REVIEW ARTICLE

Psychosomatic medicine
G. A. Fava,1,2 N. Sonino2,3,4
Linked Comment: Wise. Int J Clin Pract 2010; 64: 9991001.

SUMMARY
Psychosomatic medicine may be defined as a comprehensive, interdisciplinary
framework for: assessment of psychological factors affecting individual vulnerability
as well as course and outcome of illness; biopsychosocial consideration of patient
care in clinical practice; specialist interventions to integrate psychological therapies
in the prevention, treatment and rehabilitation of medical disease. The aim of this
review was to provide an updated definition of psychosomatic medicine, to outline
its boundaries with related disciplines and to illustrate its main contributions to
clinical and preventive medicine. A review of the psychosomatic literature, using
both Medline and manual searches, with particular reference to articles, which
could be relevant to clinical practice, was performed. Current advances in the field
have practical implications for medical research and practice, with particular reference to the role of lifestyle, the challenge of medically unexplained symptoms, the
psychosocial needs entailed by chronic illness, the appraisal of therapy beyond
pharmaceutical reductionism, the function of the patient actively contributing to
his her health. Today, the field of psychosomatic medicine is scientifically rigorous,
more diversified and therapeutically relevant than ever before.

The term psychosomatic entails different meanings

and connotations, which may explain its varying
degrees of popularity. Even though the concept was
introduced by Heinroth in 1818, modern psychosomatic medicine developed in the first half of the
past century. It resulted from the confluence of two
concepts having an ancient tradition in Western
thinking and medicine: psychogenesis of disease and
holism (1). The idea of psychogenesis characterised
the first phase of development of psychosomatic
medicine (19301960) and resulted in the concept
of psychosomatic disease (a physical illness, such
as peptic ulcer, believed to be caused by psychological factors). Despite early criticism (2), the psychogenic postulate exerted a considerable seduction
in view of its explanatory power. Engel, Lipowski
and Kissen deserve credit for setting, in the sixties,
the ground for the current psychosomatic view of
the disease.
Engel developed a multifactorial model of illness
(3), named later biopsychosocial (4). It allows
illness to be viewed as a result of interacting mechanisms at the cellular, tissue, organismic, interpersonal
and environmental levels. Accordingly, the study
of every disease must include the individual, his
body and his surrounding environment as essential

Review Criteria
The authors tried to integrate the most recent
evidence, which derives from meta analyses and
comprehensive general reviews with the insights
that derive from controlled studies concerned with
specific populations.

Message for the Clinic

Medical assessment and treatment can be improved
by using the methods, which have been developed
in psychosomatic medicine, with particular reference
to medically unexplained symptoms, chronic illness
and lifestyle modification.

components of the total system (46), in what Hinkle

in 1967 defined as an ecological perspective (7).
Lipowski gave an invaluable contribution in setting
the scope, mission and methods of psychosomatic
medicine (1). He criticised the obsolete notion of
psychogenesis, as it was incompatible with the
doctrine of multicausality, which constitutes a core
postulate of current psychosomatic medicine.
Kissen provided a better specification of the term
psychosomatic (8). He clarified that the relative
weight of psychosocial factors may vary from one
individual to another within the same illness and
underscored the basic conceptual flaw of considering
diseases as homogeneous entities.
Psychosomatic research, in the past decades, has
resulted in an impressive body of knowledge, with
contributions published in all major medical journals
and in specifically dedicated journals. The aim of this
review was to provide an updated definition of psychosomatic medicine, to outline its boundaries with
related disciplines, to illustrate its main contributions
to clinical and preventive medicine and to discuss its
main lines of development.
Most of the content of the article is based on
the findings of systematic reviews, controlled studies which underwent replication and randomised

2010 Blackwell Publishing Ltd Int J Clin Pract, July 2010, 64, 8, 11551161
doi: 10.1111/j.1742-1241.2009.02266.x

Laboratory of Psychosomatics
and Clinimetrics, Department of
Psychology, University of
Bologna, Bologna, Italy
2
Department of Psychiatry,
State University of New York
at Buffalo, Buffalo, NY, USA
3
Department of Statistical
Sciences, University of Padova,
Padova, Italy
4
Department of Mental Health,
Public Health Service, Padova,
Italy
Correspondence to:
G. A. Fava, MD,
Department of Psychology,
University of Bologna, viale
Berti Pichat 5, 40127 Bologna,
Italy
Tel.: + 390512091339
Fax: + 39051243086
Email:
giovanniandrea.fava@unibo.it
Disclosure
None.

