Behavior and Medicine E-Book

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2020

Seitenzahl: 1052

Beschreibung

Help medical and other health care students successfully prepare for behavioral science foundation courses and examinations: - Comprehensive, trustworthy, and up-to-date - Quick access to information in case examples, tables, charts etc. - Art and poetry humanize and enliven the material - Includes USMLE-style review Q & AsThe latest edition of this popular textbook on the behavioral and social sciences in medicine has been fully revised and updated to meet the latest teaching recommendations by the National Academy of Medicine (NAM). It is an invaluable resource for behavioral science foundation courses and exam preparation in the fields of medicine and health, including the USMLE Step 1. Its 23 chapters are divided into five core sections: mind–body interactions in health and disease, patient behavior, the physician's role, physician–patient interactions, and social and cultural issues in health care. Under the careful guidance and editing of Danny Wedding, PhD, Distinguished Consulting Faculty Member, Saybrook University, Oakland, CA, and Margaret L. Stuber, MD, Professor of Psychiatry and Biobehavioral Sciences at UCLA, nearly 40 leading educators from major medical faculties have contributed to produce this well-designed textbook. The following unique features of Behavior and Medicine make it one of the most popular textbooks for teaching behavioral sciences: - Based on the core topics recommended by the NAM - Numerous case examples, tables, charts, and boxes for quick access to information - Resources for students and instructors, including USMLE-style review Q & As - Specific "Tips for the Step" in each chapter guide learning - The use of works of art, poetry, and aphorisms "humanize" the material - Comprehensive, trustworthy, and up-to-date - Competitive price

Leseprobe

Behavior and Medicine

Sixth edition

Editors

Danny Wedding, PhD, MPH

Distinguished Consulting Faculty Member

Department of Clinical and Humanistic Psychology

Saybrook University, Oakland, CA

Visiting Professor

American University of the Caribbean

Cupecoy, Sint Maarten

Margaret L. Stuber, MD

Program Director, UCLA/VA Greater Los Angeles Psychiatry Residency

Associate Chair of Medical Student Education in Psychiatry

Professor of Psychiatry and Biobehavioral Sciences

David Geffen School of Medicine at UCLA, Los Angeles, CA

.

Dedicated to

my new grandson, Eli James Harrington Bach, with the hope and expectation that we will address the climate crisis in time for him to live his entire life in a world fit for human habitation.

– DW

Dedicated to

my children Ben and Emma, and my husband Larry, my inspiration and support for work in medical education.

– MS

Cover art:

Sparrow by Robert Pope (1989)

Used with permission © Robert Pope Foundation https://robertpopefoundation.com.

Robert Pope was a remarkable Nova Scotia artist who died at age 35 in 1992 from complications arising from his treatment for Hodgkin’s disease. Reproductions of several of Pope’s paintings are sprinkled throughout Behavior and Medicine. The following description of the painting Sparrow is taken from his book Illness and Healing.

The view from the window of spring-time trees in first leaf and blossom, the atmosphere of burgeoning life, contrasts with the patient’s sense of confinement and immobility. The world outside becomes a dream-like fantasy the patient longs to be a part of. Robert’s sketchbook drawings done in Toronto in 1986 introduced the patient and window theme. The window introduces contrasts of interior/exterior, inactive/active, horizontal/vertical, human/animal. Robert also re-invents a theme that is dear to him: an animal giving voice to inexpressible feelings. The bird song suggests things the patient may not be able to see from his restricted vantage point, but can nonetheless hear. It was important for Robert to try to create images of hope as well as documenting all the struggles and challenges a patient faced. This is one of the artist’s most hopeful images, as a result, it is also one of the most popular of the cancer series.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2019957403

Library and Archives Canada Cataloguing in Publication

Title: Behavior and Medicine / editors, Danny Wedding, PhD, MPH, Margaret L. Stuber, MD.

Names: Wedding, Danny, editor. | Stuber, Margaret L., 1953- editor.

Description: Sixth edition. | Includes bibliographical references and index.

Identifiers: Canadiana (print) 20200165925 | Canadiana (ebook) 20200165976 | ISBN 9780889375604

(softcover) | ISBN 9781616765606 (PDF) | ISBN 9781613345603 (EPUB)

Subjects: LCSH: Medicine and psychology—Textbooks. | LCSH: Sick—Psychology—Textbooks. | LCSH:

Health behavior—Textbooks. | LCGFT: Textbooks.

Classification: LCC R726.5 .B45 2020 | DDC 155.9/16—dc23

© 2020 by Hogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

Registered trademarks are not noted specifically as such in this publication. The use of descriptive names, registered names, and trademarks does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Cover image: Sparrow by Robert Pope (1989). Used with permission © Robert Pope Foundation.

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Format: EPUB

ISBN 978-0-88937-560-4 (print) • ISBN 978-1-61676-560-6 (PDF) • ISBN 978-1-61334-560-3 (EPUB)

http://doi.org/10.1027/00560-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

Contributors

Anjali Alimchandani, PhD, MPP

Health Sciences Assistant Clinical Professor

David Geffen School of Medicine at UCLA

VA Greater Los Angeles

Los Angeles, CA

Anjuli Amin, PhD

Clinical Psychologist

VA Greater Los Angeles

Los Angeles, CA

Chloe C. Boyle, PhD

Postdoctoral Scholar

Norman Cousins Center for Psychoneuroimmunology

UCLA Semel Institute for Neuroscience & Human Behavior

University of California

Los Angeles, CA

Clarence H. Braddock III, MD, MPH, MACP

Professor of Medicine and Vice Dean for Education

Maxine and Eugene Rosenfeld Chair in Medical Education

David Geffen School of Medicine at UCLA

Los Angeles, CA

Brenda Bursch, PhD

Professor of Clinical Psychiatry & Biobehavioral

Sciences, and Pediatrics

David Geffen School of Medicine at UCLA

Los Angeles, CA

Steven Cody, PhD

Director of Psychology

Mildred Mitchell Bateman Hospital

Clinical and Forensic Psychologist

Clayman & Associates

Charleston, WV

Andrew B. Collins, MD

Assistant Professor

Departments of Pediatrics, Neurology & Rehabilitation Medicine, and Anesthesiology

University of Cincinnati;

Divisions of Pediatric Rehabilitation Medicine and Pain Management

Cincinnati Children’s Hospital Medical Center

Cincinnati, OH

Arthur G. Gomez, MD, FACP

Clinical Professor of Internal Medicine

David Geffen School of Medicine at UCLA

VA Greater Los Angeles

Los Angeles, CA

Aaron J. Greene, MD

Psychiatric Resident

UCLA/VA Greater Los Angeles program

Los Angeles, CA

Kristine Jo Harrington, DNP, RN, AGNP-C

Assistant Professor

University of Portland

Oncology Palliative Care Nurse Practitioner

Providence Portland Medical Center Franz Cancer Institute

Portland, OR

Peter Kunstadter, PhD

Senior Research Associate

French Research Institute for Development (IRD)

