Two Studies on the Power of Placebo
The first two studies to be reviewed here
were never followed up, to my knowledge, in spite of their
potential implications. The first was published in 1962
by two Japanese researchers, Dr.'s Ikemi and Nakagawa (Ikemi
1962). In Japan there is a tree whose leaves produce a rash
similar to a poison ivy rash. These researchers had noticed
that some people developed a rash if they thought they had
touched the tree, even when no such contact had occurred.
They thought that maybe the power of suggestion was at work,
and decided to test this hypothesis with a controlled study.
They took 57 school boys, selected only the ones who reported
being allergic to the trees in question. They then performed
a simple experiment. On each boy, they brushed one arm with
harmless chestnut leaves, and the other with poisonous leaves.
They told the boys that they had done just the opposite,
however, so that the boys thought the benign leaves were
poisonous and vice-a-versa. Within minutes the "placebo"
arm reacted in many cases with a bright red rash with raised
boils, while in the majority of cases the arm brushed with
the poisonous leaves did not react at all. Thus it was shown
that a perfectly harmless substance could produce a specific
physical reaction through the power of suggestion, and that
the physical symptoms produced could match perfectly with
the symptoms that were suggested. It was also shown that
the reaction to a toxic substance could be prevented, even
in highly susceptible individuals, if they were convinced
that the toxic substance was actually a harmless one.
The second study to be reviewed was performed
in the United States in 1950, about ten years prior to the
Japanese study. In this study a bold experiment was performed,
one that might not be allowed today because it involved
lying to the participants. The author of the study, Dr Wolf,
gave a group of women a toxic substance called syrup of
ipecac that causes nausea and vomiting. He lied to the women,
however, telling them it was actually a drug that would
cure nausea and vomiting. The women in the study were already
suffering from chronic nausea and vomiting of pregnancy,
and so they gladly took the syrup of ipecac. In most cases
their symptoms ceased entirely. Objective evidence of their
improvement was also measured by Dr. Wolf, who had the patients
swallow small tubes to measure the amount of muscle contractions
in the stomach, contractions that occur with the heaving
which occure when one vomits. After taking the toxin, the
contractions subsided. This second study shows that, at
least in the short term, a drug that is highly toxic can
actually cure the very subjective and objective symptoms
that it normally causes - if the power of belief is working
in it's favor.
This second study shows that, at least in
the short term, a drug that is highly toxic can actually
cure the same subjective and objective symptoms that it
normally causes. One probable explanation is that the power
of belief is working in its favor, but there are other explanations.
Homeopathic medicines are said to work by stimulating the
body's own healing response, which is done by giving an
extremely diluted dose of a toxin. The diluted toxin is
matched carefully to the symptoms of the person who is ill,
and the toxin chosen is one that would actually cause these
symptoms if it were given to a healthy person. Even these
extremely dilute homeopathic remedies can become toxic,
however, if they are given repeatedly for a long period
of time. Although many conventional medical practitioners
are skeptical about homeopathy, over 100 double-blind placebo-controlled
trials of homeopathic remedies have been performed, and
a meta-analysis of these trials was published in the Lancet,
a leading medical journal (Linde et al 1997). The meta-analysis
found a significant positive effect from the remedies.
Whatever the explanation, this study appears
to demonstrate that the short term use of a toxic substance
when given with the belief that it will cure the very illness
that it causes, can actually cure the illness.
The idea of relying exclusively on "placebo-controlled,
randomized, double-blind" studies evolved from reviewing
studies like these. These studies have become the gold standard
of scientific research, but there are some serious doubts
about how well they actually eliminate the potential for
placebo-like effects. Double-blind studies are supposed
to distill out the "truly effective" drugs from those that
are "only placebos", but it has been shown repeatedly that
people participating in double-blind studies can usually
tell whether they are getting the placebo or the active
substance.
Participants and researchers in placebo-controlled
studies are naturally curious as to whom is getting the
real drug and who is not. Especially for the participants,
it is likely to be a question that is repeatedly on their
minds while they take their daily regimen of pills. This
has been supported by research studies designed to look
at this question which have found that patients and physicians
involved in "double blind" studies can correctly guess who
is getting placebo and who is not about 70% to 80% of the
time (Greenberg and Fisher 1997). This opens up a Pandora's
box of questions regarding the effectiveness of most drug
treatments and may explain why studies like these have not
been followed up. If the placebo effect can be so powerful
it becomes a serious threat to people who have invested
their time and energy into drug treatments.
II. Can AIDS Be Caused By Stress, Social
Isolation, and Negative Beliefs?
HIV is claimed to cause a wide variety of
symptoms in people who test positive on the HIV antibody
test, but even for the most common symptoms, like immunosuppression
and low CD4 T-cells, there is continued difficulty and disagreement
in understanding the mechanism involved (Balter 1997), a
fact that has led the original discoverer of HIV, Luc Montagnier,
to state that he does not think HIV can cause AIDS without
other unidentified cofactors (Balter, 1991).
Studies of both animals and humans have shown
that severe, chronic stress results in a syndrome remarkably
similar to AIDS, and some of the proposed mechanisms are
easily reproduced in animal and test tube models (Benson
1997, Binik 1985, Campinha 1992, Cannon 1957, Cecchi 1984,
Cohen 1988, Eastwell 1987, Golden 1977, Kaada 1989, Meador
1992, Milton 1973, Uno 1994). The effects of stress are
mediated at least in part by the hormones cortisol and epinephrine,
which cause a state of immunodeficiency characterized by
a reduction of the number of T-cells. The CD4, helper T-cells
are selectively depleted, exactly as is seen in people diagnosed
HIV+ (Antoni 1990, Castle 1995, Herbert 1993, Kennedy 1988,
Kiecolt-Glaser 1991, Laudenslager 1983, Kiecolt-Glaser 1988,
Pariante 1997, Stefanski 1998).
Severe stress has also been linked to increased
incidences of specific illnesses and symptoms that are officially
considered "AIDS defining conditions", including pneumonia,
tuberculosis, dementia, wasting, and death. Stress has been
demonstrated in both animals and humans to cause brain damage
and neuronal atrophy, resulting in a dementia that mirrors
"HIV dementia", with the same changes in the brain that
are often observed in people who die of AIDS (Axelson 1993,
Berent 1992, Brooke 1994, Frol'kis 1994, Gold 1984, Jensen
1982, Lopez 1998, Magarinos 1997, Momose 1971, Sasuga 1997,
Sapolsky 1990, 1996, Starkman 1992, Uno 1989,1994). Severe,
chronic psychological and social stress has also been linked
to increased death rates due to illnesses like pneumonia
and tuberculosis (Kennedy 1988, Luecken 1997, Russek 1997),
and has been found, in animals, humans, and non-human primates,
to cause a fatal wasting syndrome that is remarkably similar
to AIDS. These studies will be reviewed in detail later
in this paper, but here is a brief quote from one study
of captured wild monkeys:
"Wild-caught vervet monkeys... occasionally
showed a syndrome of cachexia associated with persistent
diarrhea, anorexia, and dehydration that usually proved
fatal. Those animals appeared to be socially subordinate
and to have suffered an atypically high rate of social
harrassment and attack from their peers. Two animals died
as early as one month under such conditions, and others
died after six months to 4 years in captivity... The fatal
outcome, caused by severe prolonged social stress, induced
classic pathology associated with stress, including gastric
ulcers and adrenal hyperplasia. In these animals we also
found unique insidious degeneration and resultant depletion
of neurons in the hippocampus (the area of the brain that
controls learning and memory)... Similar degeneration
was also found in cortical neurons." (Uno 1994, page 339)
Most people have heard of Voodoo hexing, where
a hexed individual succumbs to a chronic illness that often
results in death, exactly as predicted. Most people are
not aware, however, that some of medicine's leading researchers
and physicians have studied this phenomenon. In addition,
most people have not considered how this might relate to
AIDS.
