 305. 302
Dijit. D, J
399
Dill, L., 20, 49
Dillaid, D. H.,
70, 76
Dimmock, P.
W., 423, 424

Dimond, E,
G., 70, 76T
182
Dinisdale,
J E, 46,
281
Din an, T,
G-, 339,
MD
Ditto, B.,
74
Dixon, D.
C., 230

Dixon, M,, 24
DLugotf B.
C 29
Dmochowski,
R,
R 317,318.1
13 Dobbins, j.
G,t 336 312
Dobson, K.
5. 168, 171
Dolce, J,
J 265
Donaldson, C.
C. S., 323
324, 325
326,
3
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Drossman,
D. A 299,
30^ 30U
JW, 304
Dryden,
W,, 168
Dryehag, L.
E., 342
Dubos, R.,
ni
Duckro P.
N., 225
Duff, S.,
408
Duffy, F, H
128
DuHa itici,
KM 22, 26
35, !JJ

Duke, D. L,
187
Duncan, R.t
184
Dundee J.
W., 184
Dnner, D. L.,
386
Dunni, Wh J.,
230
Dunsmore,
J, 4JI
DurneyCrowky, J.,
450 451
Duvall, K.,
243
Dworkin, S.
F., 224, 225,
226, 227,
228, 229
DworkmJ, AL,
44
Dworschak,
AL, 210
Dwosh, U 410
Dyer. A. 276
Dykes, 5,
300
LVZurilla, TJ.,
L68

Eaker, E.
254 Earnest,
C., 388
Eastman, C L,
389 Easton,
P., 65, 123,
127, 153
Eaton, K. K.,
343
Eoclesion C,
168 Fddberg
R-, 242
Edinger, J. D., 396 Edkins. G,, 5 Edmesdi,
J., 205 Ed worthy S. M, +09, 410 Ee,J. S.,
140 Egolf, G., 254 Ehde, D. M, Ut, 1 Si
Eisenhcrg, D. M, 13, 14, 58, 60, 87, 430,
431,437, 457, 459,460, 462 Fkenkrjt, L,
432 Eisman, E-, 315, ill Elcelund, P,, 317,
319 Elbert, T% U4, 325 Ei-Gallcy, R. E 9
Eiger, C E., 124 Elia, a, 317
Elioptmlos, C( 430, 431, 433
Eior,
253, 254
Eltin, L, 169, J7l
Elkins, D., 484
Elkins, IX N.t 191
Elknbcrg, S. S,, 129
Ellis, A., 168, 170, 196, 369
Ellison, C, 484
Fils worth, N.. 291

It,

Elswick, R. It, 318

Emery, G., 176, 363, 369
Emley, Mr 265
Emmntt, 5, D-, 176
Emmott, S+, 303, 307
Enck, P 300, 304, J05j 306
Endre, T., 282

B, T.,

Engel,
290,118
Engel. G, U ** 11, 86, 87,443
England, R., 324
Engsrrom, D. R., 75* 157
Epping-Jordan, J, E^ 9
Epstein* IE, 127
Epstein, W. V., 413
Erbaugh, J,, 382
Erdman, H. P., 387
Enkscn, B. G, 317
Ernest, C., 384, 388
Ernst, E., 8, 12
F-shclman, S., 359
Esparza, J,, 276
Hs pc land, M, A.. 289
Ertinger, W, H 289
Ettner, S 13, 14, 58, 60, 87, 459, 462
Ertner, S. L, 430, 431, 437
Eawier* . D., 430
Evans. D-, 482
Evans, D. D.. 4, 50
Evans, F, j 22, 70, 71, 72, 76, !53s 154
Evans, J, R., 65
Evans, M. D., 169
Ewer, T. Cr, 151, 155
Expert Gonitnitiec, 276

Expert
Panel,
277, 278

Fabrizi, Il 1 Fahrion* S+, 144

FahyJ.V,, 235 Failli, L A., 27
Fairelough, I\, 305 Faith, M. S.,
221 Fall, M., 317,H5 Fanselow,
M, 8., 383 Fand. J. A., 316, 318
Faragbcr, E. B, 151, 156, 3I
Farrar, 13. J., 339, 3 4 i Farrell, E., 425, 426 Fcelty, NL,
172 Feigenbaum, S. L_, 408
Feinglus, M N., 288 Fei urti ait,
C, 75 Feinstem, A, R., 89
Feixis, G., 172 Feld, j. M, 26
Frldenkrats, 138 Feldman, J. J.,
i Feldman, J, M., Mi Felt, B>,
m Felten, D., 46 Frnger, T N.,
549 Fennis, J. F,, 30"
Fcrber* RTl 399, 400 Ferrara,
A,, 306 Feste, C. G, 283
Feuerstein, M., 74 Fklt, L. 151,
156 Field, T*, 378, 453 Findlay,
H., 205 Fine, T H.p 29 Fink, C,
M-, 411,422 Fisch, B, J,, 124
Fish, U 244 Fisher, E. B 283,
287 Fisher, J, 74
Fisher, 22, 26, 35, 69, 70, 153
Fitzgerald, J, T, 233
Flaws, Ek, 64, 65
Ftohner, M-, 46
Fletchet, E., 324
Fletcher, E, M 118
Flint, E. P., 484
Ftar, R, 114, 126, 128, 212,
325
Florin, L, 241
Flotzinger, D+, 128
Fogg, L R, 389
Polen, R. A., 340
Folkman, S., 45
Follkk, M. Jr, 265
Fonseca, V., 283
Fontaine, K. R., 1
Forbes, 229
Ford, D. E., 404
FnrdJ., 286,287
Fordyce, W. E.t 70, 71

Forrest, k. Y, Z., 281

Forshlom, C, 276
Fortney, J., 6 Foster,
C., 53, 60 Foster, R.
J., 483 Focoj>ou!os,
S. ., 71, 74 FciiadTaraii, F. M., 335
Fox, D, A,, 408 Fox,
NH, 378 Fox, $.*
127 Foxhall, K., 12
France, C R., 114,
207,209, 212
France, J. L, 114
Frank, E., 422
Frank, j. B-* 11
Frank, J. D,, 7$h 1
Frank, R. G., 12
Frankel, F. 25* 1JJ,
155
Franks, P T 281.

282

Fraser, R. J.*

2^6

Frederick, J., 124

Freed!and, K. E..
288. 292
Freedman, R. R ,
116, H4T 403
Freeman, A., 453
Freeman. D, J,, 287
Freeman, L. J 250*
251, 252
Freeman, L. W., 13
Freeman, R.T 335
French, M.. 51
Freud, S., 28
Fricton, J. R.+ 225
Fridman, J., 65
Fried. R., 361
Fried berg, F., 340
Friedman, J., 3 53
Friedman, M,* 252
Friedman, R., 2L
Fries J. F., 409,410
Frisch, N. C., 451
Frireche, G., 210
Frohberg, N., 381
Fmlkh, M.* 287
Fmmm, 157
Frymoyer, J^* 261
Fujita, T, 2M
Fukuda, K., 336, 7
Fulkerson, W. J.p 235
Fuller, J.H., 280
FuimtH, M, M**
283, 436
Frst, M., 114, 325
Puster, J. M., M2
Fyer, A., 361
Gaarder, K. R., 290
Gaeddert, A,* 59
Gaffney, R, D-, 342
Gant, D., 210 Galcta,
G., MS Galli, C, ill

