Blog

J Health Behav Med Hist 2026-5

The Behavioural Organ. A relational executive system for the design and execution of human behaviour

Robert C. van de Graaf, Performance Medicine Specialist, Director
MEDTCC Institute for Health, Behaviour, Medicine and its History, and Perform Health Clinic ,The Netherlands

Peter F. van de Graaf, Health Performance Coach
MEDTCC Institute for Health, Behaviour, Medicine and its History, and Perform Health Clinic ,The Netherlands

Abstract

Current behavioural models describe interacting determinants of behaviour, yet rarely specify a functionally defined system that produces behaviour as its output. As a result, key phenomena such as effort, stress, persistence, and non-execution remain theoretically under-specified and are often attributed to individual deficits in motivation, self-regulation or capacity.

In this paper, behaviour is conceptualised as the output of a functional executive system: the behavioural organ. This organ is defined as a relational system consisting of the person, the environment, and designed behaviour (task). Its internal anatomy can be visualised by the behavioural triangle. Behaviour is continuously designed within this system and becomes observable only when executed outside it. Whether behaviour is executed effortlessly, with sustained effort, or not at all depends on the quality of relational fit within the system.

By explicitly distinguishing between designed and executed behaviour, and by conceptualising motivation and ability as emergent relational properties rather than individual determinants, this framework offers a novel ontological and functional–physiological account of behaviour. The behavioural organ provides a coherent foundation for understanding effort, stress, and behavioural breakdown as systemic signals rather than personal failures.

Introduction

Behavioural science has produced a wide range of models aimed at explaining why people behave as they do. Determinant-based frameworks such as the Theory of Planned Behaviour, the MOA model, the Triad model [1-2], and the COM-B model [3-4] have played a crucial role in structuring behavioural research, informing intervention design, and advancing prediction and categorisation. Their contribution to the field is substantial and undisputed.

Despite their usefulness, a fundamental question remains largely unanswered: how does behaviour actually come into existence as an executable output?

In most prevailing approaches, behaviour is conceptualised as the result of internal states – such as intentions, motivation, or capacity – moderated by contextual conditions. Behaviour itself is typically treated as a dependent variable: the observable endpoint of interacting determinants. As a consequence, experiential phenomena such as effortful behaviour, stress, persistence, and non-execution are commonly interpreted as failures of motivation, self-regulation, or individual ability.

Importantly, many contemporary behavioural models can be described as system-oriented in a descriptive sense. They acknowledge interaction between multiple determinants and recognise that behaviour does not arise from a single cause. However, they do not propose an ontological system that exists as a functional entity producing behaviour. Behaviour remains conceptualised as an outcome influenced by factors, rather than as the output of a system with an internal architecture, regulatory logic, and execution constraints.

This distinction is not merely semantic. Without an explicit behavioural production system, it becomes difficult – if not impossible – to explain why identical individuals may experience the same behaviour as effortless in one context and exhausting or unsustainable in another, even when motivation appears unchanged. Effort and stress are observed, measured, and intervened upon, but they are not structurally explained.

This paper proposes a different starting point. Behaviour is not approached as a choice, intention, or outcome, but as the output of a functional executive system: the behavioural organ. The term executive is used here to denote behavioural production and regulation at the system level, rather than executive cognitive functions located within the individual.

The behavioural organ framework conceptualises behaviour as something that is first designed within a relational system and only becomes observable when executed outside that system. Whether execution occurs effortlessly, with sustained effort, or not at all depends on the quality of relational fit within the system. In this view, motivation and ability are no longer treated as causal inputs preceding behaviour, but as emergent signals reflecting system coherence.

The present paper is intended as a conceptual and ontological contribution. It introduces the behavioural organ as a functionally specified system with a defined internal architecture and regulatory principles. Empirical operationalisation and validation are explicitly left to future work. The framework builds on a series of earlier conceptual papers that progressively formalised its relational architecture and execution logic.

The need for an ontological shift

The behavioural organ framework introduces an explicit ontological shift. Behaviour is not treated as a property of the person, nor as a direct response to environmental cues, but as the output of a relational system. This shift implies that behaviour must be analysed at the level of system architecture rather than individual determinants.

Within this framework, motivation and ability are no longer understood as causal inputs preceding behaviour, but as emergent properties of relational fit within the system. Effort and stress are not interpreted as failures of self-regulation, but as functional signals indicating misalignment between system components.

The term physiological is used here in a functional–regulatory sense. It refers to energetic cost, compensatory regulation, and system coherence, rather than to specific biological substrates or biomarkers.

To articulate this shift, behaviour is conceptualised through the lens of functional anatomy and physiology. Just as other distributed organ systems are defined by their function rather than by anatomical localisation, the behavioural organ is defined by its role in designing and regulating behaviour.

Intellectual and experiential origins of the model

The behavioural organ did not emerge as a purely theoretical construct. Its development reflects a sustained interaction between clinical practice, behavioural science, organisational contexts, and personal experience.

The relational foundation of the model was first articulated by Van de Graaf in 2025 in his paper entitled Reframing Human Behaviour Through the Behavioural Triangle [5]. Behaviour was conceptualised as emerging from interaction between Person, Task, and Organisation. That paper introduced the distinction between general (abstract) behaviour and visible (executed) behaviour, and emphasised relational quality – friction versus flow – as central to behavioural sustainability.

This framework was subsequently formalised at the level of system ontology in The behavioural organ: an introduction to the system that produces human behaviour [6]. There, the behavioural organ was defined as a distributed functional system spanning organism and world, and the distinction between designed behaviour and expressed behaviour was introduced alongside the energetic logic of fit and misfit.

The developmental trajectory of this thinking was described in The evolution of a behavioural model: how the triangle shaped my thinking [7], situating the model within a longer arc of medical, organisational, and behavioural practice.

Crucially, the present framework was further refined through ongoing dialogue and collaboration with Peter F. van de Graaf, health performance coach and co-author of this paper. These exchanges sharpened the focus on behavioural execution, effort, and sustainability across clinical, organisational, and everyday performance contexts, ultimately leading to the formulation of the behavioural organ as an explicit executive system of behaviour.

The internal architecture of the behavioural organ

The behavioural organ is conceptualised as a functional, non-anatomical organ composed of three elements arranged in a stable triangular architecture: the person, the environment, and designed behaviour (task). This internal architecture can be visualised as the behavioural triangle, which serves as a schematic representation of the anatomy of the behavioural organ (Figure 1).

The person contributes functional capacities and constraints, including skills, energy, needs, and life history. The environment provides structure, culture, norms, goals, and opportunities that shape behavioural demands. Designed behaviour represents the behavioural configuration that emerges from ongoing interaction between person and environment. Crucially, the task is not an externally imposed instruction but an implicit behavioural design reflecting what behaviour is expected and feasible within a given relational context.

Designed behaviour and executed behaviour

A central contribution of the behavioural organ framework is the explicit distinction between designed behaviour and executed behaviour. Designed behaviour refers to the behavioural configuration implicitly prepared within the behavioural organ as a result of person–environment interaction. Executed behaviour refers to the observable enactment of this design in the external world.

This distinction explains why individuals may experience strong intentions, commitment, or responsibility while simultaneously struggling to act – or do not act at all. Behavioural difficulty is not necessarily the result of insufficient motivation but may reflect a mismatch between system components that prevents designed behaviour from being executed without excessive effort.

Fit as the regulatory principle

Whether designed behaviour can be executed depends on the quality of relational fit within the behavioural organ. Fit refers to the alignment between the person and the task, the task and the environment, and the person and the environment. Fit is not an attribute of any single component but a relational property of the system as a whole.

Figure 2 illustrates behavioural execution as a function of relational fit. When fit is high, designed behaviour is executed as designed, effortlessly and sustainably. When fit is partial, behaviour can still be executed but requires sustained effort and increased energetic cost, often experienced as stress. When fit is insufficient, execution fails, resulting in avoidance, withdrawal, or behavioural breakdown.

Behavioural execution is therefore determined by systemic alignment rather than by individual motivation or ability alone.

