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In its simplest sense, ‘psychosomatic medicine’ merely indicates that there is a (psyche) mind–body (soma) relationship relevant to human health. Drawing from this, many nonprofessionals believe that it is a medical specialty that concentrates on the psychological inﬂuences on disease, particularly certain ‘psychosomatic diseases.’ Actually, it is a health science that is concerned with the nature of the mind–body relationship, including its clinical applications.
More speciﬁcally, psychosomatic medicine is a ﬁeld of health science based on the concept that the human organism is a psychosomatic unity, that biological and psychological processes are inextricably inter-related aspects of its function. This stands in contrast to the still predominant, traditional biomedical model (see Engel 1977) from the nineteenth century which holds that diseases represent cellular or organ pathology arising from intrinsic defects or external bio-physicochemical agents. Psychosomatic medicine conceptualizes diseases as occurring in persons, not their components, as a consequence of their transactions with an environment that is informational, social, and cultural, as well as bio-physicochemical. It notes that people are not simply biological organisms, but sentient ones with motives, thoughts, feelings, and relationships.
Mind–body unity should not be misunderstood to imply that mental and somatic phenomena cannot be separately studied. Such reductionism is a legitimate tactic that permits the study of scientiﬁc questions limited to that system. Each organ or part function merits study by techniques appropriate to it. To understand organismic function, however, requires a perspective that includes data from all body systems, including the psychological. Psychosomatic medicine provides no theories about the nature of the underlying processes. What it provides is its holistic perspective for interpreting them. It draws on the data, theory, and techniques of all other relevant ﬁelds, integrating these in unique ways informed by its conceptual base. Thus, contrary to common lay belief, psychosomatic medicine is not a medical specialty. Nor is it a scientiﬁc discipline. Its practitioners come from a range of disciplines and clinical specialties.
Some have accused psychosomatic medicine of overweighting the importance of psychosocial factors in disease, trivializing biology. This had legitimacy during the 1940s and 1950s when a prominent segment of the ﬁeld fell into this trap (see Sect 2.3). If this seems still true, that is because its main eﬀort is directed to clarifying the eﬀects of psychosocial factors on the body. But that emphasis is necessitated by the neglect of this work by the remainder of biomedicine. Psychosomatic medicine is concerned with all mind–body relationships, giving equal importance to biology.
Doubts have been raised about the aptness of the term. To some, the bipartite nature of ‘psychosomatic’ undermines the intended unity. But it is one, unhyphenated word. Others question the absence of reference to the social, noting that many relevant factors are such. Engel’s (1977) alternative, ‘biopsychosocial model’ was meant to resolve that, as well as to circumvent the residual misinterpretation that biology is devalued. But if social is included, what about cultural? Indeed, the list could include economic and other factors. Moreover, these factors can impinge on the organism only via the psychological apparatus. ‘Psychosomatic medicine’ also has the virtue of historical continuity that includes a mass of research documentation.
From earliest times, people have been struck by instances in which physical symptoms followed noteworthy life events, and reports of these appear in ancient writings. With the beginnings of medical science, physicians added more such reports as well as describing illness outbreaks during wars and major upheavals. The idea that stressful life experiences caused illness gained wider currency. During the nineteenth century, philosophical conjectures about the holistic quality of human nature developed. This was the period when ‘psychosomatic’ came into use by physicians, although in a sense partly diﬀerent from our own.
2.2 Early Twentieth Century
With the turn of the century, Cannon’s (1915) studies on the physiology of the emotions added key data revealing how these physiological responses were adaptive to the external threats that had triggered the emotions. Building on Claude Bernard’s earlier work, he indicated (1932) how his ﬁndings ﬁt into the process by which organisms maintain their integrity by adapting to environmental change via internal responses to maintain internal equilibrium: ‘homeostasis.’
Clinical and epidemiological studies of better quality increased. By 1935, (Helen) Flanders Dunbar was able to cite some 2,251 references in her groundbreaking work, Emotions and Bodily Disease, which ushered in the modern, scientiﬁc era of psychosomatic medicine.
