Bio psycho social and spiritual dimension and chd

Bio-Psycho-Spiritual
approach in preventing and
reversing Coronary Heart
Disease
Dr. Rahul Bansal
Professor & Head
Department of Community Medicine
Subharti Medical College, Meerut

The Biopsychosocial Model and the Spiritual
Dimension
The biopsychosocial model is a modern humanistic
and holistic view of the human being. The model was
brought to medicine by George L. Engel (1913–
1999), a prominent scholar engaged in the
psychosomatic movement.
Medicines (Basel). 2017 Dec; 4(4): 79.
Published online 2017 Oct
31. doi: 10.3390/medicines4040079

As Engel stated: “all three levels, biological,
psychological, and social, must be taken into
account in every health care task”
George L. Engel
31. doi: 10.3390/medicines4040079

“Currently, many researchers think the
biopsychosocial model should be expanded to include
the spiritual dimension as well. One such researcher
is Katerndahl, whose study has shown the relevance
of spiritual symptoms and their interactions for
understanding health outcomes.”
31. doi: 10.3390/medicines4040079

Impact of spiritual symptoms and their
interactions on health services and life
satisfaction
David A. Katerndahl
Sep-Oct 2008;6(5):412-20.
doi: 10.1370/afm.886.

“Spiritual symptoms were associated with 7 of the
10 outcomes and were particularly important to
extreme use of health care services and life
satisfaction. This study has shown the relevance of
spiritual symptoms and their interactions to
understanding health outcomes.”
David A. Katerndahl
31. doi: 10.3390/medicines4040079
Impact of spiritual symptoms and their interactions on health
services and life satisfaction

The Biopsychosocial Model and the
Spiritual Dimension
“Daniel P.Sulmasy justifies the expansion of the
model to a biopsychosocial–spiritual one by
remembering that genuinely holistic health care
must address the totality of the
patient’s relational existence.”
Daniel P. Sulmasy
31. doi: 10.3390/medicines4040079

A biopsychosocial-spiritual model for the
care of patients at the end of life
Daniel P. Sulmasy
(OFM,MD,PhD)

A biopsychosocial-spiritual model for the
care of patients at the end of life
This article presents a model for research and
practice that expands on the biopsychosocial model
to include the spiritual concerns of patients.
Daniel P. Sulmasy
(OFM,MD,PhD)

Intensive Lifestyle Changes for
Reversal of Coronary Heart Disease
Dean Ornish, MD et al
President & Founder
Preventive Medicine Research Institute
CALIFRONIA
• Randomized controlled trial conducted from
1986 to 1992 using a randomized invitational
design.
JAMA. 1998;280:2001-2007
Dr. Dean Ornish, MD

Intervention
• Intensive lifestyle changes (10% fat whole foods
vegetarian diet, aerobic exercise, stress
management training, smoking cessation, group
psychosocial support) for 5 years.
JAMA. 1998;280:2001-2007
Dr.Dean Ornish, MD

Conclusions
• More regression of coronary atherosclerosis
occurred after 5 years than after 1 year in the
experimental group. In contrast, in the control
group, coronary atherosclerosis continued to
progress and more than twice as many cardiac
events occurred.
• JAMA. 1998;280:2001-2007
Dr. Dean Ornish, MD

More praise for doctor Dean Ornish
The Washington post
• “For Dean Ornish cardiovascular patient, Open
heart does not mean bypass surgery. His is a
spiritual sort of open heart- as in ‘Open your
heart’. Ornish, with his noninvasive techniques,
is accomplishing the same ends as are
his scalpel-welding colleagues.”

Author of recovering the soul
Larry Dossey, M.D.
• “This is an epochal Book. It sets a new standard
in our understanding of heart disease, and it is
the template against which all other books on
any disease whatsoever should be judged.”
Larry Dossey, M.D.

“For the purity of the science on which it rests, and
for the majesty of its spiritual wisdom, this book
has no equal in the literature of medicine and
health.”
Larry Dossey, M.D.