UMI 174/Program for HIV Prevention and Treatment (PHPT)

Chiang Mai, Thailand

Joseph D. LaBarbera, PhD

Associate Professor of Clinical Psychiatry

Department of Psychiatry and Behavioral Sciences

Vanderbilt University Medical Center

Nashville, TN

John C. Linton, PhD, ABPP

Associate Vice President and Dean

School of Medicine-Charleston

West Virginia University

Charleston, WV

William R. Lovallo, PhD

Professor of Psychiatry and Behavioral Sciences

University of Oklahoma Health Sciences Center

Director, Behavioral Sciences Laboratories

VA Medical Center

Oklahoma City, OK

Gregory Makoul, PhD

Chief Academic Officer

Senior Vice President for Innovation and Quality Integration

Saint Francis Hospital and Medical Center

Professor of Medicine

University of Connecticut School of Medicine

Farmington, CT

Kimberly N. Mallin, MD

Professor

American University of Antigua

Antigua and Barbuda

Robert Mallin, MD

Vice President for Academic Affairs

University Provost

American University of Antigua

Antigua and Barbuda

Rashmi S. Mullur, MD

Associate Clinical Professor of Medicine

David Geffen School of Medicine at UCLA

Greater Los Angeles VA Healthcare System

Los Angeles, CA

Todd E. Peters, MD

Vice President and Chief Medical Officer

Sheppard Pratt Health System

Baltimore, MD

Dean A. Sasaki, MD

Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Greater Los Angeles VA Healthcare System

Los Angeles, CA

Steven C. Schlozman, MD

Co-Director, Medical Student Education in Psychiatry,

Harvard Medical School

Associate Director, Child and Adolescent Psychiatry Residency,

MGH/McLean Program in Child Psychiatry

Staff Child Psychiatrist, Massachusetts General Hospital

Assistant Professor of Psychiatry, Harvard Medical School

Lecturer in Education, Harvard Graduate School of Education

Cambridge, MA

Adit V. Shah, MD

Research Assistant

Mindsight Institute

Postgraduate Trainee

Department of Urology

University of Southern California School of Medicine

Los Angeles, CA

Daniel J. Siegel, MD

Clinical Professor of Psychiatry and Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Los Angeles, CA

Madeleine W. Siegel

Research Assistant

Mindsight Institute

Graduate Student

Sustainability Science

The Earth Institute

Columbia University

New York, NY

David M. Snyder, MD, FAAP

Associate Clinical Professor

Department of Pediatrics

UCSF School of Medicine

Fresno, CA

Kimberly A. Sobell, DO, ABP, ABOM

Pediatric Obesity Medicine Specialist

St. John’s Well Child and Family Center

Los Angeles, CA

Linda Carter Sobell, PhD, ABPP

President’s Distinguished Professor

College of Psychology

Nova Southeastern University

Fort Lauderdale, FL

Mark B. Sobell, PhD, ABPP

President’s Distinguished Professor

College of Psychology

Nova Southeastern University

Fort Lauderdale, FL

Carl D. Stevens, MD, MPH

Medical Director

CareOregon

Portland, OR

Margaret L. Stuber, MD

Professor of Psychiatry and Biobehavioral Sciences

Semel Institute for Neuroscience and Human Behavior

David Geffen School of Medicine at UCLA

Program Director

UCLA/VA GLA Psychiatry Residency

Los Angeles, CA

Harsh K. Trivedi, MD, MBA

President and Chief Executive Officer

Sheppard Pratt Health System

Baltimore, MD

Valencia P. Walker, MD, MPH

Assistant Dean, Equity and Diversity Inclusion

Associate Clinical Professor

Department of Pediatrics, Division of Neonatology

David Geffen School of Medicine at UCLA

Los Angeles, CA

Danny Wedding, PhD, MPH

Distinguished Consulting Faculty Member

Department of Humanistic and Clinical Psychology

Saybrook University

Oakland, CA

Lindsay Wells, MD

Health Sciences Assistant Clinical Professor of Internal Medicine

David Geffen School of Medicine at UCLA

Los Angeles, CA

Sara E. Williams, PhD

Associate Professor

Department of Pediatrics

University of Cincinnati College of Medicine

Pediatric Psychologist

Division of Behavioral Medicine and Clinical Psychology

Cincinnati Children’s Hospital

Cincinnati, OH

Brandon C. Yarns, MD

Deputy Section Chief of Geriatric Mental Health

VA Greater Los Angeles Healthcare System

Health Sciences Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Los Angeles, CA

Nicole E. Zahka, PhD

Pediatric Psychologist

Division of Behavioral Medicine and Clinical Psychology

Cincinnati Children’s Hospital Medical Center

Cincinnati, OH

Tongtong A. Zhu, MD

Psychiatric Resident

UCLA/VA Greater Los Angeles program

Los Angeles, CA

|v|Foreword to the 6th edition

It has been over 40 years since George Engel first proposed the biopsychosocial model of medicine (Engel, 1977). The model sought to expand our thinking to intentionally examine the interplay between biomedical factors with the psychological and socio-environmental. This transformative concept catalyzed a period – still in progress – of cognitive dissonance within medicine, and an ongoing search in medical education for how best to create educational programs that align fully with the biopsychosocial model. Despite much progress, much work remains. Although virtually all medical schools now have robust curricula in patient–physician communication and in core skills in behavioral medicine, these areas of instruction still represent the minority of what’s taught in medical school. Further, within the culture of medical education, barriers to acceptance persist. It remains all too common for faculty to refer to such skills as a set of “soft skills,” a pejorative that seeks to position these skills as inferior in importance to the “hard” knowledge and skills of biomedicine. Students find their attention to behavioral medicine increasingly distracted by the still heavy focus on biomedical content on the infamous Step 1 of the US Medical Licensing Examination (USMLE).The situation worsens in graduate medical education, where with some rare exceptions precious little time is devoted to these topics, whether in the classroom or at the bedside. In one observational study of inpatient rounds in internal medicine and pediatrics, social and behavioral science topics arose with virtually all patients (97%) yet were recognized or addressed only 38% of the time (Satterfield et al., 2014).

