Psychotherapies with regard to on psychosomatic medicine
In psychosomatic medicine, Andrawis (2013) describes that it is not the findings alone that are decisive for a cure. A holistic view of the individual, for example, also includes psychosocial sensitivities in the background as a psychosocial factor.
In order to understand a disease, the physician should see his patient as an individual, perceive his complaints from every possible angle and put them into context (body-mind unit). What is important, as Bräutigam et. al. emphasize, is that the doctor has the phenomena of the reflexes between body and soul in view at the same time. The majority of all medical theories represent the opacity of biological processes. These procedures require the therapist’s or doctor’s full attention. The dimension of mental, conscious and unconscious inner state and emotionality, as well as the selective perception of the patient’s social environment, are further areas of the manifold theories and perspectives in psychosomatic medicine (Andrawis A, 2013).
Psychoanalyticaal Concepts of Psychosomatic Illness as a Conflict
Two guidelines for the development of psychosomatic symptom formation were decisive in the investigation of the disease conflict, namely Freud’s psychoanalysis and the psychosomatic way of thinking of the internists, which emerged from internal medicine, such as G. v. Bergmann (Berlin), V.v. Weizsäcker, L. Krehl (Heidelberg). As already described by Bräutigam et. al., the internists diagnosed this symptom formation as a functional disorder without somatic findings. Psychoanalysis has placed mental conflict in the foreground as the cause of somatic disorders. (ibid. ):
Through the practice and theories of psychoanalysis, multi-layered systems have emerged that are inexhaustible. Historically, Freud created an important access for medicine that opened up a new dimension: to treat diseases in terms of their psychosomatic effects. As already Andrawis, (2013) emphasize, the life story of early childhood traumas plays a major role in the development of human beings for bodily-mental health or illness. The influence of mental conflicts on the emotional level (bonds or separations, sexual and aggression conflicts) is often already very clearly recognizable in the pathogenesis. (ibid.).
Before going into the theories of psychoanalysis in more detail, it is useful to mention some important references to the psychoanalytic context that the author already describes:
1 Modern psychoanalysis refers to early childhood development. Various crisis points that can have an influence on later disturbances are pointed out. The healthy or disturbed instincts in early childhood have an influence on the maturation of the different instincts of the body-soul development in adulthood.
2) In psychoanalysis there is a hierarchy of mental structures. Differentiated types of experiencing and behavior prevail on that occasion: The Unconscious – the Preconscious – the Conscious, It – I – Superego, Primary Process – Secondary Process. In the course of life, during experiences of crisis or harmony, during breakdowns or successful performances, once differentiated, once elementary patterns of behavior predominate. In the successful case, there is improved adaptability in favor of conflict resolution. In the other case, regression occurs, which has a negative effect on the somatization level.
3) Psychoanalysis develops a differentiated ego and self-psychology with reference to the drive development. The so-called strength or weakness of the ego is an important prerequisite for a successful or unsuccessful conflict resolution. The weakness of the self is a weakness of the individual to adapt to his environment. This usually leads to the development of disturbances.
4 Recently, the influence of inhibitory or supportive aspects in early childhood and current relationships has been given special attention in psychoanalysis in the context of object relationship psychology. The individual human being is not understood out of his personal, genetic, psychological and individual development, but as an object-related, social being which enters into certain relationships and is dependent on relationships. Andrawis, (2013) explained that illness can also be derived from the circumstances and nature of encounters between and with fellow human beings.
The Contribution of Psychoanalysis to Psychosomatics
Psychoanalysis has developed the model of conversion by Sigmund Freud and his “Studies on Hysteria” (1895), in which hysterical symptom formation is described, e.g. psychogenic arm paralysis, hysterical dysbasia (gait disorder) and psychogenic anesthesia (emotional disorder).
As already explained by Andrawis (2013), the arbitrary movement is the model of the psychoanalytical concept of conversion, which is implemented in the design of action and motor execution, as in pointing, grasping, interpreting or closing the fist. Freud is of the opinion that conversion combats unwillingness and redirects its excitement sum to the physical level.
Unconscious conflicting fantasies thus lead to physical changes (somatic, motor or sensitive symptoms).
The psychic energy (libido) is transformed into a stimulus, bound by a symptom and held by this in the unconscious. The libido needs attention. It has both satisfying and punitive character. (ibid. ).
Freud was of the opinion that this event was a physical experience. Thus, as already Bräutigam et. al. explain, this theory and practice are still applicable today for patients who suffer from a hysteria symptom formation, not only from a paralysis, but also e.g. from a voice and sensitivity disorder. Psychosocial systems play a particularly important role in the development of physical symptoms. However, this explanation was not satisfactory for science. In a genital sexual conflict, Fenichel is of the opinion that early disorders of infantile needs are the cause of the desire for warmth, closeness and security. Rangell (1959) attempted to narrow down the concept of conversion, but this did not succeed, since this model occurred in practically all conflicts in connection with physical disorders. The question now arises as to whether this model can be retained without Freud’s intention of symbolic representation of the conflict and drive-dynamic salvation through the symptom being provable (ibid.).
In contrast to Freud and most psychoanalysts who limited the conversion model to hysteria only, Groddeck (1866-1934) also applied the model to other diseases, such as organ patients. He was of the opinion that body symptoms have a symbolism which originates from the forces of the It and which in turn can express themselves in all organs. This unconscious, the It, which according to Groddeck contains all forces of nature and instincts, is in his view the origin of all organ occupations. Thus, the internal organs controlled by the vegetative nervous system would also fall under the concept of conversion. Ultimately, Groddeck was the first to recognize the influence and importance of unconscious processes as the cause of physical illness. Despite his speculative understanding of pathogenesis and his unscientific treatment practice, his thought nevertheless provides a valuable impulse for a psychosomatic view of all diseases. The large number of psychosomatic researchers finds the concept of conversion as an explanatory principle for the majority of psychosomatic disorders to be insufficient, since it can only be applied to a certain group of symbolically defined symptom formations. As already Bräutigam et. al. emphasize, the physical symptoms are reduced to a psychogenetic level of the conscious and unconscious organ language, which does not do justice to the complex influences of most diseases. The social and psychological influencing factors are not limited to neurotic conflict tensions, but are more diverse.
Univ. Prof. Dr. Andrawis
