Medicine and Psychotherapy: two sides of the same coin

medicine and psychotherapy

"When the mind suffers, the body is sick too", said Paracelsus, a famous physician of antiquity, and the opposite is certainly also true. Mind and body are an indissoluble unity, both in health and in disease, and communicate with each other continuously.

Physical illnesses generate fear and suffering, worsening bodily symptoms, and mental attitudes cause physical ailments which in turn affect moods.

However, in the last few centuries, with the birth of modern philosophy, a vision of mind and body as distinct units has established itself, even though Plato 2400 years ago argued that "The biggest mistake in the treatment of diseases is that there are doctors for the body and doctors for the soul… ".

This artificial division has created many difficulties for therapists: but human beings become attached to their theories, and, in the words of Hegel, "If the theory does not agree with the facts, so much the worse for the facts".

The fracture.
The definitive break between psyche and soma, which permeated all subsequent Western culture, is due to Descartes in 1600. By separating matter (res extensa) from mind (res cogitans), Descartes definitively handed over human suffering to either the physical or the mental sphere.

Starting from this "Cartesian dualism", the traditional medical model has continued the work of fragmentation, with the appearance of various specializations up to "organ medicine": the gastroenterologist treats the stomach, the cardiologist treats the heart and psychotherapist deals with anxiety as if they were separate entities, without considering that anxiety worsens arrhythmias or that digestive difficulties cause anxiety in those who fear they have a serious illness.

Furthermore, this model assumes that between physical and mental processes there is a linear relationship of cause and effect, arbitrarily choosing the physical event as the cause of the mental. The process is risky, due to a frequent mistake in medicine, that of mistaking "correlation" with "causation". To say that two events happen together, such as lightning and thunder, does not mean that one causes the other.

Take the so-called biochemical theory of depression: the inconclusive observation that a deficiency of serotonin (a brain neurotransmitter) often correlates with depression has led to the conclusion that serotonin deficiency causes depression (hence therapy with drugs that increase serotonin).

The opposite could very well be true, or the two events could be caused by a third factor as yet unknown, just as lightning and thunder are two aspects of an electrical discharge in the atmosphere.
In reality, physical and mental interact with each other in a circularity in which one is simultaneously the cause and effect of the other, as exemplified by the mechanism underlying the much feared panic attacks.

Fear activates the body by producing acceleration of the heart, labored breathing, constriction in the throat, and all the typical symptoms of anxiety; the bodily signals feed back on the mind by amplifying fear which in turn will increase the activation of anxiety, and so on in a vicious circle that can lead to full-blown panic attack.

The current situation.
Imagine going to the doctor because for some time we have been feeling exhausted, we sleep little, we digest poorly and we have frequent headaches. After having examined us and checked the exams, the doctor concludes that "we have nothing" or at most that we are "stressed".

Despite our certainty that we are indisposed, we apparently do not suffer from any disease. This situation is more common than you think, and affects 20 to 50% of people who go to the general practitioner.
These are so-called "functional" or "inexplicable" symptoms, because they do not fit into a precise clinical picture and do not correspond to signs of organ abnormalities.

Despite their "inexplicability", the relationship with life situations, emotions and mental attitudes is very clear to those affected. In some cases the symptoms are organized in more specific clinical pictures such as irritable colon, tension headache, chronic fatigue syndrome, dermatitis.
These syndromes are also called "Psychosomatic" to underline the fact that they are attributed at least in part to unspecified psychological causes.

Even when we suffer from a frankly organic disease, that is, with a defined biological cause and alterations in diagnostic tests, we certainly cannot ignore the mental component. When the disease is severe, chronic or debilitating, anxiety disorders or reactive depression can appear: since emotions and mental attitudes influence the prognosis and course of diseases, it is essential that these aspects are recognized and treated.

On the other hand, there are purely mental disorders, such as eating disorders (anorexia, bulimia and vomiting syndrome), which have heavy repercussions on the body: debilitation, osteoporosis, immune depression, hormonal alterations in anorexia; esophageal damage, arrhythmias in the case of vomiting; complications of obesity in the case of bulimia. In all these cases, the treatment of the mental disorder must be accompanied by the treatment of any physical problems.

