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The suffering of the soul in medicine: Psychosomatic medicine, depression, anxiety, anger and the skin.

Introduction

Psychosomatic medicine - what does this mean to you? It is likely that the word psychosomatic and related terms such as hypochondria bring to mind illnesses that are generated by the mind and that in some way are not real. To a certain extent this idea is correct. Psychosomatic medicine is concerned with the origins, meanings, and underpinnings of disease and cannot easily be made sense of under the reigning biomedical understandings of health and illness. The key sticking point is the integration of the suffering of the soul into the health equation. Originally coined by Johann Christian August Heinroth in 1818 to take account of the body and the soul in medicine, the term psychosomatic medicine can today be understood as the study of the 'mind-body' relationship in medicine. (1) Within a psychosomatic framework symptoms or diseases are thought to arise from emotional or mental factors and to be produced within particular historical and social conditions'. (2(p. 93) (3) Within this ideographic framework there is no disease but only manifestations of the mind-body-soul. Suffering and disease are understood differently and can be explored via means that would be considered unconscionable under the biomedical model. Here, there is no disease per sc. there are only sick people. Disease expression could, for example, be understood as a metaphor, an idiom, a construction denoting something newly created to fit a particular purpose, occasion or situation'. (4(p. x) This contrasts with conventional medicine which seeks to rank and classify illness according to a prescribed taxonomy offering no place for the psyche or soul and no conception of the umwelt, the world as it is experienced by a particular individual. (5) Proof of concept in conventional medicine requires a scientifically verified evidence base, but how do we prove the suffering of the soul?

Conventional medicine and psychosomatics

Conventional medicine in Australia today is influenced by two dominant and competing models of provision, the biomedical and the biopsychosocial. In 1977, the biopsychosocial model, encompassing the idea that psychosocial factors influence the pathogenesis of all diseases, was introduced as an alternative to the biomedical model. (1 (p. 6) Within the biopsychosocial model, as it is currently played out in Australia, the social determinants of disease, classified primarily according to sociological understandings, are taken into account, as are environmental effects. (6) Today the biopsychosocial model is well accepted within medicine as influencing current understandings of health and wellness. It is my contention that most middle class Australians would see their health as the result of lifestyle choices, biology and (to a certain extent) environment. As a case in point catastrophic illness events are often discussed with reference to the fact that a person exercised, didn't drink alcohol and ate well. Although thinking is beginning to change, ideas that move beyond the current biopsychosocial framework, that take into account spiritual and affective elements of the self, are today not widely accepted in mainstream society. (1)

The multiple and competing discourses of health provision existing in Australia today underpin current understandings of psychosomatic medicine. The biomedical model positing the body as machine, comprised of component parts treatable in isolation from one another, dominates medicine, while the more holistic biopsychosocial model, which takes into account the body, mind and social determinants, structures policy provision. Elements of traditional medicines that can be evidenced within these parameters have gained popularity: for example, herbal extracts rather than herbs, dry needling rather than Traditional Chinese Medicine (TCM) and in of psychosomatic medicine consultation-liaison psychiatry. Consultation-liaison psychiatry, a sub-discipline of psychiatry, operates under a biomedical paradigm taking into account the mind/body connection in the process of clinical decision making." The practitioner is either a member of a medical team or a consultant and is responsible both to the requesting consultant and the patient. (1) Texts in this area may be entitled psychosomatic medicine and in fact an environmental search via google conflates psychosomatic medicine and liaison psychiatry. However, consultation-liaison psychiatry, as a psychiatric specialisation, is a practice of medicalisation and a far cry from the tradition and original philosophy of psychosomatic medicine.

