Investigations into psychosomatic illness have focused on the relationships between emotional life and bodily processes—both normal and pathological—and not on the isolated problems of the diseased mind or the diseased body. The mind-body dichotomy is eliminated through the thesis that there is no duality of mind and body, mental and physical, but only a unity of the total being. It is assumed that the physiology of mood, instinct, and intellect differs from other physiology in degree of complexity but not in quality. Hence, while divisions of medical disciplines such as physiology, internal medicine, and psychiatry may be convenient for academic administration, biologically and philosophically these divisions have no validity. Psychic and somatic phenomena take place in the same biological system and are two aspects of the same process.
The ever-increasing flow of observations concerning the relation of psychological and physiological processes in the human organism supports this orientation. The influence of specific emotional tensions upon biochemical, endocrinological, and physiological changes has been studied both clinically and experimentally, as has the influence of physiological changes upon the emotional life of man.
Modern endocrinology and biochemistry may well be the progeny of the earlier humoral theory that medicine sought to refute or disregard. The whole man, not just his cells, tissues, and organs, becomes the subject of study for the modern psychosomatic researcher. Facts are seen as elements of the whole. The gestalt of man is studied with the appreciation that the whole is more than the sum of the parts; but these parts, nonetheless, are integrated in such fashion as to contribute to the whole. Personality is the expression of the unity of the organism. Neurology, neurophysiology, general physiology, endocrinology, biochemistry, pharmacology, and genetics contribute to our knowledge of the structure and function of the body. Psychology, psychiatry, and psychoanalysis contribute knowledge of the subjective phenomena which are reflections of physiological processes but are also the products of past social, cultural, and interpersonal relationships that have become internalized and thus are part of the integrity of the organism. Franz Alexander observed:
The body, that complicated machine, carries out the most complex and refined motor activities under the influence of such psychological phenomena as ideas and wishes. The most specifically human of all bodily functions, speech, is nothing but the expression of ideas through a refined musical instrument, the vocal apparatus. All our emotions we express through physiological processes; sorrow, by weeping; amusement, by laughter; and shame, by blushing. All emotions are accompanied by physiological changes: fear by palpitation of the heart; anger by increased heart activity, elevation of blood pressure and changes in carbohydrate metabolism; despair by a deep inspiration and expiration called sighing. All these physiological phenomena are the results of complex muscular interaction under the influence of nervous impulses, carried to the expressive muscles of the face and to the diaphragm in laughter, to the lacrimal glands in weeping, to the heart in fear, and to the adrenal glands and to the vascular system in rage. The nervous impulses arise in certain emotional situations which in turn originate from our interaction with other people. The originating psychological situations can only be understood … as total responses of the organism to its environment. (1950, pp. 38-39)
Various somatic manifestations may accompany different transitory emotional states in the normal organism. Thus, disturbances of the stomach, bowels, cardiovascular system, or respiratory system may be expressions of anxiety. These upsets are usually reversible, and in such cases morphological changes of the cells, tissues, or organs involved are nonspecific. The anatomical structure is not permanently or grossly altered; only the function is disturbed. Since these functional disturbances are triggered by emotional factors, the psychological understanding of the diseased patient is necessary if one is to assist him fully. This may not require formal psychotherapy, since the removal of the emotionally stressing external situation may by itself re-establish a level of equilibrium. When external rearrangements are not possible, the understanding of the anatomical and physiological mechanisms involved may allow for biochemical and pharmacological interventions that can temporarily interfere with abnormal pathways of discharge and thus alleviate symptoms during the period of equilibrium re-establishment.
Often an emotionally disturbing situation triggers a conflict which exacerbates a previous conflict constellation that has been rendered unconscious and largely inactive. In such cases, the functional distress may not be easily reversed, and chronic symptomatology results. Thus, a functional disturbance of long duration or of overwhelming intensity may lead to definite and demonstrable anatomical changes and to the clinical picture of severe organic illness. Research in such diseases as duodenal ulcer, ulcerative colitis, bronchial asthma, neurodermatitis, essential hypertension, rheumatoid arthritis, thyrotoxicosis, diabetes mel-litus, glaucoma, migraine, and anorexia nervosa indicates the probability of particular personality constellations having particular vulnerability to specific conflict situations.
The particular conflicts associated with the individual disorders have been detailed in Studies in Psychosomatic Medicine (Alexander et al. 1948). In peptic ulcer, for example, it has been found that the individual has a basic core of infantile oral dependency, which he copes with in various ways, such as overcompensation, aggression, or assertiveness. When such an individual’s coping mechanisms are impaired, or his oral-dependent cravings increase, he may no longer manage the internal conflict at a psychological level. Increased gastric secretion and/or gastric vasoconstriction may give rise to symptoms of gastric distress. If there is a decrease in stress on the organism, or a bolstering of the internal or organic system, strain may be diminished without symptomatic progression and with symptom remission. If psychic stress continues, what was originally dysfunction may result in an actual organic lesion, the peptic ulcer. The oral-dependent characteristics can be detected in dreams, behavior, and general character structure.
Other conflicts have been linked with particular diseases: repressed hostility with essential hypertension, fear of separation with bronchial asthma, and fear of destruction of the self with thyrotoxicosis. These conflicts have been described in detail in Psychosomatic Specificity (1968).
For the present, the functional theory of organic disorders associated with the psychosomatic concept includes the recognition of three etiological components acting together. Certain external causative factors can act as precipitators of imbalance and give rise to functional or structural disruption. These external factors have their effect upon underlying internal systems of equilibrium and integration. Thus many chronic disturbances are not caused by external, mechanical, chemical, or infectious agents, but by the stresses of the struggle for existence. These emotional conflicts arise during daily living, in the social interchange with signifi cant figures in the environment that have symbolic as well as actual significance. Finally, one must bear in mind the predispositions to disequilibrium which reflect constitutional and experiential influences upon the organism. These include genetic factors, the influence of intrauterine and extrauterine physiological and pathological agents, the crucial parent-sibling relationships during critical personality developmental periods of the first decade of life, especially as they relate to mental functioning, and the impact of personal, social, and cultural influences in child-care and child-rearing practices. These predisposing factors constitute the underlying matrix of vulnerability to certain situations occurring later in life. Continuous and repressed fears, aggressions, and libidinal wishes can, for susceptible individuals, result in permanent chronic emotional tensions which disturb the functions of various organ systems. In this way such activities as digestion, respiration, and circulation may at first show signs and evoke symptoms of functional distress; later, if nothing is done to alleviate the disturbed situation, organic disease may follow.
