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Volume 29, Number 2 Summer, 2001

Highlights of the Annual Meeting in Raleigh


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Summer 20012 Biofeedback

This Summer 2001 issue of theBiofeedback Newsmagazineincludes a richvariety of articles, hopefully something forevery reader! I am grateful to our authors,editors and reporters for making this issuepossible.

Seb Striefel opens the Professional Issuesdepartment by exploring new issues thatemerge when behavioral professionals workin the primary care clinic. John Perrydescribes practical progress in biofeedbacktelemedicine. A demonstration at AAPBsannual meeting in Raleigh showed thattelemedicine works now for severalbiofeedback applications.

Feature articles this issue includes anarticle by Jeffrey Leonards conveying avision of a partnership between behavioral

medicine and primary care. A team of sixauthors from Mexico, led by BenjaminDominguez Trejo, describes their fascinat-ing research project with survivors ofHurricane Pauline, using psychophysiolog-ical monitoring in assessing victims, andusing stress management education toreduce the traumatic effects of the disaster.

Jeffrey Bolek describes innovative ongoingwork at the Cleveland Clinics motor con-trol program using surface electromyogra-phy in pediatric rehabilitation.

Christopher Edwards and Wendy

Webster give us a glimpse of the person

behind the research, in their biographicalarticle on Robert Freedman. Dr. Freedmanhas pioneered in the investigation of physi-ological mechanisms in human thermoreg-ulation, with applications to Raynaudssyndrome and menopausal hot flashes.

John Perry also provides a personal tributeto William Farrall (1929-2000), founder ofFarrall Instruments. Bill Farrall was a cre-ative engineer who remained involved inthe evolving field of biological monitoringfrom the late 1960s into the 1990s. Hecontributed significantly to the fields ofsexual function research, therapy forpedophiles, and incontinence therapy,among many others. He will be missed!

Jeffrey Cram contributes a technicalnote, describing the need to calibrate the

Myoscan EMG sensors used on sever-al instrumentation systems. TheBiofeedback Newsmagazinenow welcomestechnical notes on any currently usedbiofeedback instrumentation and software.The objectives of technical notes are: 1) toassist practitioners in mastering the use ofspecific instruments or software, 2) toaddress technical problems such as artifactor calibration, or 3) to discuss problems inadapting a device to specific patient groupsor disorders.

David Wakely reviews an edited volume

on cancer patients and their families, with

articles focusing on disease course, copingstrategies, and psychological interventions.Colleen Shaffer provides a review of twobooks on menopause, and recommendsboth for client use. We welcome volunteersto review new books on biofeedback,applied psychophysiology and behavioralmedicine. We also welcome suggestions onbooks to be reviewed.

The Program Highlights section pro-vides summaries of presentations from the

AAPB 2001 Annual Meeting in RaleighDurham, North Carolina, and photoglimpses of the meeting.

Finally, the Association News and Eventssection carries information about manyexciting developments taking place within

AAPB this year. It is important for every

reader to learn about AAPBs newHomeStudy Program, as well as a new AAPBarrangement with the Digiscriptcompanyproviding online audio-visual access toabout twenty hours of AAPBs 2001 annu-al meeting. The President, ExecutiveDirector, President-Elect, and MembershipChair also have messages for the member-ship. Finally, dont miss the announcementof a new special fund-raising campaign toprovide additional student scholarships forfuture annual meetings.

FROM THEEDITOR

From the Editor:Donald Moss, PhD


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Summer 2001 3Biofeedback

Biofeedbackis published four times per year anddistributed by the Association for Applied Psycho-physiology and Biofeedback. Circulation 2,100.ISSN 1081-5937.

Editor: Donald Moss PhDAssociate Editor: Theodore J. LaVaque, PhDsEMG Section Editor: Randy Neblett, MAEEG Section Editor: Dale Walters, PhDReporter: Christoper L. Edwards, PhDReporter: John Perry, PhDManaging Editor: Michael P. Thompson

Copyright 2001 by AAPB

Editorial Statement

Items for inclusion in Biofeedbackshould be for-warded to the AAPB office. Material must be inpublishable form upon submission.Deadlines for receipt of material are as follows:

November 1 for Spring issue,

published April 15. March 15 for Summer issue,

published June 15. June 1 for Fall issue,

published September 15. September 1 for Winter issue,

published January 15.

Articles should be of general interest to theAAPB membership, informative and, where possi-ble, factually based. The editor reserves the right toaccept or reject any material and to make editorialand copy changes as deemed necessary.

Feature articles should not exceed 2,500 words;department articles, 700 words; and letters to theeditor, 250 words. Manuscripts should be submittedon disk, preferably Microsoft Word or WordPerfect,

for Macintosh or Windows, together with hard copyof the manuscript indicating any special text for-matting. Also submit a biosketch (30 words) andphoto of the author. All artwork accompanyingmanuscripts must be camera-ready.

AAPB is not responsible for the loss or return ofunsolicited articles.

Biofeedbackaccepts paid display and classifiedadvertising from individuals and organizations pro-viding products and services for those concernedwith the practice of applied psychophysiology andBiofeedback. Inquiries about advertising rates anddiscounts should be addressed to the ManagingEditor.

Changes of address, notification of materials notreceived, inquiries about membership and othermatters should be directed to the AAPB Office:

Association for AppliedPsychophysiology and Biofeedback10200 West 44th Ave., No. 304Wheat Ridge, CO 80033-2840Tel 303-422-8436Fax 303-422-8894E-mail: [email protected]: http://www.aapb.org

Donald Moss, PhD 2

Emerging Ethical Issues in Primary Care 4

Sebastian Striefel, PhDBiofeedback Telemedicine: Here, Now, and Ready to Use 6

John D. Perry, PhD.

Behavioral Medicine and Primary Care: 7Greater Collaboration in the New Millenium

Jeffrey T. Leonards, PhDPsychophysiological Monitoring, Natural Disasters, 12and Post-Traumatic Stress

Benjamin Dominguez Trejo, PhD, Guadalupe Esqueda Mascorra, BA,Consuelo Hernndez Troncoso, BA, Luz Maria Gonzalez Salazar, MA,Yolanda Olvera Lopez, MA, Ricardo Aron Mrquez Rangel, BA

Surface Electromyography in Pediatric Rehabilitation: 18A Meld of Science and Art

Jeffrey E. Bolek, PhD.

The Oocket Engineer: A Conversation with Robert Freedman 2Christopher Edwards, PhD, and Wendy L. Webster, MA

William R. Farrall, PhD (1929-2000), A Personal Tribute 25John D. Perry

Technical Note: Procomp, Biograph and 27

Multi-Trace sEMG Calibration IssuesJeffrey R. Cram, PhD.

Cancer Patients and Their Families: A Book Review 28David Wakely, PhD.

The Journey through Menopause: A Review of Two Books 2Colleen A. Shaffer, LMSW-ACP

From the President 1AFrom the Executive Director 2A

From the President-Elect 3AThe AAPB Home Study Program 6ADigiscript Means New Online Access to the AAPB Annual Meeting 5AReport on Annual Meeting in Raleigh 8A

About the Authors, Winter Issue 2001 31

FROM THE EDITOR

PROFESSIONAL ISSUES

FEATURE ARTICLES

PROFILES IN PSYCHOPHYSIOLOGY

AAPB NEWS AND EVENTS

TECHNICAL NOTE

BOOK REVIEWS

ABOUT THE AUTHORS: PROFILES OF CONTRIBUTORS

Biofeedback

Volume 29, No 2

Summer, 2001


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Abstract: The primary care service arenaoffers many opportunities for the biofeedback

practitioner who is informed and competent.He or she should be aware of, and able to dealwith, the existing and emerging ethical and

practical issues related to services within pri-mary health care. Areas of interest include

issues of competence, published support forinterventions used, confidentiality, advocacyand support, and integrated treatment.

IntroductionKiesler (2000) pointed out that behav-

ioral health programs (i.e., mental healthand substance abuse treatment) have notbeen integrated with medical health care for88% of managed care populations.Generally behavioral health programs(which would generally include biofeedback

and other applied psychophysiology) havebeen covered by separate contracts calledcarve-outs. He then argues that severalstudies show that dollars could be saved byintegrating behavioral health programs intogeneral health care creating carve-ins.Doing so will be more efficient becausethere would be only one entry point intothe whole health care system and patients

would access whatever services they needfrom multidisciplinary teams of cooperatingprofessionals. He predicts a rapid shift tocarve-ins, which has many implications

for biofeedback practitioners. The implica-tions include issues of competence in addi-tional areas, published support for theinterventions used, confidentiality, advocacyand support, and treatment integration.

