History of Psychosomatics, Course of Pr. Jean-Benjamin Stora

Historical explanation of the appearance of :

-psychosomatics

-Theepistemological break brought by the integrative psychosomatics model.

Extract from the course of Integrative Psychosomatics of the Faculty of Medicine.

Integrative PSYCHOSOMATICS: the human being and the disease

Integrative psychosomatics(Jean-Benjamin Stora) is a global approach to the human being and his illnesses, referring theoretically and clinically to the interrelationships between the psychic system, the CNS (Central Nervous System), the ANS (Autonomous Nervous System), the immune system and the genome, placing these five systems in a cultural and social environment (family and socio-professional environment, and in a broader sense, political, economic, technological and physical).

 

Jean-Benjamin Stora refers to processes that interrelate the underlying systems and mechanisms.

 

A succession of approaches since Anaxagoras (4th century BC):

1. TheHippocratic approach: the individual is a whole responding to internal and external stimuli, body and psyche; the body-psyche separation is artificial.
2. L'multidisciplinary medical approach :
   • All organic
   • Every organic disease has a psychological experience or a psychopathological disorder (in psychiatry these somatic disorders are called somatoform disorders)
   • In the absence of lesional disorders, it is psychosomatic (the doctor refers the patient to a psychotherapist)

The different approaches:

1. The approaches psychoanalytical: predominance of the mind over the body :
    
   • Freud;
   • Chicago School(F. Alexander);
   • School of Paris(Pierre Marty)
      
2. Neuro-psycho-physiological approaches.

At the dawn of medical history:

• At the very beginning an intuition: there are links between states of mind and diseases: Witch attacks, traditional therapies practiced by more than 400 peoples of the earth still today, miraculous healings, etc.
• From time immemorial, human beings have assumed the influence of the mind on the body.

Comprehensive approach to disease:

• Two great physicians are precursors of the psychosomatic approach: Hippocrates and Maimonides (Cordoba, 12th century)

• Heinroth, an Austrian internist and psychiatrist, introduced the terms "psychosomatic" in 1818 and " somatopsychic " in 1828: the first term expresses the conviction of the influence of sexual passions on tuberculosis, epilepsy and cancer, the second applies to diseases where the bodily factor modifies the psychic state.

• Psyche-Soma unity: This is the basic assumption of psychosomatic medicine.

Dualist theories:

• Anaxagoras (500-428 B.C.) distinguished between psyche and soma, this dualism was maintained by Plato, taken up again in the hylomorphism of Aristotle (384-322), according to which the soul gives form (morphe) to the body (hylé, matter), the first becoming the vital principle of the second, the latter being conceived in a close unity with the psyche.

• Hylomorphism: Aristotle, Thomas Aquinas (body and soul form a single substance).

• Interactionism: Descartes (body and soul are two substances having a reciprocal influence). Descartes is at the origin of the first paradigm of medicine: the man-machine.

• Parallelism: Leibniz, (body and soul are two substances acting independently).

Dualist and monist theories:

• Parallels-psychophysics: Wundt, (body and mind are two different aspects of man).

• Monistic theories: Idealism, Berkeley (1685-1753), Hegel, (the spiritual soul is the only reality).

• Materialism: Hobbes (1588-1679), de La Métrie, Cabanis, Haeckel, (the material body is the only reality).

Psychoanalysis and Psychosomatics:

• Freud wrote in 1923 that he was aware of the existence of psychogenic factors in illnesses, but that he preferred that psychoanalysts limit themselves to the knowledge of the field of neuroses. He distinguished the psychoneuroses from the 3 current neuroses (1898): anxiety neurosis, neurasthenia and hypochondria.

• Etiology of current neuroses: The etiology is somatic and not psychic: "the source of excitation, the triggering factor of the disorder is in the somatic domain, whereas in hysteria and obsessive neurosis, it is in the psychic domain". This conception announces the psychosomatic approaches developed later.