Repositioning motivation and stress

Within the behavioural organ framework, motivation is not conceptualised as a driver of behaviour but as an emergent signal reflecting system coherence. Motivation tends to increase when relational fit improves and declines when misalignment persists. Similarly, stress is not interpreted as a personal weakness but as a physiological indicator of compensatory regulation under conditions of misfit.

This reframing resolves longstanding ambiguities in behavioural science regarding effortful behaviour, persistence, and apparent resistance to change. Behaviour that is difficult or unsustainable is no longer attributed to individual failure but understood as a predictable outcome of system dynamics.

Implications for behavioural science

By introducing the behavioural organ, this framework provides an explicit ontological foundation for behaviour. It offers a functional explanation for effort, stress, and non-execution and presents a relational alternative to individualised deficit models. Rather than replacing existing determinant frameworks, the behavioural organ complements them by supplying the architectural layer they lack.

Conclusion

This paper introduces the behavioural organ as a functional executive system that designs and regulates human behaviour. By distinguishing between designed and executed behaviour and by locating behavioural success or failure in relational fit rather than individual motivation, the framework offers a novel foundation for behavioural theory. The behavioural triangle makes the internal anatomy of this system explicit, while relational fit explains its functional physiology. Future work will focus on empirical operationalisation, longitudinal dynamics, and applications in health, work, and organisational contexts.

References

1. Poiesz TBC. Gedragsmanagement. Waarom mensen zich (niet) gedragen. Wormer Inmerc BV 1999.
2. Poiesz T. Redesigning psychology. In search of the DNA of behavior. Den Haag: Eleven International Publishing 2014.
3. West R, Brown J. Theory of addiction, 2^nd edition. UK: Wiley Blackwell 2013.
4. Mitchie S, Atkins L, West R. The behaviour change wheel. A guide to designing interventions. Great Britain: Silverback Publishing 2014.
5. Van de Graaf RC. Reframing human behaviour through the behavioural triangle: a relational systems model for understanding and change. J Health Behav Med Hist 2025-12.
6. Van de Graaf RC. The behavioural organ: an introduction to the system that produces human behaviour. J Health Behav Med Hist 2025-24.
7. Van de Graaf RC. The evolution of a behavioural model: how the triangle shaped my thinking. J Health Behav Med Hist 2025-1.

J Health Behav Med Hist 2026-4.

Without a behavioural expert, a weight-loss drug will not work

Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

Anne Roefs, PhD. Professor of Psychology and Neuroscience of Abnormal Eating.
Faculty of Psychology & Neuroscience, Maastricht University, The Netherlands

In the debate on weight-loss medication, a development has been normalised that is deeply troubling: an organ that is central to obesity is being treated on a large scale by physicians who are not trained to do so. The fact that millions of people may need to use this medication for life makes this painfully clear. Not as a medical success, but as evidence that a complex and vulnerable organ is structurally being treated under the wrong leadership.

The substantial relapse after discontinuation of medication and the prospect of lifelong use are not accidental side effects. They reveal what happens when an organ is manipulated without being truly understood or restored. This is not a failure of patients, nor proof that the medication does not work, but a systemic failure in how we approach obesity.

Obesity does not primarily arise in adipose tissue, the pancreas, or the gastrointestinal tract. It develops in what we might call the behavioural organ: the integrated system in which motivation, reward, stress regulation, impulse control, habit formation, and environmental influences jointly steer behaviour. This organ determines not only what someone eats, but also how they respond to stress, temptation, social pressure, and recovery after relapse. It is learnable and adaptive, but also vulnerable to dysregulation. It is precisely this organ that is now being influenced on a large scale by medication. That is not inherently wrong. It becomes problematic when this intervention is detached from behavioural-medical governance. An organ that organises behaviour cannot be sustainably restored without diagnosis, guidance, and long-term retraining.

In medicine, a fundamental principle applies: the lead clinician is specialised in the organ being treated. A cardiologist does not perform brain surgery; that responsibility lies with a neurosurgeon. An occupational physician does not remove a bowel tumour; that is done by a specialised surgeon. This principle is not a formality, but a basic condition for quality of care and patient safety.

In obesity care, this principle is being abandoned.

Internists, surgeons, cosmetic physicians, and increasingly newly qualified doctors prescribe medication that profoundly interferes with the behavioural organ. This increasingly happens outside regular healthcare, via commercial platforms offering ‘medical weight loss’ as a service. Physicians often act with sincere intentions and follow guidelines or continuing education. But behavioural-medical expertise cannot be replaced by a course, a protocol, or a guideline primarily developed from the perspective of other organs, such as adipose tissue.

Behavioural medicine is a specialty. It requires knowledge of behavioural diagnostics, learning processes, stress and reward systems, contextual influences, relapse mechanisms, and long-term behaviour change. Without this expertise, the complications of the behavioural organ largely remain invisible: loss of self-regulation, dependency thinking, avoidance behaviour, declining resilience, a shift of responsibility from person to product, and dysregulation of stress and reward responses. These are not abstract concepts, but real, long-term consequences that undermine functioning, work, relationships, and health.

The well-known yo-yo effect after stopping weight-loss medication is the most visible signal of this. Weight returns not because individuals fail, but because the behavioural organ has not been restored. That millions of people may require lifelong medication is therefore not proof of effectiveness, but proof that the behavioural organ has structurally remained out of view.

The conclusion is therefore unavoidable: physicians without behavioural-medical specialisation cannot be the lead clinicians in problems of a dysregulated behavioural organ. As with any complex condition, clinical governance belongs with the specialist. Other physicians can support or contribute, but not lead.

If the idea of lifelong weight-loss medication teaches us anything, it is this: obesity does not require ever more powerful drugs, but better governance. Governance that does justice to both the vulnerability and the capacity for recovery of the behavioural organ. And that begins with recognising it as a fully recognized centre of treatment.

Translation from: Zonder een gedragsdeskundige gaat een afslankmedicijn niet werken (Trouw)

J Health Behav Med Hist 2026-3.

Behaviour as an organ – the next concentration in healthcare.

Robert C. van de Graaf, MD

Director, MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

In healthcare, we know exactly where things become complex.
For a bypass, a tumour, or brain surgery, we build teams, pool expertise, and concentrate experience. We call this highly complex care – and rightly so.

But while hospitals fight to retain surgical procedures and insurers define volumes, another development is unfolding almost unnoticed. A new form of highly complex care is emerging.
For an organ we have never recognised as autonomous:
the behavioural organ.

The forgotten organ

The organ that enables us to move, chew, swallow, choose, delay, and persist. That governs what we do – and what we refrain from doing. An organ that, when dysregulated, can pull the entire body down with it.

Smoking, drinking, eating, sitting, swallowing, gambling, gaming, absenteeism – behaviours that reinforce or trigger one another,
like the sides of a Rubik’s cube. Try to align one face, and the others immediately shift.

This is precisely the area of care we are least prepared for, while it causes the greatest burden of disease. And is often the disease itself.

Unhealthy lifestyle behaviour: originating, maintaining, amplifying.

Fragmented care

The patient with an accumulation of lifestyle problems, multiple diagnoses, and a life full of counteracting circumstances finds no integrated treatment anywhere.

We cut the behavioural organ into pieces: nutrition coach, exercise coach, psychologist, addiction physician, breathing coach, sleep coach, lifestyle coach, screen-use coach, smoking cessation coach, burnout coach, medical coach, medication withdrawal clinic – each addressing a fragment of the same organ.

Everyone does their best. But no one oversees the whole. And certainly not the interaction between behaviour and the rest of the body. Not even the patient.

The patient becomes subject to a system that divides them into symptoms, disciplines, and minutes. A form of care that ragments,
while behaviour is precisely what connects.

What works

Yet we know what works. Intensive, when necessary multidisciplinary treatment, under behavioural medicine leadership and with shared goals.

The behavioural organ is not a side issue. It is an organ – living, learnable, vulnerable. A delicate organ that, like the heart or the brain, can become dysregulated, recover, and relearn how to function – but only if treated with precision.

