Spontaneous Remissions

By Dr. Ralph Moss from CancerDecisions.com Newsletter (9/11/02)

One of my clients wrote to me in desperate search of a treatment for his wife. Her doctors, using all
the methods known to them, held out little hope. He therefore sought my advice. "Over the years I
have heard of spontaneous remissions," he wrote, "but have never met anyone who personally
experienced one (including our doctors). Is there any truth to them? If so, was there any common
denominator in them?"

Serendipitously, his letter came just as I was planning to write a newsletter on this very topic. My
immediate inspiration was an article that appeared earlier this year in the journal Medical Hypotheses
with the provocative title, "Spontaneous regression: a hidden treasure buried in time." However, the
topic of spontaneous regressions, or remissions, has galvanized me since I first learned about them
almost 30 years ago.

A spontaneous remission is the disappearance of cancer without any immediate medical cause. As my
former employer, Memorial Sloan-Kettering President Lewis Thomas, MD, once said: "The rare but
spectacular phenomenon of spontaneous remission of cancer persists in the annals of medicine, totally
inexplicable but real, a hypothetical straw to clutch in the search for cure. . . . No one doubts the
validity of the observation."

For centuries, such observations astonished attentive doctors and gave heart to desperate patients.
Cancer is called a "progressive" disease, but (unlike in politics) the adjective is not meant as a
compliment. If not successfully treated, cancer "progresses" to its seemingly inevitable endpoint:
death. The fact that cancer sometimes just disappears on its own is an amazing fact. The number of
patients who experience a spontaneous remission has always been small, and (according to the
authors of the aforementioned article) is growing smaller. But it is a fact, and seeing it, or even
reading about it, alters one's view of reality. It is like suddenly seeing a UFO appear in the night sky. It
shakes your ordinary convictions and demands a profound change in worldview. After all, if Nature can
do this, why can't we mortals learn the trick and start to do it ourselves? Shouldn't medicine imitate
Nature and its ingenious cures rather than trying to devise artificial cures that are inimical to what the
body does best?

The classic work on the topic in English is Spontaneous Remission, by Brendan O'Regan and Caryle
Hirshberg. This 713-page "annotated bibliography" was published by the Institute of Noetic Sciences in
1993. The scientific advisory board included Drs. Michael Lerner, Rachel Naomi Remen and Lucy
Waletzky, all experts on the mind-body connection in cancer. This large book considered 1,574
citations, and discussed in detail hundreds of cases of malignant tumors that partially or completely
disappeared with no curative medical intervention. Brendan O'Regan died tragically of melanoma while
the book was in progress, but Caryle Hirshberg still lectures on its conclusions.

Perusing this scholarly book, you find that while there is no single cause for all the spontaneous cures
of cancer, the majority of such patients experienced an acute infection just prior to the regression of
their tumor. This is a striking fact. These infections were usually accompanied by fevers. This microbial
attack stimulated some powerful immune responses. The riled-up immune system then turned on and
destroyed a different kind of enemy, the tumor. It was as if an army had mobilized to fight one
adversary but continued marching to defeat a second, even more dangerous, foe.

Our own ingenious solutions to the cancer problem seem puny compared to the perfectly natural way
that the body sometimes gets rid of it. Why not learn from, and harness, this tremendous natural
force? For hundreds of years, the phenomenon of spontaneous remission has fascinated the greatest
minds in cancer, seeming to point the way out of a hopeless morass. In 1976, Warren Cole, MD, wrote
in a celebrated paper:

"After years of thought concerning the cause of this phenomenon [spontaneous regression], this
author is convinced that most of the cases are examples of development of an immunologic process,
and if we knew the explanation of the regression, we would be able to develop a method for regression
of many types of human cancer."

However, lately, there has been a disturbing trend: spontaneous remissions are becoming rarer. I
myself have seen but a few examples (and sometimes it is hard to distinguish those from "alternative
cures"). I knew a young woman who had such a fear of doctors that she left her breast cancer entirely
untreated. By the time she sought help, the tumor had ulcerated and spread. At one point, the tumor
became infected. What happened next was amazing. One day, while she was in the shower, the tumor
simply fell out of her chest, leaving a smooth scar.

Sadly, the tumor had already metastasized and, despite subsequent chemotherapy, she died of
metastatic disease. Nonetheless, it was a fascinating example of what might be the natural course of
some cases of this disease. I have seen a few other cases of partial spontaneous remission, such as
the disappearance of lung metastases when an affected kidney was removed.

In the article "Spontaneous regression," the authors attribute the decline in spontaneous remissions to
the modern "anti's": antiseptics and antibiotics and, I would add, antifever medications. These
ubiquitous drugs have certainly reduced the incidence of postoperative infections, much to the relief of
doctors and patients. Fevers and chills are soothed away by acetaminophen. An uncontrolled fever in a
cancer patient would be seen as a profound failure by the medical staff.

At the same time, modern treatments, especially radiation and chemotherapy, have decreased the
body's ability to mount a rip-roaring immune response if and when an infection does occur. So much
so that a recent review of the topic ended with the conclusion, "Immunotherapy applied to patients
with established tumors rarely leads to an objective response" (Forni 2000). This wasn't the opinion
fifty or one hundred years ago.

Some of the mysteries of medical history can be explained by the untutored activation of the immune
system, or the "vis medicatrix naturae," as the ancients called it. In 1742, for instance, the French
doctor H. F. Le Dran reported on a young patient who had an inoperable cancer of her left breast. The
tumor ulcerated and a gangrene infection developed. Within two days, the entire tumor sloughed off
with profuse bleeding and pus (suppuration). The wound healed in five weeks. Unfortunately, the
disease recurred, causing death eight months later.

In 1783, a Dr. V. Trnka described another patient with breast cancer who came down with malaria
(associated with chills, fever and sweating). The patient's tumor went into permanent remission within
a few weeks. A physician of the time stated: "This mortification could have been advantageous to the
patient, for it could, as we have seen sometimes, destroy the whole tumor, procuring a salutary
amputation [of the tumor] without pain."

Wonderful Toads

Because of these accidental infections, eighteenth-century physicians started to experiment with

deliberately induced infections and fevers. In 1768, G. White discussed in a letter "the wonderful
method of curing cancers by means of toads." A woman in Hungerford, England, he said, was treating
patients with breast cancer by applying a toad to the lesion until its death. (In many cultures, animals
such as guinea pigs or pigeons are applied to diseased parts of the body.) Some might consider this
"toad cure" the height of quackery. On the other hand, it is possible that the skin of the toad contains
some poisonous substances that might adversely affect cancer cells. Since the dead toad was affixed
to the breast lesion for several weeks by means of a poultice, it also provided an excellent breeding
ground for local infections.
One patient treated by this unorthodox method had been reduced to a "meer skeleton," we are told,
but had a regression of her metastatic lesions and was able to swallow once again with ease following
the "toad cure."

Other doctors in the eighteenth century deliberately applied dressings from wounds. Some surgeons
even encouraged the formation of infections in their incisions. Doctors of the time called this "laudable
pus." Today, this practice is ridiculed as a relic of bizarre and outlandish medical customs. But one
doctor of the time said, "I was often struck by the slowness with which [cancer] recurrence developed
in such cases. . .I asked myself if suppuration, in eliminating the traces of cancer which had escaped
the knife, did not play a role in delaying recurrence, and if therein lay the secret of success" (cited in
Hoption Cann 2002).

By the mid-nineteenth century it was widely accepted that leaving an infection in the surgical wound
after a cancer operation could actually benefit the patient. Stanislas Tanchou (the same doctor who
formulated the doctrine that cancer was a "disease of civilization") commented: "It is remarkable that.
. .gangrene [has] caused the largest number of cures. Gangrene may be considered as a therapeutic
agent, whether it occurs spontaneously or is induced medically."

When Sir Joseph Lister's methods of aseptic surgery gained ascendancy in the late nineteenth century,
however, these profound observations were forgotten. In addition, a fear of lawsuits made it all but
impossible to deliberately infect a patient with live bacteria. By the start of the twentieth century, this
crude sort of immunotherapy with live (and admittedly dangerous) bacteria was rejected as a relic of
pre-scientific medicine.

No one is suggesting that cancer patients today be deliberately infected with gangrene. However, there
is another option. Over one hundred years ago, a brave surgeon in New York City named William B.
Coley, MD, began a clinical experiment in the use of bacterial byproducts that still offers hope to
desperate cancer patients. In another article, I will tell the story of what happened to that most
promising treatment.

References

Cole WH. Relationship of causative factors in spontaneous regression of cancer to immunologic factors
possibly effective in cancer. J Surg Oncol 1976;8:391-411.

