M. J. MARTIN, M.D.
~YOf PSYCHOSOMATIC
MEOlONE
Psychosomatic medicine: A brief history The word "psychosomatic" is derived from the Greek words "psyche" meaning to breathe, and "soma" meaning body. Heinroth first used the word "psychosomatic" in 1818, when he discussed the two indivisible aspects of the self" Four years later, Jacobi used the term "somatopsychic" when he discussed soma tic aspects of illness. Psychosomatic medicine became the complex interface between the expanding behavioral and medical sciences-a bridge between the psyche and the soma. Although the mysterious and elusive interrelationships between mind and body have fascinated man for centuries, only within recent decades has psychophysiologic medicine been of scientific interest as a separate discipline. It was because of interest in this special area that the Academy of Psychosomatic Medicine was formed twenty-five years ago. This quarter-century milestone serves as an opportunity to trace the history of psychosomatic medicine. Primitive man believed disease was caused by spiritual powers that had to be fought by spiritual NOVEMBER 1978· VOL 19· NO II
means. He felt that evil spirits entered the body, affecting the total being. Therapy was directed at relieving men possessed of these evil spirits, and ranged from exorcism to trepanation. The medicine man of the day utilized the will to health by the power of suggestion in the best tradition of the doctor-patient relationship. Apparently primitive medicine men emphasized a holistic concept rather than a dichotomized psyche and soma. 2 The more advanced Egyptian and Babylonian cultures also believe that death and disease come into the body from the outside.) Religion played a great part. in these cultures, in the treatment of sick people. Late Assyrian civilization (about 500 B.C.) was the first to view disease as originating within the patient rather than coming upon him from outside. Assyrian texts noted that "the sick man was a sinner," and emphasized prayer and sacrifice as a form of therapy. The early Hebrews also felt that disease was predominantly punishment suffered for disobeying God or his laws. Early biblical refer-
ences note that group sin was often punished by pestilence or plague.) Greek medical culture, dominated by Hippocrates and his followers, emphasized the need for observation and theories of diseases. At that time (300-400 B.C.), it was believed that illness originated within the body and was due to an imbalance of fluid matter. Greek physicians emphasized that this imbalance could be related to, or even caused by, a similar imbalance in the patient's external environment. The elements, temperament, and body fluids all interrelated to produce disease. Aristotle observed that the emotions of anger, fear, courage, and joy affect the body. Hippocrates described depression, anxiety, and dementia or delirium. Roman medicine, personified by the Greek physician Galen, was an eclectic and often confusing summation of Greek medicine. However, the emphasis on the brain as the center of sensation, motion, and reason, together with a holistic approach to medicine, was to become the foundation of European medicine for 697
Psychosomatic medicine
one thousand years. During this millennium, a confusing array of pseudoscience, magic, and spiritual issues, dominated by a strong religious approach, pervaded all of medicine. 2 During the Renaissance (15001700), there occurred a renewed interest in the cause and effect of natural phenomena. Many great thinkers of the time became involved in the dramatic changes that led to more scientific inquiry about man and his environment. The philosopher Rene Descartes (15961650) had a significant influence on the ancient mind-body relationship,3 by renouncing all formerly held beliefs and starting afresh. Descartes' famous phrase "I think, therefore I am" gave substance to his logical explanation about the existence of spirit. However, this led to the Cartesian dualism of the mind (spirit) as being a separate and distinct entity from the body. This philosophic concept was followed by Morgagni and others who, by studying tissue at autopsies, realized that a disturbed organ could cause disease and death. Gradually, the mind came to be discussed only by philosophers, the soul by theologians, the body by physicians; and the emotions were ignored by all. Eventually, it became common to treat the disease and not the patient-a problem that continues to exist. This attitude had its foundation in the 19th century, when the mind-body schism spread widely and the ultimate soma became the cell. The healthy cell was the source of health, the diseased cell the source of bodily disease. Virchow, the German pathologist, emphasized that disease had its origin in the cell, as did Pasteur. His laboratory work was based on somatic 698
