Linnea Cooper, RN Julia Delcour, RN Karin Pearson, RN Susie

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Psychoneuroimmunology

• Linnea Cooper, RN
• Julia Delcour, RN
• Karin Pearson, RN
• Susie Clabots, RN
• Chris Peredney, RN, M.S.

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Background
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What is Psychoneuroimmunology (PNI)?

• In summary PNI is a theory that investigates the
  implications for clinical disease manifestation,
  progression, and inhibition, as a result of the
  bidirectional relationships between the mind,
  brain, and immune system.

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Phenomena of Concern in PNI

• Personality, psychology, emotional states, the
  physical response (behaviors) to these states and
  the following action on the immune system.
• The result of these interactions, in terms of
  disease acquisition or exacerbation on the
  individual person.

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Historical Context

• 460-370 BC Hippocrates
• 2nd century Galen
• 17th century Rene Descartes
• (Cartesian split- reductionism)
• Late 19th century Robert Koch- theorized that
  every disease had a simple, specific, cause
  germs.
• 1900s Anatomists first discovery of nerve
  fibers in immune tissue.
• 1920s Dr. Walter Cannon- Coined the term
  homeostasis
• His experiments gave physical proof that glands
  in body respond to stress
• 1930s Hans Seyle- flight or fight response to
  stress (GAS)

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PNI Founders

• A few big players in PNI history and development
  are
• George F. Solomon, MD and Rudolf H. Moos, PhD
• (Emotions, Immunity, and Disease, 1964)
• Dr. Robert Ader
• Professor at University of Rochester, NY
• Coined the term Psychoneuroimmunology
• Created interdepartmental Center for PNI Research
• Founding member of PNI Research Society (1993)
• Experimental study with rats (Ader Cohen, 1975)

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Is PNI Inductive or Deductive ?

• Theory is considered both inductive and deductive
  in nature.
• Beginning- many different experiments were
  finding particular phenomena in certain
  situations, leading to the idea of illness as
  being affected not only by the pathogen, but also
  by the person factors (personality, stress
  response).
• Currently- After establishing PNI inductively, it
  is now being substantiated and further refined
  deductively, using scientific research frameworks
  as the guide.

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Structure and Philosophical Orientation
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Assumptions

• There are many significant factors that affect
  health and well-being (Solomon Moos, 1964).
• Emotions play an important role in the
  development of physical disease (Langley,
  Fonseca, Iphofen, 2006).
• Different stressors produce different reactions
  in the body (Ader, 2001). These reactions alter
  the state of homeostasis (Langley et al, 2006).
• There is a bi-directional interaction between
  neuroendocrine and immune systems (Zeller et al,
  1996).

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Assumptions Continued

• Methods used to mitigate the effects of stress
  can actually help boost immunity (Fawzy et al,
  1993, as cited in Langley et al, 2006).
• Responses to stressful life experiences involve a
  complex relationship between behaviour, nervous
  system, endocrine system and immune system
  (Rabin, 1999, as cited in Ader, 2001).
• Peoples' perception of stress is ever-changing
  and depends on circumstances they find themselves
  in and the resources they have at their disposal
  (Sternberg, 2000).

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World View

• Psychological scientific
• Why??
• Focuses on causality
• Began in a psychology realm based on their own
  concepts
• Moved to a scientific realm where they were able
  to perform experiments

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PNI Paradigm

• Theory began over 40 years ago as part of the
  biopsychological paradigm
• In McCain, Gray, Walter, Robins (2005), PNI is
  defined as a paradigm itself
• PNI is an integrative paradigm for advancing
  both theoretical and empirical knowledge of
  physiological patters that contribute to the
  dynamics of health (McCain et al, 2005)

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Nursing Metaparadigm

• Person complex relationship
• Environment environmental factors
• Health Adaptational outcomes (McCain, Gray,
  Walter, Robins, 2005).
• Nursing comfort and teaching (Sternberg, 2000).

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Concept

• Psychoneuroimmunology
• Psycho
• Neuro
• Immunology

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Definitions

• Solomon and Moos, 1964 theoretical integration
  of the relation of stress, emotions,
  immunological dysfunction and disease, both
  physical and mental
• Ader, 2001 the means by which behavior and
  emotion influence immune function, and the means
  by which the immune system affects the nervous
  and psychological response.

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Related Concepts

• Interplay between the psychological states, the
  physiologic response, and the immune system
• Introduction of other concepts
• Bidirectional relationships
• Stress

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Propositions

• The individual is not seen as a collection of
  systems but as a whole without division between
  the mind and body. There are networks of
  communication that exists between the brain and
  the neurological, endocrine, and immune systems
  (Halldorsdottir, 2007 Langely, 2006).
• Immune function is capable of modification by
  non-immune stimuli (Langely, 2006).

