FThe author makes some epistemologicalconsiderations on the urge to spreadpsychosomatics. To begin with, the heavyburden of mental disturbs in health caresystems today lead to an absolute need fora proper psychosomatic training of generalpractitioners.Then the 50 years of increasingpsycopharmacological treatments availableaccount for the mainstream split-care model;as the number of psychiatrists who focuson logotherapy decreased systematicallywhile the professional body of nonmedicaltherapists has grown. Hence the impendingneed of psychosomatics as a counterbalanceto adequately deal with the bio-psychosocialaspects involved both in heath and indisease.Finally concluding that, between physicalismand panpsychism, Psychosomatic Medicinehas to find its way by getting rid of theoutdated cartesian dualism

Ramiro Verissimo

Repositório Aberto da Universidade do Porto

Psychosomatic aspects of therapy and recovery25Sztuka leczenia 1-2/2011Trends dynamics in Psychiatric Systems today 1)1) Conference on “Psychosomatic aspects of therapy and recovery”, Warsaw 22-23 January 2011  [Grants: none whatsoever/doesn’t apply]Ramiro Veríssimo, MD, PhDProfessor of Medical Psychology and Psychosomatics at the Faculty of Medicine, Oporto University (Portugal)FThe author makes some epistemological considerations on the urge to spread psychosomatics. To begin with, the heavy burden of mental disturbs in health care systems today lead to an absolute need for a proper psychosomatic training of general practitioners.Then the 50 years of increasing psycopharmacological treatments available account for the mainstream split-care model; as the number of psychiatrists who focus on logotherapy decreased systematically while the professional body of nonmedical therapists has grown. Hence the impending need of psychosomatics as a counterbalance to adequately deal with the bio-psychosocial aspects involved both in heath and in disease.Finally concluding that, between physicalism and panpsychism, Psychosomatic Medicine has to find its way by getting rid of the outdated cartesian dualism.Keywords: Psychiatric Systems, Split-care, Psychosomatics Psychosomatics as a counterbalance of trends dynamics in Psychiatric Systems todayPsychiatry is a profession in transition; and while the role of psychiatrists is changing, it remains to be seen what their place is in mental health today, and what is the impact of that on patient outcomes.In terms of global burden of disease, 4 out of the 10 most important causes worldwide are psychiatric in origin. Within this context, either as a primary disorder or as a co-morbid condition, mental disorders are very common in medical practice. Its prevalence is approximately 30% (USA); however only one-third of these individuals are actually getting some sort of treatment. And here is where the ‘psychosomatic approach’ first comes in.In other words, changes in health care delivery underscore the need for other physicians, and primary care physicians in particular, to assume responsibility for the initial diagnosis and treatment of the most common mental disorders. Prompt 26Psychosomatic aspects of therapy and recoverydiagnosis is essential to ensure that patients have access to appropriate medical services and to maximize the clinical outcome. A physician who refers patients to a psychiatrist should not only know when it is appropriate to do so, but also how to refer. He should base referrals on the presence of signs and symptoms of a mental disorder (e.g. psychotic symptoms, mania, severe depression or anxiety; symptoms of PTSD, suicidal or homicidal preoccupation; or a failure to respond to first-order treatment) and not simply on the absence of a physical explanation for a patient’s complaint [1].In the US 11% of women and 5% of men take prescribed anti-depressants. What results, from where I stand, more than depression itself, from distress; malaise if you will, and eventually conjunctural malaise as in the case of economic-financial pressures. Emotional states have starting points deeply rooted in evolution; but are unchained by actual concrete cultural situations. Furthermore emotional responses are socially elaborated, up to a point in which interpretation of emotional reactions is profoundly conditioned by culture. What implies a clinical approach that not only cannot ignore the cultural dimension, as it has to recognize itself as conditioned by that very same culture.Historically, psychiatrists dealt with all aspects of patient’s care; and many were trained heavily in psychoanalytical techniques. During the 60’s it was not uncommon for psychiatric patients to consult with their therapists five days a week. But, as drugs moved in, the number of psychiatrists who focus on logotherapy has been decreasing systematically in a dramatic way [2].In fact, since their introduction in the 50’s, the pharmacologic treatments available have increased all along the years on an almost permanent basis; while also reducing considerably their main adverse side effects. The result is an