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controlled trials. Articles which were judged to be

relevant to clinical practice were selected.

Definition and boundaries

Stemming from Lipowskis original definition (1)
and subsequent developments (9,10), psychosomatic
medicine may be defined as a comprehensive, interdisciplinary framework for:
assessment of psychosocial factors affecting individual vulnerability and course and outcome of any
type of disease;
holistic consideration of patient care in clinical
practice;
integration of psychological therapies in the prevention, treatment and rehabilitation of medical
disease (psychological medicine).
Psychosomatic medicine has recently become in
the U.S. a subspecialty recognised by the American
Board of Medical Specialties (11). This may lead to
identifying psychosomatic medicine with consultation-liaison psychiatry (11), a subspecialty of psychiatry concerned with diagnosis, treatment and
prevention of psychiatric morbidity in the medical
patient in the form of psychiatric consultations, liaison and teaching for non-psychiatric health workers,
especially in the general hospital (12). Consultation
liaison psychiatry is clearly within the field of psychiatry; its setting is the medical or surgical clinic or
ward, and its focus is the comorbid state of patients
with medical disorders (13). Psychosomatic medicine
is, by definition (1,9,10), multidisciplinary. It is not
confined to psychiatry, but may concern any other
field of medicine. Not surprisingly, in countries such
as Germany and Japan, psychosomatic activities have
achieved an independent status and are often closely
related to internal medicine (14).
Up to the seventies, psychosomatic medicine was
the only site of research at the interface between
medicine and the behavioural sciences. In those
years, however, behavioural medicine developed (15)
as an interdisciplinary field that integrates behavioural and biomedical knowledge relevant to health and
disease. It provided a room for an increasing number
of psychologists dealing with basic laboratory
research on the neural and humoral systems controlled by the brain, on visceral learning and on
other aspects of behaviour, which lead to practical
implications of medical significance (16). Its focus
on unhealthful behaviour and risk factors (such as
smoking and alcohol abuse) led to the development
of the related discipline of health psychology (17).
Interestingly, the general psychosomatic approach
has resulted in a number of sub-disciplines within

their own areas of application: psycho oncology, psychonephrology, psychoneuroendocrinology, psychoimmunology, psychodermatololgy and others. Such
sub-disciplines have developed clinical services, scientific societies and medical journals.

Assessment of psychosocial factors

affecting individual vulnerability
It is becoming increasingly clear that we can improve
medical care by paying more attention to psychological aspects of medical assessment (18), with
particular reference to the role of stress (5,8,9,19). A
number of factors have been implicated to modulate
individual vulnerability to disease. Some factors
(such as healthy habits and psychological well-being)
positively promote health rather than merely reducing
disease.

Early life events

The role of early developmental factors in susceptibility to disease has been a frequent object of psychosomatic investigation (5,19). Using animal models,
events such as premature separation from the mother
have consistently resulted in development of pathophysiological modifications, such as increased hypothalamic-pituitary-adrenal axis activation (5,19).
They may render the human individual more vulnerable to the effects of stress later in life. There has
been also considerable interest in the association of
childhood physical and sexual abuse with medical
disorders, such as chronic pain and irritable bowel
syndrome (20). A history of childhood maltreatment
was significantly associated with several adverse
health outcomes, e.g. functional disability and greater
number of health risk behaviours (21), yet the evidence currently available does not allow any firm
conclusions (22).

Recent life events

The notion that events and situations in a persons
life, which are meaningful to him or her may be followed by ill health has been a common clinical
observation. The introduction of structured methods
of data collection and control groups has allowed to
substantiate the link between life events and a number of medical disorders, encompassing endocrine,
cardiovascular, respiratory, gastrointestinal, autoimmune, skin and neoplastic disease (19,2327).