GaJti, F., 211 GaKitano, A,, 47

Galloway, N, 319 Galuska, D.
A,, 211 Galvin-Nadeau, M.,
V39 Gantz, N. M., 336 Garada,
B. M,, 335, 336 Garda, F, O.,
197 Garfield, S** 70 Garfinkel,
P, E., 22, 28 Garrod, A., 425
Garvey, M. J., 169 Gasser, T,,
127 Gatthd, R- 5 Gath, D,, 425
Gaudet, E, L* 229 Gauthier, D.
M,, 453 Gavird, J, A., 282
Geiger, A., 333, 334, 335, 336
Geisler, F, H,P 127 Gekoski, f.
L., 154 Gelenberg, A., 386
Gcllhom, E., 139,242 Goierelli*
P-, 342 Gentile, L,, 233
George, L,, w George, L, K..
484 Georgiades, A,, 239
Gerard, P.,207,212.212 Gerardi,
M. A., 290, 291 Gerardi, R. U
290, 291 Gerdes, J. JL, 90
Gerin* W.t 254 Gerlach, A. L.,
362 Grmigard, T.p 342
Gtrmino, B, B.* +36 Gershuny,
B- 387 Gerson, L, 127
Gevirtt* IL* 366, 370, 371,
372, 469
Gevirtz, R. N., 473, 474
Gcvman, j. PM 8
Ghaty, R. G 184
Ghanayim, N*, 128
Giardinu, N. D.,245
Gibbs, F. A.T 123* 127
Giblin, E, C* 403
Gkk* R, 153
Gil, K. M, 411
Gill, IX, 44
Gilltr, E. L, Jr., 46
Gilmore, $. L., 289
Gimorty, P** 317

Ginon, L.T 420

Glaros, A. G, 129, 225, 226,
227, 228,229, 230
Glaser, R., 11
Glasgow, M* S., 290
Glasgow, R. E,, 283, 287
Glasman, A., 254

Glass, EL G., 225, 226* 227, 228,

229, 230

You
have

You
have

You
have

Hulrhn, U.
L., 282

You
have

Hummer, R..
484

You
have

Humphre
ys, P. A.,

You
have

474 Hum, R.
K, 184 Hunt,

You
have

T,, 22, 153

Humer, C,

You
have

230
Hurewitz, A.,

You
have

241 Hursey,
K. G.f 74,

You
have

116,215
Hunvirz, E.

You
have

L., 187
Htisby, G.,

You
have

408
Hutenlocher,

You
have

P. R,, 400

You
have

Hirschman. RH, 3~0 Hobart,

393 Hochberg, M, C. 4 10
Hochron, S., 155, 241, 242
Hocnderdos, T. W,, 156
Hoffman, C., 430, 443
Hoffman, R. \i\, 411 Honey, D.,

Hynd, G. W.T
349

You
have

lacca ri
no, G.,

You
have

282 !
scono, W.

You
have

G,. 389
Ianni, P., 116

You
have

khise, M.,
535, 336

You
have

Ikeda, H, 485
Jmber, 5. D.f

You
have

169

You
have

lmbodcn,
J. B., 27

You
have

207,
208,

You
have

209,

You
have

lugli*,
265

You
have

Ingram,
D. D,,

You
have

281, 282
Insti tu

You
have

r for
Health

You
have

and
Aging.

You
have

430
Institute

You
have

for
Traffic

You
have

Safety
Manage

You
have

ment and
Research,

You
have

394
Institute

You
have

of
Medicine

You
have

, xi, xv
152

You
have

Intermedi
ate

You
have

Visual
and

You
have

Auditory
(IVA)

You
have

Continuo
us

You
have

Performa
nce Test,

You
have

350
Invitti,

You
have

C, 282
Iron son,

You
have

G., 253,
453

You
have

Irvine, E.
L 300,

You
have

303. 3M
Isenbtrg,

You
have

D., 409
Isenberg,

You
have

S., 241,
242

You
have

Ishii, K.,
435

You
have

Isles, C.
G., 286

You
have

I soma a,
B+, 276

You
have

Isomaki,
H., 408

You
have

I ver

You
have

sen. 1.,
128

You
have

Jabon, 5+ L.,
289 Jaccard.

You
have

J.T 28
Jackson, A.,

You
have

242 jadtson,
D-, 215

You
have

Jackson, J. L-,
43 Jackson,

You
have

J. M.,

400 Jacobs,

You
have

E., 412
Jacobs, j. J.,

You
have

59 Jacobsen,
J. H,, 400

You
have

Jacobson, E.,
110, 137,

You
have

138, 139,
140, 148

You
have

Jacobson, N.
S-, 171

You
have

Jain, D., 253

You
have

Jain,

S. C.,
243,289

You
have

Jakoubek
, B,

You
have

153, 155

You
have

James, j.
Y.T 305

You
have

Jantes, L. C.,
339

You
have

James, T,,
252

You
have

Jamner,
L D., 27

You
have

Jarrett, J.,
280

You
have

Jarrett,

You
have

M., *00

491 HANDBOOK OF MtND-RODY MEDICINE

F,, 14
, 28,1%
FORKihlstromJ,
PRIMARY
CARE
KiecoltGlaser, J. K., U, 45

Kifcuthi, Y., 257

Kim, J. Ar, 7JT 76
Kim, N., 250
King, A. C, Mfi
King, D. R., 23, 72, 76, 154
King. D. S.. 276
King, J., 251
King, T. K-, 44
King ham, j. G.. 2QQ
Kingston, R, S., 438
Kinney, J., 361
KmMn.ui, R. A,, 237
Kipchik. Cw. L, 21tt
Kirk, J., 13
Kirmayer, L. J., 44
KirsihJ., 72, 151, 152, 154. 156
KirshJ. C 355, 336
Kirshnite, C 253
Kirwan, j. 276
kifa, Mv 485
Kite, T, 485

154

Kitamura, S,, 282

Kitchener, K. 93, 95, 96, 97, 98, 99, 100, 101,

102
Kith, P., 336
Kittle, C R, 70, 76
Kiapow, J. C., 90

Kl.iusner. jL, 227

KJcber, H. D., 7
K]eiincn,J-> 184
Klein, LX F., 361

Klein, K. R,, 153

Klein, M. K.. 387

Klein* T 399
Klein man, ArT 197, 432
Kligler, 462, 463
klimcs, I.* 34<1

Kline, S. S.p 2K4P 291

Klinger, H, 378
Klinger, M. R., 44
Kloner, R. A,, 252
Kntwvich, M- A,, 387
Kntpschild, P,, 184
Knott, J. R. 123, 127
Knowles, W.F 2^6
Knox, V, j., 154
Kochhar, R, IM
Knemg, H., 13
Koenig, H. G-, 50, 192, 195, 196, 197, 484, 486
Kuemcr, K., 171
Kogan, L. G., 22, 153, 154
Kohen, D, P,, 243
Kobrt, tt\ M 276
Koiima.T., 127
Kolm, P., 23, 24, 25, 2bh 28, 153 Kolodner, K,, 20,
49 Komaroft, A. L.h 335, .336, 337 Komaroft, L.
A,, 336

