Georg Ivanovas From Autism to Humanism - systems theory in medicine

2.3 The psychosomatic confusion

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i) comorbidity and the psychosomatic complex

Comorbidity is a state where both, the ‘system body’ and the ‘system mind’, are ill. For the comorbid states of depression, ICD 10 distinguishes a primary and secondary form. Primary depression is a depression due to a ‘psychological cause’, secondary depression is one due to a ‘somatic cause’.

The resulting possibilities read as follows (Härtner 2000):

  1. a somatic disturbance causes biologically a depression (Hypothyroidism);
  2. a somatic disturbance precedes a depression in genetically vulnerable persons (e.g., Cushing syndrome is know to precede a major depression);
  3. a depression develops on the basis of a somatic disease (e.g. in cancer);
  4. a depressive disturbance precedes a somatic disturbance and may be eventually causal for it (somatisation);
  5. the somatic disturbance and the depression are not causally interconnected but coincidental.

To assign a ‘comorbid’ person to one of these classes is an arbitrary undertaking. Causality arises according to the theory of the observer. Strict neurobiological therapists see everything as biological, as somatic. When ADHD hyperactivity (understood as a disease of the soma) is combined with anxiety (understood as a disease of the psyche) the biological approach solves the ‘comorbid’ paradox, for example, by seeing everything caused by the function of the mesolimbic dopamine systems (Levy 2004).

On the other side, strong psychoanalyst and psychotherapist argue that most or all somatic disturbances are a consequence of some inner or social conflicts that influence metabolism. Even the C-reactive protein, an indicator for inflammatory processes and therefore clearly ‘body’ is elevated through anger and sadness (Suarez 2004) and blood clotting is increased through anxiety (Känel et al 2004).

The whole situation is absolutely frustrating and already Babinski found the distinction of neurological or neurotic disease not applicable to many conditions. He defined, therefore, a third area of different nature, a syndrome physiopathique (Sacks 1984: 231). But this increases only the dilemma, as the whole concept of comorbidity contradicts the understanding of humans as autonomous, self-regulating beings.

In complementary and alternative medicine (CAM) there has always been a tendency to see humans as a whole and to define diseases as an imbalance. In such a view the distinction between a psyche and a soma makes no sense. Body, psyche and mind are parts of the same system (Hammer 1990: 86). Humans are emotional embodiments as far as organs and their function allow them to be (Worsley 1982: 60). Emotional and behavioural symptoms are an expression of the ‘human’ just as gastritis or athlete’s foot. It is a matter of habitude to see a tic, for example the twitching of the eye lid, as a symptom of the eye, of the nervous system or of a mind.

Neurophysiological, emotional, behavioural or cellular aspects are then but a different way to map the human condition. It is more a question of practicability which decides on the selection of the map. If this were understood properly most disputes would vanish (Bleuler 1962: 59). The psychosomatic problem arises only if an analytical point of view is chosen and/or if the question “what causes what” is introduced.


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