Psychosomatic medicine

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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]

Quality of life (QOL) is an overarching term for the quality of the various domains in life. It is a standard level that consists of the expectations of an individual or society for a good life. These expectations are guided by the values, goals and socio-cultural context in which an individual lives. It is a subjective, multidimensional concept that defines a standard level for emotional, physical, material and social well-being. It serves as a reference against which an individual or society can measure the different domains of one’s own life. The extent to which one's own life coincides with this desired standard level, put differently, the degree to which these domains give satisfaction and as such contribute to one's subjective well-being, is called life satisfaction.

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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, internal medicine, 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]

Behavioral medicine is concerned with the integration of knowledge in the biological, behavioral, psychological, and social sciences relevant to health and illness. These sciences include epidemiology, anthropology, sociology, psychology, physiology, pharmacology, nutrition, neuroanatomy, endocrinology, and immunology. The term is often used interchangeably, but incorrectly, with health psychology.. The practice of behavioral medicine encompasses health psychology, but also includes applied psychophysiological therapies such as biofeedback, hypnosis, and bio-behavioral therapy of physical disorders, aspects of occupational therapy, rehabilitation medicine, and physiatry, as well as preventive medicine. In contrast, health psychology represents a stronger emphasis specifically on psychology's role in both behavioral medicine and behavioral health.

Liaison psychiatry, also known as consultative psychiatry or consultation-liaison psychiatry is the branch of psychiatry that specialises in the interface between general medicine and psychiatry, usually taking place in a hospital or medical setting. The role of the consultation-liaison psychiatrist is to see patients with comorbid medical conditions at the request of the treating medical or surgical consultant or team. Liaison psychiatry has areas of overlap with other disciplines including psychosomatic medicine, health psychology and neuropsychiatry.

Psychiatry is the medical specialty devoted to diagnosing, preventing, and treating mental disorders. These include various maladaptations related to mood, behavior, cognition, and perceptions. See glossary of psychiatry.

Psychosomatic disorders

Some physical diseases are believed to have a mental component derived from the 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.

Stress, either physiological or biological, is an organism's response to a stressor such as an environmental condition. Stress is the body's method of reacting to a condition such as a threat, challenge or physical and psychological barrier. Stimuli that alter an organism's environment are responded to by multiple systems in the body. The autonomic nervous system and hypothalamic-pituitary-adrenal (HPA) axis are two major systems that respond to stress.

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]

<i>Helicobacter pylori</i> Species of bacteria

Helicobacter pylori, previously known as Campylobacter pylori, is a Gram-negative, microaerophilic bacterium usually found in the stomach. It was identified in 1982 by Australian scientists Barry Marshall and Robin Warren, who found that it was present in a person with chronic gastritis and gastric ulcers, conditions not previously believed to have a microbial cause. It is also linked to the development of duodenal ulcers and stomach cancer. However, over 80% of individuals infected with the bacterium are asymptomatic, and it may play an important role in the natural stomach ecology.

Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. These symptoms occur over a long time, often years. It has been classified into four main types depending on whether diarrhea is common, constipation is common, both are common, or neither occurs very often. IBS negatively affects quality of life and may result in missed school or work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

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] 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. [12] 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".

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, 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. [13]

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. [14] Medical treatments and psychotherapy are used to treat illnesses believed to have a psychosomatic component. [15]

History

In the medieval Islamic world the Persian psychologist-physicians Ahmed ibn Sahl al-Balkhi (d. 934) and Haly Abbas (d. 994) developed an early model of illness that emphasized the interaction of the mind and the body. They proposed that a patient's physiology and psychology can influence one another. [16]

In the beginnings of the 20th century, there was a renewed interest in psychosomatic concepts. Psychoanalyst Franz Alexander had a deep interest in understanding the dynamic interrelation between mind and body. [17] Sigmund Freud pursued a deep interest in psychosomatic illnesses following his correspondence with Georg Groddeck who was, at the time, researching the possibility of treating physical disorders through psychological processes. [18]

In the 1970s, Thure von Uexküll and his colleagues in Germany and elsewhere proposed a biosemiotic theory (the umwelt concept) that was widely influential as a theoretical framework for conceptualizing mind-body relations.

Henri Laborit, one of the founders of modern neuropsychopharmacology, carried out experiments in the 1970s that showed that illness quickly occurred when there was inhibition of action in rats. Rats in exactly the same stressful situations but whom were not inhibited in their behavior (those who could flee or fight – even if fighting is completely ineffective) had no negative health consequences. [19] He proposed that psychosomatic illnesses in humans largely have their source in the constraints that society puts on individuals in order to maintain hierarchical structures of dominance. The film My American Uncle , directed by Alain Resnais and influenced by Laborit, explores the relationship between self and society and the effects of the inhibition of action.

In February 2005, the Boston Syndromic Surveillance System detected an increase in young men seeking medical treatment for stroke. Most of them did not actually experience a stroke, but the largest number presented a day after Tedy Bruschi, a local sports figure, was hospitalized for a stroke. Presumably they began misinterpreting their own harmless symptoms, a group phenomenon now known as Tedy Bruschi syndrome. [20]

See also

Related Research Articles

Mental disorder Distressing thought or behavior pattern

A mental disorder, also called a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitting, or occur as a single episode. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional.

