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The Role of Cultural, Social,
and Psychological Factors
in Disease and Illness
ROBERT A. SCOTT
Abstract
Understanding the effects of social, psychological, and cultural processes on the
body raises age-old questions that remain perplexing puzzles still today. Research
by biomedical, social, and behavioral scientists on the role played by these factors
in causing disease and people’s subjective experience of it promises to advance
understanding of issues about the connections between mind and body. This
essay summarizes findings from relevant areas of research, identifies the most
promising lines of inquiry to date, poses questions that remain to be investigated
going forward, and concludes with speculation about possible applications of
existing and prospective new knowledge in health-related and other arenas of social
practice.
Among the various avenues of research relevant to this topic, three in particular
stand out. They are (i) studies of the connections between stress and sickness, (ii)
studies of persons’ subjective experiences of physical symptoms, and (iii) studies
of expectancy effects. Studies of stress document the physical effects of long-term
exposure to adverse social, psychological, and environmental conditions, the role
these play in causing disease, their effects on people’s experiences of sickness, and
on their ability to recover. Studies of symptom perception focus on people’s subjective experiences of being ill, investigating ways in which aspects of culture, social
environment, traits of personality, and psychological states affect our awareness of
bodily symptoms, and how we interpret and experience them subjectively. Studies
of expectancy effects, commonly referred to as the placebo or the healing response, aim
to learn if beliefs alone can have physiologically measurable effects on bodily symptoms and on our perceptions of them, on how we feel and on how we respond to the
treatments we are given.
Taken together, these areas of research support the conclusion that understanding
sickness requires simultaneous knowledge of two factors: the biological conditions
diagnosed on the basis of physical signs (disease) and an individual’s subjective
experiences of the physical symptoms that a disease manifests (illness).
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.
1
2
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
FOUNDATIONAL RESEARCH
DISTINCTION BETWEEN DISEASE AND ILLNESS
Fundamental to all studies of the role of social, cultural, and psychological
factors in human, physical ailment is a distinction between disease and illness. Disease refers to the biological conditions that have been diagnosed by
a physician or other similarly qualified medical expert who make this determination on the basis of physical signs and in light of established scientific
knowledge. Illness refers to our subjective experiences of the physical symptoms we have. In effect, disease is what a medical expert determines is wrong
with us; illness is our subjective experience of it (Eisenberg, 1977).
In most instances, objective physical signs of sickness and subjective experiences of symptoms occur simultaneously and interact with one another.
However, this is not always so. Hypertension is a condition that is often
be symptom free, exemplifying an instance of a disease but not an illness.
However, certain treatments for hypertension entail use of medications with
unpleasant side effects, resulting in a situation where the disease is effectively
cured but yet the patient feels ill (Shapiro, 2001).
THE ROLE OF STRESS IN ILLNESS AND DISEASE
Studies of stress document how social conditions such as poverty, occupational strain, marital and family discord, social supports, and daily hassles
disorganized environments and peoples’ places in social dominance hierarchies are in one way or another implicated in causing disease, in affecting
the timing of its onset, and in dictating the rate of recover from it (Kulielka
& Kirschbaum, 2001).
Studies of stress link it in various ways—not yet fully understood—to disorders associated with the nervous, immune, cardiovascular, endocrine, neuromuscular, and skeletal systems (Kulielka & Kirschbaum, 2001). In each
instance, the linkage is hypothesized to be mediated through the mechanism
of allostasis, the body’s capacity to respond to changes in the environment
that protect against immediate, short-term sources of harm. The working
hypothesis is that prolonged activation of the so-called “allostatic load” (i.e.,
wear and tear on the body) results in a physiological burden that can be damaging to bodily defense systems essential for averting disease (Biondi, 2001;
Kulielka & Kirschbaum, 2001, pp. 15171–15172).
SYMPTOM PERCEPTION
Research on symptom perception seeks to understand how cognitive and
perceptual processes shape our subjective awareness and interpretation of
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
3
physical signs associated with disease. Awareness of symptoms, how we
interpret them, what we decide to do about them, how we develop the
sense that we are becoming sick, or are getting well again, are all affected by
cultural beliefs, features of our immediate social environment, personality
factors, and mood states.
Research on this topic begins with studies of initial perceptions of bodily
symptoms of discomfort and supports three broad conclusions. First, emotional states play a critical role in sensitivity to physical symptoms. Those
suffering from mood disorders such as depression and chronic anxiety, for
example, are more attentive to bodily symptoms than those whose characteristic mood states are of hopefulness, optimism, and a desire for sociability
(Pennebaker, 1982). Second, cultural heritage is related to sensitivity to symptoms. For example, people belonging to different cultural groups are found to
differ in their sensitivity to bodily symptoms, with Italian and Jewish Americans in the aggregate showing greater sensitivity to internal bodily states
than so-called “Yankees.” Third, sensitivity to and thus awareness of internal
bodily sensations are directly affected by characteristics of one’s immediate
environment. For example, those exposed to highly stimulating, distracting
environments are much slower to notice symptoms of internal bodily states,
if at all; alternatively, when the external environment is lacking in stimulation, attention is more readily directed toward the body and inner feeling
states (Pennebaker & Lightner, 1980; for a review of studies of symptom perception, see Scott, 2010, pp. 151–155).
