Response: Psychosomatic Medicine
Rides Again
Robert Ader, PhD
Hypotheses come and go almost daily. Good hypotheses or
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theories can be tested and are capable of being refuted-
shot down, if you prefer. Some hypotheses last longer than
others, depending not so much on direct experimental test-
ing, it seems, as on the rate at which new knowledge
accumulates. The passing of a hypothesis is sometimes
noteworthy, but it is not a unique event or a cause for either
celebration or mourning. And when an old theory is sup-
planted by a new or better one, it is a notch on the collective
belt of science.
Steven Hyman’s colorful phraseology in “Another One
Bites the Dust: An Infectious Origin for Peptic Ulcers”
For personal use only.
seems to applaud the demise of Franz Alexander’s notions
about peptic ulcer disease. The research Dr. Hyman cites
regarding Helicobacter pylori and the pathogenesis of ulcers,
however, does not address Alexander’s ideas about peptic
ulcers and has little direct bearing on psychoanalytic formu-
lations. If Dr. Hyman’s column is controversial, it is because
of the generalizations that might be derived from this new
information about an infectious pathogenesis of peptic ulcer
disease. That the mechanisms through which intrapsychic
processes were presumed to influence peptic ulcer disease
were incorrect addresses only a part of Alexander’s notions
about peptic ulcers and does not refute the possibility that
psychosocial factors play a role in the predisposition to or
the precipitation or progression of the development of ulcers
or other diseases.
Neither Alexander nor the surgeons who performed va-
gotomies can be faulted for developing hypotheses or devis-
The author, supported by a Research Scientist Award (KO5
MH06318) from the National Institute of Mental Health, completed
this column while a Fellow at the Center for Advanced Study in the
Behavioral Sciences, Stanford, Califi, with support from the John
D. and Catherine T . MacArthur Foundation.
Reprint requests: Robert Ader, PhD, Department of Psychiatry,
University of Rochester School of Medicine and Dentistry, Roches-
ter, NY 14642.
HARVARDREVPSYCHIATRY
1994;1:296-7.
Copyright 0 1994 by Harvard Medical School.
1067-3229/94/$1.00 f . l o 89JlJ60480
296
ing interventions based on what was generally accepted to
be the mechanism underlying the development of peptic
ulcers. Scientists enjoy the luxury of not being forced to
draw conclusions on the basis of inadequate information.
Clinicians cannot afford such luxury; they must often make
clinical decisions on the basis of incomplete information.
If, in the minds of physicians, psychological factors are
assumed to influence the development of or recovery from
peptic ulcer disease or other diseases, it is not because Franz
Alexander said so, but because their clinical experience has
shown it to be true. Based on observations implicating
H. pylori in the pathogenesis of peptic ulcer disease, Dr.
Hyman rejects Alexander’s speculations, because his hy-
pothesized mechanisms are wanting. It would be more
defensible to reject Alexander’s formulations on the grounds
that they cannot be tested. Correctly, however, Dr. Hyman is
careful not to reject the possibility that “stress or some
other psychosomatic factor” might influence ulcer forma-
tion or, presumably, the development of other chronic or
recurrent diseases. That is what psychosomatic medicine is
all about. Still, Dr. Hyman expresses some dated notions
about psychosomatic medicine, such as the assumption that
Alexander’s strict psychoanalytic views are still prevalent,
and he labels certain diseases psychosomatic disorders.
In my view, the notion of psychosomatic disorders is
antiquated. Modern research in psychosomatic medicine is
concerned primarily with the interactions among biologic,
psychological, and social factors in health and disease. Sin-
gle cause-single effect models inadequately account for the
multidetermined nature of disease processes; clinical and
experimental analyses of this point of view are given in
brief, compelling essays by Engel’ and Weiner,’ among
others, Consistent with this biopsychosocial orientation,
psychosomatic medicine concerns itself, for example, with
the role of psychosocial factors in contributing to, as op-
posed to causing, disease. In this context there are no
“psychosomatic diseases.” The designation of only some
diseases as psychosomatic implies that there are other
diseases that are not psychosomatic; that is, some diseases
are not influenced by biopsychosocial interactions. If, how-
ever, it can be shown that psychological factors can influence
any given disease, one must entertain the possibility that
psychological factors could influence any pathophysiologic
 Harvard Rev Psychiatry
Volume 1, Number 5
process. The problem is identifying the extent to which
psychosocial factors -not as single causes but in interaction
with biologic factors-contribute to disease in a given indi-
vidual. Thus Dr. Hyman’s contention that “psychological
factors play no direct role in [the] pathogenesis” of the
classic psychosomatic disorders is neither provocative nor
controversial if, by “direct,” he means “causal.” If he had
claimed that psychological factors play no role in the patho-
genesis of disease, there might be grounds for controversy.
