Selected Journal Articles
- Spiegel D, Bloom JR, Yalom ID. Group support for patients with metastatic cancer: A randomized prospective
outcome study. Archives of General Psychiatry 38:527-533, 1981.
- Spiegel D: Vietnam grief work using hypnosis. American Journal of Clinical Hypnosis 24:33-40, 1981.
- Spiegel D, Glafkides MS. Effects of group confrontation with death and dying. International Journal of Group
Psychotherapy 33:433-447, 1983.
- Spiegel D: Multiple personality as a post-traumatic stress disorder. Psychiatric Clinics of North America 7:101-110,
- Spiegel D, Spiegel H. Uses of hypnosis in evaluating malingering and deception. Law and Behavior 2:51-65, 1984.
- Spiegel D: The use of hypnosis in controlling cancer pain. Ca-A Cancer Journal for Clinicians 35:221-231, 1985.
Reprinted in Australian Journal of Clinical Hypnotherapy and Hypnosis 7:82-99, 1985.
- Spiegel D; Hunt T; Dondershine HE. Dissociation and hypnotizability in posttraumatic stress disorder. Am J
Psychiatry, 1988, 145(3):301-5 (see abstract).
- Spiegel D; Bierre P; Rootenberg J. Hypnotic alteration of somatosensory perception. American J Psychiatry,
1989, 146(6):749-54 (see abstract).
- Klein KB; Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology, 1989 Jun, 96(6):1383-7
- Spiegel D, Bloom JR, Kraemer HC, Gottheil E: Effect of psychosocial treatment on survival of patients with
metastatic breast cancer. The Lancet: 888-891, October 14, 1989 (see abstract).
- Spiegel D. Facilitating emotional coping during treatment. Cancer, 1990, 66(6 Suppl):1422-6 (see abstract).
- Spiegel D, Cardeña E: New uses of hypnosis in the treatment of posttraumatic stress disorder. Journal
of Clinical Psychiatry 51:10 (suppl):39-43, (discuss.) 44-6, 1990 (see abstract).
- Spiegel D: Mind matters: Effects of group support on cancer patients. Journal of NIH Research 3:61-62, 1991.
- Spiegel D, Cardeña E: Disintegrated experience: The dissociative disorders revisited. Journal of Abnormal
Psychology 100:366-378, 1991 (see abstract).
- Spiegel D: Neurophysiological correlates of hypnosis and dissociation. Journal of Neuropsychiatry 3:440-445,
- Spiegel D: The use of hypnosis in the treatment of PTSD. Psychiatric Medicine Vol. 10, No.4, pp. 21-30, 1992.
- Spiegel D: Editorial: Conserving breasts and relationships. Health Psychology, 11(6): 347-348, 1992.
- Cardeña E & Spiegel D: Dissociative reactions to the San Francisco Bay Area earthquake of 1989.
Am J Psychiatry Vol 150(3):474-478, 1993 (see abstract).
- Spiegel D, Frischolz EJ, Fleiss JL, Spiegel H: Predictors of Smoking Abstinence Following a Single-Session
Restructuring Intervention with Self-Hypnosis. Am J Psychiatry 150:7, 1090-1097, 1993 (see abstract).
- Classen C, Diamond S, Soleman A, Fobair P, Spira J, Spiegel D: Brief Supportive-Expressive Group Therapy for
Women with Primary Breast Cancer: A Treatment Manual Stanford University, 1993.
- Spiegel D, Koopman C, Classen C: Acute stress disorder and dissociation. Australian Journal of Clinical and
Experimental Hypnosis, Vol. 22, No. 1, pp 11-23, 1994.
- Classen C, Koopman C, Spiegel D: Trauma and dissociation. Bulletin of the Menninger Clinic, 57(2):178-194,
1993 (see abstract).
- Koopman C, Classen C, Spiegel D: Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley,
California, firestorm. American Journal of Psychiatry,151(6):888-894, June 1994 (see abstract).
- Spiegel D, Sands S, Koopman C: Pain and depression in patients with cancer. Cancer, 74(9):2570-2578, November
1994 (see abstract).
