Comprehensive Psychiatry Official
VOL.
Journal
of the American
Psychopathological
MAY/ JUNE
17, NO. 3
Is Psychosomatic
Association
Obsolete?
A Psychiatric
1976
Reappraisal
Fritz A. Freyhan
T
HE TERM “PSYCHOSOMATIC” was first used by the German psychiatrist Heinroth in 1818. The idea of psychosomatic medicine, however, goes back to the beginning of medicine. Plato, in Charmides, subtitled The Mistake 41 PhJlsicians. states, “And this is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they are ignorant of the whole which ought to be studied also: for the part can never be well unless the whole is well. It is the greatest mistake in the treatment of diseases that there are physicians who treat the body and physicians who treat the mind, since both are inseparable.” Despite Plato’s insight, physicians and philosophers continued to ponder the mind/body problem. Yet, no concrete solutions were found, which is not surprising in view of the predominance of ideologic biases that clouded basic issues. It wasn’t until the 20th century, with the use of objective methods of clinical and laboratory research, that the complex nature of psychosomatic medicine was approached. My own interest in this field began when I was a medical student at the University of Berlin in the 1930s. The two departments of internal medicine at the Charite were directed by Gustav von Bergmann and Richard Siebeck. Both were eminent pioneers in the development and clinical application of psychosomatic principles. The most decisive contribution came from von Bergmann who established a comprehensive investigative program in his clinic to break down the borders between “organic” and “functional” diseases. His most important publication on this work, Funktionellr Pathologic,’ was published in 1936. He conceived his Arbeitsrichtung as a reformation of the traditional ideas and attitudes of physicians. The last and perhaps most important chapter deals with psychosomatic aspects of medical illness. It is titled “Psychophysische Verhaltungsweisen,” or psychophysical modes of behavior. He avoided the term psychosomatic because he recognized its ambiguity. He rejected any simplistic notion of either psychic or somatic etiology, which would tend to perpetuate the autonomy of mind and body. As one reads this chapter today, it appears excitingly
Presented at the Third Congress of‘ the International College of’P.yychosomaric Medicine, Rome. Italy. September 16-20. 1975. Fritz A. Freyhan. M.D.: 2015 R Street, N. W.. Washington. D.C. Reprint requests should be addressed to Fritz A. Frevhan. M.D.. 2015 R Street. .&‘.W.. Washington. D C. 20009. c 1976 b.v Grune & Stratton, Inc. Comprehenswe Psychmtry, Vol 17. No 3 (May/June).
1976
381
FRITZ
382
A FREYHAN
modern in concept and in coverage of pertinent medical and psychiatric findings. It was the works of von Bergmann and Siebeck which enabled me to see psychiatry and internal medicine as being complementary to the understanding of human behavior and illness. PSYCHOSOMATIC
MODELS
Let me briefly review subsequent developments in psychosomatic medicine. In the early 195Os, the American Psychiatric Association added to the official diagnostic classification the group of “psychophysiological disorders.” This represented, on one hand, recognition of the role of emotional factors in the development of physical symptoms; on the other hand, avoidance of the term “psychosomatic” left the door open in as far as primacy of psychologic factors is concerned. The official classification for American psychiatry maintained a sense of caution. It was, nevertheless, inevitable that the then strong impact of psychoanalysis in American psychiatry should generate far more specific models. During the 1940s and 195Os, great credence was given to those theories which linked specific personality profiles and specific personal conflicts with various medical disorders. Flanders Dunbar and Franz Alexander originated concepts according to which psychosomatic illness became psychogenetic illness. Psychodynamic interpretations of behavior generated the hope, if not conviction, that treatment aimed at removing the harmful psychologic factors could cure, and even prevent, somatic dysfunctions and illnesses. Those were days of great expectations. But the results of psychotherapy as major treatment of such diverse diseases as bronchial asthma, ulcerative colitis, hypertension, and peptic ulcer, to name but a few, were disappointing. The narrowness of the concepts which limited a broad spectrum of pathogenetic variables to psychodynamic etiology was bound to fail. To psychologize somatic functions and disorders was merely a reversal of the mechanistic approach to medicine which psychosomatic medicine was meant to reform. The focus now shifted to nonspecific models that explored the role of anxiety and stress. Stress emotion in animals and in man could be studied in terms of action and interaction of the CNS with other physiologic systems. The development of ever more sophisticated methodologies yielded new dimensions of data and insights. Before commenting further on our current knowledge of stress, it seems important to point out that the interest in specific models is not dead. The recent theory of the so-called type A behavior as cause of coronary heart disease reveals that personality type remains a viable issue. Perhaps the most gratifying aspect of this theory is the fact of its parentage. Two cardiologists, Meyer Friedman and Ray Rosenman,’ became fascinated by their patients’ behavioral characteristics. Seemingly striking similarities were reported. Type A behavior is “hurry sickness,” a disease of modern times. A combination of aggressiveness, competitiveness, and time urgency wreaks damage by exposing the arteries to overdoses of high voltage chemicals produced by the overworked hypothalamus. On the examination room level, type A behavior carries a degree of credibility. But the idea to divide mankind into type A and B behaviors defies psychologic common sense as well as an enormous amount of data regarding the heterogeneity of personality. It may be seductive, yet too simplistic, to interpret type A behavior as a curse of
IS PSYCHOSOMATIC
OBSOLETE?