In the past decade, there have been some promising advances, including the publication by the National Academy of Medicine of the report, “Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula” (Institute of Medicine US Committee on Behavioral and Social Sciences in Medical School Curricula, Cuff, P. A, & Vanselow, 2004). This substantive report provides a road map for the integration of behavior and social sciences throughout medical school. Also, the launch of the new Medical Colleges Admissions Test (MCAT) in 2015, with its inclusion of an entirely new section, “Psychological, Social, and Biological Foundations of Behavior,” sent a very powerful message to pre-medical students about the importance of these topics in medicine (Association of American Medical Colleges, 2019). Further, it has stimulated many aspiring medical students to take undergraduate coursework in the behavioral and social sciences, which will almost certainly broaden their perspective as they enter medical careers.

With this context as backdrop, it becomes even more vital to have substantive, rigorous resources such as this book to help provide a sound and evidence-based foundation for teaching and learning in this domain. Now in its sixth edition, Behavior and Medicine is a tour de force, with a broad and diverse set of topics, all given rich and scholarly treatment. As such, it does justice to the important intersection between health, behavior, and medical care. As medical schools grapple with building or expanding their current emphasis on social and behavioral sciences, this book represents an ideal textbook and reference resource to support teaching, learning, and assessment. By placing a diverse set of topics in one book, it also reinforces the notion of integration, of how seemingly diverse topics and disciplines can be seen as intertwined. Motivational interviewing, for example, is not just a skill to be acquired and practiced, it’s an essential strategy in working with patients with addiction. Social inequalities most certainly have ethical implications. Psychodynamic approaches are equally relevant and informative in approaching the intersection of stress and illness for patients as it is for understanding the well-being of trainees and practicing physicians, critical to addressing clinician burnout.

|vi|The journey to advance the role of the behavioral and social sciences in medicine and medical education most certainly takes another step forward with the publication of this new edition of Behavior and Medicine. It will become a vital resource for educators, a portal for learning for students, and an invaluable reference for practicing clinicians.

Clarence H. Braddock III, MD, MPH, MACP

Professor of Medicine and Vice Dean for Education

Maxine and Eugene Rosenfeld Chair in Medical Education

David Geffen School of Medicine at UCLA

Los Angeles, CA

References

Association of American Medical Colleges. (2019). What’s on the MCAT exam? Retrieved from https://students-residents.aamc.org/applying-medical-school/article/whats-mcat-exam/

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science,196(4286),129–136.

Institute of Medicine US Committee on Behavioral and Social Sciences in Medical School Curricula, Cuff, P. A., & Vanselow, N. A. (Eds.). (2004). Improving medical education: Enhancing the behavioral and social science content of medical School curricula. Washington, DC: National Academies Press.

Satterfield, J. M., Bereknyei, S., Hilton, J. F., Bogetz, A. L., Blankenburg, R., Buckelew, S. M., … Braddock, C. H., III (2014). The prevalence of social and behavioral topics and related educational opportunities during attending rounds. Academic Medicine, 89,1548–1557. Crossref

|vii|Preface

Behavior and Medicine was first published in 1990. Since that time we have taught – and the book has been used by – tens of thousands of medical students. Some of the early users of the book are now physicians approaching their retirement years. Others who used more recent editions are just now launching their careers. We are confident that many of these readers are better doctors in part because of what they learned from our little book.

The two editors share a passion for convincing medical students that understanding human behavior is absolutely critical to their future practice, and we have been happy and congenial collaborators. We’re proud that Behavior and Medicine has been used to educate medical students in Canada, Great Britain, Australia, New Zealand, South Africa, Thailand, Portugal, Scandinavia, and dozens of other countries as well as the original target group—medical students preparing to take the United States Medical Licensing Examination (USMLE).

Although the book clearly targets medical students, professors in training programs in nursing, dentistry, public health, social work, and psychology have adopted the book and found its content germane to their students.

All of the sample questions at the end of the book, designed to help students prepare for the Behavioral Science questions on the National Boards, have been updated and revised to reflect the current USMLE format. To help students optimize their learning, we have also added a box titled “Tips for the Step” at the end of each chapter in which the main learning targets are briefly highlighted. The student who reads the book and reviews the sample questions should have little trouble with the Behavioral Science section of the USMLE Step 1 examination. In fact, one of our most gratifying personal rewards as editors and medical educators has been the numerous students who have reported that they “aced” the Behavioral Science section of the USMLE after studying Behavior and Medicine.

We have highlighted all key words, names, and phrases by putting them in bold type, and we have emphasized all the key concepts that we think are likely to show up on the USMLE by putting them in italics. Thus, a student who does not have time to read each chapter (and, regrettably, this may include all too many medical students) can still prepare for class examinations and the Behavioral Science portions of the USMLE by reviewing the bold and italicized text.

We have worked hard to make this new edition clinically relevant, and almost all chapters include a Case Study illustrating the application of the principles being discussed. Every case draws on the clinical experience of the authors and illustrates how the principles of the chapter can be applied in a clinical setting.

Multiple interlocking themes link each chapter in the sixth edition. One theme is the simultaneous poignancy and beauty of the transitions of life. As children we were filled with awe and fascination; later we worked through the turmoil of adolescence; still later we each trembled at the touch of a lover. Some of us will be fortunate enough to grow old with someone we care about deeply. All of us will die. Those students who take time to appreciate the majesty of this unfolding will be better physicians and more effective healers.

A second theme of the book is the salience of the sense of self. Every cell in the body changes with age and time, but a continuing awareness of self, a continuity of personal identity, significantly shapes and influences our behavior.

A third theme is reflected in the title of Behavior and Medicine. Morbidity and mortality are profoundly affected by how we behave; what we eat, drink, and smoke; whom we choose as our sexual partners; how often we exercise; and whether we take medicines as prescribed. Most people are aware of the factors affecting their |viii|health and yet continue to engage in maladaptive and harmful behavior. Only the most naive health-care provider sees his or her job as simply telling patients how they should behave.

A final theme of the book is the brevity of life and the certainty of death. The art and poems that illustrate every chapter in the book often portray scenes or descriptions of death. We believe awareness and acceptance of death can make life richer, fuller, and more meaningful.

We have spent our entire professional lives as medical educators and practitioners, and we are grateful to have had careers that allowed us to combine clinical practice with research, writing, grant management, and teaching. However, as we look back on our careers, nothing has been more satisfying than our thousands of interactions with medical students, both in and outside the classroom. We are especially grateful for the many students who have told us that they became better doctors because of the classes we taught and the books we edited.