Forni G et al. Immunoprevention of cancer: is the time ripe? Cancer Res 2000;60:2571-5.

Hoption Cann SA et al. Spontaneous regression: a hidden treasure buried in time. Med Hypotheses
2002;58:115-9.

Le Dran F. Traité des opérations de chirurgie. Paris: C. Osmont, 1742.

Trnka V. History of remittent fevers. Vienna: Vidnobonae, 1783.

White G. Letter XVIII to Thomas Pennant, 27 July 1768. In: The Natural History of Selborne. London:
G. Routeledge and Sons, 1890:56.

Welcome to the Mind-Body Revolution

Mind and body are not at opposite spectrums in
controlling our actions. Welcome to the
consciousness revolution.
By: Marc Barasch

Evidence that the mind and body influence each other abounds, and suggests something much stranger: that
awareness isn't confined to the brain; it operates 'nonlocally,' beyond the biochemical lines between brain
and, say, the immune system. This consciousness revolution is rattling the very foundation of Western
medicine.

Anyone who didn't spend 1993 in a severely media-deprived locale—an Antarctic substation, say, or the
lazily pinwheeling Russian space-lab—has probably heard the news: Rene Descartes, the 17th century
mathematician who shaped the world as we know it, has been officially pronounced dead.

The eulogy was delivered by Bill Moyers, public television's own Piers Ploughman, via his phenomenally
successful TV series and book-cum-transcript, Healing and the Mind. But in truth, the old philosophe's stiff
—which had lain for three centuries in the halls of medicine like some glass-entombed Lenin—had become
a bit of an embarrassment.

Immortalized in Bartlett's for his inscrutable, Popeye-like declamation, "I think therefore I am," Descartes
was history's most persuasive partisan of the mind-body split, a bedrock notion of modern science. Mental
events, the savant declared, occur in a separate domain from those of the flesh. Consciousness has no
business in the mean streets of matter. As a result, medical science came to be dominated by a materialism
so iron-clad that one 19th century theorist felt emboldened to quip that the mind's influence upon the
mechanism of the body was like "the steam-whistle which accompanies the work of a locomotive engine
but cannot influence its machinery."

The problem with this is obvious to anyone who ever had an unseemly thought about their junior-high
English teacher and then blushed: "The soul's passions," said Aristotle, who had it right all along, "seem to
be linked with a body, as the body undergoes modifications in their presence."

By 1900, medical science had at least begun to suspect as much. Freud and Janet's investigations of
hysterical paralysis provided a benchmark of the mind's power over the body. Dr. Walter Cannon discovered
in the 1930s that the central nervous system controlled many bodily functions and suggested that it in turn
was subject to a regulatory mechanism "which in human beings we call the personality."

Still, if anyone could be credited with shutting off the refrigeration on Descartes' mortal remains and letting
the aroma of a paradigm gone bad reach science's stuffed nostrils, it is Candace Pert, Ph.D., former chief of
the Brain Biochemistry Section of the National Institute of Mental Health and co-discoverer of the brain's
opiate receptors. Subsequent revelations that similar docking sites for "information molecules" (or
neuropeptides) were myriad as stars scattered through the bodily firmament have launched the branch of
medicine known as psychoneuroimmunology (PNI), which is busy codifying a self-evident truth: Mind and
body have their hands so deep in each other's pockets it's hard to tell whose car keys are whose.

So-called messenger molecules are suddenly turning up everywhere—in the brain (particularly in the
centers governing emotion), throughout the immune system, and in organs from gut to gland. Our thoughts
and feelings are mediated by neuropeptides; diseases secrete neuropeptides; neuropeptides may be crucial to
the healing response. What Pert proved once and for all is that brain, nervous system, and immune system,
far from being incommunicado, are at this very second hunched elbow-to-elbow at the espresso bar of the
Chatterbox Cafe, animatedly sharing your most intimate particulars.

I met Pert four years ago when she was in town to speak at a healing conference. I was already well
apprised of the mind-body factor, having suffered a hellacious bout with cancer that was accompanied by
altered states more colorful than any I'd encountered in a lifetime of Buddhist meditation. Pert was just
beginning to venture forth from the autoclaved precincts of official research to more new-age venues, trying
out the PNI gospel on an audience more receptive than most of her colleagues. In her flowing orange floral-
print dress, slinging her pointer over her shoulder with precision rifle-drill panache, her words ricocheting in
breathless spurts, she was like some hip diva of science. The next day, recognizing a kindred glimmer, we
decided to play hooky from that afternoon's lectures for a picnic lunch in the mountains.

Though she may tone it down at phlegmier scientific gatherings, Pert at ease seems on the verge of
autoelectrocution from a surfeit of cranial wattage. "Emotions exist in two realms," she told me between
exclamations about the view from a dizzying curve that sent gravel rattling into our wheel rims. "One is the
mind. The other is the realm of living matter. Of course, science expects you to dutifully exclude the soul.
But I can't. The whole thing's vibrating back and forth. We're actually talking about music."

She hazarded that each neuropeptide, the first of which has burgeoned from five just a few years ago to over
five dozen, may "evoke a unique 'tone' that is equivalent to a mood state." I pictured mind and body as a
thousand-octave piano, with every note—from the highest glissando of altruism to the middle-C of fight-or-
flight to bass-heavy autonomic arpeggios—as part of a seamless, interdigitated boogie-woogie.

Staggering stuff: What PNI has shown us is that the human being is a walking biological Heisenberg
Principle, in which the observer's thoughts, feelings, and attitudes can have measurable effects on physical
reality. Within the margins of its homeostatic aloofness, the "It" of our own biology is exquisitely
responsive to the "I" of subjective experience.

And these responses are no mere grace notes. Hypnosis, long considered a negligible medical therapy, has
been successfully employed to treat children with congenital ichthyosis, so-called fishskin disease—a
genetic illness. Meditation and relaxation techniques have been shown to affect blood platelets,
norepinephrine receptors, and cortisol levels; biofeedback to influence phagocyte activity; mental imagery
to enhance natural killer cell function in patients with metastatic cancer. In a now famous study, David
Spiegel, M.D., of Stanford University showed that women with advanced breast cancer who took part in a
psychological support group lived twice as long as those who did not take part, a benefit no known drug can
claim.

Researchers are beginning to wonder if mind-body effects may even contribute to what physician-essayist
Lewis Thomas called "the rare but spectacular phenomenon" of spontaneous remission of cancer.
Researcher Caryle Hirshberg, Ph.D., a blunt, no-nonsense biochemist, is the coauthor of a near-legendary
study that collates some 450 medically documented cases. This startling body of evidence—the One White
Crow that disproves the thesis All Crows Are Black— suggests that such events, treated in most oncology
texts as chimerical (if not unreal as a paper moon), could point to yet-unsuspected powers of body and
mind.

When I spoke with her, Hirshberg, hammering on publication deadline, grumped only half-jokingly about
having to write her acknowledgments page. "What am I supposed to say?" she asks, referring to her peers'
initial skepticism. "Thanks for telling me not to even bother?" I mention a case the late Norman Cousins
recounted concerning a San Diego woman whose cancer was so far advanced the tumor was "like a hand
grenade under a thin sheathing of skin." The woman had been sent to his office at UCLA Medical School
because she was resisting her doctors' urgent recommendations for a mastectomy.
Cousins thought there would be no harm teaching her a few visualization techniques. He showed her a stock
mental exercise that usually succeeds in slightly raising the skin temperature of the hand. The woman turned
out to be an exceptional subject: Her hand temperature shot up 14 degrees. When she returned to the
hospital after two weeks of practicing various meditations, the tumor, to his amazement, had completely
disappeared.

"Who knows what mind is capable of?" Hirshberg asks rhetorically. "For that matter, who knows what
mind is? Certainly, it's thinking and feeling. But is mind only thinking, body only feeling? I mean, mind
feels. Mind is also dreams, mind is altered states, mind is consciousness, consciousness is spirit. It's not like
we scientists know.

"Maybe the Dalai Lama knows," she adds parenthetically. "I met him once, and I think if there's a light in
the world, he's it. I sometimes think the kind of understanding he has is where we'll have to go to look at
what we're calling PNI"

In a recent documentary, as sunlight streams in through the window from the icy, glittering peaks of the
nearby Himalayas, the Dalai Lama can be seen bending over a desk, one hand pressing a jeweler's loupe to
his eye, the other twirling a screwdriver in the entrails of an old-fashioned watch. "It is my nature," the
exiled leader is saying. "As soon as I got a playtoy ... few minutes later, I try to open ... see what is inside."
He giggles delightedly, holding the watch up for inspection, then turns shrewdly to the camera: "That's the
way to learn something." He laughs again.