Many researchers are concerned with the study of specific emotional conflicts and personality organizations as they relate to particular organic syndromes. For example, the cardiovascular responses intimately linked with rage seem to be related to essential hypertension, in which inhibited expression of rage is found to be a crucial conflict (Alexander 1939a; 1939b; Saul 1939). Dependent help-seeking tendencies seem to have a close relationship to gastrointestinal activity, as is found in many duodenal ulcer patients (Alexander 1947; Alexander et al. 1934; Van der Heide 1940).
The psychosomatic concept. Although the clinical and experimental study of the mind-body relationship is a comparatively recent development in medicine, the concept is one that dates back to antiquity. The term “psychosomatic“was first used by Johann Christian August Heinroth (1818, part 2, paragraph 313, p. 49), who regarded the body and soul as one, and madness as a disease of the entire being. Christian Friedrich Nasse stated in 1838: “The business of recognizing, preventing, and treating conditions of mental disorder rests upon the fundamental investigation of the simultaneously psychic and somatic activity of man. Here it finds its scientific support, from here on it gains light and learns the road“(in Overholser 1948, p. 231). This statement, echoing an ancient principle of the organism-as-a-whole, is still accepted as an operational concept.
For clarification, one must differentiate the psychosomatic approach, process, disorders, and illnesses. Many reactions, disorders, or illnesses cannot be fully understood unless the investigator can understand the individual’s total situation. The psychosomatic approach includes both the philosophical orientation to the whole individual and the methodological means of getting data in order to assess reactions to present and past stresses. It attempts to obtain the data—genetic, physical, psychological, and sociocultural—necessary to interpret the forces affecting the life of the individual. The investigator uses varied techniques of data gathering, including interviews, tests, clinical examinations, and laboratory studies.
The psychosomatic process refers to that temporal sequential chain of events which occurs in the individual. The end result may be a transitory functional, physiological, and emotional response (psychosomatic disorder) that does not result in alteration of the basic organic structure of the individual, or the end result may be a particular syndrome that shows temporary or permanent organic changes (psychosomatic illness or disease).
Psychosomatic medicine has come into general clinical use with the reintroduction of the word “psychosomatic“by Felix Deutsch, Viktor von Weiz-sacker, Helen Flanders Dunbar, Franz Alexander, and others, all of whom stressed the necessity for considering the individual in his totality, and not just as a composite of separate entities and organs (e.g., mind-body).
Deutsch introduced the psychosomatic concept into psychoanalysis by recognizing the influence of repressed emotional conflicts and the unconscious on the functioning of an organ. Deutsch explained that psychosomatic symptoms are the end products of long-existing psychic dynamic processes that always have their origins in past disorders. He demonstrated that the dysfunction of the organic process disappears when unconscious conflicts are made conscious. He defined psychosomatic medicine as the “systematized knowledge of how to study and treat organ processes that are associated and amalgamated with the emotional processes.“Deutsch (1964) postulated that the dissolution of psychosomatic symptoms always requires treatment not of the symptoms but of the underlying illness, including the unconscious psychic conflict associated with it.
In the instance of psychosomatic disorders, the notion of a single cause for each disturbance is no longer tenable; in each patient many factors—acting singly or in combination—play significant roles. The psychosomatic approach seeks to identify and understand these variables, their relationships, and their specific contributions toward upsetting the state of equilibrium.
Homeostasis. The essential feature of homeo-stasis is the tendency to maintain a steady state or a state of equilibrium at a given time. Homeostasis is a property of psychological, emotional, and physiological processes, and involves the interplay of various mechanisms. The organism has a constant internal environment, first conceptualized by Claude Bernard, as well as an external environment. Since organisms are functionally indivisible, they cannot be split into the conventional compartments that reflect categories of specialization. Organism and environment form an inseparable pair in dynamic equilibrium. The biological internal environment is the result of natural selection and evolutionary processes. The psychological internal environment, aside from its biological substratum, is the product of the individual’s personality development and reflects the sociocultural milieu in which he lives. Although the psychological predisposition to particular patterns of stress reactions may result in part from this psychogenetic developmental process, adaptation may allow various forms of stress and tension to be handled by means of different defense or coping mechanisms and with different pathological results.
W. B. Cannon’s concept of homeostasis (1932) clearly emphasized the features of the organization of living systems whereby they tend to maintain themselves as functioning, complete organisms. His pioneering work on the relation of emotions to bodily changes set the theoretical and experimental stage for many of the later clinical and experimental studies in the field of psychosomatic medicine. [SeeHomeostasis; and the biography ofCannon.]
Stress, strain, and stimulus. Harold Wolff (1953) has considered stress as the internal or resisting force brought into action by external forces or loads. The change in size or shape of an entity as a result of the application of external force is called strain or deformation. Stimuli or external environmental agents are loads; they may be static and sustained, repeated or of brief impact with high intensity. The interaction between external environment and organism is stress. Strain is the alteration or deformation in the organism that ensues. The magnitude of the deformation and the capacity of the organism to withstand the strain determine whether or not there will be re-establishment of homeostasis or a breakdown, with disruption, disorder, disease, and finally death.
Unlike Cannon, Wolff views affect and bodily changes not as being causally connected but as being separate manifestations of response to stimulus, tempered by previous experience. Bernard saw disease as the outcome of attempts at homeostasis in which adaptive responses to noxious forces, although appropriate in kind, are nonetheless deficient. Wolff suggests that as man is confronted by threats, especially those which involve his values and goals, he initiates responses inappropriate in kind as well as in magnitude. Such reactions, appropriate to one protective purpose, may be inappropriately used for another and can, when inappropriate, be damaging or destructive to the individual.
Threats and symbols of danger may call forth emotional and physiological reactions which in vulnerable individuals differ little from the responses to actual physical assault. Freud first called attention to the signal function of anxiety as an internal reaction to such internal or external dangers. Thus, the stress response resulting from a situation (load) is based in part on the way the affected person perceives the stimulus and the conflict it then sets in motion. Perception and the subsequent interpretation of what is perceived may be dependent upon many factors, including genetically determined responsivity, basic needs and longings, conditioning experiences during formative years, parental and sibling relationships, and identification patterns, as well as other experiences having familial and sociocultural determinants. [SeeAnxiety.]
Stress disorders can be expressed psychologically and physiologically. The human organism reacts actively to stress in life situations. The proneness to stress response, the sensitivity and level of threshold, and the specific mode of response are the end products of many factors. Freud described this continuum of factors from the biological to the emotional and sociocultural as a “complementary series.“The group of illnesses in which stress seems to be a principal factor has been called stress disorders, in order to avoid using the term “psychosomatic.“The form of mental and bodily response is determined by the biological diathesis, the personality pattern, and the character of the situation. When the source of the stress is outside of conscious awareness, or when action is blocked by inner censorship or outward restraints, disharmony or a nonhomeostatic state results, and symptoms of illness appear. It must be noted that stress is the reaction inside the organism, not the force acting on it from the outside. Thus, the inner psychological and physiological dynamics and economics of the individual, as well as the prior and current social and cultural factors, seem to be significant. There are complex intrapsychic phenomena behind every illness, as well as metabolic, physiological, and even anatomical alterations. These may relate to underlying unconscious fantasies as well as to the emotional significance that different parts of the body and their functions have for the patient. They may be regressions under stress to earlier modes of operation or reflective of earlier fixations. [SeeStress.]