Further stimulus came from World War II. With astonishing foresight, the (US) National Research Council, anticipating casualties from war stress, convened a series of conferences among psychosomatic experts during the mid-1930s. This kindled additional research which culminated in 1939 with publication of the journal Psychosomatic Medicine, still the preeminent periodical in the ﬁeld. Three years later, the American Psychosomatic Society was founded to foster scientiﬁc interchange and education. US military physicians observed how war trauma led to physical as well as mental disorders, and many returned with an interest in psychosomatic medicine. Psychosomatic societies arose in other countries and, later, international meetings began.
Psychoanalysis provided further impetus. Freud and his followers were greatly interested in physical symptoms. Much of their theorizing involved a simplistic transfer of the psychoanalytic psychology of hysterical symptoms, without regard to physiology. Nevertheless, as psychoanalytic activity ﬂourished, it stirred interest among intellectuals, adding to the popularity of psychosomatic medicine. With this came the naive belief that many medical disorders were primarily psychogenic.
2.3 Speciﬁcity Theories
Paralleling major biomedical advances that elucidated the etiology and pathogenesis of disease, psychosomatic medicine undertook a search for speciﬁc psychological causative factors. Dunbar was a pioneer here too, observing that patients with several medical disorders had distinctive personality traits which she concluded were etiological. Others developed similar formulations. The identiﬁed diseases were termed ‘psychosomatic.’ This eﬀort peaked with the contributions of Franz Alexander (1950). As a psychoanalyst, he focused on unconscious processes, but his work was far more elaborate and sophisticated than others. Most importantly and enduringly, he clariﬁed that no purely psychological mechanism could explain the physiological processes of internal organs. Instead, Alexander reported that ‘speciﬁc dynamic constellations’ of motivations, defenses, and emotions characterized patients with each of a series of ‘psychosomatic’ diseases, and that life experiences which matched the vulnerabilities inherent in the particular constellation precipitated that illness. He also linked each constellation to speciﬁc physiological processes mediated through autonomic neural pathways that plausibly explained the pathogenesis of that disease. The brilliance of this work captured the imagination of many, and it became a major force in psychosomatic medicine. Belief developed that psychotherapy might cure ‘psychosomatic diseases.’
2.4 The Last Third Of The Twentieth Century
More careful studies called into question much specificity research, which had been uncontrolled for observer bias, and utilized selected subjects. Skepticism grew and spread from speciﬁcity to involve all of psychosomatic medicine. Moreover, remarkable advances in biomedicine made other factors seem irrelevant: ‘With penicillin, who needs psychology?’ The inﬂuence of the ﬁeld on the rest of medical science and practice withered.
Experiencing self-doubt and loss of external support, the ﬁeld contracted and changed. Grand theories were eschewed. Research focused on better-deﬁned questions and became methodologically tighter. Clinical studies became less common, especially those of therapy. Laboratory projects concentrated on elucidating basic psychophysiological relationships, often in normal subjects or even animals. If less exciting, this shift proved salutary, strengthening the scientiﬁc base and the quality of data.
Over time, the ﬁeld recovered. Increasing studies of clinical problems embodied a new methodological rigor gained from models provided by the continuing basic research. A variety of subgroups within the psychosomatic society grew to a critical size and formed associations of their own, expanding work further. Acceptance by clinical biomedicine grew more slowly, however.
3. Theoretical Models Of Mind–Body Relationships
The evidence of correlations between psychological and somatic processes is extensive. But how can this be understood? Five explanatory models can be adduced from scientiﬁc reports.
3.1 Concomitant Eﬀects
This model rejects causality in the relationship. It postulates that both the psychological and physical ﬁndings are products of another, precedent factor. Commonly, this is said to be genetic. Another explanation draws on the fact that life events often have multiple stimulus properties. Thus, one stimulus is said to cause the psychological ﬁndings while another produces the physical one.
3.2 Somato → Psychic Causation
This model posits that the relationship follows entirely from the eﬀects of somatic processes on the mind. This is the traditional biomedical view, which sees all disease as ‘physical’ in nature and origin. In a modiﬁcation, a feedback loop is added going back from the mind to the body, acknowledging that psychological changes may have physical eﬀects, but only secondarily. (If this is true, why cannot they do so primarily?)