CompetenceMost non medical practitioners have

been inadequately trained to function in

primary health care settings where theemphasis is on collaborative care models,cost-effectiveness, solution-focused andtime-limited activities, and outpatient serv-ices (Twilling, Sockell, & Sommers, 2000).Biofeedback practitioners need to be pre-pared to work collaboratively with physi-

cians to provide biofeedback and otherapplied psychophysiological services for cer-tain aspects of both acute and chronic dis-eases. Being located in the same officecomplex as the primary care physician is anadvantage in that it provides opportunities:to become personally acquainted withphysicians; to educate them about the skillsof a biofeedback practitioner; to be easilyaccessible for an immediate referral, assess-ment, treatment, or consultation; to learn

what the other professionals in the primarycare practice do, and the constraints of time

that they regularly encounter; and toincrease efficiency and therefore cost-effec-tiveness. Biofeedback should be attractive toboth primary care physicians and managedcare companies because it is solution-focused, objective data is readily availabledemonstrating the outcomes achieved, mostapplications are time-limited, and the costof health care may well be reduced(Twilling et al, 2000). All of these are desir-able goals. There is still a strong need foreducating primary care physicians andthird-party payors about the utility ofbiofeedback and other applied psychophysi-ological interventions.

The Association for AppliedPsychophysiology and Biofeedback (AAPB)has for the last several years been providing

workshops on biofeedback in primary caresettings in an effort to increase competence.Have you attended one of these workshops

yet? Perhaps you should, if you are going tosurvive as an ethical practitioner in the 21stCentury.

Missing IngredientsSome missing ingredients still exist. First,

there is a need for more review papers thatattest to the effectiveness and efficiency ofbiofeedback treatment. Vye, Leskela,Rodman, Olson and Mylan (2001) reportedthat there is also an increasing emphasis ordeveloping practice guidelines that encour-age service delivery that is consistent withthe existing treatment outcome literature. Apaper by McGrady, Andrasik, Davies,Striefel, Wickramasekera, Baskin, Penzien,and Tietjen (1999) on the treatment ofchronic headaches, published in PrimaryCarewhere physicians are likely to see it, isone example of a published review paper

that can be used by practitioners, con-sumers, third-party payors and other profes-sionals. Another series of reviews waspublished about five years ago in the jour-nal, Professional Psychology: Research andPractice,by members of AAPB on severaltopics. Copies of these papers and theirexact references are available from the

AAPBs publication catalog. The AAPBstarted to revise and update its White Paperson various biofeedback applications severalyears ago. To date, those papers have notbeen finished, and thus, are not readily

available for dissemination to the member-ship or other professionals. Such papers

would receive more visibility if published inthe journal ofApplied Psychophysiology andBiofeedbackor other appropriate journals.Such papers could serve to provide anothermissing ingredient, which is to educatephysicians and third-party payors on the

PROFESSIONALISSUES

Emerging Ethical Issues inPrimary CareSebastian Seb Striefel, PhD, Logan, Utah


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utility of biofeedback as a treatment com-ponent in the management of both acuteand chronic conditions. A survey of HealthMaintenance Organizations (HMOs) byChow (1997) reported that third-party pay-ors will pay for a service, such as biofeed-back, if enough of their clients ask for theservice. At the time of that survey, the

clients of only 21% of the HMOs wererequesting biofeedback services. More pub-lic education needs to be done to encourageclients to ask for such services.

It is unethical to fail to inform clientsabout the treatment of choice for their dis-order, and about risks and benefits associat-ed with that treatment, if an effectivetreatment of choice is available. Clientsshould also be informed about the majortreatment alternatives and their risks andbenefits. One dilemma faced by health careprofessionals, in general, is the lack of aconsensus on what the treatment or treat-ments of choice are for many of the condi-tions that they treat. As such, the mostcommon basis for recommending specificinterventions, e.g., biofeedback or medica-tions, is that there is some level of pub-lished support for use of the recommendedtreatment. Practitioners also rely on theirown past experience in terms of what treat-ments worked with clients with similar dis-orders. Practitioners need to have arationale for recommending a specific treat-

ment to a client. That rationale is strength-ened if it is based, at least partially, on thepublished literature.

For how many conditions is biofeedbackthe, or one of, the treatments of choice? For

what conditions that you treat is there pub-lished support? Those conditions that aretreated with biofeedback where there is lit-tle or no support would be considered non-validated; clients should be so informedduring the informed consent process.Clinical practice generally includes somenon-validated treatments because compe-

tent practitioners often see how a specifictreatment might well apply to conditions

where research support is, to date, still lack-ing. This is one of the practical realities ofclinical practice and one of the factors thatidentifies areas where research is needed.Research also identifies new applicationsthat can be used clinically. Clients need to

be able to make informed choices. As suchthey need to be aware of the rationale andsupport that exist for a treatment recom-mended by a practitioner.

What literature can you cite, to supportbiofeedback or other applied psychophysio-logical intervention, as the treatment ofchoice, as a supported treatment, or as a

non-validated treatment but one where areasonable rationale exists? The increasingethical emphasis on the need to provide thetreatment of choice for clients, also under-scores the importance of having more pub-lished papers available to attest tobiofeedbacks effectiveness (Striefel, inpress). Without such papers, providing trueand meaningful informed consent can bedifficult because the published literature isoften confusing, and contradictory resultsare sometimes reported. These contradicto-ry results are often due to differing method-ologies, differing research subjectpopulations, and differing durations oftreatment. Freedman (1993) reviewed muchof the existing literature on Raynauds dis-ease, and concluded based on that review and on some of his own research thatskin temperature biofeedback plus training

while the hands are being cooled nowappears to be the most efficacious treat-ment for primary Raynauds Disease (p.263). It should be noted that the medica-tion of choice at that time was nifedipine, a

calcium slow-channel blocker whichdecreases vasoconstriction (Freedman,1993). Are Freedmans conclusions stillvalid today?

How many similar conclusions are youaware of that could be used by practitionersto support an argument that biofeedback isthe, or one of, the treatments of choicefortreating an acute or chronic condition? Ifyou are not aware of such published sup-port for the treatments that you provide,you must inform clients of such factors toobtain meaningful and ethical informed

consent? See Striefels (1998) presidentialaddress for more information on issuesrelated to the need for more research andeducation of the public and professionalsalike on the utility of biofeedback.

ConfidentialityAs more and more use is made of technol-

ogy, such as computers and the Internet, the

risk of confidentiality violations increases.For example, electronic billing has becomevery common. A practitioner has no controlover what happens to the information onceit leaves his or her office. Increasingly infor-mation supporting the billings is beingplaced into centralized data banks accessibleby people not involved in the clients treat-

ment. Are your clients being informed ofthe risks of information going into central-ized computer banks that can be accessed byothers? Raw (2001) reported that a hackerrecently downloaded the files of 5,000clients from the University of WashingtonMedical Center in Seattle. If you have clientrecords on a computer hooked to theInternet, do you have the appropriate securi-ty measures to prevent someone from accessing your clients files? You should have theappropriate security measures in place, e.g.,passwords, encrypting, etc.

Advocacy and SupportThe membership of AAPB is relatively

small (around 2000), and thus the financialand people resources available for promot-ing biofeedback and applied psychophysiol-ogy are limited. One mechanism that canmagnify advocacy and support efforts arethe joining of a guild (or labor union) as

was done recently by AAPB members inNew York and New Jersey (one contact isSusan Antelis at [email protected]).Raw (2001) reported that pediatricians,

clinical social workers, medical doctors,optometrists, acupuncturists, practitionersof Oriental medicine, pharmacists,optometrists, and biofeedback practitionershave joined the Office of ProfessionalEmployees International Union which isaffiliated with the American Federation ofLabor - Congress of IndustrialOrganizations (AFL -CIO). A group thesize of the AFL -CIO has an immense levelof bargaining power with third-party pay-ors. It will be important for biofeedbackpractitioners who belong to the guild toeducate other professionals and membersof the AFL -CIO as to the utility ofbiofeedback and to ask for such treatmentto be included in contracts with third-party payors.

AAPB can help in this effort by makingwritten information and expertise available

continued on Page 32


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I am pleased to report that the worldsfirst public demonstration of a remoteevaluation of private pelvic floor muscles

was a smashing, resounding success! Itworked flawlessly.

