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SOMATIC PRESENTATIONS: HISTORY |
Department of Psychiatry, Pennsylvania Hospital, Philadelphia, PA
Athough recognition of the interaction of "psyche" and "soma" dates from antiquity, only in modern times have we developed the vocabulary and concepts to elucidate and then to systematically study its manifestations. With these developments came the notion of "psychosomatic disorders" (or "diseases"); however, the precise definition of these terms remained vague and holds true for all the "mental disorders." Before the mid-20th century, psychiatric diagnoses were unstandardized, varying in part from hospital to hospital, although with fair agreement on the major categories, which were predominantly psychoses. "Hospital" is used deliberately, for it was in these, primarily public mental hospitals, that early psychiatry largely had existed.
The first Diagnostic and Statistical Manual of Mental Disorders (DSM)1(1) was developed between 1946 and 1951, just after World War II. From that conflict had come a cadre of American medical officers, who observed a host of nonpsychotic disorders arising in response to military service and combat. Many medical officers subsequently became psychiatrists, but not within State Hospitals, instead devoting themselves to treating nonpsychotic patients in ambulatory settings. Moreover, they had come to understand the conditions they saw as largely psychological reactions to life experience, and requiring psychological treatment: psychotherapy. Most were influenced by psychoanalysis and a number became analysts, joining a group of European analysts who had fled to the US.
Those trends were abundantly reflected in the DSM. With the exception of the organic brain disorders and mental "deficiency" (retardation), all mental disorders were denoted as "reactions." Thus, the psychoses included Affective and Schizophrenic "Reactions"; it was noted that these reactions could occur "with or without defined physical causes or structural change in the brain," a statement consistent with the psychologism of the time.
Immediately after the psychoses was the new rubric: "Psycho-physiological Autonomic and Visceral Disorders," with an explanation that: "This term is used in preference to ‘psychosomatic disorders’ since the latter refers to a point of view on the discipline of medicine as a whole rather than to certain specified conditions." That is an important point to which we will return.
The explanation went on to state that "these reactions represent the visceral expression of affect, which may be thereby largely prevented from being conscious. The symptoms are due to a chronic and exaggerated state of the normal physiological expression of emotion, with the feeling, or subjective part, repressed. Such long continued visceral states may eventually lead to structural changes." This is not the place to dissect these interesting ideas. What is relevant is that this conceptualization is psychodynamic, psychoanalytic, and, most specifically, the formulation of Franz Alexander (2). Alexander, Co-Director of the Chicago Psychoanalytic Institute and probably the most prominent figure in the psychosomatic field at that time, was for 3 years (1947–1950) a member of the Committee that developed the DSM; a combination of roles makes full sense in the context of the history just elucidated.
The psychophysiological disorders were subcategorized into "reactions" of various organ systems: musculoskeletal, cardiovascular, gastrointestinal, genitourinary, endocrine, etc. In each, examples of the conditions included ranged over a span from symptoms through demonstrable pathology such as backache, tension headache, asthma, constipation, colitis, hypertension, and dyspareunia.
Of further note is the prominent locus of this category in the center of the overall schema between the psychotic and neurotic reactions.
DSM-II (3) was published 16 years later. By then, psychoanalysis had become established in American psychiatry, with an emphasis on clinical observation and the idiographic2approach. Analysts had assumed many chairs of medical school Psychiatry Departments. Even so, doubts had begun to increase, as had heightened awareness of the value of controlled scientific research in those academic departments. (An examination of the content of Psychosomatic Medicine and programs of the meetings of The American Psychosomatic Society during this period indicated that our field was at the cutting edge of this shift.)
These doubts and increased emphasis on empirical research were reflected in the new DSM-II. Although its general features and categories were very similar to the original edition, the ubiquitous term "reactions" was dropped; conditions were now being referred to as neuroses, psychoses, or "disorders." Psychosomatic conditions became "Psychophysiological Disorders," with "autonomic and visceral" dropped, likely reflecting discomfort with being bound specifically to the concepts of Alexander.
Subsequently, questions about psychoanalysis continued to increase, accompanied by advances in the basic and applied neurosciences relevant to mental disorders. American Psychiatry became more scientific, with an emphasis on evidence-based diagnosis and treatment resting on data derived from appropriately designed research, and it became more neurobiological. Psychology was not entirely eschewed but given less prominence, with psychoanalysis augmented or supplanted by behaviorism and cognitive science. Unfortunately, this new knowledge was applied within the tired old biomedical model rather than a "bio-psycho-social" (4) model. Even when psychological factors were deemed important, they were seen to operate in a concrete, linear way.