medicine and ignored the relationship between the psyche and soma, despite the fact that it had been noted by Heinroth, Jacobi, and Beaumont. Although Mesmer found that he could modify the course of physical symptoms through what we now call hypnotism, his work was widely criticized and largely ignored by the medical-scientific community.4 Hypnosis gained acceptance in the latter part of the 19th century when the French neurologist Charcot demonstrated the role of psychologic factors in the genesis of physical symptoms such as hysterical seizures, and used hypnosis for treatment. He directly influenced Freud who became more interested in the emotional problems of his patients, thus bringing back together the psyche and soma. Freud had a holistic outlook that went beyond reuniting the psyche and soma. He was influential in reinstating the therapeutic doctor-patient relationship, and saw the role of psychotherapy as a potent force in healing certain types of patients. Freud's classic papers on the psychodynamics of anxiety and conversion hysteria created models that physicians who were interested in psychoanalytic techniques subsequently applied to a variety of illnesses during the developmental years of what we now refer to as psychosomatic medicine. Paralleling the development of Freud's psychologic theories that explained physiologic disturbances were the studies of Sherrington, Pavlov, Cannon, and Selye that clarified the neurophysiologic mechanisms involved. 5 In 1906, Sherrington demonstrated that even the simplest reflex arc is subject to continuous alteration and even reversal by cognitive influ-
ences from the central nervous system. This indicated that significant psychologic processes such as learning are related to behavioral discharge. Pavlov's important work set the stage for what was later to be called the learning theories of behavior that eventually led to behavior modification, .~seful for the treatment of some neurotic illnesses. Cannon's experimental work in the I920s led to the discovery of adrenergic transmitter substances, and emphasized the hormonal aspects of behavior; he used the term "homeostasis" to denote total body equilibrium. In the I940s, Selye further clarified the body's organized reaction to stress, which he called the general adaptation syndrome. He focused on the response of the pituitary-adrenocortical system to stress and the role of ACTH as a mediator. The discoveries of all these novel thinkers and other neurophysiologic investigators were synthesized in the psychosoma tic theories of Flanders Dunbar and Franz Alexander. 7 Both were directly influenced by Freud and Cannon, and both elaborated on the role of the autonomic and hormonal pathways in mediating visceral dysfunction. Dunbar was the first investigator to systematically correlate particular personality profiles with specific organic illness. She believed that psychosomatic illness resulted from the overactivity of the autonomic nervous system and the endocrine glands in their attempts to inhibit discharge of psychologic tension. Although empirical studies have failed to support this hypothesis, Dunbar was important for her role in systematizing psychosomatic medicine as a distinct branch of medicine. Alexander's "organ specificity" PSYCHOSOMATICS
hypothesis was based on psychoanalytic theory.7 He proposed that specific stresses evoke specific unconscious neurotic conflicts that result in specific organic diseases; that psychosomatic illness depends on a constitutional vulnerability, particular personality patterns, and a precipitating stress to produce the pathology. Alexander and his associates in Chicago studied seven illnesses-asthma, peptic ulcer, ulcerative colitis, hypertension, thyrotoxicosis, rheumatoid arthritis, and neurodermatitis-which they believed were distinctly psychosomatic disorders; psychoanalytic therapy was their treatment of choice. Although the influence of Alexander and his group was once dominant, in recent years many modifications have been made in their theories. Thus, in 1953, when the Academy of Psychosomatic Medicine was formed, the field seemed to be exploding with knowledge. To important questions about the causes of disease, answers seemed just over the horizon. Only one year earlier, the American Psychiatric Association's first edition of Diagnostic and Statistical Manual of Mental Disorders used the term "Psychophysiological Autonomic and Visceral Disorder" to describe what is now commonly called "Psychosomatic Disorder.''8 The term was rather cumbersome and has not endured. The proposed nomenclature that may go into effect in the 1979 third edition reads "Psychological Factors Affecting Physical Disorder.''9 This is a more general category that subsumes a large variety of disorders such as obesity, migraine headache, angina pectoris, dysmenorrhea, rheumattoid arthritis, ulcerative colitis, hyperthyroidism, and many more. NOVEMBER 1978 • VOL 19 • NO II