On Sunday morning, in front of a largeaudience at the AAPB Convention in

Raleigh, NC, I conducted a live evalua-tion of the pelvic muscles of a femalepatient who was sitting in front of hercomputer in San Jose, California on theother side of the continent.

Microsofts standard NetMeeting pro-gram provided live two-way audio andvideo (web-cam) connection, and theTeleVitals Internet software provided thebiofeedback program all at the sametime. The simultaneous video and audio

were extremely valuable for observingpatient postural shifts and other artifacts

that would appear in the EMG graphs. Fordemonstration purposes, we used a wire-less T-1 internet device at the conventionhotel, but the same set up has been used

with a 56K dial-up modem with goodresults.

The pelvic evaluation was conductedusing a new Glazer-Perry Protocoldesigned for evaluating pelvic muscle dys-functions, such as incontinence and vulvo-dynia. In addition, Naras Bhatdemonstrated a Cardiac biofeedback pro-gram and Yair Lurie demonstrated an EEGsession using the same subject. The entiredemonstration was LCD-projected on ascreen for everyone to see.

Some years ago a European Psychologistcommented on a virtue of my then-newinserted vaginal EMG sensor. Referring toour ability to assess this private part of thebody without personally invading the

patients privacy, he said, Its amazing. Youcan actually be there without beingthere. Now it appears that we can evenbe there from a very safe distance of 3,000miles.

The system still has some technologicalrough edges. For instance, there was

often a nearly 1-second delay in videoupdates, and the audio speakerphone, setup for benefit of the live audience, pro-duced an echo. But the biofeedback itselffunctioned flawlessly and the audience wasquite impressed. It should be obvious thatmodalities that do not require rapid refreshrates (such as EMG, temp, etc.) easily fit

within the available Internet bandwidth,whereas multi-site EEG is still somewhatconstrained.

The TeleVital system presently workswith biofeedback hardware from J&J,

Thought Technology, and East3, with moreto come. One of these devices is connectedto the patients computers serial or USBport, and everything else is handled by

JAVA-based software residing on theTeleVital website. All session data isprocessed and stored on the TeleVital site as

well, and is available at any time for reviewby the clinician.

In addition to clinician-to-patient con-nections, it is also possible to have a three-

way supervisor-clinician-patient set up fortherapist training or supervision purposes.The same set up can also be used by a sin-gle patient for at home practice. In thatcase, the therapist can later log in to reviewall the practice graphs and statistics.

In the current programs, the therapist (orthe supervisor) can control the gain andspeed (x and y axes) of the display on thefly, and the changes are immediately reflect-

ed on both patient and therapist screens.Although the technology is ready for

prime time, TeleVital is still finalizing theirbusiness plans. Current talk is a credit card,per session fee, or a prepaid phone cardmodel, and this issue should be resolved bythe time you read this.

This technology is especially useful forconditions like vulvodynia, where trainedand experienced clinicians are few and farbetween. It also allows collaboration withnational experts when a local clinician

wants help with a difficult case.Another application made-to-order for

internet biofeedback is in a university coun-seling service setting, where all studentdorm rooms are already connected by fiberoptic networks, and all students arerequired to have computers. The therapistcan drop in on each students scheduled

home practice session to observe and guidedaily training.

Reference:For a demonstration, visit

http://www.televital.com

PROFESSIONALISSUES

Biofeedback Telemedicine:Here Now and Ready to UseBy John D. Perry, PhD


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Abstract: There is abundant literaturedocumenting the relevance of psycho-behav-ioral factors in the pathogenesis and treatmentof medical conditions. Despite this, primarycare providers have tended to remain commit-ted to biomedical therapies, frequently over-looking behavioral interventions that in thelong term could enhance clinical efficacy withtheir patients. This article reviews mountingevidence to support working partnershipsbetween family and behavioral practitioners,especially as managed care encouragesefficiency, effectiveness, and accountability

from health care networks. Such interdiscipli-nary alliances are conceptualized as integrateddelivery systems that not only optimizetreatment outcomes, but also provide insurerswith a greater capacity to control costs.

IntroductionHistorically, psychotherapy and medicine

have operated as entirely separate disciplineswith divergent philosophies, segregatedwork settings, and little more than perfunc-tory communication between them. Such asplit is best understood by considering theanalytic and rather esoteric approach ofearly psychotherapy in contrast to the posi-tivistic and empirical approach of 20th cen-tury medicine. Though still resilient, thehistorical division between medicine andmental health began to lose its philosophi-cal justification as behaviorism attempted tolegitimate its theories through the sametype of scientific rigor as modern medicine(Kazdin, 1978). Research methodology andexperimental design have become corner-stones of graduate psychology programs andhave spawned an enormous literature on

neurobehavioral and psychophysiologicaldisorders having profound implications tothe field of medicine (e.g., Knesper, Riba,& Schwenk, 1997). The long held stigmaof the behavioral sciences being consideredirrelevant to primary care medicine hasgiven way to epidemiological, treatment,and prevention research in which behavioralinterventions have proven pivotal to med-ical outcome.

Behavioral medicine, as a health-care dis-cipline, was born out of this research andhas demonstrated its utility in offering animportant, yet largely missing, dimensionto primary care medicine. The time nowseems particularly ripe for alliances betweenthese two disciplines. Friedman, Sedler,Myers, and Benson (1997) point out that

integration of behavioral and biomedicalcare is not only compatible with currentchanges in health care, but that integrateddelivery would provide clinical and eco-nomic benefits to both patients and society.Though many in the mental health profes-sion have felt victimized by managed care,it could be that managed care itself which,in the effort of promoting one-stop shop-ping and brief, yet cost-effective treatment,may actually be leading to more opportuni-ties for behavioral practitioners in primarycare and even specialty medical clinics (Bray

& Rogers, 1998; Rabasca, 1998). Thismomentum suggests that the 21st century

will bring strong growth to the field ofbehavioral medicine (Feinstein & Brewer,1998) along with increased use of and needfor applied psychophysiological interven-tions.

Historical PerspectiveBehavioral medicine refers to the ipso

facto relationship between mental healthand medical well-being. Mostofsky andPiedmont (1985) point out that as a disci-

pline behavioral medicine is a very recentoutgrowth to the centuries-old approach tomedical care that has been referred to asallopathic medicine. Allopathy encompassesthe more familiar, westernized approach tomedicine with techniques and protocolscommonly identified as the medicalmodel. It is worth remembering, though,that allopathic medicine has a significantlydifferent orientation, philosophically andpragmatically, than what people wereexposed to in earlier times. Consider that inthe days before the terms physician and

medicine were even conceptualized, peo-ple in poor health might have consulted

with an esteemed religious figure or spiritu-alist for relief from their suffering. Suffice itto say that most patients today are inclinedto visit not their cleric, but a primary carephysician (PCP) for diagnosis and treat-ment. Generally, this approach will accountfor some degree of problem resolution,often considerable.

When a patient fails to respond as expected to medical intervention, however, thereis frequently concern about somatization,

hysteria, or even malingering. A patient willoften report that their doctor now believesthe problem to be all in my head. Insteadof a medical problem, the diagnostic formulation changes to a psychiatric disorder withthe assumption that the problem in ques-tion is no longer medically credible andtherefore a waste of valuable physician time

Behavioral Medicine and

Primary Care: GreaterCollaboration in the New MillenniumJeffrey T. Leonards, PhD, Farmington, Maine

FEATURE ARTICLE


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and resources. To believe that whatever failsto show up in the body must be an artifactof the mind suggests reasoning dating backto the writings of Rene Descartes. Whatthen became known as Cartesian dualismprovided the philosophical basis for whatmany now recognize as an arbitrary divisionbetween medicine and psychology.

Nevertheless, this split between body andmind, medicine and psychology, has typi-fied the 20th century medical model, andhas promoted a dichotomous rather thanintegrated delivery network which behav-ioral medicine endeavors to change.

Problems with theTraditional Practice ofPrimary Care

Some of the shortcomings endemic to thetraditional primary care model can be illus-

trated by considering the plight of a hypo-thetical patient with a long-standing paincondition. In an attempt to diagnose thecause of pain, most such patients, at leastinitially, receive considerable attention fromthe medical community, including referralsto neurology, physiatry, orthopedics, andpossibly even physical therapy. Let usassume that this is like so many casesinvolving soft tissue injuries where, despitea multitude of studies (EMG, MRI, CT,NCS, etc.), pathophysiology remains uncer-tain. Usually by that point, considerable

time has elapsed with secondary gains nowreinforcing both pain behaviors and disabil-ity. The PCP, feeling somewhat at a loss,may begin a lengthy process of outpatientpharmacotherapy as the primary, if notexclusive treatment. Only after considerabletime and expense with perhaps little, if any,improvement in patient symptomatologymight the physician be inclined to then per-ceive the problem no longer as medical, butpsychological (or in workers compensationcases, possibly even a case of malingering).