armamentarium of useful treatments (antipsychotic drugs, antidepressant drugs, lithium, benzodiazepines and anticonvulsants) for many common disorders; leaving psychiatrists with their hands full, simply by managing prescriptions just to meet the increased demand.However there are no cures for psychiatric disorders; they are frequently recurrent, chronic and commonly marked by residual symptoms. Hence the still standing demand for talk therapy, which has been left over to an ever growing professional body of nonmedical therapists — psychologists and social workers —; that somehow keeps pace with the growth in pharmacologic treatments available. Notwithstanding, health insurance, through reimbursement policies, tends to encourage arrangements leading to shorter sessions, such as those for medication management, as compared with the psychotherapeutic ones. Lobbying influences such as these are well documented, as in the reported case on the exchanged mail while discussing the categories to be included, or not, in the DSM version to come; where one of the outcomes is the ominous influence of insurance providers [3].What is mental disorder? Are types of mental disorder natural kinds? That is, are the distinctions between them objective and of fundamental theoretical importance? Since there is not a well-defined neuropathology for psychiatric disorders, nor are there biologic markers, what happens here is that psychiatric research fails to delineate well-defined disease entities and to reliably assign individuals to affected versus non-affected categories. As a result, there are no objective diagnostic measures for any of the common psychiatric disorders. In fact the diagnostic classification scheme, upon which both research and clinical practice rely, is derived from expert consensus based on clusters of symptoms and signs and on the disease course. That is the case with DSM: the clinical entities diagnosed are not sufficiently homogeneous to warrant independent recognition. The boundaries currently drawn around disorders don’t Psychosomatic aspects of therapy and recovery27Sztuka leczenia 1-2/2011provide any certainty on what concerns an underlying and distinguishable set of neurobiological factors [4]. Despite these problems with current classifications in psychiatry, there is a general agreement on the core symptoms and strong cross-cultural similarity of manifestations. Suggesting that the central criteria for diagnosing major psychiatric disorders, although imperfectly, identify distinctive natural occurring brain diseases [4]. However there are also some epistemic flaws that must be taken into account as pointed out by Rachel Cooper [5]; for even if types of mental disorder are natural kinds, there are reasons to doubt that DSM come to reflect their natural structure. She examined the extent to which it is theory-laden, and looked in particular at how it has been shaped by social and financial factors. Ultimately concluding that, although widely used and of immense practical importance, DSM is not likely to become the best possible classification of mental disorders [5].On another hand, medical specialization, while an absolute need after the exponential growth of medical knowledge, came to hinder the holistic approach required to adequately deal with the psycho-behavioral aspects involved both in health and disease. And that is yet another aspect that lays stress on the absolute need of a ‘psychosomatic approach’. On this matter I would only bring up, merely as one example among many others, the so-called type A behavior pattern, as observed by Meyer Friedman and Ray Rosenman [6]; which is clear and unambiguously associated — throughout randomized controlled clinical trials — with a much poorer prognosis in men with Coronary Heart Disease. Or the more recent work by Janice Kiecolt-Glaser [7] showing that behavior, such as in hostile marital interactions, can influence health outcome and its immunological substrate. After this way, the required ‘psychosomatic approach’ is nothing else than the bio-psychosocial integrative model, as postulated back in 1977 by Engel [8, 9], both for research and medical intervention.Klaus Krippendorff [10], in line with the pragmatics of human communication [11, 12], argues that “meaning is a structured space, a network of expected senses, a set of possibilities … [that] emerges in the use of language”. Then within the healthcare systems of today, the meaning of “care” has been defined to be the eradication of a problem. Within this framework some spokespersons for the current mainstream split-care model argue that psychiatrists do better handling the medical side of patient care, while delegating psychotherapy to non-medical professionals. But while recognizing that patients do not wish to be regarded merely as a problem requiring eradication, some others, in the track of Engel, actually consider that an all-inclusive care model works best for patients. Among them Letiche is opposed to the very idea that complexity reduction can address