This rubric does not include conversion disorders, however. Psychosomatic studies since 1953 During the past twenty-five years there has been an exponential growth in studies related to psychosomatic disorders. Fortunately, the field has broadened to include a wide variety of conditions affecting all areas of the body that are influenced directly and indirectly by emotional and psychologic responses. It has been shown that psychologic variables or conflicts are not good predictors of specific psychosomatic illnesses. Rather, patients who have psychosomatic illnesses have a wide range of personality types and conflicts. The same psychologic conflicts and variables have been implicated across a broad spectrum of illnesses. Statistical correlations among psychologic conflicts, personality traits, and somatic illness are not the same as causal factors; and much research based on the specificity hypothesis has been misleading in its conclusions because of the erroneous equation of correlation and cause. In 1953, Mahl formulated a nonspecific hypothesis of psychosomatic illness, proposing that a multitude of stresses, rather than one specific psychologic stress, are important in the genesis of psychosomatic illness. lo He emphasized that heredity, constitution, and conditioning are crucial in determining which organ becomes the site of disease. Any stressful event may evoke chronic anxiety, but on the other hand, what is construed as stress for one person may not be stressful for another. This hypothesis implies that any event that evokes an excessive emotional reaction may precipitate a psychosomatic illness in a constitutionally
vulnerable organ which has possibly had early pathologic conditioning. This hypothesis is consistent with the current extensive body of research and clinical literature. Genetic influences, prior exposure to illness and stress, operant conditioning, personality, and individual coping strategies have all been invoked to explain the enduring psychologic and physiologic response characteristics and an individual's susceptibility to disease. This view has led Malmo to propose an individual response specificity hypothesis which indicates that a wide range of stimuli evokes physiologic responses specific for the individual and is consistent over time.s This hypothesis implies that certain people react in a certain way to many different and unrelated stresses without an anxiety state as an intervening variable. Unlike the specificity hypothesis of Alexander, there is an assumption that a wide range ofstimuli and a wide range of psychodynamic factors may account for specific psychosomatic illness. Many authors have pointed out that there is no certain relationship between any single emotional process and a specific disease. That is, dependency conflicts may be present in patients who have peptic ulcer disease, rheumatoid arthritis, muscle-contraction headaches, or many other illnesses. The use of the term "specificity" has resulted in much perplexing but as yet unresolved debate. The field has been widened by a number of studies on socio-environmental factors and a correlation of these factors with physiologic dysfunction or illness in various populations. This ecologic approach began with broad surveys of illness indices in different socioeconomic groups. Schwab ll has 699
Psychosomatic medicine
correlated many social factors with disease in large populations. The concept of stress has led to investigations focused on milieu effects. Holmes and Rahe l2 have noted that a wide variety of illnesses may be preceded by disruption or life change. Other authors have studied separation and loss as a precipitating factor of illness. Animal models have been used to elucidate some of the relevant mechanisms in an attempt to unravel the complex interaction between social deprivation and physiologic mechanisms. The biologic studies that began in the early part of the 20th century continue. Cannon's work on adrenalin and Selye's work on the pituitary adrenal responses to stress have served as touchstones for many studies of these actions believed to be mediated by the endocrine system. A large body of work has developed that shows how the endocrine system represents an integrated and intercommunicating machinery under the adaptive direction of the brain. 13 Catecholamines and other transmitter substances appear to be of key importance not only to the peripheral autonomic nervous system but also in the brain. Neurotransmitter substances that cause disturbances in central functioning are believed to influence schizophrenia and depression. A great many messenger substances are involved in the complexities of the central and peripheral nervous system. Genetic factors may also control functioning of individual cells, and in some instances hormones may influence the activity of genetic behavior.