Once signs of physical discomfort come to conscious awareness, individuals tend to organize their perceptions about them around basic cognitive
schemas. Such schemas are comprised of a mixture of elements including
notions about what people believe ails them, its likely cause or causes, its
characteristic symptoms, expectations about its duration and curability,
appropriate ways of treating it, and signs to look for that one is getting better
(Taylor & Crocker, 1978).
As with studies of sensitivity to symptoms, studies of illness-related
schemas also show that culture plays a major role in the organization
and content of the disease-related schemas people acquire. Specifically,
they demonstrate that people from different cultural backgrounds possess
different schemas for the same basic biological condition (Zborowski, 1952,
1969). Finally, once activated, illness-related cognitive schemata structure
and guide perceptions, leading people to focus their attention on bodily
sensations that provide them with confirming evidence for their initial
“diagnosis” and leading them to ignore disconfirming evidence. Moreover,
once schematic notions about “diagnosis” solidify, the resulting mental
structures prove resistant to attending to disconfirming evidence. Instead,
people tend to closely monitor bodily sensations for evidence that confirms
4
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
their provisional hypothesis and ignore the rest (Leventhal & Diefenbach,
1991).
Given that research on symptom perception is concerned with persons’
subjective experiences of being sick, much of it has naturally focused
on awareness of pain and pain thresholds irrespective of condition and
on understanding how focus of attention, social context, and cultural
expectations shape people’s experiences of physical discomfort. This has
led to a view of pain as a perceptual phenomenon in which information
transmitted through the central nervous system is integrated, processed,
and interpreted in the brain. Because the brain plays such an integral role
in how we experience pain, in principle, any factor in the environment that
impacts the brain can affect the level of pain people experience and their
ability to cope with and tolerate it.
EXPECTANCY EFFECTS
Studies of expectancy effects aim to discover if beliefs and resulting expectations effect the way people respond to the treatments they are given and if
so, how this happens. In the typical study, subjects are primed about how
the sham treatments they are about to receive in experimental or clinical situations will affect them. Researchers then look for evidence of the effects of
these implanted beliefs on uncomfortable sensations that either have been
induced experimentally or are associated with the disease condition being
treated. Several key findings emerge from this research.
One of the most consistent and striking of these pertains to pain
analgesia—that is the subjective experience of gaining relief from physical
discomfort. Under certain conditions, people primed to expect relief from
pain actually report experiencing it. Another series of studies suggests that
the manner and form in which placebos are administered affects the magnitude of the response. Administering a placebo more frequently produces
better outcomes than administering the same placebo less frequently; some
pill colors induce greater placebo effects than others; larger pills are more
effective as placebos than smaller ones; injected placebos produce stronger
effects than those that are orally ingested; and surgically induced placebo
effects are strongest of all (Bausell, 2007, pp. 135–136; Moerman, 2001, p. 66).
Expectancy effects appear to be especially pronounced for certain conditions such as asthma, intractable warts, rashes and other skin conditions,
nervous and mental conditions such as depression and anxiety, infectious
disorders, stomach ulcers, a range of inflammatory reactions, and allergies.
Other studies suggest that when care providers themselves have been misled into believing that the inert or sham treatments they are administering
are real, evidence of placebo analgesia in patients also occurs. And finally,
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
5
for certain forms of physical ailments, such as intractable warts, expectancy
effects can apparently result in permanent cure. More often, such effects do
not cure, but there can be little doubt that they help people given placeboes
feel better (for a review of relevant Research see Scott, 2010, pp. 129–133).
CUTTING-EDGE RESEARCH
Research on the role beliefs plays in perceptions of bodily symptoms and in
expectancy effects demonstrates that the mind is central. In order for sham
treatments to work, people must be aware that something has been given
to them and “primed” to expect their likely effects; in the absence of this
awareness, no expectancy effects are detected (Kraden, 2008). Does this then
mean that symptom perception and placebo effects are no more than figments of the imagination, things that exist only in our heads? Recent research
indicates that the answer to this question is an emphatic “no.” Evidence in
several recent studies shows that once activated, beliefs have detectable, measurable physiological effects that are real and help us to make sense of the
subjectively perceived effects subjects report experiencing (Benedetti, 1996;
Benedetti et al., 1998). One of the most exciting areas of such research involves
efforts to study in what manner and precisely how beliefs become physiologically consequential and the form their effects take.