Resources for teachers, including an instructor’s manual, are available via the publisher’s website at https://www.hogrefe.com

Danny Wedding

Margaret L. Stuber

Berkeley, CA

Los Angeles, CA

Acknowledgments

One of the pleasures in editing a book is the brief opportunity to thank the many people who contribute to it. We especially appreciate the chapter authors who were patient with our frequent queries and multiple revisions of their work. Every contributor is a seasoned medical educator, and all are prominent authorities in their respective fields.

We benefited tremendously from comments made by our colleagues in the Association of Directors of Medical School Education in Psychiatry (ADMSEP), the Association of Psychologists in Academic Health Centers (APAHC), and the former Association for the Behavioral Sciences and Medical Education (ABSAME). Many of these individuals use Behavior and Medicine as a text, and a significant number are chapter authors in the current edition. These colleagues made dozens of helpful suggestions that have been incorporated in this new edition.

Danny worked closely with Sue Edwards in preparation of the chapter on medical ethics. Sue is a world-class ethicist, and she collaborates with Danny in teaching medical ethics to students at the American University of the Caribbean in Sint Maarten. She has been a superb mentor and a cherished friend.

We appreciate the congenial support of Doug Pope and the Robert Pope Foundation. The Foundation helped us identify a series of new paintings we have included throughout the book, as well as the painting we selected for the cover. Other artists whose work has been used as covers for earlier editions of Behavior and Medicine include Norman Rockwell, Pablo Picasso, Jose Perez, Edvard Munch and Gustav Klimt.

Rob Dimbleby, our editor at Hogrefe Publishing, has been a wonderful friend and valued collaborator. We truly appreciate his support, good judgment, clear thinking, and consistent good humor. We also appreciate the careful editing of Lisa Bennett at Hogrefe, and her patience with our numerous queries, visions and revisions.

Danny Wedding

[email protected]

Margaret Stuber

[email protected]

|xii|Poetry Credits

The following poems are reproduced with permission of the respective rights holders.

Chapter

Poem

Permission

Chapter 1 (p. 16)

Seizure by Jeanne Murray Walker

From Poetry (1986). Used with permission.

Chapter 4 (p. 41)

Only Stars by Duncan Darbishire

Used with permission.

Chapter 4 (p. 49)

Emily Drowned by Duncan Darbishire

Used with permission.

Chapter 5 (p. 59)

The Discovery of Sex by Debra Spencer

From Pomegranate. © Hummingbird Press. Used with permission.

Chapter 5 (p. 61)

Today I Asked My Body by Hollie Holden

Used with permission.

Chapter 8 (p. 101)

The Knitted Glove by Jack Coulehan

Used with permission.

Chapter 10 (p. 128)

Two Suffering Men by Eugene Hirsch

Used with permission.

Chapter 15 (p. 188)

Peau d’Orange by Marcia Lynch

Used with permission.

Chapter 15 (p. 195)

Patients by U. A. Fanthorpe

Used with permission.

Chapter 16 (p. 202)

But Her Eyes Spoke Another Language by Duncan Darbishire

Used with permission.

Chapter 20 (p. 265)

Rock of Ages by Jack Coulehan

Used with permission.

Chapter 23 (p. 308)

All the Dead Boys by Christopher Soto

Source: Bullets into Bells: Poets and Citizens Respond to Gun Violence. Copyright © 2017 by Christopher Soto. Reprinted by permission of Christopher Soto.

Contents

Foreword to the 6th edition

References

Preface

Acknowledgments

Poetry Credits

Part 1 Mind–Body Interactions in Health and Disease

1 Brain, Mind, and Behavior

Brain and Mind

Experience and Genes Shape the Brain: Relationships, Culture, and Lifelong Development

Central Organizing Principles

The Brain in the Palm of Your Hand

The Scientifically Established Role of Subjective Experience in Clinical Practice

Case Study

Summary

Suggested Readings

2 Memory, Emotion, and Mirror Neurons

Experience and Forms of Remembering

What is Emotion?

Left Meets Right

Neurons That Mirror Other Minds

Case Study

Summary

Suggested Readings

3 Families, Relationships, and Health

What is a Social Network?

How Families and Friends Alter Diagnosis and Treatment Decisions

How Families and Friends Help Patients Cope

How Families and Friends Help Patients Recover From Illness

How Families and Friends Are Affected by Illness

The Role of the Religious Community and Spiritual Belief in Health

How to Work With Families and Communities

Summary

Case Study

Suggested Readings

4 Birth, Childhood, and Adolescence

Overview of Development

Structural Theories of Development

Developmental Snapshots

Summary

Case Study

Suggested Readings

5 Early Adulthood and the Middle Years

Marriage

Marital Problems

Being Single

Work

Adapting to Changes in Health

Summary

Case Study

Suggested Readings

6 Old Age

Introduction and Demographics

Normal Changes With Aging

Assessment of the Older Adult

Disorders

Treatment

Special Topics

Summary

Case Study

Suggested Readings

7 Death, Dying, and Palliative Care

Death and Dying in the 21st Century

Palliative Care

Summary

Case Study

Suggested Readings

8 Chronic Pain

What Is Pain?

Neurophysiology of Pain

Models of Pain

Comorbidities of Chronic Pain

Chronic Pain Treatment

Interventions

Summary

Case Study

Suggested Readings

Part 2 Patient Behavior

9 Stress and Illness

Definition

History of the Stress Concept

Psychological and Emotional Contributions to Stress Responses

Physiological and Psychological Stress

Brain Mechanisms of Emotions and Stress Responses

Stress Responses, Biasing of Physiological Output Systems, and Illness

Cardiovascular Disorders

Wound Healing and Surgical Recovery

Gastrointestinal Disorders

Pain

Immune System Dysfunction

Asthma

Major Depressive Disorder

Posttraumatic Stress Disorder

Drug and Alcohol Abuse, Pathological Gambling, and Eating Disorders

Hippocampal Function and Memory

Interventions

Summary

Case Study

Suggested Readings

10 Addictive Disorders

The Neurobiological Basis for Addiction

Recovery

Treatment

The Opioid Crisis of the 21st Century

Summary

Case Study

Suggested Readings

11 Psychodynamic Approaches to Human Behavior

Introduction

Freud’s Four Indispensable Concepts

Development and Resolution of Symptoms and Suffering

Primary and Secondary Gains

Summary

Case Study

Suggested Readings

12 Facilitating Health Behavior Change Using Motivational Interviewing

MI Development and Overview

Is Motivation a State or a Trait?