Try to open. See what is inside. Now imagine a whole society turning its mental jeweler's tools in the
innards of the mind, investing 1,200 years in a top-priority, national Inner Space Program. For eras, while
the world blustered through the age of steam, spit electricity's cold fire in the face of the night, and
unleashed the railing demons of the atom, Tibetan followers of the Lord Buddha sat calmly by the flickering
light of millions of yak-butter lamps, calipering the depth and breath of the soul, doing essential R&D on
consciousness itself, souping up the spiritual software.

Westerners have viewed Tibetans as Mind-Body Masters on the World's Rooftop ever since French pilgrim
Alexandra David-Neel secretly entered Lhasa and returned bearing stories of monks sitting in the snow,
drying water-soaked sheets on their naked bodies (a feat she puckishly filed under "psychic sports"). More
than a decade ago, Harvard cardiologist Herbert Benson, M.D., best known for his best-seller, The
Relaxation Response, on the medical effects of meditation, decided to investigate.

With the Dalai Lama's blessing, he wired up monks in India's northern foothills with electronic measuring
devices while they performed their sheet-drying stunt. To his amazement, their skin temperature rose as
much as 17 degrees above normal, even though in such near-freezing weather the body invariably routes
blood from the periphery to keep core organs warm. "If an ordinary person were to try this," Benson says,
"they would shiver uncontrollably and perhaps even die. But here, within three to five minutes, the sheets
started to steam and within 45 minutes were completely dry."

How is such a feat possible? Benson offers that the yogis may have somehow learned to induce
"nonshivering thermogenesis," a metabolic state in which the body burns so-called brown fat—a substance
thought to be metabolized only in hibernating animals. But he adds, "It's difficult to understand from what
source such energy is emanating. By our calculations of the amount of heat generated, there must be an
energy source in the body other than the ones we're currently aware of."

Similarly, Candace Pert asked Moyers, "Can we account for all human phenomena in terms of chemicals? I
personally think we're going to have to bring in that extra-energy realm, the realm of spirit and soul that
Descartes kicked out of Western scientific thought."
And therein lies the rub. Today's mind-body theorists seem peering over the precipice of the world-view
espoused in the droll cat-and-cockroach classic, the lives and times of Archie and Mehitabel:

"I can show you love and hate and the future dreaming side by side in a cell in the little cells where matter
is so fine it merges into spirit."

The love-and-hate-and-cells stuff, which would have been difficult to swallow even a few years ago, is now
fair game for any PNI investigator clever enough to design a credible experiment. It's the matter-merging-
into-spirit part that's become an Olympic triple-axel skating routine on very thin ice.

"There's a great mystery of how thought is translated into material response, and PNI, even though it's the
darling of the emerging sciences, hasn't shed any light on it whatsoever," remarks Larry Dossey, M.D., co-
chairman of the Panel on Mind/Body Interventions at the National Institutes of Health (NIH).

Dossey's panel falls under the NIH Office of Alternative Medicine, a government entity that has appeared as
suddenly as an April crocus in the courtyard of the nation's firmest bastion of biomedical research. The
office's allotment of $2 million of the $10 billion NIH behemoth "the flea on the elephant, pen-and-pencil
money," says director Joseph Jacobs, M.D., the superbly trained half-Mohawk Indian health-care expert
tapped to helm what he calls "the Starship Enterprise"—could be used to study anything from acupuncture
to herbal medicine to the antitumoral properties of shark cartilage.

But it is Dossey's panel that promises to become the Enterprise's glowing, dilithium-crystal core, for its
mandate is to zero in on therapies—from hypnosis and biofeedback to exotica like therapeutic touch and
prayer—where the driving force of healing is Western philosophy's most debated (and science's most
derided) factor x—the human spirit.

Dossey, who grew up in a hardscrabble, King Cotton Texas prairie town where life revolved around a one-
room country church, seems undaunted. In his teens, he played gospel piano for a fiery tent-show evangelist
before leaving the farm for college and medical school, then served as a battalion surgeon in Vietnam. After
entering private practice, Dossey found himself reading works of Eastern and Western spirituality
"insatiably." He took up the practice of meditation, eventually writing a series of well-received books
exploring the intersection of medicine and mysticism.

A report of the Panel on Mind/Body Interventions, which Dossey coauthored, loses no time assailing the
trepid with the Really Big Questions: "What are mind and consciousness? How and where do they
originate? How are they related to the physical body? Why is it necessary to reintroduce mind and
consciousness into the modern medical agenda?"

"Let me tell you something," confides Dossey in soft, still-detectable Texas diphthongs. "If we ignore issues
of consciousness, it'll be the ruin of alternative medicine. It could wind up just being something used as
ruthlessly as synthetic drugs or stainless-steel scalpels. In my opinion, the most important research activity
in the entire field will be the investigation of nonlocal manifestations of consciousness."

Nonlocal manifestations of consciousness? Have we fallen off the edge of the map? The panel's report
explains that "studies in mental and spiritual healing show that the mind can somehow bring about changes
in far-away physical bodies, even when the distant person is shielded from all known sensory and
electromagnetic influences. These events, replicated by careful observers under laboratory conditions,
strongly suggest that there is some aspect of the psyche that is unconfinable to points in space, such as brain
or body, or to points in time, as in the present moment."

The eye comes to a screeching halt seeing such phrases laid out, neat as you please, in an official document
of the United States government. These are not the florid, metaphysical ramblings of a 19th-century
occultist, but the words whispered in the side corridors of the highest citadel of American rationalism: The
mind, it is rumored, has escaped the brain.

"These ideas do have a pretty high Boggle Factor," Dossey admits, but he claims the evidence is mounting.
He points to the work of William G. Brand, Ph.D., senior research associate at San Antonio's Mind Science
Foundation: In a typical experiment, one person—called the "influencer"—was placed in one room, while in
a different part of the building a "subject," fingers hooked up to electrodes to measure galvanic skin
response, settled into a chair. At randomly selected times, the influencer tried to affect the subject's
electrodermal response by, for example, visualizing the subject while repeating, "Relax ... relax...." Later
analysis showed that the subject's electrodermal responses had varied at the same time as the influencer's
thoughts, at a rate 43,000 to one against chance.

Another of Braud's studies posed the question of whether people could affect the rate of decay of human
blood cells in test tubes by thought alone. Red cells drawn from volunteers were placed in a solution with
low salt content, which normally would cause them to rupture. The volunteers were told to try to mentally
"protect" their own distant blood cells from harm. Astonishingly, measurements made with a computer-
linked spectrophotometer revealed that nearly a third of the participants had succeeded, seemingly, in
mentally slowing their blood cells' destruction. The odds here, gleaned from 64 separate sessions, were
nearly 200,000 to one.

Overall, Braud has performed more than 500 such experiments, all aimed at detecting the nonlocal influence
of consciousness—pure thought—on biological processes as diverse as the spatial orientation of fish, the
locomotor activity of small rodents, and the brain rhythms of people. Consciousness, he has concluded,
produces verifiable biological effects in distant human 'targets' as well as in bacteria, neurons, cancer cells,
enzymes, fungi, mobile algae, plants, protozoa, larvae, insects, chicks, gerbils, cats, and dogs. In human
subjects, these "telesomatic" effects occurred even when the target was unaware of the effort. "I very much
doubt that mobile algae," Dossey deadpans, "are susceptible to suggestion or the placebo effect."

It is doubtful that the majority of Dossey's colleagues will be susceptible to his suggestion: that the mind-
body revolution is leading inexorably toward a consciousness revolution—one so profound that some long-
cherished scientific truisms may have to be subsumed within a much larger, much stranger framework. The
heretical theses being nailed to the church door are unsettling: that mental forces can violate the laws of
physical causality; that the mind's influence on the body goes beyond the biochemical links between brain
and immune system posited by PNI; that there are things that mind can do that a physical brain could not.
What Dossey is talking about in a fairly unvarnished way is the science—or as some would have it, the
nonscience or nonsense—of parapsychology, a bastard-turned-prodigal child that may be on the verge of
claiming its share of the patrimony.

It's not as if it was ever entirely scratched out of the family portrait. William James, the father of American
psychology, spent 25 years examining psychic phenomena, spiritism, and religious experiences, producing a
radical empiricism that respectfully made room for altered states. Freud admitted that when it came to such
oddities as visions of the future, "attempts at giving a psychological explanation have been inadequate to
cover the material collected, however decidedly the sympathies of those of a scientific cast of mind may
incline against accepting such beliefs."