- Spiegel D, Scheflin A: Dissociated or Fabricated? Psychiatric Aspects of Repressed Memory in Criminal and Civil
Cases. The International Journal of Clinical and Experimental Hypnosis, Vol. XLII, No. 4:411-432, October 1994
- Spiegel D: The Pros and Cons of Dissociative Identity (Multiple Personality) Disorder. Jrnl. Prac. Psych. and
Behav. Hlth, 1(3):158-166, 1995.
- Spiegel D: Health caring. Psychosocial support for patients with cancer. Cancer, 74(4):1453-1456, August 15,
1994 (see abstract).
- Koopman C, Classen C, Cardena E, Spiegel D: When disaster strikes, acute stress disorder may follow. Journal
of Traumatic Stress, 8(1)29-46, 1995 (see abstract).
- Spiegel D: Essentials of psychotherapeutic intervention for cancer patients. Support Care Cancer 3252-256,
1995 (see abstract).
- Spiegel D, Kato PM: Psychosocial influences on cancer incidence and progression. Harvard Review of Psychiatry,
4(1):10-26, 1996 (see abstract).
- Spiegel D: Psychosocial aspects of breast cancer treatment. Seminars in Oncology 24(1), Suppl 1 (February):S1-36-S1-47,
1997 (see abstract).
- Gabbard GO, Lazar SG, Hornberger J, Spiegel D: The economic impact of psychotherapy: a review. American Journal
of Psychiatry, 154(2):147-155, 1997 (see abstract).
- Jasiukaitis P, Nouriani B, Hugdahl K, Spiegel D: Relateralizing hypnosis: Or, have we been barking up the wrong hemisphere? International Journal of Clinical and Experimental Hypnosis, 45(2):158-177, 1997 (see abstract).
- Kogan MM, Biswas A, Pearl D, Carlson R, Spiegel D: Effects of medical and psychotherapeutic treatment on the survival of women with metastatic breast carcinoma. Cancer, 80(2): 225-230, 1997 (see abstract).
- Spiegel D, Stroud P, Fyfe A: Complementary medicine. Western Journal of Medicine, 4(168):241-247, 1998 (see
- Classen C, Koopman C, Hales R, Spiegel D: Acute stress disorder as a predictor of posttraumatic stress symptoms.
American Journal of Psychiatry, 155(5):650-624, 1998 (see abstract).
- Koopman C, Hermanson K, Diamond S, Angell K, Spiegel D: Social support, life stress, pain and emotional adjustment to advanced breast cancer. Psycho-Oncology. 7(2): 101-111, 1998 (see abstract).
- Spiegel, D: Healing words: emotional expression and disease outcome. Journal of the American Medical Association, 281(14): 2328-2329, April 14, 1999 (see article).
- Biswas A, See D, Kogan M, Spiegel D: Hypnotizability and the Use of Traditional Dhami-Jhankri Healing in Nepal. The
International Journal of Clinical and Experimental Hypnosis, 48(1):6-21, 2000.
- Spiegel D: Efficacy and Cost-Effectiveness of Group Psychotherapy for Patients with Cancer. ONE (Oncology Economics), 1(5):53-58, 2000.
- Lang E, Benotsch E, Fink L, Lutgendorf S, Berbaum M, Berbaum K, Logan H, Spiegel D: Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. The Lancet, 355:1486-1490, 2000.
- Sephton S, Sapolsky R, Kraemer H, Spiegel D: Diurnal Cortisol rhythm as a Predictor of Breast Cancer Survival. JNCI 92, (12):994-1000, 2000.
- Turner-Cobb J, Sephton S, Koopman C, Blake-Mortimer J, Spiegel D: Social Support and Salivary Cortisol in Women with Metastatic Breast Cancer. Psychosomatic Medicine, 62:337-346, 337-345, 2000.
- Kosslyn S, Thompson W, Costantini-Ferrando M, Alpert N, Spiegel D: Hypnotic Visual Illusion Alters Color Processing in the Brain. Am J Psychiatry 157:1279-1284, 2000.
- Cacioppo JT, Ernst JM, Burleson MH, McClintock MK, Malarkey WB, Hawkley LC, Kowalewski RB, Paulsen A, Hobson JA, Hugdahl K, Spiegel D, Berntson GG: Lonely traits and concomitant physiological processes: the MacArthur social neuroscience studies. International Journal of Psychophysiology 35(2-3):143-54, 2000.