Weighing the Pros and Cons of Change

Understanding and Rolling With Resistance

Eliciting or Evoking Change Talk

Key MI Skills, Rationale, and Examples of Using These Skills With Patients

Summary

Case Studies

Suggested Readings

13 Human Sexuality

Introduction

Definitions

Human Sexual Response Cycle

Sexual Behavior

Sexual Dysfunction

Comprehensive Sexual Health Assessment and Intervention

Case Study

Suggested Readings

Part 3 The Physician’s Role

14 Medical Student and Physician Well-Being

A New Language and a New Role

You Can’t Know Everything

The Culture of Medicine

Asking for Academic Help

Asking for Nonacademic Help

Taking Care of Yourself

Summary

Case Study

Suggested Readings

15 Medical Ethics

Core Principles

Ethics and the Law

Competency Versus Capacity

Surrogate Decision Makers

Informed Consent and Refusal

Privacy and Confidentiality

Reproductive and Pediatric Issues

End-of-Life Issues

Organ and Tissue Donation and Transplantation

Ethics and Clinical Research

Summary

Case Study

Suggested Readings and Viewings

Part 4 Physician–Patient Interactions

16 Communicating With Patients

The Patient

The Physician

The Setting

The SEGUE Framework: Integrating Communication and Clinical Tasks

Information Sharing

Handling Patient Emotions

Summary

Case Study

Suggested Readings and Resources

17 Diagnostic Reasoning

Nosology: The Science of Disease-Naming

The Logic of Diagnosis

Summary

Case Study

Suggested Readings

18 Patient Assessment

Mental Status Examination

Psychologic and Neuropsychologic Testing

Summary

Case Study

Suggested Readings

19 Managing Difficult Patient Encounters

Background

The Physician’s Frame of Reference

Managing Patient Expectations

Managing Difficult Patient Encounters

Terminating a Patient Relationship

Summary

Case Study

Suggested Readings and Websites

20 The Humanities and the Practice of Medicine

What are the Humanities? What is Their Relationship to the Practice of Medicine?

The Contributions of the Humanities to the Art of Medicine

The Rebirth of the Humanities in the Medical Canon

The Future of the Humanities and Medicine

Are Formal Studies of the Humanities Appropriately Placed in the Medical Cannon?

Potential Collaborations of Modern Scientific Medicine With the Humanities

Suggestions for Applications of the Humanities to the Practice of Medicine

Summary

Suggested Readings

Part 5 Social and Cultural Issues in Health Care

21 Culturally Competent Health Care

Culture and Health Care

The Culture of the Medical Profession in America

The Practice of Culturally Competent Health Care

Attributes of the Culturally Competent Physician

Summary

Case Study

Suggested Readings

22 Complementary and Integrative Health

Introduction

Overview

Epidemiology and Patterns of Use

Health Care Expenditures

Areas of Research

Integration Into Clinical Care

Case Study

Summary

Suggested Readings

23 Health Equity: Addressing the Social Determinants of Health

Historical Context

Definitions

Evidence for Health Disparities

Health Disparities and the Clinical Encounter

Interventions

Summary

Case Study

Suggested Readings

Part 6 Appendices

How Doctors Die

USMLE-Type Questions

Answers to USMLE-Type Questions

Index

|1|Part 1Mind–Body Interactions in Health and Disease

|3|1Brain, Mind, and Behavior

Daniel J. Siegel & Madeleine W. Siegel

To speak, to walk, to seize something by the hand! . . .

To be this incredible God I am! . . .

O amazement of things, even the last particle!

O spirituality of things!

I too carol the Sun, usher’d or at noon, or as now, setting;

I too throb to the brain and beauty of the earth . . .

WALT WHITMAN

Song at Sunset

Leaves of Grass

What does a professional in the art of healing need to know about the science of the brain and the nature of the mind? How does knowledge about the brain and its influence on behavior enrich clinical practice? Why should a practitioner who works to help alleviate the suffering of others invest the time and energy into understanding the brain and behavior when there are so many other details to learn about illness and treatment? The simple answer to each of these questions is that in order to understand how to treat people, we need to understand how patients experience their illness, how they perceive their encounter with you, and their behaviors that may support a path toward healing. At the heart of a person’s inner experience and outer behavior is the mind.

One dictionary definition states that the mind is “considered as a subjectively perceived, functional entity, based ultimately upon physical processes but with complex processes of its own: it governs the total organism and its interaction with the environment.” The mind is often viewed as synonymous with the psyche, the soul, the spirit, and the intellect. From this perspective, the mind is not distinguished from the “heart,” and thoughts are not separated from feelings. In this chapter we will explore the ways in which we can view the mind as the core of a person’s evolving identity. The ways in which that person responds in an interview, a diagnostic test, or a discussion about potential illnesses, and his or her specific attitude and approach to treatment are each a function of that person’s mind.

Figure 1.1 Four facets of mind. Illustration by Madeleine Siegel, © Mind Your Brain, Inc. First published in Siegel (2018).

One aspect of the mind is a process that regulates the flow of energy and information. Your mind is taking in the information of these words at the moment you read them. You are investing energy in the reading of this |4|sentence, and the layers of information processing beneath your awareness are making linkages to ideas and facts you’ve thought of in the past. In fact, most of the flow of energy and information – the essence of our minds – is beneath our awareness. Mental activity, such as feeling and thinking, can enter conscious awareness and subsequently be shared within our own conscious mind and with other people. When the important feelings and thoughts in our nonconscious mental lives remain out of the spotlight of conscious attention, they can still influence our decisions, reactions, and behaviors. This is true whether we are professionals or patients.

In this chapter we’ll be offering you a way to think about the mind at the center of human experience that includes subjective experience, consciousness, information processing, and the regulatory process of self-organization (see Figure 1.1). The benefit for you in reading through this chapter will be that you’ll gain a new perspective into the minds of others, and perhaps even your own. This skill can be called “mindsight” and permits us to see and shape the internal world. Research has now clearly shown that knowing your own mind can help you in many important ways in your work as a clinician. Because of the necessary brevity of this discussion, only major concepts will be highlighted. If you are interested in further reading you may find the works cited in the Suggested Readings to be an excellent way to learn more about this fascinating topic.

The separation of psychology from the premises of biology is purely artificial, because the human psyche lives in indissoluble union with the body.

C.G. JUNG

Brain and Mind

You can see from the definition given above that the mind has the interesting quality of being “based ultimately upon physical processes” but that it also has “complex processes of its own.” The mind is a subjective entity, meaning that we each experience within us the process of mind that may not be wholly available to objective, and especially quantitative, analysis. The reason we need to pay attention to subjective mental life is that objective research shows us that physical health is directly related to mental well-being. The subjective nature of the mind and the mind’s well-being are, in fact, some of the most important contributors to physiological well-being. For example, studies have quantitatively proven that how patients focus their attention during a medical treatment, such as “light therapy” for psoriasis, has a profound impact on the outcome of medical interventions. People who practice a form of attending to the present moment, called mindful awareness, have been shown to have improved immune function, reduced inflammation by alterations in epigenetic regulation, and optimization of telomerase levels that help repair and maintain the ends of chromosomes. Physicians trained in mindful awareness also have diminished stress from their intense medical practices. The focus of attention literally means how you regulate the flow of information – i.e., how you regulate your mind. Our mental life directly affects medical states – such as those of the heart, immune system, and lungs.