A number of reports, mostly by Western physicians
working in traditional societies, have appeared in medical
journals over the years. The phenomenon has been called
"Voodoo death", "root work" and "bone pointing" (Benson
1997, Binik 1985, Campinha 1992, Cannon 1957, Cecchi 1984,
Cohen 1988, Eastwell 1987, Golden 1977, Kaada 1989, Meador
1992, Milton 1973). A similar phenomenon occurring in modern,
"developed" societies has also been described, where people
have died after receiving terminal diagnoses from their
physicians, but before the pathology has spread enough to
cause death. This has been called "unexplained death", "self-willed
death", "the given-up-giving-up complex", and "the nocebo
effect" (Benson 1997, Engel 1968, Milton 1973). As one small
example of what will be presented in that section of this
paper, Meador (1992) reported on two men given voodoo hexes
by very different medicine men, one modern, and one traditional.
"The first patient, a poorly educated man
near death after a hex pronounced by a local voodoo priest,
rapidly recovered after ingenious words and actions by
his family physician. The second, who had a diagnosis
of metastatic carcinoma of the esophagus, died believing
he was dying of widespread cancer, as did his family and
his physicians. At autopsy, only a 2 cm nodule of cancer
in his liver was found." (page 244)
Another comparison between these two phenomena
had been provided twenty years before by the Australian
physician G.W. Milton (1973) in a special article to the
Lancet, a top medical journal. The following is a quote
which also suggests that such deaths can occur in Western
societies as well.
"There is a small group of patients in whom
the realisation of impending death is a blow so terrible
that they are quite unable to adjust to it, and they die
rapidly before the malignancy seems to have developed
enough to cause death. This problem of self-willed death
is in some ways analogous to the death produced in primitive
peoples by witchcraft ('pointing the bone')." (page 1435)
Because of the controversy surrounding this
topic, as well as its possible significance in AIDS, this
subject will be reviewed with extensive quotes in the final
portion of this paper.
In addition to the severe stress of living
with such a devastating prognosis, people diagnosed HIV+
also often face severe social rejection and isolation. The
groups of people primarily affected by AIDS, male homosexuals
and IV drug users, already experience this kind of rejection,
often by members of their own families. This isolation is
made much worse by being diagnosed HIV positive, in spite
of efforts by caring family, friends and health care workers.
Tragically, these same friends and loved ones may unintentionally
perpetuate the social isolation because of fear of infection.
Social isolation has been shown to be an independent risk
factor for immunosuppression and to lead to low levels of
CD4 T-lymphocytes. Socially isolated people, when compared
to people with high levels of social support, have been
found in over eight studies to have between double and triple
the death rates (Berkman 1979, House 1988, Ornish 1997).
A recent study found that people diagnosed HIV positive
were two to three times more likely to "progress to AIDS"
if they were socially isolated and under high levels of
stress (Leserman 1999). Here are some quotes from the abstract
of their paper:
"Faster progression to AIDS was associated
with more cumulative stressful life events (p<0.002),
more cumulative depressive symptoms (p<0.008), and
less cumulative social support (p<0.0002). ...At 5.5
years, the probability of getting AIDS was about two to
three times as high on those above the median on stress
or below the median on social support..." (page 397)
Other studies have looked at this question,
but every one, including the one quoted above, suffers from
a fundamental oversight which is critical to the argument
of this paper. None of them take into account the severe
stress and feelings of isolation associated with being diagnosed
"HIV positive", but instead only examine other major stressors.
A study focusing on the stress of an HIV-positive diagnosis
would be challenging to design, or perhaps even impossible,
without breaking people's right to be fully informed about
their own medical diagnoses, but this does not solve the
quandary. Similar problems exist with a number of other
studies of HIV that would shed light on this issue.
III. Severe, Chronic, Psychological Stress:
A Painful and often Terminal Disease
Severe, chronic psychological stress and social
isolation can have health effects that are nearly identical
to AIDS, especially when combined with physical stress or
illness. Stress causes a state of immunodeficiency characterized
by a reduction of the number of T-lymphocytes, with special
targeting of CD4, helper T cells. There is also a reduced
CD4:CD8 ratio, with a relative increase in CD8, suppressor/cytotoxic
T cells (Antoni 1990, Bonneau 1993, Castle 1995, Herbert
1993, Kennedy 1988, Kiecolt-Glaser 1988, 1991, Laudenslager
1983, Pariante 1997, Stefanski 1998). Both of these immunological
changes are considered characteristics specific to AIDS.
Since being diagnosed with AIDS carries with it a high level
of psychological stress and social isolation, low CD4 counts
are likely caused, at least in part, by stress.
A marked increase of the hormone cortisol,
which is released during times of stress, appears to be
one of the primary causes of these immune changes. Catecholamines
like epinephrine, which are also released, have also been
implicated but to a lesser degree. Multiple studies have
found that people diagnosed HIV positive have chronically
elevated cortisol levels (Azar 1993, Christeff 1988, 1992,
Coodley 1994, Lewi 1995, Lortholary 1996, Membreno 1987,
Norbiato 1996, Norbiato 1997, Nunez 1996, Verges 1989).
It is important to note, however, that chronic stress can
induce immune suppression even when cortisol and epinephrine
are not elevated (Bonneau 1993, Keller 1983), so that the
mechanisms by which stress affects health and immunity are
not at all completely understood.
Severe stress has also been shown to cause
brain damage and neuronal atrophy, especially in the hippocampus,
the area of the brain that controls learning and memory
(Axelson 1993, Bremner 1995, Brooke 1994, Frol'kis 1994,
Gold 1984, Gurvits 1996, Jensen 1982, Lopez 1998, Magarinos
1997, Sapolsky 1990, 1996, Sasuga 1997, Sheline 1996, Starkman
1992, Uno 1989,1994). This results in decreased mental function
similar to what is often called "HIV dementia". The most
chilling research, however, is research that has demonstrated
that severe social and psychological stress can cause a
fatal wasting syndrome in animals, humans, and non-human
primates that is very similar to AIDS (Benson 1997, Binik
1985, Campinha 1992, Cannon 1957, Cecchi 1984, Cohen 1988,
Eastwell 1987, Golden 1977, Kaada 1989, Meador 1992, Milton
1973, Uno 1994), a topic that will be covered in detail
later in this paper.
Being diagnosed HIV-positive is perhaps one
of the greatest stressors one can imagine. Not only does
it raise the constant and extreme fear of a relentless deterioration
and death, but it also creates a social isolation that pervades
all aspects of people's lives. To make matters worse, many
of the people diagnosed with AIDS already suffer from social
isolation and rejection. Social isolation, alone, has been
associated with a 100% to 200% increase in mortality in
several large prospective studies, and the increase in mortality
is equal to the increase associated with smoking (Berkman
& Syme 1979, House 1988). The amount of psychological
stress in people diagnosed HIV positive is likely to be
much greater than the stress in the people in these studies.
III A. The Effects of Stress and Social
Isolation on T-lymphocytes
The reduction of CD4 cells in people diagnosed
HIV+ has been called the "hallmark of the disease" (Balter
1997), and it has been claimed since the initial discovery
of HIV that it selectively targets these cells, creating
a CD4/CD8 ratio with a value less than one, referred to
as an "inverted" ratio. The mechanisms by which it might
do this have not yet been uncovered, in spite of vast sums
of money spent on HIV research. Other research has shown
that CD4 cells become depleted in a wide variety of ways
and that low CD4 counts is an incredibly non-specific finding
which is common in many people suffering from all types
of physical and psychological stress (Bird 1996, Carney
1981, Feeney 1995, Junker 1986, Kennedy 1988, Lotzova 1984,
Pariante 1997, Zachar 1998). Low CD4 counts are even relatively
common in people with no illness (Bird 1996). All of these
findings raise the possibility that low CD4 counts in people
diagnosed HIV-positive may not be caused by HIV at all,
but rather by one of the many other factors present in these
people. For a complete review of this topic see the author's
comprehensive review of the literature, which shows that
low CD4 counts and other immune system changes claimed to
be specific to HIV commonly occur when a person's system
is under nearly any kind of physical or psychological stress
(Irwin 2001).
Low CD4 Counts in Chronic Illness
In 1981 a group of researchers looked at CD4
and CD8 counts in ten consecutive patients with acute mononucleosis,
and compared their counts with those of ten healthy volunteers
(Carney 1981). At this time CD4 counting was a newly discovered
technique, as was the idea of looking at CD4/CD8 ratios.