Early developments in psychosomatics:

• Felix Deutsch, a Viennese psychoanalyst who emigrated to the United States, reintroduced the notion of psychosomatics with his colleagues: Flanders Dunbar, F. Alexander, M. Schur, T. Benedek, etc. This movement was revived in Europe after the end of the Second World War.

Psychological Approaches:

• Some authors have proposed to establish the specific personality profile that would predispose to "psychosomatic diseases":
   
  • Flanders Dunbar (1943) establishes personality profiles from questionnaires: road accident offenders, angina sufferers, coronary patients. Links between a profile and a psychosomatic disease.
     
  • F. Alexander and the Chicago School (1952).
    
    Determination of specific conflicts in the psychoanalytical sense and physiological modifications. Two types of psychosomatic illnesses: one is the expression of blocked hostile aggressive tendencies (fight or flight), not reflected in overt behavior; the other is the expression of inhibited dependency and support-seeking tendencies.
    
    "Chicago Seven": Chronic visceral responses lead to disorders of visceral functions and Alexander distinguishes seven psychosomatic diseases: bronchial asthma, rheumatic arthritis, ulcerative colitis (UC), essential hypertension, neurodermatitis, thyrotoxicosis (Graves' or Graves' disease, thyroid hormone), gastric and duodenal ulcer.
    
    The theory of specificity: A single theory cannot account for all psychosomatic disorders, some are hysterical in nature; most syndromes (group of psychosomatic diseases) also called vegetative neuroses, are associated with certain character types or associated constellations. Alexander's unilinear theoretical model seems limited today. It is important to reconsider this theory from another angle.

Harold Wolff (1950), W.J.Grace, D.T.Graham

• According to this theory, life events have an effect on the general state of health; individuals hit by life events are more likely to suffer from diseases of various etiologies than those who have had an easier life. The studies of these theorists refer to non-specific factors that would play a role in the maintenance of health and the onset of disease. 

The precursors of the school of Paris :

• Psychoanalytical approach to psychosomatic diseases: Felix Deutsch proposed a method of associative anamnesis at the origin of Pierre Marty's method of investigation. Margolin underlined the existence of a psychic regression in the patients, consecutive to defects of the ego, which would lead to a re-somatization according to Schur, Sigmund Freud's doctor.

• Max Schur, Sigmund Freud's physician: Under the effect of stress and the reactivation of the unconscious conflict, the patients would regress in their thinking from secondary to primary processes (regressive symbolism, regressive thinking) while at the same time the re-somatization of their responses would appear. The affects are accompanied by somatic changes, e.g. oscillations in blood pressure, secretion of gastric juice, etc. The progressive detachment from the psychic life is called by Schur de-somatization.

• Margolin, Grinker, Kubie: The matrix of psychosomatic disorders is established in the first months of life. The disease consists of a regression to a stage of insufficient differentiation between the biological and the psychological. From the psychoanalytical point of view, the serious psychosomatic diseases present points of fixation and regression located at a pregenital period of evolution. These authors speak of "organ psychoses" for them the psychosomatic patients are situated in the fringe between neurosis and psychosis.

The Szondi Test:

• Profile of the psychosomatic patient: sexual immaturity, pregenitality, persistence of very strong oral and/or anal needs, relations very dependent on the Object (significant person for the subject's affective life) - individual clinging to a dual mode of relation, failure in front of the Oedipus. Table associated with rigid defenses and submission to reality and the laws of the social group, with negation and projection - very strong defenses against the emergence and recognition of desire. Somatization would be a collapse of the subject-desiring.

The Paris School:

• Pierre Marty, Michel Fain, Christian David and Michel de M'Uzan, (1962) develop a theoretical and clinical corpus, inherited from previous contemporary contributions. Pierre Marty develops a psychosomatic approach inspired by psychoanalysis (new concepts: operative thought, essential depression, etc.) which will be taken up again in the general course. This approach is a good synthesis of the theoretical hypotheses put forward by their predecessors.

The psychosomatic phenomenon:

• For Pierre Marty, this phenomenon is considered to be different from the neurotic phenomenon, it is a real disorganization of the mental life. The somatic symptom is devoid of meaning, the doctor is faced with a void, a deficit. The operative thought signs this deficit of the psychosomatic structure. The correlative of the operative thought is the devitalized, disaffected language.