Komernw, D. B., 404 Kondwani, K., 289

Konclal, J., 184 Konen,
C,T 281 Kcmkol.
U 412 Konstantinov, M. A+l 243 Koocher, C.
P., 95, 102 Koother, G. P.. 95, 96, 97, 98
Korbte, L., 4, 244 Korszun, A,, 225
Korzekwa. KL t 419, 420, 421, 422, 423,
424
KosaJ., 20
Kosinski, IX J., 46
Koskenvuo, 404
Kosten, T, tt., 184
Kost is, J. B.,2^9
Koazcr,&.t 126
Kotchen, T. A., 282
Kotchnuhey, B,, 128, 129
Kotses, H., 4, 242, 244
Kouha. ft. 7j
Kovacs, \Xr [71
Koyama, R, 22, 28
Kraemtr, R C. 156, 157, 197,280
Kramer, NX, 401
Krasncrp L., 154
Krau*, R M., 2S7
Krause, P.J., 126
Krauss, H. R, 13
Kneger, D., 454
Krippner, S,, 191, 192, 194, 196 kriihanan,
R., 254 Kriss, M. R., 169
Kroenke, K.p xv, 5, 6, 43, 47, 51, 85
KronauLT. R. E., 399
Kfoner-Htrwig, B-, M6
Krueger, J. M., 408
Kfursi, M, J., 335, 339, 340
Kruger, D, F.p 282, 283
Kuhszyn, T,t 8S
Kubier, A., 128
Kuboki, T.p 124, 220
Kudrow. L, 211
Kuhajda, M, 44
Kukolski, P. J., 481
KuEkosky, P. J., 353
Kuller, I* H-. 281
K uni a no. H., J24
KUEIZCI,
116
Kupier, D, J*, 401
Kurarsune, M., 485
Kuriyama, S., 59
Kuril, R, \X, 154
Kushner, H- S., 4H0
Kussm, P. S 235
Kutner,
265
Kutncr, N. G*, 14
Kuyper, M B 432
Kvaal, S. A., 114, 207, 209, 212

j,

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S06

HANDBOOK OK MlND-BODY MEDICINE FOR PRIMARY CARE

Mohn, U-, 116
Mokdad, A, H 231
Moldofcky, H., 324, 409
Monastra, VJ 127, 149
Monga, T. N., lb5

Monjaud, L, 283

Monro, S. M., 386

Montana ri, E., 117, 3U
Montgomery, A., 148
Montgomery, G., 151, 152, 156
Momjoy, C Q*, 378
Mooney, R,, H7
Moore, J. E-, 51
Moore, N. C, 131,370
Moore, P. JL, 207, 111
More, R, ],, 59
Moore, T*t 477
Moorkens, G,, 14, 342
Moos, R., 420, 42J
Moos, R. 30
MooyJ. M_, 281, 282
Mora b ta, A,, 280
Moran, G.t 253
Morgan, A- Hr, 155
Morgan, M,, 423

Morin, C, 396

Morin, C. M., 22. 23

Moriey, S., 168
Morse, C. A., 425, 426
Morse, G>, 425, 426
Morcola, j, F., 420
Morton, S., 432
Moscovitch, M.r 28
Moss, D., 4, 9, 0, 11, 84, 113, 116,

364, 467,
477,481, 486

Mossey, C., 323 MossMorris, R-, 167 Motomiya,

T,, 282 Moulton, A, W.( 444
Mountz, j, \I., 339, 34(1
Mubbashar, M., 88
Mubbashar, S., 88
Mueller, H., 323, 324, 325, 327, 129,
33
Mucl 1er-Ohcrlingha usen, B., 383
Muenchcn, R. A,, 349
Mulder, P 254
Mu Holland, T,t 110
MoJIer-Lner, 5., 300, 303, 3M
Munoz, P.. 205
Muoz, R. FH 173, 174
Murphy, A, L, 155
Murphy, D., 156
Murphy, G- E-, 387

Myers, T* C.t 210 Mykkarccn, L, 276

Myllykangas-LtUMujarvi, 408 Myran,
D 176, 305, 307
Nate, E, P., 154
Nadeau, ML, 11
Nadon, R.t 29, 154
SidijJy, P, A,, 291
Nacser, M. A., 184
Nagano, Y., 485
Nagaraja, H, N,, 33it
Nagel, R,, 43, 44, 153, 155
Nahmias, C,f 151
Nakagawa-Kogan, H., 4
Nakao, M., 290
Naliboff, B. D.. 2S2
Nam, C., 4S4
Napoli, L., 211
Nappi, G,, 211
Nardi, A. E., 362
Narrow, W. E., 86, 359, 361, lh4
Nascimento, J., 362
Nash, J., 154
Nash, M. R., 157
NateUon, B, H,, 341
National Academy of Sciences,
Institute of Medicine, 29 National
Association of Cognitive-Behavioral
Therapists, 453
National Outer for Complementary and
Alternative Medicine (NCCAM), 58, 62,
64, 66, 437, 44 5, 454

National Certification Board for

Therapeutic Massage and Bodywork,
454 National Commission on Sleep
Disorders Research, 393
National Heart, Lung, and Blond Institute,
236, 238, 245, 253, 329 National
Institute of Dental and Craniofacial
Research, 231
National Institutes of Healrh <NIH} J7, 58,
64, 65, 18 L, 184, 187, 198, 315, 339.
351, 413,437. 445, 452, 474
National Institutes of Health Technology
Assessment Panel, 30 National Sleep
Foundation, 394 Nawrocki, T-r 378
Nebletr, J., 230 Needham, ]* 187 NwlJ,
V 277, 280, 281 Neely, R. D,T 287
Nehra, V., 20Q Neimeyer, R 172
Nclescn, R. A., 46 Nelson, C. B., 359
Nelson, D 325, 327, 320 Nelson, D, V.,
262 Nelson, ft. R, 205

Murray, T. Jh, 205

Murthy, KH C, 243
Mussel man, D. L., 50 Musso, A., 29Q,
791 Myrr, A., 377 Myers, M. A,, 50

Copyrighied
material

Author
Ncmeroff* C, 50 Nemiah, J. C* 25 Neri,
M., 24-1 Nesse* R. M,, 362 Ne-ufdd* J.
D* 207, 212 Neumann* L.* 323 Nevitr*
M., 413 New berg, A., 481 Newell, Rr, 3
[15 Newman, L. C. 209
New York College of Health Professions,
451
Nezu, A, M, 168
NE, N, K. Y.* 187
Niaura, R., 44
Nicassto, P. M., 396, 411
Nicholson, j. A,, US
Nicolaisen, T., 265
NieUn* B. A-, 444
Nieman* L- Z., 444
Nikson, A., 276
Nisenbaum, R.* 339
Nixon, P., 250, 251* 252, 255
Nixon* P. V\, 361
Nobel, E., 348
Nochasiski, 7 .* 118
Nohr, S, B.* 318
Nolen-Hoeksema* 5 * 170* 172
Nollet-Gemencon, C.* 364
Nomura, S.* 290
Norcross, J. C.t 50* 434, 435, 436
Nordahl, T.f 348
Norell, J, S,* 5
Noriock* F. E., 58, 60
Nrrie, J.* 2S7
Norris, P, A,, 144

Nonfiei, A,, 319

Norchridge, M. F * 280
Northnip, C-, 437
Norton, N, J-, 30k 302* 304
Norton, P., 317
Nouwcn, A,, 265
Notiwen* H. J. M.* 483
Nun, P. L,* 126
Nussbaum, G,* 46
Nutt* D. J,* 359* 404
Nyhhn* K. T.* 431
Oakland University* 461 Oakman, J. M,,
155 OBamon* K,, 237 O^Brien, C. P., 7
O Brien, P, M, 423 Ochs* L,* 328, 323