While clinical impressions suggest that there is a specific relation between the psychological stress and the physical disorder that follows, it is not clear how this transformation occurs. The World Health Organization report on psychosomatic disorders (1964, p. 9) summarizes the prevailing ideas on the sequence of involvement as follows:
(a) constitutional predisposition based on heredity;
(b) constitutional predisposition laid down as a result of early experience and development (both physiological and psychological experience, and the prenatal period as well as infancy, are included here);
(c) personality changes of later life that affect organ systems;
(d) the weakening of an organ, as by an injury or infection;
(e) the fact that an organ is in action at the moment of strain or emotional upheaval;
(f) the symbolic meaning of the organ in the personality system of the individual;
(g) organ-fixation as a result of arrested psychological development.
Empirical, clinical, demographic, and laboratory experimental research involving man and other animals has investigated the effects of psychological stress in symptom-free subjects, as well as in patients suffering from such diseases as duodenal ulcer, ulcerative colitis, bronchial asthma, neuro-dermatitis, thyrotoxicosis, essential hypertension, rheumatoid arthritis, diabetes mellitus, glaucoma, migraine, and coronary heart disease. Clinical studies of human patients have revealed the temporal relation between the onset and the exacerbation of the patient’s disease with characteristic emotional upsets. When such patients were treated intensively, e.g., with psychoanalysis, and over a long period of time, much information was obtained, and higher-level abstractions could be formulated for the psychological patterns observed. Some of these empirical clinical studies were published in a volume by Alexander and his associates (1948).
The differentiability of the formulations for seven of these diseases is discussed in Psychosomatic Specificity (1968). In one such study, two matched teams of psychoanalysts and internists studied identical interview protocols obtained from patients having one of seven diseases (peptic ulcer, ulcerative colitis, bronchial asthma, neurodermatitis, essential hypertension, rheumatoid arthritis, or thyrotoxicosis). These interviews, carefully edited to remove all possible references or cues to the disease of the patient, were evaluated by the two groups from the point of view of formulation and diagnosis of the disease. From the primary clinical information, formulations were prepared which were to explain how psychosocial and emotional conditions predisposed, precipitated, and perpetuated the disease. These comparative diagnoses (by analysts and internists) were statistically evaluated and compared. The results indicate that by and large it was possible to distinguish most of the seven diseases correctly on the basis of psychological abstractions. These abstractions had earlier been derived from the empirical observations of patients seen diagnostically or for therapeutic purposes. These formulations are now being tested by additional studies of families of patients who have psychosomatic diseases, by studying children who have psychosomatic diseases, by detailed investigation of the therapeutic interactions of patients with these illnesses, and by newer laboratory and experimental researches utilizing artificial stresses, such as films, and recording physiological and psychological data following exposure to the conflict situations.
Experimental studies of patients and control groups have been able to reproduce and verify some aspects of the relation between emotional stimuli and the pathophysiological changes of particular diseases. Such studies do not, however, demonstrate pathogenesis in the total etiological sense. What they do show is that particular emotional stresses in sensitive, vulnerable, and predisposed individuals may activate pathophysiological mechanisms which can eventually give rise to anatomical alteration and, thence, to characteristic patterns of disease syndromes. (See Alexander 1950 for discussion of such specific studies.) The precipitating or aggravating situations have specific emotional meaning for the patient because of their connection to his earlier life experiences, his personality development and structure, and his unresolved conflicts that may have been compensatorily handled in various ways until the external situation resulted in too great a stress, with a resulting internal disequilibrium. In this regard, one must recognize that decompensation of adaptive mechanisms may result from too great external demands that cannot be successfully mediated internally, or from a breakdown or weakening of internal control or integrating mechanisms, making the individual more susceptible to disequilibrium effects.
Three major developments occurred early in the twentieth century: the monumental discoveries and theories of Sigmund Freud; the classic and basic physiological and neurophysiological experiments and theories of Walter Cannon; and Ivan Pavlov’s research and studies of conditioned reflexes. Contributions were made to the psychosomatic field at two theoretical levels: the first sought to construct general theories and to derive universal principles and concepts, while the second dealt with theories related to studies of particular diseases in which psychosomatic stress is of major significance. Research has continued in both areas. The second level of somewhat limited theory formation offers an opportunity for testing the explanatory aspects of more general and universal theories of psychosomatic functioning. The psychoanalytic and physiological contributions will be discussed here in fuller detail. [SeeLearning, article onClassical Conditioning; and the biography ofPavlov.]
Psychoanalysis contributed to the understanding of psychosomatic relationships by providing a procedure—free association—which made it possible to study sequences connecting psychological and physiological phenomena. It included the previously undiscovered linkage of unconscious ideas. In addition to improved observation and data gathering, psychoanalytic theory provided a plausible means of reasoning and of understanding previously unintelligible and irrational phenomena, such as dreams and neurotic symptoms. The psychoanalytic method not only permitted the reconstruction of unconscious motivational links and conflicts, but also allowed them to be brought to consciousness and, thus, to be used therapeutically.
Freud’s discovery of unconscious mental phenomena and the process of repression threw new light on many bodily expressions of mental phenomena. These mental tensions can be discharged somatically into (1) muscular activities leading to a change of the body in relation to its environment; (2) laughter, crying, screaming, or speech; (3) respiratory, cardiovascular, and other visceral systems. The end effects of these modes of discharge are subjectively experienced as feelings, affects, or emotions. Affects and emotions can be repressed and then are no longer experienced as such, although the processes discharging them into specific somatic systems can still occur. In his study of the unconscious, Freud discovered that strongly charged but repressed fantasies, conflicts, and memories found distorted expression in somatic symptoms and in impairments of somatic functions. It was discovered that these symptoms were expressions, in symbolic body language, of psychological conflicts. They were called “conversion symptoms“: the conflict was “converted“from a purely psychological one into a disorder manifesting itself primarily through somatic symptoms which had no organic pathological correlate. Thus one could see hysterical paralysis, hysterical amnesia, hysterical vomiting, etc. [SeeHysteria.]
