A bright future for PNI

Psychologists' work in the field of psychoneuroimmunology is expanding the understanding of how psychosocial factors can protect or damage our health.

By TORI DeANGELIS

June 2002, Vol 33, No. 6 

Psychologists are lead players in a booming field that only 15 years ago was considered on the fringe of science: psychoneuroimmunology, or PNI, the examination of the relationship between stress, the immune system and health outcomes.

"The sheer weight of the studies in PNI--both animal and human--has really been very convincing," says Janice Kiecolt-Glaser, PhD, of The Ohio State University, who along with her husband Ronald Glaser, PhD, is one of the field's pioneers. "There's much more acceptance among basic scientists and clinicians that the links between stress, the immune system and disease really do mean something."

PNI researchers began their studies in the 1960s making broad-brush associations between stress and immune functioning. Today's investigators are increasingly sophisticated and specific in their work. They're examining how psychosocial factors such as optimism and social support moderate stress responses; they're mapping the biological and cellular mechanisms by which stress affects the immune system; and they're testing new theories, such as the idea that the immune system acts as a "sixth sense" that gives the brain valuable information about a person's health status.

And the field is becoming truly interdisciplinary, as basic scientists join forces with more socially oriented researchers.

"PNI is no longer this little area off by itself," comments University of California, Los Angeles (UCLA) researcher Shelley E. Taylor, PhD, who is widely known for her optimism research and a new theory of the female stress response. "It's become a big area, and lots of people are working in the field who at one time in their careers might never have gone near it."

While researchers still have further to go to show definitive links between PNI variables and disease and to devise targeted interventions based on these findings (see articles on the following pages), they have turned up promising discoveries on the mind-body connection and its potential to fight AIDS, cancer and the common cold. Below are some of the field's recent findings.

A 'bi-directional' model

One of the newest PNI theories proposes a flow of information that hasn't been posited before: a data link from the immune system to the brain rather than the other way around, says Steven Maier, PhD, director of the Center for Neuroscience at the University of Colorado at Boulder.

"It says that things that go on in the body can have potent effects on the brain's activity," he explains.

According to the theory, the immune system is itself a messenger that alerts the brain to infection or injury by releasing proteins called proinflammatory cytokines. These cytokines, research is finding, travel to the central nervous system and brain to communicate information about the body's distress. In turn, the brain releases its own cytokines that signal the central nervous system to initiate a cascade of responses such as fever and listlessness that, theorists believe, help the body adapt by reducing energy output. (PNI researchers are, in fact, increasingly interested in cytokine activity because it represents an immune response that can go awry.)

The work also raises intriguing questions about the origins of psychological and cognitive states such as depression and memory dysfunction. Researchers posit that these states may have arisen as part of the sickness response to conserve energy during times of infection. Maier and others are investigating that idea through animal studies.

So far, they have found that mice exposed to tail shocks show the same types of plasma-level changes that infection produces, and that these changes fail to occur if cytokine activity is blocked in the brain. In addition, they've shown that brain-based cytokines interfere with the consolidation of memory and induce depressed behaviors, providing further evidence that infection and stress responses are linked, Maier notes.

A new theory on stress and its impact

PNI researcher Margaret Kemeny, PhD, of the University of California, San Francisco (UCSF), and colleagues at UCLA are testing a theoretical model that's challenging Hans Selye's well-known general theory of stress.

Selye's theory maintains that no matter what the stressor, people respond with a similar set of hormonal and immune changes. The California team posits instead that there are two stress reactions: the classic "fight-or-flight" response and a withdrawing reaction where a person pulls back to conserve energy, says Kemeny, who directs UCSF's health psychology and behavioral neuroscience program. These reactions have been noted in animals and Kemeny's team is now extending them to humans.

She and colleagues have been examining a cognitive angle to this theory as well. They're finding that people respond to the same stressful event in different physiological ways depending on how they appraise it. Take the example of a loved one's death. Depending on how they perceive the loss--as sad but normative or as a major threat--they will either withdraw or become agitated, explains Kemeny. "The body is responding to what's going on in the brain, not to what's going on in the environment," she explains.

The researchers also have been investigating which types of cognitive appraisals most affect people's health. In a study conducted on HIV-positive men before the advent of protease inhibitors, Geoffrey M. Reed, PhD, and colleagues including Kemeny and UCLA's Taylor found that asymptomatic HIV-positive men who held negative though realistic beliefs about their disease progression, and who had lost a close friend or partner to AIDS within the last year, developed AIDS symptoms more quickly than HIV-positive men with a more optimistic outlook on their prognosis or men who had not been bereaved.

