PSYCHOSOMATIC MEDICINE. — At the basis of psychosomatic medicine is the conception that emotional states can condition particular somatic manifestations of a general character (vasospastic phenomena, hypertonicity of the smooth musculature, secretory and oedematous processes, etc.) at the level of the various organs and systems: the chronic character of emotional tension, with the consequent somatic reactions, would be capable of determining well-defined pathological syndromes, known to general medicine.
Such a possibility has always been more or less generically admitted in medicine and has antecedents extending back to the Hippocratic theories, by which it was indeed broadly supported. Modern psychosomatic medicine seeks to establish more precisely the relations between the two spheres, psychic and somatic, of the human organism; its theoretical presuppositions belong to that broad current of medical psychology initiated in the first psychoanalysis (v.). “It is no longer permissible today to refer generically to emotions in the vague terms of anxiety, emotional tension, emotional imbalance, etc.; the actual content of an emotion must be studied with the most advanced methods of dynamic psychology and related to the somatic reactions” (Alexander).
Like psychoanalysis, and perhaps more than the latter, since it considers organic diseases particularly in their psychogenetic motivation, psychosomatic medicine is polemical toward the positivist orientation of medicine, which found its greatest expression in the nineteenth century in the organic concepts of the anatomopathologist Virchow. “War psychiatry” provided the first impetus for psychosomatic medicine, and almost simultaneously the term “psychosomatic,” coined by Draper, appeared; it was subsequently changed to the current term “psychosomatic.” In 1915 Cannon’s book Bodily Changes in Pain, Hunger, Fear and Rage was published. From then on, the psychosomatic tendency spread rapidly, especially in the U.S.A., and an abundant literature on the subject arose. In 1935 Dunbar collected the various bibliographical materials in her volume Emotions and Bodily Changes, regarded as a fundamental work for information and guidance regarding this new tendency. In psychosomatic medicine, two tendencies with different approaches are encountered: according to some, “the diseases belonging to the psychosomatic category have characteristics clearly distinct from those of diseases primitively referable to other broad etiological categories”; they consist in “a physical alteration whose nature can be evaluated only when emotional disturbances are investigated in addition to the physical ones” (Halliday). According to others, all diseases are psychosomatic, while the term “psychosomatic” itself is inadequate (the term “integral medicine” has already been suggested), since it tends to perpetuate the opposition between the two poles, psyche and body, whereas biologically it is more accurate to speak of the psyche as an unconscious vital force that acts in parallel upon both spheres of the living unity (Draper). These are, in any case, differences of little importance as regards therapeutic practice.
Essentially, therefore, the psychosomatic method addresses the most common pathological processes, which are the subject of general medicine, accompanying the physical examinations customarily employed with an in-depth study of the subject’s personality. This should always be done, according to Draper and the other authors who regard all diseases as psychosomatic; whereas, as we have seen, Halliday would generally limit psychological investigation only to those cases that display certain characteristics. The psychosomatic orientation is still evolving, and diseases that have a “functional” significance, recognized as such by everyone and for a long time, are not always rigorously distinguished from other diseases that are strictly organic in their manifestations and whose psychogenesis can be brought to light only after careful investigation. Nevertheless, there are general criteria in the behavior of these latter disorders that can provide guidance in diagnosis. For Halliday, psychosomatic diseases meet six fundamental requirements: 1) emotion as a triggering factor, 2) personality type, 3) variability in the incidence of sex in the various diseases, 4) tendency to association with other psychosomatic diseases, 5) familial inheritance of the same or similar disorder, 6) physical course. The same author also emphasizes the importance of the social environment as a cause of repercussions, at first psychic and then somatic.
With regard to the pathways through which the psychosomatic relationship is established and the psychic conflict is discharged upon a particular organ, the various authors agree in maintaining that emotional charges find their way through the autonomic nervous system (v.) and its diencephalic correlations; this, moreover, was an understanding that preceded psychosomatic medicine. As for the problem of the specificity of localization in one particular organ rather than another, Alexander explains that symptoms affecting the functions of relational life (voluntary motility and sensory apperception) may be assigned a symbolic meaning of conversion, as occurs in hysteria. The same does not apply to those falling within the domain of the autonomic nervous system (that is, affecting the visceral organs); in these cases, which are the subject of psychosomatic medicine, it might often be possible to establish a relationship between the diseased organ and the stage of psychic development to which the patient’s personality has regressed.
Other authors, however, explain that the action of emotional factors might be discharged more strongly upon the organ which, constitutionally or as a result of previous pathological processes, constituted a “locus minoris resistentiae.” Thus, according to the first mechanism of production, in Alexander’s view, in the case of peptic ulcer, for example, regarded as a typically psychosomatic disease, the psychic basis would consist in the unconscious desire to be loved, which coincides, according to psychoanalytic schemes, with the desire to be nourished. The unconscious psychic stimulus, through the autonomic nervous system, would act upon the vascular, secretory, and muscular conditions of the stomach, which would consequently come to behave as if it were taking in, or were about to take in, food. This chronic functional disorder would be of essential importance in determining the formation of the organic lesion, namely, the ulcer.
The treatment of psychosomatic diseases psychotherapy (v.); once the psychogenesis of the disorder has been established, it is necessary to arrive at the underlying diagnosis, that is, the psychiatric diagnosis, and resolve the subject’s psychic conflict. The method followed is the psychoanalytic one, precisely in view of the theoretical premises of psychosomatic medicine. Naturally, psychotherapy does not exclude general medical therapy; rather, it successfully accompanies II.
Apart from the reservations that may be expressed concerning the purely psychoanalytic pathogenetic and therapeutic approach of present-day psychosomatic medicine, its profound truth and the fecundity of its practical applications cannot, in substance, be denied.