You may be wondering how a “subjective entity” such as the mind can affect the physical processes of the cardiovascular system, the regulation of genes, or the activity of the immune system. One way to explore this relationship between mental function and physiology is to take a look at the connection between the information and energy flow of the mind and the physical activity of the brain.

Many disciplines of science are concerned with understanding the mind. One of those fields is the fascinating area of neuroscience, the study of the structure and function of the nervous system. Branches of this field study specific aspects of neural functioning, such as how the activity of the brain is associated with thinking, emotion, attention, social relationships, memory, and even moral decision-making. Taken as a whole, the field of neuroscience has been exploding with new insights into the correlation between the brain’s function and internal mental processes affecting the outward expression of behaviors. The numerous and expanding insights into brain-mind correlations have direct relevance for the clinical practitioner.

Future generations, paying tribute to the medical advances of our time, will say: “Strange that they never seemed to realize that the real causes of ill-health were to be found largely in the mind.”

LORD PLATT

Professor of Medicine, Manchester, UK

British Medical Journal

|5|Neural Activity Correlates With Specific Mental Processes

While science demonstrates correlations between activity in the brain and the subjective experience of the mind – as with emotion, memory, attention, and thought – we can only say at this point that these are associational findings. In other words, neural activity in one area of the brain at one point in time correlates directly with mental activity of a certain type. Here’s one example: When you look at a picture of, say, the Golden Gate Bridge, we know that the posterior part of your brain, in the occipital lobe of the neocortex, will become active. You may already know that this back part of your brain has been called the visual cortex because of this association. We even know that if you remember the visual scene of the Golden Gate Bridge, that same area of the cortex will be activated. In fact, remembering anything you’ve seen will activate that posterior region.

But here’s a new finding that puts a slight twist on what we should call that area. It’s been known for some time that blind people use the occipital cortex to process what they feel with their fingers, including the raised letters of Braille. A study examined the brain function of people who volunteered to be blindfolded for five days and use only their fingers to feel their way around the controlled environment in which they lived during that period of time. Without the input of their optic nerves during that sightless period, the input from their fingers became dominant in influencing the activity of their occipital lobes, and their occipital lobes were activated whenever they touched something with their fingers.

What does this mean? This study proves that the brain is an ever-changing, dynamic organ that is extremely responsive to experience. Also, as this study reveals, the precious information-processing real estate of the brain is open to “the most competitive bidder.” In the study just described, the now dominant input from the fingers to sense the spatial world came to be “processed” in the occipital lobe. In fact, some researchers have suggested that the visual cortex be renamed the “spatial cortex.” For us, the important issue is that our five senses and where we focus our attention directly shape the neural architecture and function of the brain.

The overly simplistic view that the mind is “just the activity of the brain” can mislead us into reductionistic thinking and unhelpful conclusions. In the example given, our minds can be understood to harness any neural machinery necessary to create a three-dimensional perspective and image of the spatial world. In fact, a range of studies has demonstrated that how we harness the flow of energy and information – how our mind functions with the focus of attention – can directly shape the connections in the brain: “Where attention goes, neural firing flows, and neural connection grows” is one way to remember how the mind can change the brain. Some people even believe that the mind “uses the brain” to create whatever it needs. In this chapter, we embrace this open dimension of the associational and bi-directional influence of mind–brain relationships.

Mental Experience Occurs as Neurons Become Active

Mental processes occur when neurons fire. Whenever you think of “experience,” try translating that, in part, into the idea of “neural firing in the brain.” That is to say, every time you have an experience, there is specific activity occurring in your brain where only certain clusters of neurons are becoming active. The benefit of this thinking is that it helps you understand aspects of how the mind works. The firing of neurons can lead to a cascade of associated firings because the brain is an intricate, interwoven set of web-like neural circuits. Specific regions in the brain are devoted to specific forms of mental processing, such as spatial perception for the occipital regions, as we discussed earlier. Knowing a bit about brain anatomy can therefore inform us about the functional architecture of our mental lives. The more we can understand the underlying structure and function of our internal, mental lives the more we can understand ourselves and patients. In fact, studies of the doctor-patient relationship reveal that such an understanding of others’ minds, called empathy, is one of the more important factors in determining the extent to which clinicians can help others with their difficulties.

To understand the mind in a deeper way, we are turning toward the brain for scientifically based insights that can build our capacities to be empathically sensitive to the subjective lives of others. Here we are starting with the principle that mental processes emerge as neurons fire in specific areas of the brain. What does “neural firing” really mean? Recall that the basic cell of the nervous system is the neuron. This long, spindly cell reaches out to other neurons to connect at a space called the synapse. Synaptic junctions are generally at the receiving neurons’ cell body or its dendrites. The electrical current, known as an action potential, passing |6|down the length of the neuron, leads to the release of neurotransmitters from the pre-synaptic neuron to influence the firing of the post-synaptic neuron. Ultimately the summation of the excitatory versus inhibitory transmitters at the synaptic cleft will determine if the downstream (post-synaptic) neuron will in turn send an action potential down its membrane to influence further neural firing.

Here are the numbers that illuminate the fascinating complexity of the whole process: The average neuron in your brain is connected directly to about ten thousand other neurons, and the estimated twenty to one hundred billion neurons in your brain allow for trillions of connections in a spider-web of soft neural tissue in your skull. When we add to this the trillions of supportive cells, called glia, that have uncertain but likely contributions to information flow in the brain, then we can see how complex the neural processes are that influence our mental lives.

Head stripped from top to show ventricles and cranial nervesJ. Dryander (1537). Courtesy of the National Library of Medicine. Brain size and cranial capacity have not been demonstrated to be meaningfully related to intelligence in humans.

Neurons That Fire Together, Wire Together

Before this seems too overwhelming, remember that there are several principles that make this intricate anatomy actually quite understandable, interesting, and relevant for clinical practice. One of these is our third general principle: neurons that fire together, wire together.

