Linnea Cooper, RN

Julia Delcour, RN

Karin Pearson, RN

Susie Clabots, RN

Chris Peredney, RN, M.S.

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.

Phenomena of Concern in PNI1. Personality, psychology, emotional states, the physical

response (behaviors) to these states and the following action on the immune system.

2. The result of these interactions, in terms of disease acquisition or exacerbation on the individual person.

Historical Context460-370 BC: Hippocrates2nd 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- physical proof that glands in body

respond to stress1930s: Hans Seyle- flight or fight response to stress (GAS)

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)

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.

AssumptionsThere 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).

Assumptions ContinuedMethods 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).

World View Psychological scientific Why??

Focuses on causality Began in a psychology realm based on their own

conceptsMoved to a scientific realm where they were able to

perform experiments

PNI ParadigmTheory began over 40 years ago as part of the

biopsychological paradigmIn McCain, Gray, Walter, & Robins (2005), PNI is defined

as a paradigm itselfPNI 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)

Nursing MetaparadigmPerson: complex relationship

Environment: environmental factors

Health: Adaptational outcomes (McCain, Gray, Walter, & Robins, 2005).

Nursing: comfort and teaching (Sternberg, 2000).

ConceptPsychoneuroimmunology

“Psycho”

“Neuro”

“Immunology”

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.

Related ConceptsInterplay between the psychological states, the

physiologic response, and the immune system

Introduction of other conceptsBidirectional relationshipsStress

PropositionsThe 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).

Propositions Communication systems include:

 HPASympathetic nervous system (SNS) Noradrenergic innervate immune systemCytokines induce symptoms of illness

 

(Thorton & Andersen, 2006)

Propositions Cofactors are those components that have the potential to

predispose an individual to certain stress, coping and health patterns.Personal characteristicsHealth related featureIndividual transactional processes (McCain, 2005).

Psychosocial Functioning

Quality of Life

Physical Health

HEALTHHEALTH

Psychosocial Moderators

Coping Patterns

Person Factors

Pre tx: Critical Factors

Potential Co-Factors

Neuro-EndocrineMediators

Immunological MediatorsPerceived

Stress

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.

ClarityDefinitions

Concepts are not operationally defined Developed over time with multiple authorsDefinitions were not always exactly the

sameAuthor assumed the known definition from

their respective fields

Examples of the definition of the PNI concept throughout researchKemeny: “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.

Clarity ContinuedDiagrams

Very clear and straightforwardOffer insight into how the theory is structuredDifferent versions of the theory showed similar diagrams

Intersubjectivity - (shared agreement within the relationships between the concept)

Not consistent across the different theoristsRelationship has been substantiated but the mechanisms still

remain unclear.

CongruenceValues of PNI Theory

Inductive and Deductive ReasoningPersonal ObservationsEvidenceCollaboration

Congruence with professional valuesDeductive ReasoningPersonal ObservationsEvidence

Congruence with social valuesThe Social Setting of Nursing

1. Is the role of the nurse within the model congruent with the role of the nurse as perceived by society?

2. Are actions and outcomes congruent with societal expectations of nursing?

(Meleis, 2007)

LevelMicro-Macro

The interplay between the micro functions of the body systems and the outward behavior of the individual.

MicroBiological, neurological, and immune functions interacting

is all within the person.

LevelSolomon 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.

And then……..? What does this mean to my practice?

NPCNSMidwife“Psychiatric Nurse”AdministratorManager

Nursing Use

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

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

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

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

Working BackwardReduction of PTSD by boosting the immune system

(Lewitus et al, 2008)T-cells are important factors in psychological stress

responseImmunization with a myelin-related peptide to alleviate

chronic consequence of PTSD

How does this relate to your practice

NPCNSMidwife“Psychiatric Nurse”AdministratorManager

TestabilityThe theory is supported by a large and growing peer

reviewed research baseSeveral nursing schools have programs in developing,

assessing, implementing and evaluating the applicability and efficacy of PNI based interventionsUCSF-NursingSan Jose State-NursingUSF-NursingVirginia Commonwealth Nursing School

Who is testing?• UCLA - Semel Institute

Cousins 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 Psychoneuroimmunology, entitled “Frontiers in Psychoneuroimmunology: The Emotional Interface”, September 18-21, 2008

• The list goes on…..

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

REFERENCES Ader, R. (2001). Psychoneuroimmunology. Current Directions in Psychological Science 10(3), 94-98. 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), 1231–1240.

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., O’Connor, 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), 933–940.

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), 699–708.

Halldorsdottir, S. (2007). A psychneuroimmunological 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), 1130–1137.

Langley, P., Fonseca, J. & Iphofen, R. (2006). Psychoneuroimmunology and health from a nursing perspective. British Journal of Nursing 15(20), 1126-29.

REFERENCES Lewitus, G., Cohen, H., Schwartz, M. (2008) Reducing post-traumatic anxiety by immunization. Brain,

Behavior, and Immunity 22(2008), 1108–1114. 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 psychoneuroimmunology into pediatric chronic illness interventions. Journal of Pediatric Psychology. 1-13.

 O’Donnell, 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. 1241–1247.

 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). Psychoneuroimmunology: an emerging framework for nursing research. Journal of Advanced Nursing. 23, 657-664.