Psychosomatic disease and the problem of causation

Despite its impressive rate of growth in the past few decades, an increasing amount if dissatisfaction with the area of psychosomatic medicine is reflected in recent literature. The discipline's failures relate to concepts of pathogenesis and therapeutic application of research findings. These failures are explained as a necessary consequence of the philosophical tenet of mind-body dualism which underlies medical theory. It is urged that advocates of psychosomatic medicine give the concept of “holism” meaning at the most fundamental level by establishing a rational basis for theory, or else forsake this line of research for others which yield causal relationships conducive to effective therapy.     

The fundamental principle of medicine

“Nature, is the physician of all diseases”, the guiding principle of ancient Greek medicine is interpreted in the present paper in a modern way. This fundamental principle of medicine is regarded as a corollary of evolution theory according to which in order to survive the organism has to anticipate the environmental threat. Its genetic pool stores the neceessary programs to withstand all noxae encountered by the species up to the present to be implemented if neccessary into phenotypic strategies. From the medical point of view “Disease” represents the observed interplay between environmental threat and the appropriate strategy recruited by the organism to with-stand it. Thus according to the evolution theory, in order to survive, each species has to “know” how to cure itself otherwise it would have been eliminated. These arguments provide the foundation for the modern interpretation of the fundamental principle: “The organism anticipates all diseases”, which regards further the set of all genetically stored strategies (or anticipations) as the “vis medicatrix naturae”.Such a reasoning excludes the existence of any cause and effect relationship between a pathogen and a strategy. Etiology thus does not search for causes of diseases but assigns to each strategy the pathogens which trigger it.Neoplasia represents according this view an optimal strategy of the vis medicatrix naturae to withstand the harmfull effect of carcinogens.     

Psychosomatic medicine today: an overview.

The current status of several areas of interest in psychosomatic medicine, including specificity theory, life changes, and peptic ulcers, is reviewed, and their relevance to the practice of psychosomatic medicine discussed. The importance of neuro-psychopharmacological research to psychosomatic medicine is stressed, and a perspective is given on the usefulness of drugs in conjunction with intensive psychotherapy.     

Liaison psychiatry as a systems approach to behavior.

In this overview, the psychosomatic theory is discussed from an evolutionary perspective. From its initial concern with relationship between emotions and physiology through psychopathology and anatomo-physio-pathology to socio-psycho-pathophysiology, psychosomatic medicine and its theory is presently viewed as an empiric science utilizing a number of conceptual approaches derived from developmental psychology, classical psychiatry, physiology, sociology and anthropology. These are applied to the study and care of patients in ambulatory and inpatient settings, which are the arenas of the consultation-liaison activity and may be viewed as the clinical laboratories of psychosomatic medicine. In these laboratories, a new language has developed which is largely phenomenological and which attempts to utilize theoretical concepts from several disciplines in explaining the illness illness phenomenon in the present. As such, the practitioner of Liaison Psychiatry is a general systems analyst who analyzes the illness situation of the patient and his attendants in an attempt to decipher the identified problem, explaining it by utilizing selected theoretical concepts from the basic sciences of behavior. Psychosomatic theory is seen as an evolving and bridging science attempting to integrate and combine particulate theory into a more comprehensive synthesis.     

Neural substrates of implicit and explicit emotional processes: a unifying framework for psychosomatic medicine

There are two broad themes in psychosomatic medicine research that relate emotions to physical disease outcomes. Theme 1 holds that self-reported negative affect has deleterious effects and self-reported positive affect has salubrious effects on health. Theme 2 holds that interference with the experience or expression of negative affect has adverse health consequences. From the perspective of self-report these two traditions appear contradictory. A key thesis of this paper is that the foundational distinction in cognitive neuroscience between explicit (conscious) and implicit (unconscious) processes, corresponding to Themes 1 and 2, respectively, provides a unifying framework that makes empirical research on unconscious emotional processes more tractable. A psychological model called "levels of emotional awareness" is presented first that places implicit and explicit emotional processes on a cognitive-developmental continuum. This model holds that the ability to become consciously aware of one's own feelings is a cognitive skill that goes through a developmental process similar to that which Piaget described for other cognitive functions. Empirical findings using the Levels of Emotional Awareness Scale are presented. A parallel hierarchical model of the neural substrates of emotional awareness is presented next supported by recent neuroimaging and lesion work. The evidence presented in this review suggests that the neural substrates of implicit and explicit emotional processes are distinct, that the latter have a modulatory effect on the former, and that at the neural level Theme 1 and Theme 2 phenomena share critical similarities. The implications of this psychobiological model for research in psychosomatic medicine are discussed.     