In addition, Kemeny is finding that negative self-appraisal--blaming one's self for negative events--is linked to poorer health outcomes, such as faster rates of CD4 T-cell decline in patients with HIV. These findings are discussed in a summary article by Taylor, Kemeny, Reed and colleagues in the American Psychologist (Vol. 55, No. 1).

The findings are pioneering in two ways, notes Reed, now the APA Practice Directorate's assistant executive director for professional development. For one, they imply that cognition itself may play a role in health outcomes, challenging the traditional view that emotions mediate between psychological factors and immunity. "We're suggesting that there may be something about cognitive processes that has a direct effect on the immune system," he says.

They also call into question a view commonly touted by mental health practitioners: that a realistic acceptance of one's situation is synonymous with mental health.

"Our data show that people who have a life-threatening illness can say these unrealistic, positive things about their future and still behaviorally do things to take care of their health," Reed says. "Being overly optimistic may actually be healthy." Future research could test some of these findings in interventions, he suggests.

Personality variables in HIV progression

UCLA's Steve Cole, PhD, is using the same data set as the UCSF and UCLA researchers to study personality factors in disease progression. In particular, he's examining why some gay men may hide their sexual orientation in the tolerant city of Los Angeles, and why those same men who have HIV might become ill more quickly than HIV-positive peers who are out of the closet.

Studies by Cole, Kemeny, Taylor and others show that the men who stay closeted share characteristics of the nervous system that render them especially sensitive to social rejection. And the physiological correlates of this introverted personality type--in particular a greater tendency to go into "fight-or-flight" mode when facing stress--may make them more vulnerable to attack by HIV, Cole contends.

Cole has supported his theories through studies on the men's stress hormones, immune-cell functioning and psychological characteristics. He's also thinking about interventions that might help reduce these men's automatic stress responses. Scientists know, for example, that enhancing brain levels of serotonin can mitigate people's tendencies toward shyness. So, one intervention, Cole speculates, is medications that increase serotonin activity; another is stress-reducing behavioral interventions like meditation or biofeedback.

Tend and befriend

In still another theory that challenges old views of stress, UCLA's Taylor has proposed a model of the female stress response that she calls "tend and befriend," in contrast to the "fight-or-flight" model. Taylor has found that in response to stress, females tend to engage in nurturing activities that protect themselves and their offspring. She believes these patterns have hormonal underpinnings, and she's particularly interested in the role of a pituitary hormone, oxytocin. While the hormone is found both in males and females, it's strongly linked to maternal behavior in females, and may foster the tend-and-befriend pattern. For example, oxytocin's calming effects are enhanced by estrogen, but antagonized by androgen, she notes. Taylor first delineated her theory in Psychological Review (Vol. 107, No. 3) that's since been updated in a book by Taylor released this March, "The Tending Response" (Holt).

Now she is exploring the links between estrogen and oxytocin by looking at postmenopausal women on estrogen-replacement therapy compared with those who are not. Preliminary evidence finds that those on the treatment are better able to manage stress, in keeping with the theory's contention that estrogen augments the effects of oxytocin.

Stress and marriage

Another recent finding by PNI researchers is exploring the impact of marriage on health.

A study in press at APA's Journal of Clinical and Consulting Psychology by The Ohio State University's Kiecolt-Glaser, Cynthia Bane, PhD, Ronald Glaser, PhD, and William B. Malarkey, MD, reports on a longitudinal study in which the team took blood samples of married couples to test stress factors at the beginning of the study, and then examined them in relation to marital status 10 years later. They found that couples who divorced at 10 years had already displayed a 34 percent higher rate of the stress hormone norephinerphine at the beginning of the study than couples who stayed married.

In addition, stress hormones were higher in the conflicted couples at the beginning of the study even when they weren't arguing, suggesting a chronic pattern of stress in these marriages that started early, the study finds.

"These findings show us in a microcosm how close personal relationships can get translated into health outcomes," comments Kiecolt-Glaser. "They show that marital quality is as good a predictor of subsequent health as any of the usual major prognostic indicators."

Susceptibility to colds

Sheldon Cohen, PhD, of Carnegie Mellon University, was the first to show a link between stress and upper-respiratory infections. Now he's plying that research in two new directions, one physiological and the other social.