This research builds on the finding of earlier studies showing that the body
is capable of manufacturing its own version of the pain killer morphine
known as endorphins (endogenous morphine’s), the so-called “the poppy
fields of the mind.” Physiologists have identified where in the body they are
released, what triggers their release, and the biochemistry of what happens
once they are activated (for a review of relevant research, see Scott, 2010,
pp. 141–144). Subsequent studies using functional magnetic resonance
imaging (fMRI) scans have pinpointed the precise regions of the brain
where pain analgesia occurs and how it works. fMRI technology entails
using magnetic resonance imaging technology to measure brain activity
by detecting associated changes in blood flow. They show that areas of the
brain where known pain receptors are located and activated when pain is
administered to subjects, go “dark” when subjects are given placeboes they
are told will curtail, diminish, or abolish their pain, and that regions where
the manufacture of natural painkillers (endorphins) are initiated, “light up”
following administration of the placebo medication (Wager et al., 2004).
Adding further credence to the idea that expectancy-induced pain analgesia is real are studies showing that analgesia that has been induced in laboratory studies can be neutralized using a drug (Naloxone) originally developed
as an opioid antagonist in treating persons addicted to morphine. These studies have established that Naloxone blocks the effects of placebo-induced pain
6
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
analgesia in exactly the same way and to the same degree that it interferes
with the pain numbing effects of morphine (Levine and Fields, 1978).
A second cutting-edge area of research that highlights the linkages between
mental and internal physiological processes points to its direct relevance for
the body’s ability to ward off and fight disease. These studies monitored
the physiological effects of psychological interventions aimed at uncovering enduring long-suppressed traumatic life events by allowing subjects to
“open up” about them. A series of studies show that those given the opportunity to write about such events show a dramatic decline in reported episodes
of illness as measured by use of health services, and activation of the immune
system in the form of increases in T-cell counts that are both robust and long
lasting (Glaser & Kielcot-Glaser, 1994; Pennebaker, 1990).
KEY ISSUES FOR FUTURE RESEARCH
The studies referenced in this essay provide compelling evidence that mind
and body are tightly interconnected and show that human sickness cannot be
fully understood without giving equal attention and weight to both. Research
on this topic to date has established that mental processes and factors in
the social and cultural environments affecting them can have measurable
impacts on physiological processes. Only now are we beginning to understand how these effects happen; not at all understood is whether it is possible
to capture the powers inherent in such phenomena as expectancy states, perceptions, beliefs, and other facets of mental processes and employ them telically to affect health outcomes in desired and intended ways. Although we
know that placebo effects are real and can have real consequences, until we
understand more fully how and why they do, and when they do not, why
they do not, we cannot begin to fashion interventions that will allow us to
tap into the power of belief in aid of clinical interventions. Herein lies one of
the most promising and exciting areas of investigation for future research.
The beginning point for such research must be to acquire more complete
and systematic knowledge about the various ways in which mind affects
body, whereas many of the studies referred to in this essay came about in
a somewhat haphazard, ad hoc fashion. Medical scientists invited social and
behavioral scientists to affiliate with research programs relating to specific
types of disease in the belief that the disease they study and treat has important behavioral and social components. The result of this way of proceeding
has provided an important beginning, but at present yields something of a
patchwork of findings, lacking clear conceptualization of the types of diseases that are most affected by social, cultural, and situational factors, and of
the kinds of roles social and behavioral are likely to play in the genesis, onset,
course, and outcome of different types of diseases. It is likely that all such
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
7
factors thus far identified do not play equally important roles for all forms
of disease and at all stages of their development. Developing a scheme that
brings conceptual clarity to this matter would not only advance knowledge
but also provide a welcome corrective to the sometimes exaggerated claims
made for the role of social and behavioral factors in illness (for a comprehensive assessment of this topic see Bausell, 2007).
To do this, it will first be necessary to devise a conceptualization of diseases
based on the likely effects (or not) of culture, social environment, and mental processes on them, then to systematically monitor internal physiological
states as measured by changes in blood chemistry, fluctuations in vital signs,
immune system functioning, brain activity, and other facets of bodily functioning, and in turn to study linkages between these changes and variations
in emotional states, mental processes, life events, sources of stress, and other
features of the external social and cultural environment.
Doing this will require collaborative interdisciplinary teams of scientists drawn from fields such as of human biology, genetics, neuroscience,
biomedicine, psychology, social psychology, sociology, and anthropology
working together as unitary investigative wholes.
