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No. 69 Mind & Body |
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 Modern psychosomatic medicine developed in the first half of the past century, even though the concept was introduced by Johann Christian Heinroth in 1818. It resulted from the confluence of two concepts with, as Lilian Furst has shown in the preceding article, an ancient tradition in Western thinking and medicine: the psychogenesis of disease and holism. The idea of psychogenesis characterized the first phase of the development of psychosomatic medicine (1930–1960), and resulted in the concept of “psychosomatic disease,” i.e. a physical illness, such as peptic ulcer, believed to be caused by psychological factors. Despite early criticism, the psychogenic postulate exerted considerable influence in view of its explanatory power, particularly in a field then dominated by psychoanalytic investigators. George Engel, Zbigniew Lipowski and David Kissen deserve credit for laying out, in the 1960s, the ground for the current psychosomatic view of disease.Engel developed a multifactorial model of illness, subsumed under the rubric of “biopsychosocial” [1]. In this model, illness is viewed as resulting from the interaction of mechanisms at the cellular, tissue, organismic, interpersonal and environmental levels. Accordingly, the study of every disease must take into account the individual, his or her body, and the surrounding environment as essential components of a total system. The various social factors involved may range from socioeconomic status (e.g. poverty, nutritional deprivation, loss of social support) to toxic environmental exposure, to give a truly ecological perspective. Psychosocial factors may operate to facilitate, sustain or modify the course of a disease, even though their relative weight may vary from illness to illness, from one individual to another and even between two different episodes of the same illness in the same individual. Susceptibility to disease may be influenced by activation of a variety of central nervous system pathways. The aim of such contemporary disciplines as psychoneuroendocrinology and psychoimmunology, which have evolved out of biopsychosocial research, is to unravel the complex balance and interaction between emotions and disease.Lipowski provided an invaluable contribution by setting the scope, mission and methods of psychosomatic medicine [2]. He criticized the obsolete notion of psychogenesis, since it was incompatible with the doctrine of multicausality, which constitutes a core postulate of current psychosomatic medicine.Kissen provided a better specification of the term “psychosomatic”: “It would appear possible for an illness generally thought of as being ‘psychosomatic’ to be ‘non-psychosomatic’ in certain individuals. Likewise an illness not generally thought as ‘psychosomatic’ may be psychosomatic in some individuals” [3]. He thus clarified that the relative weight of psychosocial factors may vary among individuals with the same illness and underscored the basic conceptual flaw of considering diseases as homogeneous entities. Instead of asking “Which psychological factors give rise to which illnesses?” Kissen suggested we should ask “Who are the patients within a given illness population for whom psychosocial variables are of primary significance?”Psychosomatic research has generated an impressive body of knowledge, with contributions published in all the major medical journals as well as those specifically dedicated to the field such as Psychosomatic Medicine, Psychosomatics, Psychotherapy and Psychosomatics and the Journal of Psychosomatic Research. As a result, psychosomatic medicine may now be defined as a comprehensive, interdisciplinary framework for: (1) the assessment of psychosocial factors affecting individual vulnerability, course and outcome of any type of disease; (2) the holistic consideration of patient care in clinical practice and (3) the specialist interventions to integrate psychological therapies in the prevention and treatment of medical disease and subsequent rehabilitation [4].Psychosomatic medicine has recently become a subspecialty recognized by the American Board of Medical Specialties. It is, by definition, multidisciplinary, is not confined to psychiatry and should concern all physicians.The assessment of psychosocial factors affecting individual vulnerability A number of factors modulate individual vulnerability to disease, among which early life events have been the subject of many studies. Using animal models, events such as premature separation from the mother have consistently resulted in the development of physiological vulnerability, such as increased hypothalamic-pituitary-adrenal (HPA) axis activation and prolactin secretion. In humans, such changes may render individuals more vulnerable to the effects of stress later in life.That meaningful events and situations in a person’s life may be followed by ill health has been a common clinical observation. The introduction of structured methods of data collection and control groups has substantiated the link between life events and a number of medical disorders, encompassing