According to Freud, the physiological manifestations of anxiety have a psychological meaning. In his early works he wrote that they consist of a repetition of the physiological manifestations which occurred at the time of the individual’s birth. In later writings Freud likened anxiety to a signal used to alert the individual to danger from either internal or external sources. Thus, later threats to survival would evoke physiological responses which occurred in the earliest stress situation, the birth process. [See the biography ofRank.]
Hysterical conversion symptoms should not be called psychosomatic disorders, for they do not result in pathological organic processes or lesions, even though they involve the body. They can, however, result in secondary organic disturbances. For example, if a hysterical paralysis of the arms or legs persists, there will be progressive atrophy of the involved limbs because of muscular inactivity.
At its outset psychoanalysis had only a single aim, that of understanding something of the nature of what were then known as the “functional“nervous diseases. The neurologists, with their high respect for physiochemical and anatomical-pathological facts, sought further to establish an intimate and possibly exclusive connection between certain functions and particular parts of the brain. They were puzzled by the psychical factor and did not seem to understand it. In fact, it was believed unscientific to consider these phenomena without neurological explorations. As late as 1885, when Freud was studying at the Salpetriere, he found that hysterical paralyses were explained by slight functional disturbances of the same parts of the brain which, when severely damaged, led to the corresponding organic paralyses.
In the 1880s, hypnotism provided convincing proof that striking somatic changes could be brought about solely by mental influences which had been set in motion by the patient and were “unconscious“processes. Hypnosis played an important role in Freud’s study of hysteria. Charcot’s experiments greatly impressed him, especially when Charcot, by suggesting a trauma under hypnosis, was able artificially to induce paralyses. Charcot’s pupil Pierre Janet was able to show, with the help of hypnosis, that the symptoms of hysteria depended on certain unconscious thoughts (idees fixes). Janet attributed to hysteria a supposed constitutional incapacity for holding mental processes together—an incapacity which led to a disintegration (dissociation) of mental life. [SeeHypnosis; and the biographies ofChakcotandJanet.]
Josef Breuer was the first to study and treat hysteria with hypnosis. His work with a young woman patient made it possible for the first time to obtain a more complete view of a case of hysteria, see the meanings of the symptoms, and note that these symptoms arose in a situation of mental conflict: an impulse toward action had been suppressed because of contrary moral prohibitions, and symptoms appeared in place of the suppressed action. The patient’s emotions, involved in a psychic conflict, precipitated the illness, although the traumatic precipitating causes and all the mental impulses relating to them were lost to the patient’s memory. Under hypnosis, memories were recovered and, with the subsequent catharsis of affect, the symptoms disappeared.
Breuer and Freud (1893-1895) stated that in hysteria, blocked affect was changed into an unusual somatic innervation (conversion) and resulted in symptoms. Soon after this publication, Breuer and Freud parted, and Freud went on to develop psychoanalysis. He gave up hypnosis for free association and developed his theories of resistance, transference, repression, mental conflict, unconscious mental functioning, and the nature and development of sexual and aggressive drives, including the importance of infantile sexuality.
Freud also suggested that hypochondria and somatic delusions, and their relationship to the pathological return (regression) to an earlier state of psychological organization, are other clinical entities related to psychosomatic syndromes, even though no demonstrable organic pathology is noted in these disorders, as it is in the conversion hysterias. His descriptions and theories of pain and pleasure, and their relationship to feelings and emotions, provide us with an understanding of states of tension. His writings on anxiety and psychic trauma permit us to understand psychic disorganization, its manifestations, and its signal functions. Thus, from the nosological point of view, Freud introduced, described, and explained three clinical categories that are still important: conversion hysteria, anxiety states, and hypochondria and somatic delusions. His concept of the actual neuroses is also of importance, since it states that the buildup of tension and toxic products without discharge can affect the organism. Freud noted (1910) that not all somatic changes caused by psychological forces were conversions, just as not all physical symptoms were expressions of specific fantasies or conflict compromises. He pointed out that unconscious attitudes may influence organic functions in a physiological way, without the changes having any definite psychic meaning.
Although Freud did not directly address himself to the somatic aspect of affect, his student Karl Abraham wrote about various anatomical zonal correlates of personality (oral and anal stages), and Sandor Ferenczi dealt more directly with the relationship of emotion and mental functioning to organically demonstrable disease. Ferenczi described (1916) pathoneuroses that supervene as a consequence of actual organic illness or injury. Unlike hypochondria, where demonstrable changes in the organ are absent and have never been present at all, pathoneuroses are found in states of actual insult to bodily integrity. In 1922, Hollos and Ferenczi’s Psychoanalysis and the Psychic Disorder of General Paresis described psychological reactions following central nervous system syphilis. This diagnosis of pathoneurosis is now more generally used to describe the psychic reactions to organic diseases. Ferenczi also described transference manifestations, having psychosomatic implications, that clearly demonstrate Freud’s initial idea of fixation and temporary regression to an earlier state of physiological functioning induced by a current situation. [See the biographies ofAlexander; Ferenczi.]
Ferenczi also differentiated organ neuroses from conversion hysteria (1926). In the latter there are mainly symbolic and subjective disturbances involving the body, while in the former initially there are mainly objective and demonstrable difficulties affecting organ functioning. Ferenczi described nervous asthma, upper gastric disturbances, intestinal difficulties, cardiac disorders, headaches, fainting, and seasickness as organ neuroses. He noted that purely organic complaints may leave organ-neurotic disturbances behind after they have healed. These may be considered as “secondary gain“phenomena, a situation in which there are psychological advantages of a neurotic variety secondarily connected with the previously present but now absent organic disease.
Among other early psychoanalysts who pioneered in the psychosomatic field, Georg Groddeck (1923) saw purposive activity in all morbid afflictions. Thus, a cold was seen as the wish to avoid smelling, and gynecological disorders as the unconscious wish for chastity. Groddeck’s theory is perhaps the most extreme representative of a panpsychological orientation. He introduced the term Es (”id“or “it“) as the unconscious formative principle of all normal and abnormal bodily processes. The early writings of Deutsch also indicate the application of Freud’s concept of conversion to all dysfunctions of the body. Smith Ely Jelliffe in the United States also attempted to explain all psychosomatic phenomena as direct expressions of highly specific repressed ideas or fantasies (1939). His work, based on careful clinical studies, began as early as 1916, when he first published a paper on psoriasis. Subsequently he and his associates wrote about psychological aspects of tuberculosis, multiple sclerosis, epilepsy, bone disease, postencephalic disorders, endocrinopathics, and eye disorders. Jelliffe was the first American scientist to apply psychoanalytic concepts to organic diseases.