the humanity of each individual healthcare situation [13]. He argues that, through narratives and through complexity based social theory, the complexity of each individual situation must be transcended through mindful listening and engaged dialogue. Letiche suggests that in the absence of such mindfulness, the lack of time for true listening, and the inability of providers and systems to allow for patients and family to engage in dialogue lies both the roots of the problem and the potential for its solution. If complexity theory has a role in the analysis understanding and betterment of social systems, then approaches such as the one Letiche undertakes will become essential tools of the trade.Although it still remains to be clearly established beyond any doubt what model benefits patients more and in which circumstances, there is already some empirical evidence supporting — at least for disorders such as depression — that a combination of both psychotherapy and medication works better than either treatment alone. But psychiatry must undergo a profound change, in order to make patients’ 28Psychosomatic aspects of therapy and recoverypsychotherapy need financially feasible. And the way I see it, as previously mentioned this is where psychosomatic reasoning must come about.Talk of psychological, social and biological factors integration within health care is one thing; to actually have them integrated in clinical practice is something else. In fact, what we usually have, when everything goes for the best, is the confluence of those perspectives — psychological, social or biological — within a multidisciplinary health care environment. However, the clinical approach to the patient still is performed by specialists; who are deeply conditioned by their highly differentiated knowledge.In a bottom-up approach, Psychiatrists claim themselves from a biological field. The underlying assumption being that human behavior may be reduced, in a last instance, to the ongoing cosmic ballet of neurotransmitters and other elemental molecules at a cellular level. Thus remitting themselves to analytically diagnosing imbalances at this level, and to prescribe accordingly.However, although some of the more disruptive, and even dangerous behavioral problems, are effectively dealt this way, the fact is that the underlying condition remains unaltered. The achievement is to bring the patient to a level of functioning where communication is made possible; while considering social reintegration as well. And here is where the top-down intervention fits in: logotherapists and social workers. The assumption here, in turn, is that from the complex synthesis of systems such as the human being, new properties emerge that can no longer be fully explained, solely through decomposition to subsystems or base elements. In other words, elementary mechanisms fail to elucidate the functioning as a whole; they simply can’t be detailed enough to realistically predict behavior of such complex systems and validate the model. Moreover, changes in behavior are also assumed to bi-directionally influence, onto some extent, what goes on at biomolecular level; illustrated by cases such as the ‘pink spot’ in schizophrenia [14, 15] which has been reproduced at will with the urine of monks who underwent deep meditation. However, on the other hand, these higher level models seriously risk being delusional, or merely interpretative, if you may; having per se a much lower predictive power and requiring some further proof of reality.Either way, although both approaches complement each other, the model remains infirmed by Cartesian dualism; and this brain-ghost dissociation still is probably the major handicap to be overcome by psychosomatic workers: may they be clinicians, researchers or philosophers. This being the case, Psychosomatic Medicine has to find its way between physicalism and panpsychism; which has been paved somehow in the past two decades by developments in neurosciences that allow us today to inform a more effective psychotherapy; and so we must.In fact neuroscience no longer supports the mind-brain identity theory, because the brain cannot be isolated from the rest of the nervous system; moreover, there is evidence that the mind is hormonal as well as neural. In other words, according to nonlinear neurodynamics — the new cognitive science paradigm of dynamic systems theory —, the borders of mental embodiment cannot be neatly drawn at the skull. Mental phenomena emerge, not merely from brain activity, but from an interacting nexus of brain, body and world. The mind can be seen, not as an organ within the body, but as a ‘behavioral field’ that fluctuates within this brain-body-world nexus [16].References[1] Reus VI. Mental Disorders. In: Harrison’s Principles of Internal Medicine 17th Ed. McGraw-Hill Companies, 2008. p 2710-2723Psychosomatic aspects of therapy and recovery29Sztuka leczenia 1-2/2011 [2] Mojtabai R, Olfson M. National Trends in Psychotherapy by Office-Based Psychiatrists Arch Gen Psychiatry. 