Whether or not such assumptions have

validity, referral to a behavioral specialist isoften a last resort intervention, sometimesoccurring years later, which may then com-municate to the patient that the doctor hasgiven up, that the patients symptoms (inthis case, pain) are no longer credible. Thepain has now shifted from being interpretedbiologically to being thought of as an emo-

tionally driven phenomenon. The irony isthat when a physician wittingly or unwit-tingly communicates this to their patient, itmay not only invalidate the symptom, butthe patient as well (Sullivan, Turner, &Romano, 1991). Paradoxically, when apatient comes to feel rejected by the physi-cian (often the perception when referred to

mental health), a self-fulfilling prophecy candevelop with the patient feeling alone, mis-understood, and ultimately depressed. Thisperception of emotional abandonment pro-motes a profound sense of loss, which tendsto seriously compromise the healing process

with the patient now feeling, perhaps forthe first time, genuine suffering (Fordyce,1989). In short, the psychiatric issue reifies,serving only to exacerbate the initial painproblem, though now with possible suicidaland/or other dysfunctional behaviors.

What is noteworthy about this vignette isthe dichotomous and rather fragmentedprocess involving a medically orchestrateddelivery of services followed, often muchlater, by a totally separate psychiatricprocess of its own. The idea that body andmind could be meaningfully connected isone that for practical purposes is oftenignored, particularly at an early stage ofassessment. This certainly does not imply,though, that the body/mind connection isunknown to the medical community. Infact, it has been widely reported in medical

journals that a significant percentage ofpatients wishing to be seen by their familyphysicians may actually be suffering fromsome unresolved emotional problem,despite initial presentations with ostensiblymedical symptomatology (Rosenberg &Hoffman-Wilde, 1989).

In a vast number of cases, however, theseproblems are not recognized as having psy-chogenic implications when they are firstseen (Hoeper, Nycz, & Regier 1980).Consider, for example, the type of condi-tions that commonly present to a family

practitioner. These might include colds,influenzas, insomnia, headaches, gastroin-testinal disorders, incontinence, high bloodpressure, chronic pain, infectious diseases,broken bones, or a variety of other possibili-ties, including malignancies. There is noquestion that the physician can diagnoseand treat many of these conditions without

referral to mental health. On the otherhand, behavioral medicine evaluations onthis same population frequently revealmasked affective disturbances, concomitantsof prolonged exposure to psychosocialstress. Moreover, highly stressed individualstend to exhibit pronounced autonomicarousal which often leads secondarilyto the

very medical problems that the PCP isinclined to treat as primary.

Although identification of psychogenicissues is critical to long term treatment effi-cacy, another problem is that physicians as agroup are often reluctant to address them(McLeod, Budd, & McClelland, 1997).This may be a function of time constraints,insufficient knowledge, or simply a lack ofinterest. One study, for example, reportedthat primary care doctors appear to missthe diagnosis of psychiatric disorders inindividual patients about 50% to 75% ofthe time (Coulehan, Zettler-Segal, Block,McClelland, & Schulberg, 1987). Anotherstudy pointed out that despite the recog-nition of serious alcohol problems by thephysicians, the problem is not addressedroutinely, even among patients that are rec-ognized as alcoholic (Cleary, Miller, Bush,

Warburg, Delbanco, & Aronson, 1988).

ResearchHaving evolved from a recognition that

what is real in the mind can and does havereal implications in the body, behavioral

medicine as a discipline has a fraternal andeven symbiotic relationship with allopathicmedicine. In the multidisciplinary setting,

which is a cornerstone of behavioral medi-cine, there is an understanding by bothphysician and psychologist that emotionalproblems can ultimately lead to diagnosablemedical conditions and vice versa. Suchbeliefs are based on an enormous literatureshowing established links between biologi-cal and psychological conditions.

While it is beyond the scope of this paperto review that literature, a brief samplingshould illustrate some of these relationshipsConsider, for example, the co-morbiditybetween depression and other medical dis-orders. One recent study conducted by theNational Institute on Aging suggested thatdepression, when present for at least sixyears, was associated with an increased riskof cancer (Penninx, Guralnik, Pahor,


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Ferrucci, Cerhan, Wallace, & Havik, 1998).Holland, Korzun, Tross, Silberfarb, Perry,Comis, & Oster (1986) have shown thatdepression is often the first symptom ofpancreatic cancer, and others have founddepression to be not only common in dia-betics (Wilkinson, Borsey, Leslie, Newton,Lind, & Ballinger, 1988), but a frequent

side effect of cancer treatment (Massie &Holland, 1987). Depression is also asequela of Parkinsons disease (Starkstein &Robinson, 1989), multiple sclerosis(Schiffer & Babigian, 1984), and cerebralvascular accidents (Robinson, Kubos, Starr,Rao, & Price, 1984).

Depression is not the only emotion to co-occur with disease states. In reality, there isan equal representation of studies that asso-ciate other mood states with disease.Sometimes these affective disturbancesappear as causes, sometimes as conse-quences, but their importance to medicalconditions seems inarguable. Booth-Kewley& Friedman (1987), for example, docu-ment consistent co-morbidity betweencoronary disease and such negative emo-tions as hostility, anger, anxiety, and depres-sion. Even suppressed anger, particularly

when combined with genetic and environ-mental factors, seems causally related tohypertension (Taylor & Aspinwall, 1990).In a related vein, research on nicotine usesuggests a causal relationship with anxiety

(Gold, 1990), depression (Lerman,Caporaso, Main, Audrain, Boyd, Bowman,& Shields 1998), and even pain (Gatchel,1996). Insomnia, another condition com-monly seen in primary care practices, hasitself been shown to co-vary with a multi-tude of psychological conditions (Morin,1993).

While studies such as these illustrate theimportant interplay between psychologyand physiology, there is also abundantresearch showing not just efficacy, but fre-quent superiority of behavioral interven-

tions over more traditional allopathicapproaches when treating a wide range ofmedical conditions. The literature on treat-ment for chronic pain disorders reflects as

well as any the importance of behavioral asopposed to more traditional biomedicalapproaches. A fairly recent article, for exam-ple, published in theJournal of the American

Medical Association (NIH, 1996), citedstrong evidence for the use of cognitive-behavioral techniques, relaxation, andbiofeedback in treating chronic pain andinsomnia. In his book, Psychological

Management of Chronic Headaches, Martin(1993) outlines a promising behavioralstrategy for managing intractable headaches

that suggests greater long-term efficacy thanconventional medical treatment.

Although differential diagnosis is criticalin distinguishing among the many variantsof headaches, it is clear that a significantpercentage of sufferers ultimately proverefractory to pharmacotherapy. This is apopulation for which bio-behavioral inter-ventions could be essential in finding anysemblance of relief. Even among those for

whom medication has proven effective,many patients are averse to depending onmedications and are instead motivated tolearn more effective self-control and preven-tion strategies. Judging from auspicious lit-erature reviews, there is certainly reason forsuch patients to expect improvement frombehavioral approaches. A recent study, forexample, by Wittrock & Myers (1998) sug-gests that a significant variable to considerin headache phenomenology are the differ-ences in coping strategies between headachepatients as compared with non-headachecontrols. Training in coping skills could notonly reduce the frequency, severity, and

intensity of chronic headaches, but seems toprove equally effective with chronic painpatients in general, regardless of circum-stances. In their book, Coping with ChronicPain, Hanson and Gerber (1990) allude tosuch a model by presenting cognitive-behavioral approaches to self-management.Gatchel and Turk (1996) follow a similartheme in outlining a variety of non-phar-macological approaches for effective painmanagement. Together, these authors advo-cate exercise, biofeedback, bibliotherapy,hypnosis, operant conditioning, distraction,

recreation, cognitive restructuring, as well asboth group and family therapy.