Chronic stress and allostatic load

Life changes are not the only source of psychological
stress. Subtle and long-standing life situations should
not too readily be dismissed as minor and negligible,
as chronic, daily life stresses may be experienced by

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Physical/emotional stressors

Allostatic load
Psycho neuro endocrine immune
network

Personality, genetic determinants,

environmental factors

Adeguate coping

New homeostatic balance

resilience

Insufficient coping

Homeostatic derangement
impairment

Figure 1 Interacting mechanisms in individual vulnerability

the individual as taxing or exceeding his her coping

skills. Mc Ewen and Stellar (23) proposed a formulation of the relationship between stress and the processes leading to disease based on the concept of
allostasis and the ability of the organism to achieve
stability through change. The concept of allostatic
load refers to the wear and tear that results from
either too much stress or from insufficient coping,
such as not turning off the stress response when it is
no longer needed (Figure 1). Biological parameters
of allostatic load, such as glycosylated proteins, coagulation fibrinolysis markers and hormonal markers,
have been linked to cognitive and physical functioning and mortality (19).

Health attitudes and behaviour

Unhealthy lifestyle is a major risk factor for many of
the most prevalent diseases, such as diabetes, obesity
and cardiovascular illness (28). In 1985, Geoffrey
Rose (29) showed that the risk factors for health are
almost always normally distributed and supported a
general population approach to prevention, instead of
targeting those at the highest risk. Switching the general population to healthy lifestyles would be a major
source of prevention. The need to redesign primary
care practice to incorporate health behaviour change
has been recently underscored (30,31). Also the
American Academy of Pediatrics in 2008 underscored
the need to address the current epidemic of childhood obesity through enhanced adherence to dietary
guidelines and increasing physical activity (32).

Social support
Prospective population studies have found associations
between measures of social support and mortality,

psychiatric and physical morbidity and adjustment to

and recovery from chronic disease (10). An area that
is now called social neuroscience is beginning to
address the effects of the social environment on the
brain and the physiology it regulates (19).

Psychological well-being
Positive health is often regarded as the absence of
illness, despite the fact that half a century ago, the
World Health Organization defined health as a state
of complete physical, mental and social well-being
and not merely the absence of disease or infirmity
(33). Research on psychological well-being has indicated that it derives from the interaction of several
related dimensions (34). Several studies have suggested that psychological well-being plays a buffering
role in coping with stress and has a favourable impact
on disease course (35,36). Antonovskys sense of
coherence, a resource that enables people to manage
tension, to reflect about their external and internal
resources, to promote effective coping by finding
solution, has been found to be strongly related to perceived health, especially mental health and to be an
important contributor for health maintenance (37).

Personality factors
The notion that personality variables can affect
vulnerability to specific diseases was prevalent in the
first phase of development of psychosomatic medicine (19301960) and was particularly influenced by
psychoanalytic investigators, who believed that specific personality profiles underlay specific psychosomatic diseases. This hypothesis was not supported
by subsequent research (1,17). Two personality constructs that can potentially affect general vulnerability
to disease, type A behaviour and alexithymia (the
inability to express emotion), have attracted considerable attention, but their relationship with health is
still controversial (3840). The social-cognitive
model of personality assumes that personality variables interact with social and environmental factors
and result in differences in the features of the situations that individuals select (41). In this sense,
personality variables (e.g. obsessive-compulsive, paranoid, impulsive) may deeply affect how a patient
views illness, what it means to him her and his her
interactions with others, including medical staff.

Holistic consideration of patient care

Psychosocial and biological factors interact in a number of ways in the course of medical disease. Their
varying influence determines the unique quality of
the experience and attitude of every patient in any
given episode of illness.

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Psychiatric disturbances
Psychiatric illness, depression and anxiety in particular, is strongly associated with medical diseases.
Mental disorders increase the risk for communicable
and non-communicable diseases; at the same time,
many health conditions increase the risk for mental
disturbances, and comorbidity complicates recognition and treatment of medical disorders (42). The
potential relationship between medical disorders and
psychiatric symptoms ranges from a purely coincidental occurrence to a direct causal role of organic
factors either medical illness or drug treatment
in the development of psychiatric disturbance. The
latter is often subsumed under the rubric of organic
mental disorder whose key feature is the resolution
of psychiatric disturbances upon specific treatment
of the organic condition (43), such as depression in
Cushings syndrome (25). Not surprisingly, a correct
diagnosis of depression in primary care is a difficult
task. A recent meta analysis (44) indicated that there
are more false positives than either missed or identified cases.
Major depression has emerged as an extremely
important source of comorbidity in medical disorders (45). It was found to affect quality of life and
social functioning and lead to increased health care
utilisation, to be associated with higher mortality
(particularly in the elderly people), to have an
impact on compliance and to increase susceptibility
to medical illness (4548). The relationship between
anxiety disorders and comorbid medical illness has
also been found to entail important clinical implications (49).

