Transcript Peter Henningsen – Powerpoint presentation – Psychosomatic

Autumn School “Embodied and Embedded Approaches to the
Self in Psychiatry and Psychosomatic Medicine” 27.10.2011
Psychosomatic Medicine:
an application for embodied and embedded
approaches in medicine
Peter Henningsen
Dept of Psychosomatic Medicine
and Psychotherapy
Technische Universität Munich
Overview
 Some history
 the two traditions of psychosomatic medicine
 A little detour
 Levels of explanation in psychological medicine
 Embedded/ embodied approach: a psychosomatic perspective
 Disorders of the embodied self and their therapy
Psychosomatic Medicine: history
 Not very informative: “As old as medicine”, “since antiquity”
 More informative: “counter reformation” against natural science
preponderance in late 19th century medicine
 But: two very different forms of “counter reformation”
at the beginning of 20th century
Psychosomatic Medicine: history
 Psychogenetic tradition (Psychoanalysis!)
 body as theatre of the soul (“puzzling leap” – “conversion”)
Psychosomatic Medicine: history
 Psychogenetic tradition
1891-1964
 e.g. Franz Alexander: Psychosomatic Medicine (“The medical value of
psychoanalysis”)
Psychosomatic Medicine: history
 Psychogenetic tradition
 problem: dualistic approach, less acceptable to patients (“either-or”)
“Medicine for bodies without souls and for souls without bodies”
 advantage: - clear (psycho-)therapeutic strategies,
- takes part in development of (psychodynamic)
psychotherapies since Freud (insight, new emotional
experiences, re-structuring of personality)
- conceptual basis for psychosomatic specialists and
departments
Psychosomatic Medicine: history
 Integrative (“holistic”) approach
 from Internal Medicine/ Neurology, with background in biology
 organism (body and soul) in its interaction with the environment
Psychosomatic Medicine: history
 Biology: Jakob von Uexküll
“Strolls through the environment of animals
and humans”
1864-1944
 “relational” instead of “atomistic” approach
 meaning of environment for the organism
Jakob von Uexküll 1910
Psychosomatic Medicine: history
 Psychosomatic Medicine: Thure von Uexküll
1908 - 2004
Thure von Uexküll 1950-70s
Psychosomatic Medicine: history
 Viktor von Weizsäcker
1886 - 1957
 Der Gestaltkreis: Theorie der Einheit von Wahrnehmen und Bewegen
(The Gestalt circle: Theory of the Unity of Sensing and Moving)
 biological acts/ achievements
instead of physiological functions/ output
 participant observer/ “bipersonality” (saw)
 “introduction of the subject”
(rehabilitation of teleofunctionalist
explanations in science/ medicine)
Psychosomatic Medicine: history
 Both T v Uexküll and V v Weizsäcker applied
their concepts to medicine
 Both were concerned with psychosomatic disorders
 VvWs goal was not “integrated psychosomatic medicine”,
but anthropological medicine and, in the end,
medical anthropology
 advantage: good acceptance by patients (“as well as”),
clear guidance for clinical contacts in all
of medicine, good integration of body
psychotherapy, but:
less clear (psycho-)therapeutic strategies
Psychosomatic Medicine: history
 Institutionalization in relation to psychiatry
 German specialty
 Chairs and Departments of Psychosomatic Medicine founded
around 1970 to ensure “Psychotherapy in Medicine”, because
German psychiatry was reluctant to integrate psychotherapy
 Karl Jaspers was always highly critical of the theoretical status of
psychoanalysis (mix of “Explaining” and “Understanding”) and
also of V v Weizsäckers concepts
Psychosomatic Medicine today: disorders
 Primarily concerned with those bodily distress disorders
which are amenable to psychotherapy
 somatoform disorders/ functional somatic syndromes
 somato-psychic disorders including psycho-oncology, psycho-cardiology
 eating disorders
 post-traumatic disorders
 Overlap with psychiatry concerning
 Depressive/ anxiety disorders
 Personality disorders (e.g. Borderline)
Psychosomatic Medicine today:
aspects of aetiological models
 Disposition – Trigger - Maintenance
 Developmental, i.e. early relationship experiences influence
attachment patterns and stress resilience (epigenetics)
 Symptoms as consequence of developmental deficit and
of functional/ intentional adaptation
 Interpersonal context highly relevant for symptom manifestation
and maintenance
Psychosomatic Medicine today:
clinical methods as applied here
 Disorder-oriented psychotherapy on psychodynamic basis
 (bodily) symptom patterns in affective – relational context
 explanatory model
 personality factors
(structural deficits/ mentalization, conflicts, resources)
 Multi-modal therapy (day clinic/ in-patients)
 psychotherapy – single and group
 body psychotherapy/ physiotherapy
 art therapy
 somatic diagnostics and therapy incl. psychopharmacology
 Consil-Liaison-Psychosomatics
 diagnostics, psychoeducation, counseling, team supervision
Psychosomatic Medicine today:
research methods as applied here
 Clinical research
 Screening and diagnostic studies of psychosomatic disorders
(psychooncology, dizziness etc.)
