Map of life expectancy at birth from Global Education Project.

Tuesday, May 23, 2006

Thinking ourselves sick?

This subject may not be exciting the masses, but I will press on. In our last episode, as you may recall, Sigmund Freud had provided psychiatry with theories, tools, and a direct link to physical illness through the "conversion disorders."*

Beginning in the 1930s, psychiatrists sought to further advance their prestige within medicine by extending beyond the concept of functional disorders to create the field of psychosomatic medicine. In a functional disorder, a psychodynamic process causes the patient to experience a physical symptom such as paralysis, numbness or blindness. However, no organic disease process can be discovered. In a psychosomatic condition, in contrast, organic disease is found; for example, a gastric ulcer or coronary artery disease.

In the early theories of psychosomatic illness, organic syndromes were thought to be linked to psychodynamic processes according to a sort of narrative logic. For example, ulcers were related to conflicts over the symbolic meaning of food in connection with a patient's relationship with the mother. Based on such theories, psychiatrists of the 1930s and '40s claimed to be able to cure a variety of diseases through psychoanalysis.

The development of psychosomatic medicine contributed to dramatic advances for psychiatry within the general medical establishment. During the 1930s, psychiatrists increasingly found jobs in general hospitals and medical schools. The Rockefeller Foundation made numerous grants to establish psychiatric liaison programs in university teaching hospitals. For example, one grant given in 1932 to the University of Colorado placed a psychiatrist to teach in the departments of obstetrics, medicine, surgery and pediatrics, "to demonstrate to the students the applicability and usefulness of psychiatric knowledge and the importance of regarding the patient as possibly an individual with mental maladjustment or disease as well as physical illness."

World War II brought further advances for psychosomatic medicine as the psychological stress and trauma of the battlefield frequently led to physical manifestations. However, in the 1950s, according to Okun, "the bubble burst". The use of psychoanalysis to treat physical syndromes simply could not be empirically confirmed, and the field became discredited.

Since then, it has made something of a comeback, but in not quite the same form. There is plenty of evidence that chronic emotional stress, by affecting the secretion of hormones, is associated with hypertension and vascular disease. (For what it's worth, however, a recent study finds that chronic stress actually reduces the risk of breast cancer in women.) Chronic anxiety and post-traumatic stress disorder are associated with physical symptoms such as shortness of breath and heart palpitations and need to be considered when diagnosing such complaints. The little understood syndromes of fibromyalgia and chronic fatigue syndrome are hypothesized to be associated with PTSD and/or feedback processes involving the cerebral cortex, and are susceptible to behavioral treatment. The hypothesis that the powerful link between social status and general health is somehow driven by the brain is very popular, but it has not been proved and the exact mechanism is unknown. Unfortunately, proposals that optimism and emotional tranquillity improve outcomes and survival in cancer now appear very shaky, at best.

The bottom line is that, while the duality of mind and body is becoming obsolete, the connection between mental states and physical health now appears to be largely non-specific. Stress, of whatever origin, broadly influences health. Psychiatrists get a piece of the resulting action, but it is not really in the medical major leagues.

Next: The mind in the body and the age of psychopharmacology.

*For today's post I acknowledge a substantial debt to Donald Okun, "Liaison Psychiatry (Liaison Medicine)". Adv. psychosom. med., Vol. 11 pp. 23-51 (Karger, Basel, 1983)