2008; 65(8): 962-970. [3] Cooper R. Classifying Madness: A philosophical examination of the Diagnostic and Statistical Manual of Mental Disorders. Springer, 2005[4] Hyman SE & Kandel E. Biology of Psychiatric Disorders. In: Harrison’s Principles of Internal Medicine 17th Ed. McGraw-Hill Companies, 2008. p 2705-2710[5] Cooper R. What is wrong with DSM? History of Psychiatry 2004; 15(1): 05-25[6] Friedman M, Thoresen CE, Gill JJ, Ulmer D, Powell LH, Price VA, Brown B, Thompson L, Rabin DD, Breall WS, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project.  Am Heart J 1986; 112(4): 653-65.[7] Kiecolt-Glaser JK, Loving TJ, Stowell JR, Malarkey WB, Lemeshow S, Dickinson SL & Glaser R. Hostile marital interactions, proinflammatory cytokine production and wound healing. Arch Gen Psychiatry 2005; 62: 1377-84. [8] Engel GL. The need for a new medical model: a challenge for bioscience. Science 1977; 196: 129-136.[9] Engel GL. The Clinical Application of the Biopsychosocial Model. Am J Psychiatry 1980; 137: 535-544.[10] Krippendorff K. The Semantic Turn. Boca Raton, London, New York: Taylor & Francis CRC Press, 2006.[11] Watzlawick P, Bavelas JB, Jackson DD. Pragmatics of Human Communication New York: Norton, 1967[12] Watzlawick P. How Real is Real? New York: Random House, 1976[13] Letiche H. Making Healthcare Care - Managing the Complex Vol 3. ISCE Publishing, 2008[14] Hoffer A, Osmond H and Smythies J. Schizophrenia – new approach. J Ment Sci 1954; 100: 29.[15] Heath RG et al. Behavioral changes in non-psychotic volunteers following the injection of taraxein. Am J Psychiatry 1958; 114: 917.[16] Rockwell WT. Neither Brain nor Ghost: a non-dualist alternative to the mind-brain identity theory. Cambridge, Massachusetts: MIT Press books, 2005.Addrress of the authorRamiro Filipe B. Veríssimo, MD, PhD Medical Psychology & PsychosomaticsFaculty of Medicine, University of Porto Al. Prof. Hernâni Monteiro4200-319 PORTO Portugal E-mail:  rave@netcabo.pt Phone:  + 351 22 551 3672 Fax: + 351 22 551 9571

Trends dynamics in Psychiatric Systems today

Open Repository of the University of Porto

Psychosomatic aspects of therapy and recovery
25
Sztuka leczenia 1-2/2011
Trends dynamics in Psychiatric Systems today 1)
1) Conference on “Psychosomatic aspects of therapy and recovery”, Warsaw 22-23 January 2011  [Grants: none whatsoever/
doesn’t apply]
Ramiro Veríssimo, MD, PhD
Professor of Medical Psychology and Psychosomatics at the Faculty of 
Medicine, Oporto University (Portugal)
FThe author makes some epistemological 
considerations on the urge to spread 
psychosomatics. To begin with, the heavy 
burden of mental disturbs in health care 
systems today lead to an absolute need for 
a proper psychosomatic training of general 
practitioners.
Then the 50 years of increasing 
psycopharmacological treatments available 
account for the mainstream split-care model; 
as the number of psychiatrists who focus 
on logotherapy decreased systematically 
while the professional body of nonmedical 
therapists has grown. Hence the impending 
need of psychosomatics as a counterbalance 
to adequately deal with the bio-psychosocial 
aspects involved both in heath and in 
disease.
Finally concluding that, between physicalism 
and panpsychism, Psychosomatic Medicine 
has to find its way by getting rid of the 
outdated cartesian dualism.
Keywords: Psychiatric Systems, Split-care, 
Psychosomatics 
Psychosomatics as a counterbalance of 
trends dynamics in Psychiatric Systems 
today
Psychiatry is a profession in transition; and 
while the role of psychiatrists is changing, 
it remains to be seen what their place is in 
mental health today, and what is the impact 
of that on patient outcomes.
In terms of global burden of disease, 4 out 
of the 10 most important causes worldwide 
are psychiatric in origin. Within this context, 
either as a primary disorder or as a co-
morbid condition, mental disorders are very 
common in medical practice. Its prevalence 
is approximately 30% (USA); however only 
one-third of these individuals are actually 
getting some sort of treatment. And here is 
where the ‘psychosomatic approach’ first 
comes in.
In other words, changes in health care 
delivery underscore the need for other 
physicians, and primary care physicians 
in particular, to assume responsibility for 
the initial diagnosis and treatment of the 
most common mental disorders. Prompt 
26
Psychosomatic aspects of therapy and recovery
diagnosis is essential to ensure that 
patients have access to appropriate medical 
services and to maximize the clinical 
outcome. A physician who refers patients to 
a psychiatrist should not only know when it 
is appropriate to do so, but also how to refer. 
He should base referrals on the presence 
of signs and symptoms of a mental disorder 
(e.g. psychotic symptoms, mania, severe 
depression or anxiety; symptoms of PTSD, 
suicidal or homicidal preoccupation; or 
a failure to respond to first-order treatment) 
and not simply on the absence of a physical 
explanation for a patient’s complaint [1].