ndex 425

O'Connell. P., 211 OConnor* P, D. 265

OConnor, R,, 378* 383 ODtineEl* F.*
205, 211 O'Donndl* F.. 3 52 Ogata, M.
485
Okabe, 5.* 237 OKeane, V** 33?, Q
Okubo* Y., 127 Olandtr, R. T,* 184
Oldenburg, B * 51 Older, S.* 323, 324
O'Leary* A., 413 O'Leary* T. A., 369
Olesen* j., 207* 212 Olfson, M., uv Olik,
D** 187 Olmsted* M.* 171 O] ne, K.*
30* 72, 77 Olsen* C. G., 435, 436
Oison* A.* 304 Oison* K,, 483 Orchard*
T. J.* 281 Orebaugh-, C** 117* 290
Orgili, . AH, 127* 111 Orleans* C.* xv
Orne* E. C.* 21* J 54 Ornish, D.* 196,
255 Oros, M, T,, 450* 451 Orr* M.* 324
Orth-Gomcr* K., 280 Oschnun, j. L.T 62
Ostbye* T., .323* 324* 326 Ostensen*
M.* 408 Ostcrhaus* J. T.* 205
Onenvveller* J. E., 341 Otto, M, W.* 387
Okislandtr* J, G.* 313 Owaid* L* 252
Owens, J, E,, 452 Oxman, T. E.* 47
Packard, R. C.* 211
Packer, M,, 250
Padesky* C. A 174* 175, 176
Padgett, L.* 432
P ad iti. Eu* 3 S3
Page* A .* 244
Page* G. G,* 11
Pagliaro* A, M., 351
Pagliaro* L A-, 351
Palenque, M-* 241
Pallmeyer* T. P>* 290, 291
Palsson* O, S,* 28* 90* 300, 307, 444*
445
Paira, M,* 404
Panagiohdrs* H., 378
Panavi, G, S., 408
Pantriti* A, A.* 153
Paoletli, C.* 184
L. A,, 36J
Para* V,, 44
Pareja* J., 341
Parlament* K. L* 484
Park* S. J.* 244
Parker, J., 343

Papp*

Copyrighted
material

Qualls, T, J., 75* 158 Quigly, M, A., 253 Quill,

T. E. 5* 21 Quiller-Couch* A,, 430 Qu Ilian,
R. E., 396 Quinn, A* A,, 450 Quinn, j. Ar* 451
Rabin* B. 5.* 46 Ridanan, S, Jr* 359, 361
Kacfcynski, J. M, 265 Radder* J. K,, 287
Kademaker* A, W., 335 Radii,, T., 153, 155
Radnit* C L*, 203, 214 Radojevic, V.T 352,
411 RjJtkc, R. A,, 396 Rae*Dr5T* 86,
359*361,364 Racier, L ft, 411 Rahe, R. H-* 47
Rai* L* 243 ftaichk* M. E,, 34 S Ram ford. G<
L, xiii Ramforth, M,, 239 Rams, J, C, 213 Ram,
K.* 243 Ramadan. N. M, 206 Ramey, D,, 413
Ramm* M,* 242 Rammohan, EG W,, 333
Ramsey, S. D.* 3 Randles, J,, 305, 107
Ranganarh* C, 382, 383 Rao* M., 383
Rao* S. S., 300j 304, 3QL 306
Raphael, KL G., 227
Rapkm* A. J** 423
Rapoport, A. VL* 209, 213
Riisey, Jk* 124
Raster* j. J.* 41, 412
Rasmussen* B. EG* 207* 212
Rardiffe, M- A.* 156
Rafey, J. j., 351
Rarh'Harvy, D. M., I
Rause* V,, 431

Ravussin, EL, 276

Ray* Vi', J,, 153

Rea, M, R., 284* 2iil

Read* J,, 343

Read* L, 31S

Reed* M. L, 205
Rees* A.. 386* 3S7
Reeves* W. C,* 339
Regier, D. A,, 86, 359* 361, 364
Register, P, A., 29* 154
Regiand, B.* 342
Rehni* L. P.* 168

Reid, R,* 421, 422

Reid, S, A,, 444

Reinecke, M, 4J3 Rentier* H,, 22 Ren* C.,

154 Rcndina, V,* 282 Rescorla, R. A.* 23
Resnick* R. J.* 351, 352 Resron, J,, 182
Reyes* M.* 139 Reynolds* C. F*T Ilk 401
Reynolds* ft* V.* 4 Reynolds, R, V. C,*
244 Reynolds, 5,T 386* 387 Reicnde* RM
228 Rhodes, j.* 305 Rhodes* L* 434
Ricrio* C, A.* 349 Rice* B. L, 289 Rice,
D., 430, 443 Rice, EG M,* 13 Rich*
S.,24* 1J5 Richards, J. M* 50 Richards* P.
S*, 195 Richardson* G. S_> 399
Richardson* M. T* 341* 343 Richardson*
P. H,* 187 Richardson, W. S.* 7 Rich-Ed
words* J. W,* 283 Richman* J. A., 335,
340 Rkhter* H. E.* 319 Richter. R., 242*
243, 244 Rteder, C E.* 225 Riemsrna, R.
P.* 41,1, 412 Rgden* S.* 342 Riley, D,*
66 Ritchey C, 254 Ritchie* I*, 348 Ritter,
P., 430* 431, 432 Ritz* T,* 242
RiveraTuvar* A., 422 Roarta, S,+ L39
Robbins* J, M.* 44 Robert* J. JM 364
Roberts, A. H., 71* 76 Roberts, U xiii
Roberts* S. J,* 20 Robertson* 1_. 6,* 2t)
Robinson* E., 411* 412 Robinson. F, P.*
450 Robinson, H., 146, 147 Robinson* J.
C.T 118 Robinson, ML Er* 265 Roche* S,
M-* 154 Rockland* C.* 384 Rodin* J 156
Rodrigues M, S* 48 Roeykens* ],* 341
Rogers* L.* 116 Rogers* M. E., 449
Rogers* R,, 484

Schneider, R. H., 2H9 Schnyer* R., 5

Schoenen, J., 207, 2i2^ 212 Schnberger*
L. B,, 336
Schondorf* R., 335* 339
School* P. J.f 115
Schere* A. NM 362
Schroeder* A. Fn 20, 49
Schroevers, M, 211
Schulte J* H,* 137* 139* 144, KL 148
Sehukz, J,* 110
Schufri. L, R,* 211
Schulz* L. O,* 276
Schulze:, M., 70
Schuman* S, H** xi
Schumann-B rzcziuski* C, 21
Schuster, M, M>, 304, 305* 307
Schuyler, D,, SS
Schwartz, B, S,h 205
Schwarrz, G. E,* 27, US
Schwartz, M, Sr* 102
Schwartz, M*. 9* 113, 115, 117, 120. 205,
2.15, 467* 474
Schwartz, R. B.* 335, 336
Schwarz, S, F,, 303. 306
Schwarz-McMnrris, S, P.,
305 Schwitzgebeli R* 75
Seaward, B. L-* 152 Seely*
H. Vi;^ 399 Sega!, D., 207,
209, 212 Segal* N* L.* 15 J
Segal* Z. V.* 169* 170* 172, 175* 1?6.
303, 32 Segreto* J, 242 Seidel* H-, 265
Seleshi, E,* 207, 212
Sella, G,. 266* 323* 324, 325* 326, 327*
122
Sdmi, P, M, 387
Selyr* H., 113
Scer, S., 214
Semple* W. E.. 348
Senrhilsclvan, A,* 364
Scrduia* M. K , 291
Scrfontein* G,, 127, l
Sevcsu* M., 317, 3IS
Seyddi E, R,. 412
Shaffer, F,, 484
Shafranskc, E, Pr* 191
Shah* N. p 355
Shanker, ]-* 229
Shannon, S,, 61
Shapiro, A,, 70. 71
Shapiro, D. A.* 386, 387
Sharma, A. M-, 281
Sharpe, M,, 44. 340
Sharpe* M, C.* 336, 337
Sharpe, N.* 167
Shaughn O'Brien* P. M,, 424
Shaver* J,* 420* 422, 423
Shaver* J, R,, 403