The CD4 counts in the healthy volunteers were 73% higher
than those found in people with mononucleosis. The CD8 cells
in people with mono were increased, resulting in an inverted
CD4/CD8 ratio in every single patient. The average ratio
was only 0.2, compared to the normal average of 1.7 found
in controls. Of the nine patients whose CD4 counts were
measured, the three with the lowest CD4 counts had 194,
202 , and 255 cells/mm3. People who are HIV positive with
less than 200 CD4 cells are immediately diagnosed with AIDS,
and the assumption is made that HIV is attacking their T-cells.
This assumption that seems ill-advised in light of findings
like this one.
More recently another group of researchers
looked at CD4 counts in HIV negative people, this time in
102 consecutive Intensive Care Unit (ICU) patients who were
admitted for a variety of reasons (Feeney 1995). Fully 30%
of these patients had CD4 counts less than 300. They do
not discuss how many were below 200, the level diagnosed
as "AIDS" in people with a positive HIV antibody test. They
also did not find that low CD4 counts were linked with poor
health, nor were they linked with a poor prognosis. Here
are the author's comments on their findings.
"Our results demonstrate that acute illness
alone, in the absence of HIV infection, can be associated
with profoundly depressed lymphocyte concentrations. Although
we hypothesized that this depression would be directly
related to the severity of illness, this was not seen
in our results. The T-cell depression we observed was
unpredictable and did not correlate with severity of illness,
predicted mortality rate, or survival rate. This study
was consistent with prior studies that have shown similar
decreases in T-cell counts in specific subsets of acutely
ill patients. These subsets included patients with bacterial
infections, sepsis, septic shock, multiple organ system
failure, tuberculosis, coccidioidomycosis, viral infections,
burns, and trauma patients. Most of these studies reported
decreases in lymphocyte populations, some of which were
severe and included CD4/CD8 ratio inversions...
"In the largest study to date of hospitalized
patients, Williams et al (1983) evaluated T-cell subsets
in 146 febrile patients with serious acute infections...
with 19 of 45 patients having a CD4 count of less than
300 per microliter." (page 1682-3)
"We also found that CD4 counts were linearly
related to total lymphocyte concentrations, as Blatt et
al. (1991) reported in HIV-positive patients." (page 1683)
Curiously, although these researchers did
find the low CD4 cell counts as seen in AIDS, they did not
find that such counts were very good measures of immune
function. One major double-blind study of AZT use in over
2000 HIV positive people found the same result. AZT increased
the number of CD4 T-cells, but in spite of this people who
received AZT earlier died at a faster rate (Seligman 1994).
This study was the major reason AZT fell out of favor as
the sole drug used on HIV positive people, but it also seriously
questioned the value of CD4 T-cells as a marker for immune
health.
Stress, Cortisol and CD4+ T-lymphocytes
In contrast to the confusion over how HIV
affects the immune system, the mechanism for the immunosuppression
during states of chronic physical and psychological stress
is comparatively well understood. One of the major changes
during times of stress is an outpouring of the hormones
epinephrine and cortisol, which lead to a dramatic reduction
in the number of T-lymphocytes. The strength of the correlation
between decrease in T-cells, also called "lymphocytopenia",
and excess cortisol is so strong that low T-cells is one
of the diagnostic criteria for identifying excess cortisol.
Here are some quotes on this topic, from a
basic textbook on physiology used in most medical schools
(Guyton 1996).
"Almost any type of physical or mental stress
can lead within minutes to greatly enhanced secretion
of ACTH and consequently cortisol as well, often increasing
cortisol secretion as much as 20-fold" (p.966).
"Cortisol suppresses the immune system,
causing lymphocyte production to decrease markedly. The
T lymphocytes are especially suppressed." (p.964)
"Cortisol decreases the number of eosinophils
and lymphocytes in the blood; this effect begins within
a few minutes of injection of cortisol and becomes marked
within a few hours. Indeed, a finding of lymphocytopenia
or eosinopenia is an important diagnostic criterion for
overproduction of cortisol by the adrenal gland. Likewise,
the administration of large doses of cortisol causes significant
atrophy of all the lymphoid tissue throughout the body...
This occasionally can lead to fulminating infection and
death from diseases that would otherwise not be lethal,
such as fulminating tuberculosis in a person whose disease
had previously been arrested" (p.965).
This description of death from infections
that "would otherwise not be lethal" sounds identical to
a description of the symptoms usually blamed on HIV.
Many studies have linked cortisol levels with
CD4 depletion, and some have linked epinephrine, as well.
These are the two major hormones released during times of
stress, and when injected into humans and laboratory animals,
immune suppression results (Crary 1983a, 1983b, Tornatore
1998). Tornatore (1998), for example, found reductions of
70% in the number of CD4 cells in both young and elderly
people after a single injection of a synthetic analogue
of cortisol called methylprednisone. After the single injection,
it took 8-12 hours for the numbers of lymphocytes to return
to normal.
It is important to note that studies have
found that these are not the only mechanisms. The adrenal
glands are the source of both cortisol and epinephrine,
but when rats have their adrenal glands removed they still
have reduced T-cell number and function when subjected to
stress (Bonneau 1993, Esterling 1987, Keller 1983).
People diagnosed HIV+ have been found in a
number of studies to have elevated levels of cortisol, and
some have reduced cortisol responses when artificially stimulated,
which indicates the presence of chronic stress as well as
chronically overactive cortisol production (Membreno 1987,
Christeff 1988, 1992, Verges 1989, Azar 1993, Coodley, 1994,
Lewi 1995, Lortholary 1996, Nunez 1996, Norbiato 1996, Norbiato
1997). Norbiato et al. (1997), for example, compared patients
with AIDS with healthy, HIV negative controls. They placed
the AIDS patients into two groups, those with normal cortisol
receptor affinity (AIDS-C) and those with low cortisol receptor
affinity (AIDS-GR), and compared both these groups to HIV-negative
controls. When comparing urinary free 24 hour cortisol levels,
they found that patients with AIDS-GR had 451 micrograms/24hr,
while control subjects had only 79 micrograms/24hr. People
with AIDS excreted nearly six times as much cortisol as
normal controls. AIDS-C patients had levels of 293 micrograms/24hr,
3.7 times higher than normal. Plasma cortisol levels were
also increased, with levels nearly three times as high in
AIDS-GR patients as in normal controls. Their comments on
their findings are revealing:
"In HIV disease, the normal interaction
between hypothalamic/pituitary axis is altered, thus producing
an oversecretion of cortisol, resulting in immune suppression.
In most patients, this trend continues throughout the
course of the disease." (page 3262)
These levels are compatible with levels of
cortisol commonly found in patients with Cushing's Disease,
a disease of cortisol overproduction that results in severe
immunosuppression, opportunistic infections, neuropsychiatric
abnormalities, muscle wasting, weakness, and fat deposits
in the upper back, face, and belly (Britton 1975, Momose
1971, Robbins 1995, Starkman 1992).
Several studies have linked high stress with
a selective depletion of CD4 helper T-cells, often with
increased CD8 cells. One of the problems in comparing the
immunsuppression due to stress with that in people with
AIDS, however, is that most researchers do not consider
CD4 counts to be a good measure of immune function, and
therefore most studies do not measure CD4 counts. Instead,
lymphocyte responsiveness is preferred, which is nearly
always reduced in states of chronic psychological stress
(Antoni 1990, Kiecolt-Glaser 1988). There are studies that
look at T-cells in times of stress, however, and these will
be focused upon here. The results to be reviewed first will
be from a study of non-human primates, followed by several
human studies.
Social Isolation and Cortisol Levels in
Non-Human Primates
A study by Sapolsky et al. (1997) looked at
the effects of social isolation and social subordination
on cortisol levels in twelve wild baboons. They found basal
cortisol levels four times as high in the six more isolated
baboons, when compared with the six more socially connected
baboons, an astounding and statistically significant difference.
Here are some excerpts from their report:
"Hypersecretion of glucocordicoids (excess
cortisol production) can have deleterious effects on immune
defenses, metabolism, reproductive physiology, tissue
repair, and neurological status...
