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EDITORIAL |
Professor Emeritus of Psychiatry and Biobehavioral Sciences, Neuropsychiatric and Brain Research Institutes, University of California, Los Angeles, Los Angeles, CA 90024
ABSTRACT
OBJECTIVE: To celebrate the 60th anniversary of the publication of Psychosomatic Medicine, a review of its first 45 years of existence was performed to highlight the conceptual, methodological, and scientific advances made.
METHOD: A very selective overview of key articles was made to illustrate the evolution of concepts and to document scientific progress.
CONCLUSION: Psychosomatic Medicine has published important contributions to the development of an integrative theory of medicine.
In some ways, it is surprising (and gratifying) that Psychosomatic Medicine is entering its 61st year of publication and that the American Psychosomatic Society, which sponsors it, is also as old. There was a time in the 1960s and for the subsequent 10 or more years when many members were pessimistic about whether either the Journal or the Society would survive, both for substantive and financial reasons, and whether the basic ideas presented in the journal had any scientific validity or usefulness in the care of patients. This pessimism was well expressed by Wittkower in 1960 (1). He pointed out that about three-quarters of the articles were written by psychiatrists, many with a strong psychoanalytic bent, but he admitted that the remaining articles were experimental and not only observational. He questioned whether psychosomatic medicine should merely be a part of psychiatry; it should, he asserted, have an interdisciplinary base.
Arguably, the predominant figures in the first 20 years of the Journal’s life were W. B. Cannon, H. Selye, and F. Alexander (2), who inspired many investigators. Harold Wolff also had a quieter but strong influence. He was not only an acute observer but also an experimentalist who trained a large number of investigators who continue to play key roles in the Journal and the Society. Therefore, the most influential figures were not only psychoanalysts and psychiatrists.
The methods used by Alexander and many psychoanalysts have repeatedly been criticized, perhaps no more succinctly than by Lipkin (3). He pointed out that "... the observation of clinical phenomena is notoriously treacherous, particularly when guided by preconceived notions." He also noted that the very nature of the doctor-patient relationship may provoke individual reactions that are then generalized and believed to represent the psychological characteristics of patients with a particular disease. But the matter went further: Such studies were often not repeated; reporting was selective; the memory of the patient and observer were fallible; and there was a common tendency to report observations admixed with inferences about them. In other words, recorded observations needed to be more systematic and verifiable.
Nonetheless, some of Alexander’s formulations were validated in the 1950s and 1960s by systematic studies. In my opinion, his major contributions were to stimulate further research and to point out that at least the diseases he had studied were multifactorial in origin. This concept was specified and strongly supported by Mirsky (4) and Hinkle (5), who also added, respectively, a social and a social-ecological dimension to the factors that promote disease.
Hinkle pointed out that a long and contentious history existed in Western philosophical thought between idealists and realists. In fact, those persons who were idealists and were influenced by Sigmund Freud emphasized that the "primary reality lies in the world of the mind," embedded in the formulation that the pathogenesis of (some) diseases could be laid primarily at the door of intrapsychic conflicts. But humans are also social beings; they live with others in mutual interaction and are a product, in part, of shifting cultural, historical, evolutionary, economic, and other social influences, which they interpret and sometimes internalize. A difficult synthesis between idealism and realism was called for. Hinkle’s influential work and thought led to a spate of reports on the many natural and experimentally produced conditions that challenged the person or animal and might lead to illness and disease.
Morton Reiser demanded scientific rigor in the articles that he published while serving as editor. At the same time, he was "generous and inclusive" (6) and, one might add, had impeccable, scientific taste. He broadened the purview of the journal and increased the number of its publications. During his editorship, remarkable technical advances occurred, of which perhaps the most important was the development of radioimmunoassay by Berson and Yalow, which allowed investigators to measure very small quantities of proteins, peptides, steroids, etc. That technique promoted an explosion of investigations of the endocrine correlates of disease and their behavioral correlates in sleep and wakefulness, during development, and during exposure to danger, challenge, and change.
At the same time, as more and more behavioral scientists published in the journal, observations became increasingly systematic and reliable. New and progressively more sophisticated data-analysis methods were developed to add to the scientific merit of the journal’s publications. Although these developments enhanced the scientific credibility of the journal, a price had to be paid: Many important and relevant aspects of behavior, relationships, and psychological functioning lose their humanity, richness, subtlety, and quality when attempts are made to capture them by scales and to measure them quantitatively.