In an in-press study in Psychosomatic Medicine, Cohen and colleagues report that people in the lab who displayed high levels of the stress-related hormone cortisol in response to a task that provoked a defensive reaction were more likely to get sick than those who didn't react as strongly. The finding supports the theory of a "reactive" personality style that seems to be linked to health problems, including heart disease, he notes.

Another study in press in Health Psychology by Natalie Hamrick, PhD, of Carnegie Mellon, Cohen and colleagues looks at how real-world variables play into Cohen's earlier lab findings that social support provides greater immune protection from colds. The new study suggests that a well-rounded social life may bear a cost, too: Well-connected people who reported a lot of stress became sick more often than anyone else, the study finds. In keeping with Cohen's earlier results, however, nonstressed people with diverse networks got sick less often than their less-connected counterparts who didn't report stress. The findings support the hypothesis that people with more diverse social networks may be more vulnerable to illness than others when under stress because they're exposed to a wider range of pathogens.

"These are important findings, because in the 1960s, everyone was studying what was bad about social relationships, and in the 1970s, they were saying that social relationship are always good for you," Cohen says. "Our results show that both are true."

Language, connection and health

At the University of Texas at Austin, James Pennebaker, PhD, is conducting a new series of studies showing that the way people use language--in particular pronouns like "we," "I" and "you"--is highly related both to personality styles and to health variables such as depression, suicide-proneness and health-center visits.

"I never in a million years thought I'd be talking to anybody about pronouns," he chuckles. "But these pronouns are very important because they give us a sense of how socially connected people are, the degree to which they're self- or other-focused."

A study by Sherlock Campbell of the University of Texas at Austin and Pennebaker, in press at Psychological Science, demonstrates that people who are more flexible in their use of pronouns when writing expressively about traumatic events in their lives show greater health improvements, as measured by number of physician visits, than those who consistently used the same patterns of pronouns.

Likewise, a study by Shannon Wiltsey Stirman of the University of Pennsylvania and Pennebaker that's reported in Psychosomatic Medicine (Vol. 63, No. 4), shows that famous suicidal poets made far few references to other people late in their careers than nonsuicidal poets.

Stress and older adults

PNI researcher Susan Lutgendorf, PhD, has been conducting a number of studies on how healthy older adults cope with moderate life stresses. In one recent study, reported in Psychology & Aging (Vol. 14, No. 4), she looked at how well elderly people's immune systems functioned a month before they were to move from their homes of many years to group-living facilities.

She found that the event did have a short-term effect: Movers showed about a 30 percent decline in natural killer-cell activity during this stressful time compared to nonmoving controls.

In addition, Lutgendorf has found that older women with severe life stresses, such as caring for a partner with Alzheimer's disease, show greater disregulation of interleukin-6, a type of proinflammatory cytokine implicated in many age-related diseases. As compared with older women with moderate or minimal life stress, this finding suggests there may be a "dose-response" effect of life stress to immune decline among the elderly above and beyond that of normal aging. This work was reported in theJournal of Gerontology: Medical Sciences (Vol. 54A, No. 9).

Lutgendorf is also interested in what may buffer stress among these older adults. She used a measure called "sense of coherence," which assesses people's ability to find meaning in their lives and in stressful events. She found that older people with the highest sense of coherence had natural killer-cell levels in the same range as controls a month before they moved. By contrast, movers with a low sense of coherence showed the poorest immune response. The findings, also in the Psychology & Aging article, suggest people could benefit from interventions that help them perceive meaning in stressful activities, she says.

Intervention directions

As their research continues, PNI researchers are also exploring ways to apply their findings.

"Our challenge is to take basic science and bring it into the clinic in a logical and straightforward way and maybe make people's lives a lot less miserable," says Christopher Coe, PhD, professor of psychology at the University of Michigan and immediate past-president of the Psychoneuroimmnology Research Society. "A lot of PNI is basic science, but in the next few years we'll see more direct applications of it," he predicts.

Researchers have already begun to identify which intervention characteristics may bolster the immune response. For instance, a recent meta-analysis of 85 psychological interventions found that more successful interventions included classical conditioning procedures drawn from animal models, hypnosis and interventions such as those advocated by Pennebaker that encourage people to write about distressing experiences. The study, by Gregory Miller, PhD, of Washington University and Cohen of Carnegie Mellon, is reported in Health Psychology (Vol. 20, No. 1).