"Detailed data about adult male social behavior
were collected by one of us (S.C.A.) during the two months
prior to darting for anesthetization. These data were
collected as part of a larger multi-year study of adult
male baboon social behavior and presented an opportunity
to examine social correlates of hypercortisolism (excess
cortisol production)." (pages 1137-8).
"Socially isolated males had significantly
higher basal cortisol concentrations than males that were
well-connected socially (the six more isolated baboons
averaged 850 mmol/L compared to only 213 mmol/L in the
six more socially connected baboons)." (page 1141, figure
1)
"In a previous study with a wild population
of baboons, we observed that among dominant males, those
with the lowest rates of grooming with females and social
interactions with infants had markedly elevated cortisol
levels... These studies cannot reveal whether there is
any causality to this link. However, studies with rodents
and captive primates demonstrate the power of social proximity
or affiliation to blunt the cortisol response to various
stressors, suggesting that these baboons are hypercortisolemic
because they lack the stress-reducing advantages of social
affiliation... This association echoes the classic finding
in behavioral medicine that social isolation represents
a highly notable mortality risk factor across a wide range
of maladies in humans (House 1988). A key finding in those
studies was that no particular form of social affiliation
(spouse, friend, or community group) was more protective
than the others, but that the association instead emerged
from the aggregate of social connections. Simlarly, we
did not observe any 1 of the 8 measurements of social
connectedness to predict adrenocortical status; instead,
it was their aggregate that was highly predictive." (pages
1141-1142)
Some of the studies mentioned by Sapolsky
et al above were analyzed by Coe (1993). He reviewed the
research that examined the effect of psychosocial factors
on the immune systems of non-human primates. Many studies
showed that when young, captive monkeys were separated from
friends or from their mothers, their T-cells showed markedly
impaired function. Researchers also tried to assess why
some monkeys were more affected than others, and found that
many subtle variables such as the timing of the separation,
the age of the monkeys, and the way the separation was created,
could all have a significant effect. Thus measuring the
effects of social support is a complex task, as is measuring
psychological stress. The influence of subtle factors related
to the social environment and to the person's internal coping
mechanisms may have significant mediating effects.
A review by Levine et al. (1996) looked at
research showing that social relationships significantly
buffered the effects of stress in a variety of animal studies.
Here are some of the authors' comments.
"Our initial studies of squirrel monkey
adrenocortical activity showed that social separations
of mother and infants produce striking increases in cortisol
in both mothers and infants... We also showed that the
magnitude of this physiological effect is at least partly
dependent on the degree of social support available to
the infants. In the company of mothers and/or familiar
peers, social buffering of stress-induced increases in
cortisol is apparent. Dramatic increases in cortisol occur
during maternal separations when infants are placed in
novel environments... Long-lasting increases in cortisol
also occur in subadults and adults..." (page 211)
"Social separations can induce long-lasting
increases in cortisol, whereas companionship can result
in social buffering... From 1 to 21 days post separation,
however, cortisol remains elevated above pre-separation
controls." (page 216)
One section of this review applies particularly
to people diagnosed HIV positive. The authors discuss the
effects of creation of newly formed social groups on stress
and cortisol levels, along with the effects of major changes.
"Novelty, uncertainty, and lack of predictability
are all psychogenic factors known to activate the HPA-axis
in a variety of animals, and increased cortisol levels
have previously been reported in newly formed squirrel
monkey groups. Recent evidence suggests, however, that
group formation-induced changes probably depend on a monkey's
prior social-psychological state." (Page 218)
This applies to the members of the gay community,
where AIDS still concentrates, who had recently created
a new community in San Francisco as well as a few other
cities. It also applies to people for whom many social contacts
are disrupted or eliminated as a result of their HIV positive
antibody test.
Stress and Lymphocytes in Humans, Non-human
Primates, and Other Animals
A group of researchers led by Robert Sapolsky
has done a great deal of work observing the effects of psychological
stress on baboons and other primates. Most of their work
has focused on neurotoxicity, which will be reviewed in
a later section of this paper. In one study, however, they
measured total lymphocyte counts and cortisol levels in
a group of baboons that were invaded by a highly aggressive
young male baboon, whom they named Hobbs (Alberts 1992).
Hobbs was particularly threatening to females in the group,
and was apparently attempting to use fear, physical intimidation,
and abuse to increase his chances of successful mating.
Cortisol levels in the group nearly doubled after Hobbs
joined the group, with a slightly greater increase among
females. T-lymphocytes plummeted in the group, from a pre-Hobbs
level of 67 per 10,000 red blood cells (field conditions
prevented them from determining the number of lymphocytes
per microliter of blood, or from measuring CD4 cells) to
a level of about 39, a drop of 42%. When looking at only
the levels in baboons who were victims of Hobbs' aggression,
the levels fell even more steeply, to only 29 per 10,000
RBC's, a drop of 55%. Interestingly, Hobbs, himself, had
the lowest number of lymphocytes in the group, and the highest
cortisol level, suggesting that his behavior may have been
taking an even greater toll on his system than it did on
the victims of his aggression. The authors comment on their
use of lymphocyte counts instead of more sophisticated methods:
"Whereas most studies of the effects of
stress upon immunity examine functional indices of immune
competence (e.g. mitogen stimulation tests, antibody generation,
cytokine responsiveness), our field conditions limited
us to this rather crude quantitative measure of numbers
of cells." (Alberts 1992 page 174)
It is notable that these researchers also
agree that T-cell function tests are the best way to measure
immune competency, something supported by earlier reports
that question the value of CD4-cell counting (Feeney 1995,
Seligman 1994).
Pariante et al. (1997) measured the CD4 helper
T-cells and CD4/CD8 ratio of people who were under chronic
stress due to being caregivers of severely handicapped family
members. They found that the caregivers had "significantly
lower percentages of T cells, a significantly higher percentage
of T suppressor/cytotoxic cells, and a significantly lower
helper:suppressor (CD4/CD8) ratio." Another study of caregivers,
this time of people caring for people with late-stage Alzheimers,
also found decreased CD4/CD8 ratios, in addition to impaired
T-cell function (Castle 1995).
A study in rats compared the effect of three
weeks of chronic stress in rats who either had normal pre-natal
experiences, or who were exposed to ethanol in utero. Males
were especially affected, and ethanol exposed rats had significantly
more lowering of CD4 counts when placed in a stressful environment
than non-exposed rats (Giberson 1995). This suggests that
chemical insults can increase the susceptibility to stress-induced
immunodeficiency, especially if the exposures occur in utero,
a finding that is especially significant to childhood AIDS
cases as many of them are born to women who are IV drug
users.
It is important to note that short-term stress
can have very different effects from long-term stress. For
instance, one study compared the effects of two hours of
social stress in rats with the effects of 48 hours of stress.
After two hours, there were decreases in the number of T-cells,
but an increase in the CD4/CD8 ratio. After 48 hours of
the same social stress, however, the CD4/CD8 ratio had lowered
to the normal range, while T-cell numbers remained reduced
(Stefanski 1998).
The effects of stress also show a lot of individual
variance, which may be due to factors like coping strategies
and social support. Several studies have found that isolated
people have more immune dysfunction than people with high
levels of social support (Kennedy 1988, Kiecolt-Glaser,
1984, 1991). These studies will be reviewed in the next
section of this paper. Another mediating factor appears
to be the amount of control that one has over the source
of stress. Rats who were given some measure of control over
the source of stress showed normal lymphocyte responses,
while rats who had no control showed impaired responses,
even though the amount of external stress producing events
(electric shocks) were equal (Laudenslager 1983). A review
of relevant studies from 1988 examined some of these variables,
with the following comments:
"Data are given which document immunosuppressive
effects of commonplace, short-term stressors, as well
as more prolonged stressors, such as marital disruption
and caregiving for a relative with Alzheimer's disease.
Immune changes included both quantitative and qualitative
changes in immune cells, including changes in herpes virus
latency, decreases in the percentages of T-helper lymphocytes
and decreases in the numbers and function of natural killer
cells. These effects occurred independently of changes
in nutrition. Psychological variables, including loneliness,
attachment and depression were related to the immune changes.