In the US 11% of women and 5% of men take 
prescribed anti-depressants. What results, 
from where I stand, more than depression 
itself, from distress; malaise if you will, 
and eventually conjunctural malaise as in 
the case of economic-financial pressures. 
Emotional states have starting points deeply 
rooted in evolution; but are unchained 
by actual concrete cultural situations. 
Furthermore emotional responses are 
socially elaborated, up to a point in which 
interpretation of emotional reactions is 
profoundly conditioned by culture. What 
implies a clinical approach that not only 
cannot ignore the cultural dimension, as it 
has to recognize itself as conditioned by that 
very same culture.
Historically, psychiatrists dealt with all aspects 
of patient’s care; and many were trained 
heavily in psychoanalytical techniques. 
During the 60’s it was not uncommon for 
psychiatric patients to consult with their 
therapists five days a week. But, as drugs 
moved in, the number of psychiatrists who 
focus on logotherapy has been decreasing 
systematically in a dramatic way [2].
In fact, since their introduction in the 50’s, 
the pharmacologic treatments available 
have increased all along the years on 
an almost permanent basis; while also 
reducing considerably their main adverse 
side effects. The result is an armamentarium 
of useful treatments (antipsychotic 
drugs, antidepressant drugs, lithium, 
benzodiazepines and anticonvulsants) 
for many common disorders; leaving 
psychiatrists with their hands full, simply 
by managing prescriptions just to meet the 
increased demand.
However there are no cures for psychiatric 
disorders; they are frequently recurrent, 
chronic and commonly marked by residual 
symptoms. Hence the still standing demand 
for talk therapy, which has been left over 
to an ever growing professional body of 
nonmedical therapists — psychologists and 
social workers —; that somehow keeps pace 
with the growth in pharmacologic treatments 
available. Notwithstanding, health insurance, 
through reimbursement policies, tends to 
encourage arrangements leading to shorter 
sessions, such as those for medication 
management, as compared with the 
psychotherapeutic ones. Lobbying influences 
such as these are well documented, as in the 
reported case on the exchanged mail while 
discussing the categories to be included, or 
not, in the DSM version to come; where one 
of the outcomes is the ominous influence of 
insurance providers [3].
What is mental disorder? Are types of mental 
disorder natural kinds? That is, are the 
distinctions between them objective and of 
fundamental theoretical importance? Since 
there is not a well-defined neuropathology 
for psychiatric disorders, nor are there 
biologic markers, what happens here is 
that psychiatric research fails to delineate 
well-defined disease entities and to reliably 
assign individuals to affected versus non-
affected categories. As a result, there are 
no objective diagnostic measures for any 
of the common psychiatric disorders. In fact 
the diagnostic classification scheme, upon 
which both research and clinical practice 
rely, is derived from expert consensus based 
on clusters of symptoms and signs and on 
the disease course. That is the case with 
DSM: the clinical entities diagnosed are 
not sufficiently homogeneous to warrant 
independent recognition. The boundaries 
currently drawn around disorders don’t 
Psychosomatic aspects of therapy and recovery
27
Sztuka leczenia 1-2/2011
provide any certainty on what concerns 
an underlying and distinguishable set of 
neurobiological factors [4]. Despite these 
problems with current classifications in 
psychiatry, there is a general agreement on 
the core symptoms and strong cross-cultural 
similarity of manifestations. Suggesting that 
the central criteria for diagnosing major 
psychiatric disorders, although imperfectly, 
identify distinctive natural occurring brain 
diseases [4]. However there are also some 
epistemic flaws that must be taken into 
account as pointed out by Rachel Cooper 
[5]; for even if types of mental disorder are 
natural kinds, there are reasons to doubt that 
DSM come to reflect their natural structure. 
She examined the extent to which it is theory-
laden, and looked in particular at how it has 
been shaped by social and financial factors. 
Ultimately concluding that, although widely 
used and of immense practical importance, 
DSM is not likely to become the best possible 
classification of mental disorders [5].