In mild cases, primary care guidance may suffice. But in severe dysregulation, highly complex behavioural medical care is required: concentrated, multidisciplinary, clinical when needed.

With physicians, psychologists, physiotherapists, dietitians, and others – provided they are specialised in behavioural medicine.
Working together on one treatment plan, around one person
and their behavioural organ.

The next concentration

We have centres for the heart, brain, and lungs. Perhaps it is time for centres of expertise for the behavioural organ. Where we no longer operate on the consequences, but treat the behavioural organ itself, with the same surgical precision it deserves.

If the behavioural organ is the most decisive organ of our time,
then this is the next logical concentration.

Translation from: Gedrag als orgaan – de volgende concentratie in de zorg (Arts & Auto).

J Health Behav Med Hist 2026-2

Seeing inside ourselves: reflections on consumer total body scans

Robert C. van de Graaf, MD, director

MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands.

Introduction

Consumer total body scans have become increasingly available, and many people choose to use them. This paper does not question that availability, nor the demand for it. It also does not approach total body scans primarily as a medical intervention to be defended or rejected.

Instead, it reflects on scan-consuming behaviour as a phenomenon that emerges at the intersection of medical technology, human curiosity, uncertainty, and meaning-making. Medical considerations are undeniably part of this picture, but they do not fully explain why people seek scans, how scans are experienced, or what role they come to play in people’s lives.

The central question explored here is therefore not whether consumer scans are “good” or “bad,” but what it means that people want to look inside their own bodies – and what they expect that visibility to provide. This reflection builds on earlier explorations of healthcare consumption, scanning practices, and the cultural dynamics of uncertainty [1-3].

A long-standing human fascination

Human fascination with the inside of the body is ancient. Long before modern imaging existed, people sought to understand how the body was structured and how life was organized beneath the surface. For centuries, however, this curiosity was shaped and constrained by cultural and religious meanings. The body was regarded as sacred and meaningful – a creation of God – not to be opened lightly. Looking inside the body was therefore primarily a moral and cultural question, rather than a technical or medical one.

Over time, this position gradually shifted. Anatomical dissection, the development of anaesthesia and surgery, and later imaging technologies – X-rays, electrocardiography, laboratory diagnostics, CT, and MRI – made it possible to access the interior of the body, increasingly without violating its physical integrity. Each step altered how people related to their bodies, adding new layers of understanding without fully replacing older meanings.

Consumer total body scans can be seen as part of this long historical trajectory. They are not a rupture with the past, but a contemporary expression of an enduring human desire: to make the invisible visible. What is new is not the curiosity itself, but the immediacy, accessibility, and personalization of bodily images. What was once rare, exceptional, and mediated has become individual and commercially available.

What a scan provides – and what it does not

A total body scan produces anatomical data. Different scanning technologies visualize different structures, each with specific strengths and limitations. What becomes visible depends on the technology used and the way the body is examined.

From a medical perspective, scans may sometimes reveal abnormalities or structural changes that are relevant to a specific clinical question. At the same time, they may also reveal variations that are common, benign, or of uncertain significance. Both outcomes are inherent to scanning. The potential benefits and limitations of such findings are well documented and cannot be ignored.

Yet beyond their medical implications, scans have a more fundamental characteristic: they do not provide conclusions by themselves. Images do not speak. They require interpretation, context, and knowledge to become meaningful. Without that, they remain images – often impressive and detailed, but intrinsically open-ended.

In this sense, a scan does not so much deliver answers as it generates material for reflection.

Expertise and personal meaning

When scans are interpreted in a clinical context, radiological and medical expertise is essential. Professionals bring structure, experience, and judgment that are necessary when questions concern disease or treatment.

At the same time, scan images are also encountered by non-professionals. Like mirrors or photographs, they evoke personal responses – fascination, reassurance, unease, recognition, reflection – that do not belong exclusively to the medical domain, yet strongly shape how the scan is integrated into one’s life.

This creates a familiar tension. A scan may carry limited clinical relevance while holding considerable emotional or symbolic meaning. Interpreting the image medically does not automatically address the broader meaning it has acquired. In that sense, consumer scans occupy an intermediate space: they may require medical expertise to explain, while simultaneously functioning as personal images that speak to identity, vulnerability, and responsibility. Earlier work has described scanning in this context not primarily as fear-driven behaviour, but as a form of orientation, particularly among individuals accustomed to uncertainty and responsibility [3].

Curiosity, uncertainty, and availability

People seek consumer scans for many reasons. Curiosity about bodily structure, uncertainty about health, and a desire for reassurance often coexist. None of these motivations are new; they are deeply human.

What has changed is availability. When the interior of the body becomes visible on demand, the act of looking itself can acquire significance. Visibility begins to feel meaningful in its own right – as if seeing might offer grip in a complex and uncertain world.

This resonates with broader cultural patterns in which care and medical engagement increasingly function as a language for dealing with discomfort, disruption, or uncertainty – even when no clear illness is present. Such patterns have been described as a societal tendency toward pathophilia, in which medical frameworks become a dominant way of interpreting and managing life’s uncertainties [1]. In this context, scanning can become not only a diagnostic act, but also a culturally sanctioned way of seeking orientation.

Yet visibility does not guarantee understanding, nor does understanding necessarily lead to reassurance or direction. In some cases, seeing more introduces new questions rather than resolving existing ones.

Two needs that increasingly overlap
From a behavioural and cultural perspective, it is useful to distinguish between two different layers of expectation that often converge in scan use.

One concerns understanding one’s own body: a general desire for knowledge, insight, and structural explanation. The other concerns understanding oneself through the body: a more personal search for meaning, safety, orientation, or control.

Total body scans are well suited to the first. They show structure. They are far less suited to the second. They cannot explain how someone will feel, function, or live over time. Tension arises when scans are implicitly expected to bridge both layers at once.

The scan as a reflective object

Seen in this light, consumer total body scans are neither purely medical tools nor merely consumer products. They can be understood as reflective objects: visual representations that invite interpretation rather than dictate action.

A scan does not inherently initiate behavioural change, prescribe direction, or resolve uncertainty. What follows depends on how the image is taken up – whether as a moment of orientation, a source of reassurance, a prompt for further investigation, or simply a snapshot without lasting impact.

The significance of the scan lies less in the technology itself than in the expectations, narratives, and frameworks people bring to it.

Scale, context, and unintended effects

When scans are used without a clearly articulated personal or clinical question, they often generate information without direction. While scans can be meaningful in specific contexts, widespread or routine use does not automatically translate into better understanding or better outcomes.

Moreover, large-scale scan consumption may produce unintended effects – not only medically, but culturally – such as increased worry, additional testing, or a growing tendency to approach life’s uncertainties primarily through a medical lens. Seen more broadly, this raises the question of whether healthcare itself – and the technologies associated with it – has become a default response to a wide range of uncertainties, rather than a targeted answer to clearly defined problems [2].

Meaning emerges only when there is coherence between what a scan is intended to address, what it can realistically inform, and what lies beyond its scope.

Closing reflection

Consumer total body scans bring together ancient curiosity and modern technology in a way that is unprecedented in accessibility. They can inform, reassure, unsettle, or simply intrigue. Their medical possibilities and limitations matter, but they do not fully explain why people seek them or how they are experienced.

Ultimately, a scan does not tell someone who they are, how they should live, or what the future holds. It shows one version of the body at one moment in time.

Perhaps the more revealing question, then, is not what did the scan show, but rather:

What do we hope visibility will give us – and what will always remain beyond the reach of images?

References

1. Van de Graaf RC, Mirza A. The Pathophile Society. J Health Behav Med Hist 2025-7.

2. Van de Graaf RC. Is healthcare itself the biggest tap? J Health Behav Med Hist 2025-13.

3. Van de Graaf RC. Scanning at a different level. J Health Behav Med Hist 2026-1.

J Health Behav Med Hist 2026-1.

Scanning at a Different Level

Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

The debate about total body scans is often framed in terms of fear and medicalisation.
About people who are supposedly afraid of illness.
About commercial parties capitalising on that fear.