William C. Roberts, M.D.
Editor in chief
American Journal of cardiology
• “Doctor Ornish is on the right road and we need
to get on it also.”

Reader’s digest
• “For the first time, we have a carefully done
scientific study that shows, even in advanced
stages, this disease can be reversed with lifestyle
changes. This is a landmark study.”

• “I am coming to believe that our emotional and
spiritual health are exceptionally important to the
health of our hearts. I’ll share the latest scientific
research in this exciting new field and explain how my
own background helped to convince
me of its value.”
Dr. Dean Ornish, MD

Chapter 7
Opening your heart to your feelings and to
inner peace
“Studies in Boston, New york, California, England
and in other parts of the world were proving, for
example, that meditation can lower blood pressure,
decrease the frequency of irregular heart rhythms,
reduce cholesterol levels, and so on. Yet
almost all of these techniques
ultimately derive from yoga.”

“Meditation and imagery, too, are also ancient yoga
techniques. Herbert Benson, MD, a well known
cardiologist at the Harvard medical school, has
spent the past two decades conducting pioneering
research on the beneficial effects of meditation.”
Herbert Benson, MD
Founder
Mind, Body ,Medicine
Institute Of Massachusetts
General Hospital,
BOTSON

• He found that regular elicitation of what he terms
the relaxation response (in contrast to the fight-or-
flight response) can lower blood pressure, decrease
premature heartbeats, inhibit gastric acid secretion,
and produce other beneficial effects

• Jon kabat-zinn, Ph.D, Director of the stress
reduction clinic at the University of Massachusetts
medical school, has found similar results in using
yoga techniques with his patients.
Jon kabat-zinn, Ph.D

Deep Breathing
• Deep breathing is one of the simplest yet most
effective stress management techniques. You can
do it anywhere, at any time. It becomes even
more effective with practice.
Dr. Dean Ornish, MD

• The technique of alternate nostril breathing was
developed to “rebalance” the equilibrium of
breathing. Whether or not it works for the reasons
that yoga teachers believe, alternate nostril breathing
is an exceptionally powerful technique for calming
and relaxing your mind and body.
Dr. Dean Ornish, MD

Chapter 9
Opening your heart to a Higher self
• Whatever allows you to experience a higher
force- whether through prayer, meditation,
contemplating nature, and so on can be a
powerful means of transcending feelings of
isolation.
Dr. Dean Ornish, MD

Contd….
A direct experience of something larger than
ourselves can profoundly transform our lives when
we realize that we are not isolated and we are
never alone.
Dr. Dean Ornish, MD

• “There are almost Certainly Cardiovascular risk
factor that Framingham Investigators did not
identify. Some of these factors are likely in the
“psychosocial” domain that Framingham
investigators decided to ignore when the study was
taken over by the NHI in the early 1950s.”
Dr. Sandeep Jauhar

“In the early 1970s , Sir Michael Marmot and his
colleagues at the UC Berkeley school of public health
studied nearly four thousand Middle-aged Japanese
men living in the SanFrancisco Bay Area.They found
that immigrants who stayed true to their Japanese
roots had a much Lower prevalence of heart disease,”
Dr. Sandeep Jauhar

Contd….
“even when they matched Americans in terms of serum
cholesterol and blood pressure, than Immigrants who
were more integrated into their new culture.
“Traditional” Japanese immigrants had coronary
Disease rates in line with their homeland
counterparts.”
Dr. Sandeep Jauhar

If cutting traditional cultural ties increases the risk
of heart disease, then Psychosocial factors must play
a role in cardiovascular health.Today we know this
to be true in many strata of human society. For
example, American blacks in poor urban centers
have a much higher prevalence of hypertension and
cardiovascular disease than other groups.
Dr. Sandeep Jauhar