Early investigators did not distinguish between (a) hysterical conversions based on changes in sensory organs or organs under voluntary nervous control (Freud’s view) and (b) changes in internal vegetative organs which are involved with basic visceral functions and are not involved in expressing details of psychological content and in the communication of ideas, thoughts, and feelings. The vocal apparatus, facial expressions, weeping, laughter, blushing, and motor actions discharge and express specific emotional tensions. The internal organs are involved with various bodily processes involving digestion, respiration, circulation, endocrinology, integration, etc. The heart can only beat, the stomach secrete, the bowels contract, the blood vessels constrict or dilate. Although these internal organs respond to emotions, the range of their reactions is limited. Internal organs do not react to specific repressed ideas such as those which underlie hysterical symptoms, but to general emotional states. Neither do these processes, as is true of conversion symptoms, discharge tensions; instead, they are sustained by them.
Alexander made the important distinction between hysterical conversion symptoms and adaptive changes in vegetative functions stimulated by emotional tensions. His ideas followed the concepts of Cannon, who related emotional states, such as fear and rage, to consequent activated physiological functions involving the digestive, endocrine, and cardiovascular systems.
Interest in psychological factors in organic disease became noticeable in Germany after World War i; the work of Leopold Alkan (1930) is especially noteworthy. He indicated that psychogenic disturbances within the autonomic nervous system may result finally in organic changes, the morphological mechanisms of which form the last link of an intricate causal chain. He postulated that intrapsychic conflicts may be expressed somatically and can result in organic disease which is not reversible.
Karl Fahrenkamp demonstrated the influence of emotions on fluctuations of blood pressure and presented a strong case for the psychogenic origin of essential hypertension (1926). Viktor von Weiz-sacker, strongly influenced by Freudian views, emphasized the influence of emotions upon bodily disturbances and of bodily disease upon the psyche (1925; 1925/1926; 1926; 1933). His clinical presentations demonstrated the emotional components and antecedents of bodily disease. Bergmann (1913a; 1913b) and Westphal (1914) suggested the neurotic origin of duodenal ulcers.
Much research in psychosomatic phenomena has also been carried out within the framework of conditioning theory. Animal studies of psychosomatic disturbances are now on the increase, and there has been considerable study of conditioning of biological functions in humans (e.g., Hofer & Hinkle 1964; Moutsos etal. 1964).
Much interest has been shown in patterns of autonomic responses in normal persons and in patients suffering from psychosomatic disorders, at rest and under stress. Stress can be induced through hypnotic suggestion, interviews, “staged“situations, various test situations—including movies —and by total or partial perceptual isolation. Its effects can be assessed. Physiological variables studied include skin potential, skin temperature, finger pulse volume, cardiac and respiratory rates, blood pressure, and muscle activity. Individual differences in various emotional states, and differences between various psychosomatic disorders, have been reported.
Conditioning experiments demonstrating the effects of anxiety have been carried out on humans and animals (see Dykman et al. 1962; Edwards & Acker 1962; Moss & Edwards 1964; Porter et al. 1958). Predictive studies on the relationship between ovarian activity and psychological processes have been made by Benedek and Rubenstein (1942); on the relationship between emotional states and thyroid function by Dongier and his colleagues (1956); on the etiology of peptic ulcer by Mirsky and his colleagues (1952) and Weiner and his colleagues (1957); and on the appearance of bronchial asthmatic symptoms by Knapp (1963).
Cultural studies indicate that with the extension of Western civilization into rural areas little touched by such acculturation, there is a rising frequency of psychosomatic disturbances (e.g., Collomb 1964; Yap 1951). Contrary evidence has appeared about the existence of culture-specific factors determining the choice of symptoms and of disease.
George H. Pollock
[Directly related are the entriesHysteria; Mental Disorders, article onBiological Aspects; Pain; Stress. Other relevant material may be found inEmotion; Gestalt Theory; Illness; Psychiatry; Psychoanalysis; and in the biographies ofAlexander; Freud.]
Alexander, Fkanz 1939a Emotional Factors in Essential Hypertension. Psychosomatic Medicine 1:173-179.
Alexander, Franz 1939b Psychoanalytic Study of a Case of Essential Hypertension. Psychosomatic Medicine 1:139-152.
Alexander, Franz 1947 Treatment of a Case of Peptic Ulcer and Personality Disorder. Psychosomatic Medicine 9:320-330.
Alexander, Franz 1950 Psychosomatic Medicine: Its Principles and Applications. New York: Norton.
Alexander, Franz et al. 1934 The Influence of Psychological Factors Upon Gastro-intestinal Disturbances: A Symposium. Psychoanalytic Quarterly 3:501-588.
Alexander, Franz et al. 1948 Studies in Psychosomatic Medicine: An Approach to the Cause and Treatment of Vegetative Disturbances. New York: Ronald Press.
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Deutsch, Felix 1964 Training in Psychosomatic Medicine. Advances in Psychosomatic Medicine 4:35-46.
Dongier, M. et al. 1956 Psychophysiological Studies in Thyroid Function. Psychosomatic Medicine 18:310-323.
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Dunbar, Helen Flanders 1943 Psychosomatic Diagnosis. New York: Hoeber.
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Dunbar, Helen Flanders 1948 Synopsis of Psychosomatic Diagnosis and Treatment. St. Louis, Mo.: Mosby.
Dunbar, Helen Flanders 1959 Psychiatry in the Medical Specialties. New York: McGraw-Hill.
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Grinker, Roy R. 1953 Psychosomatic Research. New York: Norton.
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Hofer, Myron A.; and Hinkle, Lawrence E. Jr. 1964 Conditioned Diuresis in Man: Effects of Altered Environment, Subjective State and Conditioning Experience. Psychosomatic Medicine 26:108-124.
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Jelliffe, Smith E. 1939 Sketches in Psychosomatic Medicine. Nervous and Mental Disease Monograph No. 65. New York: Nervous and Mental Disease Monograph Publishing.
Knapp, P. H. 1963 Short-term Psychoanalytic and Psychosomatic Predictions. Journal of the American Psychoanalytic Association 11:245-280.
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Massachusetts General Hospital, Boston, Psychiatric Service 1952 Case Histories in Psychosomatic Medicine. Edited by H. H. W. Miles, Stanley Cobb, and Harley C. Shands. New York: Norton.
Mental Health Research Fund, Conference, Second, Oxford, 1958 1960 Stress and Psychiatric Disorder: The Proceedings. Edited by J. M. Tanner. Oxford: Blackwell.
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Psychosomatic medicine is the study, diagnosis, and treatment of physical health conditions that stem from emotional problems. It emphasizes the unity of the mind and body in health and medicine. Many physicians believe understanding the psychological causes of illnesses is a key in understanding and treating the physical symptoms of the illnesses themselves.