Psychological symptoms
Current emphasis in psychiatry is about assessment
of symptoms which result in syndromes identified by
diagnostic criteria (DSM). However, emerging awareness that psychological symptoms which do not
reach the threshold of a psychiatric disorder also
may affect quality of life and entail pathophysiological
and therapeutic implications led to the development
of the Diagnostic Criteria for Psychosomatic Research
(DCPR) (50) together with a specific interview to
assess patients (51). The DCPR were introduced in
1995 and tested in various clinical settings (5053)
(Table 1). They do provide also a classification for
illness behaviour, as the ways in which individuals
experience, perceive, evaluate and respond to their
own health status (54).

Quality of life
While there is neither a precise nor agreed definition
of quality of life, research in this area seeks essentially two kinds of information: the functional status

Table 1 The diagnostic criteria for psychosomatic

research (DCPR)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Health anxiety
Thanatophobia
Disease phobia
Illness denial
Persistent somatisation
Conversion symptoms
Functional somatic symptoms secondary to a psychiatric
disorder
Anniversary reaction
Demoralisation
Irritable mood
Type A behaviour
Alexithymia

of the individual and the patients appraisal of health

(55).The concept stems from the fact that measures
of disease status alone are insufficient to describe the
burden of illness and that the subjective perception
of health status (e.g. lack of well-being, demoralisation, difficulties fulfilling personal and family responsibilities, etc.) should integrate that of the clinician
in evaluating outcome (55,56).

Integration of psychological therapies

in medicine
Psychological interventions in the medically ill
patients may be performed by different health professionals and may range from reassurance and effective
communication to specific psychotherapeutic and
psychopharmacological treatments. Many of the
initial clinical trials of psychological therapies have
involved highly trained and experienced specialists,
but there is increasing evidence that clinicians who
are not trained psychiatrists or psychologists can also
carry out such interventions (57,58).

Lifestyle modification
An increasing body of evidence links the progression
of severe medical disorders to specific lifestyle behaviours (28,5861). The benefits of modifying lifestyle
have been particularly demonstrated in coronary
heart disease (24) and type 2 diabetes (58). Further,
a number of psychological treatments have been
found to be effective in health-damaging behaviours,
such as smoking (62). A basic psychosomatic
assumption is the consideration of patients as partners in managing disease. The partnership paradigm
includes collaborative care (a patientphysician relationship in which physicians and patients make
health decisions together) (63) and self-management
(a plan that provides patients with problem-solving

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skills to enhance their self-efficacy) (64). Selfmanagement appears to be particularly valuable in

the settings of chronic medical disease and rehabilitation medicine (65,66). Indeed, in this latter area, a
multidisciplinary, psychosomatic approach is often
endorsed.

preventive efforts: individuals with excessive health

anxiety were found to take worse care of themselves
than control subjects in several studies (54). Indeed,
they may be so distressed by their belief of having an
undiagnosed or neglected disease that choices which
may yield benefits in the distant future appear to be
irrelevant to them.

Treatment of psychiatric comorbidity

Psychiatric disorders, and particularly major depression, are frequently unrecognised and untreated in
medical settings, with widespread harmful consequences for the individual and the society. Treatment
of psychiatric comorbidity such as depression, with
either pharmacological or psychotherapeutic interventions, markedly improves depressive symptoms,
health-related functioning and the patients quality
of life, although an effect on medical outcome has
not been demonstrated (67).

