DISEASE PREVENTION AND RESTORING HARMONY: CONTROL THE EMOTIONS

essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Most people recognize that emotional distress can contribute to disease. The emotions, or their immediate secondary effects--such as digestive stress and disturbed sleep--may weaken the body and make one susceptible to infection. The emotions may also trigger flare-ups of chronic diseases; many patients with autoimmune disease mention that this occurs after an emotionally stressful time. But, the question is, how to regulate the emotions so that resistance to disease remains strong?

This subject has been an important topic in the field of Chinese medicine. Since ancient times, disease causation was understood to fall into two major categories-external and internal. External causes included extremes of weather and the influence of pathogens, while internal causes were attributed to the emotions. Today, we recognize that emotions don't directly cause disease, but they make it more likely that a disease process will overcome the body's defenses and homeostatic mechanisms.

There are specific means of attaining balance and harmony that are incorporated into the Chinese culture, based on a long history of seeking good health and longevity. For example, the ancient classics suggest that one should:

Go by the laws of yin and yang, do body-building exercises best suited to one's conditions, practice temperance in food and drink, follow a regular schedule in daily life, avoid overexertion, and keep calm and cheerful.

Such suggestions may seem quaint in the modern world, but they are an integral part of the 2000-year-old culture that may have something to offer today, at least for those who are concerned about fragile health.

The Chinese descriptions of the effect of emotions on health rely on some terms that are not familiar to most Westerners. The main ones are:

• qi (pronounced "chee"), which describes a circulating essence controlling body functions;
• shen, which describes the human spirit that is said to be seated in the heart and is manifest as the mind and is part of the trio of shen, qi, and jing, the latter being the fundamental essence that nurtures the body;
• seven emotions, which is the group of emotions that are traditionally listed and are said to each have differing effects on the body; and
• primary internal organs or organ networks, called zang and fu (these Chinese terms are not used in this text, to avoid confusion). The internal organs defined in traditional Chinese medicine have some differences with those defined by modern medicine; most importantly, the "spleen" refers here to an organ system that is defined to incorporate a number of digestive system functions.

These terms appear in descriptions of emotional excess and emotion-caused symptoms and diseases, and of their remedies that act by strengthening the body and calming the mind. As to strengthening the body, there are many methods, including proper eating habits, which will then help prevent emotional distress. Following is an explanation from Yang Jizhou in The Great Compendium of Acupuncture and Moxibustion (Zhenjiu Dacheng; ca. 1590), with a quote from an older Taoist source Daoyin Benjing:

The spleen is situated at the center of the five organ networks...It contains and fosters the five flavors, it brings about the five mental faculties, and it moves the four extremities....As soon as there is irregular intake of food and drink or overexertion of any kind, the spleen qi will be harmed....If we therefore force ourselves to eat when we are not hungry, the spleen will suffer. If we force ourselves to drink when we are not thirsty, the stomach will bloat. If we eat beyond capacity, the vessels in which the qi circulates will become obstructed, and the body's center (stomach region) will become jammed and shut off. If we eat too little, on the other hand, the body will become emaciated, the stomach will grow anxious, and our thoughts will become unsteady. If we eat contaminated food, the heart's ability to differentiate will become blurred, and we will grow more and more restless. If we eat things that we should not eat, the four great upheavals will occur and bring along disease. None of these types of behavior represents the way of good health. Therefore, it is most important to consume our food at the appropriate time, to drink our fluids in regular intervals, and to avoid both overeating and hunger pains. If we eat and drink according to these simple guidelines, then not only the spleen/stomach network itself will remain unspoiled and function perfectly, but also the organ networks will all be in a harmonious state of health.

