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Special Article

388 http://ap.psychiatryonline.org AcademicPsychiatry, 31:5, September-October 2007

Psychosomatic Medicine: The Scientiﬁc Foundation of the Biopsychosocial Model

Dennis H. Novack, M.D., Oliver Cameron, M.D., Ph.D.Elissa Epel, Ph.D., Robert Ader, Ph.D., Shari R. Waldstein, Ph.D.Susan Levenstein, M.D., Michael H. Antoni, Ph.D.Alicia Rojas Wainer, M.D.

Received December 4, 2005; revised November 15, 2006; acceptedNovember 20, 2006. From Drexel University College of Medicine,Ofﬁce of Educational Affairs, Philadelphia, Pennsylvania. Addresscorrespondence to Dr. Novack, Drexel University College of Medi-cine, Ofﬁce of Educational Affairs, 2900 Queen Lane, Philadelphia,PA 19072; dennis.novack@drexelmed.edu (e-mail).Copyright

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2007 Academic Psychiatry

Objective:

This article presents major concepts and research ﬁndings from the ﬁeld of psychosomatic medicine that the au-thors believe should be taught to all medical students.

Method:

The authors asked senior scholars involved in psychosomatic medicine to summarize key ﬁndings in their respective ﬁelds.

Results:

The authors provide an overview of the ﬁeld and summarize core research in basic psychophysiologicalmechanisms— central nervous system/autonomic nervous system, psychoneuroimmunology, and psychoendocrinology—in three major disease states—cardiovascular, gastrointestinal, and HIV virusinfections.

Conclusions:

Understanding the core scientific concepts and research findings of psychosomatic medicine should provide medical trainees with a scientific foundation for practicing med-icine within a biopsychosocial model of care.

Academic Psychiatry 2007; 31:388–401

n 1977, George Engel challenged the medical profes-sion to reconsider a strict biomedical approachtomedi-cal education and care and embrace a “new medicalmodel,” the biopsychosocial model (1). Engel argued thathumans are at once biological, psychological, and socialbeings who behave in certain ways that can promote orharm their health. Many interacting factors, from the cel-lular to the social, contribute to health and illness. A dis-turbance in any sphere of human functioning affects all of them.Ifphysicians aretorealizetheirpotentialtopromotethe healing of patients’ illnesses, as opposed to narrow ef-forts to diagnose and cure diseases, they must understandthe nature of these interactions.Engel was proposing an alternate way to constructclini-cal reality, another way to see. If physicians understandhow a variety of psychosocial factors interact to promoteor maintain illness, they can intervene at a varietyoflevels.No longer constrained to intervening only at a biologicallevel, clinicians can intervene with cognitive, behavioral,and/or emotional strategies as well, knowing that these in-terventions can have positive effects at all levels of func-tioning.Despite a general acceptance of the biopsychosocialmodel in medical education, U.S. medical education andcare are still largely biomedical in focus, and physicianshave many deficiencies in biopsychosocial formulationsand care (2–4).Part of the problem may be that medical students arenot offered a sufficient scientific foundation for under-standing the biopsychosocial model. Since the inceptionof the modern era of psychosomatic research in the early1940s, this science has flourished and provided that sci-entific foundation.Psychosomaticresearchinvestigatesthemultilevel interactions that contribute to health andillness(5), including genetic susceptibility, biological insults (e.g.,

NOVACK

ET AL.

Academic Psychiatry, 31:5, September-October 2007 http://ap.psychiatryonline.org

389

carcinogens and microbes), early childhood experiences,socioeconomic status, personality, acute and chronicstressors, behaviors, life style, social networks, and theircombined effects on physiological functioning. The Insti-tute of Medicine (IOM) recently issued a report on en-hancing behavioral and socialscienceeducationinmedicalschool curricula, and emphasized major topic areas in psy-chosomatic medicine, including mind-body interactions inhealth and disease (6). Now that the American Board of Medical Specialties has approved the specialtydesignationof “psychosomatic medicine” for psychiatrists who careforthe medically ill (7), there is a unique opportunity to in-corporate the science of psychosomatic medicine intomedical curricula. Specialists in psychosomatic medicine will likely be tapped to lead the efforts in teaching thefundamentals of biopsychosocial care.We believe that physicians cannot truly practice withina biopsychosocial perspective without understanding thescientific basis for this perspective. As a resourceformedi-cal educators, we offer in this article an overview of majordomains, concepts and research findings in psychosomaticmedicine that we believe should beintegratedintomedicalschool curricula.We first present an overview of the domains of psycho-somatic medicine. Next, wepresentphysiologicalpathwaysfor intersystem communication among the neural, im-mune, and endocrine systems—and possible biologicalmechanisms for the pathogenesis of some diseases. Thefollowing three sections offer examples of psychosomaticresearch in cardiovascular, gastrointestinal, and infectiousdisease. We then comment on issues related to integratingthis science into undergraduate medical education.