It will also require greater methodological rigor if we are to produce
the kinds of findings that can intelligently inform clinical research and
practice. For example, studies of expectancy effects need to be designed
to correct a problem with the way many placebo studies have been conducted. Standard placebo studies compare two randomly assigned groups
of subjects—those who receive treatments considered appropriate and
effective for the condition in question and those who are led to believe they
are receiving the same drug or procedure but in fact do not. The degree
of the placebo effect is then inferred by comparing outcomes for the two
groups. Critics of this design point out that it fails to take into account the
fact that many illnesses are self-limiting and will go away of their own
accord. To accurately gauge whether the placebo effect is genuine, a third
group should be added—participants with the same condition who receive
no treatment at all. When this is done, some (but not all) of the previously
accepted evidence for the existence of the placebo effect becomes suspect
(Hrobjartsson & Goetzsche, 2001, pp. 1594–1602).
Much of the research discussed in this essay has been about health and illness, but there is no reason to believe that findings of research on mind–body
interactions should be limited to the area of human health alone. To the extent
that future studies enable us to understand how to capture the force and
power inherent in expectancy effects, perceptions, and the like, it should
become possible to apply them equally to other domains of human experience such as, for example, the intentional management of mental landscapes
that can produce changes in destructive mood states (Gentner, 2001; Pick,
8
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
2001), or enhance performance by heightening feelings of self-efficacy, hope,
and optimism (Bandura, Coprara, Bararanelli, Gerbino, & Pastarelli, 2003).
REFERENCES
Bandura, A., Coprara, G., Bararanelli, C., Gerbino, M., & Pastarelli, C. (2003). Role
of affective self-regulatory efficacy in diverse spheres of psychosocial functioning.
Child Development, 74, 769–783.
Bausell, R. P. (2007). Snake oil science: The truth about complimentary and alternative
medicine. New York, NY: Oxford University Press.
Benedetti, F., M. Amanzio, Baldi, S., Casadio, C., Cavallo, A., Mancuso, M., … ,
Maggi, G. (1998) The specific effects of prior opioid exposure on placebo analgesia
and placebo respiratory depression. Pain 75, 313–319.
Benedetti, F. (1996). The opposite effects of the opiate antagonist naloxone and the
cholecystokin antagonist proglumide on placebo analgesia. Pain, 64, 535–543.
Biondi, M. (2001). Effects of stress on immune functions: An overview. In R. Ader, D.
L. Felton & N. Cohen (Eds.), Psychoneuroimmunology (Vol. 2, 3rd ed., pp. 189–226).
San Diego, CA: Academic Press.
Eisenberg, L. (1977). Disease and illness: Distinctions between professional and popular ideas of sickness. Culture, Medicine, and Psychiatry, 11, 9–23.
Gentner, D. (2001). Psychology of mental models. In N. Smelser & P. B. Baltes (Eds.),
International encyclopedia of the social and behavioral sciences (Vol. 14, pp. 9683–9387).
Amsterdam, The Netherlands: Elsevier.
Glaser, R., & Kielcot-Glaser, J. (Eds.) (1994). Handbook of human stress and immunity.
San Diego, CA: Academic press.
Hrobjartsson, A., & Goetzsche, P. (2001). Is the Placebo powerless: An analysis of clinical trials comparing Placebo with no treatment. New England Journal of Medicine,
344, 910100.
Kraden, R. (2008). The Placebo response and the power of unconscious healing. New York,
NY: Routledge.
Kulielka, B. M., & Kirschbaum, C. (2001). Stress and health research. In N. Smelser
& P. B. Baltes (Eds.), International encyclopedia of the social and behavioral sciences
(Vol. 22, pp. 15710–15778). Amsterdam, The Netherlands: Elsevier.
Leventhal, H., & Diefenbach, M. (1991). The active side of illness cognition. In J. A.
Skelton & R. T. Croyle (Eds.), Mental representation in health and illness. New York,
NY: Springer Verlag.
Levine, R. J., & Fields, H. L. (1978). The Mechanism of Placebo Analgesia. Lancet, 2,
654–657.
Moerman, D. (2001). Meaning, medicine and the “Placebo Effect”. Cambridge, England:
Cambridge University Press.
Pennebaker, J. W. (1982). The psychology of physical symptoms. New York, NY: Springer.
Pennebaker, J. W. (1990). Opening up: The healing power of expressing emotions. New
York, NY: Guilford Press.
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
9
Pennebaker, J. W., & Lightner, J. M. (1980). Competition of internal and external
information in an exercise setting. Journal of Personality and Social Psychology, 39,
165–174.
Pick, H. L., Jr. (2001). The psychology of mental images. In N. Smelser & P. B. Baltes
(Eds.), International encyclopedia of the social and behavioral sciences (Vol. 14, pp.
9681–9683). Amsterdam, The Netherlands: Elsevier.
Scott, R. A. (2010). Miracle cures: Saints, pilgrimages and the healing powers of belief .