“Peter Sterling, The University of Pennsylvania
neurobiologist, has written that hypertension in
such communities is a normal response to what he
calls “chronic arousal”or Stress.In small
preindustrial communities, he writes, people tend
to know and trust one another.”
Peter Sterling

Contd….
“Generosity Is rewarded; Cheating tends to be
punished. When this milieu is disrupted, as in
migration or urbanization, there is often an
increased need for vigilance.People get estranged
from their neighbors.”
Peter Sterling

“The chronic arousal triggers release of hormones,
such as adrenaline and cortisol ,that tighten blood
vessels and cause retention of salt. These in turn
lead to long-term Changes like arterial wall
thickening and stiffening that increase the blood
pressure that the body tries to maintain.”
Dr. Sandeep Jauhar

• “In sterling’s formulation, nothing is broken
(except perhaps “the system”). The body is
responding exactly in the way it should to the
chronic fight-or- flight circumstances in which it
finds itself. If takotsubo cardiomyopathy proves
that acute psychological disruption can damage the
heart, Sterling’s theories suggest that chronic, low
level Stress may be just as harmful.”

Contd….
“His theories put psychosocial factors front and
center in how we think about and approach heart
problems. They show that chronic heart disease,
unloosed from a Framingham cage, is inextricably
linked to the state of our neighborhoods, jobs and
families.”
Dr. Sandeep Jauhar

• “Friedman and Rosenman’s research was girded
by the idea “that a person’s feelings and thoughts
have an influence on the development of
coronary heart disease.”
Dr.Meyer Friedman Dr.Ray H. Rosenman

• “They wrote, “Too many finely executed studies
suggested that neither cholesterol nor the fat
content of various diets could always explain
coronary heart disease. Other factors just had to
be playing a part.”

Feasibility of altering type a behaviour pattern
after myocardial infraction
Recurrent coronary prevention project study methods
baseline results and preliminary findings
MEYER FRIEDMAN, M.D.
Ahajournals.org Received June 6,1981 Circulation 66,
No.1,1982

SUMMARY
“We studied 1035 consecutive post infarction
patients to determine the feasibility of altering type
A behaviour and the effect such alteration might
have on subsequent rates of infarction and
cardiovascular death.”
Dr.Meyer Friedman
M.D.

RESULT
• After the first year of this 5- year study, the rates of
infarction and cardiovascular death were lower
(p<.01 and p<.05, respectively) among subjects who
received both cardiologic and behavioural counseling
than among the control subjects.
Dr.Meyer Friedman

Distrust,Rage may be ‘toxic core’ That Puts
‘Type A’ person at Risk
Chris Raymond, PhD
JAMA 1989;261(6):813.
It’s not talking fast, feeling pressed for time, and
putting in long hours that will kill you. It’s being
suspicious of and hostile toward your fellow humans
that will do you in. So finds Duke University medical
centre’s Redford B. Williams, Jr, MD, professor of
psychiatry at the Durham, NC campus.

• “We paid little attention to “psychosocial”
factors during fellowship. The focus of our
seminars was on pressure-volume loops, cardiac
work cycles, resistant of fluid-filled pipes, and
capacitance of fluid-filled chambers.”
Dr. Sandeep Jauhar

Contd….
We concentrated on clinical trial design, biological
mechanisms, and understanding the heart as a
machine. As with most academic training programs,
the fact that there was an emotional world that
could damage (or heal) this pump was largely
ignored.
Dr. Sandeep Jauhar

“Ironically, the view that heart disease results from
unfulfilled social or psychological needs was widely
accepted in primitive societies. That is almost
certainly how people thought about heart disease in
rural Punjab in the 1950s.”
Dr. Sandeep Jauhar

• “However, this narrow focus on biological
mechanisms has hurt patients. We have overused
stents and pacemakers. We have moved away from
the emotional heart to a narrow focus on the
biomechanical pump.”
Dr. Sandeep Jauhar

• “We need a better way, one that recognizes the
power and importance of emotions that the heart-
the metaphorical heart- was believed to house for
millennia.”
Dr. Sandeep Jauhar

Retardation of Coronary
Atherosclerosis with Yoga Lifestyle
Intervention
SC Manchanda,
All India Institute of Medical Sciences, New Delhi, India.

