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Psychosomatic Medicine
G. A. Fava; N. Sonino
Int J Clin Pract. 2010;64(10):1155-1161.

Abstract and Introduction

Abstract

Psychosomatic medicine may be defined as a comprehensive, interdisciplinary framework for: assessment of

psychological factors affecting individual vulnerability as well as course and outcome of illness; biopsychosocial
consideration of patient care in clinical practice; specialist interventions to integrate psychological therapies in
the prevention, treatment and rehabilitation of medical disease. The aim of this review was to provide an
updated definition of psychosomatic medicine, to outline its boundaries with related disciplines and to illustrate
its main contributions to clinical and preventive medicine. A review of the psychosomatic literature, using both
Medline and manual searches, with particular reference to articles, which could be relevant to clinical practice,
was performed. Current advances in the field have practical implications for medical research and practice, with
particular reference to the role of lifestyle, the challenge of medically unexplained symptoms, the psychosocial
needs entailed by chronic illness, the appraisal of therapy beyond pharmaceutical reductionism, the function of
the patient actively contributing to his/her health. Today, the field of psychosomatic medicine is scientifically
rigorous, more diversified and therapeutically relevant than ever before.

Introduction

The term 'psychosomatic' entails different meanings and connotations, which may explain its varying degrees
of popularity. Even though the concept was introduced by Heinroth in 1818, modern psychosomatic medicine
developed in the first half of the past century. It resulted from the confluence of two concepts having an ancient
tradition in Western thinking and medicine: psychogenesis of disease and holism. [1] The idea of psychogenesis
characterised the first phase of development of psychosomatic medicine (19301960) and resulted in the
concept of 'psychosomatic disease' (a physical illness, such as peptic ulcer, believed to be caused by
psychological factors). Despite early criticism, [2] the psychogenic postulate exerted a considerable seduction in
view of its explanatory power. Engel, Lipowski and Kissen deserve credit for setting, in the sixties, the ground
for the current psychosomatic view of the disease.

Engel developed a multifactorial model of illness, [3] named later 'biopsychosocial'.[4] It allows illness to be viewed
as a result of interacting mechanisms at the cellular, tissue, organismic, interpersonal and environmental levels.
Accordingly, the study of every disease must include the individual, his body and his surrounding environment
as essential components of the total system,[46] in what Hinkle in 1967 defined as an ecological perspective. [7]

Lipowski gave an invaluable contribution in setting the scope, mission and methods of psychosomatic
medicine.[1] He criticised the obsolete notion of psychogenesis, as it was incompatible with the doctrine of
multicausality, which constitutes a core postulate of current psychosomatic medicine.

Kissen provided a better specification of the term 'psychosomatic'. [8] He clarified that the relative weight of
psychosocial factors may vary from one individual to another within the same illness and underscored the basic
conceptual flaw of considering diseases as homogeneous entities.

Psychosomatic research, in the past decades, has resulted in an impressive body of knowledge, with
contributions published in all major medical journals and in specifically dedicated journals. The aim of this
review was to provide an updated definition of psychosomatic medicine, to outline its boundaries with related
disciplines, to illustrate its main contributions to clinical and preventive medicine and to discuss its main lines of
development.

Most of the content of the article is based on the findings of systematic reviews, controlled studies which
underwent replication and randomised controlled trials. Articles which were judged to be relevant to clinical
practice were selected.

Definition and Boundaries

Stemming from Lipowski's original definition[1] and subsequent developments,[9,10] psychosomatic medicine may
be defined as a comprehensive, interdisciplinary framework for:

assessment of psychosocial factors affecting individual vulnerability and course and outcome of any
type of disease;

holistic consideration of patient care in clinical practice;

integration of psychological therapies in the prevention, treatment and rehabilitation of medical disease
(psychological medicine).