Basic scientists are beginning to get the picture of a complex neuroendocrine, neurochemical, and enzymatic network of mechanisms and pathways that makes it possible to trace adaptive responses from the highest brain centers to an enormous variety of peripheral pathways down to the cellular and even molecular level. Meanwhile, behavioral scientists have continued to expand their knowledge of learning in the broadest sense, and operant learning more specifically, and can now elucidate selective response, maintain positive reinforcement, or terminate negative reinforcement. Miller l4 has described visceral learning in a large number of organ systems in lower animals; and studies of heart rate, blood pressure, alpha rhythms, and muscle cell potential in humans have shown some capacity for operant learning guided by feedback from visceral outputs. This implies that human purpose can influence visceral functions and play an active role in the control of autonomic behavior, a concept that was anathema to physiologists only a generation ago. Where does this leave psychosomatic medicine now? Our predecessors bequeathed us much information and many questions, but we have few answers. Although the history of psychosomatic medicine includes much imaginative speculation, often the necessary rigorous empirical testing was missing. Many classic studies have not been replicated because they lack validation. Only recently has good re-
Dr. Martin is professor and chairman, department ofpsychiatry andpsychology, Mayo Clinic and Mayo Medical School. Reprint requests to him there, Rochester, MN 55901. 700
search with adequate controls been conducted. Skepticism plus accurate descriptions of observations rather than the application of unproven theories are needed. Past confusions must be clarified and new knowledge shared. The Academy of Psychosomatic Medicine and its journal, Psychosomatics, will continue to emphasize a comprehensive, holistic view of illness. The Silver Anniversary of the Academy gives us time to reflect, but the past is prologue-our hope is to learn from it as we continue our efforts to build the bridge between psyche and soma. 0
REFERENCES ,. Alexander FG, Selesnick ST: The History of Psychiatry. New York, Harper & Row, 1966. 2. Zilboorg G: A History of Medical Psychology. New York, WW Norton, 1941. 3. Kaplan HI: History of psychophysiological medicine in Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, /I. Baltimore, Williams & Wilkins, 1975, pp 1624-1631. 4. Schneck JM: A History of Psychiatry. Springfield, III, Charles C Thomas, 1960. 5. Sheehan DV, Hacke" TP: Psychosomatic disorders in Nicholi AM Jr (ed): The Harvard Guide to Modern Psychiatry. Cambridge, Harvard University Press, 1978, pp 319-353. 6. Dunbar F: Psychosomatic Diagnosis. New York, Hoeber, 1943. 7. Alexander F, French T: Studies in Psychosomatic Medicine. New York, Ronald Press, 1948. 8. American Psychialric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 1, Washington, DC, 1952. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 3 draft, Washington DC, 1978. 10. Mahl GF: Physiological changes during chronic fear. Ann NY Acad Sci 56:240-249, 1953. 11. Schwab JJ, McGinnis NH, Norris LB, et al: Psychosomatic medicine and the contemporary social scene. Am J Psychiatry 126:1632-1642,1970. 12. Holmes TH, Rahe RH: The Social Readjustmenl Rating Scale. J Psychos om Res 11:213-218,1967. 13. Martin JB, Reichlin S, Brown GM: Clinical Neuroendocrinology, Philadelphia, FA Davis Co, 1977. 14. Miller NE: Applications of learning and bioteed back to psychiatry and medicine in Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, II. Baltimore, Williams & Wilkins, 1975, pp 349-365.
PSYCHOSOMATICS
~YOf PSYCHOSOMATIC
MEOlONE
Psychosomatic medicine: A brief history The word "psychosomatic" is derived from the Greek words "psyche" meaning to breathe, and "soma" meaning body. Heinroth first used the word "psychosomatic" in 1818, when he discussed the two indivisible aspects of the self" Four years later, Jacobi used the term "somatopsychic" when he discussed soma tic aspects of illness. Psychosomatic medicine became the complex interface between the expanding behavioral and medical sciences-a bridge between the psyche and the soma. Although the mysterious and elusive interrelationships between mind and body have fascinated man for centuries, only within recent decades has psychophysiologic medicine been of scientific interest as a separate discipline. It was because of interest in this special area that the Academy of Psychosomatic Medicine was formed twenty-five years ago. This quarter-century milestone serves as an opportunity to trace the history of psychosomatic medicine. Primitive man believed disease was caused by spiritual powers that had to be fought by spiritual NOVEMBER 1978· VOL 19· NO II
means. He felt that evil spirits entered the body, affecting the total being. Therapy was directed at relieving men possessed of these evil spirits, and ranged from exorcism to trepanation. The medicine man of the day utilized the will to health by the power of suggestion in the best tradition of the doctor-patient relationship. Apparently primitive medicine men emphasized a holistic concept rather than a dichotomized psyche and soma. 2 The more advanced Egyptian and Babylonian cultures also believe that death and disease come into the body from the outside.) Religion played a great part. in these cultures, in the treatment of sick people. Late Assyrian civilization (about 500 B.C.) was the first to view disease as originating within the patient rather than coming upon him from outside. Assyrian texts noted that "the sick man was a sinner," and emphasized prayer and sacrifice as a form of therapy. The early Hebrews also felt that disease was predominantly punishment suffered for disobeying God or his laws. Early biblical refer-
