Massimo Biondi, M.D.
Professor and Chair
Department of Neurology and Psychiatry
Dr. Baile: Good afternoon, I'm Walter Baile Director of the Interpersonal Communication and Relationship Enhancement (I*CARE) Program at MD Anderson and this is our ACE lecture series Achieving Communication Excellence and we have the great pleasure of having a speaker from abroad today but before that I wanted to acknowledge the fact that this is Nurses Week and so everybody who's a nurse can you hold your hand up so we can give you a big round of applause, thank you.
[ Applause ]
For your service. So just a couple of little housekeeping items if you could please fill out the evaluations that you have at the end of the conference so that we can get support from the administration for having sponsored these lectures the generosity of Dr. Burke's office and the other administrative offices and on May 26 we're going to have a very interesting lecture by Rebecca Walters who is a trained psycho dramatist on using psychodrama methods in dealing with patients and staff conflicts and things of that sort so that would be very interesting. I noticed despite the fact that we have a speaker from Italy today that the classical Italian sandwiches did not go as fast as the rest, okay. And it's always amused me that this room is kind of beveled in the middle so that everybody slides towards the ends, you know we have a little bit of space so if...understand, so anyway let's get down to business
It's my great pleasure today to welcome Professor Massimo Biondi who is a good friend and colleague from the University of Rome where he is Chair of the Department of Psychiatric Sciences and Psychological Medicine and also Director of their Psychiatric Professional Specialization program. Professor Biondi is the author of 4 and editor of 12 books and over 300 scientific publications, about 70 in English and other international journals and he's editor of a member of the Advisory Board of the American Psychiatric Association, Textbook of Psychiatry, a very important work that comes out of the APA every year. His background is very interesting because as a psychiatrist he's interested in traditional psychiatric issues such as mood disorders and anxiety disorders but also psychosomatic medicine that he's been working on for the past 20 years so that many of his articles are around some of the issues related to the neuroendocrine and immune changes that occur in stressful environments like the one that we all occasionally work in here and so today he's going to talk about the psychosomatic aspects of provider-patient communication as it can play out in a cancer center such as ours where we're always dealing with stress and difficult patients sometimes and difficult families. So without further ado Massimo, thank you for joining us
[ Applause ]
Let me get this so you can move this okay and then you can use the pointer here okay.
Dr. Biondi: I am honored to be here and glad also. I wish to give thanks to Professor Baile for his kind invitation and for what he is doing in the professional training of providers and in health communication for what he has done for us in Italy and in Europe and so this is an issue, my presentation which is peculiar, I hope it can be of interest for you. And we start by remembering that our medical literature traditionally treats provider-patient communication as strictly a matter of our mind, our thought or our emotions that is that it ignores the [inaudible] of the brain and of the body in communications. This communication however is full of brain and bodily changes. I think that any one of us can recognize them. It hopefully involves intense activation of brain centers and the centers which are involved in emotional distress, anxiety, anger, fears and other kind of emotions that we can all interpret often as markers of distress of tension or discomfort during the communication with patients. This distress is not overt many cases is covert, hidden inside and it is not only in nurses, doctors, patients it is also in family members which are involved in the communication of the disease. We see it available in data about the psychobiology communication of especially in oncology but not at all in oncology, really scarce. We do some research in the past about the data very few. I present some very early data suggesting how the doctor-patient communication in the relationship and the hidden dimension. And in the dimension that is related to the emotional cost that this communication has for providers, for nurses, for doctors and it is responsible for professional burnout and also for moreover, cynicism, distancing from the patient. Avoidance of communication is protective and however it is ineffective for protecting at the deep biological level of suffering. The findings that I'm going to show could help you to explain the burden of caring for severely ill people. I hope also that this lecture might help you to understand how profoundly intense on a somatic level our patient communication is and hopefully it also suggests that training communication is a need for all work involving communication with patients.
Emotional arousal can have correlates at many levels in our body from brain pathways right down to the main biological systems such as the autonomic nervous system, the neuroendocrine system, the immune inflammatory system and the musculo-skeletal system, there's a lot of research on these findings since about 30 or 40 years. So we can ask what happens when emotion is elicited within personal relationships and communication. Recent research in neurobiology discovered the specific parts of the brain which are devoted to the communication, the interplay with others. They are named social brain circuits. The Theory of Mind is a technical term developed in psychobiology tries to explain how social interactions with other people including conversation, beliefs, attitudes all have correlates at the cerebral level in the brain and after in seconds in the body. That is our brains are not built for or designed to handle all the arousal and emotions which are elicited in some communication like those negative, intense interactions with people who are suffering.