The body-mind unity.
Fortunately, in recent decades we have seen a countertrend. Starting from the 70s, a model of medicine that took into consideration, in addition to clinical aspects, also psychological and social ones (Engel's biopsychosocial model) has emerged:
since then more and more studies confirm what shouldn't need confirmation, namely that emotions, expectations and moods they influence the perception of symptoms, the response to treatment and ultimately the course of the disease.

One of the most striking and also the most common examples is the well-known placebo effect, whereby the mere expectation of an improvement can induce and favor the improvement itself, even in the absence of active therapy.

This effect, unfairly underestimated or even denigrated by some, is instead a precious ally because it positively uses the influence of the mind on the body. A therapist able to orient the patient's mind towards improvement and healing, that is, to exploit the placebo mechanisms, will obtain better results in terms of both efficacy and efficiency of the intervention.

Over the years, the study of the connections between body and mind has produced a considerable amount of experimental data and clinical observations, and a new discipline has been born, Psycho-Neuro-Endocrine-Immunology (PNEI), which integrates the psyche with the nervous, endocrine and immune systems. PNEI studies how emotions and moods affect the immune system, the perception of symptoms, hormone levels and organ functioning.

Again paraphrasing Paracelsus, this discipline provides a scientific guise to the fact that "The imagination can create hunger and thirst, produce abnormal secretions and cause disease".

The state of the art.
Unfortunately, despite the abundance of data, a complete integration of the medical and psychological disciplines is still a long way off. Starting from university courses, to continue while carrying out their respective professions, doctors and psychotherapists they walk side by side without ever really meeting.

It is therefore desirable to have a greater dialogue between the two disciplines, a deepening of knowledge of the respective areas of intervention, which while maintaining their own necessary individuality, often overlap.

We have higher mental disorders, such as major depression, or schizophrenia, in which treatment with psychotropic drugs sets the conditions for subsequent psychotherapeutic or rehabilitative intervention. In less disabling disorders, such as mild depression, psychotherapy may be accompanied by drug treatment. In other cases, such as in anxiety disorders, psychotherapy is considered the treatment of choice, as confirmed by many international guidelines.

Considering strictly organic disorders, when the disease is mild, acute and non-disabling, the therapy of choice is medical (drugs, surgical procedures or other types of interventions on the body). However, in psychosomatic illnesses and in all functional disorders, it is necessary to combine the medical one with psychological therapy, to support the management of stress or other life situations of the patient.

Finally, in patients suffering from serious, chronic or debilitating diseases, it is necessary to take care and worry about the psychological implications, because the prognosis worsens if a reactive depression or simply a sense of helplessness appears.

Finally, in any type of medical intervention, we must consider the importance ofmental attitude of the patient on its adherence to the indications (compliance). We know from the data in the literature that the traditional medical communicative approach is ineffective: pharmacological indications are followed to the letter only by 50-70% of patients, dietary prescriptions by 10% and the indication to quit smoking is accepted only by 2. % of patients.

The doctor's work becomes useless if the patient does not comply with the prescriptions, and this has serious negative repercussions both on the health of the patients and on the healthcare costs.
In this context, a psyche specialist can recognize and manage the patient's resistance and increase his compliance, thus improving the effectiveness of medical intervention.

Fortunately, the seeds of change have been sown, and are rapidly growing, as both patients and their carers increasingly feel the need for an integration between body and mind care. The path is still uphill: it takes time to update the courses of study and to change the traditional medical model of organ pathology.

However, continuing in this direction, promoting collaboration between different aid professionals at all levels, the artificial boundaries between medicine and psychotherapy will sooner or later disappear, and integrated psyche-body medicine will no longer be only desirable, but inevitable.

Dr. Simona Milanese
(Doctor, psychotherapist, lecturer and official researcher of the Strategic Therapy Center)

References
Nardone G. (2015), "The noble art of persuasion“, Ponte alle Grazie, Milan.
Milanese R., Milanese S. (2015), "The touch, the remedy, the word”, Ponte alle Grazie, Milan

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