It is imperative to recognize that psy-chophysiological research is as enormous asit is compelling, and the few citations pre-sented above reflect only the barest cross-section dealing with mind-body interaction.Friedman et al (1997), for example, report-

ed that since 1972 over 2700 articles havebeen published relating to relaxation alone.Our purpose in mentioning this literature isto emphasize that mind/body relationshipsare not only inexorable and well-estab-lished, but that for medicine and psycholo-gy to practice without dialogue can onlyincrease the chance of overlooking impor-

tant variables that affect treatment outcome

Clinical Utility ofBehavioral Medicine

An overriding tenet of behavioral medi-cine is that a multitude of medical problemfrom which people commonly suffer can beameliorated, cured, or prevented in the firstplace through changes in thinking and/orbehavior. Achieving optimal behavioral out-comes presupposes a psycho-educationalcomponent, so that our hypothetical painpatient, for example, would learn that,

unlike pain in the acute stage, chronic painshould not be interpreted to mean the dis-continuing of any activities that promotediscomfort. Simply knowing that, withrespect to chronic pain, there is no causalrelationship between hurt and harmbecomes a cognitive change that for thepatient can mark a breakthrough in termsof his/her receptivity to approaching painmanagement behaviorally rather than justpharmacologically.

This brings to mind one of the chief

flaws in contemporary primary care: pre-scribing practices involving psychotropicmedication. In a setting where patientsbecome accustomed to receiving medica-tions as the primary and often exclusiveavenue of treatment, patients learn toassume a passive role, largely depending onthe medical provider for relief. Rarely insuch settings are self-management skillstaught, which makes the patient more likelyto have recurrences of the same presentingproblems. Perhaps not surprisingly, a reviewarticle in theAmerican Journal of Psychiatry

(Orleans, George, Houpt, & Brodie, 1985)reported an abundance of literature to sug-gest that PCPs actually tend to over-pre-scribe psychotropics. Elsewhere it has beenreported that primary care practitionersprovide a larger percentage of psychotropicdrug visits than psychiatrists in every psy-chotropic class exceptlithium (Beardsleyet al, 1988).


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This literature on psychotropic prescrib-ing practices (see also Pincus et al, 1998)seems to underscore how ubiquitous psy-chogenic disorders are in the primary caresetting, a point which by itself should high-light the need for behavioral health as animportant component of primary care. It isalso important to realize that when medica-

tions become the primary treatment forpsychiatric patients, the initial therapeuticgains, which are admittedly rapid, are ofteneclipsed by recrudescence over the long run.

While there is no doubt that the uni-dimensional approach of traditional medi-cine can frequently prove helpful, its

widespread promotion by the insuranceindustry seems to have more to do withshort-term cost-benefits than with long-term clinical outcome. Indeed, longitudinalresearch on primary-care patients havingbiopsychosocial issues has shown that out-comes at one, five, and ten-year follow-uptend to be optimized through multi-compo-nent interventions with strong behavioralfeatures.

While the medical model can be extreme-ly effective by itself, it would appear to bestrengthened rather than compromised

when it is joined in an interdisciplinarypartnership with behavioral medicine.Patients receive the benefits of high-techmedical and pharmaceutical interventions

while

simultaneously being coached in self-effi-cacy training. In contrast to traditionalallopathy, behavioral medicine promotes aparadigmatic shift in which the patient isencouraged to become more active andresponsible in cultivating healthy lifestylechanges. Approaching wellness throughbehavioral change can dramatically improveself-confidence and lead to significantimprovements in systemic functioning, asexemplified by impressive research in thefield of psychoneuroimmunology.

Current TrendsEmbryonic in scope, there are neverthe-

less important changes occurring in primarycare with respect to clinical training andpractice that auger well for behavioral medi-cine as a burgeoning component in healthcare delivery. With the increasing acuity ofpatients in ambulatory care settings, col-leges of osteopathic medicine, for example,

are undergoing significant changes in cur-riculum in order that medical studentsreceive more comprehensive training inbehavioral sciences (Magen, 1992).Considered an integral component of inter-nal medicine, behavioral medicine is alsoreported as being slowly incorporated intomedical residencies (Rosenberg &

Hoffman-Wilde, 1989). Such trainingwould seem to be motivated by a growingsentiment that closer working relation-ship(s) between general practitioners andmental health workers is productive andvalued (Thomas & Corney, 1993). Asidefrom enhancing the treatment competencyof physicians, this medical training shouldpromote an increase in behavioral medicinereferrals.

Increasingly, PCPs are recognizing anassortment of behavioral interventionsincluding relaxation, biofeedback, counsel-ing, diet, and exercise as legitimate medicalpractice (Berman et al, 1998). Attitudessuch as these have made for some unprece-dented change in the status of health psy-chologists. For example, psychologists at theUCLA Medical Center have not onlybecome an integral part of the primary careteam, but have been made full voting mem-bers of the medical staff, allowing them tobe equal partners in the delivery of healthcare (Rabasca, 1998). A similar theme isechoed by Robinson (1998), who reports

that on-site mental health services enablePCPs to improve their quality of care todepressed patients.

While these trends may be auspicious forbehavioral clinicians, it is clear that manypractitioners in the field of mental healthhave neither the training nor the experienceto work effectively in primary care settings(Bray & McDaniel, 1998). To bridge thisgap, some doctoral psychology programs,albeit few at this stage, have modified theircurriculum to include co-training withphysicians (Murray, 1999). A prototype,

operating out of Louisiana State University,provides internship training geared to pro-moting better collaboration between physi-cians and psychologists.

Once trained, behavioral cliniciansshould expect to find growing opportunitiesnot only in primary care, but also in corpo-rate settings, such as the Sleep Easy

Education Program (SLEEP) initiated byKaiser Permanente to help patients over-come insomnia. It is also conceivable thatthe same schemes to attract psychiatriststo work in primary care settings (Barber &

Williams, 1996) will eventually be extendedto behavioral medicine specialists. Equipped

with skills in applied psychophysiology,

these practitioners typically provide measur-able treatment for a diverse assortment ofconditions commonly seen in primary care,such as headaches, bruxism, anxiety, chronicpain, diabetes, IBS, TMJ disorders,fibromyalgia, and addictions (Schwartz,1995).

ConclusionBecause of well-established mind/body

principles, behavioral medicine is increas-ingly regarded as having enormous value toprimary care and ultimately to society at

large. Studies abound as to the efficacy ofbehavioral interventions, distinguishing thisapproach from alternative medicine becauseof the latters largely unproven methodolo-gies. A partnership between allopathic andbehavioral medicine avoids duplication ofservices, which is among a multitude of fac-tors demonstrating its cost-effectiveness(Sobel, 1995). Expanded training acrossprovider groups should promote growingrecognition of the implicit value in this typeof professional alliance, and with thisshould come stronger incentives including

better coverage for such partnerships fromthe insurance industry (Lehrman, 1996).

There is already momentum at thenational level for recognizing behavioralmedicine as an integral part of primaryhealth care. Fueled in part by a landmarkpublication, Primary Care: Americas Healthin a New Era (Donaldson et al, 1996),Congress in 1997 recommended the devel-opment of standards for preparing behav-ioral clinicians to work in primary caresettings. As such models are being devel-oped, credentialing will be needed to docu-ment competency among those who aspireto work in this environment, and accredita-tion procedures should be designed to eval-uate graduate-level training and regulatefuture practice. Notwithstanding themechanics of implementing these objec-tives, behavioral medicine is at an epochalstage in its evolution. That medicine and


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mental health can no longer afford to oper-ate in a vacuum should be apparent. Withthe politics of isolation being clearly outdat-ed, interdisciplinary collaboration shouldcarry us convincingly into the new millen-nium.

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Turk, D.C., Meichenbaum, D., & Genest, M.(1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: Guilford Press.

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Medicine, 20, 118-134.


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Abstract: Throughout life people areexposed to a variety of experiences, includingstressful and traumatic events. The individ-uals coping during and after such eventsdetermines the eventual need for assessmentand treatment for Post-traumatic StressDisorder (PTSD). The authors summarizeseveral models which account for the varyingdegree of impact traumatic events have on the

individual, including the psychosocial modeland the psychophysiological model. They alsoreview methods utilized to measure the impactof stress and natural disasters on the individ-ual: a)self-reports, b) performance tests, c)

psychophysiological measures, and d)biochemi-cal assessment. Multiple measures are oftenmore effective. The authors report on an inter-vention with survivors of Hurricane Paulinein Mexico. Psychometric questionnaires, psy-chophysiological monitoring, and biochemicalindices were used to assess the relative impactof the hurricane on victims of the disaster.

Stress management workshops andPennebaker-style emotional journal trainingwere conducted with hurricane survivors. Theworkshop reduced the symptoms of post-trau-matic stress disorder and improved immune

function. The authors are hopeful that theirnon-invasive assessment techniques and theself-regulation workshops will provide useful

tools not only for individuals, but also forentire disaster-stricken communities in theunderdeveloped world.