But Dr. Hyman allows that stress or other psychosocial
factors may alter the timing, intensity, and duration of
disease, and this would seem to make him a proponent of
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modern-day psychosomatic medicine.
Even the phrase “disorders formerly thought to be psy-
chosomatic” is not controversial. It derives, I suggest, not
from a disagreement over the interpretation of data relating
psychosocial factors to disease but from this antiquated
concept of psychosomatic medicine and a failure to appreci-
ate contemporary notions of biopsychosocial interactions.
The use of the term falsification in connection with retro-
spective studies, however, is inflammatory. There are limi-
tations to the conclusions that can be drawn from retrospec-
tive studies, but these limitations are hardly confined to
For personal use only.
studies in psychosomatic medicine. Abundant prospective
data implicate psychosocial factors in health, disease, and
survival to an extent that matches or exceeds more readily
accepted nonpsychological risk factors. The role of social
support3 is a case in point.
Dr. Hyman speculates that a “promising connection
between stress and medical illness. . . is the possibility that
certain stressors may suppress immune function.” Psycho-
social factors may contribute to illness susceptibility or
progression via changes in immune function associated with
the adaptative processes that occur in response to stressful
life experiences. Psychoneuroimmunoloa, the study of
brain-immune system interactions, is in its infancy, but a
rapidly growing database indicates this is a plausible hy-
pothesis. Data from humans and animals document the
effects of stress on infectious disease p r o c e s s e ~and
~ ~ ~the
immunomodulating effects of stress.6 Unfortunately, how-
ever, one cannot conclude that changes in immune function
seen in one study are biologically relevant to, let alone
mediate, the increased or decreased susceptibility to disease
observed in another study. Furthermore, as Dr. Hyman
implies, the health consequences of stress-induced alter-
ations in immune function have yet to be established.
Relevant data are being collected, however, and several
studies in animals document the biologic impact of behav-
iorally conditioned alterations in imm~nity.’”~ The delayed
onset of autoimmune disease and the prolonged survival of
allografts in response to conditioned stimuli previously as-
sociated with immunosuppressive drugs are prime exam-
ples. This remains a promising avenue for research and one
that, like the relationship between H.pylori and ulcers, may
contribute to the redefinition of some diseases.
Ader 297
One source of confusion in Dr. Hyman’s comments re-
lates to the issue of responsibility. I was unaware (and, in
the absence of data, remain unconvinced) that physicians
attributed serious but heretofore idiopathic illnesses to psy-
chological factors or disclaimed responsibility for poor treat-
ment outcomes or recurrent bouts of disease. How can
patients be assigned responsibility for what physicians do
not yet understand? At the risk of seeming naive, I fail to
see how physicians would try to sell this idea to their
patients. The proposition that psychosocial factors influence
disease is not necessarily an indictment of the patient. Value
judgments aside, however, if people engage in high-risk
behaviors (e.g., alcohol and drug abuse), the clinician may
want to inquire into the current biologic, psychological, and
social functioning of those patients.
Although I agree with many of Dr. Hyman’s points, I
remain unsure of whether he is acknowledging a meaningful
role for psychosocial factors in disease (he offers no citations
in support of this position), is merely paying lip service to
the view that psychosocial factors can influence disease, or is
implying that the assumption that psychosocial factors play
a role in disease survives as a device by which physicians can
hide their ignorance of “real causes” and shift responsibility
for disease to the patient. I am reasonably sure, however,
that Dr. Hyman’s column is a belated observance of the
demise of the once-dominant psychoanalytic orientation in
the field of psychosomatic medicine. I assure you, however,
that modern psychosomatic medicine is alive and well.
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