Shaw* B. E., 170, 171* 176

Shaw* G.* 305 Shea, S,* 280
Shear* M. K.* 8
Shed 1er, J.* 28
Sheehan, D* V.* 155
Sheehan, M*, 231
Sheehan, P, W.* 75* 158
Shefidl, F, D.* 213
Shtllenberger, R., 115, 117
Shelton, R. C., 386
Shen* Y.* 127
Shepherd, J.* 286
Sheppard* Wr* 289
Sheridan, P,* 34fi
Sherman, A* C* 195
Sherman, M., 253
Shertzer* C. L 22* 153, 155
Sherwood* A,, 254, 2S9
Shevrin* H.* 28
Shidafa, T.* 124
Shimosawa* T.* 90
Shipley* M. J.* 280
Shirat* K., 237
Sboor* S.* 4 J 3
Shor, R, Er, 2, 154
Shouse, M* N., Il7, 128. 352
Shutn, K*, 154
Sibbald* B+T 88
Siegd, S.* 72* 73, 76
Siegfried* W.* 241
Sierpina* V,* 462, 463
Sierpina* V, S.* 88
S lever* D,. 389
Sifneos* P. E,, 25
Sigal, Rr Jr* 283
Sigmon, S, T,, 421* 422
Sihvonen, T.* 265
Silberstein* R, B,, 126
Silbemein* S. D * 206* 208,
211*213
Silman* A. J-, 407
Silver* R. C., 44, 50
Silvergladc, L., 241
Simkin* P., 453
Simkin* S., 340
Simmnns, J,, 195
Simon, D,, 205
Simnn, G, E., 5 1
Simone, D,, 423
Simons* A. D,. 386* 387
Simons* D.* 261
Simonton. O. C., 452
Sindrup* S,* 210
Singer, D.* 320
Singh, G,, 413
Sirr, S. A.. 341
Sisson, RJ+ 450
Sisto, S, A.* 341
Skarcud, J,. 404

P.

Strang,
IL, 205 Strasser, M. R.t 408
Straus, S. E+p 7, 334, 335, 336, 337,
339.140
Strebe], B,, 378
Sireeten, D., 335
SirchL U., 328, 129
Strlakov, S, A,, 243
SwieH S., 94, 95, 98, 99, 102, 128, 129,
212
Strong, S. K,, 22, 23
Strong, W, B,, 51, 2B9
Strube, M. j., 154
Stuart, E- M.T2H
Smart, M, 462, 463
StudiY'Ropp, R, C, 411, 413
Stimuli, R. K., 22, 153
Stux, G,, 187
Suarez, L, 276, 2'8
Suchowcrsky, O., 210
Suddcrth, D. B.s 35
Surmatsu, H., 124
Sulkhanova, A., 48
Sullivan, E. M., 463
Sullivan, M. D., 43, 48
Summerson, J, H., 281
Sung, H., 430
Sung, H.-Y., 443
Supeno-Cabsby, E,, 413
Stipcrko, RJf 255
Surawy, C., 340
Surwit, R, S., 282, 288
Sussrt, J. G., 118
Svedlund, J., 305
Swallow, S, R,, 172
Swan, R-, 197
Swann, \, 305
Swartwood, D. 1., 128
Swaitwood, j. N., 352
Swaitwood, M, Q t 128, 352
Swartzman, L, 155
Swindle, R., 51
Syme. S. L-, 254
Szedicman, H., 151
Szold, A., 26
Taal, E,, 411, 412
Tabacchi, K. N., 229
Tafii, M., 409
Tait, R , C., 225
Taitel, M. A 244
Talcott, G, W*, 230
Talley, M. J 299, 300, 301, 31R
TaLukdar, R-, 289
Tamura, G., 237
Tan, S. Y.,
Tang, T. Z., 168
Tansey, VL, 352
Tarakcshwar, N., 485
Totka, I., S, 2

2Sf

Touboul, P.,

281

Tart, C., 110

Tatman, 5, M-, 153
Taub, E., 115
Taylor, A,, 211 Taylor, A, ., 116, 305,
306 Taylor, A, GM 452 Taylor, A. W., 313,
314 Taylor, C, B 253 Taylor, D,, 425, 426
Taylor, E, > 153 Taylor, R., 340 Taylor,
R. R., 335 Tay!or-Vai$ey, A., 47 Teasdale,
J+ D., 175 Tedcrs, S, J,, 4
Tel legen, A., 21, 24,29, 75, 152, 154,
155
Temple, R-, 129
Temple, R. D., 299
Tennen, 409
Tennessee State University, 451
Tepley, N., 206
Ter Riet, G-, 184
Terry', R., 413
Terwiel, J, P., 156
Test of Variables of Attention iTOVA}.
35P
Thasc, M. E., 386, 387
Thatcher, R. W,, 65, 126, 127
Thcofanous, A. G., 215
Thorell, T., 254
Thoft, J, S., 422
Thomas, G. I., 70, 76
Thomas, J. E+T 362, 320
Thomasma, D. C, iit
Thompson, L, 130, 352
Thompson, M,, 130, 352

Thompson, W, G., 299, 300,

M, 303* 34

Thong, D., 198

Thoresen, C.* 50
Thom, B, ., 44
Thomhy, J, L, 444
Thome, S. E, 430, 431, 432, 433
Thornton, K,, 128
Thorogood, M., 284
Thorpy, M. J.+ 396
Thuras, P., 131
Thys-jacobs, S,, 424
Tian, Jr, 424
Tibbetts, V 242
Tice, H. VL, 335, 336
Ticmens, B., 434
Tiller, W., 32Q_
Tiller, W, Ar, 254 Timmermann, D. L, 128
Timmons, 361 Tkach, W,T 182 Tobin, D.
Lp 116 Tobin, L. R+, 74 Tomenscm, B,t
35
Toner, B. B,, 22, 28h 176, 300, 305, 307
Topper, M. D., 198
Toro, VL, 127
Torrey, E. F,, 198
Tosi, DJ,, 241

Tougas, G,, 184

Townsend, D,, 230

Author Index
Trahira W., 362

Ttanek Dr, 383, 384

Taugot, M, 73
Travel l+ J,, 261
Treiber, F. A., 51, 289
Trepetin, M., 127

Tri arta-Alexander, 3.39, 340

Trio, 315,1113
Trill, K-, 241
Trimarco, ,, 282
Trotter* R. T,, III, J91
Truax, P, Ar, 171
Trudeau, D. L., 131
[ ruong, X. T.f 70, 73
Tuason, V. ., 169
Tueker, D. M, 126
Tuftin, M, Ml
TugwdJ, P., 205
Tunis, M M., 26

Tuomi, T,, 276

Turek, F. W., 399
Turk, D., 325
Turk, D.C., 168, 212
Turner, D, Cn 432
Turner, L C-, 107
Turner, J., 115
Turner, J. A., 43, 48, 70, 71

Turner, J, R., 289

Turner, L., 51, 290
Turner, M. J,, 107
Turner, R-, 51, 192
Turner, R. A., 411
Turner, S, C, 2L4
Turner, T,, 50
Trp, j, C., 226
U,5. Department of Healrh and
Human Services, 4 Uemarsu, S,, 75
Ulcman, j. 5., 28
Ufctt, A., 154 Ullman, !.. \\ 154 Ulmsten, U.,
3 1 7 , 3 1 8 , 3 1 9 Umberm, D-. 30 Untrzer, J 4 6 , 4 9

Univrsity of California at San

Francisco* 451,
University of Virginia Health
System, 452
m
Urrows, S , 409 Utz, S, W.,
291.432

UppaJ, A,,

Vaccarino, 325 va der Wal, R., 51

Vacs, J., 49 Yaisberg, G,, 323
VaJdeon, C-, 453
Valdez, R, 127
Valccha, A+> 243
Valenca, AH M,, 362
Valencia, M E.t 276
Valfe, Mr, 171 Van
Akkcrvee ken, P. F+l