An interesting concept is this one that in the social circuits of the...circuits of the social brain are engaged in this communication and they are expanding resources by chemical resources at the neuronal level and that the second concept is that these resources which are serotonin, dopamine, [inaudible] and so on are limited, are limited. These are an example of the social brain circuits as they are serving many tasks, experimental tasks, that is interesting literature you can consult. You see that it's virtually the frontal and pre frontal areas are involved. Also as we see the cortical, subcortical,and cortical circuits and it's interesting to point out that when one is seeing a patient or another person in pain we have our own pain centers activated. Not the peripheral pathway but pathways which are possessing the effective content of the stimulus resulting in the pain experience. Central brain pathways possess stimuli and give the colors to them, the colors of unpleasant experiences and eliciting fear, anxiety, anticipation of other pain that is the effect of experiencing pain. In viewing another person in pain our centers of pain are activated just viewing and imagination of the other state of mind that is [inaudible] mind. Empathy for pain activates these brain effected components for pain and we can see that empathy can be defined as the ability to have an experience of another's pain at this level. This is fundamental because when we see people suffering to some extent we are mirroring them inside in the brain. Our circuits of pain are activated to some extent.
It's also interesting to see that the more intense is the relationship with the person, more intensely we react, that is if the pain is of a loved one the response is much more intense. This is the Empathy Involvement Scale and this is the intensity of the response in the insular cortex and the singular cortex. The paper was originally published in "Science." So we can ask what happens in the body? Which are the consequences? We can study what happens by means of [inaudible] psychophysiology, I mean psychology they are as you see common parameters in the study of psychophysiology. They have the advantage of being simple, easy to use, not expensive, able to perform long recordings such as in the clinical setting in a clinical room about to be engaged in a complex apparatus like the resonance or something like that so they are ideal for using a [inaudible] such as the provider patient communication.
This one maybe many of you know well the GSR, that is the galvanic skin response is a measure of the sweating of hands. It is related to electrodermal activity produced by the sympathetic arousal. It is a response lasting just a few seconds. It's a very sensitive measure, it is the measure used in the lie detector machine and we will take a look at this device which has only sensors and fingers based on the electrodermal response, this is a simple apparatus and this is one apparatus I am using in some sessions. ^M00:17:30 [ Laughter ] ^M00:17:34 So you can imagine that it's not easy to make a recording...so how many variables can we record, maybe it's better to use one or two, not no more because too much we are intrusive. This is a typical electrodermal response based on sweatiness. You see that we are at a peak here, together we've changed the heart rate of blood pressure, this is the respiratory rate. But what is interesting is that the GSR responses are strictly related to the activation of contralateral brain circuits That is if you are recording on the right hand you have information about what is happening in the contralateral left cortex, left frontal cortex. So it's like a window into the brain, simple, inexpensive and reliable. What we can see through this window in the provider-patient communication and we start with the patient, this is what we can record. The patient is spontaneously speaking about some personal issues, his partner's infidelity, which is exposed during the session and the patient is expressing anger at this partner. The patient is speaking loudly with an angry tone and the GSR is peaking giving information about his emotional arousal. This is another subject and this is the beats of heart rate per minutes, you see that when the patient is expressing criticism, is reporting another infidelity is another patient, is very angry and so also the heart rate is parelleling minute by minute responses. Also recording muscle tension of the frontal lobe peaks while the patient is emotionally activated then it goes down when he starts relaxation.
Now we can explore the impact of effective communication and how some techniques can change the psychophysiological responses. For instance in these picture you have a patient, the blue line, the patient is preoccupied by her medical situation. She speaks and the provider follows the rule if you don't ask me about bad news I don't tell you. In this way the provider avoids emotion, avoids that pain and adapts a distant posture. In the same situation the same situation in a second patient, the red line, the provider introduces some empathic communication, for instance asked the patient about major concerns, let her express feelings, explores them and responds emphatically by saying, "I know it's difficult for you to talk about these topics" or "I imagine it's difficult for you to be here." Blood pressure decreases in this patient, not in the other one. And again this is another example of how sensitive it is to what the provider is saying and how a specific empathic comment repeated can reduce emotional tension that is acting on the brain of the subject. It could be [inaudible] this is maybe unethical but... ^M00:23:05 [ Laughter ] ^M00:23:09 A little unethical but is [inaudible] by...in general we do not use these techniques in Italy with our patients, no. It's interesting also to see this [inaudible] for business, for business it seems to be only a moral integrity but could also have psychophysiological effects in this study [inaudible] suggests that forgiveness is related to a reduction in blood pressure. Forgiveness probably involved the capacity for empathy. And what are the roles of the others that are around you that is a social support.