Psychosomatic medicine has recently become in the U.S. a subspecialty recognised by the American Board of
Medical Specialties.[11] This may lead to identifying psychosomatic medicine with consultation-liaison psychiatry,
[11]
a subspecialty of psychiatry concerned with diagnosis, treatment and prevention of psychiatric morbidity in
the medical patient in the form of psychiatric consultations, liaison and teaching for non-psychiatric health
workers, especially in the general hospital. [12] Consultation liaison psychiatry is clearly within the field of
psychiatry; its setting is the medical or surgical clinic or ward, and its focus is the comorbid state of patients
with medical disorders.[13] Psychosomatic medicine is, by definition, [1,9,10] multidisciplinary. It is not confined to
psychiatry, but may concern any other field of medicine. Not surprisingly, in countries such as Germany and
Japan, psychosomatic activities have achieved an independent status and are often closely related to internal
medicine.[14]

Up to the seventies, psychosomatic medicine was the only site of research at the interface between medicine
and the behavioural sciences. In those years, however, behavioural medicine developed [15] as an
interdisciplinary field that integrates behavioural and biomedical knowledge relevant to health and disease. It
provided a room for an increasing number of psychologists dealing with basic laboratory research on the neural
and humoral systems controlled by the brain, on visceral learning and on other aspects of behaviour, which
lead to practical implications of medical significance. [16] Its focus on unhealthful behaviour and risk factors (such
as smoking and alcohol abuse) led to the development of the related discipline of health psychology. [17]

Interestingly, the general psychosomatic approach has resulted in a number of sub-disciplines within their own
areas of application: psycho oncology, psychonephrology, psychoneuroendocrinology, psychoimmunology,
psychodermatololgy and others. Such sub-disciplines have developed clinical services, scientific societies and
medical journals.

Assessment of Psychosocial Factors Affecting Individual Vulnerability

It is becoming increasingly clear that we can improve medical care by paying more attention to psychological
aspects of medical assessment, [18] with particular reference to the role of stress. [5,8,9,19] A number of factors have
been implicated to modulate individual vulnerability to disease. Some factors (such as healthy habits and
psychological well-being) positively promote health rather than merely reducing disease.

Early Life Events

The role of early developmental factors in susceptibility to disease has been a frequent object of psychosomatic
investigation.[5,19] Using animal models, events such as premature separation from the mother have consistently
resulted in development of pathophysiological modifications, such as increased hypothalamic-pituitary-adrenal
axis activation.[5,19] They may render the human individual more vulnerable to the effects of stress later in life.
There has been also considerable interest in the association of childhood physical and sexual abuse with
medical disorders, such as chronic pain and irritable bowel syndrome. [20] A history of childhood maltreatment
was significantly associated with several adverse health outcomes, e.g. functional disability and greater number
of health risk behaviours,[21] yet the evidence currently available does not allow any firm conclusions. [22]

Recent Life Events

The notion that events and situations in a person's life, which are meaningful to him or her may be followed by
ill health has been a common clinical observation. The introduction of structured methods of data collection and
control groups has allowed to substantiate the link between life events and a number of medical disorders,
encompassing endocrine, cardiovascular, respiratory, gastrointestinal, autoimmune, skin and neoplastic
disease.[19,2327]

Chronic Stress and Allostatic Load

Life changes are not the only source of psychological stress. Subtle and long-standing life situations should not
too readily be dismissed as minor and negligible, as chronic, daily life stresses may be experienced by the
individual as taxing or exceeding his/her coping skills. Mc Ewen and Stellar [23] proposed a formulation of the
relationship between stress and the processes leading to disease based on the concept of allostasis and the
ability of the organism to achieve stability through change. The concept of allostatic load refers to the wear and
tear that results from either too much stress or from insufficient coping, such as not turning off the stress
response when it is no longer needed (Figure 1). Biological parameters of allostatic load, such as glycosylated
proteins, coagulation/fibrinolysis markers and hormonal markers, have been linked to cognitive and physical
functioning and mortality.[19]
Interacting mechanisms in individual vulnerability