To the authors' surprise, however, stress-management interventions--usually group-therapy sessions that teach patients about their illness and how to manage their stress--showed weaker effects than other interventions examined in the meta-analysis, Miller says. Two exceptions are a series of studies on HIV infection by Michael Antoni, PhD, and Neil Schneiderman, PhD, of the University of Miami, and a study of melanoma patients by Fawzy Fawzy, MD, and Kemeny, both of UCLA. Both trials showed positive changes in immune responses--and in Fawzy's study, longevity--following the interventions, perhaps because the authors designed them for specific stages in the patients' illnesses, Miller speculates.

APA's Reed emphasizes, however, that stress-management interventions can show health benefits besides immune changes. A recent study by Duke University psychologist James Blumenthal, PhD, underscores the point: Male heart patients who participated in a stress-management intervention had fewer cardiac events over a five-year follow up than those in an exercise or a standard-care intervention (see the March Monitor).

"While stress-management interventions may not be associated as strongly with immunological changes as other kinds of interventions, it doesn't mean those interventions wouldn't be effective in other ways for other populations," Reed says.

Miller notes that the main strength of his and Cohen's meta-analysis lies in suggesting specific intervention characteristics worthy of future examination.

"Naively, we all expected in the beginning that any intervention we threw at people would influence the immune system," he says. "It's turning out to be more subtle than that, but we seem to be finding the way."

Tori DeAngelis is a writer in Syracuse, N.Y.

How do mind-body interventions affect breast cancer?

By TORI DeANGELIS

June 2002, Vol 33, No. 6 

Print version: page 51

Some of the greatest hopes in the field of psychoneuroimmunology have been in breast cancer treatment. The recent replication of a key study dimmed some of those hopes when it found that a group therapy intervention made no difference in the survival rates of women with metastatic breast cancer compared to controls, as first found in 1989 by Stanford University's David Spiegel, MD.

But the news isn't all discouraging: The replication study did find that women who engaged in group therapy experienced quality-of-life benefits, including reduced pain and improved psychological symptoms, especially among women who were distressed to begin with.

"We were able to confirm clear evidence of psychological benefits in terms of mood and pain control, and those benefits were greatest in women who had psychological distress or poorly controlled pain at the time they entered the study," says Pamela Goodwin, MD, a medical oncologist at the University of Toronto's Mount Sinai Hospital who led the team that sought to replicate Spiegel's findings.

Goodwin's study is not, of course, the last word, say psychologists and others who are continuing to explore mind-body links in cancer.

Psychologists also emphasize that the medical community should not assume from one study that group therapy doesn't help prolong life and, moreover, should look beyond length of life and consider therapy's contributions to quality of life.

"It would be really unfortunate if the survival test is the only one people use when judging the value of these groups," says Geoffrey M. Reed, PhD, the APA Practice Directorate's assistant executive director for professional development. "While Goodwin very clearly articulates that psychotherapy groups have benefits other than survival, we do have some concern that her findings will be interpreted by health systems or hospitals as suggesting that psychotherapy is of negligible value for breast cancer patients."

The Spiegel and Goodwin studies

The study by Spiegel and colleagues was published in the Oct. 14, 1989, issue of The Lancet (Vol. 2, No. 8668). It found that women with metastatic breast cancer who received a year of intensive supportive-expressive group therapy lived 18 months longer on average from study entry than controls. The findings raised the hopes of many that mind-body interventions could make a significant difference in the health outcomes of very ill patients.

But the results also have been criticized for being potentially misleading and building false hope among patients. Goodwin's study, published in the Dec. 13, 2001, issue of the New England Journal of Medicine (Vol. 345, No. 12), studied 158 women with metastatic breast cancer who received the type of therapy Spiegel administered in his study, compared with 77 controls who didn't get the treatment. Although the Goodwin study found quality-of-life benefits, "to our disappointment, we were not able to confirm a survival benefit; there wasn't even a trend toward it," she says.

Spiegel notes that Goodwin's findings shouldn't stop people from using empirically validated treatments with obvious benefits for participants. "It's clear by now that this kind of psychotherapy helps cancer patients," Spiegel says. "How it helps them is a matter of legitimate disagreement. That it helps them is not."

And, says cancer-intervention researcher Barbara Andersen, PhD, of The Ohio State University, the Goodwin study "is just one study, just as Spiegel's was. One of two discrepant findings can't invalidate the other. What Goodwin's finding suggests is the need for additional tests."