An example of the Chinese approach to having a healthy emotional life is presented in The Mystery of Longevity by Liu Zhengcai, who begins by referring to the main text of traditional Chinese medicine, the Nei Jing:

The Canon of Medicine (Nei Jing) advises, in summing the experiences of centenarians in remote times: 'Do not be weighed down by perplexing thoughts; strive to be calm and optimistic; be complacent [calm in the face of situations that can cause anger]; keep sound in body and mind. This way, one can live to the age of 100.' The Canon of Medicine recognizes that emotional and psychological factors are important causes for illness. It indicates that excessive emotion impairs the internal organs of the human body. 'Anger hurts the liver, joy hurts the heart, brooding hurts the spleen, and melancholy hurts the lungs.' Hence, it proposes regulating the emotions by 'keeping the heart calm and cheerful and the mind free of worries.' 'Where can disease come from when the emotional state maintains inner composure?' Scholars on the art of healthy living in subsequent generations set forth many specific methods of maintaining optimism in accordance with this principle.

A good rendition of Chinese ideas of the dealing with emotions by calming the mind was presented by Yuan Liren and Liu Xiaoming of the Beijing College of Traditional Chinese Medicine as part of their series of articles on health preservation published in the Journal of Traditional Chinese Medicine. Their description of the nature of emotions and their depiction of traditional methods for dealing with the emotions is quoted here at length.

In traditional Chinese medicine, all such concepts as consciousness, feeling, and thought are referred to as shen, meaning mind, which is considered to be stored in the heart and to govern all the activities of the organism. Regulation by the mind is necessary in all physiological functions. In fact, the so-called three treasures [shen, jing, qi] are: mind, essence (which constitutes the material basis of the human body), and qi (which is the motive force of all life activities). A sound mind is considered the basis of health and longevity; similarly, scarcity of essence, deficiency of qi, and weakness of mind are the main causes of illness and aging. Since mind plays the role of governing life and commanding all the physiological functions of the primary internal organs and those of the rest of the body as well, it is easily depleted or impaired. Hence, taking good care of the mind is particularly important.

The activities of the mind can be classified into two kinds: emotional and mental. The former refers to changes of mood, known in traditional Chinese medicine as the seven emotions, i.e., joy, anger, melancholy, anxiety, grief, fear, and terror; while mental activities refers to consciousness and thinking. Since the activities of the mind are the general responses of the organs in conforming with the outside environment under the guidance of the heart, maintenance of the mind is bound to involve many aspects, which include roughly the following: preserving the tranquil mind, easing the mind, and regulating emotions. A brief account of these methods is given below.

Preserving a tranquil mind. Tranquil here refers to the state of mind being peaceful, tranquil, free from excessive desires and distracting thoughts, unaffected by outside changes. Such a state of mind will harmonize the organs and maintain a smooth circulation of qi and blood, benefiting the health. This consists of the following aspects:

1. Minimize egoism and personal desires: Excessive egoism and unbounded desires tend to deplete one's mentality, causing disharmony between qi and blood, and with the organs as well, inviting disease, whereas, less egoism and desires helps remove unnecessary mental burdens, enabling one to take a calm and nonchalant attitude toward fame, wealth, and other desires, hence, the mental qi will be preserved and health protected. Here are two points that are essential. First, one should be aware of the harmful effect of excessive egoism and desires so that the mind may be rationally controlled in a tranquil state; second, one should take a correct attitude toward personal gains and losses. An ancient book entitled Health-Preservation Skills Developed by Taishang Laojun points out: 'Those who are expert at health preservation will always first try to eliminate the six harmful elements, namely: fame and profit, the desire for which should be suppressed; the desire for sex, to which one should not abandon oneself; wealth, for which one should not be greedy; rich food, which one should not eat with abandon; unrealistic fantasies, which should be got rid of, for they distract one's thoughts from reality and are harmful to one's mind; and jealousy, which should also be eliminated.' Eradication of the above-mentioned six harmful factors has since ancient times been considered essential for health preservation and is therefore worthy of our attention.
2. Be broadminded in conducting oneself in society: When faced with undesirable things and situations, one should be broadminded and try to look on the bright side. In handling various kinds of complicated problems and abrupt changes in one's daily life, a stable state of mind and an optimistic attitude toward one's life is very good for preserving a sound mind. This includes the following aspects: first, set a lofty goal in life-health preservation requires first and foremost that one should cherish hopes, love life, and keep a lofty goal, a noble ideal, and sound morality, all of which guarantees for a sound mind; second, be content and be happy, for it keeps one satisfied with what one has, caring little about temporary setbacks and failures, and this, in turn, will bring about both physical and mental health.

