Psychosomatic medicine

Some physical diseases are believed to have a mental component derived from the stresses and strains of everyday living. This has been suggested, for example, of lower back pain and high blood pressure, which some researchers have suggested may be related to stresses in everyday life.[3] The psychosomatic framework additionally sees mental and emotional states as capable of significantly influencing the course of any physical illness. Psychiatry traditionally distinguishes between psychosomatic disorders, disorders in which mental factors play a significant role in the development, expression, or resolution of a physical illness, and somatoform disorders, disorders in which mental factors are the sole cause of a physical illness.

It is difficult to establish for certain whether an illness has a psychosomatic component. A psychosomatic component is often inferred when there are some aspects of the patient's presentation that are unaccounted for by biological factors, or some cases where there is no biological explanation at all. For instance, Helicobacter pylori causes 80% of peptic ulcers. However, most people living with Helicobacter pylori do not develop ulcers, and 20% of patients with ulcers have no H. pylori infection. Therefore, in these cases, psychological factors could still play some role.[4] Similarly, in irritable bowel syndrome (IBS), there are abnormalities in the behavior of the gut. However, there are no actual structural changes in the gut, so stress and emotions might still play a role.[5]

The strongest perspective on psychosomatic disorders is that attempting to distinguish between purely physical and mixed psychosomatic disorders is increasingly obsolete as almost all physical illness have mental factors that determine their onset, presentation, maintenance, susceptibility to treatment, and resolution.[6][7] According to this view, even the course of serious illnesses, such as cancer, can potentially be influenced by a person's thoughts, feelings and general state of mental health.

Addressing such factors is the remit of the applied field of behavioral medicine. In modern society, psychosomatic aspects of illness are often attributed to stress[8] making the remediation of stress one important factor in the development, treatment, and prevention of psychosomatic illness.

In the field of psychosomatic medicine, the phrase "psychosomatic illness" is used more narrowly than it is within the general population. For example, in lay language, the term often encompasses illnesses with no physical basis at all, and even illnesses that are faked (malingering). In contrast, in contemporary psychosomatic medicine, the term is normally restricted to those illnesses that do have a clear physical basis, but where it is believed that psychological and mental factors also play a role. Some researchers within the field believe that this overly broad interpretation of the term may have caused the discipline to fall into disrepute clinically.[9] For this reason, among others, the field of behavioral medicine has taken over much of the remit of psychosomatic medicine in practice and there exist large areas of overlap in the scientific research.

Studies have yielded mixed evidence regarding the impact of psychosomatic factors in illnesses. Early evidence suggested that patients with advanced-stage cancer may be able to survive longer if provided with psychotherapy to improve their social support and outlook.[10][11][12] However, a major review published in 2007, which evaluated the evidence for these benefits, concluded that no studies meeting the minimum quality standards required in this field have demonstrated such a benefit.[13] The review further argues that unsubstantiated claims that "positive outlook" or "fighting spirit" can help slow cancer may be harmful to the patients themselves if they come to believe that their poor progress results from "not having the right attitude".

On the other hand, psychosomatic medicine criticizes the current approach of medical doctors disregarding psychodynamic ideas in their daily practice. For example, it questions the broad acceptance of self-proclaimed diseases such as gluten-intolerance, Lyme disease and Fibromyalgia as a gain of illness for patients to avoid the underlying intra-psychic conflicts eliciting the disease, while at the same time, challenging the reasons for this neglect in the doctors’ own avoidance of their emotional intra-psychic conflict.[14]

While in the US, psychosomatic medicine is considered a subspecialty of the fields of psychiatry and neurology, in Germany and other European countries it is considered a subspecialty of internal medicine. Thure von Uexküll and contemporary physicians following his thoughts regard the psychosomatic approach as a core attitude of medical doctors, thereby declaring it not as a subspecialty, but rather an integrated part of every specialty.[15] Medical treatments and psychotherapy are used to treat illnesses believed to have a psychosomatic component.[16]

In the medieval Islamic world the Persian psychologist-physicians Ahmed ibn Sahl al-Balkhi (d. 934) and Haly Abbas (d. 994) developed an early model of illness that emphasized the interaction of the mind and the body. They proposed that a patient's physiology and psychology can influence one another.[17]

In the beginnings of the 20th century, there was a renewed interest in psychosomatic concepts. Psychoanalyst Franz Alexander had a deep interest in understanding the dynamic interrelation between mind and body.[18] Sigmund Freud pursued a deep interest in psychosomatic illnesses following his correspondence with Georg Groddeck who was, at the time, researching the possibility of treating physical disorders through psychological processes.[19]

In the 1970s, Thure von Uexküll and his colleagues in Germany and elsewhere proposed a biosemiotic theory (the umwelt concept) that was widely influential as a theoretical framework for conceptualizing mind-body relations.

Henri Laborit, one of the founders of modern neuropsychopharmacology, carried out experiments in the 1970s that showed that illness quickly occurred when there was inhibition of action in rats. Rats in exactly the same stressful situations but whom were not inhibited in their behavior (those who could flee or fight – even if fighting is completely ineffective) had no negative health consequences.[20] He proposed that psychosomatic illnesses in humans largely have their source in the constraints that society puts on individuals in order to maintain hierarchical structures of dominance. The film My American Uncle, directed by Alain Resnais and influenced by Laborit, explores the relationship between self and society and the effects of the inhibition of action.

In February 2005, the Boston Syndromic Surveillance System detected an increase in young men seeking medical treatment for stroke. Most of them did not actually experience a stroke, but the largest number presented a day after Tedy Bruschi, a local sports figure, was hospitalized for a stroke. Presumably they began misinterpreting their own harmless symptoms, a group phenomenon now known as Tedy Bruschi syndrome.[21]

• Healing Words: Poetry and Medicine (documentary film)
• Medical students' disease
• Mirror box
• Nocebo effect
• Placebo effect
• Placebo studies
• Psychoneuroimmunology
• Psychosomatic Medicine (journal)
• Somatoform disorder (or somatic symptom disorder)

• Mind-Body Medicine: An Overview, US National Institutes of Health, Center for Complementary and Integrative Health
• NIH
• Academy of Psychosomatic Medicine
  • Psychosomatics, journal of the Academy of Psychosomatic Medicine
• American Psychosomatic Society
  • Psychosomatic Medicine, journal of the American Psychosomatic Society