Material and Methods
• We evaluated possible role of lifestyle modification
incorporating yoga, on retardation of coronary
atherosclerotic disease. In this prospective, randomized,
controlled trial, 42 men with angiographically proven
coronary artery disease (CAD) were randomized to
control (n=21) and yoga intervention group (n=21) and
were followed for one year.
Dr.S.C. Manchanda

Contd….
The active group was treated with a user-friendly
program consisting of yoga, control of risk factors,
diet control and moderate aerobic exercise.
Dr.S.C. Manchanda

Results
• At one year, the yoga groups showed significant
reduction in number of anginal episodes per
week, improved exercise capacity and decrease
in body weight. Serum total cholesterol, LDL
cholesterol and triglyceride levels also showed
greater reductions as compared with control
group.
Dr.S.C. Manchanda

Contd….
Revascularisation procedures (coronary angioplasty
or bypass surgery) were less frequently required in
the yoga group (one versus eight patients; relative
risk = 5.45; P=0.01).
Dr.S.C. Manchanda

Conclusion
• Yoga lifestyle intervention retards progression
and increases regression of coronary
atherosclerosis in patients with severe coronary
artery disease. It also improves symptomatic
status, functional class and risk factor profile.
(JAPI 2000; 48 : 687-694)
Dr.S.C. Manchanda

Yoga-Based Cardiac Rehabilitation
After Acute Myocardial Infarction A
Randomized Trial
JOURNAL OF THE AMERICAN
COLLEGE OF CARDIOLOGY
VOL. 75, NO. 13, 2020 ª 2020
Dorairaj Prabhakaran, DM

OBJECTIVES
• This study sought to evaluate the effects of yoga-
based CR (Yoga-CaRe) on major cardiovascular
events and self-rated health in a multicenter
randomized controlled trial.
Dr.Dorairaj Prabhakaran

METHODS
• The trial was conducted in 24 medical centers across
India. This study recruited 3,959 patients with acute
myocardial infarction with a median and minimum
follow-up of 22 and 6 months. Patients were
individually randomized to receive either a Yoga-
CaRe program (n ¼ 1,970) or enhanced standard
care involving educational
advice (n ¼ 1,989).
Dr. Dorairaj Prabhakaran

CONCLUSIONS
• Yoga-CaRe improved self-rated health and
return to pre-infarct activities after acute
myocardial infarction
Dr. Dorairaj Prabhakaran

Bimal Chhajer et al
Biomedical and pharmacology Journal
• This multi-centric prospective study was held in
the Saaol heart center in different cities (Delhi,
Kolkata, Bangalore, Chennai, and Mumbai) of
India from 1995 to 2015.

• In this study, total 5,000 CAD patients having co-
morbidity of obesity, hypertension, and diabetes were
enrolled. A yoga-based lifestyle modification
counseling (consist the essential components; cardiac
education, plant-based balanced diet, regular walk,
yoga, and meditation) was administrated to study
subjects .”
Bimal Chhajer

• The results of this study demonstrate a
significant improvement in angina with
reduction of New York Heart Association
(NYHA) angina classification score from
3.08±0.56 (mean±SD) to 2.45±0.70 and also
reduce the intake of anti-anginal drugs from
4.36±1.35 to 3.82±1.20.
Bimal Chhajer

• In this study, a significant improvement was also
observed in heart attack protection score from
56.68±13.53 to 104.13±14.55.
Bimal Chhajer

Positive Thinking Helps
Heart Patients
Courtney Ware
• Positive Expectations About Recovery May Increase
Survival in People With Coronary Artery Disease
• Hospitalized patients diagnosed with coronary
artery disease who had a positive outlook about
their recovery were less likely to die over the next 15
years and had better physical functioning after one
year, according to a new study.