383
modern times. On the scientific level, this seems to be a reductionistic formula which pays only lip service to the complexity of other pathogenetic variables. It is therefore not surprising that the type A behavior theory stands in open conflict with other reported findings. PSYCHIATRIC
CONSIDERATIONS
From a psychiatric point of view, some current trends in psychosomatic medicine pose new problems. The fluctuations between specific and unspecific theories may be at least partially resolved if we look at recent developments in psychiatric thinking. Of particular pertinence are two questions. (1) Are certain psychosomatic disorders actually manifestations of psychiatric illness? (2) Are the so-called functional disorders still believed to be psychogenetic in origin? Let me deal with the second question first. Although even recent U.S. textbooks still place the chapters on affective and schizophrenic disorders under the general title. “disorders of psychogenetic origin,” this is no longer in accord with scientific discoveries regarding the role of genetic and biochemical factors. The psychogenetic model has lost out to multifactorial models which represent interactions on many levels of organism and social environment. Controversies on significance and magnitude of psychologic and biologic determinants of mental disorders can be clarified today with the aid of multifactorial analyses. Recent developments in psychopharmacology have gone a long way to identify the biologic substructures of so-called functional mental disorders. What is known today about mood disorders is particularly relevant for the advancement of psychosomatic theories. In as far as clinical symptomatology is concerned. mental depressions affect mind and body equally. Physicians have, therefore, always known that “psyche” and “soma” are intellectual abstractions from a unitary process. It is now, however, widely recognized that endogenous depressions can be treated, and even prevented, by biologic treatment. Thus, while depression may be a basic normal emotion, endogenous depressions are illnesses in terms of epidemiology, clinical manifestations, and treatability. Another question arises in regard to those psychosomatic disorders which affect nearly all body systems in multiple combinations of symptoms and syndromes. Recent research has provided growing evidence that these physical manifestations should be interpreted as “depressive equivalents.” Although the patients with these afflictions do not complain of being depressed, and may even deny it, thorough psychiatric evaluaticns adduce evidence of depressive mood disorder. It is now believed that masked depressions account for a very considerable fraction of complaints which bring patients to the office of the general practitioner, the internist, and the orthopedic surgeon. The diagnosis is, in most instances, confirmed by these patients’ favorable responses to antidepressant drugs. New research methods have been developed which permit valid conclusions regarding the relationship of treatment response to diagnosis. Antidepressant drugs are therefore, at least to some extent, useful diagnostic tools. The relationship of psychosomatic medicine to depressive disorders requires revision. Lopez Ibor” puts it this way, “The whole approach to so-called psychosomatic medicine requires radical revision. Everyone will agree that since the Second World War this branch of medicine has acquired tremendous importance
384
FRITZ A. FREYHAN
and in some places it has even become a discipline in its own right. This, however, is going too far, because the vast majority of patients in this category are really psychiatric cases, inasmuch as they are suffering from masked depression or depressive equivalents.” An upsurge of interest in the relationship of life events to the onset of illness is now upon us. New strategies are being developed which concern the quantification of stressful life events. To measure stress, scales and schedules have been designed which require persons, patients and nonpatients, to evaluate life events. One purpose of these studies is to enable investigators to translate life event data into numerical forms suitable for use in large-scale field studies on the interaction of life events and their psychosomatic consequences. Studies by Holmes4 and Rahe5 indicate that the more life changes an individual has, the more drastic the changes, the more likely he is to fall ill within the next 6 months. Positive correlations have been reported between stressful life events and the development of great varieties of acute and chronic illnesses. From a psychiatric point of view, these methods, while intriguing as new research tools, also pose problems of major importance. The literature uses terms such as “life events,” “life change,” and “experience” interchangeably. But