Psychosomatic medicine is an interdisciplinary medical field exploring the relationships among social, psychological, and behavioral factors on bodily processes and quality of life in humans and animals.[1]
The academic forebear of the modern field of behavioral medicine and a part of the practice of consultation-liaison psychiatry, psychosomatic medicine integrates interdisciplinary evaluation and management involving diverse specialties including psychiatry, psychology, neurology, psychoanalysis, internal medicine, pediatrics, surgery, allergy, dermatology and psychoneuroimmunology. Clinical situations where mental processes act as a major factor affecting medical outcomes are areas where psychosomatic medicine has competence.[2]
Psychosomatic disorders
Some physical diseases are believed to have a mental component derived from stresses and strains of everyday living. This has been suggested, for example, of lower back pain and high blood pressure, which some researchers have suggested may be related to stresses in everyday life.[3] The psychosomatic framework additionally sees mental and emotional states as capable of significantly influencing the course of any physical illness. Psychiatry traditionally distinguishes between psychosomatic disorders, disorders in which mental factors play a significant role in the development, expression, or resolution of a physical illness, and somatoform disorders, disorders in which mental factors are the sole cause of a physical illness.
It is difficult to establish for certain whether an illness has a psychosomatic component. A psychosomatic component is often inferred when there are some aspects of the patient’s presentation that are unaccounted for by biological factors, or some cases where there is no biological explanation at all. For instance, Helicobacter pylori causes 80% of peptic ulcers. However, most people living with Helicobacter pylori do not develop ulcers, and 20% of patients with ulcers have no H. pylori infection. Therefore, in these cases, psychological factors could still play some role.[4] Similarly, in irritable bowel syndrome (IBS), there are abnormalities in the behavior of the gut. However, there are no actual structural changes in the gut, so stress and emotions might still play a role.[5]
The strongest perspective on psychosomatic disorders is that attempting to distinguish between purely physical and mixed psychosomatic disorders is increasingly obsolete as almost all physical illness have mental factors that determine their onset, presentation, maintenance, susceptibility to treatment, and resolution.[6][7] According to this view, even the course of serious illnesses, such as cancer, can potentially be influenced by a person’s thoughts, feelings and general state of mental health.
Addressing such factors is the remit of the applied field of behavioral medicine. In modern society, psychosomatic aspects of illness are often attributed to stress[8] making the remediation of stress one important factor in the development, treatment, and prevention of psychosomatic illness.
Connotations of the term “psychosomatic illness”
In the field of psychosomatic medicine, the phrase “psychosomatic illness” is used more narrowly than it is within the general population. For example, in lay language, the term often encompasses illnesses with no physical basis at all, and even illnesses that are faked (malingering). In contrast, in contemporary psychosomatic medicine, the term is normally restricted to those illnesses that do have a clear physical basis, but where it is believed that psychological and mental factors also play a role. Some researchers within the field believe that this overly broad interpretation of the term may have caused the discipline to fall into disrepute clinically.[9] For this reason, among others, the field of behavioral medicine has taken over much of the remit of psychosomatic medicine in practice and there exist large areas of overlap in the scientific research.
Criticism
Studies have yielded mixed evidence regarding the impact of psychosomatic factors in illnesses. Early evidence suggested that patients with advanced-stage cancer may be able to survive longer if provided with psychotherapy to improve their social support and outlook.[10][11][12] However, a major review published in 2007, which evaluated the evidence for these benefits, concluded that no studies meeting the minimum quality standards required in this field have demonstrated such a benefit.[13] The review further argues that unsubstantiated claims that “positive outlook” or “fighting spirit” can help slow cancer may be harmful to the patients themselves if they come to believe that their poor progress results from “not having the right attitude”.
In her book Authors of Our Own Misfortune, Angela Kennedy argues that psychogenic explanations for physical illnesses are rooted in faulty logic and moralistic belief systems which situate patients with medically unexplained symptoms as deviant, bad and malingering. The diagnosis of a psychogenic disorder often has detrimental consequences for these patients as they are stigmatised and denied adequate support because of the contested nature of their condition and the value judgements attached to it.[14]
On the other hand, psychosomatic medicine criticizes the current approach of medical doctors disregarding psychodynamic ideas in their daily practice. For example, it questions the broad acceptance of self-proclaimed diseases such as gluten-intolerance, chronic Lyme disease and Fibromyalgia as a gain of illness for patients to avoid the underlying intra-psychic conflicts eliciting the disease, while at the same time, challenging the reasons for this neglect in the doctors’ own avoidance of their emotional intra-psychic conflict.[15]
Treatment
While in the US, psychosomatic medicine is considered a subspecialty of the fields of psychiatry and neurology, in Germany and other European countries it is considered a subspecialty of internal medicine. Thure von Uexküll and contemporary physicians following his thoughts regard the psychosomatic approach as a core attitude of medical doctors, thereby declaring it not as a subspecialty, but rather an integrated part of every specialty.[16] Medical treatments and psychotherapy are used to treat illnesses believed to have a psychosomatic component.[17]