Indeed, psychologists emphasize that replication efforts such as Goodwin's are crucial because aspects of the 1989 study had methodological problems. For one, Spiegel's original sample may have been unintentionally biased, notes James L. Spira, PhD, who heads the division of health psychology at the Naval Medical Center in San Diego. Psychologist Bernard Fox, PhD, for example, argued in Psycho-oncology (Vol. 7, No. 5) that Spiegel's control group died at a faster rate than the normal population of recurrent breast cancer patients, while the treatment group lived as long as would be expected in a general population of these patients. In addition, notes Spira, Goodwin's study has a large sample size of 235 women, compared with Spiegel's of 86.

Medical advances in breast cancer treatment may also help explain the discrepancy between Spiegel's and Goodwin's findings, speculates Gregory Miller, PhD, of Washington University. "Many breast cancer patients will survive because of these outstanding medical advances, so there isn't as much room for a psychological intervention to make a difference," Miller points out.

And, he adds, the culture of social support has changed dramatically since Spiegel's original study. "Breast cancer was much more stigmatized when David conducted his seminal study," Miller says. "His intervention provided an incredible outlet for women who didn't have anywhere else to go to discuss this very stigmatized condition. Today, however, people are finding their own sources of support and they don't necessarily need to go to a group to get it."

Psychologists and Spiegel himself concede that he took on a tall order by trying to show survival effects in such an ill population. "Obviously, metastatic cancer is a very powerful biological process," says APA's Reed. "In some ways, it was the 1989 finding by Spiegel and his colleagues that was surprising: that a psychological intervention could affect survival outcomes in this patient group."

Like other earlier studies in this area, Spiegel set out to look only at psychosocial variables. Only later did he conduct analyses of disease outcomes, notes Andersen. "It's only in the last five years that studies have been designed to look directly at survival outcomes," she says.

New intervention trends

Although research shows that group therapy can enhance patients' quality of life, the psychological community is concerned about how the new data will be used. Indeed, psychologists have seen the medical establishment ignore quality-of-life findings before.

"Twenty years of research documents that psychosocial interventions impact a wide range of quality-of-life variables, including ability to sleep, fatigue reduction, improved mood, increased vitality, pain reduction and more general functional capacities like one's ability to exercise," says Spira. "Unfortunately, this news has been known for a while and it won't make the front pages unless there's a physical-health outcome benefit."

Meanwhile, a trend emerging in cancer-intervention research is replacing the focus on survival rates: testing which interventions work best with what populations.

It's an important line of inquiry because research shows that shotgun approaches are spotty at best, observes Margaret Kemeny, PhD, director of the health psychology and behavioral neuroscience program at the University of California at San Francisco.

"What we tend to do now is to take these psychological techniques used in psychotherapy--like the supportive-expressive technique that David Spiegel uses, or cognitive-behavioral techniques--and use them in all contexts with all patients," Kemeny says. "What might be more valuable is to characterize the people we're putting in interventions, select people with a particular psychological state or vulnerability that might warrant some kind of intervention, then target the intervention to them."

Research is pointing to who some of these patients might be, adds Andersen, who is conducting a long-term psychological intervention study of 240 women with Stage-II and Stage-III breast cancer. Research in the area, she explains, is confounded by the fact that many people's stress levels plummet from time of diagnosis on, regardless of whether they've entered an intervention or not. "You have these big, whopping time effects, and oftentimes they wipe out the intervention effects," she notes.

Yet studies consistently find that if you split the sample of treated patients into groups that initially experienced high versus low distress, "lo and behold, there are all of these [positive] changes in the high-distressed groups," says Andersen, whose review of research on outcomes in cancer patients following psychological treatment will appear in this month's issue of the Journal of Consulting and Clinical Psychology (see sidebar, on previous page). Hence, she notes, clinical researchers may want to start thinking about targeting interventions toward these more distressed women.

A group-therapy treatment manual to be published this fall by APA, "Group Psychotherapy for Women with Breast Cancer: A Treatment Manual," by Spira and Reed, addresses some of these distinctions. For instance, the manual provides different protocols for working with first-occurrence and recurrent breast cancer patients, since research shows that these two groups benefit from different types of interventions.

A companion volume to the manual, "The Breast Cancer Notebook: The Healing Power of Reflection," likewise taps into recent research findings, in particular that writing about trauma can be good for your health. Written by Ava Stanton, a licensed clinical social worker in Santa Monica, Calif., and Reed, the book is designed to help women with breast cancer understand and take charge of their own experience.

