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From science to the person .The person centered health paradigm and the Medicine change
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Results of the application of Person Centered Clinical Method in Clinical Practice
Abstract
Studies on the interactions between the central nervous, immunitary and endocrinological systems, the mind and behaviour, permit a theory of medical science to be formulated . The variability of immunitary reactions to the experimental possibility offered to animals to escape - or otherwise - conditions of stress determined the obsolescence of Selye’s concept of stress and permitted the formulation of a theory on «the determinate relativity of animal coping» while, for the indeterminate human world, a theory on «the indeterminate relativity of human coping» was developed, where biological variables were related to psycho-sociological, anthropological and existential ones. The results of such studies made it possible to introduce a new theoretical paradigm of research and practice to medical epistemology, refounding it on new key words such as «biological reactions», «possibility of coping» and «quality of coping», and overcoming such concepts of the philosophy of science as « biological laws» only definable a posteriori by the greater or lesser variability of biological reactions.
Biological reactions in non-humans appear to be subject to a foreseeable determinism that is explained by a theory of «general determinate relativity«, while human biological reactions appear to be subject to a theory of «general indeterminate relativity».
These new theories seem to suggest that research, clinics and medical
1 Correspondence to: Prof. Giuseppe R. Brera MD, Milan School of Medicine, Università Ambrosiana, Vle Romagna 51, 20133 Milano (Italy)
E-mail: gbrera@unambro.it
Aims:
Coping strategies may be significantly associated with health outcomes. This is the first study to investigate the association between baseline coping strategies and cardiovascular disease (CVD) incidence and mortality in a general population cohort.
Methods and results:
The Japan Public Health Center-based prospective Study asked questions on coping in its third follow-up survey (2000-04). Analyses on CVD incidence and mortality included 57 017 subjects aged 50-79 without a history of CVD and who provided complete answers on approach- and avoidance-oriented coping behaviours and strategies. Cox regression models, adjusted for confounders, were used to determine hazard ratios (HRs) according to coping style. Mean follow-up time was 7.9 years for incidence and 8.0 years for mortality.The premorbid use of an approach-oriented coping strategy was inversely associated with incidence of stroke (HR = 0.85; 95% CI, 0.73-1.00) and CVD mortality (HR = 0.74; 95% CI, 0.55-0.99). Stroke subtype analyses revealed an inverse association between the approach-oriented coping strategy and incidence of ischaemic stroke (HR = 0.79; 95% CI, 0.64-0.98) and a positive association between the combined coping strategy and incidence of intra-parenchymal haemorrhage (HR = 2.03; 95% CI, 1.01-4.10). Utilizing an avoidance coping strategy was associated with increased mortality from ischaemic heart disease (IHD) only in hypertensive individuals (HR = 3.46; 95% CI, 1.07-11.18). The coping behaviours fantasizing and positive reappraisal were associated with increased risk of CVD incidence (HR = 1.24; 95% CI, 1.03-1.50) and reduced risk of IHD mortality (HR = 0.63; 95% CI, 0.40-0.99), respectively.
Conclusion:
An approach-oriented coping strategy, i.e. proactively dealing with sources of stress, may be associated with significantly reduced stroke incidence and CVD mortality in a Japanese population-based cohort.
Background:
Psychological stress is a modifiable risk factor for health outcomes and can be managed through coping mechanisms. Biological and behavioral hypotheses have been proposed to explain the association between stress coping strategies and cancer outcomes.
Methods:
The Japan Public Health Center-based study asked questions on coping behaviors in its 10-year follow-up survey. 55,130 subjects aged 50-79 without a history of cancer diagnosis and who provided complete answers on coping were included in analyses on cancer incidence and mortality. Hazard Ratios (HR) according to coping style were determined using Cox regression models adjusted for known confounders for cancer.
Results:
Mean follow-up time was 9.5 years for cancer incidence and 9.8 years for cancer mortality. The utilization of the approach-oriented coping strategy (HR=0.85, 95% CI: 0.72-0.99) and a behavior of positive reappraisal (HR=0.84, 95% CI: 0.72-0.97) was associated with a reduced risk of cancer mortality. The approach-oriented coping strategy was further associated with localized cancer incidence (HR=1.13, 95% CI: 1.01-1.27) and screening-detected cancers (HR=1.35, 95% CI: 1.15-1.58). The avoidance oriented coping strategy was inversely associated with cancer incidence (HR=0.69, 95% CI: 0.50-0.94) only after excluding events occurring in the first three years of follow-up.
Conclusion:
The results of this study may favor the behavioral hypothesis to explain associations between premorbid coping styles and cancer outcomes.
Biological, psychological and social processes interact over a lifetime to influence health and vulnerability to disease. A wealth of epidemiological data has documented the relationship between socioeconomic status (SES) and health, with low SES groups fairing poorest across multiple outcome measures. Using new methodologies, recent work exploring molecular epigenetic mechanisms of gene expression (in humans as well as other comparative mammalian systems) has provided us with evidence demonstrating that the genome is subject to regulation by surrounding contexts (e.g., cytoplasmic, cellular, organismic, social). I will present data demonstrating that organisms with identical genomes are capable of manifesting dramatically different phenotypic profiles in response to different environmental conditions and experiences. Old assumptions about an inert genome are simply incorrect. It appears that these epigenetic processes may be the missing link which will allow us to understand how social and political conditions, along with individual subjective experiences, can directly alter gene expression, and thereby contribute to observed social inequalities in health. The very recent and powerful new results demonstrating that the epigenome is subject to environmental regulation may provide the direct link between the biological and social/psychological worlds. I suggest that new methods in molecular biology and gene regulation will play a profound role in how we currently conceptualize health inequalities, by informing our concepts regarding the somatization or embodiment of social inequalities.