endocrine, cardiovascular, respiratory, gastrointestinal, autoimmune, skin and neoplastic disease. Within a multifactorial frame of reference, stressful life events may affect the regulatory mechanisms of neuroendocrine-immune functions in a number of ways.It is not only dramatic life changes, like bereavement or job loss, that are a source of psychological stress. Subtle and long-term life situations should not be too readily dismissed as minor and negligible, since chronic, daily life stresses may be appraised by an individual as taxing or exceeding his or her coping skills. McEwen and Stellar [5] formulated a relationship between stress and the processes leading to disease based on the concept of allostasis, the ability of an organism to achieve stability through change. Through allostasis, the autonomic nervous system, the HPA axis and the cardiovascular, metabolic and immune systems protect the body by responding to internal and external stress. An allostatic load is derived from chronic exposure to fluctuating or heightened neural or neuroendocrine responses resulting from repeated or chronic environmental challenges that an individual reacts to as being particularly stressful. Their model emphasizes the hidden cost of chronic stress on the body over long periods of time, the concomitant changes then acting as predisposing factors for disease. Biological measures of allostatic load, such as glycosylated proteins, coagulation/fibrinolysis markers and hormonal markers, have all been linked to poorer cognitive and physical functioning, as well as mortality.Although experienced individually, stress is inflected by its social context, and prospective population studies have found associations between measures of social support and mortality, psychiatric and physical morbidity and adjustment to and recovery from chronic disease. Interventions designed to alter the social environment and interpersonal relationships have been successful in facilitating psychosocial adjustment to medical disorders.Social context is also relevant to the concept of well-being. Positive health is often regarded as the absence of illness, despite the fact that, half a century ago, the World Health Organization defined health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [6]. Ryff and Synger [7] remark that, historically, health is equated with the absence of illness rather than the presence of wellness. Research on psychological well-being has indicated that it depends on the interaction of several intercorrelated dimensions and plays a buffering role in coping with stress, with a favorable impact on the course of a disease.Some diseases are clearly partially self-induced and there is a growing awareness that certain personality habits, such as smoking cigarettes, drinking alcohol and eating a diet rich in cholesterol and saturated fats, are highly likely to have an impact on health. Beliefs about risks associated with certain health-damaging behaviors are not necessarily associated with the absence of those risk behaviors. In a survey of health behaviors in young adults in eight European countries, those who drank and smoked were just as well aware of the negative consequences of these health-damaging behaviors as those who did not engage in these habits. On the other hand, beliefs about the positive effects of health-protective behaviors, such as eating a low-fat diet, exercise and participating in health screening exams (e.g. testing for breast or prostate cancer) were strongly associated with their practice.Primary care physicians and medical practitioners rarely assess these psychosocial factors that have a strong potential to influence individual vulnerability to illness. However, and especially when symptoms lack an adequate physical explanation, even after a reasonable work-up, the physician must evaluate the specific contribution of life stress.First it is important to seek a temporal relationship between life events and symptom onset or relapse. The loss of a body part or bodily function can induce grief reactions. Gradual changes which occur with chronic progressive disease may give the individual time to perceive and tolerate the changes, whereas sudden modifications are potentially more disruptive and grief-inducing.Does the patient perceive the environment as exceeding his or her resources (allostatic load)? Often patients deny a relationship between their allostatic load and symptomatology, because they are unaware of the latency between stress accumulation and symptom onset (“I had bowel symptoms yesterday, which was an easy day at work, and not the previous days, which were awful”). Symptomatic worsening during weekends and vacation time is a common manifestation of this latency.Another area that may need exploring is the presence of physical and/or sexual abuse at some point in the patient’s life, while there is also a need to assess whether interpersonal relationships are providing a buffering role for stress, and to identify the individual’s psychological assets.All this information may be crucial for managing patients with unexplained somatic symptoms, in difficult patient-doctor relationships or when laboratory