Berkeley: University of California Press.
Taylor, S., & Crocker, J. (1978). Schematic bases of social information processing. In
H. T. Higgins et al. (Eds.), Social cognition: Ontario symposium on personality and social
psychology. Hillsdale, NJ: Erlbaum.
Shapiro, D. (2001). Psychosocial aspects of hypertension. In N. Smelser & P. B. Baltes
(Eds.), International encyclopedia of the social and behavioral sciences (Vol. 10, pp.
7-98–7-101). Amsterdam, The Netherlands: Elsevier.
Wager, T. D., J. K. Rilling, E. E. Smith, Sokolik, A., Casey, K. L., Davidson, R. J., … ,
Cohen, J. D. (2004). Placebo-induced changes in fMRI in the anticipation and experience of pain. Science 303, 1162.
Zborowski, M. (1952). Cultural components in responses to pain. Journal of Social
Issues, 4, 16–30.
Zborowski, M. (1969). People in pain. San Francisco, CA: Jossey-Bass.
FURTHER READING
Ader, R., Felton, D. L., & Cohen, N. (Eds.) (2001). Psychoneuroimmunology (Vol. 2, 3rd
ed.). San Diego, CA: Academic Press.
Bandura, A. (2001). Self efficacy and health. In N. Smelser & P. B. Baltes (Eds.), International encyclopedia of the social and behavioral sciences (Vol. 20, pp. 13815–13820).
Amsterdam, The Netherlands: Elsevier.
Bausell, R. P. (2007). Snake oil science: The truth about complimentary and alternative
medicine. New York, NY: Oxford University Press.
Harrington, A. (Ed.) (1997). The Placebo effect: An interdisciplinary exploration. Cambridge, MA: Harvard University Press.
Sternberg, E. (2009). Healing spaces: The science of place and well-being. Cambridge, MA:
Belknap Press of Harvard University press.
ROBERT A. SCOTT SHORT BIOGRAPHY
Robert A. Scott was a Deputy Director of the Center for Advanced Study
in the Behavioral Sciences at Stanford University from 1983–2001 and again
from 2009–2010. Before that, he was a Professor of Sociology at Princeton
University. He has published widely on the applications of social science
knowledge to public policy in the areas of health and mental health, physical
disability, crime, and other major social problems. Most recently, his interests have turned to Gothic Medieval building during the Medieval period
10
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
in Europe and the phenomena of miracle cures at Medieval and present day
healing shrines.
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-
The Role of Cultural, Social,
and Psychological Factors
in Disease and Illness
ROBERT A. SCOTT
Abstract
Understanding the effects of social, psychological, and cultural processes on the
body raises age-old questions that remain perplexing puzzles still today. Research
by biomedical, social, and behavioral scientists on the role played by these factors
in causing disease and people’s subjective experience of it promises to advance
understanding of issues about the connections between mind and body. This
essay summarizes findings from relevant areas of research, identifies the most
promising lines of inquiry to date, poses questions that remain to be investigated
going forward, and concludes with speculation about possible applications of
existing and prospective new knowledge in health-related and other arenas of social
practice.
Among the various avenues of research relevant to this topic, three in particular
stand out. They are (i) studies of the connections between stress and sickness, (ii)
studies of persons’ subjective experiences of physical symptoms, and (iii) studies
of expectancy effects. Studies of stress document the physical effects of long-term
exposure to adverse social, psychological, and environmental conditions, the role
these play in causing disease, their effects on people’s experiences of sickness, and
on their ability to recover. Studies of symptom perception focus on people’s subjective experiences of being ill, investigating ways in which aspects of culture, social
environment, traits of personality, and psychological states affect our awareness of
bodily symptoms, and how we interpret and experience them subjectively. Studies
of expectancy effects, commonly referred to as the placebo or the healing response, aim
to learn if beliefs alone can have physiologically measurable effects on bodily symptoms and on our perceptions of them, on how we feel and on how we respond to the
treatments we are given.
Taken together, these areas of research support the conclusion that understanding
sickness requires simultaneous knowledge of two factors: the biological conditions
diagnosed on the basis of physical signs (disease) and an individual’s subjective
experiences of the physical symptoms that a disease manifests (illness).
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.
1
2
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
FOUNDATIONAL RESEARCH
DISTINCTION BETWEEN DISEASE AND ILLNESS
Fundamental to all studies of the role of social, cultural, and psychological
factors in human, physical ailment is a distinction between disease and illness. Disease refers to the biological conditions that have been diagnosed by
a physician or other similarly qualified medical expert who make this determination on the basis of physical signs and in light of established scientific
knowledge. Illness refers to our subjective experiences of the physical symptoms we have. In effect, disease is what a medical expert determines is wrong
with us; illness is our subjective experience of it (Eisenberg, 1977).
