Could Tuberculosis be a Psycho-somatic disease an alternative view point
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- Title
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Could Tuberculosis be a Psycho-somatic disease
an alternative view point - Creator
- Anand Zachariah
- Date
- 1998
- extracted text
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an alternative view
Could Tuberculosis be a Psycho-somatic disease
point
( A modified version of the article, "Can stress cause disease?
Revisiting the tuberculosis research of Thomas Holmes, 1949-1961.
Barron H Lerner. Annals of Internal Medicine 1996;124:673-680."
Robert Koch's discovery of M.tuberculosis in 1882 proved that
tuberculosis was an infectious disease. However the introduction of ;■>
skin testing in 1908 showed that many more persons were infected with
the bacillus than acutally had the disease.
In India skin test
surveys show that one-third of all people are infected with TB
(primary tuberculosis). Only a small proportion of people 'reactivate'
the disease in adulthood (secondary tuberculosis). The factors that
have been identified that lead to the spread and occurrence of disease
are urbanisation, overcrowding, poor housing, unhealthy working
conditions, specific occupational exposures, immunosuppression and
undernutrition.
Many of these factors are thought to act by
increasing the risks of air borne transmission. However if most of the
adult tuberculosis is due to endogenous reactivation, how do the above
factors facilitate this reactivation process.
A large amount of TB research today is focussed on the immune
response; why do only a few people develop tuberculosis, why do people
respond differently to treatment. An area of research which is ignored
in current literature is 'psycho-somatic research' in tuberculosis.
Rene Dubos, and other early TB researchers discussed that the issue of
stress was closely related to the concept of resistance to
tuberculosis. But with the focus on the germ and therapeutics, these
ideas have not been pursued.
Thomas Holmes was a pioneer in psychosomatic research credited
for showing the relationship between stressful life events and disease
in general, and his work became the cornerstone of modem 'mind-body'
research.
He started his work on psycho-somatic research as a
physician in a United States TB sanatorium in 1949 exploring the
relationship between stress and tuberculosis. Although he lacked the
sophistication of modem epidemiological techniques, several of his
studies showed that persons who had experienced stressful situations
such as divorce, death of spouse, a loss of a job were more likely to
develop tuberculosis and less likely to recover from it. He devised
numeric scales that quantified stressful events and did prospective
studies with control groups (some of his work is- summarised below).
Although Holme's work was rudimentary, and open to scientific
criticism, his basic contention may have been correct,
Holmes was
well regarded among his colleagues and his work received governmental
funding. His scientific findings however were not necessarily
accepted. This may have been because the focus at that time was on the
'germ' and TB treatment was believed to be causing a major decline in
the disease prevalence.
He left TB research in 1962 and his
subsequent work was published in psychosomatic journals.
Holmes also emphasized the need to understand each patient
holistically. The following is a discussion of a 29 year old black
woman at a case presentation:
. . .2
2
At this point in her life, the man she later married returned
from war service to the small town in Louisiana, and after a month of
The marital
superficial acquaintanceship they were married,
adjustment was always poor .... She spoke of herself as "not a
_ _______
Her husband
hotblooded woman" who preferred
church __________
activities,
preferred sports and parties. She resented the fact that he was not
a good provider and stated, "My father built a good home for my
mother.
The husband
Here we are packed in; I need my own home".
chose Seattle as a place to live, and in 1946 they moved here. . . . The
patient always resented the separation from her family and stated, "I
always keep the far home available".
Holmes then explained why this particular woman had become
tuberculous : "It was in the setting of unfulfilled dependency needs, A
and an increasingly strained marital adjustment in a new and
unsympathetic environment, that the patient developed pulmonary
tuberculosis " .
This analysis recalled the holistic approach to
psychosomatics that placed disease in the context of a patient's
personal history.
The contention of this article is not that Holme's work proved
the link between stress and tuberculosis, but that the body of his
research has been completedly ignored in contemporary tuberculosis
literature.
His research and his presentations sought to challenge
the standard model of the disease as a straightforward infection.
"Although infection with the bacillus was necessary, tuberculosis
could not be understood without recognition of the etiologic role
played by underlying personalities and stressful situations".
The
research agenda that he initiated, has remained unworked on since that
time.
While Holmes developed a sophisticated model of tuberculosis as
a 'psycho-somatic disease', he had little say about its prevention and
treatment. Of course one way to alleviate stress among poorer people
would have been to provide them with better jobs, housing and
nutrition. However like most contemporary medical people he advocated
educating people how to anticipate stressful events and thus adjust to
them better.
The fate of Holmers$work is not unusual. Although we know that
tuberculosis is a disease with social and environment roots, our
technical solutions ignore this.
Could the various factors that we
are discussing, urbanisation, overcrowding, poverty mediate some of
their
influences through stress ?
Is there a different way of
looking at the same problem ?
Summary of Thomas Holmes work of tuberculosis
* In a study of .109 sanatorium residents Holmes found that patients
who had localised resolving tuberculosis, were anxious and had normal
5
or high urinary ketosteroid levels, whereas those with
... .3
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advanced and deteriorating TB were depressed and had low urinary
ketosteroid level.
* In a study of Seattle residents' he found that the disease
predominated in areas where there were poorer'and non-white people.
* To understand the effect of emotional stress and difficult social
relations, he interviewed 100 patients admitted to the Seattle
sanatorium. He found that 71 % had experienced financial hardship, 52
31 % met criteria for alcoholism and that
% job dissatisfaction,
these factors clustered in the 2 years preceding the admission.
* He did the same study using a control group and a interview schedule
which he devised to measure the previous occurence of psychosocial
stress (Schedule of Recent Experience).
He compared 20 matched
sanatorium employees who developed TB and those who did not and found
disturbing occurences more frequently in the preceding two years of
tuberculous employees alone.
He also assessed
their "emotional
integration" by a different scale and found that the TB employees were
more frequently 'pathologically disturbed".
* In the next study he used a partially prospective design, comparing
patients who redeveloped sputum positivity on treatment after 3 months
of sputum negativity (21 patients), to patients who remained sputum
negative (24 patients) .
He found that those who had "thrown a
positive" faced emotional problems during hospitalisation and had long
histories of unstable lifes, lack of social,economic and family
supports. Based on this data, he devised a new instrument to measure
the level of emotional disturbance which predisposed to "throwing a
positive". He re-analysed the baseline psychological difficulties of
10 controls using his instrument. On this basis he predicted that two
of the controls on followup would 'throw a positive' and his
prediction actually came true.
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* His final major study titled 'Experimental study of prognosis' used
the Berle Index, an instrument that identified psychological and
social factors characteristic of recovering patients. A high Berle
score predicted recovery from the illness. He prospectively studied 41
randomly selected newly detected tuberculosis patients. After five
years followup, among the 26 who had achieved a normal or high Berle
score, there were no treatment failures.
However five treatment
failures occurred among fifteen patients who had low Berle scores.
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