- Koopman C, Gore-Felton C, Marouf F, Butler L D, Field N, Gill M, Chen X H, Israelski D, Spiegel D: Relationships of perceived stress to coping, attachment and social support among HIV-positive persons. AIDS Care, 12(5):663-672, 2000.
- Cardena E, Koopman C, Classen C, Waelde L, and Spiegel D: Psychometric Properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): A Valid and Reliable Measure of Acute Stress. Journal of Traumatic Stress, 13(3):719-734, 2000.
- Hart S, Gore-Felton C, Maldonado J, Lagana L, Blake-Mortimer J, Israelski D, Koopman C, Spiegel D: The relationship between pain and coping styles among HIV-positive men and women. Psychology and Health, 15:869-879, 2000.
- Giese-Davis J, Hermanson K, Koopman C, and Spiegel D: Affective Engagement and Couple's Adjustment to Metastatic Breast Cancer. Journal of Family Psychology, 14(2):251-266, 2000.
- Classen C, Field N, Koopman C, Nevill-Manning K, Spiegel D. Interpersonal Problems and Their Relationship to Sexual Revictimization Among Women Sexually Abused in Childhood. Journal of Interpersonal Violence, 15(6):495-509, 2001.
- Spiegel D and Sephton S: Psychoneuroimmune and Endnocrine Pathway in Cancer: Effects of Stress and Support. Seminars in Cliical Neuropsychiatry, 6(4):252-265, 2001.
- Vosvick, M., Gore-Felton, C., Koopman, C., Thoresen, C., Krumboltz, J., & Spiegel, D. Maladaptive coping strategies in relation to quality of life among HIV+ adults. AIDS and Behavior, 6(1), 97-106, 2002.
- Spiegel D: Effects of psychotherapy on Cancer Survival. Nature Reviews, 2:338-389, 2002.
Healing Words: Emotional Expression and Disease Outcome
David Spiegel, MD
We have been closet Cartesians in modern medicine, treating the mind as though it were reactive to but otherwise disconnected from disease in the body. Although medical science has productively focused on the pathophysiology of disease, such as tumor biology, coronary artery disease, and immunology, it has done so at the expense of studying the body’s psychophysiological reactions to these disease processes. These reactions are mediated by brain and body mechanisms, including the endocrine, neuroimmune, and autonomic nervous systems. While a large portion of the variance in any disease outcome is accounted for by the specific local pathophysiology of that disease, some variability must also be explained by host resistance factors which include the manner of response to the stress of the illness. For example, in a series of classic experiments in animals, Riley[1, 2]; showed that crowding accelerate the rate of tumor growth and mortality. In a recent authoritative review of human stress literature, McEwen documented the adverse health effects of cumulative stressors and the body’s failure to adapt the stress response to them. Activation of the hypothalamic-pituitary-adrenal axis (HPA) is an adaptive response to acute stress, but over time, in response to cumulative stress, the system'’ signal-to-noise ratio can be degraded, so that it is partially “on” all the time, leading to adverse physiological consequences, including abnormalities of glucose metabolism, hippocampal damage, and depression[6, 7].
Abnormalities of hypothalamic function, including glucocorticoid receptor hypersensitivity, have also been found to be associated with posttraumatic stress disorder.[8, 9]. Thus, adverse emotional events, ranging from traumatic stressors to cumulative minor ones, are associated with HPA dysregulation. Glucocorticoids are potently immunosuppressive, so the effects of acute and chronic stress and hypercortisolemia may include functional immunosuppression as well, as has been shown extensively in animals,[10-13] and for which there is a growing body of evidence in humans.[14, 15]
On the other hand, the social environment can have a buffering effect on stress. The same stressor that when given to an animal who is alone increases plasma cortisol levels by 50% does not increase it at all when the animal is surrounded by familiar companions. Being socially imbedded is associated with less autonomic arousal than social isolation. Indeed, social connection has profound consequences for health. Being well integrated socially reduces all-cause age-adjusted mortality by a factor of 2-fold, about as much as having low vs high serum cholesterol levels or being a nonsmoker. Furthermore, the nature of one’s position in the social hierarchy has health consequences, including relatively higher status within the same social class. People are statistically more likely to die after rather than before their birthdays and important holidays.