Positive Outlook, Longer Survival
Study author John C. Barefoot
• Researchers at Duke University Medical Center
followed 2,818 heart patients after they had
coronary angiography to evaluate blood flow in
the coronary arteries of the heart.
Courtney Ware

Meditation and coronary heart disease: a
review of the current clinical evidence
Ochsner J. Winter 2014;14(4):696-703.
et al

• During the past few decades, multiple studies
have demonstrated the beneficial effects of
meditation on various CV risk factors. In
addition to decreasing CV mortality, meditation
has also been shown to improve conditions such
as hypertension, type 2 diabetes mellitus,
dyslipidemia, and high cortisol levels.

Women, Loneliness, and Incident
Coronary Heart Disease
Rebecca C. Thurston, PhD and Laura D. Kubzansky, PhD, MPH
Psychosom Med. 2009 Oct; 71(8): 836–842.
Rebecca C. Thurston Laura D. Kubzansky

• Among women, high loneliness was associated
with increased risk of incident CHD (high:
hazard ratio = 1.76, 95% Confidence Interval =
1.17â2.63; medium: hazard ratio = 0.98, 95%
Confidence Interval = 0.64â1.49; reference:
low),

Contd….
• controlling for age, race, education, Income,
marital status, hypertension, diabetes,
cholesterol, physical activity, smoking, alcohol
use, systolic and diastolic blood pressures, and
body mass index. Findings persisted additionally
controlling for depressive symptoms.

Social Integration and Reduced Risk of
Coronary Heart Disease in Women
The Role of Lifestyle Behaviors
Shun-Chiao Chang et al
• Seventy-six thousand three hundred and sixty-
two women in the Nurses Health Study, free of
CHD and stroke at baseline (1992), were
followed until 2014.

• Social integration was assessed by a simplified
Berkman–Syme Social Network Index every 4
years. End points included nonfatal myocardial
infarction and fatal CHD.
Shun-Chiao Chang

• Adjusting for demographic, health/medical risk
factors, and depressive symptoms, being socially
integrated was significantly associated with
lower CHD risk, particularly fatal CHD.
Shun-Chiao Chang

Contd….
The most socially integrated women had a hazard
ratio of 0.55 (95% confidence interval, 0.41–0.73) of
developing fatal CHD compared with those least
socially integrated (P for trend <0.0001).
Shun-Chiao Chang

THE ROSETO STUDY
“Those with the conventional risk factors are more
likely to develop myocardial infarction [heart attacks]
Than are those without the risk factors, but an even
larger proportion of the population may have the risk
factors and not succumb to myocardial infraction
over a period of nearly three decades” if they are
protected by a strong sense of connection
and community.
AUTHOR: DR.DEAN ORNISH

The Heart’s Code
DR. Paul Pearsall, Ph.D.
“You know that the heart loves and feels, but did you
know that the heart also thinks, remembers,
communicates with other hearts, helps regulate
immunity, and contains stored information that
continually pulses through your body?”

In the heart’s code, Dr. Paul Pearsall explains the
theory and science behind energy cardiology, the
emerging field that is uncovering one of the most
significant medical, social, and spiritual discoveries
of our time: The heart is more than just a pump; it
conducts the cellular Symphony that is the very
essence of our being.

What Doctors Don’t Get to study in Medical
School
Has cardiology lost its heart?
“Studies have shown that the human mind plays a
vital role in cardiological disease scenario, as in any
other field.In a manner of speaking every single
disease is slightly “mental”.
Author: Dr. BM Hegde
cardiologist,
professional educator and author
Co-Chairman of the TAG-VHS Diabetes Research Centre, Chennai
chairman of Bharatiya Vidya Bhavan, Mangalore.