Other promising avenues for intervention include studying the psychoneuroimmunology of cancer and testing interventions based on those findings (see A bright future for PNI) and examining the benefits of other forms of psychosocial and alternative therapies in addition to group therapy. Few studies, for example, look at the potential benefits of individual therapy for cancer patients or at alternative techniques such as acupuncture, meditation or yoga, says Spira.

As researchers examine which interventions are most helpful to breast cancer patients, there's a group of people they should keep in mind: the patients themselves, emphasizes Reed.

"We have to be careful about concluding a lack of benefit from any intervention without asking participants what the intervention meant to them," he says. "Typically, participants in these groups describe them as being terribly important in terms of finding meaning, connecting with others and expressing their deepest fears in a way that helps them feel they can control these feelings. These are important experiences, even if they're not well-reflected in standardized outcomes scales."

Tori DeAngelis is a writer in Syracuse, N.Y.

The World

“In times of change learners inherit the earth, while
the learned find themselves beautifully equipped to deal with a world
that no longer exists.“ by Eric Hoffer

Curing the Incurable

Hypnosis is the only known cure for the congenital problem of fishskin disease. There is no medical solution for this disease. So if hypnosis can lead to even a partial healing it must be a very powerful process. Many practitioners of hypnosis now believe that hypnosis allows a special access to bodily change processes that is not normally possible.

Let's look at the fishskin study. In a 1952 issue of the Lancet , the British medical journal, Dr. Mason described his treatment of a young patient who seemed at first to be a very bad case of warts (Mason, A. A. (August 23rd, 1952). About 90% of the patient's body (except his chest, neck and face) was covered with an unsightly, lumpy, raised growth. The skin felt as tough as a fingernail and tended to crack with normal movement, leading to the constant presence of oozing blood stained serum. As a result, there was very unpleasant smell around the young man. You can imagine how uncomfortable his life was, since normal movement was severely limited because of the inflexibility of his tough skin. He didn't look very good either.

Mason was introduced to the patient when he was helping out with a skin graft operation that was not going very well. He thought he was looking at a case of warts and he knew that hypnosis could often be an effective treatment for warts. So he commented to the surgeon that hypnosis might be the thing to try. The surgeon gave him a funny look but said o.k., why don't you try it. At the first treatment session in the hospital ward, Mason asked the boy to relax, and then suggested that the left arm would clear and return to normal in a few days time. He touched the parts of young man's shoulder to show where this would happen. When he returned to see the patient again 5 days later, the thick horny skin had just flaked off. The pink flesh now visible looked normal.

With further treatment, eventually most of the skin became soft and normal again. The treatment effect was about what Mason had expected. However, when he showed the initial result to the surgeon, his jaw dropped and he told Mason to go off to the library to read up on the disease called Icthyosiform Erythrodermia of Brocq. This is a congenital disease. Patients with this problem lack oil-producing glands in the skin, so that instead of sloughing off from time to time, layers of skin build up one on top of the other, creating the symptoms that Mason had treated. The surgeon was so impressed with the hypnotic treatment he arranged for himself and Mason to give a talk about the case at the highly respected Royal Society.

Mason later pointed out that had he realised exactly what he had been dealing with, a congenital skin disease, he would never have tried hypnosis, because it seems so unlikely that the mind could cure a genetic physical problem for which medicine had no solution. In a later interview he said it was as likely that hypnosis could do anything for this condition as that it could cure a club foot.

There have been several other cases described in the Lancet since Mason's original study. Not all have had the same degree of success, but where healing was more limited there was often evidence of a psychological barrier to explain the lack of effect. Even so, since there is no medical treatment for the condition, all of these studies stand as strong testimony to the potential power of psychological factors in bodily healing.

One of the really fascinating aspects of these cases is that the patients did not have to understand how the healing effect could be achieved for healing to occur. Mason's case was a young man of 16 years, who had never heard of fishskin disease. Even more fascinating, Mason didn't know what the disease was either at the beginning. He thought he was treating the young man for a terrible case of warts.

In my opinion the most likely factor leading to improvement in such cases is the use of the imagination. The patient's imagining of body healing. But whatever the explanation, it is pretty clear that if healing change is possible in cases of congenital health problems, there would seem to be almost no limit on what might be achieved.

While treatment for fishskin disease is one of the most spectacular successes reported for hypnosis, there seem to be many other possibilities for self healing and change opened up through the use of hypnosis. For instance, reducing the damage from serious burns, removal of warts, modification or elimination of allergy responses, breast enlargement, or the elimination of profound levels of acute and chronic pain.