430

265 Vanast, W. J., 2S

Van Cauter, E., 50 van
der Kolk, B. A., 6
Vjnderpuol, H. X, 484
van der Wal, R., 290
Van Deusen, P., 127,
342 Van Dulmcn, A.
M., 3Q7 Van Horn, Y.,
412 Vau Rompay, M , ,
13, 14, 58, 60, 87,
430,431,437, 459, 462
Vanfielow, N* A., si. KV
Van Sweden, B_, 327
van Week C., 319
Varady, A, N,, 2S0
Varhw, 0,317, 318,
319 Vamavides, K.,
425, 426 Vamer, R. E,,
313, 319 Vaschilto, B.,
243 Vaschillo, E 243,
244 Vaughan, f\T 199
Vaughan, S. C , 28
Vaughan, T. M., 128
Vazquez, M . 1.,
241,242 Vedamhan, F,
K., 243 Velten, ., 24,
153 Vera, ML, 364
Verge, M, 409
Verleget, R., 127
Verri, A. P., 211
Verslnot, J. M., 265
Vertommen, J., 341,
342 Viernnad, V., 282
Viera, A. J 117 Vila,
G 364 Villamirqa, M.
A., 153 Vincent, C. A.,
187 Vincenz* L. M.? 26
Viol, G. W., 117,290
Vipaio, G 324
Vipraio, GH A., US
Vogel, P. A., 341
Vokonas, P. 254 Volpe,
M 282 Von
Bertalanffy, L., xii Von
Korff, M., Kviii, 51, 70,
71, 434 Von Korff, M.
R., 226 Von Scheele,
B. H, C, 361, iZQ von
Scheele, I. A- M,, 361
Voss, R. W., 198
Voudourls, N .J., 72,
76
Wadden, X A.,
153, 155, 156
Wade, J. H., 22,
153, 154

Copyriihsed
material

Wagaman, M. J,, 22, 28

Wagjcner, D. K.* 364

Wagner, C, 242
Wagner, E. H.* xviii
Wagner, L, 340
Wagner, T, H,, 313

Wagner-Nosiika, D., 232

Wahl, E., 43
VFahlhy, V., 46
Wats R 242

Waltzkin, H., 44, 50

Watichj H,, 7, ft, 66
WakzykJ.,335
Wald, A., 300, 301* 302,1M

Waldforgct, S., 90
Walker, . A.T 46, 49,
300 Walker, l. G, 156
Walker, R. A,, 127
Walk J., 283 Wall, 1C,
324 Wall, P. 0., 262
Walk V,J 156
Walter, 3 ift Walter,
W. G*, 123 Walters,
E. D+1 10, 109, 110
Wanula, 5. P., 280
Wang, M., 341. 343
Ward, C, 382 Ward,
j,T 323, 324 Ward* M.
413 Ward, P., 431.
432 Wardley, B. L.,
214 Ware, C 22, 23,
153 Ware, j. C, 22,
23 Warner, D., I53r
154 Warwick, A. VI.,
154 Warwick, H. M
C., 176 Warier, A.,
300 Warkin, L*, 254
Watkins, J. T.t 169
Watkins, L. R., 46
Watson, D., 21, 30,
152 W'atson, j., 449,
449 Watson, S., 453
Waugh, R,, 29
Weaver,
291 Webb, R. A., 23,
76, 154 Weber,
R., 196 Weber, 5.,
4iH Weder, A. B ,
277, 280, 281
Weeks,
369
Weg, J,
362
Weil, A., 89 Weiler.
C, 207 Wein, T 335,
112 Weinberger, D.
A., 27, 28
Weinberger, M. W.,
319 Weinman. J,, 167
Weinstein, T. A., 304

72,

M, T+,

C.,
C.,

Wrise-Kdly, L.,
73. 76 Weisman,
M. H., 411 Weiss,
R. L, 54 Weiss,
5. T 254 Welch,
K+ M. A., 206
Welch, P., 191,
152 Wells, A.,
1A1 W'ells,
G.,411 Wendorf, \
1., 231 W'cmg, P., 116
Werbach, M. R.,
83 Werner, K. E.,
450 Wessel, M.,
243 Wessley, S,,
^40 W'estdorp, .
K-, 126 Wester,
F., 432 Westgate,
C E+, 195
Westlry, G J*,
430, 4J7
Westmorland, B ,
327 Wetzel, M.
S., 457, 459, 460
Wetzel, R. D., 387
Wexner, S. D.,
100* 301, 104
Weyand, C. M.,
408 Whalen, C. K , ,
M2 Wheeden, A.,
453 Whelan, V.,
305, 12
Whdtcm, P., 277
Wheltcm, P. 1C.
289
Whitt House Commission On
Complementary and Alte ma rive
Medicine Policy, 454 White, A.,
8, 12
Whitt, C. A., 168, r0,
172, 176 White, 1C,
323, 324, 326
Whitehead, E, W., 299,
300, 30K33
Whitehead, W. ., 300,
3QL 302, 304,
305. 307,

31ft
Whitworth,
P+,
387
Whorton, j. C,
13

Whorwtll, PJ., 151, 153, 156,

300, 304, 305, Ifll Wickless, C.,
154
Wickramasekera. I., v, 6, 9, 10,
11. 19,21, 22, 23, 24, 25, 26,
27, 28, 29, 30, 31, 33,48, 70,
72, 73, 74, 75, 76, 77, 90, 114,

151, 152, 153, 154, 155, 156,

157, 158, 212, 365, 446, 473
WickTamasekera, L, 11+ 156
Widen, EH, 276 Widmark, G.,
226 W ieder hold, B., 474
Wiedcrhold, M,, 4?4 Wiegen, Ot|

Author index
411,412 Wigal, J. K., 4, 244
SIS
Wigcf, S. H+, 34 WiEbcr, K.,
60, 61, 63 Wikox, K.J^ 24, 155
Wilcox, S- A-+ 225 Wikoxon, L,
A., 70 Wilder, R. L., 46 Wilhelm.
F. H., 8, 362 Wilke, W. 5., 335

Copyricihsed
material

Wilkey, S., 13, 14, 58, 60, 87, 450, 431. 437, 459,
462
Wilkinson, M., 209
Willen, W. C, 233

Wurtman, R., 424

Wyatt, K. M., 423, 424
Wyman, 1, F\, 318

Williams, A., 168

Williams, B., 317
Williams, DL A,, 168
Williams, J. B.. xv, 4 J
Williams, J. M. G., 172, 173, 175
Williams, K. M., 215
William*, R, B., 253
Williams, W, J, 28
Williamson, D-, 254
Williamson, D, F.t 291
Williamson, P. R.a 306
Wilson, D.* 313, 114
Wilson, C. T, 44, 281, 29 1
Wilson, J 432
Wilson, K.p 409
Wilson, S. R 244
Wtng,W\. 127,343
Wingard, D- L* 276, 27 S
Winktrlman, M. J., 192
Wmkleby, M, 280
Wise, C. G., 304
Wise, 1\5., 241
W'isen, 0,* 25
Witelt-Jamisek, L,* 45
Wittert, G, A.t 276
Wury. T. E* 343
Woerncr, M,h 290, 291
Wohlfcenmtith, W,lt,, 396
Wolf, 254
Wolf, S. L,, 14, 265
Wolf, S. VL, 126
Wolfe, F., 323, 324, 329, 409, 410
Wolff, H, G.j 206
Wolfson, 5, K,h 281

Wynne* E* 243

Wollt, A 280
Wotner'Haussen, P-, 314
Wolpaw, J, RT 128
Womack, W., 156
Wong* M,, 225
Wood, L, M., 127

Zarconc* V,, 397

Zanki, J. J., 30
ZbofDwtki, M. J., 70
Zee, P. C* 399
Zeigler, D. K-. 214
Zeiss, A* M 173* 174