ences note that group sin was often punished by pestilence or plague.) Greek medical culture, dominated by Hippocrates and his followers, emphasized the need for observation and theories of diseases. At that time (300-400 B.C.), it was believed that illness originated within the body and was due to an imbalance of fluid matter. Greek physicians emphasized that this imbalance could be related to, or even caused by, a similar imbalance in the patient's external environment. The elements, temperament, and body fluids all interrelated to produce disease. Aristotle observed that the emotions of anger, fear, courage, and joy affect the body. Hippocrates described depression, anxiety, and dementia or delirium. Roman medicine, personified by the Greek physician Galen, was an eclectic and often confusing summation of Greek medicine. However, the emphasis on the brain as the center of sensation, motion, and reason, together with a holistic approach to medicine, was to become the foundation of European medicine for 697
Psychosomatic medicine
one thousand years. During this millennium, a confusing array of pseudoscience, magic, and spiritual issues, dominated by a strong religious approach, pervaded all of medicine. 2 During the Renaissance (15001700), there occurred a renewed interest in the cause and effect of natural phenomena. Many great thinkers of the time became involved in the dramatic changes that led to more scientific inquiry about man and his environment. The philosopher Rene Descartes (15961650) had a significant influence on the ancient mind-body relationship,3 by renouncing all formerly held beliefs and starting afresh. Descartes' famous phrase "I think, therefore I am" gave substance to his logical explanation about the existence of spirit. However, this led to the Cartesian dualism of the mind (spirit) as being a separate and distinct entity from the body. This philosophic concept was followed by Morgagni and others who, by studying tissue at autopsies, realized that a disturbed organ could cause disease and death. Gradually, the mind came to be discussed only by philosophers, the soul by theologians, the body by physicians; and the emotions were ignored by all. Eventually, it became common to treat the disease and not the patient-a problem that continues to exist. This attitude had its foundation in the 19th century, when the mind-body schism spread widely and the ultimate soma became the cell. The healthy cell was the source of health, the diseased cell the source of bodily disease. Virchow, the German pathologist, emphasized that disease had its origin in the cell, as did Pasteur. His laboratory work was based on somatic 698
medicine and ignored the relationship between the psyche and soma, despite the fact that it had been noted by Heinroth, Jacobi, and Beaumont. Although Mesmer found that he could modify the course of physical symptoms through what we now call hypnotism, his work was widely criticized and largely ignored by the medical-scientific community.4 Hypnosis gained acceptance in the latter part of the 19th century when the French neurologist Charcot demonstrated the role of psychologic factors in the genesis of physical symptoms such as hysterical seizures, and used hypnosis for treatment. He directly influenced Freud who became more interested in the emotional problems of his patients, thus bringing back together the psyche and soma. Freud had a holistic outlook that went beyond reuniting the psyche and soma. He was influential in reinstating the therapeutic doctor-patient relationship, and saw the role of psychotherapy as a potent force in healing certain types of patients. Freud's classic papers on the psychodynamics of anxiety and conversion hysteria created models that physicians who were interested in psychoanalytic techniques subsequently applied to a variety of illnesses during the developmental years of what we now refer to as psychosomatic medicine. Paralleling the development of Freud's psychologic theories that explained physiologic disturbances were the studies of Sherrington, Pavlov, Cannon, and Selye that clarified the neurophysiologic mechanisms involved. 5 In 1906, Sherrington demonstrated that even the simplest reflex arc is subject to continuous alteration and even reversal by cognitive influ-
ences from the central nervous system. This indicated that significant psychologic processes such as learning are related to behavioral discharge. Pavlov's important work set the stage for what was later to be called the learning theories of behavior that eventually led to behavior modification, .~seful for the treatment of some neurotic illnesses. Cannon's experimental work in the I920s led to the discovery of adrenergic transmitter substances, and emphasized the hormonal aspects of behavior; he used the term "homeostasis" to denote total body equilibrium. In the I940s, Selye further clarified the body's organized reaction to stress, which he called the general adaptation syndrome. He focused on the response of the pituitary-adrenocortical system to stress and the role of ACTH as a mediator. The discoveries of all these novel thinkers and other neurophysiologic investigators were synthesized in the psychosoma tic theories of Flanders Dunbar and Franz Alexander. 7 Both were directly influenced by Freud and Cannon, and both elaborated on the role of the autonomic and hormonal pathways in mediating visceral dysfunction. Dunbar was the first investigator to systematically correlate particular personality profiles with specific organic illness. She believed that psychosomatic illness resulted from the overactivity of the autonomic nervous system and the endocrine glands in their attempts to inhibit discharge of psychologic tension. Although empirical studies have failed to support this hypothesis, Dunbar was important for her role in systematizing psychosomatic medicine as a distinct branch of medicine. Alexander's "organ specificity" PSYCHOSOMATICS