But perhaps we are asking the wrong question.

Not: what does such a scan do?
But: who is the person who chooses to be scanned?

Their position

By now, I have met many of them. What stands out is not anxiety or vulnerability, but position. They are entrepreneurs. Executives. Also within healthcare. Fellow medical specialists. People who make decisions every day that extend far beyond themselves. Decisions about organisations. About care. About systems that must not fail. About lives.

Their lives are not extreme. Their lifestyle is strikingly ordinary. Average Dutch. Some excess weight. Too little exercise. Living under pressure. On average, they smoke less than others. But they often drink a little more. Not out of ignorance, but out of context. Out of dinners where decisions are prepared. Out of evenings where work and private life blur into one.

Are these fearful people? Easy targets for exploitation?
These are people accustomed to working with uncertainty. Who know that complete information does not exist. Who make daily choices with consequences – financial, organisational, human. And who understand that not looking is also a choice. Often the easiest one. Rarely the wisest.

For them, a scan is not a hunt for disease. Not a step towards treatment or a patient role. It is a moment of orientation. A pause in action. A way of looking beyond the daily mirror. Because even those who lead others sense, somewhere, that they themselves are not invisible.

Anatomical knowledge

Just as they read figures, weigh scenarios and explore risks, they also want to understand how the body functions that carries all of this. A total body scan provides anatomical information. Images of structures. Sometimes an abnormality. Sometimes nothing. Produced by medical technology, assessed by radiologists.

In that sense, it is medical. But anatomical knowledge is not automatically healthcare. It is not treatment. Not the exclusive domain of doctors. Just as the mirror in the bathroom is not medicine.

There, too, we see ourselves. A little older. A little heavier. A little more tired. The mirror makes nothing ill. It cures nothing. It shows what is already there. A scan does the same – but beneath the skin.

A tool

The difference lies not in the knowledge, but in what we expect from it. Those who expect a scan to rescue, solve or reassure turn information into a promise. That is where medicalisation begins. But those who see information as a tool to carry responsibility more consciously use it differently.

Not: am I healthy?
But: where do I stand – given what I do and what I carry?

That is not a medical question.
That is a question at a different level.

Perhaps we should therefore speak differently about this group. Not as anxious consumers exploited by dubious scanners, but as people willing to face themselves at the level at which they operate. Not to control everything. But to continue leading with open eyes.

That is not medicalisation.
That is mature responsibility.

Translation from: scannen op een ander niveau (Arts en Auto)

J Health Behav Med Hist 2025-31.

Medicine is missing an organ – and obesity treatment has exposed the gap.

Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

Modern medicine is organised around organs. We diagnose their diseases, train specialists to treat them, and construct entire health systems around their failures. Yet the leading causes of global morbidity and early mortality – unhealthy eating, tobacco use, alcohol misuse, drug dependence, sedentary behaviour, compulsive gambling, and harmful digital use – do not originate in any recognised organ. These conditions arise from behaviour. What is missing is the organ that produces it.

The issue is not that medicine needs a new organ. The organ already exists – medicine has simply never learned to see, understand, and treat it.

Human behaviour – what we eat, crave, inhale, inject, click, avoid, or repeat – is generated by a distributed biological system that integrates sensory signals, neural circuits, hormonal cues, metabolic states, stress physiology, social norms, and commercial and digital architectures. In modern medicine, an organ can not only be defined by its anatomical location, but also by its function. Like the immune or endocrine system, this behavioural organ consists of multiple components acting together to perform a unified role: the regulation of behaviour in a changing environment.

Despite its centrality, this system has no name, no medical specialty, and no clinical owner. Without recognition, its dysfunction remains conceptually invisible. No diagnostic framework describes its collapse; no safety standards protect it; no medical discipline prevents iatrogenic harm. To correct this omission, we need to recognise this system for what it is: the behavioural organ.

Dysfunction of this organ drives more disease than any other. It fuels obesity, type 2 diabetes, cardiovascular disease, liver disease, many cancers, depression, anxiety, burnout, criminal behaviour, relationship breakdown, and widespread disability. These conditions appear diverse, yet their origins converge in reward dysregulation, habit fixation, stress-driven behavioural collapse, sleep disruption, exhaustion, deprivation, and environments engineered for instant consumption and hyperstimulation. Seen together, they reveal a single organ under strain – one whose dysregulated outputs sustain global epidemics.

What has changed is not human biology but the environment. Over millennia, behaviour evolved as the primary interface between organisms and their surroundings: a flexible, rapid-response organ enabling survival, exploration, bonding, and energy regulation. Today, this ancient system is overwhelmed by environments designed to hijack its vulnerabilities. High-calorie palatable foods, psychoactive substances, digital reward loops, engineered attention capture, and chronic stress create conditions in which the behavioural organ is chronically dysregulated. Yet medicine continues to mainly treat downstream consequences rather than the organ whose malfunction drives them.

However, medicine is already intervening directly in the behavioural organ – often powerfully – without acknowledging it. Addiction pharmacotherapies, such as methadone, varenicline and disulfiram alter craving and reinforcement. But the most dramatic evidence comes from obesity treatment. GLP-1 agonists and bariatric procedures do not primarily target digestion or fat tissue; they target another organ. They alter appetite, satiety, reward sensitivity, motivation, impulsivity, and emotional regulation. They reshape the behavioural organ itself.

This creates a profound clinical paradox. For the first time, behaviour is being biologically altered at population scale, yet these interventions are delivered predominantly by specialists trained in gastrointestinal or endocrine organs – not in the behavioural organ whose function they are manipulating. As a result, predictable complications of behavioural-organ injury – addiction transfer, compulsive gambling or shopping, alcohol misuse after bariatric surgery, disordered eating, behavioural collapse under stress, mood instability, and disturbances in social functioning and identity – are commonly misinterpreted as psychological weakness, if recognised at all. In reality, they are often iatrogenic injuries to an organ medicine has never named.

We would not accept cardiologists inadvertently damaging the immune system, nor neurologists manipulating endocrine function without training. Yet we accept surgeons and metabolic physicians altering behaviour without any recognised background in behavioural physiology. This is no longer tenable.

By the established criteria of modern physiology – unified function, characteristic dysfunction, identifiable mechanisms, and targetable pathways – the behavioural organ qualifies unequivocally. Its mechanisms include reward processing, habit formation, attention capture, memory, stress responses, sleep–wake regulation, metabolic signalling, executive function, social norms, and environmental influence. Its dysfunction manifests in craving, compulsion, reward hijacking, habit collapse, substitution behaviour, and behavioural instability. Its treatments already exist across pharmacology, psychotherapy, behavioural interventions, coaching, and environmental redesign.

Recognising the behavioural organ is not symbolic. It is structural. Naming an organ creates coherence, responsibility, safety standards, specialist training, precision diagnostics and treatment techniques, and ethical boundaries. Most importantly, it protects patients from unintended behavioural harms of medical and commercial interventions.

The rapid rise of pharmacological behaviour-modifying obesity treatments has exposed a blind spot medicine can no longer afford. Until the behavioural organ is formally recognised, its diseases will remain misunderstood, its complications misattributed or missed, and its treatment scattered across specialties not trained to manage it.

A healthy behavioural organ produces healthier behaviour – and healthier behaviour produces fewer diseases. We do not need to invent a new organ. We need to recognise the one that already shapes the health of the world, before the consequences of ignoring it spiral further out of control.

J Health Behav Med Hist 2025-25.

Performance Medicine: reframing medicine around human functioning. A vision for a function-oriented medical specialty.

Abstract

Despite unprecedented advances in diagnostics and therapeutics, contemporary medicine increasingly struggles to address a growing group of patients whose primary problem is not disease, but declining functioning. These individuals experience progressive loss of energy, resilience, and capacity to function in work, relationships, and daily life, often without a single explanatory diagnosis. Rather than recovery, they accumulate symptoms, treatments, and care providers, while coherence and personal agency gradually erode. This vision paper defines Performance Medicine as a distinct medical specialty focused on human functioning over time. Performance Medicine reframes health not as an endpoint, but as a dynamic precondition for adaptation, recovery, and meaningful participation in life and work. By integrating medical knowledge with behavioural medicine, addiction medicine, occupational and rehabilitation medicine, preventive and lifestyle medicine, and life-course analysis, Performance Medicine addresses a structural blind spot in modern healthcare. Through integrated clinical illustrations, this paper demonstrates how Performance Medicine operates in practice, what it contributes, and what it deliberately does not replace.