Easing the mind. Moods are the responses of people to their surroundings, and everyone experiences the seven emotions and six desires [six harmful elements, described above]. If not properly regulated, the emotions will cause stagnation of qi and blood, and disharmony between the organs, leading to illness, even early death. Those who lived a long life, according to historical records, are almost all people apt to regulate their moods, the essence of which is to cultivate the mind with virtuous and elevated ideas and mold the temperament. Various methods have been developed and described by people in the past, which can be boiled down to the following: creating a happy mood by engaging in a great variety of carefree, light, and lively activities in which spirit is heightened, intelligence is increased, muscles and tendons are exercised, and circulation of qi and blood is activated so that health preservation is achieved in the midst of amusement and sports, achieving the aim of nurturing the mind, strengthening the body, and prolonging life. Some traditional methods employed for this purpose include taking up hobbies, such as playing the piano and chess; raising flowers, plants, birds, or fish; sightseeing; and chatting with friends.

Adjusting emotions. In one's daily life, the complicated situation is bound to influence one's moods such as from joy to anger, grief, etc. When one is in a bad or abnormal mood, one should try to adjust and control it lest it go to an extreme. As a mental means of health care, the following methods are used:

1. Exercising self-control: Traditional Chinese medicine holds that the seven emotions, i.e., joy, anger, melancholy, anxiety, grief, fear, and terror, are, in the extreme, one of the main causes of illness. Therefore, timely adjustment of one's emotions with a view to preventing them from going to the extreme is an effective method of health preservation. Ever since ancient times, experts in health preservation have believed that anger is the chief pathogenic factor, for great anger may impair the liver and also affect the heart, stomach, and brain. Hence, control of anger is an important method of adjusting the emotions. The essence is to control emotions by rational reasoning, that is, to cultivate one's morality, train one's will, consciously control one's mood, and overcome emotional impulses with reason. As the ancients put it: 'When faced with something exasperating, one should calmly consider which is more important-anger or health?' This comparison will enable one to gradually eliminate anger.
2. Providing outlets for anger. This is to help regain one's psychological balance by finding proper outlets for detrimental emotions accumulated in one's mind. This method can be explained in three parts. First, direct release: When one is in great sorrow, he should have a good cry so that he may feel comfortable after his sorrow has been fully given vent to. This is a measure beneficial to health care; it helps regulate the circulation of qi and blood and, consequently, prevent depression. Other measures are: a loud cry when in great pain; a thorough pouring out of one's heart when in great anger; a deep sigh or moan when worried; or hearty singing when in great joy. Different forms of expression are used for different emotions, all to restore the mind to a peaceful and tranquil state. Second, there is controlled release: in contrast to direct release, this measure stresses a controlled and gradual release of pent-up emotion in one's mind when in bad moods. For instance, one may confide in relatives or good friends the bitterness or grievance, or express feeling by saying poems or writing articles. The advice and consolation of one's relatives and friends and the release of emotion will enable one to acquire psychological comfort and support, broaden the mind, and finally become happy and at peace. This is a good method for eliminating detrimental emotions. Third, there is the method of diverting one's attention. This is also known as diverting one's emotion, that is, changing the focus of excitation, the principle of which is to free a person from entangling emotions by taking certain measures to separate oneself from harmful stimulating factors....For instance, when in great distress or depression, one may listen to a favorite piece of music or when one is in great sorrow following some misfortune, one may stay with relatives or good friends for a period of time; the change of surroundings and atmosphere may divert bitter emotions, allowing one to restore normal life after calming the mind. Or when one is afflicted by troubling thoughts, one may take a walk so that the surroundings of nature may relax and refresh the mind, and thinking ability will be restored.