 RCTs of disorder-oriented short term psychotherapies
(somatoform, eating disorder, depression in CHD,
PTSD, body therapy etc)
 Guideline development, health care research, quality of life research
 Neurophysiological studies
 Neuroimaging
 Neurophysiological studies (HRV etc.)
 Oxytocin
 Epidemiological studies (in co-operation)
 Conceptual stuff…
Psychosomatic Medicine today:
strategic preferences
 Common ground/ synthesis of the advantages of psychogenetic
and integrative tradition for own profile in research and clinic, e.g.
 Non-reductionist explanatory models
 Interactional, relational perspective (participant observer)
 Organismic rather than dualistic understanding of human illness in
general and typical “psychosomatic” problems in particular
 Scientific foundation of coherent concepts
A little detour: levels of explanation in
psychological medicine
 Kendler KS in Kendler KS, Parnas J (Eds):
Philosophical Issues in Psychiatry (2008)
 “Psychiatry is witnessing an increased domination of reductionist
approaches being fueled partly by dramatic advances in sciences
such as molecular and systems neuroscience, imaging and molecular
genetics and partly by less savory forces including financial pressures
to move psychiatry away from psychotherapeutic approaches and
more toward strictly
psychopharmacology-based practice.” (p 5)
Multilevel explanatory models
 Explanatory models are often implicit in day to day research
Multilevel explanatory models
 Explanatory models are often implicit in day to day research
 However, modern versions of the “neuron doctrine” have
massively gained acceptance (Gold and Stoljar Behav Brain Sc 1999)
 eliminativist rather than reductionist
Multilevel explanatory models
 Explanatory models are often implicit in day to day research
 However, modern versions of the “neuron doctrine” have
massively gained acceptance (Gold and Stoljar Behav Brain Sc 1999)
 eliminativist rather than reductionist
 The “bio-psycho-social model” is no real model
(Engel GL. Science 1977; 196:129-136)
 eclectic “Vanilla model”
(Ghaemi N BJ Psychiatry 2009)
Multilevel explanatory models
 Explanatory models are often implicit in day to day research
 However, modern versions of the “neuron doctrine” have
massively gained acceptance (Gold and Stoljar Behav Brain Sc 1999)
 eliminativist rather than reductionist
 The “bio-psycho-social model” is no real model
(Engel GL. Science 1977; 196:129-136)
 eclectic “Vanilla model”
(Ghaemi N BJ Psychiatry 2009)
 Karl Japers’ strict dichotomy of explaining and understanding is
also not very helpful (Fuchs T in Kendell K, Parnas J, l.c.)