Health Attitudes and Behaviour

Unhealthy lifestyle is a major risk factor for many of the most prevalent diseases, such as diabetes, obesity and
cardiovascular illness.[28] In 1985, Geoffrey Rose[29] showed that the risk factors for health are almost always
normally distributed and supported a general population approach to prevention, instead of targeting those at
the highest risk. Switching the general population to healthy lifestyles would be a major source of prevention.
The need to redesign primary care practice to incorporate health behaviour change has been recently
underscored.[30,31] Also the American Academy of Pediatrics in 2008 underscored the need to address the
current epidemic of childhood obesity through enhanced adherence to dietary guidelines and increasing
physical activity.[32]

Social Support

Prospective population studies have found associations between measures of social support and mortality,
psychiatric and physical morbidity and adjustment to and recovery from chronic disease. [10] An area that is now
called 'social neuroscience' is beginning to address the effects of the social environment on the brain and the
physiology it regulates.[19]

Psychological Well-being

Positive health is often regarded as the absence of illness, despite the fact that half a century ago, the World
Health Organization defined health as a 'state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity'. [33] Research on psychological well-being has indicated that it derives
from the interaction of several related dimensions. [34] Several studies have suggested that psychological well-
being plays a buffering role in coping with stress and has a favourable impact on disease course. [35,36]
Antonovsky's sense of coherence, a resource that enables people to manage tension, to reflect about their
external and internal resources, to promote effective coping by finding solution, has been found to be strongly
related to perceived health, especially mental health and to be an important contributor for health maintenance.
[37]

Personality Factors

The notion that personality variables can affect vulnerability to specific diseases was prevalent in the first phase
of development of psychosomatic medicine (19301960) and was particularly influenced by psychoanalytic
investigators, who believed that specific personality profiles underlay specific 'psychosomatic diseases'. This
hypothesis was not supported by subsequent research. [1,17] Two personality constructs that can potentially affect
general vulnerability to disease, type A behaviour and alexithymia (the inability to express emotion), have
attracted considerable attention, but their relationship with health is still controversial. [3840] The social-cognitive
model of personality assumes that personality variables interact with social and environmental factors and
result in differences in the features of the situations that individuals select. [41] In this sense, personality variables
(e.g. obsessive-compulsive, paranoid, impulsive) may deeply affect how a patient views illness, what it means
to him/her and his/her interactions with others, including medical staff.

Holistic Consideration of Patient Care

Psychosocial and biological factors interact in a number of ways in the course of medical disease. Their varying
influence determines the unique quality of the experience and attitude of every patient in any given episode of
illness.
Psychiatric Disturbances

Psychiatric illness, depression and anxiety in particular, is strongly associated with medical diseases. Mental
disorders increase the risk for communicable and non-communicable diseases; at the same time, many health
conditions increase the risk for mental disturbances, and comorbidity complicates recognition and treatment of
medical disorders.[42] The potential relationship between medical disorders and psychiatric symptoms ranges
from a purely coincidental occurrence to a direct causal role of organic factors either medical illness or drug
treatment in the development of psychiatric disturbance. The latter is often subsumed under the rubric of
organic mental disorder whose key feature is the resolution of psychiatric disturbances upon specific treatment
of the organic condition,[43] such as depression in Cushing's syndrome. [25] Not surprisingly, a correct diagnosis of
depression in primary care is a difficult task. A recent meta analysis [44] indicated that there are more false
positives than either missed or identified cases.

Major depression has emerged as an extremely important source of comorbidity in medical disorders. [45] It was
found to affect quality of life and social functioning and lead to increased health care utilisation, to be
associated with higher mortality (particularly in the elderly people), to have an impact on compliance and to
increase susceptibility to medical illness. [4548] The relationship between anxiety disorders and comorbid medical
illness has also been found to entail important clinical implications. [49]

Psychological Symptoms

Current emphasis in psychiatry is about assessment of symptoms which result in syndromes identified by
diagnostic criteria (DSM). However, emerging awareness that psychological symptoms which do not reach the
threshold of a psychiatric disorder also may affect quality of life and entail pathophysiological and therapeutic
implications led to the development of the Diagnostic Criteria for Psychosomatic Research (DCPR) [50] together
with a specific interview to assess patients. [51] The DCPR were introduced in 1995 and tested in various clinical
settings[5053] (). They do provide also a classification for illness behaviour, as the ways in which individuals
experience, perceive, evaluate and respond to their own health status. [54]

