Models of pathogenesis of psychosomatic disorders and the concept of psychosomatic scenario

Introduction

Psychosomatic disorders (PDs) are pathological conditions that arise as a result of the interaction of mental and somatic provoking factors and lead to the development of mental disorders as a reaction to somatic pathology, somatic disease against the background of psychogenic factors, as well as to the somatization of mental disorders [1-4].

 The prevalence of PDs ranges from 15 to 50% in the general population, from 21 to 33% in outpatient, and from 28 to 53% in inpatient institutions of somatic profile [5–8]. However, taking into account the variety of clinical manifestations of PDs and patients seeking help not only from psychiatrists but also from doctors of other specialties and representatives of alternative medicine, these indicators are significantly higher in real life. The untimely detection of a psychosomatic factor in the development of a somatic disease often leads to the appointment of unreasonable and expensive treatment, including invasive interventions [9, 10].

Due to the high relevance of the problem of verification of PDs, the purpose of this study was to develop an integral approach to the diagnosis of psychosomatic diseases based on the analysis of existing concepts and concepts. In order to achieve this goal, a literature review was conducted by means of using the electronic libraries Scopus, PubMed, Cochrane Library, and CyberLeninka (keywords such as “psychosomatic disorder”, “psychosomatics”, “psychosomatic medicine”).

The term “psychosomatics” (Greek language: “psycho” — mind, “soma” — body) was introduced by the German psychiatrist Heinroth in 1818. In 1922, Felix Deutsch formulated the concept of “psychosomatic medicine”, but it acquired its modern form only in the 1930s as a result of merging two concepts (disease psychogenesis and holism), having an ancient tradition in Western thoughts and medicine [11]. The idea of psychogenesis led to the emergence of the concept of psychosomatic illness — a physical illness caused by psychological factors, including personality traits and subconscious conflicts [12–14].

Nowadays, psychosomatic medicine is based on the main postulates of multicausality of the biopsychosocial model proposed by George Engel, a therapist and psychoanalyst [15]. Thus, the state of illness or relative health is a consequence of the interaction between biological (heredity, contact with infectious agents), mental (personality traits, mental disorders), and social factors (presence of relatives, friends, working conditions, psychological well-being at work).

Psychosocial factors may support, contribute to, or alter the course of the disease; their relative severity may vary from disease to disease, from one person to another, and even between two different episodes of the same disease in one person. This can affect susceptibility to the disease by activating various central nervous system pathways [16–18].

Stress as the psychosomatic disorders basis

According to the recommendations of the 6^th seminar of the World Health Organization, held in Switzerland in 1970, the main component of PDs is to be considered physiological disorders against the background of vivid emotions. Emotional stress caused by stress leads to the hyperactivation of the neuroendocrine and autonomic nervous systems, which together with a hereditary predisposition leads to a disease of one or another internal organ [19].

First of all, it is important to notice that stress affects the neuroendocrine system, which coordinates the processes of the whole body, regulating the functions of the cardiovascular and immune systems, as well as behavioral reactions. Therefore, neurotransmitters catecholamines are released, in particular dopamine, norepinephrine, and adrenaline. At the conscious command of the brain, motor neurons are responsible for voluntary movements, for instance, for teeth-clenching. In a stressful situation, teeth-clenching may occur in a similar way under the influence of motor neurons, but this action is not necessarily to be carried out consciously. In response to stress, the hypothalamic-pituitary-adrenal system is activated, which results in the increased production of corticosteroids with an antistress effect [21]. According to academic specialists who have studied the effect of biological stress reactions of psychological, physiological, and physical genesis on the body, in response to chronic stress, innate and adaptive immunity is activated. This leads to changes in the maturation and functioning of dendritic cells, neutrophils, macrophages, and lymphocytes, as well as to the increased production of cytokines leveling out the immunosuppressive corticosteroid effect. Thus, a high level of IL-1, IL-6, and TNF-α is detected, which promotes the transcription of proinflammatory cytokine genes that can cross the blood-brain barrier by acting on central monoamine neurotransmitters. Immunoactive substances cause so-called “painful behavior” that imitates depression [22][23]. Fuligni et al. report elevated levels of C-reactive protein (a marker of inflammatory response) in men and women against the background of chronic stress [24]. The suppression of the innate and adaptive immune response is carried out by the disbalance of type 1 and type 2 T-helper cells: a decrease in the number of immunoprotective cells causes the development of chronic inflammation [25].

In addition, according to the results of molecular biological studies, fear and anxiety directly activate certain genes through histone acetylation and demethylation, which leads to a change in the chromatin structure and the development of neoplastic, autoimmune, and mental disorders [26]. Thus, constant anxiety and unprocessed experiences may cause somatic disease.

American academic specialists have identified the most common psychosomatic diseases, the so-called “Holy Seven” or “stress diseases”: essential hypertension, bronchial asthma, duodenal ulcer and stomach ulcer, ulcerative colitis, atopic dermatitis, rheumatoid arthritis, and hyperthyroidism [27][28]. Nowadays, it has been established that diseases with psychosomatic etiology are also psoriasis, lichen ruben planus, coronary heart disease, diabetes mellitus, infertility, migraine, and many others [29]. As a rule, these diseases have a chronic recurrent course with episodes of exacerbation against the stress background. Long-term functional changes gradually destroy the target organs, and the process acquires a somatic character.