Multilevel explanatory models
 Explanatory models are often implicit in day to day research
 However, modern versions of the “neuron doctrine” have
massively gained acceptance (Gold and Stoljar Behav Brain Sc 1999)
 eliminativist rather than reductionist
 The “bio-psycho-social model” is no real model
(Engel GL. Science 1977; 196:129-136)
 eclectic “Vanilla model”
(Ghaemi N BJ Psychiatry 2009)
 Karl Japers’ strict dichotomy of explaining and understanding is
also not very helpful (Fuchs T in Kendell K, Parnas J, l.c.)
 Explanatory aims are mostly not well differentiated
in psychological medicine
 mechanisms: constitutive explanations
 aetiology – prognosis: explanation of transitions
Multilevel explanatory models
Revensuo 2003
Models of clinical practice/ therapy
 In daily practice, these models of practice are competing
 biomedical:
- therapist as scientist clinician,
formerly known as “biological psychiatrist”
- psychotherapy as drug
- symptom reduction as
correction of mechanistic deficit
Models of clinical practice/ therapy
 In daily practice, these models of practice are competing
 biomedical:
- therapist as scientist clinician,
formerly known as “biological psychiatrist”
- psychotherapy as drug
- symptom reduction as
correction of mechanistic deficit
 interpersonal: - therapist as participant observer,
formerly known as “psychotherapist”
- therapy as interpersonal process, also for drugs and
other interventions aiming at neurobiology
- alleviation of suffering/ motivational insight – change
as new meaning/ adaptation
- compatible with minimal representationalism
( systemic:
- therapist as non-intentional pertubator
- therapy as pertubation of an autopoietic system
- compatible with radical enactivism)
Link between explanatory and therapeutic
models?
 Identity diffusion in psychological medicine?
 Unclear explanatory models
 Competing models of clinical practice/ therapy
 There may be other than scientific justifications of therapeutic models
 No manifest link between explanatory and therapeutic models
What aspects does the embodied/ embedded
approach bring to these debates?
 Embodied cognition, i.e. significance of sensori-motor (and other
bottom-up) processes for the explanation of higher level
(e.g. cognitive) processes
 independent of differences between “embodied” and “bodily”
What aspects does the embodied/ embedded
approach bring to these debates?
 Embodied cognition, i.e. significance of sensori-motor (and other
bottom-up) processes for the explanation of higher level
(e.g. cognitive) processes
 independent of differences between “embodied” and “bodily”
 Developmental perspective, i.e. significance of experience
dependence on a psychological as well as on a neurophysiological
level (e.g. attachment, activation of the MNS, stress resilience)
What aspects does the embodied/ embedded
approach bring to these debates?
 Embodied cognition, i.e. significance of sensori-motor (and other
bottom-up) processes for the explanation of higher level
(e.g. cognitive) processes
 independent of differences between “embodied” and “bodily”
 Developmental perspective, i.e. significance of experience
dependence on a psychological as well as on a neurophysiological
level (e.g. attachment, activation of the MNS, stress resilience)
 Interactional perspective, i.e. significance of person-person and
person-environment interactions
 independent of differences between teleofunctionalist self model and
non-representational, enactivist approaches
What aspects does the embodied/ embedded
approach bring to these debates?
 A disorder of the self is a lack of coherence that is beyond the
norm and/ or causes suffering and/ or dysfunction
related to identity, agency and self-awareness
 In conventional terms, disorders of the embodied self can be
mental disorders as well as neurological or other organic disorders
(in fact, many chronic diseases, irrespective of aetiology)
 e.g. schizophrenia, borderline personality disorder, somatoform/
functional somatic syndromes, autism, dementia
 brain damage, brain infarction, Parkinson, epilepsy, cancer, eating
disorders, dissociative disorders
Disorders of the embodied self
F de Vignemont Neuropsychologia 2010; 48: 669-80
Disorders of the embodied self
 Where disorder is defined on the level of experience and
behaviour (in most mental disorders) , there is a need to
 quantitatively evaluate the alterations in lower level aspects of
self (e.g. homoeostatic neuroimmunological mechanisms)
 maintain a balanced view of symptoms as indicators of (mal-)
adaptation and of deficit (e.g. depressive inactivity)
 Where disorder is defined on the neurological level
(e.g. in brain infarction), there is a need to
 qualitatively evaluate the alterations of higher level aspects of self
(beyond experimental neuropsychology,
e.g. case histories by Oliver Sacks)
 view symptoms not only as indicators of deficit, but also of
adaptation
(e.g. differences in agency between pointing and
grasping in neurological lesions – K. Goldstein)
Disorders of the embodied self
 It follows that
 there is an element of illness, i.e. an intentional, adaptational
element in all “organic” disease
- e.g. cancer-related fatigue, on-off in parkinson, frequency of
seizures in epilepsy etc.