The data are discussed in a framework in which quality
interpersonal relationships may serve to attenuate the
adverse immunological changes associated with psychological
distress, and may have consequences for disease susceptibility
and health." (Kiecolt-Glaser 1988).
Another review article (Antoni 1990) has several
discussions of this topic, including some discussion of
the effects of stress in people with AIDS. Following are
some of the author's statements regarding effects on T-cells:
"Animals subjected to uncontrollable stressors,
for instance, have been noted to display... immune system
decrements such as thymic involution, decreased NK cell
cytotoxicity, suppressed lymphocyte proliferation, and
decreased helper/suppressor cell ratios." (page 41)
"In research using naturally occuring uncontrollable
stressors in human subjects... (there were) decreases
in total T-lymphocyte number, total macrophage number,
and total number of CD4 cells." (page 41-42)
"Other recent work has noted that a high
stress level, increased depressive symptoms, dissatisfaction
with social support, and limited use of coping strategies
predicted decreased CD4 cell number and increased CD8
cell number." (page 42).
Several different types of stressors led
to these immune system changes, including loneliness,
lack of social support, and bereavement, all three of
which have a high prevalence in people diagnosed with
AIDS. A final quote from this article (Antoni 1990) discusses
the impact of HIV diagnosis on immune function.
"Indeed, we have observed discrete and significant
psychological and immunological changes among asymptomatic
gay men across the anticipatory period preceeding HIV-1
antibody testing and during the impact period following
news of diagnosis. Furthermore, we have noted significant
benefits of behavioral interventions on psychological
and immunological functioning among asymptomatic, HIV-1
seropositive and seronegative gay men." (page 46)
It is notable that these two reviews (Antoni
1990, Kiecolt-Glaser 1988), and also a meta-analysis (Herbert
1993) of studies looking at the effects of stress on immune
function consistently find CD4 helper T cells selectively
reduced in people subjected to chronic stress together with
a decrease in CD4/CD8 ratio. If found in someone who is
HIV positive, these effects would unquestionably be blamed
on HIV, and the effects on immunity of the extreme stress
of living with an HIV positive diagnosis would be ignored.
III B. Stress-Induced Dementia
Multiple studies have found that chronic psychological
stress, and the resultant hypercortisolism, induces brain
damage characterized by atrophy of cortical neurons, especially
in the hippocampus, the region of the brain that controls
learning and memory. Another reported finding is enlargement
of the ventricles in the brain (Axelson 1993, Brooke 1994,
Frol'kis 1994, Gold 1984, Jensen 1982, Lopez 1998, Magarinos
1997, Mimose 1971, Ohl 1999, Sapolsky 1990, Sasuga 1997,
Starkman 1992, Uno 1989,1994). Dementia is a classic finding
in people diagnosed with AIDS, and similar changes in the
brain have been reported.
A commonly recognized example of how severe
stress impairs mental function is the gaps in memory that
people often have in relation to periods of prolonged trauma,
as occurs in many cases of childhood sexual abuse, for example.
Most people are not aware, however, that chronic stress
actually causes atrophy of the brain tissue.
A quote from Uno et al (1994), in the introduction
to this paper, discussed the cases of stress-induced fatal
wasting syndrome in monkeys. The authors also indicated
that they found atrophy of cortical neurons in the hippocampus,
as well as in other areas of cortex. This phenomenon was
observed both in wild-caught animals subjected to severe
social stress by their peers, as well as in animals injected
with synthetic analogues of cortisol.
This phenomenon has also been observed in
humans. Jensen et al reported in 1982 that torture victims
showed long-term signs of dementia, as well as other problems,
and described their findings in five such victims:
"Examination of torture victims throughout
the world has revealed a high incidence of late physical
and neuropsychiatric sequelae. The most prominent mental
and neurologic symptoms are impaired memory and ability
to concentrate, headache, anxiety, depression, asthenia
(loss of strength), sleep disturbances, cerebral asthenopia
(aching and burning of the eyes), and sexual dysfunction.
These conditions are present in other conditions in which
brain atrophy or intellectual impairment or both are frequent
findings.
"We recently examined five young men subjected
to to various forms of torture years earlier. These previously
healthy young men (mean age 31 years) had all been tortured
severely for from two to six years. Similar mental and
neurologic symptoms developed in all of them immediately
or shortly after torture; these symptoms persisted unaltered
until examination (an average of four years later)...
Computerized axial tomography (CT scans) showed definite
cerebral atrophy that was cortical in four men and central
in one...
"The symptoms and signs in the present cases
were in many ways comparable to those seen in survivors
of World War Two concentration camps. Although the social
and mental complications in concentration camp survivors
were initially considered to be transient, later follow-up
studies showed that signs of dementia occured in a high
proportion of cases 10 to 20 years after detention (Thygesen
1970). The same long-term effects with signs of irreversible
brain damage may occur in today's torture victims..."
(Rasmussen 1980, page 1341).
Alzheimer's patients have also been found
to have hippocampal atrophy whose severity correlated with
high cortisol levels (DeLeon 1988), and people with depression
have been found to have enlarged ventricles and greater
cognitive impairment if their cortisol levels were elevated.
Starkman et al (1992) studied the effects
of chronic excess cortisol on brain function and hippocampal
atrophy. They found hippocampal atrophy that was correlated
with the amount of cortisol in the patient's blood, just
as was found in Alzheimer's patients (Starkman 1992). In
their conclusions they briefly discuss these effects as
observed in various studies:
"Significant correlations between elevated
cortisol levels and severity of hippocampal atrophy have
been reported in patients with Alzheimer's disease, as
well (De Leon 1988). In a broader context, it should be
noted that the role of cortisol in cognitive dysfunction
likely extends beyond its specific effects on the hippocampus.
For example, CT scans revealed ventricular enlargement
and cortical atrophy in patients with yhypercortisolism
due to Cushing's disease (Momose 1971). In primary depressive
disorder, patients with abnormally high cortisol were
more likely to have larger ventricles, as measured by
ventricle to brain ratios (VBRs), and those patients with
large VBRs demonstrated greater global cognitive impairment."
(page 764)
Cortical atrophy and ventricular enlargement
are two characteristics commonly found in what is called
"AIDS Dementia Complex" (Robbins 1996). Patients with Cushing's
Disease have also been found to develop meningitis, due
to cortisol-mediated immunosuppression, which is another
common neurological complication in people diagnosed HIV
positive (Britton 1975).
While cortisol has been studied the most,
epinephrine, the other major hormone released in times of
stress, also causes brain atrophy and impaired brain function,
as has been indicated by controlled animal experiments.
Gold (1984) performed such an experiment using epinephrine
injections:
"a single injection of epinephrine results
in long lasting change in brain function... The findings
suggest that some hormonal responses may not only regulate
neuronal changes responsible for memory storage but may
also themselves initiate long-lasting alterations in neuronal
function." (p. 379)
There are also likely other mechanisms by
which this brain damage occurs that are not yet understood,
but no matter what the mechanism, the effects appear to
be swift and often irreversible.
Robert Sapolsky authored an article published
in Science that reviewed the literature on the effects of
stress in the brain (Sapolsky 1996). A number of direct
quotes from this review follow:
"Glucocordicoids (GCs) like cortisol, along
with epinephrine and norepinephrine, are essential for
surviving acute physical stress (evading a predator, for
example) but they may cause adverse effects when secretion
is sustained.
"Excessive exposure to GCs has adverse effects
in the rodent brain, particularly in the hippocampus,
a structure vital to learning and memory (McEwen 1992,
Sapolsky 1994)... Over the course of weeks, excess GC
reversibly causes atrophy of hippocampal dendrites, whereas
as GC overexposure for months can cause permanent loss
of hippocampal neurons. Although studies suggest that
similar effects can occur in the brains of primates (Magarinos
1996, Sapolsky 1990, Uno 1989), until recently there has
been no evidence (except perhaps Jensen et al, 1982) for
GC induced damage in the human. Some new exciting studies
present such evidence.