At Rome University I studied psychobiology stress for many years since the 80's and we also investigated the role of social support given to subjects in a very difficult situation. Here we have a volunteer performing a task to a computer and the task is very hard to do, this score however is decreasing because initially we give back a false score to him. The person is in anxiety and is disappointed however the experimenter can make neutral statements or supportive statements. The difference is impressive because in the unsupported group, cortisol which is a strong stress response in plasma, peaks like blood pressure, while in the supported group goes down. The situation is the same, the frustration is the same. It seems like words are translated into biological changes and protects the individual during a very difficult situation. And it is also interesting to see what commonly everyday we can observe, that is the framing effect, maybe you know and the choice is affected by the way you present it, the treatment. Many people chose the same identical treatment if you presented them this way and diffuse it if you present the treatment by this way. Why, it could be because the communication elicits a response in the fierce brain circuits at the amygdale level. That is again the words we use effect the brain and the choice, the consequence choice.
But what happens to the provider, the other part of the communication. This is the GSR of a psychiatrist doing an interview with a difficult patient and experience of the psychiatry that however has an inner emotional arousal confronting with this patient especially when the patient suddenly stands up, maybe for possible acting out. Why this other is a calm, quiet session with [inaudible] the patient which is going well in therapy and the GSR is very suggestive of a sort of relaxed session. While here the session is different, the session is relaxing, the patient is an obsessive/compulsive patient and like the typical behavior of this patient he's repeating and repeating to be sure to be correctly interpreted and listened toby the provider and the provider maybe is waiting for the end of the session and however the patient does not leave and continues to repeat his symptoms. The therapist is to some extent highly irritated and we see the peak at the end of the session. This more clearly is the difference between two patients and the provider with a patient very speaking loudly, angry, agitated, criticizing the doctors and another patient very calm, quiet, confident for the doctor. The differences are you can imagine the different costs for the provider in listening to these two different kind of patients. And finally with an oncology patient. The oncology patient you see that this apparatus's reflections are activation of GSR because there is a decrease of resistance linked to the increased sweatiness of hands and the first response of the provider is when the patient starts to cry. Then when the patient shows open despair and if the patient is [inaudible] and the patient showed emotional recovery. This is the parallel of what we've seen that imagine just before of how the brain of the provider showed pain and also the EMG shows the similar pattern because it shows a peaking and again a peaking when the wife of the patient comes in.
And these are other examples from the literature, literature is very scarce. Communicating bad news in medical students during a simulated session is stressing and heart rate can be up to 20 beats per minute, that situation is a simulated session as well as in this other study. We also studied a new response, the study can be correlated to empathy. A personality characteristic which is high, and secure effective attachment in which it suggests avoidance of involvement, avoidance of difficult communication, low empathy seems to be related to changes in NK activity or this is what were seeing in studying psychosomatic medicine. This is the group with the avoidant attachment, this is the group that were not provided avoidant effective attachment. This is another study from Walter Baile from MD Anderson showing the NK activity together with the heart rate increase in medical students involved in training of communicating bad news. And as the research we have shown the more we are involved the more pain we feel, more we have the risk of exhaustion, emotional exhaustion and what we can do. Communication is not a matter of words only, communication involves many levels, involves the brain circuits, that is a point I would like to stress more and that is [inaudible] have physical causes, not only emotional causes.
Ultimately, the brain resources of the provider can exhaust because they are not unlimited so the mind and the body periodically need something to be restored. Need a break from the stress of care giving in order to let the brain recover, you can have humor, poetry, music, sport, movies, play, love, passion, belonging, friends, relaxation and many other self-intervention, we need them and many others. And we need if you could I love very much to go to the Maldives and do snorkeling and love to watch the fish, colored fish or South India, it may be a little far for me but you have the Caribbean Ocean which is very nice or [inaudible] under water just passing some time just to see what happens with these fishes which is a splendid activity just to see what happens. Or if you prefer you don't like warm and tropical climates you can go to the north of Canada and this is the habits, windy, stormy, romantic and so on.
Finally main points are that communication is not only a method of words, it has central, neural and somatic correlates including communication skills we need it and enhances the quality of care and reduces the stress so it reduces the cost at this level. It's not only a matter of better handling relationships, it is a matter of restoring for serving as providers. We know very little about the impact on the patient but probably the patient too needs a better communication from the provider and his physiology too maybe could improve. The emotional costs are not only emotional but are biological in the brain and in our body and can suggest the bases of pathophysiology. And now we see and what happens when day by day we see the pain from others, we see so many people suffering in despair and finally that self-care is needed to replenish and preserve. thank you.