 there is an element of disease, i.e. structurally fixed deficit in all
“psychological” illness
- e.g. deficits in structural abilities like mentalization
 a developmental interpersonal perspective is one common
aetiological background for intentional maladaptations as well as
structural deficits
Some implications for therapy 1
 Therapy of disorders of the embodied self will necessarily
 be complex/ multimodal in all cases (neurological as well as mental)
- “Psychotherapy” and “biological therapy” describe endpoints of a
spectrum of foci of therapeutic interventions
 have interlevel effects across the intention – mechanism divide
- e.g. psychological effects of sensorimotor therapies
- e.g. biological effects of psychotherapy
 overcome the distinction of “verum” and “placebo”
as elements of all therapies
Some implications for therapy 1
Diederich NJ, Goetz CG.
Neurology 2008; 71: 677-84
Some implications for therapy 2
 Therapy of disorders of the embodied self will necessarily
 have adaptational rather than curative aims throughout
- cures are very rare and curative intentions often go hand-in-hand
with narrow one-level approaches
 have as overarching therapeutic aims better adaptation in terms of
identity, agency and self-awareness
Some implications for therapy 2
 Treating patients as having disorders of the embodied self
– a “mental” and “bodily” entity, in need of intentional
descriptions of all, also of its “bodily” interactions –
 may provide a scientifically sound conceptual “anchor” supported by
neuroscience, developmental psychology, philosophy for a coherent
integration of different therapeutic approaches
 (in particular, it provides an anchor also for the integration of body
psychotherapy in multimodal therapy)
Some implications for therapy 3
 The interaction of therapist and patient is a necessary element
of all therapy
 there is no non-communication
 relevant aspects/ dimensions for (training of) therapists are
- self reflection
- emotions as indicators of relations and motivations
- shared decision making, “Umgang”,
- background knowledge e.g. of attachment patterns, iatrogenic harm
 Two symmetrical risks
- without close observation of the interaction, intentional aspects of a
disorder will easily be overlooked
- overemphasizing the therapeutic interaction will lead to a neglect
of (structural) deficits in a patient
 Additional risk in chronic cases: dependency undermining agency
Some implications for therapy 4
 Are we any further than with the broad notion of a
“bio-psycho-social model” in medicine?
 A tentative “Yes”
 therapeutic approaches are not mere additions of
incompatible methods (“bio-psychosocial” as addition of “bio”, i.e.
pure biomedicine and “psychosocio”, i.e. pure psychotherapy),
instead they have different foci within the same overall approach
(bio-psychosocial and bio-psychosocial) …but
Some implications for therapy 4
…but there is a lot of work to do scientifically, e.g.
 analyze the therapeutic potential of addressing the intentional
elements in “organic” disease and vice versa
 define the boundaries of the concept of “disorders of the self”
 develop adequate evaluation of complex interventions that incorporate
quantitative and qualitative elements
(“what works for whom in what respect, in which context and why?”)