Psychosomatic and mental pathology as essential and interrelated parts of general human pathology

The authors suggest extending the list of conventionally studied general pathological processes with psychosomatic and mental variants of pathology. These variants are relatively new in respect to evolution, are characteristic only for man and, in much lesser degree, for higher animals and have gained recognition in the last 50-100 years by defining the modern specificity of the nosological principle in medicine. The analysis of psychosomatic and psychic aspects of diseases may be of key importance for further development of general human pathology as a science.     

An exploratory analysis of U.S. FDA Class I medical device recalls: 2014–2018

Abstract

Medical device manufacturing and distribution is globalised; consequently, medical device failures pose serious but preventable global public health hazard. Moreover, a clear understanding of recalls will help firms improve their operations. This study examines 871?U.S. FDA Class I (i.e. most serious) medical device recalls, highlights the shortcomings of the recall reporting system and proposes recommendations for improvement. Top three recall reasons are: “packaging” (47.4%), “component” issues (14%) and “design” (13.3%). About 40% of recall events have mischaracterised or ambiguous “FDA Determined Cause”. Ninety-four firms are related to the recalls and the majority (78%) of the recall events emanate from U.S.-headquartered firms. Thirty-four firms (36%) have been acquired or are a subsidiary of another. Results also yield recommendations for improvement. The cause classification scheme needs revision and there might be a case for more than one classification scheme. Specifically, the “device design” cause designation is conflated with “component quality” issues. “Other”, “unknown” and “under investigation” designations should be replaced with real cause determinations. The effectiveness of “Good Manufacturing Practices (GMP)” and the impact of mergers and acquisitions (M&A) on device quality should be examined. Devising a “recall severity measure” and improving and standardising the recalls database are other important issues. Results and recommendations may hold lessons for other jurisdictions as well.     

Knowing versus doing: The value of behavioral change models for emotional communication in oncology

Responding to emotion is a central function of communication in medicine. However, many clinicians miss opportunities to engage their patients’ emotions, and these lapses can negatively affect the patient’s relationship with the clinician. As such, responding to emotion serves as a useful example of communication challenges in cancer care. The clinician’s response to emotion is likely influenced by cognitive, social, economic, and cultural factors. In psychology, models of behavioral change seek to understand and predict how individuals will act in specific circumstances by incorporating these multiple determinants. However, behavioral change models have not been applied specifically or rigorously to clinicians’ communication behaviors in oncology. In this article, we argue that applying such models in oncology can provide benefits to clinicians and communication researchers. To frame this argument, we will apply the Information–Motivation–Behavioral Skills (IMBS) model of behavioral change to communication about emotion in oncology. We will then propose specific ways in which applying behavioral change models to communication can benefit clinicians and patients. Improving communication behaviors requires more than commonsense solutions. Behavioral change models might support the enactment of communication skills and knowledge, bridging the gap between “knowing” and “doing.”     

What does the word "psychosomatic" really mean? A historical and semantic inquiry

Semantics and history of psychosomatic medicine are not popular topics nowadays, if they ever were; yet both of them constitute indispensable facets of any discipline that lays claim to a separate identity, as psychosomatics does. The latter, being an inchoate and inherently complex field of study, is especially in need of repeated efforts to clarify the meaning of its key terms, to delineate its scope, and to chart its development over time. Such efforts should pay off in improved teaching of this subject and in more effective communication with workers in other disciplines and with the general public. I have tried in this paper to sketch the historic development of psychosomatic conceptions and address some relevant semantic issues. It appears that early in this century, the convergence of two ancient conceptions, the holistic and the psychogenic, prepared the ground for the emergence in the 1930s of psychosomatic medicine as an organized scientific discipline and a counterreformation against the mechanistic view of man and medicine. Those two conceptions came to be subsumed by the word "psychosomatic" and thus contributed its two distinct connotations. The latter have not usually been clearly distinguished; hence, the ambiguity of the term. I have argued that only the holistic connotation should be retained, as it properly conveys the contemporary viewpoint. It is unfortunate that the word "holistic" has been appropriated recently by an anti-scientific and antiintellectual so-called "holistic health movement" (67), with resulting increment in semantic confusion and, in the eyes of many, loss of credibility for the misappropriated term. However, to retain it has merit as it is short, simple, and derived from the Greek - as were the very conceptions it has come to connote. Moreover, "holistic" has been part of the basic vocabulary of psychosomatic medicine from the beginning and conveys its core premises and purpose faithfully. As a historian aptly put it, the historic function of the psychosomatic movement has been to "vitalize the whole of medicine, psychiatry no less . . . with the holistic and ecologic viewpoint" (59, p. 9).(ABSTRACT TRUNCATED AT 400 WORDS)     