Jung, whose early work was influenced by F.W.H. Meyers, founder of the Society for Psychical Research,
conceived of the brain as simply a "transformer station": "In the deeper layers of the psyche which we call
the unconscious, there are things that cast doubt on the indispensable categories of our conscious world,
namely, time and space. The existence of telepathy is still denied only by positive ignoramuses."

But, we might ask ... so what? Say the human mind can work some inexplicable mojo on algae: It doesn't
mean you can sit in a chaise lounge and mentally skim the pool clear of pond scum. But proponents say the
implications are sweeping: They pertain to no less than the mind-brain connection, the mysteries of healing,
and the underpinnings of Western science itself.

In a single stroke, Dossey's panel has resurrected a bete noir, a bugaboo, a haint that experimental
reductionism has kept from haunting the premises for centuries: "the ghost in the machine" (as Oxford
philosopher Gilbert Ryle derisively called the notion of nonphysical selfhood)—a spook that, instead of
vaporously passing through walls, could eventually bash in the front door of The House That Science Built.

The question devolves on this: How does attitude influence the brain, and thence the body, in the first place?
In which vestibule of our gray matter, on what wetware coat hook, does the mind hang its hat? If, as Braud's
experiments suggest, the mind isn't quite "inside" the brain, can it take jaunts around the perimeter? And
what is that perimeter? What are the limits—and prerogatives—of consciousness?

This is far from the first time the question has come up. Every major religion claims to own and operate the
sole franchise. Every world-class philosophy has mud-wrestled with it. Any surgeon who ever unscrewed
the lid of the skull, peeled back the dura mater, and stared into the container of vanilla pudding said to
include all the ingredients of a human being has had at least one preposterous moment of awe—and utter
doubt.

Pioneering neurophysiologist Sir John Eccles, who won the 1963 Nobel Prize for his work on the synapse,
once commented that the hair-trigger sensitivity of the brain's intercellular connections suggests "a machine
designed to be operated by a ghost." Eccles proposed that the way that consciousness affected the brain
might be via psychokinesis (literally "soul-motion"), or the direct influence of thought upon matter. The
mind might be like a concert virtuoso tickling the ivories of the brain, performing "cognitive caresses" of
the cortical neurons. Fellow brain-mapper Wilder Penfield called it "the ultimate of ultimate problems." He
came to believe that "the dualist hypothesis (the mind is separate from the brain) seems the more reasonable
of explanations."

I recently attended a Harvard Medical School seminar on the frontiers of mind-body medicine. During the
question period, a doctor from Cambridge rose from the audience and described her cardiac arrest during
her own Cesarian section. She had had no heartbeat. Her eyes had been taped shut. Still, the obstetrician told
her rapt colleagues, "I could see everybody in the room, hear the swearing as they tried to revive me, just as
if I were standing at the head of the operating table."

"But I could see nothing was working. My brachial artery had narrowed too much to get a line through my
neck. Suddenly I saw the chairman of the department, whom I had never met, reach in and through my
abdomen and put his ungloved hand around my aorta. I felt a powerful surge of energy. He held my aorta in
this very firm and loving way until it started to beat again." Later, she said, every detail of this account was
confirmed by those who were present at her operation.

Michael B. Sabom, M.D., cardiologist and professor of medicine at Emory University, staff physician at the
Atlanta VA Medical Center, was skeptical of increasingly common accounts of such out-of-body
experiences, or OBEs. He set out to compare a group of heart-attack patients who had never had OBEs to
those who claimed that they had. He found, to his surprise, that those who had ostensibly experienced OBEs
were able to provide far more accurate descriptions of cardiac procedures, and that some were able to give
highly specific, verifiable details of their own particular resuscitations.

At end of his 1982 book, Recollections of Death: A Medical Investigation, he states, "If the human brain is
actually composed of two fundamental elements—the 'mind' and the 'brain'—then could the near-death
crisis even somehow trigger a transient splitting of the mind from the brain in many individuals? My own
beliefs are leaning in this direction. The out-of-body hypothesis simply seems to fit best with the data at
hand."
The NIH's Dossey told me, "How mind might operate beyond the physical brain is not comprehensible. But
the inconceivable has become commonplace in fields like quantum mechanics. With phenomena like the
instant, simultaneous change in the spin characteristics of photons separated by distances of light-years,
what I'm calling 'nonlocal mind' is right at home in modern physics. Physicists don't have a clue how things
in the quantum world can happen, but they don't question that they do. They honor the data."

Indeed, many theorists are looking to the brain-teasing, mind-twisting strange-but-true factoids of quantum
physics to provide at least provisional explanations for the mysteries of consciousness. Brian Josephson,
who won the Nobel Prize in 1973 for his work on quantum tunneling and superconductivity, has said that
evidence for apparent faster-than-light signaling in quantum physics "raises the possibility that one part of
the universe may have knowledge of another part—some kind of contact at a distance." Josephson suggests
that such interconnections could permit the operation of 'psi functioning' between humans, currently
anathema to biomedical science.

"The fact that nonlocal events are now studied by physicists in the microworld," the NIH report adds,
"suggests a greater permissiveness and freedom to examine phenomena in the biological and mental
domains that may possibly be analogous."

That, according to renowned neurobiologist Gerald Edelman, M.D., is nothing but a load of Mandrake the
Magician-class hooey. Edelman and colleagues at Rockefeller University's Neurosciences Institutes are
working assiduously on a purely biological theory of how "higher-order consciousness" could be produced
in the brain through a reflexive "bootstrapping process" of its own neuronal circuitry.

Edelman, who once planned a career as a concert violinist, sees the mind as an emergent property of brain
tissue-"an orchestra without a conductor, an orchestra which makes its own music," in the approving
summation of fellow neurologist Oliver Sacks, M.D. "To attempt to explain aspects of consciousness using
as-yet-undiscovered physical fields or dimensions," Edelman comments acerbically, "is a bit like a
schoolboy who, not knowing the formula of sulfuric acid asked for on an exam, gives instead a beautiful
account of his dog Spot."

"Some very good physicists," he adds, "have reached beyond the biological facts and have supposed that
[the quantum is] the answer to the riddle of consciousness. This is an off-putting way of proposing physics
as a surrogate spook."

Michael Scriven, Ph.D., a philosopher of science who can recall with relish the occasion when, barely more
than a graduate schoolboy himself, he argued with Einstein over "whether time could be closed as well as
space," finds such dismissals a little glib. "I'm a little irked," he says in his crisp Down Under accent, "about
mainstream scientists' knee-jerk reactions to strangeness, as if kangaroos can't be real because they've never
seen one themselves. It's pathetic to hear Nobel-Prize winners acting like children seeing a ghost at night."

Scriven, who has been around the scientific block (he worked for the NIH in the forties and in the fifties
served on the board of the Journal of Mental and Nervous Diseases), is a member of a loosely affiliated
group of thinkers who are trying to come up with less reductionist solutions to the conundrums of
consciousness. He refers to himself as the "Guardian at the Logical Gates" for the group (dubbed the
Causality Project and sponsored by the same Fetzer Foundation that funded the Moyers series.)

"But it's also wrong to say," he hastens to add, "that just because there's something parapsychological out
there, everything we know must crumble. The basis of science is so well founded, so built up layer upon
layer, that this stuff is no more than a little crack at the edges of some very old, very solid monuments."

Others think, however, that the cracks could widen into a serious structural flaw. Consider Spiegel's
Stanford study, where women with advanced breast disease who attended a psychological support group
lived twice as long as those who didn't attend. Suppose an anticancer drug were undergoing trials, and the
experimental group, unbeknownst to the experimenters, contained a disproportionate number of patients
who were also in group therapy. Longer survival rates might not have to do entirely with the efficacy of the
pharmaceutical, but with the patients' state of mind. Thus, even carefully designed experiments could be
hopelessly, invisibly skewed.

This would be what Larry Dossey calls a "local" effect of consciousness, the stuff of PNI: a person's
attitudes, emotions, and thoughts can have effects on their bodies. But Dossey and the Panel on Mind/Body
Interventions go yet further, pointing to evidence suggestive of "non-local" effects: that the body may be
"influenced by events occurring at a distance from the patient and outside his or her awareness."

If this is true, it could topple the tallest spire on the cathedral of science—the double-blind experiment.
Science works by accounting for—and controlling—every variable and influence that could conceivably
affect an experimental outcome. What if there are factors that must be taken into account that have
heretofore been ruled out as theoretically impossible? For all we know, Dossey says, outcomes could be
influenced "by people outside the experimental arena, like well-wishing friends or praying kinfolk. When
we look back on our present era, I think we're going to be astonished how naive we were, that we actually
believed we could isolate people in such a way that the influence of consciousness could be annulled."