Anderson R. BMJ 2008; 337: 944-45
 develop ethical framework for defining the relative weight of
different therapeutic interventions
(e.g. “is there a basis for a preponderance of making sense, i.e. for
intentional treatments or is it preferable/ less stigmatizing to adopt an
approach that treats disorders of the self as mechanistic failures”)
Some implications for therapy – a first example
 Somatoform/ functional somatic disorders
 can be conceptualized as disorders of the embodied self with a
disturbance not only of sensation but also of interpersonal attribution of
symptom control to self or non-self
Henningsen P in Rudolf G/ Henningsen P. Somatoforme Störungen. Schattauer 1998
Henningsen P, Vogeley K. Neural correlates of self attribution in somatoform disorders. DFG-Antrag 2003/4
 are candidates for an interface category between general medical and
mental disorders in DSM-V and ICD-11
Löwe B, Mundt C, Herzog W, Brunner R, (…), Henningsen P. Psychopathology 2008
 have been shown to react best to activating interventions aimed at
mind/ brain (psychotherapies, psychopharmacology, multimodal treatments) but applied in a medical setting
DFG-Grant “PISO”, Depts of Psychosomatic Medicine Munich, Heidelberg, Hannover, Münster, Düsseldorf
Henningsen P, Zipfel S, Herzog W. Lancet 2007; 369: 946-55
Some implications for therapy – a first example
 Somatoform/ functional somatic disorders
 Short trainings are insufficient for primary care physicians, but
collaborative care models between GPs and psychosomatic specialists
in the medical setting show promising results
BMBF-Grants “Funktional” and “SpeziALL”, Dept of Psychosomatic Medicine, University Heidelberg
 Guidelines on the treatment of “Organically unexplained bodily
symptoms” are under way – across all relevant medical disciplines,
in Germany and Europe
DKPM/ DGPM (Henningsen P, Hausteiner C, Sattel H, Ronel J et al.) and
Creed F, Henningsen P, Fink P (eds), Medically unexplained symptoms and bodily distress, CUP 2011
Conclusions 1
 Parts of the concepts of psychosomatic medicine are a
fore-runner of current embodied/ embedded approaches
 The strategic preferences of current psychosomatic medicine
could gain support from the embodied/ embedded approach
 The descriptive category of “disorders of the embodied self”
and of their therapy is helpful for a broader view on the
interrelations of different
levels of description and explanation for bodily and mental
phenomena in mental and physical disorders
 “Integrated psychosomatic medicine” with a clear therapeutic
profile is the best application of the embodied/ embedded
approach in medicine
Conclusions 2: try the Heidelberg recipe…
 Take the methodological rigour
- but not the therapeutic skepticism of KJ
 Take the “introduction of the subject
into medicine” (a teleofunctionalist
principle) – but not the misconception
of “Umgang” as systematic therapy
of VvW
 Take the focus on systematic therapy
- but not the insensitivity to nonintentional deficits in disease –
of AM
…and think well before mixing!
Karl Jaspers (1883-1969),
psychiatrist and philosopher
Viktor von Weizsäcker
1886-1957,
neurologist and internal specialist
Alexander Mitscherlich
1908-1982,
neurologist and psychoanalyst
Thank you
Generic aetiological model for functional somatic
syndromes
Henningsen P, Zipfel S, Herzog W. Lancet 2007; 369: 946-55
Stresssystem and mütterliches Verhalten
(Michael Meaney, Toronto)
Nest bout
Nursing
Grooming and licking
pup licking and grooming (LG) and arched-back nursing (ABN)
low-LG-ABN mothers.
high-LG-ABN mothers.
Stressempfindlichkeit der Nachkommen hängt vom
Pflegeverhalten der Mütter ab:
wenig Pflege = hohe Empfindlichkeit und umgekehrt
high-LG-ABN Mütter
mäßige Stress-Antwort
Liu D et al Science 277; 1997
low-LG-ABN Mütter
hohe Stress-Antwort
Epigenetische Mechanismen vermitteln zwischen
mütterlichem Pflegeverhalten und Stresssensitivität
NGFI Binding site
Offspring of high-LG-ABN
very low methylation in 5’ CpG
of NGFI Binding site
Offspring of low-LG-ABN
high Methylation in 5’ CpG
of NGFI Binding site
Stress and Dopamine depending on attachment
experience
Pruessner J, Champagne F, Meaney MJ,
Dagher A, J Neurosc 2004