On another hand, medical specialization, 
while an absolute need after the exponential 
growth of medical knowledge, came to hinder 
the holistic approach required to adequately 
deal with the psycho-behavioral aspects 
involved both in health and disease. And 
that is yet another aspect that lays stress 
on the absolute need of a ‘psychosomatic 
approach’. On this matter I would only 
bring up, merely as one example among 
many others, the so-called type A behavior 
pattern, as observed by Meyer Friedman 
and Ray Rosenman [6]; which is clear and 
unambiguously associated — throughout 
randomized controlled clinical trials — 
with a much poorer prognosis in men with 
Coronary Heart Disease. Or the more recent 
work by Janice Kiecolt-Glaser [7] showing 
that behavior, such as in hostile marital 
interactions, can influence health outcome 
and its immunological substrate. After this 
way, the required ‘psychosomatic approach’ 
is nothing else than the bio-psychosocial 
integrative model, as postulated back in 
1977 by Engel [8, 9], both for research and 
medical intervention.
Klaus Krippendorff [10], in line with the 
pragmatics of human communication [11, 
12], argues that “meaning is a structured 
space, a network of expected senses, a set 
of possibilities … [that] emerges in the use 
of language”. Then within the healthcare 
systems of today, the meaning of “care” 
has been defined to be the eradication of 
a problem. Within this framework some 
spokespersons for the current mainstream 
split-care model argue that psychiatrists do 
better handling the medical side of patient 
care, while delegating psychotherapy to non-
medical professionals. But while recognizing 
that patients do not wish to be regarded 
merely as a problem requiring eradication, 
some others, in the track of Engel, actually 
consider that an all-inclusive care model 
works best for patients. Among them Letiche 
is opposed to the very idea that complexity 
reduction can address the humanity of 
each individual healthcare situation [13]. 
He argues that, through narratives and 
through complexity based social theory, the 
complexity of each individual situation must 
be transcended through mindful listening and 
engaged dialogue. Letiche suggests that in 
the absence of such mindfulness, the lack 
of time for true listening, and the inability of 
providers and systems to allow for patients 
and family to engage in dialogue lies both 
the roots of the problem and the potential for 
its solution. If complexity theory has a role in 
the analysis understanding and betterment 
of social systems, then approaches such 
as the one Letiche undertakes will become 
essential tools of the trade.
Although it still remains to be clearly 
established beyond any doubt what 
model benefits patients more and in which 
circumstances, there is already some 
empirical evidence supporting — at least 
for disorders such as depression — that 
a combination of both psychotherapy and 
medication works better than either treatment 
alone. But psychiatry must undergo 
a profound change, in order to make patients’ 
28
Psychosomatic aspects of therapy and recovery
psychotherapy need financially feasible. And 
the way I see it, as previously mentioned 
this is where psychosomatic reasoning must 
come about.
Talk of psychological, social and biological 
factors integration within health care is one 
thing; to actually have them integrated in 
clinical practice is something else. In fact, 
what we usually have, when everything 
goes for the best, is the confluence of those 
perspectives — psychological, social or 
biological — within a multidisciplinary health 
care environment. However, the clinical 
approach to the patient still is performed by 
specialists; who are deeply conditioned by 
their highly differentiated knowledge.
In a bottom-up approach, Psychiatrists 
claim themselves from a biological field. 
The underlying assumption being that 
human behavior may be reduced, in a last 
instance, to the ongoing cosmic ballet of 
neurotransmitters and other elemental 
molecules at a cellular level. Thus remitting 
themselves to analytically diagnosing 
imbalances at this level, and to prescribe 
accordingly.
However, although some of the more 
disruptive, and even dangerous behavioral 
problems, are effectively dealt this way, the 
fact is that the underlying condition remains 
unaltered. The achievement is to bring 
the patient to a level of functioning where 
communication is made possible; while 
considering social reintegration as well. And 
here is where the top-down intervention 
fits in: logotherapists and social workers. 
The assumption here, in turn, is that from 
the complex synthesis of systems such as 
the human being, new properties emerge 
that can no longer be fully explained, solely 
through decomposition to subsystems or 
base elements. In other words, elementary 
mechanisms fail to elucidate the functioning 
as a whole; they simply can’t be detailed 
enough to realistically predict behavior of 
such complex systems and validate the 
model. Moreover, changes in behavior 
are also assumed to bi-directionally 
influence, onto some extent, what goes on 
at biomolecular level; illustrated by cases 
such as the ‘pink spot’ in schizophrenia [14, 
15] which has been reproduced at will with 
the urine of monks who underwent deep 
meditation. However, on the other hand, 
these higher level models seriously risk 
being delusional, or merely interpretative, 
if you may; having per se a much lower 
predictive power and requiring some further 
proof of reality.