This summation by Yuan and Liu shows that one should respond promptly and effectively to emotional distress and should cultivate habits and thought patterns that help one avoid frequent experience of emotional excess. In the traditional Chinese medical view, the emotion-based causes of disease, like the external-based causes, are assumed to fade out as circumstances change. For example, for someone who is exposed to severe cold, which causes or contributes to some diseases, the weather in the summer will eventually turn hot and the initial cause will be removed, at least for a while. Similarly, if one experiences severe anger, fright, or fear, one will certainly experience something else later. Rather than waiting for circumstances to change gradually, one can more immediately respond to the situation, for example, by warming up the body after exposure to extreme cold or relaxing anger after a threatening encounter.

There can be circumstances where causative factors remain prevalent, but this is usually because of failure of the person to accept and follow the basic rules that have been developed over the centuries. If one lives in a region of the country where the weather is cold most of the time, then one is expected to adapt to this circumstance by dressing warmly, eating warming foods, and staying physically active. If one experiences anger or other emotion repeatedly, one is expected to adapt to the circumstance by altering behavior and changing attitudes. For the Chinese, the changes are made in accordance with one or more of the traditionally provided means of accomplishing the task: Confucianism, Taoism, and Buddhism. These philosophical and religious systems (often referred to as the three pillars of Chinese society) instruct people in living properly. In the West, many people turn to Eastern philosophy for assistance in this realm. Still, people often feel most comfortable discussing the issue in terms of health and not in relation to the religious and cultural peculiarities of the East.

Shi Tianji, a scholar on the art of healthy living in the Ming Dynasty, proposed 'Six Always' for maintaining a calm and cheerful state of mind, summarized here:

1. Always be peaceful in mind. Remain peaceful in mind without vain hopes. Do not covet, do not indulge in vain wishes, do not worry about personal gains and losses. Hence, Shi Tianji said, 'If one has few desires, his mind will naturally be peaceful. Just look at secluded hills and remote valleys! Most people there enjoy long life spans because they have few desires and always remain peaceful in mind.'
2. Always be kind-hearted. A kind-hearted person often takes pleasure in helping others and has no desire to harm others. Whenever he conceives an idea, makes a remark, or does a deed, he always ponders whether it is beneficial or harmful to others. 'When others are evil, I remain upright; when others are vicious, I remain kind-hearted; when others stir up troubles, I strive to alleviate troubles; when others harm people, I serve people. If I act in this way, I shall have a clear conscience and naturally feel calm and tranquil in mind.'
3. Always uphold justice. Distinguish between evil and virtue and between right and wrong. Virtue and evil are antagonistic, and right and wrong are not to be confused. If one maintains his awareness, upholds integrity, and remains clear-headed and sharp-eyed, he will naturally be free from worries and troubles. Hence, Shi Tianji said, 'When the sun shines in the sky, obscurity is naturally cleared away. When one grasps this miraculous concept, he will be cured of disease and attain longevity as well.'
4. Always be cheerful. Adapt to different circumstances; feel complacent at all times; avoid overdoing anything and do not hurt anyone's feelings. As Bai Juyi says in a poem: 'Be cheerful, whether rich or poor; he who does not laugh can only be a fool.' One should often have hearty laughs. A folk saying goes, 'A good laugh makes one ten years younger; worry turns the hair gray.'
5. Always be pleasant. Harmony is paramount in human relations. Be amiable, modest and prudent, broad-minded and magnanimous; do not be calculating and do not worry about trifles. To be amiable in dealing with others will bring happiness to both the others and oneself.
6. Always be contented: it is a rare person who avoids all adversity. One should remain cheerful despite adversities. Yan Feitai had a wise epigram on caring for life. 'Just step back to think everything will naturally be all right.' 'Contentment is happiness.' Whenever this is adversity, compare it with a worse circumstance and one will feel calm and cheerful.