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Propositions

• Communication systems include
•  HPA
• Sympathetic nervous system (SNS)
•  Noradrenergic innervate immune system
• Cytokines induce symptoms of illness
•  

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(Thorton Andersen, 2006)
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Propositions

• Cofactors are those components that have the
  potential to predispose an individual to certain
  stress, coping and health patterns.
• Personal characteristics
• Health related feature
• Individual transactional processes (McCain,
  2005).

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Psychosocial FunctioningQuality of
LifePhysical Health

HEALTH
Psychosocial Moderators
Potential Co-Factors
Neuro- Endocrine Mediators
Person Factors
Immunological Mediators
Coping Patterns
Perceived Stress
Pre tx Critical Factors
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Concept and Proposition Critique

• 1. Underlying mechanism for the weakened immune
  system is unclear.
• 2. If stressors were gone we would always expect
  to see a health gain.
• 3. Healing is intangible.

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Application of PNI Theory
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Clarity

• Definitions
• Concepts are not operationally defined
• Developed over time with multiple authors
• Definitions were not always exactly the same
• Author assumed the known definition from their
  respective fields

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Examples of the definition of the PNI concept
throughout research

• Kemeny bidirectional relationships between
  mind, brain, and immune system and its
  relationship to clinical disease.
• McCain and associates put the emphasis of PNI on
  developing an understanding of how the immune
  system is influenced by both sociobehavioral and
  physiological interactions.
• Langley and associates treat PNI as an
  interdisciplinary field of study of the
  interactions between psychological processes and
  neurological, endocrine, and immune function and
  their influence on health.
• Halldorsdottir states it to be the study of
  interaction of the psycho, neuro (CNS), and
  immune within the body and the body communicates
  with a multidirectional flow of information,
  holistically.

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Clarity Continued

• Diagrams
• Very clear and straightforward
• Offer insight into how the theory is structured
• Different versions of the theory showed similar
  diagrams
• Intersubjectivity
• - (shared agreement within the relationships
  between the concept)
• Not consistent across the different theorists
• Relationship has been substantiated but the
  mechanisms still remain unclear.

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Congruence

• Values of PNI Theory
• Inductive and Deductive Reasoning
• Personal Observations
• Evidence
• Collaboration
• Congruence with professional values
• Deductive Reasoning
• Personal Observations
• Evidence

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Congruence with social values

• The Social Setting of Nursing
• Is the role of the nurse within the model
  congruent with the role of the nurse as perceived
  by society?
• Are actions and outcomes congruent with societal
  expectations of nursing?
• (Meleis, 2007)

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Level

• Micro-Macro
• The interplay between the micro functions of the
  body systems and the outward behavior of the
  individual.
• Micro
• Biological, neurological, and immune functions
  interacting is all within the person.

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Level

• Solomon and Moos (1964) introduced the theory in
  order to describe and explain phenomena between
  systems.
• As the theory developed the application of the
  theory is used to control and manipulate the
  outcomes.

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And then.
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And then..?

• What does this mean to my practice?
• NP
• CNS
• Midwife
• Psychiatric Nurse
• Administrator
• Manager

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Nursing Use

• Nursing interventions to reduce psychological
  stress have direct positive effects on prevention
  of, or recovery from, physiological insult.

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Inflammation

• Relaxation on Inflammatory cytokines (Koh, et al,
  2008)
• Tissue Necrosis Factor (TNF) Interleukins (WBC
  signaling)
• Self esteem on cardiovascular in inflammatory
  response (O Donnell et al, 2008)
• TNF Interleukins
• Anger on wound healing (Gouin et al, 2008)
• Cortisol

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Outbreaks and Manifestation of Viral Diseases

• Laughter and natural killer cell (Bennett et al,
  1998)
• Psychological stress and vaginal HSV-1 infection
  and outbreaks (Ashcraft and Bonneau, 2008)
• CD8 T-cells
• Tai Chi and HIV (Robins et al, 2006)
• Reduction of HIV related psychological distress

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Third party stress

• Family psychological stress and frequency of
  illness in children. (Caserta, et al, 2008)
• Significant relationship between parental mental
  illness and physiological illness in children

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Working Backward

• Reduction of PTSD by boosting the immune system
  (Lewitus et al, 2008)
• T-cells are important factors in psychological
  stress response
• Immunization with a myelin-related peptide to
  alleviate chronic consequence of PTSD

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How does this relate to your practice

• NP
• CNS
• Midwife
• Psychiatric Nurse
• Administrator
• Manager

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Testability

• The theory is supported by a large and growing
  peer reviewed research base
• Several nursing schools have programs in
  developing, assessing, implementing and
  evaluating the applicability and efficacy of PNI
  based interventions
• UCSF-Nursing
• San Jose State-Nursing
• USF-Nursing
• Virginia Commonwealth Nursing School

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Who is testing?