All this was embodied in the vastly changed nature of DSM-III (5), which appeared 12 years later. Its major features included: 1) the naming of conditions as "disorders," a term chosen deliberately as etiologically neutral (although many subtle clues of biogenic bias were evident elsewhere); 2) the listing of sets of specific, defined criteria to be used as the basis for diagnosis; and 3) the organization of diagnostic categories in a hierarchy, with diagnoses of later categories often requiring the absence of earlier ones.
Within the hierarchy of disorders, "Psychophysiological Disorders" was removed. Instead, there was a new category designated as "Psychological Factors Affecting Physical Condition." The nature of this category speaks for itself: Psychological processes can influence primarily physical, i.e., biological, conditions, but are modifiers, operating in a lesser, secondary role. Nor is there any hint of their transactional relationship with the biological. This category was placed at the very end of the hierarchy, to many conveying its less important status.
A new feature of DSM-III provided for diagnoses to be placed within a "multiaxial" format, in which preexisting personality disorders or mental retardation, concomitant medical conditions, stressors, and functional capacity were included. With this incorporation of psychological, biological, and social factors into a dynamic framework, this system has the capacity to portray nonlinear psychosomatic causal adaptive processes (6). Unfortunately, perhaps because of its complexities, most psychiatrists pay lip service to the use of this novel, creative system.
Fourteen years later, DSM-IV (7), with the same overall design as its predecessor, continued the same trends. Additional empirical data collected over the interval allowed for the refinement of diagnostic criteria, and a few disorders were added, dropped, relabeled or reorganized, but the changes were minor. One subtle, but telling, shift was the dropping of the term "neurosis"—which implies psychogenesis—which had been left optional for a few disorders in DSM-III.
Two changes were made in the disorders of our current interest. "Psychological Factors Affecting Medical condition" was substituted for ".... Physical" condition, a further narrowing. More significant, this rubric no longer had the status of a category in itself, but became one of a series of subsections within the category "Other Conditions that May Be a Focus of Attention," grouped with medication-induced problems, relationship problems, abuse, etc: A step further down—or out. The subcategory also was broken down into several types: Mental disorders ..., psychological symptoms ..., personality disorders or traits ..., and stress responses ... affecting medical conditions; and maladaptive health behaviors. All are reasonable, useful distinctions; but the overall effect was to further downgrade the role of psychological factors and, thus, to dilute the concept of psychosomatic processes.
As we look ahead toward the next DSM, we need to confront a fundamental and important question: Should there be a category for "Psychosomatic Disorders" at all? Psychological and biological factors are involved in all aspects of human function, healthy and disordered. All disease, and health, are psychosomatic; there are no "psychosomatic disorders" because there are no non-psychosomatic ones.
To be practical, there are situations in which biological factors play a more major role or are more pressing or amenable to treatment and, thus, must be the focus of diagnostic attention (noting that the same is true for psychological factors). Traumatic injuries must be treated on a gurney, not a couch. Such issues assume genuine importance when we shift our focus away from abstractions about the nature of disease to the concrete actualities of sick persons. In this sense, there is justification for having a rubric: "Psychological Factors Affecting Physical Condition"—although an equal case can be made for adding a corresponding, "physical disorders affecting a psychological condition."
But neither—nor any single diagnostic label—can adequately reflect the complex nature of human disease as an adaptive psychosomatic process. It may be that a better solution to the problem will be a broadened application of a multiaxial system (6), which can allow us to portray more accurately the array of specific psychological and somatic (biological) processes operating transactionally in a patient, reflecting the true psychosomatic nature of human disease.
Donald Oken, MD, is Editor Emeritus of Psychosomatic Medicine.
NOTES
1There was no I suffix; at the time, no one could imagine how the new nosology would evolve. 
2Idiographic: pertaining to or involving the study of cases or events as individual units, with a view to understanding each one separately.
This article is being co-published by Psychosomatic Medicine and the American Psychiatric Association.
DOI:10.1097/PSY.0b013e31815b003d
REFERENCES
This article has been cited by other articles:
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  J. E. Dimsdale, V. Patel, Y. Xin, and A. Kleinman Somatic Presentations A Challenge for DSM-V Psychosom Med, November 1, 2007; 69(9): 829 - 829. [Full Text] [PDF]
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