*This is an article from the Fall 2023 issue of Contentment Magazine.
By Marcia Uddoh, MD (candidate), PhD, MPH, MS, MSW, FAIS
The good news about the benefits of guided imagery for cancer patients should consider the underlying disease process that led to its implementation.1 This inclusion will allow for a better understanding of the mechanics and scientific basis of the process. Therefore, it is crucial to explore guided imagery and the mechanism of the disease process. To accomplish this, a conceptual model would be suitable as it offers a more comprehensive overview of the entire narrative.
Introducing the Stress Vitals Cancer Image Model: A Multidisciplinary Approach
The Stress Vitals Cancer Image Model (SVCIM) is a conceptual framework that can provide valuable insights to this discussion (see Figure 1). The model takes the form of an infinity sign, with one side representing the guided image process and the other representing the cancer mechanism. The center of the infinity loop is marked by a tension point, which represents stress. Stress is denoted by a positive sign (+), while the absence of stress is denoted by a negative sign (-). 
Within the context of the model, the presence of stress within the cancer loop can be viewed with the progression of the disease. Similarly, the absence of stress can be considered within the guided imagery loop regarding relaxation.
The brain lies at the precise center of the model, marked by the crosshairs. The brain serves as the pivotal point from which either pathway can be initiated. This dual role is because the brain is connected to the disease process through stress and the guided imagery process that leads to relaxation. Understanding the role of cognition in both pathways is crucial for a comprehensive discussion of this topic.
Various fields of study can classify and label the components of this conceptual framework differently. For this discussion, we will refer to the portion of the loop that visualizes the brain and its connection to cancer as “psychoneuroimmunology/cognitive theory.” The portion that visualizes the brain and guided imagery will be referred to as “neuroaesthetics.”
Guided imagery is a technique that involves the controlled visualization of goals, behaviors, and desired outcomes3 (Giacobbi). On the other hand, neuroaesthetics is a relatively new field that gained prominence in the 1990s when Semir Zeki coined the term. Zeki, a professor at the University College of London, focused his research on aesthetic experiences.4
The inclusion of neuroaesthetics within the stress vitals cancer image model is appropriate because we aim to consider the aesthetic aspect and the expanded connection to psychological, aesthetics, biological mechanisms, and the human condition.4
The Role of Psychoneuroimmunology in Stress-Induced Cancer Progression
It is essential to define psychoneuroimmunology to understand better the role of immunity and stress in cancer. Psychoneuroimmunology is the study of how the brain, immune system, and behavior interact.5 Within this field, the neuroendocrine system is a crucial mediator connecting stress to cancer. This system comprises the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS).6 Stress triggers the release of three stress-related hormones: epinephrine, norepinephrine, and glucocorticoids. In turn, these hormones activate cytokine secretion and molecular signaling pathways, which alter the tumor microenvironment (TME).6 The TME, consisting of immune cells, blood vessels, stromal cells, and the extracellular matrix (ECM), varies depending on the type of tumor.7 Rather than being a passive observer, the TME actively promotes cancer progression. In the early stages, the TME establishes a reciprocal relationship with cancer cells, enabling their survival, local invasion, and metastasis to other parts of the body.7
The Science of Healing: Exploring Guided Imagery Through Multiple Lenses
Guided imagery, also known as mental imagery or visualization, is an established intervention in integrative oncology. It has been extensively researched and has shown positive effects on the immune system.8 Various terms have been used to describe guided imagery, but the one that aligns closely with our conceptual model is the one proposed by Green, Walters, Green, and Murphy. Their model considers cognition and perception relevant to the healing process.9
In their self-regulation theory, Green et al. consider how individuals process cognitive information and how it affects their behavior.9 According to their conceptualization, the perception or image triggers an emotional response, which in turn elicits a biochemical response in the limbic, hypothalamic, and pituitary areas. This biochemical response can lead to physiological changes that individuals become aware of and respond to. Green et al. describe this process as a “cybernetic feedback loop.”9
Another interpretation of guided imagery is the cognitive theory, which suggests that changing negative thought patterns can decrease arousal in the autonomic nervous system (ANS).9 Also, the psychoneuroimmunology paradigm proposes that guided imagery can downregulate the hypothalamic-pituitary axis, thereby reducing the stress response and promoting relaxation.9
Overall, guided imagery has been studied from various perspectives, including its effects on the immune system, cognitive processes, and the stress response. These different approaches provide insight into the mechanisms by which guided imagery can promote healing and well-being.
Quantifying the Effects of Guided Imagery: An Immunological Perspective
There are two main types of evaluation, enumerative and functional, that can assess the effectiveness of guided imagery from an immunological standpoint.8 Enumerative assessment focuses on counting the different components of the immune system, while functional assessment involves the conduction of various laboratory tests.8 In this discussion, our main focus is on the components of the white blood cell population, such as granulocytes, NK cells, B-lymphocytes, T-lymphocytes, and monocytes. Additionally, the population of antibodies in the blood, specifically immunoglobulins A, G, and M, is also of importance.8
One study examined the effects of guided imagery on immune cell counts, specifically white blood cells, neutrophils, and lymphocytes. The results showed that these counts decreased with the stages of relaxation experienced during the intervention.8 Moreover, there was a noticeable reduction in stress levels.8 
Another study implemented a psychoneuroimmunology-based intervention that incorporated guided imagery. The findings revealed increased immune markers, including CD8+ T cells, B cells, natural killer cells, serum immunoglobulin A, and immunoglobulin M.10 Furthermore, a separate study with guided imagery observed an increase in NK cell cytotoxicity in the group that received the guided imagery intervention.11 Specifically, when a comparison was made with the intervention group and the control group, the researchers discovered higher NK cell cytotoxicity at different effector cell-to-target cell ratios (E:T) (100:1, 50:1, and 25:1) (p < .01 to p < .05). Additionally, there was increased activation of IL-2 at different E:T ratios (100:1, 50:1, 25:1, and 12.5:1) (p < .01 to p < .05).11
Images and Artwork in Guided Imagery: A Neuroaesthetic Perspective
The connection between guided imagery and neuroaesthetics lies in the use of images or artworks as a foundational element in the process. It has been determined that images or artworks are an effective modality for guided imagery.8 By incorporating neuroaesthetics, we can delve deeper into the interaction between these two fields and better understand the cognitive processes involved in images or artworks.8
It is believed that an image can be used in guided imagery to induce healing on its own as long as it is capable of evoking vivid imagery. Furthermore, researchers have discovered that the image alone can have a similar positive impact on the immune system.12
By exploring the relationship between Guided imagery and neuroaesthetics, we can uncover valuable insights into how images and artworks can be utilized to enhance the healing process and positively influence the immune system.