Throughout recorded history, people are said to have been cured of diseases by various mystical practices, such as incantation, prayer, the laying on of hands, and other rituals. It is unclear exactly when medical practitioners made a connection between the mind and certain diseases, although records show that it dates back to at least the 1700s.
In 1774, German physician Franz Anton Mesmer (1734–1815) applied a scientific basis for mysticism when he waved magnets over some patients to cure them. He later discovered the magnets were not needed and he could get the same results by passing his hands over some patients. He called his technique "animal magnetism," and said it was based on the principle that illnesses occur when the body's flow of natural electromagnetic energy becomes blocked. He opened a practice in Vienna, Austria, and later went to Paris, where he lived and worked for six years, using magnetism and hypnosis to treat illnesses. He was eventually driven out of both cities and labeled a "quack" since his techniques did not always work.
Mesmer's work was studied by American scientist and statesman Benjamin Franklin (1706–1790) and French chemist Antoine Lavoisier (1743–1794), who became famous for isolating oxygen. Both spent years duplicating Mesmer's work, but with no successful results. However, the research led Franklin to conclude that the mind does have an influence over physical ailments; that in some patients, the belief that they will be cured actually cures them.
Further research into psychosomatic medicine was conducted by Austrian psychologist Sigmund Freud (1856–1939) in the late 1800s. Research continued, and by the 1960s the field had gained respect by the general medical community. Today, biofeedback , hypnosis, prayer, and humor are considered legitimate facets of psychosomatic medicine.
The primary benefit of psychosomatic medicine is that it does not involve drugs, surgery, or other invasive treatments. It is also greatly beneficial in conditions created by the mind rather than a physical condition. In addition, in psychosomatic medicine, the patient has the greatest ability to control the healing process through various positive thinking techniques.
In tne April 2002 issue of Managed Healthcare Executive, Dr. David Sobel, director of Patient Education and Health Promotions for Kaiser Permanente's Northern California region, explained that one of the first things he noticed when he started practicing medicine is that a large number of his patients had problems that could not be explained by conventional medical and diagnostic techniques. He said that, "Up to 20% possess diagnosable psychiatric disorders but even more impressive is that upwards of 80% of the patients will be suffering significant levels of psychosocial distress." He went on to say "distress often expresses itself through physical or bodily symptoms … if not causing the symptoms, then certainly exacerbating them." He calls the condition a deficiency of mind-body regulation.
To address this, Kaiser Permanente developed a mind-body core program that includes teaching patients how to relax, manage stress , communicate more effectively, and think more positively.
There is no preparation needed to undergo psychosomatic treatment, other than a willingness to believe it may be effective.
Patients should be wary of psychosomatic practitioners who do not have degrees in medicine or psychology, or specialized training in either field. Some patients may also need conventional medical care or a combination of conventional and psychosomatic therapies.
There are no known serious side effects of psychosomatic treatment in patients deemed suitable for the treatment by a qualified medical practitioner.
Research & general acceptance
A study published in 2002 by researchers at the Carnegie Mellon University Department of Psychology found that people with positive emotions were less likely to catch the common cold . A study by the University of California at San Francisco, published in 2002, reported that people with AIDS who had a positive attitude had a lower death rate from AIDS-related complications.
A Canadian study published in 2002 showed that people with breast or prostate cancer , who meditated and practiced yoga regularly, had an enhanced quality of life and reduced stress regarding their illness. A study published in 2000 by the Center for Health and Aging Studies at Maharishi University of Management in Fairfield, Iowa, showed that people who practiced Transcendental Meditation significantly reduced their cholesterol levels. Meditation also improved brain and immune system functions of patients in a study by several universities, which was published in 2003.
Training & certification
Many colleges and universities have psychosomatic medicine departments or training programs for certification. Practitioners usually are certified physicians or psychiatrists, but can also be other medical professionals, such as psychologists and nurses. However, practitioners can also include those with no medical training, such as hypnotists, counselors, ministers, and yoga and meditation instructors.
Dreher, Henry. Mind-Body Unity: A New Vision for Mind&-Body Science and Medicine. Baltimore, MD: John Hopkins University Press, 2004.
Ramos, Denise. The Psyche of the Body: A Jungian Paradigm in the Understanding of the Psyche-Body Phenomenon. London, England: Brunner-Routledge, 2004.
Scarf, Maggie. Secrets, Lies, Betrayals: The Body/Mind Connection. New York, NY: Random House, 2004.
Taylor, Graeme J. Psychosomatic Medicine and Contemporary Psychoanalysis (Stress and Health Series, Monograph 3). Guilford, CT: International Universities Press, 1987.
Ullman, Dana. The One Minute (or So) Healer: 500 Simple Ways to Heal Yourself Naturally. Berkeley, CA: North Atlantic Books, 2004.
Carlson, Linda E., et al. "Mindfulness-Based Stress Reduction in Relation to Quality of Life, Mood, Symptoms of Stress, and Immune Parameters in Breast and Prostate Cancer Outpatients." Psychosomatic Medicine (July-August 2003): 571–81.
Cohen, Sheldon, et al. "Emotional Style and Susceptibility to the Common Cold." Psychosomatic Medicine (July-August 2003): 652–7.
Davidson, Richard J., et al. "Alterations in Brain and Immune Function Produced by Mindfulness Meditation." Psychosomatic Medicine (July-August 2003): 564–70.
Jesitus, John. "Mind+Body Medicine: Putting Mind Over Health Matters." Managed Healthcare Executive (April 2002): 33–6.
Kroenke, Kurt. "Psychological Medicine: Integrating Psychological Care into General Medicine Practice." British Medical Journal (June 29, 2002): 1536–8.
Moskowitz, Judith Tedlie. "Positive Affect Predicts Lower Risk of AIDS Mortality" Psychosomatic Medicine (July-August 2003): 620–6.
Schneifer, R.H., et al. "Lower Lipid Peroxide Levels in Practitioners of the Transcendental Meditation Program." Psychosomatic Medicine (January-February 1998): 38–41.
American Psychosomatic Society. 6728 Old McLean Village Drive, McLean, VA 22101. (703) 556-9222. <http://www.psychosomatic.org>.
Association for Psychosomatic Medicine. 4560 Delafield Ave., Bronx, NY 10471-3905. <http://www.theamp.org>.
"Psychosomatic Medicine: The Puzzling Leap." National Library of Medicine. History of Medicine Division. Emotions and Disease [cited May 29, 2004] <http://www.nlm.nih.gov/hmd/emotions/psychosomatic.html>.
Ken R. Wells
It is difficult to provide an exact definition of psychosomatics. To some extent the term itself already indicates a theoretical bias. It joins together the normal or pathological dynamics of both mental and somatic structures and assumes their close interaction. According to Pierre Marty, psychosomatics is the clinical observation of individual mental or somatic organization, disorganization, and reorganization, the attempt to draw from those observations theoretical findings, and the practical application of those findings to the therapeutic situation. If considerably broadened, psychosomatics would involve a global understanding of what it is to be human.