Psychosocial interventions
Use of psychotherapeutic strategies (cognitivebehavioural therapy, stress management procedures,
brief dynamic therapy) in controlled investigations
has yielded a substantial improvement in a number
of medical disorders (65,68,69). Examples are interventions that increase social support, improve mood
and enhance health behaviour in patients with breast
cancer (70), foster self-control and self-management
in chronic pain (71) and improve emotional disclosure (72).
Research on psychotherapy has brought up
common therapeutic ingredients such as: the therapists full availability for specific times (attention);
the patients opportunity to ventilate thoughts and
feelings (disclosure); an emotionally charged, confiding relationship with a helping person (high arousal);
a plausible explanation of the symptoms (interpretation); a ritual or procedure that requires the active
participation of both patient and therapist and that
is believed by both to be the means of restoring the
patients health (rituals) (10). These ingredients may
be employed successfully within any patientdoctor
relationship.

Treatment of abnormal illness behaviour

For many years, abnormal illness behaviour has been
viewed mainly as an expression of personality predisposition and considered to be refractory to treatment
by psychotherapeutic methods. There is now evidence to challenge such pessimistic stance (10,50,51).
For instance, several controlled studies on psychotherapy indicate that hypochondriasis is a treatable
condition by the use of simple cognitive strategies.
The correlation between abnormal illness behaviour and health habits may have implications in

The timeliness of psychosomatic

medicine
There have been major transformations in health
care needs in the past decades. Chronic disease is
now the principal cause of disability and use of
health services consumes almost 80% of health
expenditures (64). Yet, current health care is still
conceptualised in terms of acute care perceived as a
product processing, with the patients as a customer,
who can, at best, select among the services that are
offered. As Hart has observed, in health care the
product is clearly health and the patients is one of
the producers, not just a customer (73). As a result
optimally efficient health production depends on a
general shift of patients from their traditional roles
as passive or adversarial consumers to become producers of health along with their health professionals
(73, p. 383).
The need to include consideration of function in
daily life, productivity, performance of social roles,
intellectual capacity, emotional stability and wellbeing, has emerged as a crucial part of clinical investigation and patient care (55). These aspects have
become particularly important in chronic diseases,
where cure cannot take place and also extend over
family caregivers of chronically ill patients and health
providers. Patients have become increasingly aware
of these issues. The commercial success of books on
complementary medicine and positive practices as
well as the upsurge of mind-body medicine exemplify the receptivity of the general public to messages
of well-being pursuit by alternative medical practices.
Psychosomatic interventions may respond to these
emerging needs within the established medical system
and may play an important role in supporting the
healing process.
Medically unexplained symptoms occur in up to
3040% of medical patients and increase medical
utilisation and costs (1,18). The traditional medical
specialties, based mostly on organ systems (e.g. cardiology, gastroenterology), appear to be more and
more inadequate in dealing with symptoms and
problems, which cut across organ system subdivisions and require a holistic approach. The
interdisciplinary dimension that characterises most
rehabilitation units and pain clinics (65,66) is a

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practical consequence of this appraisal. In the UK,

the establishment of psychological treatment centres
within the National Health System for providing psychotherapy to patients with anxiety and depressive
disorders (74,75) is an unprecedented opportunity of
integration of different treatments.
The exponential spending on preventive medication justified by the potential long-term benefits to a
small segment of the population is now being challenged (76), whereas the benefits of modifying lifestyle by population-based measures are increasingly
demonstrated (58,62,65) and are in keeping with the
biopsychosocial model. Yet, at present, almost all of
health care spending are directed at biomedically oriented care. Overemphasis on pharmacological treatment has lead to a dangerous reductionism, which
neglects the fact that therapeutic outcomes are always
the result of several ingredients, specific or nonspecific (10), as outlined above.
As Kroenke has argued, neither chronic medical nor
psychiatric disorder can be managed adequately in the
current environment of general practice, where the
typical patient must be seen in 1015 min or less (18).
In clinical medicine, there is the tendency to rely
exclusively on hard data, preferably expressed in the
dimensional numbers of laboratory measurements,
excluding soft information such as impairments
and well-being. This soft information can now, however, be reliably assessed by clinical rating scales and
indexes, which have been validated and used in psychosomatic research and practice (77). It is not that
certain disorders lack an explanation; it is our assessment that is inadequate in most of the clinical
encounters, as it does not reflect a global psychosomatic approach (77,78). Similarly, addressing the
origins of disparities in physical and mental health
care within a biopsychosocial model early in life may
produce greater effects than attempting to modify
health-related behaviours or improve access to health
care in adulthood (79).

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Paper received August 2009, accepted September 2009

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