Introduction

Modern medicine is highly effective in identifying pathology and managing disease. Its epistemological foundations, training structures, and reimbursement systems are primarily oriented toward diagnosis and treatment. This orientation has produced remarkable gains in survival, symptom control, and technological sophistication. At the same time, it has contributed to a growing mismatch between the prevailing medical model and the types of problems increasingly encountered in clinical practice.

Across healthcare systems, patients present with persistent fatigue, stress-related complaints, burnout, maladaptive coping behaviours, relational difficulties, sexual dysfunction, or a loss of meaning. Frequently, no single diagnosis adequately accounts for the extent of functional impairment. When diagnoses are established, they often accumulate without restoring functioning. Patients move between specialties and receive multiple interventions, often accompanied by side effects that are not always recognised as such, while nonetheless experiencing a progressive erosion of their capacity to function in daily life and work.

This phenomenon does not reflect a failure of individuals—neither patients nor clinicians. Rather, it exposes a structural limitation of disease-centred medicine itself. The contemporary medical system lacks a coherent framework for understanding functioning as a primary clinical object. Performance Medicine emerges precisely in response to this conceptual and clinical gap.

From disease to functioning as the central clinical object

Performance Medicine starts from a fundamentally different premise. Instead of asking primarily which disease is present, it asks how a person functions in the present, how that functioning is maintained, and how sustainable it is over time. Health, in this framework, is not defined as the absence of disease, but as the dynamic capacity to mobilise energy, attention, and adaptive resources in response to life’s demands.

This shift has important clinical consequences. Consider an individual who maintains high occupational performance despite chronic fatigue, poor sleep, and increasing reliance on alcohol to unwind. From a disease-oriented perspective, normal test results may justify reassurance. From a performance medicine perspective, however, this presentation signals functioning sustained through maladaptive compensation. The clinical task is not reassurance or symptom suppression, but understanding the adaptive strategy, its short-term utility, its long-term costs, and its likely trajectory.

Performance Medicine therefore introduces the concept of functional sufficiency. The central question is not whether symptoms meet diagnostic criteria, but whether current functioning can realistically be sustained without breakdown, addiction, or long-term disability.

Performance, behaviour, and lifestyle as adaptive dynamics

A defining feature of Performance Medicine is its understanding of behaviour and lifestyle as adaptive responses rather than isolated risk factors. Lifestyle behaviours do not exist independently of performance demands. High performance under chronic pressure reshapes sleep, nutrition, physical activity, and coping strategies. Initially, these adaptations may preserve functioning and even enhance output. Over time, however, they often undermine recovery and resilience, necessitating further compensation.

Clinical practice repeatedly illustrates this dynamic. A healthcare professional may gradually sacrifice sleep, movement, and social connection to meet professional expectations, experiencing temporary reinforcement through recognition and responsibility. Only later do emotional exhaustion, cynicism, and somatic complaints emerge. Temporary rest may alleviate symptoms, but returning to the same configuration reliably reproduces decline.

Performance Medicine does not frame such cases as failures of stress management or resilience. Instead, it evaluates whether the configuration of demands, behaviour, identity, and recovery remains functionally viable in the future. This explicit focus on sustainability distinguishes Performance Medicine from behavioural counselling and symptom-focused care.

The limits of symptom-based and fragmented care

Another recurring clinical pattern involves patients who accumulate diagnoses and treatments while overall functioning deteriorates. Chronic pain, obesity, fatigue, and mood complaints are addressed separately, often by different specialists, each acting within their legitimate scope. Yet the combined effect of medication side effects, activity avoidance, fear, dependence of medical care, and loss of agency produces a downward functional spiral.

Performance Medicine introduces a different clinical move: functional synthesis. Rather than asking which diagnosis is missing, it examines how medical interventions, behavioural adaptations, and contextual constraints interact over time to shape functioning. In some cases, the most effective intervention is not escalation, but de-escalation and reorientation, restoring movement, confidence, and agency within realistic medical boundaries.

This approach does not reject specialist care. Instead, it contextualises it. Performance Medicine explicitly guards against both undertreatment and overmedicalisation by evaluating interventions through their impact on functioning rather than through disease metrics alone.

Addiction and maladaptive coping as functional adaptations

Addiction medicine has long recognised substance use disorders as chronic conditions. Performance Medicine complements this understanding by emphasising the functional intelligence embedded in maladaptive coping. Substance use often emerges as a means of emotional regulation, sleep induction, or performance maintenance under prolonged strain.

Clinical experience demonstrates that abstinence achieved without functional replacement is fragile. Relapse frequently occurs during stress or transition, not because treatment has failed, but because the original functional problem remains unresolved. Performance Medicine therefore frames recovery as the development of alternative regulatory strategies capable of sustaining future functioning. In doing so, it stabilises addiction treatment by embedding it within a broader functional context.

Functioning beyond the individual: work, relationships, and meaning

Performance Medicine extends the clinical lens beyond individual symptoms to domains that are essential to human functioning yet traditionally marginalised in medical reasoning, most notably work, relationships, and meaning. Functioning in these domains is rarely reducible to isolated pathology. Work participation, relational and sexual functioning, and experiences of purpose or disengagement are shaped by the interaction of fatigue, stress, medication effects, identity development, role expectations, organisational context, and life-phase transitions. When functioning deteriorates in these areas, it typically does so not as a collection of separate problems, but as an expression of broader functional imbalance.

By approaching complaints related to work, intimacy, or meaning as signals of disrupted functioning rather than isolated deficits, Performance Medicine avoids both pathologisation and performance-driven optimisation. The clinical objective is not enhancement or correction of discrete domains, but the restoration of conditions under which sustainable work participation, relational connection, and experienced meaning can re-emerge as natural consequences of coherent and resilient functioning.

Positioning performance medicine among medical disciplines

Attention to functioning is not unique to Performance Medicine. Functional considerations are present across multiple medical disciplines. Occupational medicine and rehabilitation medicine explicitly address work ability and functional recovery. Addiction medicine and psychiatry include functioning as an important treatment outcome. Lifestyle and preventive medicine recognise functioning as a downstream effect of health-related behaviour. Even organ-based specialties increasingly consider functional impact when evaluating treatment options and outcomes.

What distinguishes Performance Medicine is not the introduction of functioning into medicine, but the decision to make functioning itself the primary organising principle of clinical reasoning. In most existing specialties, functioning is addressed within the boundaries of a specific organ system, diagnosis, or treatment pathway. Functional decline is therefore interpreted as a consequence of disease, treatment, or behaviour within a delimited domain. Problems that arise from the interaction of multiple domains—such as health, behaviour, work demands, relational context, identity, and life phase—tend to fall between specialties, without a clear locus of clinical responsibility.

Performance Medicine explicitly addresses this gap. It provides a function-oriented synthesis across organ-based, behavioural, occupational, rehabilitative, preventive, and lifestyle perspectives. Rather than extending the scope of any single specialty, it reframes the clinical task: to understand how people function across domains and over time, how adaptive and maladaptive patterns emerge at their intersections, and whether current configurations are sustainable into the future. In this sense, Performance Medicine is not only a new focus within medicine, but also a bridging specialty, restoring clinical coherence where responsibility for functioning has become fragmented across diagnosis-bound and organ-centred models of care.

Conclusion

Performance Medicine represents a necessary evolution of medical practice in response to the realities of contemporary life. In modern societies, the dominant health challenge is increasingly not acute disease, but a progressive erosion of functioning driven by chronic load, maladaptive coping, and persistent mismatch between human capacity and contextual demands. Traditional disease-centred models are poorly equipped to address this form of decline, particularly when it unfolds across domains and over time.