The phylogenetic approach for viral infectious disease evolution and epidemiology: An updating review

In the last decade, the phylogenetic approach is recurrent in molecular evolutionary analysis. On 12 May, 2019, about 2 296 213 papers are found, but typing “phylogeny” or “epidemiology AND phylogeny” only 199 804 and 20 133 are retrieved, respectively. Molecular epidemiology in infectious diseases is widely used to define the source of infection as so as the ancestral relationships of individuals sampled from a population. Coalescent theory and phylogeographic analysis have had scientific application in several, recent pandemic events, and nosocomial outbreaks. Hepatitis viruses and immunodeficiency virus (human immunodeficiency virus) have been largely studied. Phylogenetic analysis has been recently applied on Polyomaviruses so as in the more recent outbreaks due to different arboviruses type as Zika and chikungunya viruses discovering the source of infection and the geographic spread. Data on sequences isolated by the microorganism are essential to apply the phylogenetic tools and research in the field of infectious disease phylodinamics is growing up. There is the need to apply molecular phylogenetic and evolutionary methods in areas out of infectious diseases, as translational genomics and personalized medicine. Lastly, the application of these tools in vaccine strategy so as in antibiotic and antiviral researchers are encouraged.     

The alexithymia construct. A potential paradigm for psychosomatic medicine

During the past decade, the alexithymia construct has undergone theoretical refinement and empirical testing and has evolved into a potential new paradigm for understanding the influence of emotions and personality on physical illness and health. Like the traditional psychosomatic medicine paradigm, the alexithymia construct links susceptibility to disease with prolonged states of emotional arousal. But whereas the traditional paradigm emphasizes intrapsychic conflicts that are presumed to generate such emotional states, the alexithymia construct focuses attention on deficits in the cognitive processing of emotions, which remain undifferentiated and poorly regulated. This paper reviews the development and validation of the construct and discusses its clinical implications for psychosomatic medicine.     

The flavour of emotions

Emotions in psychotherapy are considered in the light of contemporary emotion theory, of neuroimaging, of narratives about emotion, and in relation to emotional disorder. One difficulty in comparing these different theories is that the term “emotion” is itself used differently. According to some theories, emotions are discrete conscious experiences, but according to others, a person may have and be influenced by emotions of which they are not aware. “Unconscious” emotions are of particular interest to the psychotherapist. The wide range of happenings that are associated with them are considered, and a general term proposed for them—“emotor”. The main point of the paper is to establish that emotors may have an emotional flavour which is capable of inducing an emotion in a person who experiences the emotor, and that this is not the same process as a person reacting emotionally to an emotor. Emotors may acquire their emotional flavour, and their capacity to induce emotions, independent of a subject experiencing the emotion. This, it is argued, is one reason why we may experience emotions not just as reactions, but as given to us by the world. It may also be an explanation for some aesthetic or religious feelings being experienced as both transcendent and real.     

Specificity revisited and updated

Typicality is probably a better representation of Alexander, Dunbar and others' conclusions than specificity, which was always too absolute a term. As such it became a valid cause of objection by opponents. No genuine attempts to repeat the original studies have been made and most of the original opposition to the concept is now acknowledged as invalid. Typicality (specificity) in psychosomatic disorders appears to be conferred by coping mechanisms acquired through interaction with mother and early surrogates in infancy and childhood as a means of reducing tensions and restoration of homeostatic emotional equilibrium. Psychosomatic medicine patients share one such mechanism, notably superstability/alexythymia, but contained within it are coping mechanisms typical for differing disorders. Examples are listed, and also mention of typicality of recurrently provocative life events/situations. Until typicality is appreciated, taught, learned and practised, success in management of psychosomatic disorders will be limited. The current bio-psycho-social approach is too imprecise.     