3.3 Psycho → Somatic Causation
This is the counterpart of the preceding. It states that psychological responses to external events cause the somatic changes. Most commonly, stress or strong emotions are invoked as intervening mechanisms. Weiner (1977) noted that it may be the behavioral concomitants of the psychological processes which act on the body: ‘lifestyle factors’ such as smoking or substance abuse. Except for ‘speciﬁcity’ theories already described, the ‘choice’ of the resultant disease is usually left to other, biological factors. Again, secondary feedback is often added, bodily changes acting back on the mind.
3.4 Bidirectional Psycho – Somatic Causality
This is a combination of the last two models, allowing for causation in both directions and the feedback variations of each. Thus, longer causal chains are possible: … psycho … somato … psycho … somato … (etc.); but these remain linear.
3.5 The Modern Psychosomatic Model
This is a holistic model that includes all the preceding models and their variants, indicating that each explains some psychosomatic processes. Beyond this, it suggests that several are usually operating simultaneously, and to this adds that there are usually webs of relationships involving multiple stimulus–response linkages. To explain this, it invokes data about the operation of the mechanisms which integrate human function.
4. Integrative Mechanisms
From the biological side, the brain is the organ of the mind; mentation is subject to the same physical inﬂuences as all other organ functions. Beyond this, it is the body’s chief regulatory and coordinating organ. Inputs to the brain come from both the body and environment. Similarly, its output alters bodily functions and, via behavior, the external world. These inputs from inside and out converge on many of the same brain centers, and the resultant messages alter both psychological and somatic functions.
From a psychological perspective, input consists not merely of sensations but of information organized into meanings. Meanings have individual as well as shared components. The same event or somatic message has diﬀerent nuances, at least, for each person. The origins of these meanings, as well as those shared in the culture, derive from life experiences: they are learned. Some visceral responses to psychological stimuli also are ‘learned,’ but the learning that establishes these psychosomatic linkages is not the familiar, conscious process, but conditioning, of both Pavlovian and operant types. Most of this occurs in early life. Manipulations during early development can alter brain anatomy, neurotransmitters, and hormone levels, and modify subsequent stress responses.
When important meanings are attached to inputs, emotions are activated. These further aﬀect body functions. The original response becomes a stimulus, too. In studying organismic function, what is deﬁned as stimulus, and what as response, is arbitrary; it depends on what part of the process is being examined and at what point in time. Nor is this a simple chain of stimulus–response pairs. A network of actions follow, in which some responses aﬀect one organ, some another, and some both, while some of these inﬂuences are stimulating and others inhibitory; and the succeeding responses become additional stimuli of the same variegated nature. Because many life events have more than one meaning, several such networks may be in process simultaneously. In most instances, then, a stimulus sets oﬀ a transacting web of responses and new stimuli with both psychological and somatic components.
Ordinarily, inhibitory processes ﬁnally dominate, and the person returns to a resting state. Sometimes, especially if the stimulus persists, inhibition may fail, so that the reaction continues or recurs. These extended responses are homeostatically maladaptive, and likely to cause organ damage and disease.
The endocrine and immune systems also serve as integrators of organismic function, directly and in their inter-relationships with each other and the brain. Pituitary secretions, which control many other endocrines, are themselves subject to control by hormones and neurotransmitters from the hypothalamus. Psychological stress is associated with stimulation of adrenocortical hormones via the pituitary, as well as neurally mediated adrenaline release from the adrenal medulla. The distinction between neurotransmitters and hormones is blurred: active neuropeptides and neuroamines are present in many peripheral organs. Hormones act back on the brain to inhibit their own overproduction, but also modify cognitive and emotional states.
Stress also aﬀects both cellular and humoral immune functions, partly through the action of adrenal steroids; depression may have especially potent eﬀects. Animals subjected to a variety of psychological stressors have increased morbidity and mortality to injected pathogens along with changes in immune functions. Hypnosis can cure warts and alter the hypersensitivity reaction to injected antigens. The immune system can ‘learn’ too: immune responses to previously inert substances can be conditioned.