Under his prodding, the NIH's Panel on Mind/Body Interventions has sandwiched into its report a daring
call for a Task Force on the Nature of Consciousness, to comprise representatives from every discipline:
psychologists, neurophysiologists, artificial intelligence experts, physicists, physicians, and philosophers.
Similarly, the professionally variegated Causality Project has already been meeting for years, aiming for
nothing less than a new paradigm of science. Other enclaves—with exotic names like the Bay Area
Consciousness Group, the Princeton Engineering Anomalies Research lab (PEAR), and Temple University's
Center for Frontier Sciences—are already pins in the sketchy map of a brave new world.

A project is even underway to create an internationally affiliated group of first-class "Consciousness

Research Laboratories" that would exchange data and provide replication of each other's work. All the
baroque-sounding formulations that have sparked centuries of philosophical wrangling—Descartes' "radical
dualism," Leibniz's "psychophysical parallelism," Spencer's "mindstuff theory"—may soon move from the
Victorian armchair to the cyclotron, the petri dish, the electron-tunneling microscope.

But what species of researcher is going to risk grants, tenure, and professional repute by venturing out into
the night with a high-tech jelly-jar to try to capture a flitting, hypothetical psychic quark? Typical of a new
breed of what might be called experiential experimentalists, biophysicist Beverly Rubik, Ph.D., director of
Temple University's Center for Frontier Sciences, has logged time on a Zen meditation cushion and also
taught for three years at an institute run by Catholic mystic Father Matthew Fox. Rubik, a well-regarded
hard scientist, recently attended a White House meeting on health care in her capacity as advisor to the NIH
Office of Alternative Medicine, where she heads a panel on electromagnetic interventions." The panel will
examine everything from electrical therapies used to accelerate bone healing to a "neurobiochemical
stimulator" (which, she says, "has created profound changes in animals' brain chemistry and moods"). Her
passion, she says, is "how energy fields maybe including a nonlocal field of consciousness itself—interact
with life."

Like a number of her Causality Project colleagues, Rubik feels her various spiritual sojourns have given her
an inside track on the mind-brain puzzle. Her accounting makes it sound as if Descartes, last seen at his
recent, merciful public interment, may yet shake off the clods of soil to meander among the scientific living.
"I agree Cartesianism is dreadful," she muses "but there is something immaterial about who we are. Maybe
we'll need to go back to Eastern mystical concepts like an 'etheric' or 'astral' energy domain."
Clearly, these ideas—particularly as they emerge from the belly of what looks suspiciously like a new-age
Trojan Horse wheeled in sometime around the dawn of Aquarius—will irritate some sensibilities. "Media
Blitz for Mind/Body Malarkey" blared a recent headline in a scientific-muckraking newsletter called Probe.
The article took aim at what it held to be the moonier aspects of Moyers' TV series, which it called
"seductively anti-medical, anti-scientific, and anti-rational." Its claim that "a campaign has been launched to
radically change and spiritualize America's science-based medicine" received wide press coverage.

"It's not as if anyone's saying science is completely wrong," counters Beverly Rubik. "Conventional science
is appropriate within a conventional framework. But there can be other sciences which exist outside of that
box. We need multiple ways of inquiry that accord with—and I realize this will sound odd—our levels of
being. Our usual practice of science is based on the lowest common denominator of human consciousness:
of feeling separated from the rest of universe.

"What's missing," she says, "is attention to the inner state of the investigator. We've been pretending we're
neutral, playing dead, putting our feet in concrete shoes and saying we can't jump. It's time to try on some
different footwear."

One Causality Project member told me, "the study of consciousness may require scientists who are willing
to risk being transformed in the process of observation." Fetzer Foundation president, Robert Lehman,
concurs: "We'll need investigators who can work more according to an old medieval notion: that to observe
nature's deeper secrets, you must personally strive to create 'eyes to see, ears to hear.'"

The Buddhist monks whose meditations raise their skin temperatures are not just performing a stunning
biofeedback experiment but are, they tell us, practicing an inner science of compassion. The purpose of their
inquiries into the body's most arcane chemistries is to transcend divisions between self and other, subject
and object dualities that one Buddhist translation refers to as "primitive beliefs about reality." Similarly,
physicists at Princeton's PEAR lab, whose experiments seem to indicate that mind may affect subatomic
particles, have concluded there is now "a need on the part of science to soften the boundary between 'I' and
'not I.'"

The Buddhist monks, and increasingly some adventurous physicists, biologists, and doctors, represent a
radical new model of science, one that does not posit inviolable distinctions between spirit and matter,
perceiver and perceived. The new paradigm may well deem any models of reality that deny the
intersubjectivity of existence to be fundamentally unscientific.

The glory of science has always been its commitment to "follow the data" on a quest for the unadorned,
replicable, verifiable truth. But what if the data have begun leading us to a truth more marvelous than we, in
our scientific "reality" of isolated egos, dead physical nature, and decoupled mind and body, have imagined?

Here at the close of the second millennium, sometime between the world-fragmenting fall from Babel and
the Last Trump, we search for a unifying Theory of Everything, still ignorant—in some ways, willfully—of
where we ourselves fit into the astonishing world of cells, particles, and parsecs we have discovered. Too
often, perhaps, our measure of mind, body, and nature has been a little like pre-Columbian maps of a flat
Earth: cutting off boundaries at the visible horizon, ignoring the Mercator projections of the soul,
consigning the psyche's deeps and expanses to "Here Lie Dragons."

Medicine, once the crown jewel of reductionist scientism, has improbably opened up an unexpected vista.
Its newly discovered mind-body pathways are leading to the largely unexplored terrain of the human spirit.
We seem to suddenly be on the cusp of a moment foreseen by Claude Bernard, the founder of modern
physiology: "I have conviction," he wrote, "that when Physiology will be far enough advanced, the poet, the
philosopher, and the physiologist will all understand each other." Surely, the late Buckminster Fuller—
syncretic thinker extraordinaire—would have understood. Asked where a proper investigation of the human
condition should commence, he answered without hesitation: "You start with the universe."

Taramul dragonilor – abordarea de teme la frontiera stiintei, al caror impact ar fi mare

“ Lumea Noua”

Psychology Today Magazine, Jul/Aug 1993

Last Reviewed 17 Apr 2006

Psychology and Medicine: Working Together to Unlock the Puzzle

The implications for physicians and psychologists of the interrelationship of body and mind were discussed in a recent
workshop sponsored by Pearson entitled �Medical Psychology: The Newest Frontier in Practice Development.�
Brent Van Dorsten, PhD, John Brendel, MD, and other workshop presenters explained the role of psychology in
medical settings and provided participants with information about tools specifically designed for medical patients.

Consider these statistics and how they might apply to a medical patient population:

• Nearly 10% of U.S. adults meet the criteria for a DSM™ diagnosis of depression and more than 18% meet
the criteria for a DSM diagnosis of anxiety in any given 12-month period.1
• Patients with psychological disorders consistently use medical services more than those without such
disorders.2, 3, 4
• 80% of all physician visits are for a pain complaint.5
• 40�50% of patients with pain disorders also have diagnosable anxiety.6,7

A challenge for primary care physicians

Van Dorsten explained the considerable challenge primary care physicians face in accurately diagnosing
psychological issues. Patients often visit their primary care physicians with complaints that may mask a depression
diagnosis. For example, Van Dorsten mentioned a high symptom concordance between medically diagnosable
depression and many medical conditions, including appetite or weight changes, poor sleep, lethargy, reduced libido,
optimism or activity.8, 9

Even though 80% of all visits to a physician are for a pain complaint, the average primary care physician receives 2
hours or less each year of residency training in pain management—and much of this focuses on medications for
treating pain.10 Up to 80% of those patients presenting with back pain will have no abnormal findings on diagnostic
testing11, thus increasing the number of referrals for conservative management and behavioral care.

Implications for physicians

Patients with misdiagnosed or undiagnosed depression are at a disadvantage when physicians attempt to treat their
medical condition. According to Van Dorsten, medical patients with depression are likely to:

• use more medication but are less likely to adhere to instructions than patients without depression12, 13, 14, 15
• have impaired rehabilitation16
• terminate their treatment plan early17

Depression and/or anxiety are also associated with unhealthy lifestyle behaviors such as smoking, inadequate
exercise, and alcohol use.18 Additionally, patients with anxiety often do not comprehend all the information provided to
them during a medical visit. Up to half of such information may be lost on anxious patients.19

Van Dorsten presented several other psychosocial threats to medical treatment outcome, then discussed pros and
cons of different testing strategies when using psychometric testing in a clinical practice. For example, he mentioned
that several measures are sensitive but not specific, often resulting in over-diagnoses. Van Dorsten briefly discussed
the various psychological assessments that are commonly used specifically for chronic pain patients, noting that when
the tests used are normed on medical patients and the number of subscales is limited, the test is more useful to
medical practitioners.

