PSYCHOSOMATIC MEDICINE. — The basis of psychosomatic medicine is the concept that emotional states can condition particular general somatic manifestations (vasospastic phenomena, hypertonus of smooth musculature, secretory and edematous phenomena, etc.) at the level of various organs and systems: the chronic nature of emotional tension, with its consequent somatic reactions, is capable of determining well-defined pathological conditions, familiar to general medicine.
Such a possibility has always, more or less generally, been acknowledged in medicine and finds antecedents even in Hippocratic theories, by which it was indeed widely supported. Modern psychosomatic medicine seeks to establish more precisely the relationships between the two spheres, psychic and somatic, of the human organism; its theoretical presuppositions are part of that broad current of medical psychology, initiated in the first decades of the century by psychoanalysis (q.v.). “To speak generically of emotions in vague terms such as anxiety, emotional tension, emotional imbalance, etc., is no longer permissible today; the actual content of an emotion must be studied with the most advanced methods of dynamic psychology and related to somatic reactions” (Alexander).
Like psychoanalysis, and perhaps more so in that it considers organic diseases in their psychogenetic motivation, psychosomatic medicine is in polemic with the positivist direction of medicine, which in the 19th century found its highest expression in the organicist concepts of the pathologist Virchow. “War psychiatry” provided the first impetus for psychosomatic medicine, and almost simultaneously the term “psychosomatic” was coined by Draper, later becoming the current term. In 1915 Cannon’s book Bodily Changes in Pain, Hunger, Fear and Rage was published. From then on, the psychosomatic trend spread rapidly, especially in the U.S.A., and an abundant literature on the subject arose. In 1935, Dunbar compiled the various bibliographic material in her volume Emotions and Bodily Changes, considered a fundamental book for information and orientation in this new trend.
Within psychosomatic medicine, two trends of differing approaches are encountered: according to some, the diseases that fall into the psychosomatic category have characteristics distinct from those diseases primarily attributable to other etiological categories; they consist in “a physical alteration whose nature can be assessed only when emotional disturbances are investigated in addition to physical ones” (Halliday). According to others, all diseases are psychosomatic, while the very term “psychosomatic” is inadequate (the term “integral medicine” has already been suggested), since it tends to perpetuate the opposition of the two poles, psyche and body, whereas biologically it is more accurate to speak of the psyche as an unconscious vital force that conditions both spheres of the living unity in parallel (Draper). These are, however, differences of little relevance with regard to therapeutic conduct.
Substantially, therefore, the psychosomatic method addresses the most common pathological processes, which are the object of general medicine, accompanying the usual physical examinations with an in-depth study of the subject’s personality. This should always be done, according to Draper and other authors who consider all diseases to be psychosomatic; whereas, as we have seen, Halliday would generally limit psychological investigation only to those cases that meet certain characteristics. The psychosomatic orientation is still evolving, and those diseases that have a “functional” significance, long recognized by all, are not always rigorously distinguished from other diseases that are purely organic in their manifestations and whose psychogenesis can be revealed only after careful investigation. There are, however, general criteria in the behavior of the latter affections that can guide diagnosis. For Halliday, psychosomatic diseases meet six fundamental requirements: 1) emotion as a triggering factor, 2) type of personality, 3) variability of sex incidence in various diseases, 4) tendency to association with other psychosomatic diseases, 5) family inheritance of the same disorder or similar disorders, 6) phasic course. The same author also emphasizes the importance of the social environment as a cause of repercussions, first psychic and then somatic.
Regarding the ways in which the psychosomatic relationship is established and psychic conflict is loaded onto a specific organ, various authors agree in maintaining that emotional charges find their path through the neurovegetative system (q.v.) and its functional correlations, which, moreover, fall within the scope of psychosomatic medicine itself. Regarding the problem of the specificity of localization in one organ rather than another, Alexander explains how symptoms affecting the functions of the life of relation (voluntary motility and sensory apperception) can be attributed a symbolic meaning of conversion, as occurs in hysteria. This is not the case for those that fall within the domain of the neurovegetative system (i.e., involving visceral organs); for these, the object of psychosomatic medicine, a relationship can often be established between the diseased organ and the phase of psychic development to which the patient’s personality has regressed.
Other authors, instead, explain that the action of emotional factors could discharge more intensely on that organ which constitutionally or due to previous pathological processes constitutes a “locus minoris resistentiae.” Thus, according to the first mechanism of production, in Alexander’s view, in the case of peptic ulcer, e.g., considered a typically psychosomatic disease, the psychic basis would consist in the unconscious desire to be loved, which coincides, according to psychoanalytic schemas, with the desire to be nourished. The unconscious psychic stimulus, through the neurovegetative system, would act on the vascular, secretory, and muscular conditions of the stomach, which would thus come to behave as if it were taking in or about to take in food. This chronic functional disturbance would be of essential importance in determining the formation of the organic lesion, i.e., the ulcer.
The treatment of psychosomatic diseases is centered above all on psychotherapy (q.v.); once the psychogenesis of the disorder is ascertained, it is necessary to arrive at the underlying diagnosis, i.e., the psychiatric one, and resolve the subject’s psychic conflict. The method followed is the psychoanalytic one, given the theoretical premises of psychosomatic medicine. Naturally, psychotherapy does not exclude, but rather successfully accompanies, general medical therapy.
Apart from the reservations that may be made regarding the pathogenetic and therapeutic approach based purely on psychoanalysis in current psychosomatic medicine, the profound truth and the fertility of its practical applications cannot be denied.