"A first example by Sheline and colleagues
concerns major depression (Sheline 1996). Approximately
half of depressed patients studied secrete abnormally
high amounts of GCs... The authors of the new study report
MRIs with far more resolution than in previous studies
and have excluded individuals with neurologic, metabolic,
or endocrine diseases. They have found significant reductions
in the volume of both hippocampi... The authors ruled
out alcohol or substance abuse, electrocunvulsive therapy,
and current use of antidepressants. Remarkably, there
was a significant correlation between the duration of
the depression and the extent of atrophy.
"A similar relation was seen in patients
with Cushing's syndrome (where) there is bilateral hippocampal
atrophy (Starkman 1992)... The extent of GC hypersecretion
correlated with the extent of hippocampal atrophy, which
also correlated with the extent of impairment in hippocampal
dependent cognition...
"In Vietnam combat veterans with post traumatic
stress disorder (PTSD), Bremner et al (1995) found a significant
8% atrophy of the right hippocampus, and near significant
atrophy in the left. In (another study) Gurvits et al.
(1996) also examined Vietnam veterans with PTSD and found
significant 22 and 26% reductions in volumes of the right
and left hippocampi. Finally, in another study... Bremner
et al (1996) found a 12% atrophy in adults with PTSD due
to childhood abuse... These studies controlled for age,
gender, education, and alcohol abuse... In the studies
by Bremner.. there were nearly as large (but non-significant)
reductions in volumes of the amygdala, caudate nucleus,
and temporal lobe...
"How persistent are these changes? Although
the Cushingoid atrophy reverses with correction of the
endocrine abnormality (excess cortisol/GC production),
in the PTSD and depression studies, the atrophy occurred
months to years after the trauma or last depressive episode...
Thus, these changes could represent irreversible neuron
loss." (Sapolsky 1996, pages 749-750)
III C. Stress and Social Isolation's Effects
on Mortality
Large, prospective clinical trials of the
general population have found that people with low levels
of social support have between double and triple the death
rates of people with the highest levels of social support
(House 1988, Berkman & Syme 1979). In addition, socially
isolated people have reduced numbers of T-lymphocytes (Kennedy
1988, Kiecolt-Glaser 1984, 1991), as do socially isolated
non-human primates (Sapolsky 1997). These types of results
are extremely consistent and go back for decades in the
medical literature. In 1956, for instance, socially isolated
people were found to have much higher rates of tuberculosis,
even when they lived in wealthy neighborhoods (Holmes 1956).
It is worth noting that tuberculosis is an "AIDS defining
illness", so these people would have been diagnosed with
AIDS if they tested positive on the HIV antibody tests.
The effects of social support on survival
of cancer has been examined by many researchers, as well.
In all eight prospective studies found by this author in
which levels of social support were compared among cancer
patients, increased survival was observed in people with
higher levels of social support. These increases were statistically
significant in seven of the eight studies (Cassileth 1988,
Colon 1991, Eli 1992, Goodwin 1987, Maunsell 1995, Reynolds
1990, 1994, Waxler-Morrison 1991). Similar results for heart
disease have also been found in a large number of studies
(Ornish 1998).
Perhaps the most tragic findings regarding
social support and human contact involve childhood development.
Infants raised in severely understaffed Romanian orphanages
have been found to have extremely high rates of developmental
disorders and very high death rates (Carlson & Earls
1997, Rosenberg 1992).
Social Support and Survival of Cancer
Cancer patients with high levels of social
support have as much as double the survival rates as those
with low levels of social support (Berkman & Syme 1979,
Colon 1991, Reynolds 1994), Every prospective study looking
at this issue found higher survival rates for cancer patients
with higher levels of social support (Cassileth 1988, Colon
1991, Eli 1992, Goodwin 1987, Maunsell 1995, Reynolds 1990,
1994, Waxler-Morrison 1991). Social support interventions
were also found to increase survival in two of three studies
where a group of cancer patients receiving a social support
intervention was compared to a control group (Fawzy 1993,
Gallert 1993, Spiegel 1989). Further weight was added to
these results by the fact that the two studies with statistically
significant results (Fawzy 1993, Spiegel 1989) were also
those that used randomized group selection, giving them
much more external validity than the other, nonrandomized
study by Gallert et al. (1993). Siegel et al. (1989) found
that women with late stage breast cancer randomized to receive
social support group interventions lived nearly twice as
long, and Fawzy et al (1993) found that only three of 34
melanoma patients randomized to receive group education
and support intereventions died after seven years compared
to ten of 34 who did not. there was also a trend for decreased
recurrence, with seven recurrences in the group receiving
group interevention compared to thirteen in the control
group.
III D. Social Support, Human Contact, and
Childhood Development
One of the great tragedies of the 20th century
has been the suffering of children in Romanian orphanges
that occurred under the rule of Nicolae Ceausescu. Two different
teams of researchers have studied these children and come
to heart rending conclusions. The children have suffered
extremely high rates of developmental delay, mental retardation,
delirium, and death. Because these children received adequate
food, clothing, shelter, and medical care when sick, the
researchers concluded that these children suffered and died
because of lack of physical and emotional contacts during
their infancy. The first quotes are from a letter published
in JAMA in 1992 (Rosenberg 1992).
"Since the downfall of Nicolae Ceausescu's
communist regime in Romania in December 1989, several
almost barbaric institutions for children have been discovered
throughout the country. Because of draconian probirth
policies implemented by Ceausescu coupled with Romania's
status as one of the poorest countries in Europe, children
were frequently abandoned by their parents and placed
in state-run orphanages. As a result, approximately 40,000
abused and neglected children languish in these orphanages...
"Prior to 1989, it was estimated that 35%
of these children died every year. During September of
1991 we conducted a neuropsychiatric assessment of the
entire population of one of these orphanages. One hundred
and seventy patients resided in this institution, and
all had been declared 'irrecuperable'.
"The orphanage was severely understaffed...
This understaffing resulted in such minimal child-staff
interaction that 75% of the children did not know their
own name or age... It should be noted, however, that the
director and many of the attendants had a true desire
to help these children but did not have the means, or
the training, to do so... 85% of the children had no family
contact whatsoever." (page 3489)
The researchers report the results of their
neurospychiatric assessment in table 1 on page 3489. They
found that fully 94% of the children had developmental language
and speech disorders, 40% were mentally retarded, 26% had
muscular atrophy, 22% were "completely immobile", 14% suffered
from delirium, 12% had epilepsy, 10% had autism, and 4%
had psychosis.
Another description of these children is given
by a husband and wife team from Harvard Medical School and
School of Public Health, Mary Carlson and Felton Earls (Carlson
& Earls 1997). Their analysis is both moving and comprehensive,
and extended quotes from their work follow.
"The situation of infants and children living
in state-operated residential institutions in Romania
provides a setting in which the consequences of severe
social deprivation can be examined. These children experience
a form of social care in which their medical and nutritional
needs are met, but but their social and psychological
needs are not. We believe it is scientifically and ethically
imperative to analyze the developmental deficits of such
children within the context of the social and material
resources available to them... Study of the defecits or
capacities of the decontextualized child can lead to invalid
attributions of intrinsic causation within the child (eg.
genes for temperament or IQ)...
"Studying children in a situation of extreme
deprivation provokes such a strong reaction that pursuing
an ethical voice to govern one's work would seem crucial.
We intend to... become advocates for these children at
the same time that we assess the consequences of their
living conditions...
"The demonstration of direct relation between
tactile modality and social deprivation was established
in the laboratory of Henry Harlow where it was shown that...
tactile (but not visual or auditory) deprivation was a
critical determinant of the autistic-like behavioral syndrome
that resulted from early social deprivation. These studies
were continued by Mason and many others, including one
of the authors of this article." (pp. 419-420)
The authors go on to give a detailed account
of the mechanisms by which touch induces healthy responses
in brain neurotransmitters, receptors, and neuronal development,
and go on to describe how increased cortisol (glucocorticoids)
can inhibit this process. They then describe the condition
of these children, and outline a small program that successfully
reversed much the damage that had been done.