In the liaison psychiatry literature, textbooks and clinical and diagnostic manuals focus on practice and process, addressing the philosophy of doing psychosomatic medicine only in passing. (1,8,9) Diagnosis takes place with reference to a manual similar to the Diagnostic and Statistical Manual of Mental Disorders (DSM). (10) The Clinical Manual of Psychosomatic Medicine (2012) classifies psychosomatic symptoms as somatoform and related disorders', including somatisation disorder, undifferentiated somatoform disorder, undifferentiated somatoform disorder, hypochondriasis, conversion disorder, body dysmorphic disorder, pain disorder, factitious disorder, and malingering. (9)

The language of consultation-liaison psychiatry fits well within the biomedical model and the biopsychosocial model. Patients with various named disorders and diseases can be studied, ranked, and classified, and statistical analysis via evidence-based studies and meta-analyses can be undertaken. The effects of psychotropic drugs can be measured and catalogued and predictions made about the likely efficacy of medication for other patients displaying similar symptoms.

The tensions between the biomedical model and biopsychosocial model can be seen to be played out within the context of the current drive to discredit integrative medicine, and in particular disciplines such as osteopathy, Chinese medicine, and homeopathy. Were it on their radar as something other than consultation-liaison psychiatry, psychosomatic medicine, as a framework that moves beyond the biopsychosocial model to take account of the spirit and soul would, I am sure, would be a discipline labelled by Friends of Science in Medicine as 'Quakademia'. (11, 16) Our current conventional medicine paradigm, positioned as it is within competing biomedical and biopsychosocial paradigms, sets up the conditions for a rejection of psychosomatic medicine as it was originally conceived, and as a consequence clinical-liaison psychiatry has grown in popularity while psychosomatic medicine languishes on the sidelines.

Rather than looking deeply into the psyche and the soul where disease originates we have manipulated psychosomatic understandings to fit within a particular framework of understanding - one in which symptoms rather than causes remain the focus. This means that stress responses such as neck and back pain and skin disorders are understood as problems to be cured rather than signs and symbols of deeper spiritual suffering.

Stress effects

Today stress is commonly seen to be the basis for a range of ailments and is widely accepted as a precursor or exacerbator of a range of somatised disorders. (12) General medicine, psychoanalysis and psychosomatic medicine may agree that stress often manifests itself as a somatic disorder but ideas about the meaning of the symptom and pathways to cure, or transcendence, vary greatly. (13, 14) Nonetheless, all would agree that a reduction in allostatic load, or repeated exposure to stress, is desirable.

Strategies to deal with excessive stress can be found in lifestyle cures such as mindfulness and meditation. Mindfulness is a relatively new player in the Western medical and psychological literature: over the past thirty years its popularity, and a corresponding body of empirical evidence, has continued to grow. Over the past 15 years mindfulness has moved from the margins to the mainstream and more recently GPs in the UK have begun prescribing mindfulness meditation for a host of physical and mental ills. (15)

This is a step in the direction of an understanding of psychosomatic causes of illness. It does encompass the psychosomatic idea that 'emotional factors influence all body processes through nervous and humoral pathways'. (16(p,52) But while mindfulness and meditation practices may soothe the nervous system, alone they do not necessarily heal the trauma of the underlying causes of the stress response. Mindfulness practices do not help us to understand and explain, for example, why two people respond to the same stimulus differently, nor do they provide a means to understand the cause of allostatic overload. Many of the traditions from which mindfulness practices are drawn are thousands of years old. Healing was empirically observed but the means by which it took place were not well understood. With functional Magnetic Resonance Imaging (fMRI) and other technologised techniques our understandings of the processes by which disease develops and healing takes place are evolving.

Depression, anxiety, anger and the skin

Recent research in molecular biology supports links with inflammatory and vascular factors in the aetiology of skin disorders because of immune dysfunction. (17) A wealth of clinical experience and uncontrolled case series publications provide support for the common opinion that stressful life events and skin diseases exist in relationship to one another. (1923) From a psychosomatic perspective skin disorders can be understood in terms of repressed expressions of anger and hostility, in particular the expression of anger. (18,19,20) The skin and the central nervous system share an embryological relationship, as well as several hormones, neurotransmitters and receptors. It is therefore not surprising that a link between the skin and psychological diseases has been noticed and described. (20) For example, patients frequently indicate stress or emotional stress as triggering factors for an outbreak of eczema. (21)