5. Basic Psychosomatic Concepts
5.1 Health And Disease
Psychosomatic medicine rests on the fundamental physiological concept of homeostasis: the human organism exists in a state of constantly dynamic equilibrium subject to both endogenous shifts and perturbations induced by an ever-changing environment. These trigger homeostatic responses which keep the changes from exceeding viable limits, thereby maintaining organismic integrity and permitting continuing function in the environment. If the change is excessive or the compensatory adjustments become so, damage results. When damage signiﬁcantly impairs adaptation, disease occurs: disease is failure of adaptation. At any given moment, every person is more or less healthy and more or less diseased.
Psychosomatic medicine enhances this concept to take account of our inherent psychological and physiological properties as well as the sociocultural and informational content of the physical world. Moreover, although ‘disease’ may seem to have a ﬁxed deﬁnition, diﬀerent times, places, and persons have provided diﬀering criteria for deciding what disease exists and whether one is sick at all. (Epilepsy in ancient Egyptian royalty was a manifestation of divinity.)
5.2 The Nature Of Disease; ‘Psychosomatic Disease’
Many physicians and others dichotomize disease states as ‘organic’ (physical) or ‘psychological’ (sometimes extending these, respectively, as ‘real’ or ‘imaginary’). Speciﬁcity theorists separated oﬀ ‘psychosomatic’ diseases in which psychogenesis played a uniquely central role. Psychosomatic medicine takes a wholly diﬀerent view, conceptualizing every disease in every person as physical AND psychological. There are no ‘psychosomatic diseases’ because all diseases (and health) are psychosomatic.
Even in the simple instance of accidental injury, it is the overall impact of the event on the person, not just the injured part, that deﬁnes the illness—including instances where behavioral factors played no causal role and no psychic ‘trauma’ results. The extent of pain, bleeding, swelling, etc., will be determined not only by the injury but by the victim’s entire prior psycho-physiological state; and the victim’s reactions to each of these eﬀects, as well as his attitudes about the injured part and its functions, will alter that state. (For example, if anger arises, blood vessels may dilate, increasing bleeding.) The reactions of others, including health care providers, will also aﬀect the psycho- physiological responses, as will the meanings of the treatment given. The somatic problems will be paramount medically, at least until late consequences require chronic care. Conceptually, however, even this extreme example of ‘pure physical illness’ can be fully understood only from a psychosomatic perspective. Optimal care will result only if health care providers are responsive to psychosocial needs throughout the course of treatment.
5.3 The Etiology Of Disease
Similarly, the causes of all diseases are psychosomatic. Take malaria for example. The plasmodium, usually mosquito-borne, is prerequisite. But, what is to be said of the US soldier in the tropics who contracts malaria after failing to take prescribed prophylactic medication or to sleep beneath issued netting, or who ﬁshes in a swamp designated ‘oﬀ limits.’ It is no less valid to categorize such behaviors as causative than the biological factors. Sociocultural factors, even political ones can enter in too. Examples include being a parentless child, or living in a culture ignorant of the mosquito’s role or under a political system too poor or uncaring to provide public health programs. Any such factors or other psychological events can be involved in any given person. Often several are.
The choice of an infectious disease was deliberate. Traditional medicine views these as the prototype of external causation. However, as Dubos (1960) indicated, all people are incubators for various microorganisms growing in their throat, intestine, etc.; and in these circumstances, why are people not sick all the time? The real question is why some people become sick with what they do, when they do. External factors explain only part of this. Host resistance variables, including diﬀerences in immunity, are necessarily involved too; and psychosocial factors aﬀect these.
5.4 Pathogenesis; The Onset Of Disease
Among the psychosocial causes of illness, stress is the best documented. Selye (1950) demonstrated that the response to any noxious stimulus precipitated a nonspeciﬁc ‘General Adaptation Syndrome’ superimposed on the speciﬁc eﬀects of the stimulus. He focused on the adrenocortical response, but it became clear that many other systems are involved in the syndrome, especially other hormones, the cardiovascular system, blood elements, including those active immunologically, and the psychological apparatus. Psychological stressors have proved as potent as physical ones. Indeed, some eﬀects of physical stressors have proved to result from their psychological properties. Multiple clinical studies have documented that a variety of illnesses arise in the context of accumulated life stress.