"The muteness, blank facial expressions,
social withdrawal, and bizarre stereotypic movements of
these infants bore a strong resemblance to the behavior
of socially deprived macaques and chimpanzees. Most of
the children... had experienced severe tactile/social
deprivation due to the high child:caretaker ratios and
custodial rearing practices... we discovered an early
enrichment program..., organized by an American psychologist,
Joseph Sparling. In this program, two groups of 2-9 month
old infants were randomly assigned to either a social/educational
enrichment program with child:caretaker ratio of 4:1 or
left in standard depriving conditions with a child:caretaker
ratio of 20:1...
"In the 9 month period necessary to obtain
funding, this intervention program lost its support. Thus,
after 13 months of enrichment, children in the intervention
group were once again living in the depriving conditions.
The children in the intervention group had shown significantly
accelerated physical growth and mental/motor development
compared to the control group during the enrichment period,
but 6 months after the program ended they were no longer
superior to the control children (as measured on the Denver
Development Screening Test). Measures of weight and height,
head, triceps and chest circumference, and mental and
motor performance (using the Bayley Scales of Infant Development)
revealed that the intervention group had lost the advantage
gained from the enrichment experience. At this same time,
we measured cortisol levels using the non-invasive method
of saliva sampling to determine its level, diurnal variation
(cyclic daily variation), and its reactivity to a stressful
event... The control group levels can be seen (Fig 2)
to rise significantly at noon, compared to intervention
group levels. Significant correlations were found between
levels of cortisol and physical growth (Denver Developmental
Scale) as well as mental and motor performance (Bayley
Scale)." (pp. 422-424)
The authors later provide a brief description
of other studies showing memory loss and brain damage (neuronal
death and shrinkage of the hippocampus) in adults who were
victims of prolongued stress, and discuss chronically elevated
cortisol as a possible cause.
"This study of psychologically deprived
and stressed young children not only carries implications
for deficient learning and memory, but also may convey
a life-long vulnerability to certain psychiatric disorders.
The results of this research will be compared to clinical
studies of psychiatric conditions in adults that reveal
similar factors of HPA (hypothalamus-pituitary axis) dysregulation,
hippocampal neuron degeneration, and declarative memory
loss...
"The most profound similarity with the work
in rodents is the finding of significant hippocampal shrinkage
in patients with post-traumatic stress disorder. The presence
of shrinkage is strongly associated with declarative memory
deficits... Both changes in hippocampal volume and verbal
memory loss have been associated with the degree of cortisol
elevation in adults with Cushing's disease. Elevated levels
of cortisol associated with memory impairment are seen
in depressed adults and adolescents, and elevated levels
of exogenous glucocordicoids administered for control
of asthma have been shown to produce memory deficits and
other cognitive changes in children." (p 426)
Finally, Carlson and Earls provide the following
comparison to conditions in the United States, where child
neglect is also present.
"Although this research undoubtedly has
implications for the nature of affiliative relations in
Romanian society, we are increasingly concerned about
the consequences of the growing numbers of children under
age 5 who live in poverty in this country (a rate that
has increased from 15% to 26% over the past 20 years).
When this reality is coupled with the increasing rates
of maternal unemployment, which is the objective of "workfare",
and the insufficient supply of satisfactory child care
services, the enduring negative effects on child well-being
for a large segment of American society should be appreciated."
(page 426)
IV. Voodoo Hexing, Root Work, Bone Pointing,
and AIDS
We have seen how stress and social isolation
can cause immune deficiency that resembles AIDS, and also
how they can cause dementia and increased rates of chronic
and often fatal illnesses. The most dramatic syndrome caused
by stress, however, is a fatal wasting syndrome that results
when a "voodoo hex", is cast in certain traditional societies.
Physicians observing this phenomenon postulate that the
power of such a hex is derived from the group beliefs of
the person, their family and their society. Such syndromes
are not limited to humans, however.
Stress-Induced AIDS in Wild-Caught Baboons
A study that looked at the effects of severe
stress on the health of monkeys found that some monkeys
who had been subjected to severe social harrassment and
attack from their peers showed a relentless wasting syndrome
that usually proved fatal. The authors comments were quoted
at the beginning of this paper, but bear repeating:
"Wild-caught vervet monkeys... occasionally
showed a syndrome of cachexia associated with persistent
diarrhea, anorexia, and dehydration that usually proved
fatal. Those animals appeared to be socially subordinate
and to have suffered an atypically high rate of social
harrassment and attack from their peers. Two animals died
as early as one month under such conditions, and others
died after six months to 4 years in captivity...
"The fatal outcome, caused by severe prolonged
social stress, induced classic pathology associated with
stress, namely gastric ulcers and adrenal hyperplasia
(adrenal hyperplasia is caused by chronic excess cortisol
secretion). In these animals we also found unique insidious
degeneration and resultant depletion of neurons in the
hippocampus... Similar degeneration was also found in
cortical neurons." (Uno 1994, page 339)
This description resembles the syndrome that
is called "AIDS", as do some of the descriptions in the
articles on voodoo hexing which follow. It is the author's
hope that by seeing how much damage negative beliefs can
cause, our readers of this article will help people reintroduce
healthy beliefs, such as people diagnosed HIV-positive.
The Voodoo Hex in the Medical Literature
Walter Cannon, the renowned professor of physiology
at Harvard School of Medicine who first described the hormonal
effects of the "fight or flight" response, was also the
first to publish a review of the phenomenon that he called
"Voodoo death". He compiled reports from a number of Western-trained
physicians who lived in areas of the world where native
inhabitants believed in, and practiced, this phenomenon
(Cannon 1957). These physicians attempted to rule out other
explanations for the deaths, such as poisoning. Here are
a number of excerpts from this classic article:
"Dr. S.M. Lambert of the Western Pacific
Health Service wrote to me that on several occasions he
had seen evidence of death from fear. In only one case
was there a startling recovery... When Dr. Lambert arrived
at the mission (in Mona Mona in North Queensland, Australia)
he learned that Rob (the chief helper at the mission)
was in distress and that the missionary wanted him examined...
He was impressed by the obvious indications that Rob was
seriously ill and extremely weak. From the missionary
he learned that he had had a bone pointed at him by Nebo
(a local medicine man) and was convinced that he must
die. Thereupon Dr. Lambert and the missionary went for
Nebo, threatened him sharply that his supply of food would
be shut off if anything should happen to Rob. At once
Nebo agreed to go with them. He leaned over Rob's bed
and told the sick man that it was all a mistake, a mere
joke-indeed, that the bone had not been pointed at him
at all... That evening Rob was back at work, quite happy
again, and in full possession of his physical strength.
(page 183)
"Dr. Lambert (also) wrote to me concerning
the experience of Dr. P.S. Clarke. One day a Kanaka (a
local native resident) came to his hospital and told him
he would die in a few days because a spell had been put
upon him and nothing could be done to counteract it. The
man had been known by Dr. Clarke for some time. He was
given a very thorough examination, including an examination
of the stool and of the urine. All was found normal, but
as he lay in bed he gradually grew weaker. Dr. Clarke
called upon the foreman to come to the hospital to give
the man assurance, but on reaching the foot of the bed,
the foreman leaned over, saying, "Yes, doctor, he will
soon die". The next day at 11 o'clock in the morning he
ceased to live. A postmortem examination revealed nothing
that could in any way account for the fatal outcome."
(pages 183-184)
"Dr. J.B. Cleland, professor of Pathology
at the University of Adelaide, has written to me that
he has no doubt that from time to time the natives of
the Australian bush do die as a result of a bone being
pointed at them, and that such death may not be associated
with any of the ordinary lethal injuries... In his letter
to me he wrote, 'Poisoning is, I think, entirely ruled
out in such cases.' " (page 184).
Cannon also provides the following eloquent
description of how the reaction of the hexed person's community
and family combine to multiply the force of the words of
the medicine man. These words emanate from the early part
of this century into ours with prophetic power. The description
is chilling in its similarity to what often happens in people
diagnosed HIV positive.
"Now to return to the observations of W.L.
Warner regarding the aborigines of northern Australia.