Brain/EmotionsWe already have rather good evidence

about our psychological reactions, i.e.,thoughts, beliefs, emotions, etc., physiologi-cal responses, i.e., hormonal and autonomic

changes, and overt behavioral answers to awide variety of events. Once an eventoccurs, some of the more than 10 millionneurons begin to interconnect with neuronsin other places. Changes in our emotionalstate occur and a new muscular state is pro-duced (Wolf, 1998). The measurements ofthe amount of transmitters or neuropep-tides and the density of receptors in specificbrain areas helps us to identify specific cir-cuits in a functional and dysfunctional per-spective. This certainly is valuableinformation. Nevertheless is not enough toexplain how, when and especially in whomthe emotional, behavioral and cognitive pat-terns change in response to the effects ofthe everyday as well as exceptional events.Perhaps, in this field, the most importantfuture task will be to determine and deal

with the environmental or organically realand impalpable afferent influences (stres-

sors) capable of producing a disturbance inthe healthy and normal neural trafficresponsible for appropriate adaptation tothe life experience (Vanderwolf, 1998).

The emotions occupy a predominantplace in human life. Without any doubt formost of us love is a far-reaching issue inclose intimate relationships, friendship, andin the relationship between parents and

their children. The fear of offending mem-bers of our social group is still an essentialpart of our evolutionary endowment. Thesame kind of evolutionary concept can alsobe applied to the so called positive andnegative emotions. In spite of all this,research on emotions has only very recentlygained the appreciation and attention of thescientific community. The modern scienceof psychology, despite recognizing the roleof emotions, devoted incomparably moreeffort to traditional areas like perception,learning, and intelligence (I.Q.). It is

important to differentiate among emotions,states of mind, and emotional tendencies.In general, emotions appear to suddenlyinterrupt any previous activity organizingour mind to deal with a situational change.In contrast, states of mind do not emerge soabruptly, and can last for hours or months.Finally, emotional tendencies have much in

FEATURE ARTICLE

Psychophysiological

Monitoring, NaturalDisasters, and Post-Traumatic StressiBenjamin Dominguez Trejo, PhD,Guadalupe Esqueda Mascorra, BA,Consuelo Hernndez Troncoso, BA, LuzMaria Gonzalez Salazar, MA,YolandaOlvera Lopez, MA, Ricardo Aron

Mrquez Rangel, BAMexico City, Mexico

Benjamin DominguezTrejo, PhD

Luz Maria GonzalezSalazar, MA

Guadalupe EsquedaMascorra, BA

Yolanda Olvera

Lopez, MA

Ricardo Aron

Mrquez Rangel, BA


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common with personality features and arethe basic fundament of individual differ-ences (Jenkins, Oatley, & Stein, 1998).

Stress andEnvironmental Changes

Stress is the preservation of life as adynamic balance of superior order, against

the many adversities, while facing a state ofconstant threat to such balance. Organismsproduce adaptive tendencies that counter-balance the forces (stressors) disturbinghomeostasis. The survival of an individual,and therefore finally of his species, dependson his ability to adapt to a continuouslychanging environment (Chrousos & Gold,1995; Kutas & Federmeier, 1998; Porges,1995).

Single-cell organisms adapt themselvesthrough appropriate biochemical changes.Multi-cell beings do it through complex

and well-coordinated neural, humoral andcellular changes that involve multipleorgans and tissues. Social organisms, whosesurvival depends on community coopera-tion, have developed extremely refinedsocial links in their group that contribute toenvironmental adjustment.

The stress system receives informationfrom external sources, i.e., the environment,and from internal sources, i.e., the body,through various sensorial systems. Theafferent information that the thinking

brain receives has already passed throughmidbrain areas like the amygdala and thehippocampus, often referred to as parts ofthe emotional brain (LeDoux, 1998).These midbrain systems are supplied inturn by the mesocorticolimbic system. Invulnerable individuals exposed to constant,frequent or severe stressors the stress systemcan loose its maintenance function and turnmaladaptive (McEwen, 1998). Excessiveactivation of this system can produce psy-chological and physiological pathologies; inaddition dysregulation of the stress system

can cause serious harm to mind and body.Atypical or seasonal depressions, thefibromyalgia/chronic fatigue syndromes andmany auto-immune diseases are related toinadequate glucorticoid responses toimflamatory stimuli and thus are excellentexamples of cases where one or more com-ponents of the stress system are hypoactiveand/or hyper-reactive. Progress in under-

standing molecular aspects of the stress sys-tem (Chrousos & Gold, 1995) mightenable us to identify intrapersonal risk fac-tors, including individual vulnerability toan often-underestimated number of humanhealth problems. It will also enable us todevelop benign preventive, pharmacotreat-ment, and perhaps not far in the future,

genetic interventions to counteract theadverse effects of stress (Postel-Vinal, 1998).

Emotional Impact andPsychophysiologicalEvaluation

Each day the risk increases for world pop-ulations to be exposed to life-threateningevents, severe injuries, and violence(Trauma Responses, 2000). Such probabili-ties leave many individuals in a state ofhelplessness or loss of control, and often in

a state of severe anxiety or fear. Neverthelessonly about 25% of individuals exposed toobjectively traumatic situations will finallyshow the pathological reactions we know asPTSD. One of the main challenge in psy-chological research in general, and psy-chophysiological monitoring in particular, isto identify and describe factors that helpdistinguish those individuals who developPTSD after traumatic exposure from those

who do not. We need to better understandhow many individuals are able to proceed

with little or no professional help from the

status of victim-to-survivor-to-witness.This kind of research would not only haveserious practical impact, it would also haveimportant financial implications. Diagnosistreatment of these populations could berefined. . Another benefit of this kind ofresearch would be to allow the simultaneousidentification of subtle background vari-ables like the influence of cultural factors inthe ability to cope with traumatic episodesand its externalization (Pennebaker, 1995).

Contemporary theoretical approaches canbe categorized into those emphasizing psy-

chological factors and those stressing bio-logical ones. The importance ofdispositional factors in the development ofPost-Traumatic Stress Disorder (PTSD) hasalready been recognized. It has also beenfound that pre-trauma and trauma factorsinteract to define the meaning of a particu-lar traumatic episode. Davidson and Baum

(1995) illuminated the psychosocial per-spective when they described reaction pat-terns to trauma. They created a conceptualmodel that took into account characteristicsof the individual, as well as boundary con-ditions of the environment. In this sense,characteristics of the individual (how he orshe perceives, understands and responds to

the event) interacts with characteristics ofthe social and physical environment. Insome cases the psychosocial factors canfacilitate the individuals recovery from thetrauma.

A more recent trend in PTSD theoriesemphasizes the role of central and peripher-al physiological processes and the role ofinjuries in the Central Nervous System(CNS) provoked by the trauma. In suchcase, the processes triggered since the psy-chological evaluation and the processing ofthe trauma are analyzed.

It is crucial to have observations of howindividuals respond to adverse situationschallenging normal functioning, in orderto appropriately evaluate the emotionalimpact of these events. Psychophysiologicalmonitoring is one of the most useful tech-niques to accomplish this objective. Initiallypsychophysiological monitoring was knownas a Stress Interview (Mittleman & Wolff,1942). More recently they have been calledPsychophysiological Stress Profilesii (PSP)(Domnguez, Martinez, Hernandez,

Esqueda, Olvera, Lizano, Flores, Morales,& Tam, 1998a). Basically, the PSP is aninterview in which a subjectsbehavioral/emotional and physiologicalstress indicators are monitored during alter-nating rest and challenge periods. The PSPis a more conclusive technique than statisti-cal comparisons, because it allows one tolink (or to dismiss) significant emotionalevents to changes in bodily states as a reli-able index of emotional impact.

Verbalization after

Stressful EventsExperimental evidence has accumulatedshowing that stories told by survivors ofstressful events can be seen as a specificindicator of the way these people havecoped with environmental changes. Thesedescriptions vary dynamically with the timethat has passed after the event. Descriptionsshow the meaning that an individual assigns


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to a traumatic event. Old Mayas used to saythat It was healthier to talk [to re-make astory] than to keep the sorrows (Lopez

Austin, 1993). In the sixteenth century,during the widespread European plagues,everybody painstakingly looked for curesand devices to survive. One saying, Happymen do not become infected with the

plague (Thomas, 1971, p. 8), was passedby word of mouth as a powerful remedy.Modern research has confirmed the impor-tance of these kind of phenomena(Pennebaker, 1995). Kiecolt-Glaser andGlaser (1992) commented on the relation-ship between verbal expression and adap-tion to stress: At the beginning broken up,but finally coherent and with a great per-sonal/emotional meaning, the expression ofa verbal or written description appears inparallel to an important reduction of symp-toms and adaptive behavioral changes, andeven with positive immune changes.