Table 1. The diagnostic criteria for psychosomatic research (DCPR)

1. Health anxiety
2. Thanatophobia
3. Disease phobia
4. Illness denial
5. Persistent somatisation
6. Conversion symptoms
Functional somatic symptoms secondary to a psychiatric
7.
disorder
8. Anniversary reaction
9. Demoralisation
10. Irritable mood
11. Type A behaviour
12. Alexithymia
Quality of Life
While there is neither a precise nor agreed definition of quality of life, research in this area seeks essentially
two kinds of information: the functional status of the individual and the patient's appraisal of health. [55] The
concept stems from the fact that measures of disease status alone are insufficient to describe the burden of
illness and that the subjective perception of health status (e.g. lack of well-being, demoralisation, difficulties
fulfilling personal and family responsibilities, etc.) should integrate that of the clinician in evaluating outcome.
[55,56]

Integration of Psychological Therapies in Medicine

Psychological interventions in the medically ill patients may be performed by different health professionals and
may range from reassurance and effective communication to specific psychotherapeutic and
psychopharmacological treatments. Many of the initial clinical trials of psychological therapies have involved
highly trained and experienced specialists, but there is increasing evidence that clinicians who are not trained
psychiatrists or psychologists can also carry out such interventions. [57,58]

Lifestyle Modification

An increasing body of evidence links the progression of severe medical disorders to specific lifestyle
behaviours.[28,5861] The benefits of modifying lifestyle have been particularly demonstrated in coronary heart
disease[24] and type 2 diabetes.[58] Further, a number of psychological treatments have been found to be effective
in health-damaging behaviours, such as smoking. [62] A basic psychosomatic assumption is the consideration of
patients as partners in managing disease. The partnership paradigm includes collaborative care (a patient
physician relationship in which physicians and patients make health decisions together) [63] and self-
management (a plan that provides patients with problem-solving skills to enhance their self-efficacy). [64] Self-
management appears to be particularly valuable in the settings of chronic medical disease and rehabilitation
medicine.[65,66] Indeed, in this latter area, a multidisciplinary, psychosomatic approach is often endorsed.

Treatment of Psychiatric Comorbidity

Psychiatric disorders, and particularly major depression, are frequently unrecognised and untreated in medical
settings, with widespread harmful consequences for the individual and the society. Treatment of psychiatric
comorbidity such as depression, with either pharmacological or psychotherapeutic interventions, markedly
improves depressive symptoms, health-related functioning and the patient's quality of life, although an effect on
medical outcome has not been demonstrated.[67]

Psychosocial Interventions

Use of psychotherapeutic strategies (cognitive-behavioural therapy, stress management procedures, brief

dynamic therapy) in controlled investigations has yielded a substantial improvement in a number of medical
disorders.[65,68,69] Examples are interventions that increase social support, improve mood and enhance health
behaviour in patients with breast cancer, [70] foster self-control and self-management in chronic pain [71] and
improve emotional disclosure.[72]

Research on psychotherapy has brought up common therapeutic ingredients such as: the therapist's full
availability for specific times (attention); the patient's opportunity to ventilate thoughts and feelings (disclosure);
an emotionally charged, confiding relationship with a helping person (high arousal); a plausible explanation of
the symptoms (interpretation); a ritual or procedure that requires the active participation of both patient and
therapist and that is believed by both to be the means of restoring the patient's health (rituals). [10] These
ingredients may be employed successfully within any patientdoctor relationship.
Treatment of Abnormal Illness Behaviour

For many years, abnormal illness behaviour has been viewed mainly as an expression of personality
predisposition and considered to be refractory to treatment by psychotherapeutic methods. There is now
evidence to challenge such pessimistic stance. [10,50,51] For instance, several controlled studies on psychotherapy
indicate that hypochondriasis is a treatable condition by the use of simple cognitive strategies. The correlation
between abnormal illness behaviour and health habits may have implications in preventive efforts: individuals
with excessive health anxiety were found to take worse care of themselves than control subjects in several
studies.[54] Indeed, they may be so distressed by their belief of having an undiagnosed or neglected disease that
choices which may yield benefits in the distant future appear to be irrelevant to them.