By placing functioning rather than pathology at the centre of clinical reasoning, Performance Medicine realigns medical care with how people actually live, work, adapt, and ultimately break down. Health, within this framework, is not an endpoint to be achieved, but a condition that enables participation, agency, recovery, and resilience. Performance Medicine does not replace existing medical disciplines; it corrects a structural imbalance in their organisation and focus. In doing so, it defines a function-oriented medical specialty whose emergence is not aspirational, but necessary.

J Health Behav Med Hist 2025-24.

The behavioural organ: an introduction to the system that produces human behaviour

Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

Abstract

Human behaviour is the primary means through which individuals engage with the world, yet the system that generates behaviour has never been recognised as an organ in its own right. This paper introduces the concept of the behavioural organ, a distributed relational system spanning both the internal world of the individual organism and the external world in which action unfolds. The structure of this organ can be conceptualised through the behavioural triangle, which consists of the organism, the designed behaviour that arises from internal and external invitations, and the world that shapes and enables action. Behaviour is the moment-to-moment expression of this system as it responds to continual changes in both internal and external conditions. Although the behavioural organ has always existed, contemporary environments make its recognition newly essential. Understanding this organ offers a coherent way to explain why behaviour flows in some contexts and fragments in others, and provides a foundation for supporting human functioning with greater clarity and precision.

Introduction: the missing organ of human behaviour

Human behaviour is often interpreted as a product of personal traits, motivation, willpower or intention. Such explanations treat behaviour as if it originated solely inside the individual, emerging from an isolated psychological or biological mechanism. Yet behaviour is not generated privately. It unfolds within a relational system that includes the person, the behavioural patterns invited by the situation and the environment in which action becomes possible.

This paper introduces the concept of the behavioural organ, the distributed system responsible for producing human behaviour. Unlike anatomical organs, it does not exist in a single location. Rather, it emerges in the dynamic relation between organism and world. Its recognition allows us to describe behaviour not as an isolated act, but as the output of a living system that must remain coherent as both internal and external conditions continually shift.

The behavioural organ

The behavioural organ spans biological, psychological and environmental processes.

Individual organism

Within the organism, it integrates perception, emotion, reward processing, attention, memory, habit systems, meaning-making, stress physiology and executive control into a single functional whole. These internal components are never static. Physiology shifts with fatigue, hunger, circadian rhythms, hormonal cycles and ageing. Anatomy evolves through maturation, injury, illness and physical training. Cognitive capacities change as a result of learning, trauma, practice and experience. Emotional life moves with memory, appraisal and interpretation. Identity, values and motivations deepen, reconfigure or transform across the lifespan.

External world

Yet the behavioural organ is not confined to the individual. It also incorporates the external world as an active part of its structure. Behaviour takes form within the physical, social, cultural, institutional, digital and ecological environments through which a person moves. These environments shape what is possible, meaningful, safe or desirable. They impose demands, offer affordances, communicate expectations and organise the opportunities for action.

Behaviour emerges from the ongoing negotiation between what arises inside the organism and what unfolds outside it. This dual responsiveness – to the changing internal world and the shifting external world – is what gives the behavioural organ its character as an organ. Its unified purpose is to generate coherent, adaptive and meaningful behaviour amid perpetual change.

The behavioural triangle: a structural representation of the behavioural organ

The behavioural triangle [1] offers a structural map of the behavioural organ. It consists of three interdependent components whose interaction produces behaviour.

The first component is the individual organism. This includes the biological and psychological capacities that make action possible: physiology, attention, emotion, memory, identity, habit, meaning, and the broader personal history that shapes readiness and limitation.

The second component is the designed behaviour. Designed behaviour is the behavioural pattern the organ is preparing to express. It arises from two directions. Internally, the organism generates invitations to act – hunger, curiosity, fatigue, values, impulses and needs. Externally, environments embed norms, expectations and behavioural structures – tasks, roles, cultural codes, conversational cues and institutional demands. Designed behaviour represents the behavioural blueprint that exists before action, shaped jointly by the organism and the world.

The third component is the external world. This includes the physical environment, social atmosphere, cultural norms, institutional structures and digital architecture. It defines which behaviours are possible, safe, meaningful or coherent within a situation. The environment does not merely influence behaviour; it co-creates it.

Behaviour is produced not by one component alone, but by the dynamic interplay of all three. The behavioural organ is therefore not located in the organism, the behaviour or the world, but in the relation between them.

Designed behaviour and expressed behaviour

A central distinction in the behavioural organ model is that between designed behaviour and expressed behaviour. Designed behaviour is the intended, invited or required behavioural pattern formed by internal and external conditions. Expressed behaviour is the behaviour that actually appears in the world.

These two forms of behaviour often diverge. A person may intend to act in one way yet find themselves acting differently. This is not a failure of motivation or discipline. It indicates that the behavioural organ, at that moment, could not align its components closely enough for designed behaviour to be expressed. When the organ is coherent, designed and expressed behaviour converge. When the organ is incoherent, behaviour falters or fragments.

This distinction reveals why behaviour varies across settings, why intention does not guarantee action and why even highly competent individuals may struggle in destabilising environments.

Fit, misfit and the energetic logic of behaviour

The behavioural organ operates according to an energetic logic. When the organism, the designed behaviour and the environment align, behaviour requires little energy. It feels fluent, steady and purposeful. People describe this state as clarity, ease, focus, flow or vitality. The organ is coherent.

When these components misalign, behaviour becomes energetically expensive. A chaotic environment, an unclear behavioural demand or an organism under internal strain creates friction. The system must invest additional regulatory effort simply to maintain stable functioning. This is experienced as stress.

Because the behavioural organ is relational, stress does not remain within the individual. Misfit radiates outward, influencing the tone of interactions and the functioning of groups. Likewise, environmental incoherence exerts pressure on the organism. Coherence and incoherence propagate through the behavioural field in both directions. The behavioural organ can never be understood as an internal mechanism alone.

Why recognising the behavioural organ matters

The behavioural organ has always existed, yet for most of human history its functioning was supported by relatively stable environments and roles. Modern life demands continuous behavioural adaptation, rapid switching between contexts and the negotiation of multiple, often conflicting behavioural invitations. These conditions expose the need for a formal understanding of the organ that generates behaviour.

Recognising the behavioural organ enables a systemic, non-moralising understanding of human functioning. It clarifies why behaviour depends on the alignment of organism, designed behaviour and world, and why interventions targeting only one element often fail. It shifts attention from isolated acts to the relational system that produces them.

Understanding the behavioural organ provides a foundation for designing environments, roles and practices that support behavioural coherence rather than undermine it. In an increasingly complex world, this recognition is no longer optional but essential.

Conclusion

The behavioural organ is the living system that produces behaviour through the interaction of organism, designed behaviour and world. It exists in the relation between these components, not inside any single one. Its coherence determines whether behaviour flows or fragments, whether energy is generated or depleted, and whether individuals and groups function effectively.

This organ has always been with us. What has changed is our need to name it, understand it and work with it consciously. Recognising the behavioural organ offers a clearer way to see human behaviour and a more grounded basis for helping individuals and organisations function with clarity, coherence and vitality.

References:

1. Van de Graaf RC. Reframing Human Behaviour Through the Behavioural Triangle: A Relational Systems Model for Understanding and Change. J Health Behav Med Hist 2025-12.

J Health Behav Med Hist 2025-23.

Healthcare is still a patient itself

Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

“Patients do everything they can to burden healthcare as little as possible. The patient as a ‘Little Miss Greedy’ doesn’t exist. What they do ask for is: ‘Good guidance, especially when it comes to self-care and lifestyle.’” – Arthur Schellekens, Dutch Patients Federation [1]

A reassuring message, you might think. Patients don’t want more care – they want to learn how to take better care of themselves.
Until you read where they seem to be asking for that help: within healthcare itself. And that’s where it starts to chafe.

Because if there’s one sector that struggles with lifestyle and self-care, it’s healthcare itself. Anyone who knows the field up close knows how thin the line is between caring and burning out.