there is no simple way to translate the impact of events into individual experiences. Moreover, these new methods do not remove the danger of circular reasoning with regard to which events are causes and which are effects. If one looks at the “Schedule of Recent Experiences,” one finds no distinction between events which are externally imposed or which, on the other hand, are intrinsic in origin. The death of a spouse, personal injury, and retirement represent one category. Sex difficulties, change in eating habits, and change in sleeping habits strongly suggest already existing psychopathology or may be the symptoms of incipient physical disorders. Under no circumstances do these correlations shed any light on whether the events measured have etiologic significance, are incidental, or perhaps most likely, trigger off an illness. Any evaluation of stressful life events is, insofar as measurement is concerned, tentative at best. The quantitative approach is nevertheless seen as a matter of unquestioned validity in some quarters. Take for example the test, “Rate your stress level this year,” based on Holmes’s social readjustment rating scale. The person completing the self-rating scale is advised that a total score of 150-300 gives him a 5 1% chance of suffering poor health. Should his score be more than 300, he faces odds of 80% that he will become sick. Actually, there are other reports in the literature which indicate that such figures greatly overestimate the risk of illness. But, more importantly, there is not, in fact, even theoretical agreement on the pathogenic power of stressful life events. Furthermore, there is no agreement whether it is the subject or the investigator who should do the measurement. According to Brown0 accepting the theory of a causal link between life events and illness does not mean “that we naively accept the respondent’s account either in answer to general questions or in terms of a structured questionnaire.” Brown advocates a contextural approach to avoid errors stemming from various types of contamination inherent in self-evaluations of life events. Brown concludes that only the investigator can assess the contextural phenomena on which to base objective evaluation.
IS PSYCHOSOMATIC
OBSOLETE?
385
Scientifically, only prospective longitudinal studies can enlighten us on matters relating to etiology. Such studies are conspicuously, almost totally, absent from the literature. A few studies of this nature exist, however, and they seem to document that even highly stressful events do not adversely affect the health of large proportions of representative populations. Hinkle’s’ study of 270,000 men employed by the Bell System throughout the United States shows how many assumptions in the literature are presently mere biases. His prospective study of coronary heart disease is a case in point. This study of a subgroup which began in 1962 revealed that “new cases of coronary heart disease rarely if ever occur, except among men who have some combination of hyperlipidemia, abnormalities of carbohydrate metabolism, hypertension, cigarette smoking, and a family history of this disease. In many instances, these people also have preexisting evidence of arteriosclerosis in other vessels.” Hinkle’s findings demonstrate that every disease has more than one cause. Predisposing physiologic factors, preexisting illness, or susceptibility to illness are major variables in interaction with stressful life events. What may become the most important prospective study is the Johns Hopkins University Precursors Study.8 Nearly 30 years ago investigators at Johns Hopkins School of Medicine began interviewing the first of more than 1000 medical students in one of the most ambitious studies of psychosomatic disease ever undertaken. This study was started without specific hypotheses. It centered on the identification of biologic and psychologic characteristics which appeared decades before the clinical onset of illness. In as far as coronary heart disease is concerned. this study revealed the surprising fact that most of the coronary victims scored high on tests of depression, anxiety, nervous tension, and anger under stress. They tended to rank low academically, they had insomnia, and they were more likely to be tired on awaking. Biologically, the coronary group also had in common certain constitutional factors. The main characteristic, besides high cholesterol, was short stature. The psychologic profile of the coronary heart disease patient in this study has virtually nothing in common with the type A personality. On the contrary, the psychologic qualities, as described here, are opposites in characterologic aspects. Furthermore, the reference to constitutional factors could be a great gain in reviving research for common elements of both organism and personality. THE FUTURE