Wood, L. W., 146, 147

Wood, P. D., 291
Woods, N. F., 403, 420, 422. 423
Woods, S. W\, 8
W'ondward, S,* 403
Woody, E.* 151
Wool folk, R, L, 137, 13S, 140
World Health Organization, 88. 184, 420, 422, 423
Wormsley, S, B,. 333, 334, 335, 336
Wouters, J, M,. 411
W'rtght, E, W., 230
Weight, G. E.h 411
w'right, u m
Wulff, D. N-p 196
Wtilsin, L, R,, 6
Wurtman, ], 424

Zhang, M-, 6
Zhao, Sr* 359
ZitbUnd, S 284
Zimbardo, P, G., 155
Zimmer. P, AM 276
Zimmer, P. Z., 275
Zimmerman, A. W*, 349
Zimmerman, G. L* 435, 436
Zimmerman, M., 382
Zin, W. A., 362
Zingerman, A. M-, 243
Zinn, M.T 153
Zocco, L, 30
Zsembik, C.p 44, 153
Zucker man, E. L 97
Zwinderman, A. H.* 2B7

Xiangcai, X., 14, 361,481

Xu, T., 14
Yaffe, M. 44
Yaituguchi, J., 371
Yanovski, S. Z., 44,281,191
Yasushi, M, 124
Yeager, R. J., 196
Ycap. ft. B,* 276, 342
Yehuda, EG, 46
Yelin, E,, 413
Yen, S. 420
Yingling, K. W, $
Yokode, M., 485
Yonker, R 290
Yordy, K. D., xi, xv
Young, G. A,, 242
Young* L D.* 413
Young, Mr 389
Young, T.. 404
Youngren, M. A., 173, 174
Yudlan, P., 284
YoaipEj-pSO
Yunus, M. 323, 324, 329
Zithanac, EG, Ul, 152, 153*
154
Zakharevich, A. 5., 243
Zamhie, E,, v
Zametkin, A, j., 348
Zandli, E., 407
Zancrti, G_, 317* 111
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1230 HANDBOOK
MIND-BODY
MEDICINE133 electroencephalograph,
hy pertension and, 290OF
imagery,
L11
electrocardiogram,
inc ut a l health applications. 10 muscl
relaxation, 111 openness to change and, 7J
origins, 109
placebo effect and, 69-7?, 11* repetition of
words. 111 respiration and, LQ selective
remembering, 111 skin temperature and, 10
stress management and, 138, 305
understanding mind-body link, 10 urinary
incontinence and, 9, 117, 3IS, 319 See also
specific types of b lofted back;
Bio teed hack* applications of;
QEEG assessment; Tran hypnotic ability
Biofeedback, applications of, 115-1 18
anxiety disorders. 65t 116, 117 asthma, 117
attention deficit disorder, 117
bruxism* H7
chrome pain. 117
dermatological disorders, 117
epileptic seizures, 11?
essential hypertension. I6-1P
fecal incontinence, 117
global effects, 115-116
headaches, 115* 116, 117
hypertension, 1 15-11 fa. i 17
irritable bowel syndrome and, 9. 117
motion sickness, 117
muscle^ disorders, 1 17
muscle tension and, 10. 115
nausea/vorniiing, 117
nocturnal enuresis, 117
phantom-limb pain, 117
KayiuudTs disease, 116, 117
Temporomandibular joint dysfunction. 117
tinnitus, 117
urinary incontinence and, 9, U"
Riofrcdback-assisted relaxation therapy,
diabetes and, 289
B it feedback Certification Institute of America
(BOA), *168, 4T4
Rtofcedbatk learning principles, M4-115 shaping,
115
Btofecdback outcome research,
methodological problems in. 1(7-118
Budeedback practitioners, 4 personality
of, 115 Biofeedback Research Society, 110
Riofcedback Society of American, 4^4
Bioteedback system, basic, 30
Bioiecdback training:
in diaphragmatic breathing, 8 Biomedical
instrumcnts/procedures, 109, 111-113

FOR PRIMARY CARE

112
dectromyograph, 111 phoioplethysmograph
113 placebo effects and, 75-76 respiration
feedback, 113 kin conductance* 112 skm
temperature, 111-112 See dlio EEC binfetdback;
EMC biofeedback; Heart rate variability (HRV)
bioftcdback; Respiratory sinus arrhythmia (RSA)
biofeedhack; Temperature biofeedhack (TEMP)
Biomedical model,
195 Biomedicine, 57
historical roots, 59-60
Biopsychosoehl mode], xii, xiii, 11, 83, 86, 443,
448 Bipolar disorder T, 379, 380, 382 with rapid
cycling. 382 See aho Bipolar disorders Bipolar
disorder H, 379, 380, 382 with rapid cycling, 382
Sec also Bipolar disorders Bipolar disorders, 382
criteria, 381
hypomamc episode, 381 manic episode, 381
Body sensations, shifts in, 193 Bowel and
anorectal disorders, functional. 299 diagnostic
requirements, 302 prevalence, 299
primary care clinicians and treatment of, 308
psychological distress and, .300-301
psychological functioning and. 301 social
functioning and, 30 f symptom
profil^assessment, 301-303
See J/SD specific functional bowel and anorectal Jaorrfers;
Bowel and anorectal disorders,
trcJiment/interventauns for functional Bowel and
anorectal disorders.
treatment;interventions for functional*
106-307 antidepressant medications, 303
conventional medical treatment, 305-305
fiber supplementation. 303 laxatives* 303304 tong-term outcome studies, 307 stress
management training, 3fl5 .See also specific
interventions and botvfl and anorectal disorders

Breast cancer, spiritual experiences and, 197

Breathing retraining, anxiety' disorders and, 359,
321 Bruxism, biofcedback and-, 117
Bulimia. 22
high hypnotic ability and. 153
Calendar of Premenstrual Experiences {COPE).
420 California Board of Registered Nursing, 453
Cancer, psychological effects of
cognitive-behavior therapy and, 168
Capitation, shared-risk model of, 90 Cardiac
behavioral intervention research, 252-254

Copyrighted
material

Subject index
anger, 252-254 anxiety,
254 depression, 254 social
isolation, 254
Cardiac disease, low hypnotic ability and 155
Cardiac disorder, functional:
Af/B applications, 473
Cardiac dynamics., anatomy/pbysiology of,
2 JO Cardiac psychology, 473 Cardiac
rehabilitation, AP/B applications, 473
Cardiac surgery response, low hypnotic
ability and, 153
Cartesian mind-hody dualism, 83-84 Center
tor Studying Health System Change, 87
Center for the Study of Complementary
and .Alternative Therapies, University of
Virginia, 452
Center for the Study of Ethics in Professions, 99
Centers of Alternative Medicine,
N1H-sponsored, 64 ChanriNy
deport, 57-58 Chemotherapy,
anticipatory nausea and vomiting
and: absorption and, 1.55 Chest pain:
absorption and, 155
low hypnotic ability and, 153
nonorganic, 22
Child bearing, urinary incontinence and, 114
Chiropractic therapies, 12, 13 Chiropractors,
4 Christian mystics, 480-48 I Chronic/illness,
7, 429, 478 children with, 430 definition,
430 doctor visits for, 48 management
principles, xvsii most prevalent, 430
perception of threat in, 479 prevalence,
429, 430 reaction ro diagnosis, 44
symptoms, 4 through life cycle, 49
JJJO specific chronic diseases und candkiom
Chronically ill people: caring for, 429-43S
enhancing health behaviors/self-care, 434437 medical management principles, 433434 See 11so Stages of change; Stepped
care, individualized
Chronically 11 people, assessment of, 431433 cultural understanding, 432 personal
perspectives, 432 therapeutic partnership,
431-432 trusting relationship, 431
Chronically ill people, task lists for, 432, 438
Chronic benign pain: definition, 325
fibromyalgia and, 324-325
Chronic fatigue;
differentiating from chrome fatigue
syndrome, 333 prevalence, 333
Chronic fatigue syndrome (CFS), 47, 99, 263,
327, 333