Incorporating Spiritual Themes in Guided Imagery: Implications for Future Studies
Our approach places a central focus on the image or artwork. The objective is to remove stress and promote relaxation, as stress is known to initiate the disease process. One potential thematic focus for the images/artworks is spirituality, which has been studied extensively with breast cancer survival.2 Numerous studies have explored spiritually-based interventions and their impact on psychoneuroimmunological (PNI) measurements.2 Given that 92% of Americans believe in God or a higher power, and 56% consider religion very important in their lives, according to Pew Forum Research data,2 incorporating spiritual images into our research seems plausible.
In conclusion, it is encouraging that guided imagery has emerged as an effective intervention in cancer treatment. By utilizing neuroaesthetics and images/artworks, we can further enhance the scientific exploration of this approach.
References
1. Eremin O, Walker MB, Simpson E, et al. Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: A randomised controlled trial. Breast. 2009;18(1):17-25. doi:10.1016/j.breast.2008.09.002
2. Hulett JM, Armer JM. A Systematic Review of Spiritually Based Interventions and Psychoneuroimmunological Outcomes in Breast Cancer Survivorship. Integr Cancer Ther. 2016;15(4):405-423. doi:10.1177/1534735416636222
3. Giacobbi P, Loughman L, Brink C, Shawley-Brzoska S, Misra R. Thematic Analysis of Guided Imagery Scripts in a Multi-Health Behavior Change Intervention. Am J Lifestyle Med. Published online 2023. doi:10.1177/15598276231196531
4. Magsamen S. Your Brain on Art: The Case for Neuroaesthetics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075503/
5. Maier SF, Watkins LR, Fleshner M, Mh-00314 R. Science Watch Psychoneuroimmunology The Interface Between Behavior, Brain, and Immunity. Published online 1991.
6. Liu Y, Tian S, Ning B, Huang T, Li Y, Wei Y. Stress and cancer: The mechanisms of immune dysregulation and management. Front Immunol. 2022;13. doi:10.3389/fimmu.2022.1032294
7. Anderson NM, Simon MC. The tumor microenvironment. Current Biology. 2020;30(16):R921-R925. doi:10.1016/j.cub.2020.06.081
8. Trakhtenberg EC. The effects of guided imagery on the immune system: A critical review. International Journal of Neuroscience. 2008;118(6):839-855. doi:10.1080/00207450701792705
9. Serra D, Robertson Parris C, Carper E, et al. Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clin J Oncol Nurs. 2012;16(6):617-623. doi:10.1188/12.CJON.617-623
10. Chacin-Fernández J, Chacin Fuenmayor M, Piñerua-Shuhaibar L, Suarez-Roca H. Psychological intervention based on psychoneuroimmunology improves clinical evolution, quality of life, and immunity of children with leukemia: A preliminary study. Health Psychol Open. 2019;6(1). doi:10.1177/2055102919838902
11. Lengacher CA, Bennett MP, Gonzalez L, et al. Immune responses to guided imagery during breast cancer treatment. Biol Res Nurs. 2008;9(3):205-214. doi:10.1177/1099800407309374
12. Bedford FL. A perception theory in mind-body medicine: Guided imagery and mindful meditation as cross-modal adaptation. Psychon Bull Rev. 2012;19(1):24-45. doi:10.3758/s13423-011-0166-x
Acknowledgments
This article’s main text utilized Artificial Intelligence Support (AIS) by OpenAI for final sentence refinement. San Francisco, CA, USA.
ABOUT THE AUTHOR
Marcia Uddoh is a pioneer in stress research and management, specializing in neurology and cognition. Grounded in Christian ethics but welcoming individuals of all faiths, she is a graduate of Dr. Andrew Weil’s esteemed integrative health research internship program at the University of Arizona School of Medicine. Dr. Uddoh has dedicated her career to holistic approaches to stress management.
As the founder of Stress Vitals Institute LLC, she has developed innovative, evidence-based stress assessments and interventions. These are delivered through cutting-edge methods like visualization and heart rate variability (HRV), aiming to empower individuals, especially in low-income communities.
Contentment Magazine
The dictionary defines “content” as being in a state of peaceful happiness. The AIS magazine is called Contentment because we want all of our guests and members to find contentment in their lives by learning about stress management and finding what works best for each them. Stress is unavoidable, and comes in many shapes and sizes that makes being in a state of peaceful happiness seem like a very lofty goal. But happiness is easy to find once you are able to find ways to manage your stress and keep a healthy perspective when going though difficult times in life. You will always have stress, but stress does not always have you!
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