What will be the future of psychosomatic medicine? As I see it, there is no longer any place for simplistic models. To equate psychosomatic with psychogenetic is indeed pointless and obsolete. Psychosomatic medicine as an interdisciplinary approach remains viable and necessary for medical practice and for research. In this context, psychosomatic relates to psychologic variables within a multicausal system. This requires changes of interest from specificity theories to individual components which manifest themselves as characterologic and biologic predispositions. The use of multifactorial models in psychiatry should pave the way for the use of similar models in psychosomatic medicine. The current emphasis on stressful life events is in danger of becoming an “after-the-fact” attempt to search for psychosocial etiology. Stress may often be nothing more than the last link in a long
386
FRITZ
A. FREYHAN
chain of interrelated events. This, at any event, would seem to be the lesson of the few, but impressive, projective studies which demonstrate the complexity of interacting factors. REFERENCES 1. von Bergmann G: Funktionelle Pathologie. Berlin, Springer, 1936 2. Friedman M, Rosenman RH: Type A Behavior and Your Heart. New York, Knopf, 1974 3. Lopez IJJ: Depressive equivalents, in Kielholz P (ed): Masked Depression. Basle, Hans Huber, 1973, p 97 4. Holmes TH, Masuda M: Life change and illness susceptibility, in Dohrenwend BS, Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 45 5. Rahe RH: The pathway between subjects’ recent life changes and their near-future illness reports: Representative results and methodological issues, in Dohrenwend BS, Dohrenwend
BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974,73 6. Brown GW: Meaning, measurement, and stress of life events, in Dohrenwend BS, Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 217 7. Kinkle LE Jr: The effect of exposure to culture change, social change, changes in interpersonal relationships on health, in Dohrenwend BS. Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 9 8. McBroom P: Study of disease in MDs clarifies psychic factors. Med Tribune August 1975
VOL.
Journal
of the American
Psychopathological
MAY/ JUNE
17, NO. 3
Is Psychosomatic
Association
Obsolete?
A Psychiatric
1976
Reappraisal
Fritz A. Freyhan
T
HE TERM “PSYCHOSOMATIC” was first used by the German psychiatrist Heinroth in 1818. The idea of psychosomatic medicine, however, goes back to the beginning of medicine. Plato, in Charmides, subtitled The Mistake 41 PhJlsicians. states, “And this is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they are ignorant of the whole which ought to be studied also: for the part can never be well unless the whole is well. It is the greatest mistake in the treatment of diseases that there are physicians who treat the body and physicians who treat the mind, since both are inseparable.” Despite Plato’s insight, physicians and philosophers continued to ponder the mind/body problem. Yet, no concrete solutions were found, which is not surprising in view of the predominance of ideologic biases that clouded basic issues. It wasn’t until the 20th century, with the use of objective methods of clinical and laboratory research, that the complex nature of psychosomatic medicine was approached. My own interest in this field began when I was a medical student at the University of Berlin in the 1930s. The two departments of internal medicine at the Charite were directed by Gustav von Bergmann and Richard Siebeck. Both were eminent pioneers in the development and clinical application of psychosomatic principles. The most decisive contribution came from von Bergmann who established a comprehensive investigative program in his clinic to break down the borders between “organic” and “functional” diseases. His most important publication on this work, Funktionellr Pathologic,’ was published in 1936. He conceived his Arbeitsrichtung as a reformation of the traditional ideas and attitudes of physicians. The last and perhaps most important chapter deals with psychosomatic aspects of medical illness. It is titled “Psychophysische Verhaltungsweisen,” or psychophysical modes of behavior. He avoided the term psychosomatic because he recognized its ambiguity. He rejected any simplistic notion of either psychic or somatic etiology, which would tend to perpetuate the autonomy of mind and body. As one reads this chapter today, it appears excitingly
Presented at the Third Congress of‘ the International College of’P.yychosomaric Medicine, Rome. Italy. September 16-20. 1975. Fritz A. Freyhan. M.D.: 2015 R Street, N. W.. Washington. D.C. Reprint requests should be addressed to Fritz A. Frevhan. M.D.. 2015 R Street. .&‘.W.. Washington. D C. 20009. c 1976 b.v Grune & Stratton, Inc. Comprehenswe Psychmtry, Vol 17. No 3 (May/June).