The term psychosomatics appeared in 1818 in the work of J. C. H. Heinroth, a German psychiatrist, and reflects a naturalist and vitalist approach to medicine. The context was formalized in 1945 by British psychologist James L. Halliday. The word has been in use since then among a wide range of practitioners, often with different interests. In the United States it is often referred to as psychosomatic medicine.
Prior to these developments, the interaction of psyché and soma, both within and beyond the context of philosophy and religion, reflected a vague association of the term with organic disease. It has been said (Kamieniecki) that "the history of medicine has written the prehistory of psychosomatics." This prehistory has gradually distinguished psychosomatic medicine, in various socio-cultural contexts, from its philosophical, mystical, and religious corollaries, the Corpus Hippocraticum being a good example. Since then there has been a continued effort to identify the links between "the ontological unity of being and the phenomenological duality of its operation."
This project, which has become for some researchers an original and fundamental discipline, can be considered part of a psychoanalytic framework, for it "consists in subjecting the somatic to the same dynamic and the energic considerations that govern the life of individuals undergoing analysis," according to the authors of L'investigation psychosomatique (Psychosomatic investigations; Marty, M'Uzan, and David). It must be noted that this project has generated no consensus, since it is a matter of applying these principles to the field of organic disease from the standpoint of psychoanalysis, a concept that has its detractors. Psychosomatics relates to the human individual in its concrete being, living and sexual, acting through its own body and mental organization—including the conflict within the individual movements between life and death (Marty)—and where illness is an incarnation of the logic governing the living being.
In the area of organic disease, where research in psychosomatics has been directed, what has been referred to as the "psychosomatic phenomenon," the interaction of psyché and soma, remains problematic and has led to numerous claims that have further confused the concept: psychogenesis, generalized conversion, somatization, and so on, not all of which have the same heuristic value. Somatization, seen as the result of a process in which mental causality (in the broad sense) plays a role, has become a doctrine for some. However, the real problem and focus of interest for the psychosomatic psychoanalyst, aside from any reactive mental disturbances, remains the discovery of a process for understanding and interpreting the reality of the disease, any possible exacerbation, and its resurgence in times of crisis. This entails the question of causal factors, while at the same time giving medical factors their due. It therefore includes the notion of a possible psychic causality that would interweave two histories of pathological alteration that belong to different orders but whose interactions are not purely random. When the two fields do not interact, there is no psychosomatic phenomenon, only the evolution of somatic morbidity along biological lines. The possible psychic causes remain an open question; these may be neither necessary nor sufficient but cannot be overlooked, even if we do not believe in psychogenesis or a limited determinism, and even if we feel that the "constructed meaning" of a symptom is not the cause or the origin of the disturbance.
Freud was not overly concerned with a strictly psychosomatic approach to disease, but in 1923 he wrote, "According to the indications of some analysts, the psychoanalytic treatment of obvious organic disturbances is not without a future, since it is not unusual for a psychic factor to play a role in the genesis and persistence of these affections" (1923a ). The libidinal organization points to the somatic as a source; the description of actual neurosis and its underlying hypotheses (for some this is related to the so-called process of somatization); the idea of libidinal stasis identified in the organic disease; and the emergence of the id (the term originates with Groddeck, a precursor of psychosomatics according to some authors)—all these theoretical hypotheses, after being reworked, have led to the conclusion that Freud was also a pioneer in this field.
More recent interest in psychosomatics can be traced to the investigations of the American researchers Helen Flanders Dunbar and especially Franz Alexander during the 1940s. Their work helped develop later research and elements of it can be found, in modified form, among psychosomaticians and clinical psychologists. The so-called New York School (Dunbar) was associated with the culturalist movement of the time. They related organic pathology to pre-morbid "personality profiles," specific to certain clinical symptoms: the structure of the personality would expose a specific part of the organism to external aggression and would prepare the way for somatization. Dunbar also hypothesized an emotional dynamic, derived from Darwin, who assigned a defensive goal to the emotions, coupled with the affective repercussions within the body itself. Dunbar was one of the first to take a neovitalist approach—the degradation of vital energy—to developing an understanding of psychosomatics. For him, the exclusion of conflict outside consciousness would result from a short-circuiting of the mental (though he does not use this word), through subcortical mechanisms. This school of thinking concluded that psychoanalysis alone would provide a deeper understanding of the processes in question.
Franz Alexander believed that the personality profile alone was not sufficient to determine causality. He centered his hypotheses on the notion of a "specific psychodynamic constellation." This constellation was based on basic reactions that ensued following an increase in tension within the psychic apparatus, reactions that encompassed the autonomic nervous system and the subcortical stem, along with basic dispositional characteristics. The idea of psychosomatic medicine (the title of his first book) was both established and subject to criticism because of its over-reliance on biology. But internal conflicts and emotional reactions culminating in physical changes also played a role. This sequence led to the concept of "organ neurosis," corresponding to the abnormal stagnation of a quantity of energy in an organ or system. These connections between affective states and somatic behaviors resulted in "psychosomatic patterns" that, from functional disturbances, could produce organic symptoms. One finds in his work profound intuitions that have contributed to contemporary theory in spite of his overly biological approach and pertinent suspicion about the concept of organodynamics, a concept picked up by Henri Ey.
During the 1960s, two approaches to psychosomatics appeared in France. These were the sources of a number of subsequent developments that altered, weakened, and expanded certain hypotheses, and modified the clinical and therapeutic approach to the field. Jean-Paul Valabrega promoted an approach to somatic symptoms through a model of generalized conversion isolation, whose rediscovered source in fantasy would give meaning to the symptom. For Valabrega the isolation of the conversion phenomenon from its source and its specifically hysterical environment resulted in the development of manifestly visceral symbolizations, which originated in conversion phenomena and were unexplained by reference to a hysterical kernel common to all neuroses. In this context of "psychosomatic conversion," Valabrega insisted on the resurgence of the fantasy at the very site from which it had been expelled, a hypothesis associated with the general problem of the accessibility of the symptom to symbolization and meaning. The psychosomatic symptom was said to constitute a physical barrier that had to be crossed by separating it from its hidden fantasy elements, which had been kept in check. "In other words, according to the hierarchical etiology, the specificity is defined less by physiopathological or psychopathological mechanisms than by the singular mode of organization which underlies both mechanisms" (1966/1974).