522

AP/B applications, 473

behavioral/neuropsychiarric aspects,
138=119 cognitive-behavior therapy and,
168 defining, 136
defining characteristics, 333 depression and,
339
differentiating from chronic fatigue, 333
dysautunumia and, 335
epidemiology, 334-335
etiology, 333, 334
fibromyalgia and, 333
gender and, 334
laboratory findings and, 33b
most common concerns in, 338
neurofeedback and, 66

overlap syndromes. 333

pathophysiology, 335
physical examination findings and, 335 336

radiological findings and, 336

signs and diagnostic criteria, 335-336

stress and, 339
symptoms, 333, 334
versus major depression, 340
Chronic fatigue syndmme (CFM,
management/irnerventiotis fur: activity,
337 acupuncture 339 aerobic activity,
341
alternative and traditional comb mari on, 343
alternative therapies, 339
amphetamine-like drugs, 338
antidepressant medications, 338
behavioral, 333J4D
bioitedhatk, 339
cognitive-bvhavkiral, 340-341
dietary changes, 339
exercise, 339
herbal remedies, 339, 342
homeopathy, 339

hypnosis, 139

tong-term, 342-343
meditation, 339
neurofeedback, 339
physical therapies, 341-342
sleep medications, 338
nutrition, 337-338, 342

pain medications, 318

rcassu ra ncr/cd uca ti o n, 3 36 -3 37
.relaxation training, ^ 19
traditional management of, 336-338
umisual/eKtreme, 342
vitamins, 339, 342
Chronic obstructive pulmonary disease, 430
Chronic pain. 22

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1232 HANDBOOK

OF MIND-BODY MEDICINE

CET treatment protocol, |T6

cognitive-behavior therapy and*
168 in primary care .sector, 45
low hypnotic ability and, 153
Chronic pain care;

FOR PRIMARY CARE

AJVB applications, 473 Chronic urticaria

intensity, high hypnotic ahility and, 153
CLinJcal/dentai phobia seventy, high hypnotic
ability and, 153
Clinically standardized mtdiration (CSM), I3T
treatment protocol, 146*147 Clinical
psychophysiology', 3, 6, 11 Cognition,
levels of;
automatic thoughts, 169, I"'4-175 core
beliefs, 169, 170, 174, 176 underlying
assumptions, 169-170, 174, J75
Cognitive^behavioral therapy iCETi, 8, 30,
11ft, 449, 453
anxiety disorders and* 359* *63, 369, 371,
372 asthmatic children and, 244-245 chronic
fatigue syndrome and, 340-341 computeradministered, 3S7 functional bowel/anorectal
disorders and, 305 goals, 217
headaches and, 217-218 hypnosis and, 156
irritable bowel syndrome and* 9, 3iC
migraines and, 213 mood disorders and, 387,
388 problems, 341 purpirae, 411
rheumatoid arthritis and, 47, 41J-414 selfstatements, 217 sleep disorders and, 393,
396 tension headaches, 213
Cognitive-behavior therapy {C&Tl applications:
activity scheduling, 172, 173 behavioral
experiments, 174 hehavioral intervention
strategies, 172-174, 177 cognitive continuum
to modify beliefs, 174 cognitive strategies,
172, 174-176, 177 core belief log, 174 costbenefits analysts of beliefs, 174 distraction,
172
downward arrow technique 174 exercise*
172 exposure, 172, 174 graded task
assignment, 172, 173 historical test of core
belief, 174 identifying cognitive distortions.
174 "pie* technique, 174 reinforcement, 172,
173-174 iduitKNl, 172
rational-emotional role play* 174
role play* 172
social skills training, 172
targeting automatEC thoughts, 174-175
targeting core beliefs, 176

targeting intermediate beliefs,

175 thought records, 174 Cognitive
beliefs: catastro phi zing, 411
helplessness, 411
rheumatoid arthritis and, 410-411
self-efficacy, 41 L
Cognitive therapy, 168, 176, 218
asthma and, 241 back pain and,
270
functional bowd/snoreccal disorders and,
3R irritable bowel syndrome and, 306
PMDD and, 419, 424, 427 PMS and, 419,
425, 426,427 renaming* 426
stress management training and, 305 See
Up Cognitive behavioral rherapy (CBT)
Collaborative Curriculum Survey, 450
Colorado Center for Healing Touch, 453
Complementary and alternative medicine
(CAM), 12-14,57,63, 64*87,450 chronic
illness and, 430, 437 encouraging
disclosure/valuation of, 437 favors
factoring, 60 favors limiting, 60 fundamental
assumptions, 168 goal, 176
in medical school curricula, 445
medical disorders and, 16ft
origins for medical disorders, 167-168
paradigm, 13
prevalence of use, 14
principles of, 168-172
providers, S3
psychological disorders and, 168
structuring trta intent, 176-177 Western
medical paradigm and, 58-59 See also specific
CAM tnterventinns; Complementary treatments
Complementary treatments, 59 emerging,
63-66 versus alternative treatments, 59 See
ji$o specific CAM interventions-, Complementary and
alternative medicine {CAM)
Conditioned placebo hope
response* biofcetfback and,
75^76 Conditioned response
model, 6-77 origins, 73-74
Conditioned responses, personality factors and,
2-73 Congestive heart failure jCHF), 249-250,
251 management, 250 prevalence, 249
Constipation, functional, 299 diagnostic
requirements, 302 Coronary artery disease
jCAD), 249, 250 clinical manifestations, 249
conventional medical treatment for, 251
diagnosis, 25

Copyrighled mater

You
have

The Handbook of Mind-Body Medicine for Primary Care introduces an evidence- based mindbody approach to the medical and behavioral problems of primary care patients. Evidencebased mind-body practice draws on the bes! available scientific research and advocates the
integration of well-documented mind-body therapies into primary health care The handbook
summarizes current mind-body practice and provides an overview of the basic techniques,
including biofeedback, neurofeedback, relaxation therapies, hypnotherapy, cognitivebehavioral therapies, acupuncture, and spiritual therapies. The editors also thoroughly
demonstrate the application of these techniques to common disorders such as headache,
chronic pain, and essential hypertension, as well as anxiety, depression, chronic fatigue
syndrome, fibromyalgia, and sleep disorders.
The Handbook includes educational models with guidelines for physicians, nurses,
physicians' assistants, and behavioral health practitioners. The book closes with a look at the
existential and spiritual side of the human encounter with sickness and disease This
handbook will benefit a wide variety of heailh providers in primary care,
The Handbook is divided into four parts:
Part I introduces the conceptual models from the psychophysiological perspective for
understanding functional medical problems.
Part II describes specific clinical tools and interventions.
Part III overviews the best documented cognitive-behavioral approaches and alternative
therapies to common disorders.
Part IV provides educational models for practitioners in each of the mind-body disciplines.

About the Editors

Donald Moss, Ph.D., is Director of Chronic Pain Services al West Michigan Behavioral Health
Services,

Angele V. McGrady, Ph.D., is a Professor of Psychiatry and Adjunct Professor of Physiology

and Molecular Medicine at Medical College of Ohio.
Terence C, Davies, MD, is Chairman of Family and Community Medicine at Eastern Virginia
Medical School,
Ian Wickramasekem, Ph.D., is a past president of the Association for Applied
Psychophysiology. He has published widely on a range of topics including hypnosis,
psychophysiological psychotherapy, and somatization disorder

Visit our Web site at

www.SAgepiibiicattons.com

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