Summary of the book
A Revolution for the Clinical Method and Biomedical Research : the Determinate and the Quality Indeterminate Relativity of Biological Reaction
Giuseppe R.Brera ©Copyright Università Ambrosiana 1996
The book introduces the concept of "Relativity of Biological Reactions" separating these from "Biological constants" necessary for survival., leading Medicine to an indeterministic paradigm against determinism and mechanism and limiting for clinics results of experimental investigations on animals. The book is the epistemological basis of Person Centered Medicine and introduces in Medicine the interactionist paradigm, causing the end of the Stimulus-Answer model, mechanistic and deterministic one of the Selye’s stress theory centered only on animals’ biological variables change determined by bio-chemical stimula . Humans differently through subjective symbolic affective ,cognitive resources related to emotions elaborate and interpret internal and external stimula, that are influent on the gene expression.
The theory has been based on experimental studies on the interactions between central nervous, immunitary and endocrinological systems, mind and behavior.
The core of this theory is expressed in 4 equations, A-B-C-D.
The base of the theory has been the experimental evidence about the variability of immunitary reactions in relation to the experimental possibility offered to animals to escape - or otherwise - conditions of stress determining the obsolescence of Selye’s concept of stress and permitted the formulation of a theory on «The determinate relativity of animal coping» called “Equation C” . Equation C (Rb = Bc x Pt (a)) draws the relativity of animal biological reactions to coping possibilities determined by the probability of positive or negative social and/or environmental conditions in relation to drives, Individual genotype and biological homeostasis. Equation D differently draws for humans a different relativity.
Equation D
Pt x Qc
HmRb = --------------------
Bc
HmRB = Human biological Reactions
PT= Possibilities of coping
AC = Quality of coping
The equation introduces the concept of the “Quality” of coping related to the indeterminate subjective possibilities of humans ( values, emotions, affects, relations, behaviors) which determine a “ Coping quality” (Qc) related to choices in experience. This unforeseeable possibility (Pt) of choice but like animals related to genotype, biological homeostasis, social and environmental conditions but in a only human way to cognitive and psycho-sexual structural stage of development, is the indetermination constant of the Equation D. Biological constants (Bc) appear inversely related to possibilities of choices. Less possibilities of coping there are more biological reactions are determined by a direct actions of biological constants on life, how physicians and surgeons know when they work in emergency.
Different epistemological models for human and animals are dependent from the presence in humans of self-determined, cognitive and psychosexual levels, and indeterministic factors ( eg. : moral and religious thinking, hypothetic-deductive reasoning, meaning awareness and will, creativity, parents’ education ). which determine a ” quality” in cognitive and affective symbolic processes, emotions, behaviors, coping and consequently different biological reactions. These qualitative and subjective factors are strictly related to neuromodulators, hormones and immunitary system actions in a bidirectional way through a new gene expression and receptors synthesis. Quality of coping is caused by the only human quality to choose among perceived and interpreted possibilities according the cognitive and psychosexual level, like Piaget and Freud showed., but possibility of an experience is unforeseeable like a dream or an encounter. Persons give a meaning to these showing a transcendent not empirical teleology existent in human nature well described by kairological theory. Mechanistic theory of human nature is obsolete and wrong and introduces necessarily new variables in medical research, clinics and medical education if wants arrive to true results. A new concept of health related to protective factors played by human possibilities, quality of the interpretation of reality, existential choices corresponding to affective and cognitive processes and neuromodulations, hormones transduced messages to cell membranes, that is a new indeterministic universe to be explored and related to person is born. Health to date can be interpreted and defined in a new way : “ Possibilities and qualities for being an human person based on a balance between protective and risk factors, that is resilience vs/ vulnerability”
The theory of the relativity of biological reactions to possibilities and quality of coping (RBR theory) appears to introduce a new epistemological chapter in human biology and medical science allowing a reformulation of the scientific method applied to human nature and a new clinical method based on
a. the necessity of introducing into human biology and clinical research variables belonging to the subjective world of humans determining quality of life : values,beliefs,emotions, affects, coping, behaviour and level of cognitive and psychosexual development.
b. the existence of a teleology in human nature and the importance of affective and cognitive symbolic world in a culture determining possibilities and qualities in reality interpretation, choices and behaviours.
c. the impossibility to directly transfer and apply to humans experimental inferences, based only on results of experimental studies because of the difference between Equation C and Equation D
d the change of the health concept and the introduction in Medicine and Medical education the concepts of Resilience and Vulnerability.
e the necessity to change clinical method according RBR equations B and D
f the necessity of introducing in the experimental method new RBR variables according equation A and C
d. the existence in humans of a mysterious indetermination constant
The RBR (Relativity of Biological Reaction) theory opens new perspectives in Medical Science and Medicine and at clinical level constitutes the basis of the Person Centered Medicine Clinical Method.