For the individual, this verbalizationprocess seems to go along with a new senseof personal control (see Table 1). People gothrough several stages, beginning by consid-ering themselves to be victims, later seeingthemselves as survivors, and finally pro-gressing to regarding themselves as witness-es. This transition can happen in a shortperiod of time. The individual may contin-ue to report the same adversities, discom-forts and invasive thoughts and images. But

after making a cognitive adaptation theindividual no longer has difficulty toleratingthe event, and will feel that he or she hasgained control over the event (Wegner &

Wheatley, 1999).In trauma research it remains an unre-

solved question whether changes in theattribution of meanings of an environmen-tal events (There are never hurricanes in

Acapulco): 1) are merely an epiphenome-non that occurs after the physiological,behavioral and emotional changes, or 2)play an instrumental and causal role as

facilitators for health improvements andemotional relief. Clinical evidence producedby our project showed that when peoplecope with environmental adversities bysharing it with others and coming up withpersonal interpretation, this can have a pos-itive influence on their abilities to cope

with such events. Persons who discussed

and re-appraised the event were better ableto cease incapacitating rumination (Bhat& Bhat, 1999; Woodward, Drescher,Murphy, Ruzek, Foy, Arsenault, &Gusman, 1997).

Mind and Brain Duringand After Disaster

Nowadays the traditional image of thehuman brain as a receptor full of connec-tions and switches is no longer appropriate.Neither is the beliefs valid that the brainreaches its final stage of development earlyin life, with each function localized in thecortex and with sensations and cognitionsproducing a chain reaction with inputstimuli and output responses. Psychologicalresearch has shown, and now brain imagerytechniques confirm, that the brain works ina way very different from this simplisticconcept. PET (Positron Emission

Tomography), magnetic resonance imaging(MRI) and physiological monitoring haveshown in an impressive way that the minddoes not follow a predefined train ofthinking. On the contrary, thinking is per-formed in a neural network or in a group ofneurons well coordinated in their activitybut not necessary proximal in location.Often neurons simultaneously firing inresponse to a discrete event are located inseparated areas of the brain (Vanderwolf,1998; Kutas & Federmeier, 1998). In this

sense, our brain is an active builder of sen-sations, patterns, meanings and interpreta-tions (Gazzaniga, 1998; Freeman, 1995).

Additionally, the brain shows a surprisinglyhigh level of plasticity. That is, there can beconsiderable cerebral structure changes inresponse to an experience (Freeman, 1999)If psychosocial experiences can significantlychange the brain, the role of geneticsbecomes less restrictive for human perform-ance than many people believe (Postel-Vinay, 1998).

From an evolutionary perspective it is

critical to ask: What is the goal of a neuralstructure like this? If we apply evolutionarythinking to the evolution of the stress sys-tem we have to ask ourselves: What adap-tive function does this system serve? Theanswer is not too difficult: The neural sys-tem is facilitates the individuals adaptationto environmental changes. Biology and theevolutionary or Neo-Darwinian Psychology

PSYCHOLOGICAL FACTORSTHAT MODULATE THE

IMPACT OF DISASTERS1. Objective characteristics of a trau-

matic event: a) intensity, b) duration,

and c) time of exposure to the event(physical proximity).

2. Subjective characteristics of a trau-matic event: a) held meanings: ItsGod will, Nothing goes on forev-er; b) perception of control: Thereis no choice, and c) immune/emotional impact.

3. Response to an event: a) response tothe event (acute reaction), b)response after the event (chronicreaction), c) influence on the recov-ery and how much one benefits from

the available help, and d) comorbidi-ty/premorbidity.

PSYCHOLOGICAL INTERVEN-TIONS IN DISASTERS (NATURAL

AND MAN-MADE)1. Modify the role of psychological help

depending on the time of interven-tion.2. Provide information that contributes

to community security.3. Educate the public about coping

with traumatic events(appropriate/inappropriate adapta-tions).

4. Define the time at which specialistsshould withdraw from intervention(allowing for events which are indefi-nite or prolonged in impact).

5. Importance of the concepts: People

do not heal easily, PTSD can notbe healed, and traumatic memoriesdo not magically disappear.

So how can we help affected people?

Table 1

Table 2


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already provide an answer. The brainworks to make decisions that favor repro-ductive success (Gazzaniga, 1998).

With the capability to perform such atask many others that appear like gifts areimplicit. The researchers devote substantialeffort to study them while they are not pay-ing attention to reason of the existence of

the brain. When we acknowledge that thebrain can only be explained in terms of howit manages information and makes deci-sions, we considerably increase our under-standing about mind-brain relations.

Measuring theEffects of Trauma

There are four main methods to measurestress triggered by abrupt environmentalchanges: a) self-reports, b) performancetests, c) psychophysiological measures, andd) biochemical assessment. Generally, it is

considered that in order to obtain an opti-mal measure that provides a clearer and

wider understanding of stress, a multi-method approach should be applied andmore than two of the mentioned methodsshould be simultaneously used (Davidson& Baum, 1995; Domnguez, et al, 1998a).Self-report scales tap into the somatic expe-riences, the emotional changes and the clas-sification of the surrounding events to theinitial stressor. Sympathetic Nervous System(SNS) activity is related to emotional func-

tioning produced by the environmentalevents. We monitor SNS activity via indica-tors such as heart rate, blood pressure, andchanges in galvanic skin response andperipheral temperature. These indices canbe accurately assessed using psychophysio-logical monitoring devices. Finally, manybiochemical changes occur inside of thebody during periods of stress (Kielcolt-Glaser & Glaser, 1992; Domnguez,1998b). Such changes can be evaluated inthe blood, in saliva, and in some cases, inurine. Using a multi-method strategy for

assessment, it has become possible to collectdata, in cooperation with other researchers(Davidson & Baum, 1995), about their use-fulness, for example, in correctly identifyingup to 95% of the individuals affected withPTSD.

BiochemicalMeasurement of theEffects of Trauma:A Research Report

Somatic physiological consequences tostressful events include a dyregulation ofbiochemical mediators in the hypothalamic-pituitary-adrenal axis (HPA-axis) that trig-gers an immunodepressive reaction relatedto the response to perception of the threat(Porges, 1995). This reaction is mediated byhigher levels of circulating cortisol. One ofthe characteristics of experienced distress isa decrease in the production ofimmunoglobulins, mainly of IgA, that con-stitutes the primary body defense to theinvasion by pathogenic agents, mainly inthe superior respiratory tract. Researchshows that the decrease in levels of IgA is a

causal factor in the frequency of contagiousdiseases, especially upper respiratory infec-tions (Marquez, 1998).

We therefore carried out an investigationon survivors of hurricane Pauline, to deter-mine whether we could: a) identify by psy-chometric, biological andpsychophysiological measures which indi-viduals would develop PTSD following thisdisaster, and b) deliver workshops on cop-ing strategies, that would effectively reducePTSD symptoms.

Methodology: Collection of saliva and

quantification of IgA: A modification ofthe Kirschbaum and Hellhammer (1994)procedure was adopted in the collection ofsaliva. Serologic pipettes and sterile poly-styrene test tubes were used. For theirpreservation the samples were stored at 5and 0 C, and then frozen at 40C. Thelaboratory analysis was carried out through

the turbidimetric method to quantify IgAs(immunoglobulin A in saliva).

Research Sample: The sample consistedof 510 survivors, victims and witnesses ofthe Paulina hurricane in Acapulco,Mxico, that occurred in October, 1997.

From this sample a subgroup of 68 adultsof both sexes was selected for further analy-

ses: Their age ranged from 7 to 80 years.Most of them had no profession and mainlytook care of the house. The underlyingcommon characteristic and the reason whythey were selected from the larger popula-tion was their resettlement as a consequenceof the Paulina hurricane. They all weresuffering from serious material and/orhuman losses. There were also 99 teenagersfrom the Daytime Junior High School No.10 Margarito Damian Vargas.

Workshop Intervention

The researchers provided eight groupworkshops on coping strategies to sixty-eight adults and nineteen teenagers andchildren. The first workshop was conductedfor an adult group with the highest scoreson PTSD measures, seven months after thehurricane. During six site visits in the peri-od from April 4, 1998 to Mach 27, 1999 atotal of eight stress management group

workshops were provided. Each of the sixvisits lasted up to seven days and includedthe participation of four experts in the fieldof traumatic stress. The workshop were per-

formed under outdoor conditions (110F)and included: a) education about copingstrategies, b) instructions on utilizing thePennebaker emotional disclosure exercisesto verbalize emotions (written or aloud)about the hurricane, and c) training inrelaxation skills.