Brief assessments designed for medical patients are available

Van Dorsten said that some brief assessments, such as the BBHI™ 2 (Brief Battery for Health Improvement 2) or P-
3® (Pain Patient Profile) test (see sidebar) are inexpensive, normed against medical patients, and address the most
prevalent psychological issues with medical patients�depression, anxiety and somatization. He said these
assessments can also inform the physician when more in-depth evaluation is needed and are easy to use for
retesting to collect outcomes data.

A pain practitioner�s perspective on psychological testing

�Psychological assessment in pain medicine is the key to success,� says pain specialist John K. Brendel, MD.
Brendel routinely administers a brief assessment to all his patients whom he considers candidates for a certain
procedure. He believes doing this helps him run a more efficient practice and helps him be a better doctor.

His workshop presentation provided the basics of what physicians may achieve from testing, including:

1. patient mental health status in a doctor-friendly format

2. the patient�s perceived disability
3. a patient�s hidden agenda
4. a comprehensive baseline from which to measure the treatment plan
5. some ability to predict less than desirable outcomes at the outset
6. a guide to promote discussion with the patient that �it�s not in your head�
7. pain scores at different locations of the patient�s body

Brendel administers brief assessments in his office using a computerized handheld tablet that enables him to read the
results before meeting with the patient in the exam room. He also teams with psychologists when his patients� initial
assessment calls for more thorough psychological evaluation.

He suggests physicians explain to patients how their mental health affects their pain perception and how the
assessment is used to better treat the entire pain problem. He also suggests that a patient�s first appointment with a
psychologist be made by the physician�s office staff�he says patients are more likely to keep this appointment than
make an initial appointment themselves.

Brendel further recommends that physicians not proceed with diagnostic modalities, surgery or interventional
treatments until patient readiness has been achieved. He notes that when physicians leave patient �red flags�
untended to, the result is generally a �bad marriage� or poor outcomes.

In addition, Brendel uses psychological assessments to help measure treatment outcomes. He says that his ability to
provide outcome data on his practice improves his probabilities of receiving payment from insurance companies. He
also says reporting his outcomes forces greater transparency of his practice, and in turn, both he and his staff provide
their patients improved care. Brendel says physicians who measure outcomes can also use the data to educate their
colleagues and raise their status among their peers.

Brendel justifies his practice of using psychological testing by referring to research that indicates that patients free of
psychological problems are more likely to benefit from surgery. For example, Schofferman, et al., published an article
in Spine in 1992 that says 95% of injured adults who were not abused as children do benefit from surgery, but only
15% of injured adults who were abused as children benefit from surgery. Brendel wants to know at the start of a
relationship with a patient if there are any psychological issues that may impede the patient�s recovery. The
information helps him to provide better patient care and achieve better outcomes.

Brendel suggests other physicians consider the value psychological assessments can provide them, including
improved patient communication, more appropriate treatment, and the opportunity to measure treatment outcomes.
He is among the many physicians who recognize that psychological factors do influence a patient�s recovery and
have learned that the use of psychological assessments can help them solve their more puzzling patient problems
and, in turn, help them provide improved patient care.
P-3® (Pain Patient Profile)

When research showed that depression, anxiety and somatization are the factors most relevant to pain patients, C.
David Tollison, PhD, and Jerry C. Langley, DC, developed the P-3 (Pain Patient Profile) to address these issues.
Tollison presented training on the P-3 test at the recent medical psychology workshop sponsored by Pearson.

The P-3 test is a simple, straightforward instrument with only three scales to address these key factors, along with a
validity index. It was written specifically for use by a variety of medical practitioners and is normed on both pain
patients and community samples. This brief and inexpensive tool offers several administration and scoring options,
including a handheld tablet that provides immediate reports while the patient sits in the doctor�s waiting room.

Brent Van Dorsten, PhD, is an associate professor and behavioral medicine specialist at the University of Colorado
Health Sciences Center in the departments of rehabilitation medicine and anesthesiology pain management service.

John Brendel, MD, is a board-certified anesthesiologist with a subspecialty in pain medicine, practicing in Rice Lake,
WI. Both continue to offer their knowledge and expertise at various presentation opportunities, including a workshop
at the 2006 California Psychological Association annual convention.

References

1. Kessler, R.C., Wat Tat Chiu, A.M., Demler, O., & Walters, E.E. (2005). Prevalence, severity, and co-morbidity
of 12-month DSM-IV disorders in the National Co-morbidity Survey Replication. Archives of General
Psychiatry, 62, 617�627.
2. Barsky, A.J., Orav, E.J., & Bates, D.W. (2005). Somatization increases medical utilization and costs
independent of psychiatric and medical comorbidity. Archives of General Psychiatry, 62, 903�910.
3. O�Donohue, W. & Cucciare, M.A. (2005). The role of psychological factors in medical presentations. Journal
of Clinical Psychology in Medical Settings, 12, 71�77.
4. Sansone, R.A., Sansone, L.A. & Widerman, M.W. (1996). Borderline personality disorder and health care
utilization in a primary care setting. Southern Medical Journal, 89, 1367�1372.
5. Gatchel, R., & Turk, D. (1996). Psychological Approaches to Pain Management: A Practitioner�s Handbook.
New York: Guilford Press.
6. Gatchel, R. & Young, M. (2005). Premorbid and comorbid personality traits associated with chronic pain
disability. Presented at 11th World Congress on Pain, International Association for the Study of Pain, Sydney,
Australia.
7. Reid, M.D., Engles-Horton, L.L., Weber, M.B., Kerns, R.D., Fogers, E.L., & O�Connor, P.G. (2002). Use of
opioid medications for chronic noncancer pain syndromes in primary care. Journal of General Internal
Medicine, 17. 173�179.
8. Boyd, J.H., & Weisman, M.M. (1986). Epidemiology. In E.S. Payke (Ed.), Handbook of Affective Disorders.
New York: Guilford Press.
9. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (1994). Washington DC: American Psychiatric
Association.
10. Van Dorsten, B., Dingmann, C., Brewer, A., Bridgewater, J., Davies, H.R., & Benchekroun, S. (August, 2005).
A re-assessment of pain education in primary care residency in the United States. Presented at 11th World
Congress on Pain, International Association for the Study of Pain, Sydney, Australia.
11. Deyo, R.A. (1986). The early diagnostic evaluation of patients with low back pain. Journal of General Internal
Medicine, 1. 328-335.
12. Bane, C., Hughes, C.M., & McElnay, J.C. (in press). The impact of depressive symptoms and psychosocial
factors on medication adherence in cardiovascular disease. Patient Education and Counseling.
13. Cramer, J.A., & Rosenheck, R. (1998). Compliance with medication regimens for mental and physical
disorders. Psychiatric Services, 49, 196�201.
14. DiMatteo, M.R., Lepper, H.S., & Croghan, T.W. (2000). Depression is a risk factor for non�compliance with
medical treatment: meta-analysis of effects of anxiety and depression on patient adherence. Archives of
Internal Medicine, 160, 2101�2107.
15. Gehi, A., Hass, D., Pipkin, S., & Whooley, M.A. (2005). Depression and medication adherence in outpatients
with coronary heart disease. Archives of Internal Medicine, 165, 2508�2513.
 16. Frank, R.G., Elliott, T., Corcoran, J., & Wonderlich, S. (1987). Depression following spinal cord injury: Is it
necessary? Clinical Psychology Review, 7, 611�630.
17. Painter, J.R., Seres, J.L. & Newman, R.I. (1980). Assessing the benefits of the pain center: Why some
patients regress. Pain, 8, 101�113.
18. Niles, B.L., Mori, D.L., Lambert, J.F. & Wolf, E.J. (2005). Depression in primary care: Comorbid disorders and
related problems. Journal of Clinical Psychology in Medical Settings, 12, 71�77.
19. Belar, C.D. & Deardorff, W.W. (1995). Clinical Health Psychology in Medical Settings. Washington, DC:
American Psychological Association.

--------------------------------------------------------------------------------------------------------------------------------------------

Barsky AJ, Orav EJ, Bates DW: Somatization increases medical utilization and costs independent of
psychiatric and medical comorbidity.
Arch Gen Psychiatry 2005; 62: 903– 910. an estimated USD 256 billion a year in medical care costs are
attributable to the incremental effect of somatization alone. CONCLUSIONS: Patients with somatization had
approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of
nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively
little effect on this association.