In most instances, objective physical signs of sickness and subjective experiences of symptoms occur simultaneously and interact with one another.
However, this is not always so. Hypertension is a condition that is often
be symptom free, exemplifying an instance of a disease but not an illness.
However, certain treatments for hypertension entail use of medications with
unpleasant side effects, resulting in a situation where the disease is effectively
cured but yet the patient feels ill (Shapiro, 2001).
THE ROLE OF STRESS IN ILLNESS AND DISEASE
Studies of stress document how social conditions such as poverty, occupational strain, marital and family discord, social supports, and daily hassles
disorganized environments and peoples’ places in social dominance hierarchies are in one way or another implicated in causing disease, in affecting
the timing of its onset, and in dictating the rate of recover from it (Kulielka
& Kirschbaum, 2001).
Studies of stress link it in various ways—not yet fully understood—to disorders associated with the nervous, immune, cardiovascular, endocrine, neuromuscular, and skeletal systems (Kulielka & Kirschbaum, 2001). In each
instance, the linkage is hypothesized to be mediated through the mechanism
of allostasis, the body’s capacity to respond to changes in the environment
that protect against immediate, short-term sources of harm. The working
hypothesis is that prolonged activation of the so-called “allostatic load” (i.e.,
wear and tear on the body) results in a physiological burden that can be damaging to bodily defense systems essential for averting disease (Biondi, 2001;
Kulielka & Kirschbaum, 2001, pp. 15171–15172).
SYMPTOM PERCEPTION
Research on symptom perception seeks to understand how cognitive and
perceptual processes shape our subjective awareness and interpretation of
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
3
physical signs associated with disease. Awareness of symptoms, how we
interpret them, what we decide to do about them, how we develop the
sense that we are becoming sick, or are getting well again, are all affected by
cultural beliefs, features of our immediate social environment, personality
factors, and mood states.
Research on this topic begins with studies of initial perceptions of bodily
symptoms of discomfort and supports three broad conclusions. First, emotional states play a critical role in sensitivity to physical symptoms. Those
suffering from mood disorders such as depression and chronic anxiety, for
example, are more attentive to bodily symptoms than those whose characteristic mood states are of hopefulness, optimism, and a desire for sociability
(Pennebaker, 1982). Second, cultural heritage is related to sensitivity to symptoms. For example, people belonging to different cultural groups are found to
differ in their sensitivity to bodily symptoms, with Italian and Jewish Americans in the aggregate showing greater sensitivity to internal bodily states
than so-called “Yankees.” Third, sensitivity to and thus awareness of internal
bodily sensations are directly affected by characteristics of one’s immediate
environment. For example, those exposed to highly stimulating, distracting
environments are much slower to notice symptoms of internal bodily states,
if at all; alternatively, when the external environment is lacking in stimulation, attention is more readily directed toward the body and inner feeling
states (Pennebaker & Lightner, 1980; for a review of studies of symptom perception, see Scott, 2010, pp. 151–155).
Once signs of physical discomfort come to conscious awareness, individuals tend to organize their perceptions about them around basic cognitive
schemas. Such schemas are comprised of a mixture of elements including
notions about what people believe ails them, its likely cause or causes, its
characteristic symptoms, expectations about its duration and curability,
appropriate ways of treating it, and signs to look for that one is getting better
(Taylor & Crocker, 1978).
As with studies of sensitivity to symptoms, studies of illness-related
schemas also show that culture plays a major role in the organization
and content of the disease-related schemas people acquire. Specifically,
they demonstrate that people from different cultural backgrounds possess
different schemas for the same basic biological condition (Zborowski, 1952,
1969). Finally, once activated, illness-related cognitive schemata structure
and guide perceptions, leading people to focus their attention on bodily
sensations that provide them with confirming evidence for their initial
“diagnosis” and leading them to ignore disconfirming evidence. Moreover,
once schematic notions about “diagnosis” solidify, the resulting mental
structures prove resistant to attending to disconfirming evidence. Instead,
people tend to closely monitor bodily sensations for evidence that confirms
4
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
their provisional hypothesis and ignore the rest (Leventhal & Diefenbach,
1991).
Given that research on symptom perception is concerned with persons’
subjective experiences of being sick, much of it has naturally focused
on awareness of pain and pain thresholds irrespective of condition and
on understanding how focus of attention, social context, and cultural
expectations shape people’s experiences of physical discomfort. This has
led to a view of pain as a perceptual phenomenon in which information
transmitted through the central nervous system is integrated, processed,
and interpreted in the brain. Because the brain plays such an integral role
in how we experience pain, in principle, any factor in the environment that
impacts the brain can affect the level of pain people experience and their
ability to cope with and tolerate it.