The curious 2000-year case of asthma

Millions worldwide have asthma, with the numbers succumbing increasing sharply in the past two decades. After 2000 years of scientific study, who succumbs to asthma when is as puzzling as who regains health when and how. The discipline of psychosomatic medicine and science investigates and treats diseases like asthma that typically confound general medicine. Still psychosomatic medicine, like general medicine, only manages but does not remedy asthma, which can currently only be in remission but not cured. This historical review reveals the progress and missteps that have been made in the study and treatment of asthma by comparing the general medicine approach with the major research findings on asthma published over 60 years in Psychosomatic Medicine. Research has identified antecedent, collateral, and subsequent factors to scientifically describe and control this disease in terms of diagnosis, management, and treatment. Paradoxically and regrettably, the prognosis for those with asthma is worse than ever. Curious also that a noninfectious disease should spread so rapidly and mostly for specific groups identified by variables like age, gender, ethnicity, and socioeconomic status. Furthermore, partial, not full, family concordance indicates merely genetic influence, not determination. General medicine now focuses on enumerating the range of environmental and situational triggers, or stimuli, producing asthma and describing the pathophysiology of bronchial inflammation. With a more comprehensive multifactorial approach, psychosomatic medicine seems well suited to investigate further the physiological, psychological, social, and environmental factors implicated in this medical conundrum. A future challenge for psychosomatic medicine is to stem the tide of rising prevalence and cure the disease of asthma.     

Measurement of psychological distress and well-being

Psychological distress and well-being are important aspects of quality of life measurements in psychosomatic medicine. The concept of improvement in medicine refers to a clinical distance along which the current state of the patient is compared to the pretreatment position. Quality of life covers, however, more than one distance or dimension in this respect; e.g. well-being, side effects of treatment, and psychosocial stressors. The psychometric aspects of these dimensions are analysed with reference to nomothetic and idiographic methods. The nomothetic approach is the selection of the most unbiased scale tailored to the disorder under investigation. The idiographic approach is the construction of a hermeneutical or meaningful scale for the individual patient. For both methods the clinical improvement index is the most appropriate statistic.     

The Diagnosis of Love-Sickness: Experimental Psychophysiology Without the Polygraph

Psychophysiological concepts and methodology are central to the practices of Erasistratos, Galen, and Avicenna, great physicians of antiquity whose lives span a period in history from the third century, B.C., to the eleventh century, A.D. This point is illustrated by means of a diagnostic vignette common to all three physicians’clinical experience, namely, the discovery of a concealed love object by monitoring changes in pulse rate. Within the context of these case sketches can be found the seeds of modern concepts in psychophysiology and psychosomatic medicine. Some of the texts examined are new translations of Greek and Latin originals.     

Integrative Medicine in Allergy and Immunology

Integrative medicine is a relatively new discipline which attempts to combine allopathic medicine with alternative or complementary medicine, to reap the benefits of both forms of medicine in optimizing the care of patients. Integrative medicine concentrates on treating the patient as a whole, both in body and mind. While the scientific method and “evidence-based” clinical research drives the management and treatment of diseases in conventional Western medicine, alternative or complementary medicine is based on unproven yet potentially beneficial techniques that have been developed throughout history, dating back to the ancient cultures in the Middle East, Africa, and China. In spite of the lack of evidence of most alternative medicine techniques, these methodologies have been practiced for centuries with great acceptance in many countries. It is in the Western world, where “modern” medicine is dictated by the scientific method, that the most controversy in the use of these alternative modes of therapy exists. Since the science behind alternative medicine is incomplete or non-existent, it is difficult for those trained in Western medicine to accept or adopt this approach. But perhaps it is the failure of Western medicine to adequately guarantee our well being and good health that have led to the ongoing debate between the medical profession and the general public as to the benefits of these alternative treatments. In one sense, integrative medicine may be a futile attempt to coin a new term in the hope of legitimizing alternative medicine. On the other hand, there is a wealth of historical experience in the use of the techniques. Studies to evaluate the scientific basis behind ancient medical techniques are ongoing, and it is to be expected that the results will neither be uniformly positive nor negative. Of particular interest is the effect of traditional medicine, herbal formulations, and manipulative techniques on the immune system, and its application in the treatment of autoimmune and allergic diseases. Studies are being designed or conducted to investigate immune effects of herbal formulations or their components. Herbal plants or medicines may lead to skewing of the Th1/Th2 balance in either direction, thus may offer potential application in the treatment of allergic or autoimmune diseases.     

