Overview Some history  the two traditions of psychosomatic medicine

1. 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

2. 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

3. 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

4. Psychosomatic Medicine: history • Psychogenetic tradition (Psychoanalysis!)  body as theatre of the soul (“puzzling leap” – “conversion”)

5. Psychosomatic Medicine: history • Psychogenetic tradition e.g. Franz Alexander: Psychosomatic Medicine (“The medical value of psychoanalysis”) 1891-1964

6. 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

7. Psychosomatic Medicine: history • Integrative (“holistic”) approach from Internal Medicine/ Neurology, with background in biologyorganism (body and soul) in its interaction with the environment

8. Psychosomatic Medicine: history • Biology: Jakob von Uexküll “Strolls through the environment of animals and humans” “relational” instead of “atomistic” approach meaning of environment for the organism 1864-1944 Jakob von Uexküll 1910

9. Psychosomatic Medicine: history • Psychosomatic Medicine: Thure von Uexküll 1908 - 2004 Thure von Uexküll 1950-70s

10. Psychosomatic Medicine: history • Viktor von Weizsäcker 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) 1886 - 1957

11. 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

12. 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

13. 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)

14. 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

15. 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

16. 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…

17. 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

18. 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)

19. Multilevel explanatory models • Explanatory models are often implicit in day to day research

20. 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

21. 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)

22. 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.)

23. 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

24. Multilevel explanatory models Revensuo 2003

25. 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

26. 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)

27. 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

28. 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”

29. 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)

30. 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

31. 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

32. Disorders of the embodied self F de Vignemont Neuropsychologia 2010; 48: 669-80

33. 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 qualitativelyevaluate 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)

34. 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

35. 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

36. Some implications for therapy 1 Diederich NJ, Goetz CG. Neurology 2008; 71: 677-84

37. 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

38. 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)

39. 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

40. 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

41. Some implications for therapy 4 • …butthere 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 definingthe 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”)

42. 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-selfHenningsen 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-11Löwe 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 treat- ments) but applied in a medical settingDFG-Grant “PISO”, Depts of Psychosomatic Medicine Munich, Heidelberg, Hannover, Münster, Düsseldorf Henningsen P, Zipfel S, Herzog W. Lancet 2007; 369: 946-55

43. 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 resultsBMBF-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 EuropeDKPM/ 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

44. 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

45. 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 non- intentional deficits in disease – of AM …and think well before mixing! Karl Jaspers (1883-1969),psychiatrist and philosopher Viktor von Weizsäcker1886-1957,neurologist and internal specialist Alexander Mitscherlich1908-1982,neurologist and psychoanalyst

46. Thank you

47. Generic aetiological model for functional somatic syndromes Henningsen P, Zipfel S, Herzog W. Lancet 2007; 369: 946-55

48. 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.

49. low-LG-ABN Mütter high-LG-ABN Mütter hohe Stress-Antwort mäßige Stress-Antwort Stressempfindlichkeit der Nachkommen hängt vom Pflegeverhalten der Mütter ab:wenig Pflege = hohe Empfindlichkeit und umgekehrt Liu D et al Science 277; 1997

50. NGFI Binding site Epigenetische Mechanismen vermitteln zwischen mütterlichem Pflegeverhalten und Stresssensitivität 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