There are two definite movements of the social group,
he declares, in the process by which black magic becomes
effective on the victim of sorcery. In the first movement,
the community contracts; all people who stand in kinship
relation with him withdraw their sustaining support. This
means everyone he knows -all his fellows- completely change
their attitudes towards him and place him in a new category...
The organization of his social group has collapsed, and,
no longer a member of a group, he is alone and isolated.
During the death illness which ensues, the group acts
with all the outreachings and complexities of its organization
and with countless stimuli to suggest death positively
to the victim, who is in a highly suggestible state. In
addition to the social pressure upon him, the victim,
himself... through the multiple suggestions which he receives,
cooperates in the withdrawal from life. He becomes what
the attitude of his fellow tribesmen wills him to be.
Thus he assists in committing a kind of suicide.
"Before the death takes place, the second
movement of the community occurs which is to return to
the victim in order to subject him to the fateful ritual
of mourning... The effect of the double movement in the
society, first away from the victim and then back, with
all the compulsive force of one of its most powerful rituals,
is obviously drastic. Warner (1941) writes:
"'An analogous situation in our society
is hard to imagine. If all a man's near kin, his father,
mother, brothers, sisters, children, business associates,
friends, and all other members of the society should suddenly
withdraw..., refusing to take any other attitude but one
of taboo and looking at the man as already dead, and then
after some little time perform over him (death rituals),
the enormous suggestive power of this two-fold movement
of the community can be somewhat understood by ourselves.'"
(page 185)
Perhaps an analogous situation is not so hard
to imagine occurring in our society, after all, given the
similarities between what is described above and what is
experienced by someone diagnosed "HIV positive". A study
of the effects of curses and hexes on family dynamics was
published in the American Journal of Psychiatry in November,
1970 (Raybin 1970). The author provided detailed case histories
of four families in which a member of the family had been
"cursed" or "hexed", focussing on the emotional and psychological
affects of these curses on the individuals. These hexes
often resulted in severe emotional despair and repeated
suicide attempts, as well as disruption of social ties.
He states in his conclusion that:
"The four clinical vignettes have illustrated
family mythology in general, and curses and prophecies
in particular, whether they be direct or implied. These
communications can effectively disrupt or devastate a
family, or they can serve to maintain a precariously balanced
equilibrium... The dynamic issues involved in myths and
curses vary with the individual family." (p. 620)
A more recent article by Meador appeared in
the Sothern Medical Journal in 1992. Dr. Meador gave case
histories of two people who received death-hexes from medicine
men. The two men had very different outcomes, apparently
due to the ability of one of their physicians to alter the
belief structure of the patient. One of the most astounding
elements of his case histories is that one of the men was
a Haitian given a death hex by a medicine man, while the
other was an American given a death hex unintentionally
because of a false positive liver scan which appeared to
indicate widespread metastatic cancer, when in actuality
there was none. The "medicine man" who placed this second
hex was Dr. Meador, himself, the author of the article.
"The first patient, a poorly educated man
near death after a hex pronounced by a local voodoo priest,
rapidly recovered after ingenious words and actions by
his family physician. The second, who had a diagnosis
of metastatic carcinoma of the esophagus, died believing
he was dying of widespread cancer, as did his family and
his physicians. At autopsy, only a 2 cm nodule of cancer
in his liver was found." (page 244)
The actions of the physician whose patient
made a dramatic recovery were truly remarkable, and involved
something more akin to theatre, rather than medical treatment:
"The patient had been ill for many weeks
and had lost a large amount of weight. He looked wasted
and near death. Tuberculosis or widespread cancer was
considered the likely diagnosis. The patient refused to
eat and continued a downward course despite a feeding
tube.
"He soon reached a stage of near stupor,
coming in and out of consciosness, and was barely able
to talk. Only then did his wife ask to speak with Dr.
Daugherty privately... The wife told him that about 4
months before hospitalization, the patient had an argument
with a local voodoo priest. The priest summoned him to
a local cemetery late one night, and... annonced that
he had "voodooed" him, that he would die in the very near
future.
"Dr. Daugherty spent many hours that evening
pondering... what he could do to save this moribund man.
The next morning he gathered 10 or more of the patient's
kin at the bedside; they were trembling and frightened
to even be associated with this doomed man. Dr. Daugherty
announced in his most authoritative voice that he now
knew exactly what was wrong. He told them of a harrowing
encounter at midnight the night before in the local cemetery
where he had lured the voodoo priest. Dr. Daugherty reported
that he had... choked the priest against a tree nearly
to death until the priest described exactly what he had
done. Dr. Daugherty announced to the astonished patient
and family "That voodoo priest made some lizard eggs climb
down into your stomach and they hatched out some small
lizards. All but one of them died leaving a large one
which is eating up all of your food and the lining of
your body. I will now get that lizard out of your sustem
and cure you of this horrible curse." With that he summoned
the nurse, who had, on prearrangement, filled a large
syringe with apomorphine (a powerful emetic for inducing
vomiting). With great ceremony, Dr. Daugherty squirted
the smallest amount of clear liquid into the air and lunged
towards the patient, who by now had gathered enough strength
to be sitting up wide-eyed in the bed. Although he pressed
himself against the headboard trying to withdraw from
the injection, Dr. Daugherty delivered the entire dose
of apomorphine. With that he wheeled about, said nothing,
and dramatically left the ward.
"Within a few moments the patient began
to vomit. When Dr. Daugherty arrived at the bedside the
patient was retching, one wave of spasms after another.
His head was buried in a metal basin. After several minutes
of continued vomiting and at a point judged to be near
its end, Dr. Daugherty pulled from his black bag, carefully
and secretively, a live green lizard. At the height of
the next wave of retching, he slid the lizard into the
basin. He called out in a loud voice, "Look what has come
out of you. You are now cured. the voodoo curse is lifted."...
"The patient's eyes widened and his mouth
fell open. He looked dazed. he then drifted into a deep
sleep within a minute or two, saying nothing. The sleep
lasted until the next morning. When he awoke, he was ravenous
for food. Within a week the patient was discharged home,
and soon regained his weight and strength. he lived another
10, or more, years, and died of an apparent heart attack.
No one else in the family was affected...
"I reflected on this case for many years.
I could make no sense of it until I read Walter Cannon's
classic paper, "Voodoo Death"." (pages 244-245)
Dr. Meador goes on to describe Cannon's paper,
and summarizes the aspects necessary to cause a voodoo hex
to succeed, including deep belief in the hex by the victim,
the family, and the community, as well as initial social
isolation followed by expectant preparations for death.
Before describing the American man who died after a false
liver scan, he asks the following question:
"Even if such a strongly held belief could
cause death, most Westerners think of hexing as a bizarre
superstitious practice limited to ignorant people. It
has no pertinence to modern Western society... does it?"
(page 245).
This patient died with only a small patch
of pneumonia and a small nodule of cancer in his liver.
His wasting syndrome was unresponsive to antibiotics,
and he died "thinking that he was dying of cancer, a belief
shared by his wife, her family, his surgeons, and me,
his internist" (page 246).
Meador asks yet another question of the reader:
"If the first patient was cured of a hex,
did the second die of a hex?".
Some of the descriptions of the first patient's
illness bear remarkable resemblance to AIDS. The patient
"had lost a large amount of weight". He looked "wasted and
near death". Tuberculosis or widespread cancer was considered
the likely diagnosis, and tuberculosis is one of the most
common "AIDS-defining illnesses". Several types of cancer
are also considered AIDS-defining. The patient "continued
a downward course depsite a feeding tube", showing that
malnutrition alone did not explain his demise. He also suffered
from severe dementia.
Kaada (1989) presents a review of research
into the opposite of the placebo effect, dubbed the "nocebo"
effect. This is the negative effect on health associated
with harmful beliefs and psychological stressors. He comments
on voodoo hexing and the ability to resist its power as
follows:
"In its most extreme, nocebo-stimuli may
cause death, as in voodoo-death in primitive societies,
an example of the fear-paralysis reflex. Whether the outcome
is positive or negative is determined, inter alia, by
the subject's possibility of coping with the situation."
This could explain why some people live for
years after an HIV diagnosis with no ill health, while others
succomb in much shorter time.
Also quoted in the introduction of this paper
was a brief quote fr