Thanks to the availability of translated books, Westerners have relatively easy access to these Oriental traditional systems of dealing with emotions; additionally, they have other means of dealing with emotions, including their own religious heritage and established psychological aids.

SUMMARY: THE CHINESE METHODS FOR DEALING WITH EXCESSIVE EMOTIONS

Chinese literature describes two basic means of dealing with excessive emotions:

• Since excessive emotions arise because of derangements in the functions of the internal organs and disorders of the circulation of qi and blood, one can deal with the effects of the emotions by making efforts to correct these internal imbalances. Aside from receiving acupuncture and herbs from practitioners, the individual is expected to regulate daily life: arise early, eat nutritious food, carry out one's work in an effective manner, avoid excesses in sexual activity, dress according to the weather, be kind and compassionate to those one encounters, go to sleep at a reasonable hour, etc.
• Since excessive emotions lead to diseases, one must cultivate a mental condition that is calm. This is done through following the rules set down by and practices of the individual's religion and by following the advice of those who have attained a state of equanimity.

APPENDIX: How Emotions May Contribute to Cancer

The traditional Chinese medical view of cancer etiology holds that there are several possible contributing factors, and that one of the principal causes is internal factors, namely emotions. For example, Sun Binyan writes in his book Cancer Treatment and Prevention (1):

According to our understanding of the tumor patient, most have suppression of the emotions. They tend to hold in their anger. Although some patients have good results after treatment, emotional stimulation may cause them to decline again and then the previous treatment would have been in vain. Some people have a severe phobia about cancer. Before they know the real disease, they have a lot of suspicion. Once they know they have the cancer, their whole spirit breaks down. This kind of spiritual state is very bad for the treatment.

In the book Prevention and Treatment of Carcinoma in Traditional Chinese Medicine (2) Jia Kun gives 10 recommendations for prevention. In addition to good environment and personal hygiene, proper levels of work (exercise) and rest, good eating habits and proper food, avoiding smoking, and timely treatment of all ailments, he states that:

Emotional changes, such as worry, fear, hesitation, anger, irritation, and nervousness should be prevented. Mental exhaustion is harmful and life should be enriched with entertainment.

Shi Lanling and Shi Peiquan mention the etiology of various cancers in their book about Experience in Treating Carcinomas with Traditional Chinese Medicine (3), as regards the effect of emotions:

The etiologic factors of the disease involve chiefly the disturbance of the seven emotions, especially melancholy, anxiety, and anger, which are liable to impair the spleen and the liver. Impaired by melancholy and anxiety, qi will be stagnated and the spleen will lose the function of transformation and transportation, leading to disturbance of water metabolism and the subsequent accumulation of phlegm-dampness, while, impaired by anger, the liver qi will be stagnated. The stagnated liver qi, as qi is the commander of blood, may give rise to blood stasis if not relieved in time. Thus, emotional disturbance, in-coordination between the ascending-descending movement of qi of the internal organs, sluggish flow of qi and blood, and the ensuing obstruction of dampness, phlegm, and blood stasis are the fundamental pathogenesis of the disease.

The authors go on to mention other contributors, such as consumption of food that is "rough, hot, or hard," indulgence in smoking, alcoholism, traumatic injuries, and chronic ulceration. In their section on treatment of breast cancer, the authors refer to a discussion in a Ming Dynasty text by the surgeon Chen Shigong (1555-1636 A.D.) indicating that breast cancer "results from anxiety, emotional depression, and overthinking which impairs the liver, spleen, and heart and causes the obstruction of the channels." This text is also mentioned in The Treatment of Cancer by Integrated Chinese-Western Medicine (4), translated this way:

Breast cancer is due to worry and melancholy. Lots of ideas hanging around make one feel dissatisfied. Perverse flow of liver qi to the spleen leads to the obstruction of the channels and collaterals and congealations due to excessive accumulation.