In 1963, the so-called psychosomatic school of Paris (Pierre Marty, Michel de M'Uzan, Christian David, Michel Fain) formalized its approach, based on the notion of deficit, where a mental loss (fantasy, oneiric, associative, the loss of mental defenses) was seen as paradigmatic. This concept meshed satisfactorily with the findings of psychoanalysis, especially in the area of psychic economy, where the somatic symptom is asymbolic and does not produce meaning. Their approach gave rise to a number of developments. After Pierre Marty introduced the concept of operative thought, other clinical concepts emerged, such as essential depression and chronic disorganization, and Marty insisted on the reorganizing value of the regression/fixation system. The process of disorganization, triggered by trauma and incapable of stopping the regression/fixation system, became the crux of the "somatization process." However, regression can also be pathogenic and reversible illnesses are conceivable, in terms of points where disorganization is halted at various stages of somatic fixation. This model, based on monist, evolutionist, and neovitalist principles, and extensively described in Marty's writings, presents an internal coherence that has made it a classic, although not always accepted, reference in the field.
See also: Actual neurosis/defense neurosis; Alexander, Franz Gabriel; Groddeck, Georg Walther; Marty, Pierre; Psychogenesis/organogenesis; Psychosomatic limit/boundary; Somatic compliance.
Alexander, Franz. (1950). Psychosomatic medicine, its principles and applications. New York: Norton.
Kamieniecki, Hannah. (1994). Histoire de la psychosomatique. Paris: Presses Universitaires de France.
Marty, Pierre. (1990). La psychosomatique de l'adulte. Paris: Presses Universitaires de France.
Marty, Pierre, M'Uzan, Michel de, and David, Christian. (1963). L'Investigation psychosomatique. Paris: Presses Universitaires de France.
Valabrega, Jean-Paul. (1974). Problèmes de théorie psychosomatique. In Encyclopédie médico-chirurgicale: Psychiatrie. Paris: E.M.-C. (Original work published 1966)
Winnicott, Donald W. (1966). Psycho-somatic illness in its positive and negative aspects. International Journal of Psychoanalysis, 47, 510-516.
Western thinkers have grappled endlessly with these issues, positing shifting and historically-contingent theories of the mind–body relationship for centuries. The dichotomy between mind and body, which traces back to Plato's distinctions between transient materiality and transcendent truths, was reinforced by the Christian belief in the supremacy of spirit over flesh, and found its modern expression in Descartes' philosophical dualism, which confirmed and celebrated the autonomy of consciousness.
Indeed, Western medical thinkers have long been aware of the mind's influence over the body. Nevertheless, the idea that illnesses originate — and can be cured — in the mind first entered modern medicine around the late eighteenth century. Before this period, madness — or what we now call mental illness — had been considered a thing of the body, originating in disturbances of humours (bodily fluids), physiological processes, or nerves. As the physician George Cheyne colourfully noted in his 1733 opus, The English Malady:
I never saw a person labour under severe obstinate, and strong nervous complaints, but I always found at last, the stomach, guts, liver, spleen, mesentery, or some of the great and necessary organs or glands of the belly were obstructed, knotted, schirrous, spoiled or perhaps all these together.
A decisive turn from the body to the mind occurred just decades later. In 1789, the year of the Revolution in France, a British surgeon attributed insanity to the psyche, ‘independent and exclusive of every corporal, sympathetic, direct, or indirect excitement, or irritation whatever.’ This dictated a new focus on, in the words of the French alienist Esquirol, ‘the ideas, thoughts, [and] projects of the lunatic. Accompanying this change was a shift in therapeutic tactics and the rise of the ‘moral treatment’, a non-coercive, semi-psychotherapeutic, and often highly theatrical doctor–patient encounter meant to reveal the delusion or moral (read ‘mental’) flaw at the core of the disorder. This approach was made most famous, perhaps, by the treatment of George III by the English physician Francis Willis.
But the path from the moral treatment to the therapist's couch was long and twisted. Mid-nineteenth-century doctors, seeking to elevate the status of the care of the insane, pinned their hopes on science and showed decreasing tolerance for these moral cures. By the end of the century, the new field of scientific psychiatry had established itself at the university, spawned numerous professional journals, and reverted, in a sense, from the mind to the brain. New research technologies and clinical facilities furthered attempts to localize behavioural anomalies in neuroanatomy, and new diagnostic systems subsumed mental illness to what the German neurologist Max Nonne called ‘the narrow straight-jacket of exact science’. As a result, therapeutic success suffered; there was, according to an asylum doctor in Posen, ‘an enormous blossoming of psychiatric literature alongside a low level of practical success. We know a lot and can do little.’
This late-nineteenth-century paradigm shift proved both incomplete and short-lived, collapsing under the weight of various medical and social forces. By the middle of World War I, a new, psychogenic view seemed to hold sway, as the tens of thousands of cases of ‘shell-shock’ — the tics, stuttering, shaking fits, and mutism so often observed among soldiers in the aftermath of explosions — were increasingly attributed to fear, anxiety, and memory, rather than any somatic mechanism. The wishes and fears produced in modern war, noted Nonne, ‘are of a previously unimaginable versatility.’
It was around this time that Freud and his followers first turned their attentions to mind–body disturbances. Freud had, of course, described the conversion of pathological ideas into hysterical symptoms already in the 1890s, but it was the ‘wild analyst’ Goerg Groddeck who first applied psychoanalysis to the treatment of specifically organic disorders. Groddeck's Baden-Baden sanatorium was soon supplemented by the clinic of the Berlin Psychoanalytic Institute under Max Eitingon and Ernst Simmel's Tegel sanatorium, all of which treated organic disturbances with psychoanalytic methods in the 1920s.
This brief sketch should suffice to show that today's belief in psychosomatic illness — a belief under siege by accumulating advances in genetics, biopsychiatry, and psychopharmacology — represents just one phase in a cyclical and fraught process. But even in its most ‘psychological’ phases, Western society seems to cling to distinctions between pain and suffering that is ‘real’ and maladies that lie ‘just in the mind’.
Shorter, E. (1992). From paralysis to fatigue: a history of psychosomatic illness in the modern era. New York.
Porter, R. (1995). Psychosomatic disorders: historical perspectives. In Treatment of functional somatic symptoms, (ed. R. Mayou, C. Bass, and M. Sharpe). Oxford.
See also mind-body interaction; nervousness.
psy·cho·so·mat·ic / ˌsīkōsəˈmatik/ • adj. (of a physical illness or other condition) caused or aggravated by a mental factor such as internal conflict or stress: her doctor was convinced that most of Edith's problems were psychosomatic. ∎ of or relating to the interaction of mind and body.DERIVATIVES: psy·cho·so·mat·i·cal·ly / -ik(ə)lē/ adv.
www.psychosomaticmedicine.org Website of the journal Psychosomatic Medicine