• UCLA - Semel InstituteCousins Center for
  Psychoneuroimmunology
• The Psychoneuroimmunology (PNI) Research Program
  in the Institute for Behavioral Medicine Research
  at The Ohio State University Medical Center
• USF College of Nursing hosted a National
  conference for the Center for Psychoneuroimmunolog
  y, entitled Frontiers in Psychoneuroimmunology
  The Emotional Interface, September 18-21, 2008
• The list goes on..

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Future

• The field is very active
• The future is in developing and implementing
  evidence based nursing interventions based on PNI
  physiological and psychological research that
  elicit the desired effect
• Incorporation into nursing education and practice
• Working through physiological interventions to
  psychological disease

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REFERENCES

• Ader, R. (2001). Psychoneuroimmunology. Current
  Directions in Psychological Science 10(3), 94-98.
• Ader, R., and Cohen, N. (1975).
  Behaviorally-conditioned Immunosuppression.
  Psychosomatic Medicine, 37 (4) 333-40.
• Ashcraft,K. and Bonneau, R. (2008).
  Psychological stress exacerbates primary vaginal
  herpes simplex virus type 1 (HSV-1) infection by
  impairing both innate and adaptive immune
  responses. Brain, Behavior, and Immunity 22
  (2008), 12311240.
• Azar, B. (1999). Father of PNI reflects on the
  field's growth. American Psychological
  Association Monitor Online 30(6).
• Bennett, M., Zeller, J., Rosenberg, L., McCain,
  J., and Short, S. (1998). The effect of mirthful
  laughter on stress and natural killer cell
  cytotoxicity. In Proceeding of the Midwest
  Nursing Research Society Meeting, April 1998
• Caserta, M., OConnor, T., Wyman, P., Wang H.,
  Moynihan, J., Cross, W., Xin, T., and Xia, J.
  (2008) The associations between psychosocial
  stress and the frequency of illness, and innate
  and adaptive immune function in children. Brain,
  Behavior, and Immunity 22(2008), 933940.
• Gouin , JP., Kiecolt-Glaser, J., Malarkey, R.,
  and Glaser, R. (2008) The influence of anger
  expression on wound healing. Brain, Behavior,
  and Immunity 22(2008), 699708.
• Halldorsdottir, S. (2007). A psychneuroimmunologic
  al view of the healing potential of professional
  caring in the face of human suffering.
  International Journal of Human Caring. 11(2).
• Koh K., Lee,Y., Beyn, K., Chu, S., and Kim, D.
  (2008) Counter-stress effects of relaxation on
  proinflammatory and anti-inflammatory Cytokines.
  Brain, Behavior, and Immunity 22(2008),
  11301137.
• Langley, P., Fonseca, J. Iphofen, R. (2006).
  Psychoneuroimmunology and health from a nursing
  perspective. British Journal of Nursing 15(20),
  1126-29.

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REFERENCES

• Lewitus, G., Cohen, H., Schwartz, M. (2008)
  Reducing post-traumatic anxiety by immunization.
  Brain, Behavior, and Immunity 22(2008),
  11081114.
• McCain, N., Gray, D., Walter, J., Robins, J.
  (2005). Implementing a comprehensive approach to
  the study of health dynamics using the
  psychoneuroimmunology paradigm. Advances in
  Nursing Science 28(4), 320-32.
• Nassau, J., Tien, K., Fritz, G. (2007). Review
  of the literature Integrating psychoneuroimmunolo
  gy into pediatric chronic illness interventions.
  Journal of Pediatric Psychology. 1-13.
•  ODonnell, K., Brydon, L., Wright, C., and
  Steptoe, A. (2008) Self-esteem levels and
  cardiovascular and inflammatory responses to
  acute stress. Brain, Behavior, and Immunity 22.
  12411247.
•  Robins, J., McCain, N., Gray, D., Elswick R.,
  Jr, Walter, J, and McDade, E. (2006) Research on
  psychoneuroimmunology tai chi as a stress
  management approach for individuals with HIV
  disease. Applied Nursing Research 19, 2 9.
• Solomon, G., and Moos, R. (1964) Emotions
  immunity, and disease. Archives of General
  Psychiatry. 11(12), 657-674.
• Sternberg, E. (2000). The balance within The
  science connecting health and emotions. New York,
  NY W.H. Freeman and Company.
• Thorton, B. Andersen, L. (2006)
  Psychoneuroimmunology examined The role of
  subjective stress. Cellscience. 2(4).
• Zeller, J., McCain, N., Swanson, B. (1996).
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