It’s Not 'All in Your Head.' It’s in Your Brain.
Why we should not use the term 'psychosomatic'
Posted Aug 02, 2015
Women have a long, sad and frustrating history of being pathologized for physical complaints. Going back in the history of psychology and medicine, we’ve been told we are sexually frustrated, that our neuroses lead us to develop physical symptoms, that we are recruiting symptoms for psychological reasons, and in the current landscape of modern medicine, that we are prone to illnesses that “are all in our heads.”
Fortunately, current research helps us to understand that some physical illnesses, especially those that are not easily explained, are not made up at all. They are the result of complex neuroendocrine responses due to heredity, trauma and stress. The bodily symptoms are real. They are not all in one’s head. They are created by mind, body and brain.
As humans, we have been attempting to adapt to stress for thousands of years. Whereas threats once involved worrying about making it through the day without becoming dinner for a lion or other predator, as societies have evolved, the demands placed on us to cope with modern life creates interesting somatic challenges. And it is not entirely clear that our physiological mechanisms for coping with adversity have evolved in a way that matches the stresses many of us face.
Yet, some of us seem better at coping than others. Some of us can more adeptly shake off the driver that cuts us off, feel less threatened when we get negative feedback at work, and realize (without becoming overly afraid or angry) the limitations of a partner who cannot provide exactly what we need.
Stress of any kind provides a physical and psychological challenge and in the language of the body, stress equates to fear. When we can’t manage our stress levels our body, physiologically speaking, is in a constant state of fear. Moving beyond the basic understanding of fight/flight reactions however, we now have a more nuanced appreciation of the challenges we face when we experience stress as a threat to emotional and physical well-being.
The stress circuit or HPA-axis (hypothalamus-pituitary-adrenal axis) is thought to be one mechanism of how the brain and body work together to cause symptoms that can appear to be “psychosomatic.” The HPA-axis describes a feedback loop in which signals from the brain trigger the release of hormones (epinephrine, norepinephrine, and cortisol) which can impact everything from blood pressure and digestion to important parts of the brain that impact both mood and levels of fear. It is thought that one of the main regulators of the HPA axis is corticotrophin-releasing factor (CRF). In response to stress, CRF, through a complex network, controls the release of cortisol, which then acts on the immune system. In the short-term, this is a good thing; we all need cortisol to help protect our bodies when there is a physical threat. But what current research emphasizes, is that when there is too much CRF and HPA-axis activation as a result of stress, our immune systems can start to get confused. We don’t know when we really need our stress hormones to protect us and eventually, our healthy reserves of cortisol can become overwhelmed and not be available when we need it most to help control inflammation, which is a major culprit in many illnesses.
It is thought that the susceptibility to HPA axis stress is in part related to heredity. Yet, it does seem that our childhoods and the level of safety provided at this crucial time may be related to how resilient we are to manage stress and how robust our individual HPA-axis systems are. In the study conducted by the aforementioned authors, by using a better biomarker of chronic HPA activity they demonstrated that chronic adverse childhood experiences led to HPA-axis dysfunction in the form of reduced cortisol levels, which may make us susceptible to illness later in life. For example, low cortisol is implicated in the development of chronic fatigue syndrome, endometriosis and chronic pelvic pain. Another study found links between child abuse and biological markers of increased inflammation.
People who report experiencing chronic stress are also more likely to develop the common cold because reduced cortisol allows for increased inflammation.
Dysfunctional reactions of the glucocorticoid system are thought to be associated with fibromyalgia. Additionally, the effects of HPA-axis dysfunction are also thought to predispose people to asthma, eczema, migraines and a number of gastrointestinal symptoms.
What strikes me as incredible about this particular avenue of research is that it provides a biological basis for the hypotheses of hysteria rendered by Breuer and Freud (1895/1957). They stated:
“Observations such as these seem to us to establish an analogy between the pathogenesis of common hysteria and that of traumatic neurosis, and to justify an extension of the concept of traumatic hysteria. In traumatic neurosis the operative cause of the illness is not the trifling physical injury but the affect of fright—the psychical trauma… Any experience, which calls up distressing affects—such as those of fright, anxiety, shame or physical pain—may operate as a trauma of this kind; and whether it in fact does so depends naturally enough on the susceptibility of the person affected… (p. 5-6)”
Being afraid all of the time is bad for the body. Fear and stress clearly impact the immune system. Freud and Breuer, in concert with current neuropsychiatric researchers, note that some are just more biologically susceptible to the impact of certain stressors.
While it is true that we don’t fully understand how to completely fix a wounded immune system, it is the case that psychotherapy can address some of the issues that seem to predispose people to an increased sense of fear and anxiety. Especially in psychoanalytic psychotherapy we seem to be particularly good at helping people feel safe, contain and manage overwhelming emotions, learn how to be assertive (while managing anxiety about aggression) and to help with a number of other traits that are thought to be associated with a biological tendency to have stress land in the body, including the development of an emotional language and dealing with childhood disappointments and trauma. Through a biological lens, we can help people achieve a sense of security that may help regulate stress hormones.
Based on this research it is clear that the term “psychosomatic” may no longer be useful. Illness exists in the mind, body and brain.