1976
381
FRITZ
382
A FREYHAN
modern in concept and in coverage of pertinent medical and psychiatric findings. It was the works of von Bergmann and Siebeck which enabled me to see psychiatry and internal medicine as being complementary to the understanding of human behavior and illness. PSYCHOSOMATIC
MODELS
Let me briefly review subsequent developments in psychosomatic medicine. In the early 195Os, the American Psychiatric Association added to the official diagnostic classification the group of “psychophysiological disorders.” This represented, on one hand, recognition of the role of emotional factors in the development of physical symptoms; on the other hand, avoidance of the term “psychosomatic” left the door open in as far as primacy of psychologic factors is concerned. The official classification for American psychiatry maintained a sense of caution. It was, nevertheless, inevitable that the then strong impact of psychoanalysis in American psychiatry should generate far more specific models. During the 1940s and 195Os, great credence was given to those theories which linked specific personality profiles and specific personal conflicts with various medical disorders. Flanders Dunbar and Franz Alexander originated concepts according to which psychosomatic illness became psychogenetic illness. Psychodynamic interpretations of behavior generated the hope, if not conviction, that treatment aimed at removing the harmful psychologic factors could cure, and even prevent, somatic dysfunctions and illnesses. Those were days of great expectations. But the results of psychotherapy as major treatment of such diverse diseases as bronchial asthma, ulcerative colitis, hypertension, and peptic ulcer, to name but a few, were disappointing. The narrowness of the concepts which limited a broad spectrum of pathogenetic variables to psychodynamic etiology was bound to fail. To psychologize somatic functions and disorders was merely a reversal of the mechanistic approach to medicine which psychosomatic medicine was meant to reform. The focus now shifted to nonspecific models that explored the role of anxiety and stress. Stress emotion in animals and in man could be studied in terms of action and interaction of the CNS with other physiologic systems. The development of ever more sophisticated methodologies yielded new dimensions of data and insights. Before commenting further on our current knowledge of stress, it seems important to point out that the interest in specific models is not dead. The recent theory of the so-called type A behavior as cause of coronary heart disease reveals that personality type remains a viable issue. Perhaps the most gratifying aspect of this theory is the fact of its parentage. Two cardiologists, Meyer Friedman and Ray Rosenman,’ became fascinated by their patients’ behavioral characteristics. Seemingly striking similarities were reported. Type A behavior is “hurry sickness,” a disease of modern times. A combination of aggressiveness, competitiveness, and time urgency wreaks damage by exposing the arteries to overdoses of high voltage chemicals produced by the overworked hypothalamus. On the examination room level, type A behavior carries a degree of credibility. But the idea to divide mankind into type A and B behaviors defies psychologic common sense as well as an enormous amount of data regarding the heterogeneity of personality. It may be seductive, yet too simplistic, to interpret type A behavior as a curse of
IS PSYCHOSOMATIC
OBSOLETE?