Pan Mingji, in his book Cancer Treatment with Fu Zheng Pei Ben Principle (5), presents a section on etiology of cancer, listing 5 contributing factors. The first item mentioned is emotional disturbance:

TCM embodies changes of spirit and sentiment as the seven emotions: pleasure, anger, grief, fear, yearning, sorrow, surprise, all of which are emotional, physiological reactions of an organism towards external changes in its environment. Emotional disturbance refers to reactions, either excessive (excitation) or insufficient (inhibition) which will ultimately lead to disturbances in the flowing of qi and blood and the visceral functions, with subsequent illness. TCM claims rage harms the liver, excessive stimulation harms the heart, grief harms the spleen, great sorrow harms the lungs, and fear harms the kidneys. Though not necessarily precise, this belief definitely points out that emotional injury will effect the physiological functions of the qi, blood, viscera, and channels, and lower the body resistance, resulting in disease. The human body is susceptible to cancer when under emotional stress or disturbance. This is mentioned early in Chinese medical classics, such as Yellow Emperor's Canon of Internal Medicine and Golden Mirror of Original Medicine.

The Oriental view that emotions contribute to cancer formation differs from that adopted by Western scientists, who regard cancer as a change in DNA that is induced by a chemical agent, radiation exposure, or insertion of viral genes (in a few cases, the abnormal DNA may already be present in the genetic heritage of the individual). In order for the induced DNA change to lead to cancer, it is first not properly repaired by certain DNA repair proteins and then the abnormal cell is not destroyed by a natural cell death process (apoptosis). Cancer initiating factors act within the environment of the individual-which includes the person's genetic background and nutritional status-to trigger the development of cancer. Thus, lung cancer is often caused by breathing carcinogens such as those contained in cigarette smoke; stomach and colon cancer are often caused by carcinogens in the food supply; skin cancer may be induced by excessive exposure to the ultraviolet light of the sun; and leukemia may be induced by exposure to industrial chemicals, to radiation, or to a virus that resides in the bone marrow. Traditional Chinese doctors were aware of this type of external causation. For example, they recognized that cancer occurred more often in certain places and was attributed to something in the drinking water, or that cancer could be induced by rotted food and, in modern times, by smoking. Yet, it was the emotions that were often regarded as the most significant factor. At the least, the excessive and/or suppressed emotions would disrupt the functions of the internal organs and the flow of qi and blood, and then the external factors would more easily induce further damage. Pan goes on to say:

There are a lot of factors which affect the anticancer ability of the organism, but the leading one has to do with whether the spirit, nervous system, and various defenses of the organism are perfect. A lot of evidence proves that those who are optimistic and undertake exercises [in China, this refers mainly to taiji and qigong, along with similar types of practices, as well as hiking in the woods] tend to have healthy and sound function of the nervous system, strong physiques, and naturally great anticancer ability and immunity. Even if those people come into contact with outside carcinogens, they will not develop cancer. On the contrary, those who have mental injury, who are disheartened, or often have a fear of cancer, and who do not undertake exercises at all or are overtired, whose daily life is irregular and unsanitary, whose spirit and nerve function is disorganized, tend to reduce their defensive ability. As a result, the rate of cancer occurrence among those people is higher.

Western researchers have not undertaken detailed study of the possibility that persistent or repeated experience or suppression of emotions contributes to the risk of cancer for several reasons. Aside from a low motivation to undertake the study because other factors are considered more important, such research is extremely difficult to perform properly. One would have to recruit a very large number of people into the study, have some reliable method of measuring emotional status over a long period of time, and then find some way to quantitate the emotional condition (as it varied over time) so as to compare with the actual incidence of cancer among individuals under study. Still, the fledgling field of psychoneuroimmunology (the study of how psychological states and nervous system manifestations of the emotions impact the immune system) has developed some data supporting the concept that emotional stress increases a person's susceptibility to cancer (12).