In the 20 years from 1962 to 1982, the journal continued to publish basic and disease-related research on animals, a tradition that began with Gantt, Liddell, and Selye, and was carried forward with great effect by Ader, Brady, Henry, Hofer, Kaufman, Mason, and their colleagues. In part, the aim of these studies was to confirm observations on human subjects and to explore the "mechanisms" that lay behind correlative observations.
No series of papers had a greater impact on the field than those contained in Mason’s monograph in 1968. These studies were of signal importance because they showed different experimental methods of conditioning avoidance behavior on one hand and "emotional" behavior on the other and, in a predictable or unpredictable manner, elicited different patterns of hormonal secretion over time. From then on, it became essential to define precisely the nature of the experimental situation ("stressor"), the patterns of secretion (not single variables), in a time-dependent manner. As a result, investigators became increasingly aware of the need to describe the experimental situation precisely and to specify whether it was expected or not, avoidable or not, controllable or not, or could be escaped from or not, to understand its behavioral and physiological outcomes. The behavioral and physiological responses could be conceptualized as adaptive; only when adaptation failed, and the responses were inappropriate, excessive, inadequate, or disorganized, might they have pathological consequences.
Perhaps it is a regrettable historical fact that research in psychosomatic medicine was not initially influenced by the concepts of some of the great adaptive (cardiopulmonary) physiologists, such as Barcroft, Bernard, Cournand, Haldane, Henderson, and Richards. Their basic premise was that the whole organism, not just one of its isolated components, must be studied during its continuous interactions with and adaptation to the environment or to changed internal conditions. Furthermore, there was no point in measuring the carriage of oxygen by hemoglobin while paying no attention to respiration and circulation; the three systems together constituted an inseparable whole. These investigators documented the patterned physiological adaptations (and their failures) to exercise, high altitude, anoxia, injury, blood loss, various metabolic demands, and disease. At all times, the changes they observed were integrated and dynamic; no shift in a single variable could account for successful or failed adaptations. For this and other reasons, some of them were also critical of Cannon’s concept of homeostasis. As Richards pointed out, Cannon was a physiologist and knew nothing about various adaptive failures (ie, pathophysiology); the concept had limited usefulness.
Had psychophysiologists interested in topics of health, illness, and disease been instructed by the data and concepts of adaptive physiology, I believe that the road to an integrated theory of medicine would be less tortuous and difficult.
Stress research has again become a fashionable field, having recently been enriched by the work of distinguished neurobiologists, animal behaviorists, and endocrinologists. The speed and precision with which adaptive neuroendocrine, immune, and autonomic responses are invoked in the face of specific challenges, tasks, and dangers points to the integrative capacities of specific control systems in the brain. Their adaptive task generally is to mobilize responses and bodily resources in emergencies, whereas others are specific to clearly defined situations, tailor-made to meet the challenge or demand at hand, and differ if these are acute or chronic. Major advances have been made in our understanding the neural circuits subserving these categories of psychobiological responses (8).
Equally influential as Mason’s work was Henry et al.’s (9) description of the roles of social confrontation in the development of increased systolic blood pressure in dominant male mice. As blood pressure rose, an associated increase in adrenal epinephrine and norepinephrine, monoamine oxidase, tyrosine hydroxylase, and phenylethanolamine N-methyltransferase content occurred. Here was an example of an excessive response in a specific member of a social group.
Another very important article published during this period was Ader and Cohen’s (10) report on the demonstration that a conditioned taste aversion with saccharin (as the conditioned stimulus) produced a significant suppression of hemoagglutinating antibody titers in rats. This article and their subsequent work placed what is now called psychoneuroimmunology firmly in the scientific orbit.
Hofer’s (11) investigations for the past 25 years have completely revised our understanding of the behavioral and physiological consequences of separating 14-day-old rats from their mothers. He has identified the various sensory input channels by which the presence of the mother influences and regulates different aspects of the behavior and various physiological systems of the infant. At the same time, he has shown that the separation experience has later disease consequences in the maturing rat. His work has revised our notions about the separation experience, making it complex and discriminated. As a result of his studies, he has become one of the founders of developmental psychobiology.