Somatoform disorders in neurological practice. Medical comorbidity

Current Opinion in Psychiatry. 19(4):413-420, July 2006.
Allet, J Lindsay a,b; Allet, Rachel E c

Abstract:
Purpose of review: Patients with medically unexplained symptoms continue to intrigue, fascinate and frustrate
clinicians. They are common in general medicine and often present with apparent neurological disorder. This review
aims to provide insight into the recent literature that has sought to clarify epidemiology, diagnostic issues, aetiologic
understanding and treatment of patients with psychogenic disorders who usually first present to neurologists.

Recent findings: Somatoform disorders are common in neurological practice. A number of papers have addressed
issues of epidemiology and identified that medically unexplained symptoms in neurological populations are higher
than originally thought. A number of recent review papers have served to summarize areas of considerable
information (e.g. treatments) and areas of rapid growth in knowledge (e.g. neuroimaging). Studies investigating the
role of psychological factors are well represented and clarify our psychopathological understanding of somatoform
disorders in patients presenting to neurologists. Treatment studies are few and continue to be limited by population
sizes and study designs.

Summary: Somatoform disorders are common in neurological populations. Comorbidity related to somatoform
disorders with known organic neurological conditions requires further study. On account of the limitations of treatment
studies, evidence-based clinical management of these patients is awaited.

(C) 2006 Lippincott Williams & Wilkins, Inc.

Psychosomatics 42:94-99, April 2001

© 2001 The Academy of Psychosomatic Medicine

In Memoriam

George L. Engel, M.D., 1913–1999

Remembering His Life and Work; Rediscovering His Soul

Peter A. Engel, M.D.

Received June 29, 2000; revised October 18, 2000; accepted October 20, 2000. From the VA Medical Center, Albany, NY, and
The Department of Medicine, Albany Medical College. Address correspondence to Dr. Peter Engle, Geriatrics and Extended
Care, VA Medical Center, Albany, NY 12208; email: Peter.Engel@med.va.gov
Key Words: Engel, GL • Biopsychosocial Model • Illusory Memory

George Engel gave and received much from a nurturing community of family, colleagues, friends, students,
fellows, and patients. His marriage to Evelyn of nearly 60 years was one of boundless love and continuing
discovery. His life and contributions grew from the human bonds he recognized as so important to the
diagnosis, healing, and comforting of others.

My father had an extraordinary intellect, intense curiosity and a creative disregard for the conventional
boundaries of scientific thinking. I admired him for this, but more importantly, in his last years I found a
growing love between us as father and son. As he became more openly affectionate, I recognized that his
compassionate nature directed the intellectual passions of an extraordinarily productive academic career. My
father's death on November 26, 1999, severed the bond between us. But within days of his death I had an
experience that would have intrigued and pleased him. I came to believe that I had been with my father when
he died. This vivid, detailed memory, in fact, is illusory. I was home at the time more than 200 miles away,
but I am completely unpersuaded by this verifiable fact. The sorrow of this memory is sweet and intense,
and the bond, though severed, feels stronger than ever.

I would like to honor my father's memory using two perspectives: first, a biographical account of his life,
and second, an examination of my illusory memory and its implications. My father learned much about
human behavior through self-observation and reflection on his inner life. Here, in the connections between
father and son, is an opportunity to examine the phenomenologies of grief and memory, to consider the
concept of the soul, and to relate all three to my father's work. My father would be pleased if these musings
suggested new perspectives from which to understand illness and disease and a better means to care for and
about patients. These were the passions of his soul.

The Biography

George Engel was raised in New York City, attended Dartmouth College, graduated from Johns Hopkins
Medical School in 1938, and completed a 2 year rotating internship at Mount Sinai Hospital in New York.
In 1941, while a Fellow in Medicine at the Peter Bent Brigham Hospital in Boston, he met John Romano,
who recruited him to the University of Cincinnati and then to Rochester in 1946. There he received dual
appointments in the Departments of Medicine and Psychiatry. Dr. Engel completed training at the Institute
for Psychoanalysis in Chicago in 1955. Although he formally retired in 1979, he continued to teach, write,
and travel for nearly 20 more years.

From his initial pioneering work with Romano on the clinical and electroencephalographic aspects of
delirium, Dr. Engel's scholarship and research broadened into explorations of psychogenic pain, fainting,
ulcerative colitis, psychosomatic medicine, psychoanalysis, psychophysiological aspects of human behavior,
human development, medical education, and the biopsychosocial model. His scholarly work occurred
largely in the context of his long and distinguished career as a teacher and physician. In 1946 he launched
the introductory psychiatry course for second-year medical students. Over the years this course evolved into
a curriculum and later a book, Psychological Development in Health and Disease. The same year he and
Romano introduced the Medical Psychiatry Liaison Fellowship. Dr. Engel directed this program for 33
years, during which time he mentored more than 150 fellows.

George Engel became widely known as an innovative thinker, lucid scientific writer, and an outstanding
teacher. His most effective teaching evolved from the General Medical Clerkship at Strong Memorial
Hospital. It was in this setting that he and his colleagues demonstrated the extraordinary power of the
interview as a diagnostic and therapeutic instrument. The General Medical Clerkship became a signature of
the Rochester experience that placed the patient rather than the disease at the center of medical education. In
countless teaching interviews, Dr. Engel displayed his vibrant curiosity, his depth of caring for others, and
his keen observational abilities. Dr. Engel often brought unique insights to a clinical situation that no one
recognized but, once revealed, made sense to everyone.

Since the 1950s Dr. Engel recognized that the prevailing biomedical model of disease left no room for the
social, psychological, and behavioral dimensions of illness. As his thinking evolved he proposed an
alternative biopsychosocial model in a seminal 1977 article in the journal Science.1 Here was a new
framework for patient care, teaching, and research. At its core is the application of disciplined scientific
investigation to the human domain of illness and disease. The value of the biopsychosocial model is now
widely recognized and its impact is reflected in increased attention to interviewing skills at medical schools
around the country.

In his later years, with a gentling of his intellect, he became more openly affectionate and tender, now ready
to accept the help he needed. He was no less witty, mischievous, optimistic or kind. His integrity remained
exemplary; his pleasure in sharing his roses, doodles, and mementos continued. He was no less inquisitive
and maintained a remarkable capacity for self observation. "Why," he asked in his last year, "do
ophthalmologists test vision only with stationary targets when it is moving targets that I can't see?" But my
father saw perfectly well the love and community at the foundation of medicine. Being scientific in this
human domain, he knew, would generate new insights into the nature of disease and the human condition
and would strengthen our capacity to help others.

FIGURE 1. George and Evelyn Engel in the 50th year of their marriage,
1988

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The Illusory Memory

Although best known for his biopsychosocial model, my father devoted much of his scientific career to the
investigation of human relationships in the context of health, disease, and loss. My experience with my
father's death, an intensely personal loss, reifies much of his work. The illusory memory occurred in the
context of this loss, 3 days after his death while I was dressing in my bedroom. Its intensity and reality were
astonishing and the context notable because I had been in this room when I first learned that he had died. In
reflecting on this memory and using the method my father taught I have been able to discover its meaning
and, in the larger sense, to embrace his memory.

Before dawn on the morning of November 26, the day after Thanksgiving, my father called me to his
bedroom. He was in his larger old apartment at the Highlands, not the cramped assisted-living unit he had
occupied for the last 8 months. I walked from the study across the hall to his bedroom where he was in bed
to my right, surrounded by my mother's paintings and family photos. Facing him, I sat on the bed and
embraced him. I told him how much I loved him. He told me that he loved me and was proud of me. Then
life took leave of him, leaving me in sorrow and wonder at the privilege of the moment.

The visual and emotional elements of this memory are vivid and intense, whereas our communication
seemed more a sequence of thoughts than a conversation. At the moment of his death the narrative stopped,
suspended here; nothing further needed to happen. In its flaws and distortions the memory is immensely
comforting, and the strong sense of being with him remains.

This memory includes two feeling states that are intellectually contradictory but emotionally compatible: the
belief that these events occurred and the sense of knowing that they did not. My experience is comparable to
those of bereaved survivors who commonly see, hear, or sense the presence of the deceased.2–4 These
hallucinations and a certainty that the person is no longer alive occur simultaneously. Largely unexplored
are the personal meaning of these sensory phenomena and the association of illusory memories with grief.

In his last publication my father offered a conceptual background in which to study and understand human
illness and disease that is similarly applicable in the exploration of illusory memories as a phenomenon of
grief.