Thus, the presence of adverse emotional events such as traumatic stressors seems to have negative potential health consequences, while good social relations seem to be associated with positive health outcomes. Results from a recent randomized trial of patients who after experiencing myocardial infraction had participated in a program that included group support, stress management, and a vegetarian diet showed a long-term reversal of coronary artery occlusion.[21, 22] Similarly, 3[23-25] of 6[26-28] published randomized trials have provided evidence that psychosocial support is associated with longer survival for patients with longer survival for patients with breast cancer, malignant melanoma, and lymphoma. Patients with psoriasis exposed to mindfulness-meditation training tapes during treatment showed more rapid healing of lesions than those who were not exposed. One component of the effective interventions is dealing directly with emotional distress associated with fears regarding disease progression.
There is evidence that resilience to stress, including disease-related distress, is associated with how people handle their emotions. Indeed, finding meaning in the midst of a distressing situation has been linked with a positive psychological state. Adapting to a situation well does not require that a person maintain an upbeat or a rigidly positive attitude. Rather, it involves dealing directly with negative affect. Positive and negative emotions are not merely opposite sides of 1 dimension. Rather, the suppression of negative emotion tends to reduce a person’s ability to experience any emotion, positive or negative. There is evidence that patients with breast cancer who express negative emotion, including anger and uncooperativeness, or patients who express realistic optimism, often termed having the fighting spirit,  actually live longer than those who don’t.
In this issue of THE JOURNAL, Smyth and colleagues demonstrate that merely writing about past stressful life experiences results in symptom reduction among patients with asthma or rheumatoid arthritis. Patients wrote about the “most stressful experience in their entire life” for just 20 minutes over 3 consecutive days, while controls wrote about their daily schedule, following a method developed by Pennebaker et al, who showed that such an experience improves immune function. Patients with asthma randomized to spend this limited amount of time writing about distressing experiences showed increased forced expiratory volume at 4-month follow-up, and similarly, patients with rheumatoid arthritis had significant reduction in disease-related symptoms, moving from a moderate to a mild range. This study adds important data to the growing evidence that even limited interventions designed to improve management of stress may have lasting somatic effects. It is quite plausible that the interaction between disease and the stress it causes can set up an interaction that reinforces the illness, through autonomic hyperactivity, increase HPA activity or dysregulation, and effects on immune function.
Were the authors to have provided similar outcome evidence about a new drug, it likely would be in widespread use within a short time. Why? We would think we understood the “mechanism” (whether we did or not) and there would be a mediating industry to promote its use. Manufactures of paper and pencils are not likely to push journaling as a treatment addition for the management of asthma and rheumatoid arthritis. But the authors have provided evidence that medical treatment is more effective when standard pharmacological intervention in combined with the management of emotional distress. Ventilation of negative emotion, even just to an unknown reader, seems to have helped there patients acknowledge, bear, and put into perspective their distress. As has been noted before, it is not so much the nature of the “treatment on offer that determine whether the medicine is orthodox or alternative but the quality of evidence adduced in its favor”. In this and a growing number of studies, it is not simply mind over matter, but it is clear that mind matters.
- Riley, V., Mouse mammary tumors: alteration of incidence as apparent function of stress. Science, 1975. 189(4201): p. 465-7.
- Riley, V., Psychoneuroendocrine influences on immunocompetence and neoplasia. Science, 1981. 212(4499): p. 1100-9.
- McEwen, B.S., Protective and damaging effects of stress mediators. New England Journal of Medicine, 1998. 338(3): p. 171-179.
- Sapolsky, R.M. and T.M. Donnelly, Vulnerability to stress-induced tumor growth increases with age in rats: role of glucocorticoids. Endocrinology, 1985. 117(2): p. 662-6.
- Sapolsky, R., L. Krey, and B.S. McEwen, Prolonged glucocorticoidexposure reduces hippocampal neuron number: implication for aging. Journal of Neuroscience, 1985. 5: p. 1222-1227.