SETTINGS WOMEN

Renaissance City Gymnasium "shelter" 130

American University of Acapulco 20

National Pedagogical University of Acapulco 73

MEN TOTAL

20 150

9 29

23 69

"Tutzingo" Housing Buildings 42

CORRET SEDESOL 1, Housing Building 18

General Daytime Junior High School No. 10"Margarito Damian Vargas"

70

"Moctezuma" Housing Buildings 10

11 53

9 27

38 108

5 15


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InstrumentsSeven widely used diagnostic instruments

for adults were chosen and tested for use inthis study. They were translated intoSpanish and specially adapted to the needsof this project. Finally, only one of theseseven instruments passed the clinical crite-ria. One was used for the adult sample, andone for the teenagers.

Stressful Life Events (long version). Forthe general public. 20 items questionnaire;estimated application time: 5 to 10 min-utes per subject. Goal: diagnosis of themost important stressful events in life.

Stanford Questionnaire of Reactions toAcute Stress (SQRAS) (Dominguz,Valderrama, Hernndez, Esqueda, Olvera,Gonzlez; Victorio, Vazquez y Martnez,1998). Target population: adults.

Application time for an adult population:10 minutes per subject. Scale: 30 itemsassessing the existence of the symptoms of

Acute Stress Syndrome.Parent Form, Post-Traumatic SymptomsScale (PTS). Target population: Childrenand teenagers. Application time: 5 min-utes. Scale: 32 items.

Last Unpleasant Traumatic Experience.(Dominguez & Pennebaker, 1996). Targetpopulation: general public; scale: 12 items;application time: 5 to 10 minutes.

Coping Styles(see above). Designed forthe general public. 13 items in open form.

General Interview.Instrument exclusive-ly designed for this projects. Collects infor-

mation about demographic aspects, signs,and symptoms of PTSD.

Psychophysiological Stress Profile ofPeripheral Temperature and Heart Rate.Temp-time digital thermometers and a Cat-Eye counter of heart rate (BiomedicalInstruments) were used. As continuousmonitoring device these portable equip-

ments were used in the initial assessmentperiod, as well as in the subsequent devel-opment of the stress management work-shops.

Mexican-Made Portable BiofeedbackEquipment.Field assessment with proto-types was performed to obtain psychophysi-ological measures of bilateral peripheral

temperature. They were constructed accord-ing to advice and under supervision of theUNAM- National Institute of Cardiology-ESIME-IPN. This allowed the adaptationof the devices for use in relevant environ-ment al conditions (Tropicalization of theprinted circuit).

Assessment of Immune Function.Immunoglobulin A (IgA) levels in saliva

were evaluated before and after the work-shops on controlling and managing PTS foreach community group.

General ResultsIn the case of the adult population,progress was made in improving the psy-chometric properties (reliability and validi-ty) of the SQRAS for Mexican populations.The SQRAS is a self-report instrument thataccurately assesses reactions to traumaticstress. It further turned out to be applicableto correctly classify the groups that showedtraumatic consequences after exposure tohurricane Paulina.

For the teenage group we were able torefine and adapt the self-report question-

naire in a way to finally obtain 80% accura-cy in detection of post-traumatic symptoms(Parent Form of Post-Traumatic SymptomsScale, PTS).

It was found that high scores on the PTSwere related to low levels of immunoglobu-lin A (IgA) in saliva. This confirmed thevalidity of the scale in discriminating sub-

jects who are more vulnerable to stress fromthose who are not. We continue to analyzeour data on the relationship between scoresof the SQRAS and the coping styles used tomanage the post-traumatic symptoms.

Homogeneity tests showed comparablevariances for men and for women (5,12) =2.74, p > .05. The t-Student test for com-paring sample means yielded no statisticallysignificant differences: t (10) = 1.53, p >.05. The two factor analysis of variance(ANOVA) allowed to test for the effect ofthe record phases of the stress management

workshop (factor A), and the degree of PTS(factor B) on IgA levels. Results showedthat the record phases as well as the degreesof PTS affect the IgAs levels to a statisticallysignificant degree. These effects turned outto be first order effects without being speci-fied by a 2 way-interaction. There was nointeraction between the record phase pre-

intra-post-workshop and the degree ofPTSD. Factor A: F (2,12) = 97.80, p < .05Factor B: F (2,12) = 43.34, p < .05. ABInteraction (AB): F (4,12) = 2.24, l p >.05. The analysis of the immune profile wasdone applying basic statistics of central ten-dency and dispersion (arithmetical meanand standard error). It showed that subjectshigh on PTS scores had lower sIgA levelscompared to subjects with low PTS scores.

In addition we were able to show thatafter the intervention with the stress work-shop, there was a increasing tendency forsIgA levels to approximate the normal refer-ences, and in those obtained in the controlgroup not affected by PTSD, mainly themens group. To validate the immune result,this was compared with the pre-post work-shop record of heart rate and the bilateralperipheral temperature obtained for eachparticipant. In the first case, a decrease inbeats per minute (bpm) was found after the

workshop (pre: 93.05 bpm and end: 87.97bpm). The overall average difference was5.08 bpm and was significant on the .05

level one way ANOVA: F (1,6) = 75.33, p< .05. This confirmed the importance ofnon-invasive assessment techniques andself-regulation for managing stress.Sympathetic nervous activity decreased. Thebilateral peripheral temperature increased itsaverage difference from pre- to post-work-shop, left hand (before: 0.14C and after0.33C, difference: +0.19C); right hand(before: 0.13C and after 0.22C, differ-ence: +0.09C). This increase was not sig-nificant in both cases, (left hand F (1,6) =1.37, p > .05, right hand: F (1,6) = 0.71, p

> .05). The variance of the average differ-ences was homogeneous. Therefore, there

were no statistically significant differencesthat suggest signs of relaxation in this physiological response. Nevertheless, the smallgains in temperature in this interval indicat-ed a tendency of vasodilatation.

Thus one can conclude that the stress

Subgroup

CORRETSEDESOL 1

General DaytimeJunior High SchoolNo. 10 Margarito

Damian Vargas

POPULATION/AGE

68 adults/Between17 and 80 years

99 teenagers/Between

12 and 16 years


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management workshops formed conven-ient, viable and affordable packages of ther-apeutic non-invasive intervention to reducesymptoms present in PTSD.

Evidence was collected that supports theefficiency of relaxation techniques and self-reflective emotional journal writingiii

(Pennebaker, 1995), as forms of an efficient

intervention in PTSD situations.

ConclusionsIn the light of increasing global climatic

changes and natural disasters it is necessaryto accurately and appropriately identify andassess the surviving population affected bydisasters, and to effectively intervene toassist their physical and emotional recovery.

Results obtained in our study suggestedthat providing workshops to the subjectssuffering from PTSD lead to an improve-ment in immune status as measured by sali-

vary IgA. The psychophysiological profilesalso showed meaningful changes from preto -post workshop measurement. Before the

workshop the subjects showed low IgAs lev-els, high heart rates and low peripheral tem-perature. After the workshop, IgA levels andtemperature tended to increase, while heartrate decreased. These changes suggest thatthe population affected by the natural dis-tasters produced by El Nio were in theprimary stages of physiological andimmunological recovery.

The concept of individual stress vulnera-

bility allows physiological, psychologicaland immunological conceptualization, andin a very accurate manner, to predict whocan overcome these effects more quickly fol-lowing the disaster, with minimal or noassistance, and who will need professionalattention for a longer time.

The field of research reported here com-plements research that has found climaticchanges to affect human behavior in a non-linear way. Natural disasters can be regardedas natural experiments from which we canto learn a great deal. Focusing our researchon the development of prevention andadaptation tools can be beneficial for theindividual as well as for the community.

Footnotesi REPORT MADE WITH THE FINANCIAL

SUPPORT OF THE PROJECT: CONACyT REF098 P 1297 EL IMPACTO HUMANO DE ELNIO (1998-1999).

Special acknowledgement to Matthias Mehl fromthe University of Texas at Austin for his technicaland careful advice for the final English version.

Acknowledgements: We wish to acknowledge

support from: Universidad Americana deAcapulco, Matilde Zaindenweber, Irma Lorentzen,S. Fastlicht, Adriana Gmez, C. Romano

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