Healthcare professionals who teach others about balance often lack it in their own lives. We preach recovery, yet take on extra night shifts. We advise movement, yet sit for hours behind screens. We advocate rest, yet live on adrenaline, coffee – and sometimes our children’s methylphenidate.

At the end of the day, we drink to relax. We take pills from our own workplace to sleep. We take painkillers to keep going. Within healthcare, alcohol and medication misuse are more common than in almost any other sector. We numb what we can’t heal, and live off our reserves.

Healthcare is a sector full of people who care for others – and lose themselves in the process. It has become its own mirror – cloudy, yet honest.

That’s no coincidence. Healthcare was never designed to create health, but to repair disease. For centuries, “health care” was about damage control: setting bones, stitching wounds, removing tumors, fighting infections. Repair care – meant to get people back on their feet.

But the better that care became, the bigger it grew – and the further we drifted from the true source of health itself. We have come to rely on what lies outside us, and forgotten how to care for what lives within us.

Self-care became secondary, because healthcare could always fix it. Now we’re paying the price. Not because healthcare has failed us, but because we have overused it. We’ve mistaken repair for health.

And yet, it’s not strange that people seek help with lifestyle change. We’ve become so far removed from our natural self-regulation that change can even be risky without medical supervision.Those who quit smoking or drinking, or suddenly start eating healthier, can become physically destabilized.

That’s why we do need healthcare – not to do the work for us,
but to guard against the risks of recovery, and to increase the chances of success.

At the same time, healthcare itself is unwell. It has sacrificed its own health to the ideal of repair. It keeps working when the body protests. It pushes through when it’s empty. It has become a patient itself.

Perhaps that’s why healthcare is now developing the field of lifestyle medicine – not only as help for patients, but as a form of self-therapy. We are learning again how to live, how to recover — as a sector and as human beings – from our own exhaustion. Only when we master that can we truly teach others to take better care of themselves.

The patient is not a Little Miss Greedy. They’re not asking for more care, but for direction. Not for pills, but for guidance.

That direction lies outside the realm of medical care – in rest, rhythm, relationships, nature, and meaning. There grows what healthcare has been trying to restore all along.

Perhaps this is the moment to reverse the order: not care first, then healing, but healing first — and only then, caring.

[1] https://maxmagazine.nl/artikel/patientenfederatie-nederland-na-peiling-patient-als-rupsje-nooitgenoeg-bestaat-niet/ 

Translation from:

https://www.artsenauto.nl/de-zorg-is-zelf-nog-patient/

J Health Behav Med Hist 2025-22

Comfort Loop Syndrome: a new framework for understanding and addressing the pandemic of lifestyle-related health societal problems

Robert C. van de Graaf, MD

Director, MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands

Abstract

Modern societies provide unprecedented access to behaviours that offer immediate comfort and relief. While these behaviours can be benign or even adaptive in the short term, their repeated use in response to discomfort can initiate self-reinforcing cycles that gradually undermine health and resilience. We introduce the concept of Comfort Loop Syndrome (CLS) as a new explanatory framework for understanding the growing pandemic of lifestyle-related health and societal problems. CLS describes the process by which natural coping loops become chronically activated, reinforced, and biologically embedded, leading to psychosocial rigidity, chronic stress, and low-grade inflammation. By integrating behavioural, physiological, and evolutionary perspectives, CLS helps explain how everyday coping patterns interact with comfort-rich environments to produce widespread chronic disease and social challenges. We also explore how the CLS framework can inform prevention and intervention strategies at both individual and societal levels.

Introduction

Across the globe, societies face a silent but escalating pandemic: lifestyle-related health and societal problems driven by comfort-seeking behaviours. Rising rates of obesity, type 2 diabetes, cardiovascular disease, sleep disturbances, loneliness, and stress-related disorders are often explained in terms of individual choices or environmental risk factors. Yet these explanations remain fragmented, overlooking the behavioural dynamics that link these diverse problems together.

At the heart of many of these conditions lies a shared mechanism: the repeated use of short-term comfort strategies to cope with discomfort, leading to the gradual formation of self-reinforcing behavioural and physiological patterns. These patterns, shaped by modern environments saturated with comfort opportunities, are not inherently pathological; they are the result of basic human coping mechanisms operating in contexts for which they were not evolutionarily designed.

An everyday example makes this mechanism tangible. A 45-year-old office worker experiences persistent work stress. Each evening, instead of addressing the root causes of this stress, she finds temporary relief in binge-watching series and snacking late at night. Over time, this habit disrupts her sleep, leads to weight gain, and leaves her feeling more tired and stressed during the day. The initial coping behaviour, which once brought short-term comfort, becomes part of a self-reinforcing cycle of discomfort and relief that gradually undermines her health and resilience.

The same dynamic plays out at a collective level. Urban communities increasingly offer abundant access to high-calorie food, digital entertainment, sedentary transport, and climate-controlled environments. Opportunities for physical exertion, social connection, and exposure to natural challenges have diminished. This comfort-rich environment continuously triggers and rewards short-term comfort behaviours, creating population-level loops that contribute to metabolic disease, social disconnection, and chronic stress.

Despite the scale and impact of these developments, there is no widely accepted framework that integrates behavioural, physiological, and evolutionary mechanisms to explain how everyday comfort behaviours contribute to both individual and societal health problems. To address this gap, we introduce the concept of Comfort Loop Syndrome (CLS). CLS builds on stress and coping theories (Gidron, 2019; Feldman, 2020) and insights from behavioural (Cartwright, 2022) and physiological research (Rippe, 2019; Egger, 2017; Mechanik, 2016). It provides a coherent model of how repeated activation of natural coping loops in modern comfort-abundant environments can lead to maladaptive patterns over time.

The evolutionary basis of coping behaviour

Coping behaviours are not arbitrary: they reflect deeply ingrained evolutionary adaptations that helped humans survive in uncertain and challenging environments. Broadly speaking, there are two complementary coping strategies: emotion-focused coping (EFC) and problem-focused coping (PFC).

Emotion-focused coping evolved as a way to manage internal states and maintain psychological stability in the face of threats or uncontrollable circumstances. When external dangers could not be removed — such as sudden weather changes, injury, or dominance threats from stronger group members — it was adaptive to seek safety, rest, warmth, or social comfort. Seeking immediate relief from discomfort helped reduce physiological stress responses, conserve energy, and restore homeostasis. Behaviours such as retreating to shelter, eating energy-dense foods, seeking closeness to others, or withdrawing temporarily from danger had clear survival value. Comfort seeking is thus not weakness or indulgence, but a deeply rooted mechanism for maintaining internal equilibrium.

Problem-focused coping, by contrast, evolved to address situations where active intervention could improve survival or reproduction. Early humans who could plan ahead, solve problems, collaborate to hunt or build shelter, and change their environment to meet their needs had significant evolutionary advantages. PFC relies on cognitive resources and social cooperation, and typically involves effort, delay of gratification, and sometimes risk-taking. It is most effective when challenges are controllable and when the costs of action are outweighed by potential benefits.

These two strategies evolved in a dynamic balance. Emotion-focused coping allowed humans to survive periods of stress and uncertainty, while problem-focused coping allowed them to shape their environments, solve complex problems, and build resilient communities. Importantly, comfort-seeking behaviours evolved in environments of scarcity, uncertainty, and intermittent discomfort. Food, warmth, and shelter were not continuously available; comfort-seeking was episodic and restorative, not chronic and pervasive.

Modern societies have disrupted this evolutionary balance. Technological, economic, and cultural developments have created environments of constant comfort availability. High-calorie foods, temperature control, passive entertainment, and immediate distraction are continuously accessible, while many forms of natural challenge have been removed. This unprecedented abundance interacts with ancient comfort-seeking mechanisms, activating them far more frequently and persistently than they were designed for. The result is a mismatch: coping systems shaped for scarcity are operating in contexts of abundance, leading to new patterns of behaviour with unintended consequences.