EXPECTANCY EFFECTS
Studies of expectancy effects aim to discover if beliefs and resulting expectations effect the way people respond to the treatments they are given and if
so, how this happens. In the typical study, subjects are primed about how
the sham treatments they are about to receive in experimental or clinical situations will affect them. Researchers then look for evidence of the effects of
these implanted beliefs on uncomfortable sensations that either have been
induced experimentally or are associated with the disease condition being
treated. Several key findings emerge from this research.
One of the most consistent and striking of these pertains to pain
analgesia—that is the subjective experience of gaining relief from physical
discomfort. Under certain conditions, people primed to expect relief from
pain actually report experiencing it. Another series of studies suggests that
the manner and form in which placebos are administered affects the magnitude of the response. Administering a placebo more frequently produces
better outcomes than administering the same placebo less frequently; some
pill colors induce greater placebo effects than others; larger pills are more
effective as placebos than smaller ones; injected placebos produce stronger
effects than those that are orally ingested; and surgically induced placebo
effects are strongest of all (Bausell, 2007, pp. 135–136; Moerman, 2001, p. 66).
Expectancy effects appear to be especially pronounced for certain conditions such as asthma, intractable warts, rashes and other skin conditions,
nervous and mental conditions such as depression and anxiety, infectious
disorders, stomach ulcers, a range of inflammatory reactions, and allergies.
Other studies suggest that when care providers themselves have been misled into believing that the inert or sham treatments they are administering
are real, evidence of placebo analgesia in patients also occurs. And finally,
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
5
for certain forms of physical ailments, such as intractable warts, expectancy
effects can apparently result in permanent cure. More often, such effects do
not cure, but there can be little doubt that they help people given placeboes
feel better (for a review of relevant Research see Scott, 2010, pp. 129–133).
CUTTING-EDGE RESEARCH
Research on the role beliefs plays in perceptions of bodily symptoms and in
expectancy effects demonstrates that the mind is central. In order for sham
treatments to work, people must be aware that something has been given
to them and “primed” to expect their likely effects; in the absence of this
awareness, no expectancy effects are detected (Kraden, 2008). Does this then
mean that symptom perception and placebo effects are no more than figments of the imagination, things that exist only in our heads? Recent research
indicates that the answer to this question is an emphatic “no.” Evidence in
several recent studies shows that once activated, beliefs have detectable, measurable physiological effects that are real and help us to make sense of the
subjectively perceived effects subjects report experiencing (Benedetti, 1996;
Benedetti et al., 1998). One of the most exciting areas of such research involves
efforts to study in what manner and precisely how beliefs become physiologically consequential and the form their effects take.
This research builds on the finding of earlier studies showing that the body
is capable of manufacturing its own version of the pain killer morphine
known as endorphins (endogenous morphine’s), the so-called “the poppy
fields of the mind.” Physiologists have identified where in the body they are
released, what triggers their release, and the biochemistry of what happens
once they are activated (for a review of relevant research, see Scott, 2010,
pp. 141–144). Subsequent studies using functional magnetic resonance
imaging (fMRI) scans have pinpointed the precise regions of the brain
where pain analgesia occurs and how it works. fMRI technology entails
using magnetic resonance imaging technology to measure brain activity
by detecting associated changes in blood flow. They show that areas of the
brain where known pain receptors are located and activated when pain is
administered to subjects, go “dark” when subjects are given placeboes they
are told will curtail, diminish, or abolish their pain, and that regions where
the manufacture of natural painkillers (endorphins) are initiated, “light up”
following administration of the placebo medication (Wager et al., 2004).
Adding further credence to the idea that expectancy-induced pain analgesia is real are studies showing that analgesia that has been induced in laboratory studies can be neutralized using a drug (Naloxone) originally developed
as an opioid antagonist in treating persons addicted to morphine. These studies have established that Naloxone blocks the effects of placebo-induced pain
6
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
analgesia in exactly the same way and to the same degree that it interferes
with the pain numbing effects of morphine (Levine and Fields, 1978).
A second cutting-edge area of research that highlights the linkages between
mental and internal physiological processes points to its direct relevance for
the body’s ability to ward off and fight disease. These studies monitored
the physiological effects of psychological interventions aimed at uncovering enduring long-suppressed traumatic life events by allowing subjects to
“open up” about them. A series of studies show that those given the opportunity to write about such events show a dramatic decline in reported episodes
of illness as measured by use of health services, and activation of the immune
system in the form of increases in T-cell counts that are both robust and long
lasting (Glaser & Kielcot-Glaser, 1994; Pennebaker, 1990).