Described long ago, this underlying property of the nervous system has now been explored in great detail. The “linkages” among neurons, the synaptic connections interweaving numerous neurons to one another, is what we mean by the saying that “neurons wire together.” The first part of the principle, “Neurons that fire together,” means that when we have an experience the brain becomes activated in various regions. When neurons are activated at a given time, the connections among those simultaneously active neurons are strengthened. This is why if you’ve had an experience (remember, “neural firing patterns activated”) say, of hearing a certain song when you’ve felt very happy, in the future you are likely to have the same feeling (neural firing of joy) when you hear that same song (neural firing in response to the sounds of the music). This is how learning and memory work. Neurons that fire together at one time are more likely to fire together in the future because the synaptic connections that link them together have become strengthened due to the experience.

In fact, it is these synaptic connections that shape the architecture of the brain, making each of us unique. Even identical twins will have subtle differences between their brains that are created by the unique experiences that shape the synaptic connections that directly influence how the mind emerges from the activity of the brain. Our inner mental life – a life of thoughts, feelings, and memories – is directly shaped by how our neurons connect with one another – which in turn has been directly shaped by our own experiences. In addition, our external behavior is directly shaped by the synaptic connections within our skulls. In short, the brain shapes both our minds and our behavior.

The Mind Can Shape the Connections in the Brain

The fascinating relationship between brain and mind goes even deeper than the one-way street of the brain leading to mental activity and behavioral output. A fourth principle reveals the bi-directionality of mental process and neural firing: the mind shapes the connections in the brain. Recall that an important aspect of the |7|mind is the regulation of energy and information flow. Also consider the fact that the mind has “processes of its own,” beyond the physical processes of the brain from which it emerges. Researchers have clearly established the mind’s power to shape neural firing patterns.

Try this out: think of what you had for dinner last night. Now try to imagine, using visual imagery, what you’ll have for dinner tonight. In this simple exercise, you have chosen (with a little suggestion from these words, but ultimately of your own volition) to use your mind in ways that involve aspects of memory and visualization in your occipital region. Now consider this question: did your mind cause your brain to become active in these areas, or did your brain activate first followed by your mind? The force of mental power to activate the brain gives us a profoundly important insight into how our minds can directly shape the physical state of our bodies. In this exercise, the information flowing from these printed words to your eyes directly influenced your mind – the flow of energy and information within you.

It is helpful in life and in clinical work to realize that a person’s “mental will” and “intention” are both mental processes that can shape how neurons fire. In turn, how neurons fire shapes how they alter their connections with each other. As those neural connections change, the patterns of the mind – ways of thinking, feeling, and behaving – can change. In other words, the mind directly shapes the physical properties of the brain, which in turn alter how our bodies, including the brain, function. These somatic and neural changes in turn can directly influence how our minds function, and how we feel and how we interact with others. As we’ll see, the mind and the brain are profoundly social.

One way of envisioning the connections among mind, embodied brain, and interpersonal relationships is to view them within a triangle of energy and information flow (see Figure 1.2). The mind is the regulation of that flow, the brain is the mechanism shaping that flow, and relationships are how we share energy and information flow with one another.

Figure 1.2  A “triangle of human experience” that reveals how energy and information flow is shared in empathic relationships, regulated by a coherent mind, and flows through the neural connections of an integrated “embodied brain” – the brain and its extensive interconnections throughout the embodied nervous system. Illustration by Madeleine Siegel, © Mind Your Brain, Inc. First published in Siegel (2018).

Consciousness Permits Choice and Change

This raises the fifth and final principle for this section: With consciousness comes the possibility of choice and change. Neural connections in the brain allow for certain patterns of thinking, feeling, and behaving to be enacted. In the course of normal living, these mental activities are often on “automatic pilot,” and are likely shaped largely by the neural connections that then directly influence mental processes. With conscious awareness, however, something new appears to enter this otherwise automatic self-fulfilling brain prophecy. With focal attention – the focusing of awareness onto a process – the power of the mind can be engaged to actually alter old habits of behaving, emotionally responding and thinking. With consciousness there is the possibility to “wake up” and change old patterns. Studies reveal how carefully paying attention may even lead to the secretion of neurochemicals that actually promote neuroplasticity – how the brain changes in |8|response to experience. With practice in living intentionally, these new mentally activated neural firings can create the changed neural wiring that will make these new patterns of mind more likely to occur, even automatically. In other words, what initially required deliberate conscious attention – what is called “focal attention” – to change old patterns can become a new and less energy consuming set of behaviors in the future. Nonfocal attention is how our minds direct information flow outside of awareness. Sometimes our attention is pulled by extraneous stimuli, such as by our smartphones or noises from out in the hallway during a patient visit, and at other times we can guide the focus of attention. This is the essence of new learning and how it becomes embedded in new synaptic linkages in the brain itself (see Figure 1.3 and Figure 1.4). These attentional processes involve distinct networks of attention in the brain.

Figure 1.4  The human brain. Courtesy of the University of Wisconsin-Madison Brain Collection (see also www.brainmuseum.org). Few of us pause to reflect on the majesty of the human brain, or the extent to which it is an integral part of what we call the self.

Figure 1.3 Types of attention. Illustration by Madeleine Siegel, © Mind Your Brain, Inc. First published in Siegel (2018).

Experience and Genes Shape the Brain: Relationships, Culture, and Lifelong Development

As you’ve seen in our earlier discussion, experience not only involves neural firing, but it also shapes neural connections. This may come as a surprise to many who thought that genes solely dictate the structure of the brain. The fact is that both genes and experience shape the brain’s structural properties – the ways that neurons are synaptically connected to each other. About one third of our genes directly determine neural connections, and another one sixth indirectly influence synaptic connections. That’s one half of our genome influencing neural architecture. In the womb, genes play a major role in shaping the basic foundation of the brain. Even after birth, genes continue to influence how our neurons link up to one another. However, both the environment in the womb and our experiences after birth influence the synaptic linkages within our brains. When a baby is born, the distinct neural patterns emerging from these pre-birth influences contribute to what is called our innate temperament. These constitutional patterns of responding and perceiving can make some of us shy and others outgoing. Some may be quite sensitive to stimuli and become overwhelmed easily, while others thrive with intense sounds and sights.

As we grow, our temperamental features interact with our experiences in shaping the person that we become – what some call our personality. One of the earliest types of experiences that shape us is our relationship with our caregivers. Known as attachment, these early child–caregiver experiences are thought to directly shape the circuitry of the brain responsible for how a child comes to regulate emotions, govern thoughts, and engage with other people. But while early attachment is extremely important, the brain proves to be open to change throughout the lifespan. Understanding the impact of early life experiences on how you grew up has scientifically been proven to be an important aspect of how the mind can “wake up” and not repeat unhelpful learned patterns from the past. These attachment studies resulted in two important findings: (1) It is never too late to make sense of one’s early life experiences and become the person one may truly want to be and |9|(2) without such understanding, individuals often live on “automatic pilot” and repeat suboptimal ways of relating to others within their personal and professional lives. In certain ways, the physician–patient relationship may have elements of attachment in which the doctor can “see” the inner life of patients, soothe their distress, and attempt to keep them safe so that they feel a sense of security (see Figure 1.5).