The comfort loop: a natural coping cycle

Human beings constantly navigate discomfort, whether physical, psychological, or social. Coping strategies help regulate emotional states and solve problems. Emotion-focused coping provides short-term relief by reducing the immediate unpleasantness of a situation; problem-focused coping targets the source of discomfort directly. Both are essential for healthy adaptation, but their effectiveness depends on matching the strategy to the situation.

In contemporary environments, emotion-focused coping is increasingly applied to discomforts that could be addressed through problem-focused strategies. This is partly because comfort behaviours are so readily available: scrolling on a phone, eating calorie-dense snacks, seeking distraction through entertainment, or avoiding challenging situations. These behaviours bring immediate relief, but often do little to address the underlying problem.

This creates what we can call the comfort loop: discomfort triggers a comfort behaviour, which leads to short-term relief, but leaves the original problem unresolved or worsened, eventually causing new discomfort. The cycle then repeats. This loop is a normal part of human functioning. It becomes problematic only when it is triggered frequently and persistently, as is increasingly the case in modern societies.

From loop to syndrome: repetition, reinforcement, and biological Embedding

When comfort loops are activated repeatedly over time, a series of mutually reinforcing processes begins to unfold. At the behavioural level, comfort responses gradually become automated. What initially required a conscious choice turns into routine, often triggered by subtle cues in the environment or emotional state. As habits consolidate, they become less accessible to reflection and deliberate control.

At the psychosocial level, unresolved problems tend to accumulate because the underlying sources of discomfort remain unaddressed. Over time, people may find themselves with fewer active coping strategies at their disposal. Coping flexibility narrows, and individuals increasingly turn to comfort behaviours as their default response, even in situations where alternative approaches would be more effective. This narrowing of behavioural repertoire can subtly reshape social dynamics as well: people may withdraw from challenging interactions, reduce help-seeking, or disengage from meaningful activities, which in turn reinforces reliance on comfort behaviours.

Physiological processes also play a crucial role in this progression. Persistent discomfort keeps stress-response systems activated, while many comfort behaviours themselves—such as frequent consumption of energy-dense foods, smoking, prolonged sitting, or chronic sleep disruption—directly stimulate neuroendocrine and inflammatory pathways. This leads to a state of chronic low-grade inflammation, which is increasingly recognized as a key mediator between behaviour, stress, and the development of chronic disease.

Importantly, changes in behaviour often produce their own forms of discomfort. Reducing or interrupting ingrained comfort behaviours can trigger psychological and physical withdrawal symptoms—ranging from irritability and restlessness to cravings and sleep disturbances—as well as subtle social disruptions when established routines are altered. These withdrawal effects create additional discomfort, which can further strengthen the pull of the comfort loop and make change more difficult.

Over time, these behavioural, psychosocial, and biological mechanisms interlock and stabilize, creating a self-sustaining state that we call Comfort Loop Syndrome (CLS):

Comfort Loop Syndrome (CLS) is a self-reinforcing behavioural, psychosocial, and physiological state resulting from the chronic activation and reinforcement of natural comfort loops.

CLS develops gradually, often unnoticed, over years or even decades. It arises from the interaction between deeply rooted human coping tendencies and modern environments that provide constant opportunities for comfort. CLS is not a diagnosis or a discrete disease entity, but a framework for understanding how widespread patterns of lifestyle-related health and societal problems can emerge from everyday behavioural dynamics.

Prevention and intervention strategies

The CLS framework highlights the importance of both societal and individual strategies to prevent the development of maladaptive comfort loops and to intervene effectively once they have become established. Because CLS emerges from the interaction between human behaviour and the environment, meaningful change requires action on multiple levels simultaneously.

At the societal level, prevention begins with reshaping the environments that continually trigger and reward comfort-seeking behaviours. Modern settings often make the easiest choices the least healthy ones. Urban planning that encourages active transport, walkability, and access to green spaces can help reintroduce natural forms of physical activity and reduce passive comfort-seeking. Regulatory measures that limit the marketing and availability of unhealthy products, together with healthier defaults in schools, workplaces, and public institutions, shift the baseline of behaviour toward more adaptive patterns. Equally important is the cultivation of cultural norms that value meaningful challenge, recovery, and genuine social connection, rather than perpetual convenience. Policies that make problem-focused coping more feasible—such as flexible working arrangements, supportive educational systems, and equitable access to resources—create conditions in which individuals are more likely to address discomfort at its source rather than rely on short-term relief.

At the individual level, prevention focuses on strengthening coping flexibility and increasing awareness of how comfort loops operate. Educational and behavioural approaches can help people recognize when they are applying emotion-focused coping to discomforts that could be resolved through active problem solving. Interventions such as mindfulness training, self-reflection tools, behavioural coaching, and early lifestyle guidance can foster self-awareness, broaden coping repertoires, and interrupt emerging loops before they become habitual. Developing the capacity to tolerate moderate discomfort without immediately seeking relief is an important skill in this context.

When CLS is already present, intervention typically requires a more structured, gradual, and sustained approach. Long-established loops do not dissolve through simple advice or short-term interventions. The process often begins with increasing awareness of behavioural patterns and the triggers that sustain them. This is followed by modifying the surrounding environment to reduce cues that elicit automatic comfort behaviours. At the same time, physiological restoration—through improved sleep, regular movement, balanced nutrition, and stress reduction—creates a more stable internal milieu that supports behavioural change. Gradually reintroducing problem-focused coping strategies helps individuals address underlying sources of discomfort rather than perpetuating the loop. Supportive social relationships, professional coaching, and, when indicated, lifestyle and performance medicine care play a crucial role in sustaining these changes, as entrenched patterns tend to resist superficial or isolated interventions.

Ultimately, prevention and intervention strategies informed by the CLS framework emphasize restoring balance rather than imposing restriction. The goal is not to eliminate comfort, but to create environments and capacities that ensure comfort serves its original restorative role, instead of becoming a chronic escape that undermines long-term health and resilience.

Improving the societal context

CLS cannot be fully addressed through individual interventions alone; the environments in which these behaviours occur must also change. Societal transformation means rebalancing convenience and challenge, comfort and effort. It involves urban planning that encourages movement, educational systems that build coping capacities early in life, workplace cultures that support agency and recovery, and media landscapes that foster intentional rather than compulsive engagement.

Such systemic changes are challenging, but they address the root causes rather than just the symptoms. By creating contexts in which natural coping loops are used appropriately and not constantly overstimulated, societies can foster resilience and reduce the long-term burden of preventable chronic disease.

Conclusion

Comfort Loop Syndrome provides a new conceptual lens for understanding the pandemic of lifestyle-related health and societal problems. By integrating evolutionary, behavioural, psychosocial, and physiological mechanisms, it explains how everyday coping patterns interact with comfort-rich environments to create widespread health challenges.

CLS reframes these issues not as isolated habits or purely biological diseases, but as the cumulative outcome of repeated, evolutionarily natural coping loops operating in mismatched modern contexts. Recognizing and addressing CLS can inform prevention and intervention strategies that target both individual behaviour and environmental conditions.

Addressing CLS is not about eliminating comfort, but about restoring balance: ensuring that coping strategies are well matched to challenges, and that comfort serves its original evolutionary role as a restorative pause rather than a chronic escape. Achieving this requires coordinated action across individuals, communities, and systems—but it offers a promising path toward more resilient societies.

References

Gidron Y. Behavioral Medicine. An evidence-based biobehavioral approach. Cham: Springer Nature 2019.

Feldman MD, Christensen JF. Behavioral Medicine. A guide for clinical practice. 5^th edition. New York: Mc Graw Hill 2020.

Cartwright J. Evolution and human behaviour. Darwinian perspectives on the human condition. 3^rd edition. London: Bloomsbury Academic 2022.

Rippe JM. Lifestyle Medicine. 3^rd edition. Boca Raton: CRC Press 2019.

Egger G, Binns A, et al. Lifestyle Medicine. Lifestyle, the environment and preventive medicine in health and disease. 3^rd edition. London: Academic Press 2017.

Mechanik JI, Kushner RF. Lifestyle Medicine. A manual for clinical practice. Heidelberg Springer 2016.