The idea that a skin disorder could bean armouring of the body, a form of protection, and present an opportunity for someone to move forward and grow is currently not widely accepted in mainstream culture. (23) However, if we look to a psychosomatic understanding it makes logical sense. Depression, anxiety and anger are common in individuals with skin diseases. (24) In skin disorders the skin's natural protective function is turned into a form of armouring. Psychological pain such as depression, anxiety, and stress are somatised and expressed via the skin. According to Dethlefsen & Dahlke (2002) '... the sufferers are shutting themselves off in both directions. They are no longer willing to let in or out'. (23(P) (167) Dethlefsen & Dahlke's (2002) project is to promote our understandings of ourselves as human beings through our symptoms. In the skin we see not just our internal physical state but all our psychological processes and reactions. Pressure from within and pressure from without reveals itself on the skin. Dethlefsen & Dahlke (2002) suggest that behind ever) form of defence is a fear of getting hurt. (23)

Psychotherapeutic interventions have proved successful for many skin conditions. (24) The literature suggests that skin disorders are related to immune response and that writing or talking about our emotional response allows us to move beyond it and let it go, as well as positively affecting blood markers of immune function. (17,19,21) Journaling a stressful life event or childhood experience over a period of weeks can be a pathway to cure.

If we start to look through a psychosomatic lens, the notion that the body and the skin speak our inner world can be seen throughout society.4 The idea is not limited to esoteric or theoretical explorations. We see it explored in popular culture. Jeanette Winterson's (1993) novel Written on the Body, for example, explores the isolating aspects of disease. (23) We also see the relationship between symptoms and disease in religion and spiritual traditions. Understanding skin disorders from a psychosomatic perspective provides an opportunity to look below the skin to the source of the suffering.

The soul

I am interested in the shared belief in the importance of the spirit and the soul in both psychosomatic and spiritual understandings of disease. In many spiritual traditions such as Taoism, Buddhism, Yoga and Islam this link is well understood. Islam, for example, actively addresses psychosomatic illness. Prophet Muhammad is credited with saying excessive worry makes physical illness in a person'. (26(p. 150) Himalayan people's traditions such as Bon and Buddhism also make a link between how we think and the health of the body, believing that the heart-mind should be kept clean and free from pollution or defilement. (27,28) Pollution is felt to be the result of the external contamination of spiritual life where a lack of purity is manifested on the body. (28) The philosophy of Taoism, underpinning TCM, links spiritual and physical health, and the eight-fold path of yoga provides a path towards acceptance and the curing of physical ills. (29) The outcomes of psychological work and spiritual and religious experience are in many ways similar, freeing oneself from fear, experiencing love, peace, serenity, equanimity. However, the means to the ends are different.

Conclusion

A psychosomatic orientation requires more than mindfulness or meditation, more than the here and now, and more than a present moment awareness. Perhaps this requires intuition. Perhaps it requires a deeper understanding of how past experience affects the present. Perhaps it requires a new consciousness. Awareness itself can be transformative. (30) One of the basic ideas in psychosomatic medicine is that the client's body signals how to work with them. One of the basic ideas in psychosomatic medicine is that the symptoms, written on the clients body, provide a pathway for the therapist to work with the client. Symptoms are not just obstacles that need to be removed, a matter of healing the physical hurt. This healing attitude keeps the person locked within a limiting identity and away from the spirit that seeks personal growth and contribution to community'. (30) (p) (l67) There are many means by which the body can be healed. However, healing only the body obscures the deeper psychological and spiritual reasons we feel pain.

REFERENCES

(1.) Leigh H, StreltzerJ, editors. Handbook of consultation-liaison psychiatry [Internet]; 2014 [cited 2018 January 4]. Available from: ProQuest Ebook Central.

(2.) Helicon Publishing. Hutchinson trends in science-medicine and health science [Internet]. Abingdon: Helicon Publishing; 2006 [cited 2018 January 3]. Available from: ProQuest Ebook Central.