- Plotsky, P.M., M.J. Owens, and C.B. Nemeroff, Psychoneuroendocrinology of depression. Hypothalamic-pituitary-adrenal axis. Psychiatr Clin North Am, 1998. 21(2): p. 293-307.
- Posener, J.A., et al., Diurnal variation of plasma cortisol and homovanillic acid in healthy subjects. Psychoneuroendocrinology, 1996. 21(1): p. 33-8.
- Yehuda, R., et al., Enhanced suppression of cortisol following dexamethasone administration in posttraumatic stress disorder. American Journal of Psychiatry, 1993. 150(1): p. 83-6.
- Yehuda, R., et al., Cortisol regulation in posttraumatic stress disorder and major depression: a chronobiological analysis. Biol Psychiatry, 1996. 40(2): p. 79-88.
- Sheridan, J.F., et al., Psychoneuroimmunology: stress effects on pathogenesis and immunity during infection. Clin Microbiol Rev, 1994. 7(2): p. 200-12.
- Sheridan, J.F., et al., Stress-induced neuroendocrine modulation of viral pathogenesis and immunity. Ann N Y Acad Sci, 1998. 840: p. 803-8.
- Padgett, D.A., R.M. Loria, and J.F. Sheridan, Endocrine regulation of the immune response to influenza virus infection with a metabolite of DHEA-androstenediol. J Neuroimmunol, 1997. 78(1-2): p. 203-11.
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- Cacioppo, J.T., Social neuroscience: autonomic, neuroendocrine, and immune responses to stress. Psychophysiology, 1994. 31(2): p. 113-28.
- House, J.S., K.R. Landis, and D. Umberson, Social relationships and health. Science, 1988. 241(4865): p. 540-5.
- Marmot, M.G., et al., Contribution of psychosocial factors to socioeconomic differences in health. Milbank Q, 1998. 76(3): p. 403-48, 305.
- Phillips, D.P., T.E. Ruth, and L.M. Wagner, Psychology and survival [see comments]. Lancet, 1993. 342(8880): p. 1142-5.
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- Ornish, D., et al., Intensive lifestyle changes for reversal of coronary heart disease. Journal of the American Medical Association, 1998. 280(23): p. 2001-7.
- Spiegel, D., et al., Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 1989. 2(8668): p. 888-91.
- Fawzy, F.I., et al., Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry, 1993. 50(9): p. 681-9.
- Richardson, J.L., et al., The effect of compliance with treatment on survival among patients with hematologic malignancies. J Clin Oncol, 1990. 8(2): p. 356-64.
- Linn, M.W., B.S. Linn, and R. Harris, Effects of counseling for late stage cancer. Cancer, 1982. 49: p. 1048-1055.
- Ilnyckyj, A., et al., A randomized controlled trial of psychotherapeutic intervention in cancer patients. Annals of the Royal College of Physicians and Surgeons of Canada, 1994. 27(2): p. 93-96.
- Cunningham, A.J., et al., A Randomized Controlled Trial of the Effects of Group Psychological Therapy on Survival in Women with Metastatic Breast Cancer. Psycho-Oncology, 1998. 7: p. 508-517.
- Kabat-Zinn, J., et al., Influence of a Mindfulness Meditation-Based Stress Reduction Intervention on Rates of Skin Clearing in Patients with Moderate to Severe Psoriasis Undergoing Phototherapy (UVB) and Photochemotherapy (PUVA). Psychosomatic Medicine, 1998. 60: p. 625-632.
- Spiegel, D., Psychosocial intervention in cancer. Journal of the National Cancer Institute, 1993. 85(5): p. 1198-1205.
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- Greer, S., T. Morris, and K.W. Pettingale, Psychological response to breast cancer: effect on outcome. Lancet, 1979. 2(8146): p. 785-7.
- Smyth, J.M., et al., Effects of Writing about Stressful Experinces on symptom Reduction in Patients with Asthma or Rheumatoid Arthritis. Journal of the American Medical Association, 1999. 281(14): p. 1304-1309.
- Pennebaker, J.W., M. Colder, and L.K. Sharp, Accelerating the coping process. Journal of Personality and Social Psychology, 1990. 58: p. 528-537.
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- Psychosocial intervention and the natural history of cancer [editorial]. Lancet, 1989. 2(8668): p. 901.