In China, a study (7) involving a huge population (750,000 people in Beijing) attempted to find out if psycho-social factors contributed to the incidence of primary lung cancer. They reported that their study showed three factors positively associated with occurrence of lung cancer:

1. Burst of emotion that could not be controlled.
2. Poor working circumstances, including poor relationship with coworkers
3. Depressive feeling for a long time.

Poor relationship with coworkers would generally suggest that there is emotional tension during the work day, so all of these could indicate emotional disorders associated with higher incidence of cancer. When "depressive feeling for a long time" was analyzed further, it was found that this was a significantly stronger risk factor for women than men. This study supports the traditional Chinese contention that emotions can contribute to cancer incidence, but it would need to be verified by a tightly controlled trial in order to convince Western researchers that the results could have important implications for understanding the etiology of cancer.

The emotional status of patients after receiving a diagnosis of cancer has been studied, but the difficulty in monitoring emotional status was perhaps the only thing clearly revealed. In a study conducted in Denmark (6), women who had just been diagnosed with breast cancer that was considered to have a low risk of recurrence (easily treated, not metastasized) were compared with women from the general population. The results conflicted with the expectation that the patients would have a higher level of stress and anxiety, but this may simply reveal the difficulty of designing the monitor of emotional status, since other studies have found that anxiety and depression in cancer patients tends to be a significant problem.

A POSSIBLE MECHANISM INVOLVING SHORT-TERM EMOTIONAL STRESS

The Chinese physicians who comment about the role of emotions in cancer formation point to the fact that the internal viscera become weakened, thus increasing the opportunity for pathologies of all types, including cancer. Western research has already supported the idea that depression can impair immune system functions (perhaps indirectly, such as by repeatedly impairing a good night of sleep, with sleep contributing to maintenance of the immune system). It has been shown that tumor-relevant lymphocyte subpopulations, such as natural killer cells (NK cells; these can directly attack cancer cells), have receptors for various neuropeptides, including those released during stress. This finding indicates how NK cell activity might be modulated by a person's emotional responses. The level of NK cell activity has been found to be a reasonably good predictor of outcome for women with breast cancer. Further, a portion of the loss of this immune cell activity in cancer patients was shown to be correlated with psycho-social measures such as patient "adjustment" (avoiding showing distress at the cancer diagnosis/treatment), lack of social support, and symptoms of fatigue/depression (14).

Along these lines, the immune system may regulate the activities of enzymes, such as aromatase, that converts estrogens to estradiol in breast tissue (17, 18), where estradiol is thought to contribute to breast cancer. Cytokine changes (as occur with infection and inflammation) have been observed in cases of major depression, and have been suggested to be a potential cause of depression (19, 20). In fact, some antidepressant drugs are tumor necrosis factor (TNF) inhibitors; this being one of the cytokines that causes considerable adverse effects in cancer patients. It is also possible that depression, and other emotional disorders, will affect the cytokines.

In the book Why We Get Sick (10), which is based on the premise that most of our body (and mental) functions have been determined by evolutionary factors, the author explains how a potentially helpful feeling (anxiety) can have harmful physiological effects:

Everyone must realize that anxiety can be useful. We know what happens to the berry picker who does not flee a grizzly bear, the fisherman who sails off alone into a winter storm, or the student who does not shift into high gear as a term-paper deadline approaches. In the face of threat, anxiety alters our thinking, behavior, and physiology in advantageous ways....Because anxiety can be useful, it might seem optimal to adjust the mechanism so that we are always anxious. This would be distressing, but natural selection cares only about our fitness, not our comfort. The reason we are sometimes calm is not because discomfort is maladaptive, but because anxiety uses extra calories, makes us less fit for many everyday activities, and damages tissues. Why does stress damage tissues? Imagine a host of bodily responses that offer protection against danger. Those that are "inexpensive" and safe can be expressed continually, but those that are "expensive" or dangerous cannot. Instead, they are bundled into an emergency kit that is opened only when the benefits of using the tools are likely to exceed the costs. Some components are kept sealed in the emergency kit precisely because they cause bodily damage. Thus, the damage associated with chronic stress should be no cause for surprise....In fact, recent work has suggested that the "stress hormone" cortisol may not defend against outside dangers at all, but instead may mainly protect the body from the effects of other parts of the stress response.