A few publications were singled out in a highly selective manner because, in my opinion, they have markedly advanced psychosomatic research and enhanced its scientific merit. The examples I have cited entailed work on animals. But equally influential for medicine in general was Cobb’s (12) address on social support, which integrated a number of different fields. His address broadened the scope of interpersonal and socioecological research and placed it in a developmental framework. He pointed out that such support, or lack thereof, has major implications for our understanding of the onset, recurrence, course, and prognosis of disease; the healthcare-seeking behavior of patients; and their experience of symptoms.
Research on high blood pressure in human took a major step forward thanks to the work of Harburg et al. (13). They demonstrated the association of elevated blood pressure levels in African American men living in socially disrupted, inner-city neighborhoods. These men varied in the depth of their skin color, had few socioeconomic resources, were exposed to crime and violence, experienced marital breakups and police brutality, and were unable to express their resentment. These correlations did not occur in African American men living in areas of the city in which these socioecological conditions were not present, despite segregation, or in white men. This study made a major contribution to our understanding of the four-fold greater prevalence of high blood pressure in poor African American than in white men in the United States. It also emphasized the importance of the role of correlated socioecological variables in the pathogenesis of high blood pressure.
The clinically oriented articles published in the journal for the first 40 years focused mainly on diseases with specifiable anatomical lesions, such Alexander’s "holy" seven and several others. Less attention, however, was paid to those ubiquitous illnesses that medicine neglects because they have no discernible pathological anatomy. One of these is fibromyalgia, a source of major disability, including in adolescents. For years an unsuccessful search has been carried out for some putative, immunological disturbance. But, through a brilliant inductive leap, Moldofsky et al. (14) demonstrated that some but not all such patients suffered from a rather specific (
–
) sleep disorder that could easily be corrected by exercise. They went on to validate that some of the main symptoms and the sleep disorder could be induced in normal subjects.
One should welcome and not lament the fact that these and many other publications in the journal have had a significant spin-off in the form of many new journals, such as Psychophysiology; Psychoneuroendocrinology; Brain, Behavior, and Immunity; Stress; and Developmental Psychobiology.
Lastly, many conceptual advances have occurred in psychosomatic medicine and have contributed to a theory of medicine different than the traditional one. It is no longer merely an "approach to general medicine" (1). Its concepts about the etiology and pathogenesis of illness and disease are multifactorial. In other areas of medicine, physicians continue to simplify the pathogenesis of disease, reverting to proximate, unicausal explanations. No better illustration of this reversion exists than the causal ascription of several upper gastroduodenal diseases to one bacterium, Helicobacter pylori. Careful examination of the data fails to bear out this linear-causal contention (15).
Psychosomatic medicine also recognizes that each disease is heterogeneous. It also tries to incorporate socioecological, ethnic, cultural, developmental, psychological, physiological, molecular, and genetic data into its conceptual schemes. It recognizes that it will not alone solve the mind-brain problem, if that solution will ever be forthcoming. The idea that a person—a patient—has a disease or illness is central to its premises: Disease is an abstraction and should be not be the sole focus of the healer’s attention; the patient should be, a notion that is found in Hippocrates’ writings.
To some, psychosomatic medicine always seems to lag behind other fields, to be out of fashion. So be it. However, the last 60 years have shown that conceptual fashions in medicine come and go, but integrative concepts and principles have survived and have become increasingly sophisticated.
As Niels Bohr said, "Prediction is difficult, especially about the future." One would hope that in another 60 years, the Humpty-Dumpty of biomedicine will have been put together again, so that some of the integrative aims of the journal and the Society will have been met. Whereas biomedicine’s journey has increasingly become inward bound, the fact remains that biology cannot, anymore than theoretical physics can, be reduced to an ultimate particle or gene. Truly integrative ideas are needed, not only for theoretical reasons but also to ensure the best inpatient care.
REFERENCES
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  J. C. Holland Psychological Care of Patients: Psycho-Oncology's Contribution J. Clin. Oncol., December 1, 2003; 21(90230): 253s - 265. [Abstract] [Full Text] [PDF]
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 J. C. Holland History of Psycho-Oncology: Overcoming Attitudinal and Conceptual Barriers Psychosom Med, March 1, 2002; 64(2): 206 - 221. [Abstract] [Full Text]
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J. C. Nemiah A Psychodynamic View of Psychosomatic Medicine Psychosom Med, May 1, 2000; 62(3): 299 - 303. [Abstract] [Full Text] [PDF]
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