Basic ideas concerning the disease nature

In order to understand the role of the human state of mind in the pathogenesis of somatosis, it is necessary to consider the existing ideas concerning the disease cause.

Western medicine does not recognize the influence of mind and spirit on the human body, perceiving the body solely as mechanical matter consisting of “bones and chemical broth” [30]. From the position of “traditional” doctors, dysfunction of organs and systems leads to the development of a particular disease due to various disorders at the physiological level. In Oriental medicine, more attention is paid not to the state of the structure of internal organs, but to the quality of their functioning. Therefore, every organism is considered a single self-regulating ecosystem. It is believed that various ailments in the body are caused by an imbalance of Yin and Yang energy resulting from excessively experienced emotions [31][32]. According to esoteric beliefs, the disease also develops as a result of blocking, congestion, or slowing down the circulation of energy in various body systems. Special attention in esoteric pathophysiology is paid to the imbalance. Violation of the state of dynamic equilibrium at any level (physical, energetic, emotional, mental) may cause a high risk of developing both somatic and mental diseases [33][34]. From one of the most common points of view, the main component of the pathogenesis of any disease is transcendental spirituality. Thus, a believing person perceives the disease as “a given” and as a warning from supreme forces concerning the need to reconsider life attitudes and atone for the sins. The adherents of the psychosomatic theory claim that a person's vulnerability to certain diseases may be influenced by the personal characteristics of the patient, including the presence of alexithymia, as well as high allostatic load (frequent stressful events and low adaptation to them). According to the results of numerous controlled studies, a statistically reliable relationship between stressful life events and various diseases was found (such as bronchial asthma, diabetes mellitus, Cushing's disease, hypothalamic amenorrhea, peptic ulcer disease, inflammatory bowel diseases, functional diseases of the gastrointestinal tract, myocardial infarction, functional diseases of the cardiovascular system, autoimmune diseases, oncology, infectious diseases, psoriasis, nesting alopecia, urticaria, migraines, disorders of cerebral circulation, and even sudden death) [35–47].

Unfortunately, each of the above concepts characterizes only one of the four links in the development of the disease. Such unipolarity of views does not allow forming a full-fledged picture of a person as a biopsychosocial and spiritual object, in connection with which the author of this article proposed a term uniting all the hitherto disparate aspects of the development of somatic disease – an integral psychosomatic scenario.

Psychosomatic scenario of the disease

Based on the author’s personal experience accumulated over many years of scientific and practical work with psychosomatic patients, the author proposed and patented (certificate of deposit No. 2207787) the term “psychosomatic scenario of the disease” — a combination of programming and triggering psychotrauma, attitudes toward the disease and its impact on the physical and emotional state, as well as the assessment of one's future by a patient. In the author’s opinion, during each session of psychotherapy, it is necessary to work with three aspects of a person's life (present, past, and future), while focusing on the aspects that cause the most tension. The identification of the psychosomatic scenario of the disease is a fundamental condition for successful work on human healing. Based on the disclosure of the psychosomatic scenario of the disease, the doctor is able to comprehensively solve the problem of restoring health; in his/her practice, he/she can delicately use the knowledge accumulated by humankind over the centuries-old history of the art of healing development, taking only the best from each approach and not limiting him/herself to the framework of one system.

The task of the psychosomatic approach is to combine the knowledge of classical Western, Eastern medicine, and psychotherapy. The understanding of these three fundamentals allows the doctor to analyze, realize the psychosomatic scenario of the disease, and see which psychoemotional conflicts of the person him/herself and/or inherited from his/her parents and ancestors, as well as distorted ideas about his/her present and future, triggered the mechanism of adaptation to these distortions in the physical body in the form of disease (Figure 1).

A psychotherapy session should include an in-depth analysis of the patient's anamnesis in order to discover the true causes of somatic illness, in other words, to identify a psychosomatic scenario, which will make it possible to draw up an effective treatment plan. First of all, it is necessary to assess the way the patient perceives the existing symptoms him/herself, if he/she understands the associated internal conflict. One of the most important points in the course of diagnosis is the search for programming causes, emotionally negative experiences in the past, which formed the further strategy and consolidated it in the present. As a rule, the “unpacking” of the conflict occurs during a hypnosis session: when the patient is immersed in a safe state, his/her subconscious allows him/her to remember and relive the conflict. A deep study with the attending physician makes it possible to defuse the primary conflict and promotes recovery.

Conclusion

According to the Charter of the World Health Organization, only a person who is completely physically, mentally, and socially healthy, may be considered as a healthy one. The intense rhythm of life and the high stress load on modern society cause a wide prevalence of PDs, which eventually tend to somatization with the destruction of target organs. The use of the concept of the psychosomatic scenario makes it possible to form a timely diagnosis and choose an effective treatment for psychosomatic disease, which significantly improves the quality of patients’ life.