findings are borderline (e.g. slightly elevated prolactin levels). It requires a sensitive interviewing technique on the part of the physician, in some cases combined with self-rating inventories and/or techniques of self-observation (self-monitoring of daily activities and recording of the observed findings in a diary) by the patient.The assessment of psychosocial correlates of medical disease Psychosocial and biological factors interact in a number of ways in the course of medical disease. Their varying influence determines the unique quality of the experience and attitude of every patient in any given episode of illness.The potential relationship between medical disorders and psychiatric symptoms ranges from a purely coincidental occurrence to a direct causal role of organic factors – whether medical illness or drug treatment – in the development of psychiatric disturbances.Major depression, for example, has emerged as an extremely important source of comorbidity in medical disorders, and may be associated with higher mortality, particularly in the elderly. The presence of depressive symptoms in association with chronic medical illness has been found to affect quality of life and social functioning, leading to increased health care utilization, and depression can have an impact on compliance. Many cases of “suicide by default” (i.e. due to the deliberate omission of therapeutic, dietary and other measures necessary to sustain life or prevent the progress of pathology) may mask a major depressive disorder. Examples include diabetic patients who stop taking insulin, those who resume strenuous work after myocardial infarction and those who withdraw from chronic hemodialysis.Research has also suggested that depression may increase susceptibility to medical illness. The evidence is particularly impressive in cardiovascular disease, with clinical depression appearing to be an independent risk factor for coronary artery disease as well as affecting the mortality rate after myocardial infarction. Depression has also been suggested to be a marker of cardiac disease severity.Functional, i.e. nonorganic, medical symptoms are extremely common in medical practice. Their association with depression has been consistent, regardless of the design of the study. Depressed patients tend to have more somatic symptoms than nondepressed individuals, and somatizers tend to be more depressed than patients with physical disease.The current emphasis in psychiatry is on the assessment of symptoms resulting in syndromes identified by diagnostic criteria (DSM). However, there is an emerging awareness in psychiatry that psychological symptoms which do not reach the threshold of a psychiatric disorder can also affect quality of life and have pathophysiological and therapeutic implications. This is particularly true in the setting of medical disease, where most psychological symptoms cannot be assigned a suitable rubric according to psychiatric diagnostic criteria [4]. The case of hostility is exemplary here. A considerable body of evidence suggests a pathogenetic role for anger, hostility and irritable mood in physical illness. Hostility, in particular, has been identified as a risk factor for cardiovascular disease, particularly when associated with type A behavior (characterized by e.g. excessive work involvement, irritability and high competitiveness). In a similar manner, another psychological state – characterized by the giving-up complex, helplessness and hopelessness, and demoralization – has been found to facilitate the onset of disease to which the individual was predisposed.Not surprisingly, diagnostic criteria based on psychological dimensions and subclinical clusters were found to be more suitable than DSM-IV criteria in identifying distress and impaired quality of life in medical populations [4].Lipowski notes that once the symptoms of a somatic disease are perceived by a person or he or she has been told by a doctor that they are ill even if symptoms are absent, then this disease-related information gives rise to psychological responses which influence the patient’s experience and behavior as well as the course, therapeutic response and outcome of a given illness episode [2]. The study of illness behavior, defined as the ways in which individuals experience, perceive, evaluate and respond to their own health status, has yielded important information. It also gave rise to Pilowsky’s concept of abnormal illness behavior, characterized as the persistence of a maladaptive mode of perceiving, experiencing, evaluating and responding to one’s health status, despite the fact that a doctor has provided a lucid and accurate appraisal of the situation and management to be followed, with opportunities for discussion, negotiation and clarification, based on adequate assessment of all relevant biological, psychological, social and cultural factors [8]. The two main forms of abnormal illness behavior (illness affirming and illness denying) have several common expressions in clinical practice. They range from hypochondriasis and disease phobia to illness denial and lack of compliance.Quality of life, particularly in chronic diseases, has become