Introduction

In our first Cyberounds^® conference, my co-moderator Bruce McEwen and I offered a broad theory of the relationship among stress, organisms' allostatic responses, and health or illness. In that article a suggestion was made that doctors should counsel their patients about engaging in more healthy behaviors (e.g., eating more healthily, drinking moderately, not smoking, etc.). The idea was that this would render the patients more capable of tolerating stress without developing illness.

Now, suggesting that doctors counsel patients about behaviors detrimental to health seems hard to challenge. But this suggestion brought two basic questions to mind. First, how is it that human beings, who pride themselves on their intelligence, engage in so many behaviors which might not be in their own best interest? And, second, what is the impact of doctors counseling patients about such behaviors? This session of Cyberounds^® will focus on the psychological mechanisms by which individuals engage in harmful behaviors and some of the most effective ways for doctors to help them change these behaviors. The next Cyberounds^® will examine more closely the neurobiology underlying impulsive, harmful, and/or addictive behaviors.

How Do Harmful Behaviors Begin?

It is unlikely that simple ignorance of the harmful effects leads people to pursue unhealthy behaviors as substance abuse, smoking and overeating. It seems more likely that some individuals do not weigh the pros and cons of these behaviors in the way that results in the healthiest behaviors and results. In other words, while individuals might know about the risks and the benefits of these behaviors, they opt for short-term pleasures rather than focusing on the long-term value of the decisions that health care professionals would wish them to reach.

Obesity offers a good example. People know when they are overeating and when they are overweight (though they may not have a completely accurate picture as to how overweight they are). Virtually all females and many males recognize that lowering weight is desirable. While obese people often differ in their energy metabolism from thin people, it is clear that some of the obesity in America is the result of eating foods in excess of the amount which Americans know is healthy for them. The attempt to control food intake by dieting is nearly universal at some point in the lifetime of American women. Our studies of incoming college freshman women show that only 8 - 13% of women are non-dieters.(1) Further, the median age of onset of dieting is about 12.(2) So it is unlikely that the message regarding overeating is not getting to them or is arriving too late.

Despite this, the average American's weight continues to go up, indicating a lack of success at intake control.

In the area of substance abuse there is perhaps even better data from school-based studies of prevention of substance abuse documenting that knowledge of the perils of drug use isn't the problem. Several early school-based studies of prevention programs showed that the interventions offered resulted in a clear increase in the knowledge that students had about substances, but, unfortunately, had no effect or sometimes even an increase in the rate of substance use. Given these two examples, it seems quite unlikely that a simple lack of knowledge is the main problem which prevents people from avoiding harmful behaviors.(3)

Mixed Messages

These anti-substance use and anti-obesity messages do not occur in a vacuum. In fact, young people at the age of initiation of substance use (and all of us in general) get both anti- and pro- smoking, drinking and drug use messages every day. For every x-ray of lungs damaged by smoking a child or adolescent sees, he or she also receives the message that smoking is sophisticated and associated with sexuality in movies and advertising and on television. Similar competing messages occur regarding the potential pleasure and risk associated with alcohol drinking and cocaine use. Perhaps an even more subtle mixed message is obtained from food ads which tell us about how rich, creamy and good tasting a variety of substances are while the dieting, exercise, fashion and entertainment industries constantly tell us how bad obesity is. So, in each case we see a positive message about the short-term benefits or pleasures of the use of cigarettes, drugs, alcohol and rich foods; but also a negative message about the long-term problems associated with these behaviors. These mixed messages require that individuals choose or make a decision about a certain type of behavior. Let's take a look at what we know about decision-making in these situations.

Novelty Seeking Versus Harm Avoidance

We humans are not always particularly good at weighing the problems of short term benefit and long term risk. Actually, many researchers have shown that human beings differ dramatically in their tendency.

1. to pursue short term benefits and
2. to avoid taking risks.(4),(5)

Over the years much research in temperament and/or personality has identified these factors as well as a limited number of other characteristics as critical aspects of our personality with genetic determinants.(4),(5)

"Novelty seeking," a term coined by Cloninger, refers to the tendency to activate behavior in response to novelty and/or signals of reward or relief of punishment. He termed the tendency to inhibit behavior in response to signals of punishment or non-reward as "harm avoidance."(6) Individuals can be defined differing in their degree of "novelty seeking" and "harm avoidance" on the basis of their responses to questionnaires.(4),(7)

These two temperamental traits have been linked to various aspects of the harmful behavior choices we have been considering. Patients with an early onset of alcoholism are significantly higher on the dimension of novelty seeking than are other individuals.(8) Subjects with alcoholism and antisocial behavior also are low in harm avoidance.(9) It is important to note, however, that the degree of harm avoidance may also predict stability of recovery in that alcohol-dependent subjects with a history of prolonged abstinence actually have higher harm avoidance than alcoholics who have not recovered.(10) Being high in novelty seeking is also a major determinant in the initiation of smoking.(11)

Bulimic patients (those who engage in binge eating on high sweet, high fat foods) are higher in novelty seeking than are anorexics who simply drastically restrict their intake of food. However, both bulimics and anorexic restrictors are high in harm avoidance -- as one might expect, given that harm avoidance would be correlated with dieting and the attempted avoidance of the harms of obesity.(12), Thus, there appear to be temperamental differences in the degree to which people pursue new reinforcers, such as drugs and food, and the degree to which they avoid harm. Those high in novelty seeking and low in harm avoidance are thought to be most impulsive.