Dr. Baile: Thank you Massimo, you'll notice how calm Professor Biondi was during that presentation because living in Rome all he has to do is step out the door of course and have some beautiful surroundings and he will be taking names for sign up for the trip to the Maldives next so...I don't know how much he's paying but you know we'll see. So we have a few minutes for questions and Dr. Gritz
That was a wonderful and very interesting and provocative presentation and I'm wondering if there have been studies of chronic effects of these stressors and psychobiological adverse effects in care givers, do people develop more heart disease, do they have more stress related diseases and a parallel question those of us who are in the research environment also experience chronic stressors that have to do with publications, grants, results, etc and I'm just wondering if you would think that these kinds of studies could be applicable to the high powered research environment at MD Anderson.
I do not know maybe yes I suppose it could be applied, yes.
Are there studies with regard to the care of doctors, psychiatrists, whatever in terms of these effects of chronic stress related - are there comparisons??
I don't remember, I don't know if there are studies about that.
So actually there are two longitudinal studies that are done, one by the Johns Hopkins Medical Student studies where they followed Hopkins medical student studies where they followed Hopkins medical students for 25 years and they found out that those with poor coping such as alcoholism, more divorces tended to develop more chronic diseases, so that's one study the other is a series of studies on the use of coping mechanisms and out of Harvard, and it shows that people who tend to use denial or tend to avoid looking at their own stresses and doing something about it have more...require more psychiatric care and have more problems with burnout and things of that sort. I think that's...I don't know if there are any epidemiologists here but I think there's some epidemiologist logical studies on people's blood pressure too and stress so I think blood pressure is probably the most common thing studied and the Framingham study longitudinal study of blood pressure I think showed that blood pressure among women was related to the number of women entering the workforce so the more women that entered the workforce the higher the average blood pressure among women but you know so any of you who want to take long vacations and...
The response of stress is related to personality, the availability of social support mainly to what the person thinks the interpretation of events is. This is not automatic. Then stress does not create diseases it only facilitates under some situations and my experience has seen that stress is it could be positive, we need the stress, and negative. It is mainly negative when it is an impassive situation, as without sense, without possibility of coping, that is without fight or flight and especially without the possibility of repair. It depends on how we perceive it, the situation not about what the situation is. It's like to say that anything is in our mind almost in our mind. Thank you.
[ Inaudible section ]
Does everyone have the same social brain, meaning does everyone have the same empathetic potential that you outlined in your first few slides?
It is a splendid question. The study on the social brain circuits are a matter of four or five years ago they started very recently so we are not able to do that but we know a lot from psychology and from psychology we know that there is a big difference. Empathy in part is natural, in part can be learned, it is learned according to your personality disposition to learn it. And according to what you have the possibility to learn, your parents, at school your peers, your professors the person you have what they give you so you can learn the ability of using words to understand the other and so on however there is a difference between one person and another person just for personality and a difference also about education. I think that the social construction of the brain, that is, as concerns fears we can learn to counter fears the same way we can learn to develop empathic communication and modify our brain circuits by doing and doing and doing and doing experiences because emotional experiences change the brain and change the chemistry of mind.
Other questions, yes.
[Inaudible section] I did not understand exactly what [inaudible section] and there was something about multiple stimuli [inaudible].
The research was...
I'll try to find it. [ Inaudible section ]
Which one you say?
One through four, yeah.
This one...this one is just viewing person in pain or in despair just viewing the picture...yes.
It says with respect to neutral visual stimuli so...
There are...yes there is sequence of pictures and when the person sees these kind of images you see the activation of these central circuits. In a similar experiment the person reviewing the photo, the picture of the dead loved one and you had an activation of the pathways that are involving depression, this is a set of studies, a sequence of studies very interesting.
Thank you. Yes Dr. Gritz.
So why do Americans at least love to watch violent TV programs and movies?
Watching TV like many other behaviors is a way to stimulate the brain.
To stimulate it but potentially have adverse effects.
Yes, what we do with that stimulation it depends, it could have a facilitating...how to say discharge in tension if you like to see boxing, at the movies and so on. However, in some other people it can have a negative effect and facilitating the mirroring of such behaviors yes. But for many people I think that, especially today , all these activities, the brain of our [inaudible] very, very much...too much is stimulated it, I think that one of the important step of education is to learn to love leisure, leisure, leisure, free time, doing nothing, having a full moon without nothing to do.
So an interesting correlate of that is another speaker pointed out the fact that most Americans use only 40 percent of their vacation time which is kind of interesting given the fact that people work very hard and among health care professionals they probably use less than that. So you know this idea of recharging your brain that gets depleted because of taking care of people who are distressed and suffering is really I think a point that you were trying to get across.
Okay well thank you very much Professor Biondi.
[ Applause ]
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