Thus, if the "emergency kit" that is intended to respond to specific immediate dangers is left open for an extended period of time, for example, by living in a situation that the body and mind deems unsafe, then progressive damage to the tissues can occur. This damage may then cause or exacerbate chronic disease or a life-threatening event (e.g., stroke, heart attack, incurable cancer). Cortisol, which may act as a protector for the body, when elevated for long periods of time, can impair immune functions, eventually leading to damage.

Chinese researchers have attempted to quantify physical responses to emotional distress. In one study (21), rats that became angered and fought with one another were tested after this change compared to others that remained in a calm condition. The study results suggested that the stress condition induced release of extra adrenocorticotropin hormone (ACTH), raising cortisol levels, which had a secondary effect of reducing the output of hydrogen peroxide from macrophages (a type of white blood cell). It was thus proposed that the defensive function of the immune system could be slowed or impaired as a result of the emotional stress. In an Algerian study of women under stress (22), it was shown that heightened cortisol levels often occurred, and that this was sometimes counteracted by production of another hormone, dehydroepiandrosterone (DHEA), which was suggested to be a potential therapeutic substance to counter the adverse effects or raised cortisol.

It seems entirely possible that a single period of intense stress lasting months, such as occurs with a divorce, death of a family member, loss of job, or other life-changing event, rather than decades of habitual emotional distress, might lead to serious damage to the tissues which could trigger or allow the development of cancer. The stress hormones might themselves stimulate latent cancer cells into reproduction; the hormones or their metabolites might transform a normal cell to a cancer cell; or the damage to the tissues may lead to failure of normal cancer-control mechanisms. In this way, a diagnosis of cancer may be encountered a year or two after such an event (it takes that long for the cancer to develop enough to yield evident symptoms or a diagnosable lump). Such a correlation-between stressful events and subsequent cancer diagnosis (13) or recurrence of previously treated breast cancer (15)-has been supported by early studies that still require replication. If severe emotional stress (of the type that is likely to be mentioned during questioning) does sometimes give rise to cancer soon after the stress is experienced, this would certainly explain the observation made by traditional practitioners: that emotions are a cause of cancer.

REFERENCES TO APPENDIX

1. Sun Binyan, Cancer Treatment and Prevention, 1991 Offete Enterprises, San Mateo, CA.
2. Jia Kun, Prevention and Treatment of Carcinoma in Traditional Chinese Medicine, 1985 The Commercial Press, Hong Kong.
3. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine, 1992 Shandong Science and Technology Press, Shandong.
4. Zhang Daizhao, The Treatment of Cancer by Integrated Chinese-Western Medicine, 1989 Blue Poppy Press, Boulder, CO.
5. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fujian.
6. Groenvold M, et al., Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison? Journal of Clinical Epidemiology 1999; 52(6): 523-530.
7. Fan RL, Zheng SH, and Wu ZS, Study on the relationship between lung cancer at preclinic stage and psycho-social factors: a case control study, Chinese Journal of Blood Diseases 1997; 18(5): 289-292.
8. Cavaljeri EL, et al., Molecular origin of cancer, Proceedings National Academy of Sciences 1997; 94: 10,937-10,942.
9. Pan Mingji, How to Discover Cancer Through Self-Examination, 1992 Fujian Science and Technology Publishing house, Fujian, China.
10. Nesse RM and Williams GC, Why We Get Sick, 1994 Times Books, Random House, New York.
11. Guzman RC, et al., Hormonal prevention of breast cancer: mimicking the protective effect of pregnancy, Proceedings of the National Academy of Sciences USA, 1999; 96(5): 2520-2525.
12. Ader R (editor), Psychoneuroimmunology, 1981 Academic Press, New York.
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