Speciﬁc emotional states seem to operate in some circumstances. Anger and anxiety have been implicated, as well as depression, especially that associated with feelings of helplessness and hopelessness.
But disease is a process with a course that evolves variably, and often preceded by a period in which covert, even undetectable, lesions are developing; and a diﬀerent superimposed process may be required for the disease to appear. Psychosocial factors have been implicated in each of these phases, but the speciﬁcs may diﬀer from one to another, as Reiser (1975) clariﬁed. For example, the gradual accretion of coronary atherosclerosis precedes thrombosis and infarction (‘heart attack’). Anger and depression have been implicated in infarction, whereas nonspeciﬁc stress has been related to alterations in cholesterol metabolism which can lead to atherosclerosis. Of course, the events that provoke emotions diﬀer among people, depending on their psychological makeup. Research provides the broad possibilities, but only individual study can delineate the pathogenic process in a given person.
The speciﬁc ‘choice’ of illness likely rests in genetic and other purely biological factors in many instances. Individually patterned psychosomatic links may be implicated in others. Either may be responsible for ‘response speciﬁcity,’ the tendency for individuals to have particular somatic responses to a variety of stressors. Moreover, discredited but not disproved psychological ‘speciﬁcity’ remains a possibility. The remarkable consistency among various speciﬁcity theorists regarding the psychological characteristics in people with certain disorders remains suggestive. Formidable methodological problems must be over- come to study this adequately, but such research is merited.
6. Clinical Applications
The application of psychosomatic medicine to patient care rests primarily on its basic concepts. As every patient is partly unique, only by identifying the issues speciﬁc to that individual can appropriate care be provided. The fundamental need both in diagnosis and treatment is establishing a trusting professional relationship that allows patients to relax defenses and reveal personal information and feelings. Also required are interviewing skills to facilitate patients’ communications of their life experiences, along with physical symptoms and the life context of the latter. This must be accompanied by suﬃcient knowledge of psychology and social science to identify the signiﬁcance of these communications, and also of major psychosomatic research ﬁndings in order to identify correlations likely to be signiﬁcant.
Treatment requires the ability to utilize this understanding of the patient in order to select the biological therapies that are most suitable for the individual, and to provide this in a manner that helps that patient use it best. On the psychological side, the need is to quantify and facilitate the extent of emotional release most helpful and tolerable to that patient, as well as the level of insight to pursue the relevant psychosomatic correlations.
All this seems complex, and it is. But the knowledge and skills can be acquired in the course of existing professional education, provided that psychosomatic medicine is integrated throughout. This is true for all clinical specialties. As noted initially, there is no specialty of psychosomatic medicine.
At the height of interest in psychosomatic medicine, a cadre of experts began to serve as educators of physicians, medical students, and others in academic health centers. Most were psychiatrists, although some internists and other specialists participated. This became a new subspecialty, named ‘Consultation Liaison Psychiatry,’ as the service function became melded with education. In the late twentieth-century, however, as psychiatry became more biological and positioned within the biomedical model, the psychosomatic element diminished. Given the widespread public dissatisfaction with the ‘over(bio)scientiﬁc,’ ‘dehumanized’ quality of medical care, this has been a signiﬁcant loss.
But clinical psychosomatic medicine should not be confused with humanism or doing ‘good’; it is applied science. Although its clinical practitioners act in a decent, humane fashion, it is not this but their skills and knowledge as applied scientists that make them eﬀective.
7. Recent Developments
Substantial research has ﬂourished under the rubrics of ‘health psychology,’ ‘behavioral medicine,’ and ‘behavioral psychology’ as well as psychosomatic medicine itself. Consequently, high-quality research has been advancing vigorously. Psychophysiological studies have begun to use highly sophisticated probe techniques to measure meaningful physiological parameters. A particularly new and useful approach involves the application of randomized clinical trials that elucidate both causal factors and the eﬀectiveness of interventions in a number of diseases. New research designs have incorporated more real-life situations, particularly in research on stress. Information particularly relevant to actual clinical and life situations has emerged, giving meaningful promise for the future.
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