Physiological and Psychophysiological Approaches:

• Cannon and Selye have demonstrated in experimental studies that chronic emotional stimuli, like chronic stimuli of an infectious, toxic or traumatic nature, can lead to functional disorders and organic lesions.

• Orientations: These theories, especially those of Selye, the father of Stress, provided a first model allowing the exploration of the regulation of thehypothalamic axis, the autonomic nervous system, the neuro-endocrine system, and later, with immunological research, tooutline a physiological and neurophysiological basis for the study of psychosomatic medicine.

Resistance of the organism and Psychism:

• Gradually, from all these theories, a picture of illness and health emerges in which different agents play a role to varying degrees: a pluricausal approach to illness and the sick (cf. Michael Balint). The somatic resistance of the organism is related to the psychic balance of the individual.

"Man is psychosomatic by definition" (Pierre Marty)

• It can be considered that practically all illnesses can be considered as "psychosomatic illnesses" where psychic and somatic factors would play roles of different importance; the psychic apparatus would participate more or less according to the etiology to the somatic disorders.

"The human being constitutes a psychosomatic unit" (Jean Benjamin Stora)

• The approach developed by Jean-Benjamin Stora in his course is the following:
   
  • The human being constitutes a psychosomatic unit; there are no psychosomatic diseases.
     
  • the psychic system participates to a greater or lesser degree in the etiology of somatic diseases.
     
  • Psychic functioning is to be evaluated within the framework of the individual psychosomatic unit alongside the somatic and neuronal dimensions.
     
  • Theoretical details: The psychic apparatus, at the forefront of evolution, is the first defense system of the psychosomatic unit. Its dysfunctions have consequences on somatic disorders and diseases without being the cause. The integrative psychosomaticapproach is multi-causal. We thus discard the old approach of psycho-genesis of somatic diseases.
     
  • Environment and Psychosomatics: Family, social, economic, and cultural dimensions must be considered when investigating somatic patients. The integrative psychosomatic approach is multidimensional. (ref. biopsychosocial model of Prof. George Engel of Harvard Medical School).

Integrative Psychosomatics Jean-Benjamin Stora (1999)

• "The psychosomatic hypothesis that I have been putting forward since 1999 proposes to establish, in the light of the progress of the various disciplines, the relationships between the somatic functions, the central nervous system and the psychic apparatus; I no longer speak of body or psyche. The psychic apparatus, developed by S. Freud, is an integral part of the psychosomatic unit. It is then a question of understanding the participation of this apparatus in the global functioning. We are beyond psychogenesis and organogenesis. We apprehend the organism as a system of systems whose interactions and dysfunctions we must understand."

• "The psychosomatic unit: The approach that I will develop in this course is the following: the psychic apparatus participates to a greater or lesser degree in the etiology of somatic diseases. Psychic functioning is to be evaluated within the framework of the individual psychosomatic unit alongside the somatic and neural dimensions, within the context of a family, social, economic and cultural environment; this is a multidimensional approach."

• "The integrative approach in psychosomatics: The proposed psychosomatic model is a multi-factorial model at the interface of psychoanalysis, medicine and neuroscience referring to:

1. Non-specific factors disturbing the individual's homeostasis (trauma, etc.).
    
2. A specific structuring of the psychic apparatus at the end of the process of psychosexual maturation determining its capacity of resistance and the zones of fragility.
    
3. Interrelationships established by this process at the level of the CNS (Central Nervous System), ANS (Autonomic Nervous System), Immune System, and Genetic System or Genome."

• "The integrative approach in psychosomatics: It is an approach ofdynamic interrelations between different living systems. The human being is a system of systems. Over the past 17 years, I have developed a global scientific model of the psychosomatic functioning of human beings, based on Ludwig von Bertalanffy's system theory. The psyche-soma model is an aporia (dead end) developed in a metaphysical context that has never been questioned over the centuries.

  Jean-Benjamin Stora, June 19, 2012