Teaching psychosomatic (biopsychosocial) medicine in United States medical schools: survey findings

OBJECTIVE: A survey of US medical schools regarding the incorporation of psychosomatic (biopsychosocial) medicine topics into medical school curriculum was conducted. The perceived importance and success of this curriculum, barriers to teaching psychosomatic medicine, and curricular needs were also assessed. METHODS: From August 1997 to August 1999, representatives of US medical schools were contacted to complete a survey instrument either by telephone interview or by written questionnaire. RESULTS: Survey responses were received from 54 of the 118 US medical schools contacted (46%). Responses were obtained from representatives of both public (57%) and private (43%) institutions. Only 20% of respondents indicated that their schools used the term "psychosomatic medicine"; the terms "behavioral medicine" (63%) and "biopsychosocial medicine" (41%) were used more frequently. Coverage of various health habits (eg, substance use and exercise) ranged from 52% to 96%. The conceptualization and/or measurement of psychosocial factors (eg, stress and social support) was taught by 80% to 93% of schools. Teaching about the role of psychosocial factors in specific disease states or syndromes ranged from 33% (renal disease) to 83% (cardiovascular disease). Coverage of treatment-related issues ranged from 44% (relaxation/biofeedback) to 98% (doctor-patient communication). Topics in psychosomatic medicine were estimated to comprise approximately 10% (median response) of the medical school curriculum. On a scale of 1 (lowest) to 10 (highest), ratings of the relative importance of this curriculum averaged 7 (SD = 2.5; range = 2-10). Student response to the curriculum varied from positive to mixed to negative. Perceived barriers to teaching psychosomatic medicine included limited resources (eg, time, money, and faculty), student and faculty resistance, and a lack of continuity among courses. Sixty-three percent of respondents expressed an interest in receiving information about further incorporation of topics in psychosomatic medicine into their school's curriculum. CONCLUSIONS: Results of this survey reveal variable coverage of specific psychosomatic medicine topics in the medical school curriculum and differential use of nomenclature to refer to this field. There is a need for further curricular development in psychosomatic medicine in US medical schools.     

Barriers to integrating personalized medicine into clinical practice: a best-worst scaling choice experiment

PurposeAs advances in genomics make genome sequencing more affordable, the availability of new genome-based diagnostic and therapeutic strategies (i.e., personalized medicine) will increase. This wave will hit front-line physicians who may be faced with a plethora of patients’ expectations of integrating genomic data into clinical care. The objective of this study was to elicit the preferences of physicians about regarding applying personalized medicine in their clinical practice as these strategies become available.MethodsUsing a best–worst scaling (BWS) choice experiment, we estimated the relative importance of attributes that influence physicians’ decision for using personalized medicine. Six attributes were included in the BWS: type of genetic tests, training for genetic testing, clinical guidelines, professional fee, privacy protection laws, and cost of genetic tests. A total of 197 physicians in British Columbia completed the experiment. Using latent class analysis (LCA), we explored the physicians’ heterogeneities in preferences.Results“Type of genetic tests” had the largest importance, suggesting that the physicians’ decision was highly influenced by the availability of genetic tests for patients’ predisposition to diseases and/or drug response. “Training” and “guidelines” were the attributes with the next highest importance. LCA identified two classes of physicians. Relative to class 2, class 1 had a larger weight for the “type of genetic tests,” but smaller weights for “professional fee” and “cost of tests.”ConclusionWe measured relative importance of factors that affect the decision of physicians to incorporate personalized medicine in their practice. These results can be used to design the policies for supporting physicians and facilitating the use of personalized medicine in the future.Genet Med 2012:14(5):520–526