A psychodynamic view of psychosomatic medicine.

OBJECTIVE: The objective of this article is to assess the relevance of psychodynamic observations and theory for psychosomatic medicine. METHODS: The evolution of the psychodynamic formulation of psychosomatic symptom formation is described in a brief historical review. RESULTS: There are two distinctly different pathways along which stress-induced psychological arousal is transformed into somatic symptoms. CONCLUSIONS: Psychodynamic observations and theory have important implications for psychosomatic research and treatment.

Ensuring services for persons with chronic mental illness under national health care reform.

People with chronic mental illness present complex challenges for the design of health care financing reforms. In this position statement from the committee on psychiatry and community of the Group for the Advancement of Psychiatry, the authors describe chronic and severe mental illnesses as psychiatric illnesses that require acute and ongoing psychiatric assessment and treatment, as chronic medical diseases that require ongoing rehabilitative services, and as persistent disabilities that need ongoing supportive care and social services. Any proposal for health care reform must ensure parity of chronic psychiatric illnesses with other psychiatric conditions. It must also reimburse psychiatric rehabilitation at parity with other medical rehabilitation and provide equal access to and reimbursement for broad ancillary health services that reduce costs and improve quality of life.

The varieties of human experience.

The basic unit of study for psychiatric investigation is the individual human being in interaction with the environment. The psychological understanding of human biography provided by psychodynamic observation is now being supplemented by knowledge derived from phenomenological and neurobiological research. Phenomenology and neurobiology are at present primarily concerned with detecting correlations between clinical syndromes and pathological brain states; they are static rather than dynamic in approach. However, currently emerging techniques of brain imaging aimed at elucidating neurophysiological processes provide the basis for going beyond structural neuropathology to neuropathophysiology. It is suggested that the observations derived from the psychodynamic study of patients constitute markers of underlying brain function, and that the future investigation of psychiatric illness must include a correlative study of both psychodynamic and neurobiological processes.

A reconsideration of psychological specificity in psychosomatic disorders.

In this paper, the author identifies the evolution of the specificity hypothesis in the psychogenesis of psychosomatic illness across the last half century. Specifically identified is the distinction made between the mechanism of conversion and that of vegetative neurosis. Considerable attention is addressed to the personality features thought to be common to all psychosomatic patients and the refinement of this theory over the past 40 years, including the present interest in alexithymia. These concepts are explored in the consideration of a man who sustained two different specific conflictual environmental situations. The author emphasizes that our present formulations lead us to focus on the person with the illness and the processes that lead to that illness in the patient.

The role of preventive psychiatry in physical disability.

Many patients suffering from injury or chronic illness appear to experience greater disability than one would expect from the nature of their physical lesion. Although one suspects that emotional problems are complicating their somatic illness, the defence of counterdependence masks an overt show of emotional disturbance. Furthermore, their personality structure places them at risk for developing chronic psychological invalidism, the prevention of which requires (1) an early diagnostic recognition of patients characterologically at risk for psychological complications, and (2) behavior of caretakers designed to foster the drive of each patient toward independence and to minimize the regression towards psychological invalidism.