Neurology Medical specialty dealing with disorders of the nervous system

Neurology is a branch of medicine dealing with disorders of the nervous system. Neurology deals with the diagnosis and treatment of all categories of conditions and disease involving the central and peripheral nervous systems, including their coverings, blood vessels, and all effector tissue, such as muscle. Neurological practice relies heavily on the field of neuroscience, the scientific study of the nervous system.

A psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are medical doctors, unlike psychologists, and must evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments, or strictly psychiatric. A psychiatrist usually works as the clinical leader of the multi-disciplinary team, which may comprise psychologists, social workers, occupational therapists and nursing staff. Psychiatrists have broad training in a bio-psycho-social approach to assessment and management of mental illness.

Causes of mental disorders

A mental disorder is "a clinically significant behavioral or psychological syndrome or psychological pattern that occurs in an individual and that is associated with present disability or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom."

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. An old concept, its meaning has repeatedly changed due to redefinitions in its source metaphors. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they or others have, or are about to be diagnosed with, a serious illness.

The Biopsychosocial Model is an interdisciplinary model that looks at the interconnection between biology, psychology, and socio-environmental factors. The model specifically examines how these aspects play a role in topics ranging from health and disease models to human development. This model was developed by George L. Engel in 1977 and is the first of its kind to employ this type of multifaceted thinking. The Biopsychosocial Model has received criticism about its limitations, but continues to carry influence in the fields of psychology, health, medicine, and human development.

Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion and thought, which may or may not be understood as precipitating a mental disorder. Although many behaviors could be considered as abnormal, this branch of psychology typically deals with behavior in a clinical context. There is a long history of attempts to understand and control behavior deemed to be aberrant or deviant, and there is often cultural variation in the approach taken. The field of abnormal psychology identifies multiple causes for different conditions, employing diverse theories from the general field of psychology and elsewhere, and much still hinges on what exactly is meant by "abnormal". There has traditionally been a divide between psychological and biological explanations, reflecting a philosophical dualism in regard to the mind-body problem. There have also been different approaches in trying to classify mental disorders. Abnormal includes three different categories; they are subnormal, supernormal and paranormal.

Somatization disorder is a mental disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms, although it is no longer considered a clinical diagnosis. It was recognized in the DSM-IV-TR classification system, but in the latest version DSM-5, it was combined with undifferentiated somatoform disorder to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, still includes somatization syndrome.

Historically, mental disorders have had three major explanations, namely, the supernatural, biological and psychological models. For much of recorded history, deviant behavior has been considered supernatural and a reflection of the battle between good and evil. When confronted with unexplainable, irrational behavior and by suffering and upheaval, people have perceived evil. In fact, in the Persian Empire from 900 to 600 B.C., all physical and mental disorders were considered the work of the devil. Physical causes of mental disorders have been sought in history. Hippocrates was important in this tradition as he identified syphilis as a disease and was therefore an early proponent of the idea that psychological disorders are biologically caused. This was a precursor to modern psycho-social treatment approaches to the causation of psychopathology, with the focus on psychological, social and cultural factors. Well known philosophers like Plato, Aristotle etc., wrote about the importance of fantasies, dreams, and thus anticipated, to some extent, later this was developed into psychoanalytic thought and cognitive science. They were also some of the first to advocate for humane and responsible care for individuals with psychological disturbances.

Alexithymia is a personality construct characterized by the subclinical inability to identify and describe emotions experienced by one's self or others. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating. Furthermore, people with alexithymia have difficulty in distinguishing and appreciating the emotions of others, which is thought to lead to unempathic and ineffective emotional responding. Alexithymia occurs in approximately 10% of the population and can occur with a number of psychiatric conditions.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is that branch / speciality of medicine which deals with the study of biological function of the nervous system in mental disorders.

Neuropsychiatry is a branch of medicine that deals with mental disorders attributable to diseases of the nervous system. It preceded the current disciplines of psychiatry and neurology, which had common training, however, psychiatry and neurology have subsequently split apart and are typically practiced separately. Nevertheless, neuropsychiatry has become a growing subspecialty of psychiatry and it is also closely related to the fields of neuropsychology and behavioral neurology.

Psychogenic disease is a name given to physical illnesses that are believed to arise from emotional or mental stressors, or from psychological or psychiatric disorders. It is most commonly applied to illnesses where a physical abnormality or other biomarker has not yet been identified. In the absence of such "biological" evidence of an underlying disease process, it is often assumed that the illness must have a psychological cause, even if the patient shows no indications of being under stress or of having a psychological or psychiatric disorder. Examples of diseases that are believed by many to be psychogenic include psychogenic seizures, psychogenic polydipsia, psychogenic tremor, and psychogenic pain.

Psychogenic pain is physical pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors.

Differential diagnoses of depression differential diagnoses

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of completed suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who completed suicide had contact with mental health services in the prior year, a fifth within the preceding month.

A somatic symptom disorder, formerly known as a somatoform disorder, is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder. Somatic symptom disorders, as a group, are included in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders.

John Wayne Mason, M.D. (1924–2014) was an American physiologist and researcher who specialized in the interplay between human emotions and the endocrine system. Mason is regarded as an international leader and theoretician in the field of stress research, where he was one of the field's most prominent voices speaking out against the reigning model of stress promoted by Hans Selye.

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  20. Why is it so hard to track the source of a food poisoning outbreak?