Figure 1.5 The four S’s of attachment. Illustration by Madeleine Siegel, © Mind Your Brain, Inc. First published in Siegel (2018).

Given that the brain continues to make new connections and possibly even grow new neurons throughout its lifespan, each of us can use the power of our mind to alter the connections in our brains. Who we are – what our personality is – can change throughout the lifespan. The experiences we continue to have within the specific culture in which we live can continue to shape how our brains are changing in response to experience. Becoming aware of the impact of these cultural and personal experiences on our continually changing brains can help us understand the ways in which our external environment shapes our internal world and who we are.

Becoming aware of ourselves and waking up means becoming conscious of the power of the mind to make choices that may have previously been considered impossible. Neither our genes nor our early life experiences permanently restrict our minds. The key for clinicians is learning how to teach patients scientifically grounded facts about how central the mind is in shaping its own pathway.

Central Organizing Principles

Self-Regulation

These are powerful ideas that are not easily taken in and understood by either professionals or patients. Fortunately, there are a few central principles that can help organize these ideas about brain, mind, behavior, experience, and physiology. One of these principles has to do with self-regulation. In physiology we learn about the process of homeostasis and a related response to challenge called allostasis, how the body maintains its various systems in balance for optimal functioning. Whether it is the renal system, the cardiovascular system, or the respiratory system, we can examine how homeostasis is maintained to achieve a state of health and well-being. Whenever a system is stressed, homeostasis is challenged and we have an allostatic load. Some stressors lead to high-energy processes that strive to regain homeostasis; other stressors can lead to overwhelming imbalance and devastation that can cause a massive shutting down of normal functioning and even death resulting from an allostatic load that was beyond recovery.

The brain also functions as a self-regulatory system that achieves balance by using a number of domains of functioning. In the simplest terms, the brain moves toward neural homeostasis by alternately using internal and external factors. Internal components of the nervous system would include the synaptic connections in the brain itself, or the level of firing in particular regions. External factors of the nervous system would involve input from the environment, such as altering the signals being received from other people. For example, a newborn who is overwhelmed with stimuli from the external environment will fall asleep in order to maintain balance. In other words, the mind can utilize its different internal and interpersonal capacities to alter its functioning in order to maintain equilibrium in the long-run. Homeostasis of the body parallels equilibrium of the mind. The concept of self-regulation implies that this equilibrium is achieved by altering internal elements, such as how you think or feel, and external interpersonal elements, such as the people you communicate with during a stressful period. Self-regulation in our lives entails modifying both individual and relational elements to achieve equilibrium in mind, brain, and relationships. Being aware of these important internal and interpersonal factors that can serve as crucial resources of well-being as a medical student progresses into training and then practice can be crucial to avoid the burnout and anxiety that can arise from the everyday stressors of being a physician.

Out of the Balanced Flow: Chaos or Rigidity

Our brain achieves balance by directing the flow of energy and information within its neural firing patterns to optimize functioning. One way to describe this neural equilibrium is to use the metaphor of a river. Each |10|bank represents the extreme poles of brain balance: one bank is a state of chaos; the other bank is a state of rigidity. Down the middle between rigidity and chaos flows the river of well-being which can be defined as harmony. In this harmonious state, one isflexible,adaptive,coherent,energized, andstable. Using the acronym FACES can be used to remember these five qualities of neural equilibrium and mental well-being.

The neurons encased in the skull achieve equilibrium through a process called neural integration. Integration means the linking together of differentiated components into a functional whole. Neural integration is what the brain naturally strives to do. When a brain is integrated, it is able to achieve the most flexible, adaptive, and stable states of functioning, the “FACES” flow of the mind and brain that occurs when information and energy are flowing in a harmonious manner. When the brain cannot achieve such integration, a person can experience states of either chaos or rigidity. The brain may become inflexible, maladaptive, incoherent, depleted of energy, and unstable. You may notice such a stressed neural or mental system in yourself or others by observing how internal mental processes, such as thoughts or feelings, or external behaviors, such as reactions to others, occur in response to the extremes of rigidity or of chaos.

As a general starting point, this central organizing principle of self-regulation emerging from the brain’s natural drive toward integration helps us see when the everyday challenges of life become overwhelming and when stress has produced a mental pathway that is rigid or chaotic. As a professional, the river metaphor can help you understand how you, your colleagues, or your patients may be adapting to life’s daily challenges to neural homeostasis and mental well-being (see Figure 1.6).

Figure 1.6 River of integration. Illustration by Madeleine Siegel, © Mind Your Brain, Inc. First published in Siegel (2018).

The Brain in the Palm of Your Hand

We’ve now seen that behavior emanates from the neural firing patterns of the brain and other areas of the body and its nervous system in creating the mind. Mental processes emerge, in part from the firing patterns of particular clusters of neurons. Knowing a bit about these neural regions can be helpful in getting a sense of the relationships between brain and behavior. We’ve explored the notion that mental well-being and neural equilibrium flow like a harmonious, coherent river with rigidity and chaos on either side. In this flow, however, there are twists and turns as the body attempts to integrate its differentiated components to achieve these pathways. As we explore the different regions of the brain, keep in mind that this neural integration involves how differentiated, specialized areas are brought together as a functional whole. This is what neural integration is – the ways that the brain links disparate areas together as a functional whole. When integration is achieved, equilibrium is possible and that state of a coherent and harmonious mind can occur. When integration is impaired, the mind moves into rigid or chaotic states that are not adaptive.

The Logical Left and Nonverbal Right Hemisphere

One way that we can see the nature of how the overall mental system functions is through examining the emotional state of a person. Emotions involve subjective internal feelings, physiological changes in the body, and often, but not always, nonverbal communication. Nonverbal expressions include eye contact, facial expressions, tone of voice, gestures, posture, timing, and intensity of responses. You can remember these seven nonverbal signals by pointing to your eyes, circling your face, pointing to your voice box, gesturing with your hands, pointing to your body, and then pointing to your watch. Interestingly, these nonverbal expressions are both sent and received primarily by the nonverbal right hemisphere of your brain. In contrast, words are most often sent and received by your left hemisphere, the seat of logic and linear thinking. The right hemisphere, |11|however, appears to be more closely linked to our emotional limbic areas that register autobiographical memory and receive an integrated map of the body, including input from the heart and intestines. The