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Behavioral Approaches to
Prevention and Treatment
of Physical Disease:
Practical Appl ications

The recent upsurge of interest in behavioral medicine is due in part to the

hope that application of behavior modification techniques will prove effective
in modifying risk factor behaviors and lifestyles, thus improving our ability to
prevent such major diseases as cancer and coronary heart disease. Additional
impetus has come from the demonstration in the mid-1960s that application
of instrumental conditioning techniques, or biofeedback, could be successful
in directly modifYing physiological functions previously thought to be beyond
voluntary control. While there continues to be controversy in academic
psychology regarding the precise mechanisms whereby control is achieved in
humans, that early work has spawned a new clinical specialty of behavioral
medicine whereby biofeedback and other behavior therapy techniques have
come to be used on an ever-increasing scale in the direct treatment of a wide
range of physical disorders that had previously proven resistant to traditional
clinical medicine's treatment approaches. In this chapter we shall review this
burgeoning area which might be termed "applied" behavioral medicine.

General Clinical Principles

The first step in treatment must be diagnosis. With respect to behavioral
approaches to treatment of medical disorders, this means that in addition to

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© Springer-Verlag New York Inc. 1983
322 Behavioral Approaches to Prevention and Treatment of Physical Diseases

the routine medical diagnostic procedures necessary to arrive at the correct

diagnosis, it is also necessary to carry out a behavioral assessment of the patient's
problem. This involves taking a careful history regarding the situations in
which the symptom is worsened, the things the patient has learned to do
which reduce the symptom, and the specific parameters of the symptom.
This almost always involves record keeping by the patient over a period of one
to three weeks of the level of the symptom (e.g., headaches) over the course of
each day. This serves several functions. First, it enables both the patient and
the physician to determine whether there are any characteristic patterns in
worsening or improvement of the symptom. If, for example, the headache
increases in intensity toward the end of each working day and is generally
absent on the weekends, it is likely that work-related stresses are causing
increased muscle tension which leads to the headache, and that interventions
to either reduce those stresses or to prevent them from causing increased
muscle tension will prove effective in treating the headache. It is important to
note that patients will often be unaware of such temporal patterns in their
problem. Thus the clinical history alone is often insufficient to discover such
patterns; only by having the patient maintain a daily log of symptoms which
is filled out four times a day (on arising, at lunch, dinner, and bedtime) can
an accurate picture of the symptom topography be obtained. In addition to
aiding in the diagnosis of the possible precipitating factors, record keeping
serves other useful functions as well. Not only does the physician come to
note possible causal factors, but the patient, by focusing on the symptom and
keeping careful track of its occurrence, also comes to recognize situations that
are likely to cause increased symptoms. This increasing awareness will often
help the patient to take steps on his or her own which reduce the exposure to
the stress and lead to clinical improvement. Perhaps this is why clinical
experience has shown that those patients who do not maintain accurate
records of their symptoms generally do not show a good response to
behavioral treatment. Another reason may relate to the requirement in
behavioral medicine that the patient become an active collaborator in the
treatment process. Those patients who are unwilling to make the effort to
keep records of their symptoms may be the same ones who are either uncom-
mited or unable to participate in their own treatment.
A very frequent second step in behavioral treatment of various physical
disorders, particularly those involving pain related to excess muscle tension,
is the use of some form of relaxation technique. Frequently this will involve
biofeedback approaches. For example, EMG electrodes are attached to fron-
talis and trapezius muscles of the patient with muscle tension headache, and
the EMG levels are displayed (i.e., "fedback") to the patient using either
visual or auditory signals so that the patient can gain a more accurate sense
than his or her own sensory apparatus permits of whether the muscles in
question are increasing or decreasing in activity. This feedback helps the
patient to obtain better control over muscles in the same way as seeing where
the golfball goes after it is hit by the putter.