Agency, embodiment and enactment in psychosomatic theory and practice.

In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.

[Spirituality and ethics in psychosomatic medicine]. / Spiritualita a etika v psychosomatické medicíne - biopsychosociospirituální vztahy.

A patient has to cope with an illness on a physical, mental and spiritual level. There exists a difference between religiousness and spirituality even though the approach has a common foundation. Nonreligious spirituality relates to an inner experience, transcendent states of consciousness, meaningfulness, responsibility, sympathy, ethics, humanisation, faith. We encounter the spiritual point of view in humanistic psychotherapy, pastoral medicine, work of hospital chaplains, New Age, psychotherapies with religious and alternative aspects, transpersonal psychotherapy, psycho-spiritual crises, unusual states of consciousness, in meditation, Yoga, relaxation, kinesiology, ethicotherapy, reincarnation therapy, positive motivation, holotropic breathing, etc. There is description of different degrees of spiritual development, rational and irrational feeling of spirituality, Quantum Physics, spiritual intelligence, neuro-theology, physiological change, effects on improving adaptation during stress, drugs addiction, etc. Spirituality in relation with ethics is discussed in terms of socio-biology, evolution, emotions, aggressivity, genetics and social influence. The work analyses the effect of stressful situations on the deterioration of moral attitudes: during lack of time, obedience to authority and order. It is described how temperament and personality disorders can affect perception of spirituality, guilt feeling and conscience. Stressful situations, lack of time, relying only on the auxiliary objective methods leads to alienation of physician with a patient. Spirituality can partially improve the doctor-patient relationship, communication and sense of responsibility.

Psychosomatic approach is the new medicine tailored for patient personality with a focus on ethics, economy, and quality.

Over the last 40 years the proliferation of the biopsychosocial (BPS) model across clinical and theoretical research has shown that psychosocial factors can be shown to be causes, co-factors, or sequelae of many illnesses. Scientific presuppositions about the BPS model have been grounded firmly in psychobiological, psycho-behavioural, sociobiological, and socio-behavioural processes. According to the allostatic load model, stressful factors can be psychological ones or any other factor that is able to modify the stress-response system; these might include genetic factors or life experiences. Personality profiles, in particular, seem to be predictive of responses to different stressors. Stress responses preceding or following illness are clearly related, from a psychobiological point of view, to different personality traits, which themselves correlate to specific defence mechanisms. Neural processes underlying these mechanisms interact with the biological substrate of somatic illnesses. Recent advances in brain imaging with regard to neurobiological and behavioural interactions of empathy and alexithymia support the crucial role of the (psycho) therapeutic relationship across the whole of medical practice. Psychotherapies operate as biological factors on mind, brain, and body; indeed it is necessary to reconsider the doctor-patient relationship as a psychotherapeutic process. The basic methodological triad of observation (outer viewing), introspection (inner viewing), and dialogue (inter viewing) becomes essential in medical practice and in scientific research. Psychoanalytic processes such as transference, resistance, the therapeutic alliance, and attachment have been reconsidered from a neuroscientific perspective and reconceived as moments of meeting of the procedural memory and are therefore considered relevant to the relationship with patients in primary care. Indeed, they are useful to an ethical approach to understanding the meaning of illness, and they also influence the results of treatment projects. Because all these aspects impact upon illness duration and quality of life, affecting both the individual concerned and his or her family, the economic consequences of this psychosomatic approach are important in both general and specialist medicine. Medicine is becoming, and will become even more in the future, an integrated science; human illness and the maintenance of good health may be better understood if all medical disciplines are considered as a whole. The domain of psychosomatic medicine has now extended to coincide with that of medical practice. There is increasing evidence, not only in psychiatry, but in all medical fields, that care of the mental well-being of a person is essential for effective care of the body. Not only mens sana in corpore sano, but also corpus sanus in mente sana.

A basic decision-making approach to common ethical issues in consultation-liaison psychiatry.

Ethical dilemmas are found throughout the daily work of C-L psychiatrists. Unfortunately, most psychiatrists have no more training in ethics than their nonpsychiatric colleagues. Psychiatric consults spurred by ethical dilemmas can provoke anxiety in psychiatrists and leave anxious colleagues without the clear recommendations they seek. C-L psychiatrists, and probably all psychiatrists, need more training in clinical ethics. C-L psychiatrists do not need to become clinical ethicists, but competence in handling the ethical issues most commonly seen in C-L work is needed. The 2008 ABPN guidelines for specialists in psychosomatic medicine mention specific ethics topics important in C-L work, and ways of attaining competence in these areas have been discussed in the C-L literature. The four cases discussed here illustrate the high level of complexity often seen in situations in which ethical dilemmas arise in C-L psychiatry. Given the sometimes furious pace of hospital work, it can be easy for C-L psychiatrists to be seduced by the idea of the quick, focused consult that simply responds to a simple question with a simple answer. Because cases involving ethical dilemmas often involve multiple stakeholders, each with his or her own set of concerns, a brief consult focused only on the patient often leads to errors of omission. A wider approach, such as that suggested by the Four Topics Method, is needed to successfully negotiate ethical dilemmas. Busy C-L psychiatry services may struggle at first to find the time to do the type of global evaluations discussed here, but increasing familiarity with approaches such as the Four Topics Method should lead to quicker ways of gathering and processing the needed information.

Confidentiality in the age of HIPAA: a challenge for psychosomatic medicine.

This review, a work project of The Standards and Ethics Committee of The Academy of Psychosomatic Medicine, examines the challenges posed for consultation-liaison psychiatrists as they struggle to maintain the trust between patient and physician while balancing compliance with the increasing complexities of confidentiality with the provision of enough information to our medical colleagues for good clinical care. The authors discuss the moral, legal, and ethical issues that arise from the many-layered state and federal regulations, especially the impact of the Health Information Portability and Accountability Act (HIPPA) and make recommendations for practical application in the clinical setting.

Temperamento e hipertensión arterial. Divertimento / Temperament and arterial hypertension. Divertissement

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El modelo psicosomático de Pierre Marty / Pierre Marty´s psycho-somatic model

El artículo hace un recorrido por la teoría psicosomática de Pierre Marty y la escuela formada entorno al «lnstitut de Psychosomatique de Paris. (IPSO), que continúa su labor de investigación, desarrollo teórico y difusión. Se aborda, en primer lugar, la descripción del modelo teórico de Marty, según los tres aspectos fundamentales (monista, evolucionista y económico); posteriormente, las principales características del proceso de somatización y las distintas formas de presentarse la enfermedad somática y, por último, algunas consideraciones sobre diagnóstico y tratamiento (AU)

The article traces the developmetn of the psychosomatic theory of Pierre Marty and the school formed by the Institut de psychosomatique de Paris (IPSO), which continues his work in the fields of research, theoretical development and diffusion. Marty´s theoretical model is described according to three main aspects (monistic, evolutionary and economic). The author then considers the main aspects of the process of somatization, the different forms that illness can present, and its diagnosis and treatment (AU)

Helen Flanders Dunbar, John Dewey, and clinical pragmatism: reflections on method in psychosomatic medicine and bioethics.

This article outlines the method utilized by physicians and major figures in the founding of Clinical Pastoral Education, Helen Flanders Dunbar, in her work of 1943, Psychosomatic Diagnosis, and relates it to the currently evolving approach in bioethics known as clinical pragmatism. It assesses Dewey's influence on both Dunbar in psychosomatic medicine and clinical pragmatism in bioethics, and illustrates the breadth of influence of the school of philosophical thought known as pragmatism with which Dewey's name and those of William James and Charles Sanders Pierce are most often identified.