383
modern times. On the scientific level, this seems to be a reductionistic formula which pays only lip service to the complexity of other pathogenetic variables. It is therefore not surprising that the type A behavior theory stands in open conflict with other reported findings. PSYCHIATRIC
CONSIDERATIONS
From a psychiatric point of view, some current trends in psychosomatic medicine pose new problems. The fluctuations between specific and unspecific theories may be at least partially resolved if we look at recent developments in psychiatric thinking. Of particular pertinence are two questions. (1) Are certain psychosomatic disorders actually manifestations of psychiatric illness? (2) Are the so-called functional disorders still believed to be psychogenetic in origin? Let me deal with the second question first. Although even recent U.S. textbooks still place the chapters on affective and schizophrenic disorders under the general title. “disorders of psychogenetic origin,” this is no longer in accord with scientific discoveries regarding the role of genetic and biochemical factors. The psychogenetic model has lost out to multifactorial models which represent interactions on many levels of organism and social environment. Controversies on significance and magnitude of psychologic and biologic determinants of mental disorders can be clarified today with the aid of multifactorial analyses. Recent developments in psychopharmacology have gone a long way to identify the biologic substructures of so-called functional mental disorders. What is known today about mood disorders is particularly relevant for the advancement of psychosomatic theories. In as far as clinical symptomatology is concerned. mental depressions affect mind and body equally. Physicians have, therefore, always known that “psyche” and “soma” are intellectual abstractions from a unitary process. It is now, however, widely recognized that endogenous depressions can be treated, and even prevented, by biologic treatment. Thus, while depression may be a basic normal emotion, endogenous depressions are illnesses in terms of epidemiology, clinical manifestations, and treatability. Another question arises in regard to those psychosomatic disorders which affect nearly all body systems in multiple combinations of symptoms and syndromes. Recent research has provided growing evidence that these physical manifestations should be interpreted as “depressive equivalents.” Although the patients with these afflictions do not complain of being depressed, and may even deny it, thorough psychiatric evaluaticns adduce evidence of depressive mood disorder. It is now believed that masked depressions account for a very considerable fraction of complaints which bring patients to the office of the general practitioner, the internist, and the orthopedic surgeon. The diagnosis is, in most instances, confirmed by these patients’ favorable responses to antidepressant drugs. New research methods have been developed which permit valid conclusions regarding the relationship of treatment response to diagnosis. Antidepressant drugs are therefore, at least to some extent, useful diagnostic tools. The relationship of psychosomatic medicine to depressive disorders requires revision. Lopez Ibor” puts it this way, “The whole approach to so-called psychosomatic medicine requires radical revision. Everyone will agree that since the Second World War this branch of medicine has acquired tremendous importance
384
FRITZ A. FREYHAN
and in some places it has even become a discipline in its own right. This, however, is going too far, because the vast majority of patients in this category are really psychiatric cases, inasmuch as they are suffering from masked depression or depressive equivalents.” An upsurge of interest in the relationship of life events to the onset of illness is now upon us. New strategies are being developed which concern the quantification of stressful life events. To measure stress, scales and schedules have been designed which require persons, patients and nonpatients, to evaluate life events. One purpose of these studies is to enable investigators to translate life event data into numerical forms suitable for use in large-scale field studies on the interaction of life events and their psychosomatic consequences. Studies by Holmes4 and Rahe5 indicate that the more life changes an individual has, the more drastic the changes, the more likely he is to fall ill within the next 6 months. Positive correlations have been reported between stressful life events and the development of great varieties of acute and chronic illnesses. From a psychiatric point of view, these methods, while intriguing as new research tools, also pose problems of major importance. The literature uses terms such as “life events,” “life change,” and “experience” interchangeably. But there is no simple way to translate the impact of events into individual experiences. Moreover, these new methods do not remove the danger of circular reasoning with regard to which events are causes and which are effects. If one looks at the “Schedule of Recent Experiences,” one finds no distinction between events which are externally imposed or which, on the other hand, are intrinsic in origin. The death of a spouse, personal injury, and retirement represent one category. Sex difficulties, change in eating habits, and change in sleeping habits strongly suggest already existing psychopathology or may be the symptoms of incipient physical disorders. Under no circumstances do these correlations shed any light on whether the events measured have etiologic significance, are incidental, or perhaps most likely, trigger off an illness. Any evaluation of stressful life events is, insofar as measurement is concerned, tentative at best. The quantitative approach is nevertheless seen as a matter of unquestioned validity in some quarters. Take for example the test, “Rate your stress level this year,” based on Holmes’s social readjustment rating scale. The person completing the self-rating scale is advised that a total score of 150-300 gives him a 5 1% chance of suffering poor health. Should his score be more than 300, he faces odds of 80% that he will become sick. Actually, there are other reports in the literature which indicate that such figures greatly overestimate the risk of illness. But, more importantly, there is not, in fact, even theoretical agreement on the pathogenic power of stressful life events. Furthermore, there is no agreement whether it is the subject or the investigator who should do the measurement. According to Brown0 accepting the theory of a causal link between life events and illness does not mean “that we naively accept the respondent’s account either in answer to general questions or in terms of a structured questionnaire.” Brown advocates a contextural approach to avoid errors stemming from various types of contamination inherent in self-evaluations of life events. Brown concludes that only the investigator can assess the contextural phenomena on which to base objective evaluation.