The Domains of Psychosomatic Medicine

Because psychosomatic medicine research focuses onthe interactions among various traditional scholarly do-mains (biology, psychology/psychiatry, sociology, econom-ics), it is difﬁcult to categorize the domains of psychoso-matic medicine. Figure 1 illustrates one approach tocategorization, viewing topics from the vantage point of the most predominant interactions, recognizing that thereare biopsychosocial interactions relevant to all of thesetopics. Each of the domains in the ﬁgure contains majorexamples, and is not intended to be exhaustive. In this ar-ticle, we focus on the psychological/biological domain,since there may be more need for curricular guidancethanother domains which appear to be more fully presented incurrent behavioral science courses (2, 8). However, it isimportant to underscore that there is high quality empiri-cal research in all of the other domains that inform stu-dents’ understanding of biopsychosocial interactions (9,10). To cite two examples in the social/biological domain,the strength of social isolation as a risk factor for ill healthis comparable to high blood pressure, obesity, sedentarylifestyles, and possibly even smoking (11). Also, there is agradient in the relationship between socioeconomic statusand health, with each level of the hierarchy exhibiting lessmorbidity and mortality than lower levels (12).

Intersystem Communication:Psychophysiology and Disease

Because humans evolved as social beings living in anoften hostile environment, a varietyofpsychophysiologicalmechanisms evolved to maintain health in a variety ofcon-texts. These mechanisms are mediated by the central andautonomic nervous systems, the neuroendocrine and im-mune systems. These adaptive physiological mechanismshave limitations and can be compromisedbyadversesocialand environmental events. Hans Selye (13) ﬁrst describedhow chronicstresscanleadtoenlargedadrenals,atrophiedthymus,tumors,andheartdiseaseinmice.Fiftyyearslater,the psychology and psychophysiology of stress are still notfully understood. What is clear, however, is that psycho-logical stressors can have harmful effects on health. Forexample, stressors such as ego threat and lack of controlare potent stimuli for the hypothalamic-pituitary-adrenal(HPA) axis, and, chronically, can damage the resiliency of neuroendocrine axes (14). There is recent evidence thatstress modulates indices of cellular aging (15). A helpfulmodel for understanding the cumulative physiological ef-fects of chronic stress is the allostatic load model. “Allos-tasis” is the body’s adaptive responses to stress, and “al-lostatic load” the cumulative wear and tear on the body of these responses (16). According to this model, “stressors”are not just psychological but constituteany factorthatcandysregulate the stress responsesystems,includinggenetics,life experiences, and damaging health behaviors, such assmoking and alcohol use. In the following three sections, we describe basic psychophysiological mechanisms in thecentral and autonomic nervous systems, the immune andneuroendocrine systems, and their implications for healthand illness.

Roles of the Central and Autonomic NervousSystems in Psychophysiology

An understanding of the structures and functions of thecentral (CNS) and autonomic nervous systems (ANS)pro-

THE SCIENTIFIC FOUNDATION OF THE BIOPSYCHOSOCIAL MODEL

390 http://ap.psychiatryonline.org AcademicPsychiatry, 31:5, September-October 2007

FIGURE 1. The Domains of Psychosomatic Medicine*

PsychologicalBehavioralBiologicalSocial/Cultural/EconomicPsychological/Biological

Developmental psychobiologyGenetic basis of behavior/environmental influences ongene expressionPsychophysiology (CNS/ANSPNI, PNE)Stress/AllostasisPsychobiology of specificdisease processes, e.g.,GI, CV, HIV, etc.

Psychological/Behavioral

Health Behaviors (activity, diet,substance use)Attitudes – self-efficacy, healthbeliefs, motivation to changeBehavior acquisition and changePsychodynamicsSomatizationPersonality styles and disordersDevelopmental psychology

Social/Behavioral

Family/Social/Cultural/economicdeterminants of healthseeking and health practices Disparities in health careEffects of physician-patientcommunicationSocial class, income employmentstatus effects on behavior

Social/Biological

Biological consequences ofsocial isolation, economicupheaval, poverty, SESgradient, incomedistributionProtective effects of socialsupport, social capital,community cohesiveness,religiosity

Biopsychosocial

Acute illnessChronic illnessIllness behaviorPainSufferingMood disordersAddictive disordersCoping

PNI

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psychoneuroimmunology;PNE

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psychoendocrinology;GI

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gastrointestinal; CV

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cardiovascular *An earlier version of this ﬁgure appeared in Psychiatric Times (2006; 23:1, 6–8, 38)

vides a foundation for appreciating the intricacies of psy-chophysiology in mind-brain-body-behavioralinteractions.The CNS and ANS evolved to maintain homeostasis (i.e.,an optimized physiological state) in relation to theinternaland external environments, by coordinating a variety of physiological responses to stressors. The interconnectionsand individual functions of brain structures determinelearning, cognition, emotional reactions to and appraisalof interpersonal and environmental stressors. These cog-nitive and emotional reactions initiate physiological pro-cesses that inﬂuence health and illness. Quality of parent-ing and stressors during childhood can inﬂuence thereactivity of a variety of neuronal systems to later stressors(9). Knowledge of brain structures and their neurochem-istry is essential for understanding normal functioning, as well as pathological states, such as anxiety,depression,andposttraumatic stress disorder, and can be helpful in un-derstanding why certain cognitive therapies are effective. Also, understanding CNS/ANS connections with other or-gan systems illuminates how avarietyofstressorsandemo-tional states mightcontributetodysfunctioninotherorgansystems.Though we understand that most bodily tissues send in-formation to and receive information from the brain, un-derstanding psychophysiology’s contribution to pathogen-esis is a complex task. It is necessary to identifysusceptible