The Timeliness of Psychosomatic Medicine

There have been major transformations in health care needs in the past decades. Chronic disease is now the
principal cause of disability and use of health services consumes almost 80% of health expenditures. [64] Yet,
current health care is still conceptualised in terms of acute care perceived as a product processing, with the
patients as a customer, who can, at best, select among the services that are offered. As Hart has observed, in
health care the product is clearly health and the patients is one of the producers, not just a customer. [73] As a
result 'optimally efficient health production depends on a general shift of patients from their traditional roles as
passive or adversarial consumers to become producers of health along with their health professionals'. [73, p. 383]

The need to include consideration of function in daily life, productivity, performance of social roles, intellectual
capacity, emotional stability and well-being, has emerged as a crucial part of clinical investigation and patient
care.[55] These aspects have become particularly important in chronic diseases, where cure cannot take place
and also extend over family caregivers of chronically ill patients and health providers. Patients have become
increasingly aware of these issues. The commercial success of books on complementary medicine and positive
practices as well as the upsurge of mind-body medicine exemplify the receptivity of the general public to
messages of well-being pursuit by alternative medical practices. Psychosomatic interventions may respond to
these emerging needs within the established medical system and may play an important role in supporting the
healing process.

Medically unexplained symptoms occur in up to 3040% of medical patients and increase medical utilisation
and costs.[1,18] The traditional medical specialties, based mostly on organ systems (e.g. cardiology,
gastroenterology), appear to be more and more inadequate in dealing with symptoms and problems, which cut
across organ system subdivisions and require a holistic approach. The interdisciplinary dimension that
characterises most rehabilitation units and pain clinics [65,66] is a practical consequence of this appraisal. In the
UK, the establishment of psychological treatment centres within the National Health System for providing
psychotherapy to patients with anxiety and depressive disorders [74,75] is an unprecedented opportunity of
integration of different treatments.

The exponential spending on preventive medication justified by the potential long-term benefits to a small
segment of the population is now being challenged, [76] whereas the benefits of modifying lifestyle by population-
based measures are increasingly demonstrated [58,62,65] and are in keeping with the biopsychosocial model. Yet, at
present, almost all of health care spending are directed at biomedically oriented care. Overemphasis on
pharmacological treatment has lead to a dangerous reductionism, which neglects the fact that therapeutic
outcomes are always the result of several ingredients, specific or non-specific, [10] as outlined above.

As Kroenke has argued, neither chronic medical nor psychiatric disorder can be managed adequately in the
current environment of general practice, where the typical patient must be seen in 1015 min or less. [18]
In clinical medicine, there is the tendency to rely exclusively on 'hard data', preferably expressed in the
dimensional numbers of laboratory measurements, excluding 'soft information' such as impairments and well-
being. This soft information can now, however, be reliably assessed by clinical rating scales and indexes, which
have been validated and used in psychosomatic research and practice. [77] It is not that certain disorders lack an
explanation; it is our assessment that is inadequate in most of the clinical encounters, as it does not reflect a
global psychosomatic approach.[77,78] Similarly, addressing the origins of disparities in physical and mental health
care within a biopsychosocial model early in life may produce greater effects than attempting to modify health-
related behaviours or improve access to health care in adulthood. [79]

Sidebar
Review Criteria

The authors tried to integrate the most recent evidence, which derives from meta analyses and comprehensive
general reviews with the insights that derive from controlled studies concerned with specific populations.

Message for the Clinic

Medical assessment and treatment can be improved by using the methods, which have been developed in
psychosomatic medicine, with particular reference to medically unexplained symptoms, chronic illness and
lifestyle modification.

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