IS PSYCHOSOMATIC
OBSOLETE?
385
Scientifically, only prospective longitudinal studies can enlighten us on matters relating to etiology. Such studies are conspicuously, almost totally, absent from the literature. A few studies of this nature exist, however, and they seem to document that even highly stressful events do not adversely affect the health of large proportions of representative populations. Hinkle’s’ study of 270,000 men employed by the Bell System throughout the United States shows how many assumptions in the literature are presently mere biases. His prospective study of coronary heart disease is a case in point. This study of a subgroup which began in 1962 revealed that “new cases of coronary heart disease rarely if ever occur, except among men who have some combination of hyperlipidemia, abnormalities of carbohydrate metabolism, hypertension, cigarette smoking, and a family history of this disease. In many instances, these people also have preexisting evidence of arteriosclerosis in other vessels.” Hinkle’s findings demonstrate that every disease has more than one cause. Predisposing physiologic factors, preexisting illness, or susceptibility to illness are major variables in interaction with stressful life events. What may become the most important prospective study is the Johns Hopkins University Precursors Study.8 Nearly 30 years ago investigators at Johns Hopkins School of Medicine began interviewing the first of more than 1000 medical students in one of the most ambitious studies of psychosomatic disease ever undertaken. This study was started without specific hypotheses. It centered on the identification of biologic and psychologic characteristics which appeared decades before the clinical onset of illness. In as far as coronary heart disease is concerned. this study revealed the surprising fact that most of the coronary victims scored high on tests of depression, anxiety, nervous tension, and anger under stress. They tended to rank low academically, they had insomnia, and they were more likely to be tired on awaking. Biologically, the coronary group also had in common certain constitutional factors. The main characteristic, besides high cholesterol, was short stature. The psychologic profile of the coronary heart disease patient in this study has virtually nothing in common with the type A personality. On the contrary, the psychologic qualities, as described here, are opposites in characterologic aspects. Furthermore, the reference to constitutional factors could be a great gain in reviving research for common elements of both organism and personality. THE FUTURE
What will be the future of psychosomatic medicine? As I see it, there is no longer any place for simplistic models. To equate psychosomatic with psychogenetic is indeed pointless and obsolete. Psychosomatic medicine as an interdisciplinary approach remains viable and necessary for medical practice and for research. In this context, psychosomatic relates to psychologic variables within a multicausal system. This requires changes of interest from specificity theories to individual components which manifest themselves as characterologic and biologic predispositions. The use of multifactorial models in psychiatry should pave the way for the use of similar models in psychosomatic medicine. The current emphasis on stressful life events is in danger of becoming an “after-the-fact” attempt to search for psychosocial etiology. Stress may often be nothing more than the last link in a long
386
FRITZ
A. FREYHAN
chain of interrelated events. This, at any event, would seem to be the lesson of the few, but impressive, projective studies which demonstrate the complexity of interacting factors. REFERENCES 1. von Bergmann G: Funktionelle Pathologie. Berlin, Springer, 1936 2. Friedman M, Rosenman RH: Type A Behavior and Your Heart. New York, Knopf, 1974 3. Lopez IJJ: Depressive equivalents, in Kielholz P (ed): Masked Depression. Basle, Hans Huber, 1973, p 97 4. Holmes TH, Masuda M: Life change and illness susceptibility, in Dohrenwend BS, Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 45 5. Rahe RH: The pathway between subjects’ recent life changes and their near-future illness reports: Representative results and methodological issues, in Dohrenwend BS, Dohrenwend
BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974,73 6. Brown GW: Meaning, measurement, and stress of life events, in Dohrenwend BS, Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 217 7. Kinkle LE Jr: The effect of exposure to culture change, social change, changes in interpersonal relationships on health, in Dohrenwend BS. Dohrenwend BP (eds): Stressful Life Events-Their Nature and Effects. New York, Wiley, 1974, p 9 8. McBroom P: Study of disease in MDs clarifies psychic factors. Med Tribune August 1975
