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, hypertonia of the smooth musculature, secretory and edematous events, 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 pictures, known to general medicine.
Such a possibility has always been more or less generically admitted in medicine and finds antecedents as far back as the Hippocratic theories, by which it was in fact broadly upheld. Modern psychosomatic medicine seeks to establish more precisely the relationships between the two spheres, psychic and somatic, of the human organism; its theoretical presuppositions belong to that vast current of medical psychology begun in the first decades of the century by psychoanalysis (v.). "To allude generically to the emotions in the vague terms of anxiety, emotional tension, emotional imbalance, etc., is no longer permitted today; the actual content of an emotion must be studied with the most advanced methods of dynamic psychology and placed in relation to the somatic reactions" (Alexander).
Like psychoanalysis, and perhaps more than it, insofar as it considers in a particular way organic diseases in their psychogenetic motivation, psychosomatic medicine is in polemic with the positivist orientation of medicine, which found its greatest expression in the 19th century in the organic concepts of the anatomopathologist Virchow. "War psychiatry" determined the first impulse of psychosomatic medicine, and almost simultaneously there appeared the term "psychosomatic" coined by Draper, later changed to the current one of "psicosomatico." In 1915 Cannon's book was published: Bodily changes in pain, hunger, fear and rage. 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 varied bibliographical material in her volume Emotions and bodily changes, considered a fundamental book for information and orientation in this new tendency. In psychosomatic medicine two tendencies of different approach are encountered: according to some, "the diseases that fall within the psychosomatic category have characteristics well distinct from those diseases originally attributable to other broad etiological categories"; they consist in "a physical alteration whose nature can be evaluated only when the emotional disturbances are investigated in addition to the physical ones" (Halliday). According to others, all diseases are psychosomatic, while the very term "psychosomatic" is inadequate (the term "integral medicine" is already being suggested), since it tends to perpetuate the opposition of the two poles, psyche and body, whereas it would be biologically more exact to speak of the psyche as an unconscious vital force that conditions both spheres of the living unity in parallel (Draper). These are, in any case, differences of little importance as regards therapeutic conduct.
Substantially, therefore, the psychosomatic method addresses the most common pathological processes, which are the object of general medicine, accompanying the physical examinations customarily used with an in-depth study of the subject's personality. This should always be done, according to Draper and the other authors who consider all diseases psychosomatic; whereas, as has been 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 recognized by all and for some time are not always rigorously distinguished from the other diseases that are purely organic in their manifestations, and whose psychogenesis can be brought to light only after accurate investigations. Nevertheless there are general criteria in the behavior of these latter affections that can guide diagnosis. For Halliday psychosomatic diseases meet six fundamental requirements: 1) emotion as the triggering factor, 2) type of personality, 3) variability of the incidence of sex in the various diseases, 4) tendency to association with other psychosomatic diseases, 5) familial heredity for the same disorder or similar disorders, 6) physical course. The same author furthermore emphasizes the importance of the social environment as a cause of repercussions, first psychic and then somatic.
With regard to the pathways through which the psychosomatic relationship is established and the psychic conflict discharges onto a particular organ, the various authors agree in maintaining that emotional charges find their way through the neurovegetative system (v.) and its diencephalic correlations; this acquisition, moreover, predates psychosomatic medicine. With regard, then, to the problem of the specificity of localization in one particular organ rather than another, Alexander explains how the symptoms affecting the functions of the life of relation (voluntary motility and sensory apperception) can be attributed a symbolic meaning of conversion, as happens in hysteria. Not so those that fall within the domain of the neurovegetative system (that is, involving the visceral organs); for these, the object of psychosomatic medicine, a relationship could often be established between the diseased organ and the phase of psychic development to which the patient's personality has regressed.
Other authors, on the other hand, explain that the action of emotional factors could discharge to a greater extent onto that organ which constitutionally or through previous pathological processes constituted a "locus minoris resistentiae." Thus, according to the first mechanism of production, according to Alexander, in the case of peptic ulcer, for example, 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 fed. The unconscious psychic stimulus, by means of 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 were about to take in food. Such a chronic functional disturbance would be of essential importance in determining the formation of the organic lesion, that is, of the ulcer.
The treatment of psychosomatic diseases is above all centered on psychotherapy (v.); once the psychogenesis of the disturbance has been ascertained, one must arrive at the underlying diagnosis, that is, the psychiatric one, and resolve the subject's psychic conflict. The method followed is the psychoanalytic one, given, precisely, the theoretical premises of psychosomatic medicine. Naturally psychotherapy does not exclude, indeed is successfully combined with, general medical therapy.
Apart from the reservations that may be made about the pathogenetic and curative approach based purely on psychoanalysis of current psychosomatic medicine, in substance the profound truth and fruitfulness of its practical applications cannot be denied.