hypothesis was based on psychoanalytic theory.7 He proposed that specific stresses evoke specific unconscious neurotic conflicts that result in specific organic diseases; that psychosomatic illness depends on a constitutional vulnerability, particular personality patterns, and a precipitating stress to produce the pathology. Alexander and his associates in Chicago studied seven illnesses-asthma, peptic ulcer, ulcerative colitis, hypertension, thyrotoxicosis, rheumatoid arthritis, and neurodermatitis-which they believed were distinctly psychosomatic disorders; psychoanalytic therapy was their treatment of choice. Although the influence of Alexander and his group was once dominant, in recent years many modifications have been made in their theories. Thus, in 1953, when the Academy of Psychosomatic Medicine was formed, the field seemed to be exploding with knowledge. To important questions about the causes of disease, answers seemed just over the horizon. Only one year earlier, the American Psychiatric Association's first edition of Diagnostic and Statistical Manual of Mental Disorders used the term "Psychophysiological Autonomic and Visceral Disorder" to describe what is now commonly called "Psychosomatic Disorder.''8 The term was rather cumbersome and has not endured. The proposed nomenclature that may go into effect in the 1979 third edition reads "Psychological Factors Affecting Physical Disorder.''9 This is a more general category that subsumes a large variety of disorders such as obesity, migraine headache, angina pectoris, dysmenorrhea, rheumattoid arthritis, ulcerative colitis, hyperthyroidism, and many more. NOVEMBER 1978 • VOL 19 • NO II
This rubric does not include conversion disorders, however. Psychosomatic studies since 1953 During the past twenty-five years there has been an exponential growth in studies related to psychosomatic disorders. Fortunately, the field has broadened to include a wide variety of conditions affecting all areas of the body that are influenced directly and indirectly by emotional and psychologic responses. It has been shown that psychologic variables or conflicts are not good predictors of specific psychosomatic illnesses. Rather, patients who have psychosomatic illnesses have a wide range of personality types and conflicts. The same psychologic conflicts and variables have been implicated across a broad spectrum of illnesses. Statistical correlations among psychologic conflicts, personality traits, and somatic illness are not the same as causal factors; and much research based on the specificity hypothesis has been misleading in its conclusions because of the erroneous equation of correlation and cause. In 1953, Mahl formulated a nonspecific hypothesis of psychosomatic illness, proposing that a multitude of stresses, rather than one specific psychologic stress, are important in the genesis of psychosomatic illness. lo He emphasized that heredity, constitution, and conditioning are crucial in determining which organ becomes the site of disease. Any stressful event may evoke chronic anxiety, but on the other hand, what is construed as stress for one person may not be stressful for another. This hypothesis implies that any event that evokes an excessive emotional reaction may precipitate a psychosomatic illness in a constitutionally
vulnerable organ which has possibly had early pathologic conditioning. This hypothesis is consistent with the current extensive body of research and clinical literature. Genetic influences, prior exposure to illness and stress, operant conditioning, personality, and individual coping strategies have all been invoked to explain the enduring psychologic and physiologic response characteristics and an individual's susceptibility to disease. This view has led Malmo to propose an individual response specificity hypothesis which indicates that a wide range of stimuli evokes physiologic responses specific for the individual and is consistent over time.s This hypothesis implies that certain people react in a certain way to many different and unrelated stresses without an anxiety state as an intervening variable. Unlike the specificity hypothesis of Alexander, there is an assumption that a wide range ofstimuli and a wide range of psychodynamic factors may account for specific psychosomatic illness. Many authors have pointed out that there is no certain relationship between any single emotional process and a specific disease. That is, dependency conflicts may be present in patients who have peptic ulcer disease, rheumatoid arthritis, muscle-contraction headaches, or many other illnesses. The use of the term "specificity" has resulted in much perplexing but as yet unresolved debate. The field has been widened by a number of studies on socio-environmental factors and a correlation of these factors with physiologic dysfunction or illness in various populations. This ecologic approach began with broad surveys of illness indices in different socioeconomic groups. Schwab ll has 699
Psychosomatic medicine
correlated many social factors with disease in large populations. The concept of stress has led to investigations focused on milieu effects. Holmes and Rahe l2 have noted that a wide variety of illnesses may be preceded by disruption or life change. Other authors have studied separation and loss as a precipitating factor of illness. Animal models have been used to elucidate some of the relevant mechanisms in an attempt to unravel the complex interaction between social deprivation and physiologic mechanisms. The biologic studies that began in the early part of the 20th century continue. Cannon's work on adrenalin and Selye's work on the pituitary adrenal responses to stress have served as touchstones for many studies of these actions believed to be mediated by the endocrine system. A large body of work has developed that shows how the endocrine system represents an integrated and intercommunicating machinery under the adaptive direction of the brain. 13 Catecholamines and other transmitter substances appear to be of key importance not only to the peripheral autonomic nervous system but also in the brain. Neurotransmitter substances that cause disturbances in central functioning are believed to influence schizophrenia and depression. A great many messenger substances are involved in the complexities of the central and peripheral nervous system. Genetic factors may also control functioning of individual cells, and in some instances hormones may influence the activity of genetic behavior.