(3.) Shorter E. From paralysis to fatigue: A history of psychosomatic illness in the modern era. New York, NY: Free Press; 2014.

(4.) Furst L Idioms of distress: Psychosomatic disorders in medical and imaginative literature [Internet]. Albany: State University of New York Press; 2002 [cited 2018 January 3]. Available from: ProQuest Ebook Central.

(5.) Von Uexkull T. The dream of unity of psyche and body: Has it passed us by? Interview with Professor Thure Von Uexkull. Interview by Juergen-Peter Stroessel. Psychother Psychosom 1988; 50(3). 117-24. [cited 2018 January 8]. Available from: ProQuest Ebook Central.

(6.) GermovJ. Second opinion: An introduction to health sociology. 5th ed. Australia, Oxford University Press; 2014.

(7.) Saad M, Medeiros R, MosiniA. Are we ready for a true biopsychosocial-spiritual model? The many meanings of "Spiritual". Medicines [serial online]. 2017; 4(4):79. DOI:10.3390/medicines4040079

(8.) Amos J, Robinson R, editors. Psychosomatic medicine: An introduction to consultation-liaison psychiatry [Internet]. Cambridge: Cambridge University Press; 2010 [cited 2018 January 3]. Available from: ProQuest Ebook Central.

(9.) Philbrick K, Rundell J, Netzel P, Levenson, J. Clinical manual of psychosomatic medicine: A guide to consultation-liaison-psychiatry. 2nd ed. Washington, DC: American Psychiatric Publishing; 2012.

(10.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5) [Internet]. Washington: American Psychiatric Publishing; 2013. [cited 2018 January 9]. Available from: ProQuest Ebook Central.

(11.) Ernst E. Quackademia down under. [Internet] 2017 June 14. [cited 2018 January 9]. Available from: http://edzardernst.com/2017/06/guackademia-down-under/

(12.) Tareen R, Greydanus D, Jafferany M, Patel D, Merrick, J editors. Pediatric psychodermatology: A clinical manual of child and adolescent psychocutaneous disorders [internet]. Berlin/Boston: De Gruyter; 2012. [cited 2018 January 8]. Available from: ProQuest Ebook Central.

(13.) StoraJ. When the body displaces the mind: Stress, trauma and somatic disease [Internet]. London: Karnac Books; 2007. [cited 2018 January 9[. Available from: ProQuest Ebook Central.

(14.) Kimyai-Asadi A, Adil U. Theroleof psychological stress in skin disease. J Cutan Med Surg [serial online]. 2016; 5(2): 140-145. DOI: 10.1007/BF02737869

(15.) Dimidjian S, Segal Z. Prospects for a clinical science of mindfulness-based intervention. Am Psychol, [serial online]. 2015 Oct; 70(7): 593-620. doi: 10.1037/a0039589

(16.) Alexander F. Psychosomatic medicine: Its principles and applications with a chapter on the functions of the sexual apparatus and their disturbances by Therese Benedek. New York, New York: Norton; 1950.

(17.) Elsaie M, Choudhary S. Updates on the pathophysiology and management of acne rosacea. Postgrad Med [serial online]. 2015; 121(5): 178-186. DOI:10.3810/pgm.2009.09.2066

(18.) Fava G, Sonino N. (2000). Psychosomatic medicine: Emerging trends and perspectives. Psychother Psychosom 2000 Jul; 69(4): 184-197.

(19.) Picardi A, Abeni D. Stressful life events and skin diseases: Disentangling evidence from myth. Psychother Psychosom 2001; 70(3): 118-36. [cited 2018 January 3]. Available from: ProQuest Ebook Central.

Dr Michelle Mars PhD | MPhil, GradDipSocSci, PostGradDipTertiaryTeaching, BBS
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Title Annotation:ARTICLE
Author:Mars, Michelle
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Geographic Code:8AUST
Date:Sep 22, 2018
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