Joseph Newman and his colleagues at the University of Wisconsin in Madison have put impulsive individuals into laboratory situations where they are forced to make decisions about pursuing rewards and taking risks in computerized tasks.(14),(15) Newman has found that in situations where both rewards and punishments are involved highly impulsive individuals are much more likely than non-impulsive subjects to continue to perform a behavior in the hopes of achieving a reward, even as the punishment increases. They also tend to make their choices more quickly in these situations than do controls, leaving themselves less time to consider their options.

When impulsive individuals are forced to slow down and consider the results of their previous behavior, they become much more responsive to punishment feedback (i.e., they become more harm avoidant). Data from experiments like this and others carried out by Newman and his colleagues suggest that impulsive people, in this face of a mixed message about rewards and punishments, are much more likely to choose a risky behavior than are non-impulsive people. It is possible, therefore, that an adolescent faced with our mixed message problem (i.e., short term pleasure from substance use or binge eating and only long term punishment from cancer, cirrhosis and obesity) is in a situation in which those who are high in novelty seeking and low in harm avoidance are likely to go for the short term pleasure, thinking little of long term negative consequences. It is reasonable to conjecture that, if we could slow down that decision making process and teach impulsive individuals to consider more of the results of their behavior, they may make better choices.

What Doctors Can Do to Improve Patient Decision Making Regarding Healthy Behaviors

It is clear from my practice experience in a primary care clinic that a good number of the generalists with whom I work are frustrated and demoralized by the sense that their patients' alcohol use, cigarette use and the like are beyond their ability to change. This analysis of decision making processes by impulsive individuals suggests some approaches a doctor can take to help people who have problems with their choices regarding harmful behaviors.

Studies have already shown that a general doctor, working within the constraints of brief appointment times and all the other much maligned aspects of modern medicine, can have an impact on these behaviors.(16) A randomized clinical trial, conducted by the Medical Research Counsel of Great Britain and reported by Wallace and colleagues in 1988, showed positive effects of brief interventions on alcohol use.(17) In this study, 909 heavy drinkers (drinking greater than 35 drinks per week) were given brief advice from a physician to reduce or stop alcohol, a self-help booklet, weekly diaries and a written contract in the form of a prescription signed by the physician. There were significant differences on a number of outcome measures, including a twofold reduction in alcohol use, fewer episodes of heavy drinking and improved liver function test levels.

A ten-country study by Babor and colleagues(18) compared simple advice (a five minute session on sensible drinking or abstinence), brief counseling which included a 15 minute session and self-help manual and extended counseling (initial brief counseling in three or more monitoring visits). All three interventions were compared with a control group who only had a 30 minute interview prior to random assignment. In this study, which included 1661 non-dependent heavy drinkers, subjects who drank heavily and frequently but who did not show physical signs of alcohol dependence, brief interventions had a significant effect on average alcohol consumption and intensity of heavy drinking. Kristenson and colleagues actually reported differences from these kinds of brief interventions for as long as six years in follow-up.(19) While it is unclear exactly what works about physician brief intervention, (short discussions about alcohol use -- or other health threatening behavior -- and its consequences which can easily be included in daily office practice) it is clear that it does work.

While the exact means by which these brief interventions in alcohol misuse work are unknown, most have several components in common:

The identification of the problem by a physician (which may increase the patient's motivation to quit.)

Information being provided regarding the harm of drinking (which may increase the motivation of those with sufficient harm avoidance.)

Pointing out alternative positive reinforcers (It would be foolhardy to expect patients -- especially those high in novelty seeking -- to give up one of their reinforcers without some sort of substitute.)

Almost all of these interventions ask the participant to introduce some delay in their decision to engage in unhealthy behaviors. If the data from the laboratory studies of impulsive subjects are relevant, then this delay might improve the decision outcomes so that they have some time to reflect on short-term benefits vs. long-term harm.

With regard to body weight there is less reason, unfortunately, to believe that brief interventions will be effective, although one study has shown that self-help manuals can decrease binge eating (Mitchell, unpublished observations).

In summary then, we have considered some of the psychological variables underlying harmful behaviors in humans and briefly reviewed studies indicating that counseling by primary care doctors can have an important impact on decisions about engaging in these behaviors. In the next Cyberounds^® we will consider the neurobiologic mechanisms of the novelty seeking and harm avoidance systems and the current and potential treatment implications of these mechanisms.