KEY ISSUES FOR FUTURE RESEARCH
The studies referenced in this essay provide compelling evidence that mind
and body are tightly interconnected and show that human sickness cannot be
fully understood without giving equal attention and weight to both. Research
on this topic to date has established that mental processes and factors in
the social and cultural environments affecting them can have measurable
impacts on physiological processes. Only now are we beginning to understand how these effects happen; not at all understood is whether it is possible
to capture the powers inherent in such phenomena as expectancy states, perceptions, beliefs, and other facets of mental processes and employ them telically to affect health outcomes in desired and intended ways. Although we
know that placebo effects are real and can have real consequences, until we
understand more fully how and why they do, and when they do not, why
they do not, we cannot begin to fashion interventions that will allow us to
tap into the power of belief in aid of clinical interventions. Herein lies one of
the most promising and exciting areas of investigation for future research.
The beginning point for such research must be to acquire more complete
and systematic knowledge about the various ways in which mind affects
body, whereas many of the studies referred to in this essay came about in
a somewhat haphazard, ad hoc fashion. Medical scientists invited social and
behavioral scientists to affiliate with research programs relating to specific
types of disease in the belief that the disease they study and treat has important behavioral and social components. The result of this way of proceeding
has provided an important beginning, but at present yields something of a
patchwork of findings, lacking clear conceptualization of the types of diseases that are most affected by social, cultural, and situational factors, and of
the kinds of roles social and behavioral are likely to play in the genesis, onset,
course, and outcome of different types of diseases. It is likely that all such
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
7
factors thus far identified do not play equally important roles for all forms
of disease and at all stages of their development. Developing a scheme that
brings conceptual clarity to this matter would not only advance knowledge
but also provide a welcome corrective to the sometimes exaggerated claims
made for the role of social and behavioral factors in illness (for a comprehensive assessment of this topic see Bausell, 2007).
To do this, it will first be necessary to devise a conceptualization of diseases
based on the likely effects (or not) of culture, social environment, and mental processes on them, then to systematically monitor internal physiological
states as measured by changes in blood chemistry, fluctuations in vital signs,
immune system functioning, brain activity, and other facets of bodily functioning, and in turn to study linkages between these changes and variations
in emotional states, mental processes, life events, sources of stress, and other
features of the external social and cultural environment.
Doing this will require collaborative interdisciplinary teams of scientists drawn from fields such as of human biology, genetics, neuroscience,
biomedicine, psychology, social psychology, sociology, and anthropology
working together as unitary investigative wholes.
It will also require greater methodological rigor if we are to produce
the kinds of findings that can intelligently inform clinical research and
practice. For example, studies of expectancy effects need to be designed
to correct a problem with the way many placebo studies have been conducted. Standard placebo studies compare two randomly assigned groups
of subjects—those who receive treatments considered appropriate and
effective for the condition in question and those who are led to believe they
are receiving the same drug or procedure but in fact do not. The degree
of the placebo effect is then inferred by comparing outcomes for the two
groups. Critics of this design point out that it fails to take into account the
fact that many illnesses are self-limiting and will go away of their own
accord. To accurately gauge whether the placebo effect is genuine, a third
group should be added—participants with the same condition who receive
no treatment at all. When this is done, some (but not all) of the previously
accepted evidence for the existence of the placebo effect becomes suspect
(Hrobjartsson & Goetzsche, 2001, pp. 1594–1602).
Much of the research discussed in this essay has been about health and illness, but there is no reason to believe that findings of research on mind–body
interactions should be limited to the area of human health alone. To the extent
that future studies enable us to understand how to capture the force and
power inherent in expectancy effects, perceptions, and the like, it should
become possible to apply them equally to other domains of human experience such as, for example, the intentional management of mental landscapes
that can produce changes in destructive mood states (Gentner, 2001; Pick,
8
EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
2001), or enhance performance by heightening feelings of self-efficacy, hope,
and optimism (Bandura, Coprara, Bararanelli, Gerbino, & Pastarelli, 2003).
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FURTHER READING
Ader, R., Felton, D. L., & Cohen, N. (Eds.) (2001). Psychoneuroimmunology (Vol. 2, 3rd
ed.). San Diego, CA: Academic Press.
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Amsterdam, The Netherlands: Elsevier.
Bausell, R. P. (2007). Snake oil science: The truth about complimentary and alternative
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Sternberg, E. (2009). Healing spaces: The science of place and well-being. Cambridge, MA:
Belknap Press of Harvard University press.
ROBERT A. SCOTT SHORT BIOGRAPHY
Robert A. Scott was a Deputy Director of the Center for Advanced Study
in the Behavioral Sciences at Stanford University from 1983–2001 and again
from 2009–2010. Before that, he was a Professor of Sociology at Princeton
University. He has published widely on the applications of social science
knowledge to public policy in the areas of health and mental health, physical
disability, crime, and other major social problems. Most recently, his interests have turned to Gothic Medieval building during the Medieval period
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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES
in Europe and the phenomena of miracle cures at Medieval and present day
healing shrines.
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