the focus of an increasing number of publications. While there is neither a precise nor agreed definition of quality of life, research in this area seeks essentially two kinds of information: the functional status of the individual and the patient’s appraisal of health. The concept stems from the fact that measures of disease status alone are insufficient to describe the burden of illness and that the subjective perception of health status (e.g. lack of well-being, demoralization, difficulties fulfilling personal and family responsibilities, and so on) is as valid as that of the clinician in evaluating outcomes [4].All the above considerations demonstrate that psychiatric illness, psychological disturbances and abnormal illness behavior can have a profound effect on quality of life and how the disease process is experienced. This calls for a comprehensive assessment of psychosocial aspects of medical disease, which cannot be equated to a standard psychiatric evaluation and may be particularly suitable for the following clinical situations.(1) Somatization. The tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical help for them is a widespread clinical phenomenon that may involve up to 30–40% of medical patients. It may well be the most costly comorbidity. Fourteen common physical symptoms are responsible for almost half of all primary care visits, but only 10–15% are found to be caused by an organic illness over a 1-year period. Moreover, a significant proportion of problems presenting to a primary care physician cannot be assigned a suitable diagnostic rubric [4].(2) Partial response to treatment. Quality of life may often be compromised even when the patient is apparently doing well. Research on quality of life has indeed emphasized the discrepancies in health perceptions between patients, their companions and their treating physicians. In clinical medicine there is in fact the tendency to rely exclusively on “hard data,” preferably expressed in the dimensional numbers of laboratory measurements, excluding “soft information,” such as impairments and well-being. This soft information can now, however, be reliably assessed by clinical rating scales and indices [9].(3) Suspected psychiatric complications of medical illness. Timely recognition of psychiatric disorders which need specific treatments may have favorable implications for quality of life and disease course.(4) Abnormal illness behavior. Several manifestations of abnormal illness behavior (from hypochondriasis to lack of compliance) may hinder the prevention and treatment of medical disorders.Application of psychological therapies to medical disease Psychological interventions in the medically ill encompass the use of psychotherapeutic strategies and psychopharmacological interventions. They may be performed by a whole range of health professionals, including psychiatrists, psychologists, nurses and primary care physicians.The progression of severe medical disorders is often linked to specific lifestyle behaviors. In the 1990s, the benefits of modifying lifestyle were demonstrated in coronary heart disease, and more recently, several major controlled clinical trials have shown that type 2 diabetes can be delayed or prevented by lifestyle modification, such as diet and exercise, in people at high risk. A number of psychological treatments, including cognitive-behavioral therapy, have also been shown to be effective in health-damaging behaviors, such as smoking. There is, in addition, a complex relationship between psychological well-being and physical exercise, which needs to be considered for both promoting physical activity and in preventing its excess.Psychiatric disorders, and particularly major depression, frequently go unrecognized and untreated in medical settings, with widespread harmful consequences for the individual and society. Treatment of psychiatric comorbidity, such as depression, with either pharmacological or psychotherapeutic interventions, markedly improves depressive symptoms, health-related functioning and the patient’s quality of life.In controlled investigations for a number of medical disorders, the use of psychotherapeutic strategies, such as cognitive-behavioral therapy, stress management procedures and brief dynamic therapy, has yielded a substantial improvement in quality of life, coping or the course of the disease. Examples of these strategies are interventions that increase social support and enhance coping in patients with breast cancer and malignant melanoma, or writing about stressful experiences in asthma and rheumatoid arthritis. The results are not always favorable, however, and may depend on the type of psychosocial intervention and the specific populations. Nevertheless, research on psychotherapy has disclosed some common therapeutic ingredients that most psychotherapeutic techniques share, and these are outlined in table 1. Routine medical practice would also benefit from the presence of some – indeed perhaps all – of these features.Table 1. Nonspecific therapeutic ingredients that are shared by most forms of psychotherapy [10] 