While we fret and fume about the diet for the
patient, a recent very large prospective study
revealed that it is not what one eats that kills him
but it is what eats him (negative thoughts) that kills
him more often.
Chapter -61
Dr. BM Hegde

Heart disease: Creating New Meanings
Heart disease is the number one killer in the United
States. It causes more deaths than all other diseases
combined. It is perhaps in heart disease that the
power of belief and meaning- of what we feel and
think about the disease- is most vivid.
LARRY DOSSEY,M.D.

“The meanings and beliefs of persons who have heart
disease are not set in stone. They are malleable, and
new ones can be created that are health giving and
lifesaving. With changes in meaning can come,
literally, a change of heart.”
LARRY DOSSEY,M.D.

Association of psychosocial risk factors with risk of
acute myocordial infarction in 11119 cases and 13648
controls from 52 countries(the INTERHEART
study):case cantrol study
Annika Rosengren et al
The Lancet vol 364 september 11 2004
We used case control design with 11119 patients with a first
myocardial infarction and 13648 age matched and sex matched
controls from 262 centres in Asia Europe,
MiddleEeast,Africa,Australia, and North and South America.

Contd….
People with myocardial infarction reported higher
prevalence of for all four stress factor(p< -
0001).Odds ratio were 1.38 (99% CI 1.19-1.61) for
several period of work stress and 2.14(1.73-2.64) for
permanent stress at work adjusted for age sex
geographical region and smoking.

Contd….
Presence of psycosocial stressors is associated with
increased risk of myocardial infarction suggesting
that approaches aimed that modifing these factors
should be developed.

The Effect of Two Methods of Relaxation and
Prayer Therapy on Anxiety and Hope in Patients
with Coronary Artery Disease: A Quasi-
Experimental Study
Iran J Nurs Midwifery Res. 2019 Mar-Apr; 24(2)
Soudabeh Sadeghimoghaddam et al

• A quasi-experimental study was conducted in
three groups of 25 subjects (i.e., two groups of
relaxation and prayer therapy and one control
group) and two stages (i.e., pretest and posttest)
in hospitals affiliated to Isfahan University of
Medical Sciences, Iran.
Iran J Nurs Midwifery Res. 2019 Mar Apr; 24(2)

• The results showed that there was a significant
difference between the mean score of anxiety
after intervention in the three groups which was
related to each of the relaxation and prayer
therapy group with the control group.
Iran J Nurs Midwifery Res. 2019 Mar Apr; 24(2)

Positive therapeutic effects of intercessory
prayer in coronary care unit
population
RANDOLPH C. BYRD, MD, San Francisco. Calif et al.
July 1988. Southern Medical Journal. Vol 81. NO 7
To evaluate the effects of intercessory prayer(
IP) in a coronary unit population, a prospective
randomized double blind protocol was followed.Over ten
months 393 patients admitted to CCU were randomized to
an intercessory prayer group(192 patients) or to a control
group (201 patients).

Positive therapeutic effects of
intercessory prayer in coronary care unit
population
RANDOLPH C. BYRD, MD, San Francisco. Calif et al.
“The control patients required ventilatory assistance,
antibiotics and diuretics more frequently than patients in
the IP group. These data suggest that intercessory prayer
to the Judeo-Christian God has a beneficial therapeutic
effect in patients admitted to CCU”.
July 1988. Southern Medical Journal. Vol 81. NO 7
RANDOLPH C. BYRD

A Randomized, Controlled Trial of the
Effects of Remote, Intercessory Prayer on
Outcomes in Patients Admitted to the
Coronary Care Unit
William S. Harris PhD et al.
•
“Remote, intercessory prayer was associated with
lower CCU course scores. This result suggests that
prayer may be an effective adjunct to standard
medical care”.
Arch Intern Med. 1999.159:2273-2278

• The evidence is simply overwhelming that prayer
functions at a distance to change Physical processes in
a variety of organisms, from bacteria to humans.These
data , which we will later examine, are so impressive
that I have come to regard them as among the best-
kept secrets in medical science.
- Healing Words by Larry Dossey
M.D.

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