Basic scientists are beginning to get the picture of a complex neuroendocrine, neurochemical, and enzymatic network of mechanisms and pathways that makes it possible to trace adaptive responses from the highest brain centers to an enormous variety of peripheral pathways down to the cellular and even molecular level. Meanwhile, behavioral scientists have continued to expand their knowledge of learning in the broadest sense, and operant learning more specifically, and can now elucidate selective response, maintain positive reinforcement, or terminate negative reinforcement. Miller l4 has described visceral learning in a large number of organ systems in lower animals; and studies of heart rate, blood pressure, alpha rhythms, and muscle cell potential in humans have shown some capacity for operant learning guided by feedback from visceral outputs. This implies that human purpose can influence visceral functions and play an active role in the control of autonomic behavior, a concept that was anathema to physiologists only a generation ago. Where does this leave psychosomatic medicine now? Our predecessors bequeathed us much information and many questions, but we have few answers. Although the history of psychosomatic medicine includes much imaginative speculation, often the necessary rigorous empirical testing was missing. Many classic studies have not been replicated because they lack validation. Only recently has good re-
Dr. Martin is professor and chairman, department ofpsychiatry andpsychology, Mayo Clinic and Mayo Medical School. Reprint requests to him there, Rochester, MN 55901. 700
search with adequate controls been conducted. Skepticism plus accurate descriptions of observations rather than the application of unproven theories are needed. Past confusions must be clarified and new knowledge shared. The Academy of Psychosomatic Medicine and its journal, Psychosomatics, will continue to emphasize a comprehensive, holistic view of illness. The Silver Anniversary of the Academy gives us time to reflect, but the past is prologue-our hope is to learn from it as we continue our efforts to build the bridge between psyche and soma. 0
REFERENCES ,. Alexander FG, Selesnick ST: The History of Psychiatry. New York, Harper & Row, 1966. 2. Zilboorg G: A History of Medical Psychology. New York, WW Norton, 1941. 3. Kaplan HI: History of psychophysiological medicine in Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, /I. Baltimore, Williams & Wilkins, 1975, pp 1624-1631. 4. Schneck JM: A History of Psychiatry. Springfield, III, Charles C Thomas, 1960. 5. Sheehan DV, Hacke" TP: Psychosomatic disorders in Nicholi AM Jr (ed): The Harvard Guide to Modern Psychiatry. Cambridge, Harvard University Press, 1978, pp 319-353. 6. Dunbar F: Psychosomatic Diagnosis. New York, Hoeber, 1943. 7. Alexander F, French T: Studies in Psychosomatic Medicine. New York, Ronald Press, 1948. 8. American Psychialric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 1, Washington, DC, 1952. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 3 draft, Washington DC, 1978. 10. Mahl GF: Physiological changes during chronic fear. Ann NY Acad Sci 56:240-249, 1953. 11. Schwab JJ, McGinnis NH, Norris LB, et al: Psychosomatic medicine and the contemporary social scene. Am J Psychiatry 126:1632-1642,1970. 12. Holmes TH, Rahe RH: The Social Readjustmenl Rating Scale. J Psychos om Res 11:213-218,1967. 13. Martin JB, Reichlin S, Brown GM: Clinical Neuroendocrinology, Philadelphia, FA Davis Co, 1977. 14. Miller NE: Applications of learning and bioteed back to psychiatry and medicine in Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, II. Baltimore, Williams & Wilkins, 1975, pp 349-365.
PSYCHOSOMATICS