For many years, abnormal illness behavior has been viewed mainly as an expression of personality predisposition and considered to be refractory to treatment by psychotherapeutic methods. There is now evidence to challenge such a pessimistic stance. Several controlled psychotherapy studies, for example, have indicated that hypochondriasis is a treatable condition. By providing accurate information and the use of simple cognitive strategies, such as the clarification of previous faulty communications with physicians and common psychophysiological reactions (patients may in fact be unable to attribute somatic symptoms to anxiety), it is possible to deal with the hypochondriasis. Similarly, the application of simple suggestions has yielded significant improvements in controlled studies concerned with functional medical disorders. The correlation between abnormal illness behavior and health habits may have implications in preventive efforts. Indeed, individuals with hypochondriacal fears and beliefs were found to take worse care of themselves than control subjects in several studies. They may be so distressed by their belief that they have an undiagnosed or neglected disease that choices that may yield benefits in the distant future appear to be irrelevant to them.Psychosomatic treatment consists of the integration of psychological interventions (brief individual psychotherapy, behavioral techniques, group psychotherapy) and psychopharmacology with conventional medical treatments. It appears to be particularly warranted when there is refractoriness to lifestyle modifications guided by primary care or other nonpsychiatric physicians; in the presence of psychological disturbances (e.g. demoralization and irritable mood) or psychiatric illness (such as major depression or panic disorder); in the presence of abnormal illness behavior interfering with treatment or leading to repeated health care utilization, such as illness denial or hypochondriasis, and in patients with an impaired quality of life and functioning that is not justified by the medical condition.A new medicine Psychosomatic medicine needs to be incorporated into clinical practice. How an individual functions in daily life, his or her productivity, performance of social roles, intellectual capacity, emotional stability and well-being have all emerged as crucial components of clinical investigation and patient care. These issues have become particularly important in chronic diseases which cannot be cured and also extend to such patients’ caregivers – whose emotional burden has become increasingly manifest – and health providers. Patients have certainly become more aware of these problems, and their difficulties in coping with medical illness and its psychological consequences have led to the establishment of many patients’ associations. On the other hand, there is also increasing emphasis on health promotion rather than simple disease prevention. The commercial success of books on complementary medicine and positive practices as well as the upsurge of interest in mind-body medicine exemplify the receptivity of the general public to messages of health prevention and alternative medical models. Psychosomatic interventions can respond to these emerging needs and may play an important role in supporting the healing process.A significant proportion of morbidity and premature mortality in the US can be attributed to “largely preventable behaviors and exposures,” such as tobacco smoking, obesity and physical inactivity [11]. Yet almost all (95%) of health care spending is directed at biomedically oriented care, even while, simultaneously, the proliferating connections between physicians and the pharmaceutical industry have brought the credibility of clinical medicine to an unprecedented crisis [12]. The exponential spending on preventive pharmaceuticals, justified by the potential long-term benefits to a very small segment of the population, is highly questionable [13], while the traditional boundaries among medical specialties, based mostly on organ systems (e.g. cardiology, gastroenterology) appear to be increasingly inadequate to deal with symptoms and problems which cut across organ system subdivisions and require a holistic approach [12].As Noam Chomsky reminds us, “if we do not like what we see when we look in the mirror honestly, we have every opportunity to do something about it” [14]. If we do not like what we see in medicine today, we should remember that a different medicine is possible. It is called psychosomatic medicine.
 Giovanni A. Fava received his MD degree from the University of Padua in 1977. He is currently Professor of Clinical Psychology at the University of Bologna and Clinical Professor of Psychiatry at the State University of New York at Buffalo. Since 1991, he has been editor-in-chief of Psychotherapy and Psychosomatics and serves on the editorial board of Advances in Psychosomatic Medicine and several other journals. He has performed groundbreaking research in psychosomatic medicine, cognitive behavioral therapy and mood and anxiety disorders.
Giovanni A. Fava, MD Department of Psychology University of Bologna Viale Berti Pichat 5 40127 Bologna Italy giovanniandrea.fava@unibo.it |
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