Either way, although both approaches 
complement each other, the model remains 
infirmed by Cartesian dualism; and this brain-
ghost dissociation still is probably the major 
handicap to be overcome by psychosomatic 
workers: may they be clinicians, researchers 
or philosophers. This being the case, 
Psychosomatic Medicine has to find its way 
between physicalism and panpsychism; 
which has been paved somehow in the 
past two decades by developments in 
neurosciences that allow us today to inform 
a more effective psychotherapy; and so we 
must.
In fact neuroscience no longer supports 
the mind-brain identity theory, because the 
brain cannot be isolated from the rest of the 
nervous system; moreover, there is evidence 
that the mind is hormonal as well as neural. 
In other words, according to nonlinear 
neurodynamics — the new cognitive science 
paradigm of dynamic systems theory —, the 
borders of mental embodiment cannot be 
neatly drawn at the skull. Mental phenomena 
emerge, not merely from brain activity, but 
from an interacting nexus of brain, body 
and world. The mind can be seen, not as an 
organ within the body, but as a ‘behavioral 
field’ that fluctuates within this brain-body-
world nexus [16].
References
[1] Reus VI. Mental Disorders. In: 
Harrison’s Principles of Internal Medicine 
17th Ed. McGraw-Hill Companies, 2008. 
p 2710-2723
Psychosomatic aspects of therapy and recovery
29
Sztuka leczenia 1-2/2011
 [2] Mojtabai R, Olfson M. National 
Trends in Psychotherapy by Office-Based 
Psychiatrists Arch Gen Psychiatry. 2008; 
65(8): 962-970. 
[3] Cooper R. Classifying Madness: 
A philosophical examination of the Diagnostic 
and Statistical Manual of Mental Disorders. 
Springer, 2005
[4] Hyman SE & Kandel E. Biology 
of Psychiatric Disorders. In: Harrison’s 
Principles of Internal Medicine 17th Ed. 
McGraw-Hill Companies, 2008. p 2705-2710
[5] Cooper R. What is wrong with DSM? 
History of Psychiatry 2004; 15(1): 05-25
[6] Friedman M, Thoresen CE, Gill JJ, 
Ulmer D, Powell LH, Price VA, Brown B, 
Thompson L, Rabin DD, Breall WS, et al. 
Alteration of type A behavior and its effect 
on cardiac recurrences in post myocardial 
infarction patients: summary results of the 
recurrent coronary prevention project.  Am 
Heart J 1986; 112(4): 653-65.
[7] Kiecolt-Glaser JK, Loving TJ, Stowell 
JR, Malarkey WB, Lemeshow S, Dickinson 
SL & Glaser R. Hostile marital interactions, 
proinflammatory cytokine production and 
wound healing. Arch Gen Psychiatry 2005; 
62: 1377-84.
 [8] Engel GL. The need for a new 
medical model: a challenge for bioscience. 
Science 1977; 196: 129-136.
[9] Engel GL. The Clinical Application of 
the Biopsychosocial Model. Am J Psychiatry 
1980; 137: 535-544.
[10] Krippendorff K. The Semantic Turn. 
Boca Raton, London, New York: Taylor & 
Francis CRC Press, 2006.
[11] Watzlawick P, Bavelas JB, Jackson 
DD. Pragmatics of Human Communication 
New York: Norton, 1967
[12] Watzlawick P. How Real is Real? 
New York: Random House, 1976
[13] Letiche H. Making Healthcare 
Care - Managing the Complex Vol 3. ISCE 
Publishing, 2008
[14] Hoffer A, Osmond H and Smythies 
J. Schizophrenia – new approach. J Ment 
Sci 1954; 100: 29.
[15] Heath RG et al. Behavioral changes 
in non-psychotic volunteers following the 
injection of taraxein. Am J Psychiatry 1958; 
114: 917.
[16] Rockwell WT. Neither Brain nor 
Ghost: a non-dualist alternative to the 
mind-brain identity theory. Cambridge, 
Massachusetts: MIT Press books, 2005.
Addrress of the author
Ramiro Filipe B. Veríssimo, MD, PhD 
Medical Psychology & Psychosomatics
Faculty of Medicine, University of Porto 
Al. Prof. Hernâni Monteiro
4200-319 PORTO 
Portugal 
E-mail:  rave@netcabo.pt 
Phone:  + 351 22 551 3672 
Fax: + 351 22 551 9571


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Trends dynamics in Psychiatric Systems today

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