As a profession and as an institution, medicine owes its origin to three distinctively human attributes. First,
we humans are aware of death and its inevitability and realize that feeling and/or looking bad ("sick") may
be its portent. Second, we suffer when our interpersonal bonds are sundered and feel solace when they are
reestablished. Third, we are capable of examining our own inner life and experience and of communicating
such to others via a spoken and written language. Critical for all three and for the work of the physician is
the distinctively human capability of using words to communicate both what is being observed in the outer
world and what is being experienced within the inner world.... Surely, as scientists dedicated to organizing
our experiences and formulating observation, we should be careful to define science in such a way as to be
able to include verbal reporting as legitimate data.5

Using the illusory memory as legitimate data of my inner world, let us see where this leads.

Each element of this memory is derived from my life experiences. In my dad's last 2 years I held him many
times. I told him I loved him with nearly every phone call. He said the same to me. Several times he said he
was proud of me. During my last visit to his old apartment, I went to his bedroom, held him, and kissed him
good night. Each of these events bears a common emotional tone.

Other fragments of the memory are drawn from my work as a physician. Twice I was at the side of a patient
at the moment of death. The first patient, a youthful man in his forties with a high-grade glioma died while
we were visiting him on rounds. The second patient, a man in his early fifties with metastatic prostate
cancer, told me that his unwelcome assignment was "to die with dignity." To this task he brought an
exemplary vitality and wit. He died while I was standing arm and arm with his family, his nurse, and the
hospital chaplain. At this moment I sensed that the organizing, life-force was taking its leave and
presumably going elsewhere, a notion the chaplain endorsed as he spoke of the spirit and soul.
Common to every element of this illusory memory is the sense of caring and connection combined with a
feeling of loss and re-connection. When my father died, these collective experiences, times, and contexts
reassembled themselves into a new coherent memory composed of vivid images and intense feeling.

By ignoring conventional boundaries between emotion and cognition, my experience of normal grief
becomes an opportunity to explore the significance of false memories in the context of human relationships.
It was these relationships that were so important to my father and essential to his work in the human domain
of illness.

Most information on illusory memory and false recognition is derived from formal experimental paradigms
employing list learning and word or object recognition. In these studies false recognition is common. It is
accentuated by right frontal lobe injury and aging and is frequently accompanied by a sense of
"remembering" earlier exposure to items actually presented for the first time. Corresponding dynamic
imaging and neurophysiologic studies demonstrate increased frontal lobe activity during recognition tasks,
particularly in the right anterior prefrontal cortex, with both correct and illusory responses, an effect that is
attenuated with age. These studies implicate the right prefrontal cortex in restructuring the general context of
an event and in rejecting irrelevant information.6–9

Delusional misidentifications and memories are also described in individual patients with frontal lobe
injuries, but few reports include the patient's personal observations and beliefs about their own delusions.10–12
One unemployed man woke each morning convinced that he must prepare for work, was persuaded
otherwise by factual evidence only to repeat the error again the next day. He had suffered frontal injury
during an anterior communicating artery aneurysm repair. In this example, an emotionally significant
generic memory intruded into consciousness presumably unregulated by normal frontal systems
inhibitions.12 In my case the organizing force that reassembled a series of emotionally significant events is
the continuing sense of connection with my father. This intrusive illusory memory emerged uncensored or
perhaps selectively choreographed by the right anterior prefrontal cortex.

Illusory memories, misperceptions, and misattributions are sufficiently common that I had little difficulty
finding another example from my father's own writings.

Reflecting on the death of his identical twin, Frank in 1963, my father recounts his attendance at a meeting
of the American College of Physicians 5 years later. A passer-by greeted him "Hi Frank," to which he
responded without a second thought.

Only a few minutes later did I realize with amazement that I had been greeted as Frank and yet felt no
surprise. But the setting was important....The occasion for my attendance at that meeting was to receive an
award, the perfect setting to play out our rivalry. Clearly my wish that he could share (and be put down) by
my success was intense enough that for the moment at least I accepted the stranger's error as if Frank were
indeed still alive.13

Both his transient delusion and my illusory memory accurately reiterate the emotional fidelity of important
human relationships at the expense of temporal and spatial accuracy. Equally important, as my father has
emphasized for more than 40 years, is reliable access to data of this type, which is readily available to a
curious and caring observer.

Memory research generally measures speed, accuracy, sequencing, and suppression of irrelevant
information, all of which are readily quantified. It is far more difficult to determine the significance of
experimental memory performance data within the broader context of cognition and emotion and to
determine the utility of these capacities to the organism. Does age-related memory decline as conventionally
measured, for example, reflect cognitive adaptations to late life? Adaptive functions of memory likely
include the capacity to generalize, to encode new data within the context of existing concepts and beliefs,
and to retain information critical for survival.14 For these purposes, accuracy and detail may be neither
essential nor desirable. Memory distortions of time, fact, and detail may "feel right" and may be comforting
as illustrated here. These literal distortions are adaptive in that they support a sense of continuity in
important human relationships.

Illusory Memories, Grief, the Soul, and My Father's Work

In his seminal paper on the biospychosocial model, my father suggested that the reductionistic biomedical
model originated in a concession of Christian orthodoxy more than 5 centuries ago to permit dissection of
the human body.

Such a concession was in keeping with the Christian view of the body as a weak and imperfect vessel for the
transfer of the soul from this world to the next. Not surprisingly, the Church's permission to study the human
body included a tacit interdiction against corresponding scientific investigation of man's mind and behavior.
For in the eyes of the Church these had more to do with religion and the soul and hence properly remained
its domain.1

The new model invites scientific exploration of the soul in relation to human bonds and to human suffering
when those bonds are sundered.

The abstract soul may be likened to the self, mind, and spirit as distinguished from the material body. The
ability to conceptualize the mind and its properties, including awareness, motivation, intent, and deception,
has been termed "theory of mind." These abilities in humans have been attributed to the evolutionary
enlargement of the prefrontal cortex.4,15,16

The notion of a discrete mind residing in the body is so natural to human thought that it is readily extended
to the concept of an enduring soul following death. This soul-body dichotomy is reflected in ideas dating
from preliterate cultures through ancient Greece to the 17th century works of Descartes.4,17 Whereas
Descartes employed philosophical arguments to invoke the existence of the soul, clinical observations are
beginning to identify the neurobiological substrates underlying the personal experience of a nonmaterial self
or soul. Auras reported by individuals with partial complex seizures include a range of cognitive-emotional
experiences, the most relevant of which is autoscopy, seeing one's body from an external perspective. Out of
body experiences also occur in circumstances of extreme stress, such as cardiac arrest and near drowning.18–
20
In addition, the concept of a soul may have been reinforced through the millennia by deathbed experiences
in which survivors sought to understand the fate of the dying person and by the reappearance of a
disembodied presence of the deceased in the hallucinations of normal grief. I sensed the departing life force
as I stood at the bedside of my dying patient. In my illusory memory, I was present at the moment my
father's soul left his body and something of him passed to me.

I have suggested that illusory memories reflect adaptive neurobiological and cognitive processes that nurture
human bonds. Might the same be true of our capacity to conceptualize mind and soul and our inclination to
distinguish these so clearly from the body? These qualities of memory and mind that make us so uniquely
human cannot be separated from the physical and biological processes that define us.21 The mystery lies in
why relationships have become so important to us that biological mechanisms have developed to adapt to
loss. Were these processes at work in the memory that gave me so much comfort? These possibilities would
have intrigued my father as they do me, and so we maintain a connection that transcends death.

My father spent much of his career seeking a more fundamental understanding of the human experience in
health and disease. In a sense his work represents an investigation of the mind and soul. His focus and
terminology differed, but he constantly demonstrated the essential importance of relationship and dialogue in
the scientific study as well as the care of his fellow human beings. This passage, published in 1988,
eloquently reflects these ideas.

To appreciate relationship and dialogue as requirements for scientific study in the clinical setting highlights
the natural confluence of the human and the scientific in the clinical encounter itself. It is not just that
science is a human activity, it is also that the interpersonal engagement required in the clinical realm rests on
comlementary and basic human needs, especially the need to know and understand and the need to feel
known and understood. The first, to know and understand, ... is a dimension of being scientific; the second,
to feel known and understood, is a dimension of caring and being cared for. Both may be seen as derivative
and emergent from biological processes critical for survival.... The need to know and understand originates
in the regulatory and self-organizing capabilities of all living organisms to process information from an
everchanging environment in order to assure growth,... self-regulation, and survival. In turn, the need to feel
known and understood originates.... in the life-long need to feel socially connected with other humans.... The
need to know and to understand ultimately achieves its most advanced development in the disciplined
curiosity that characterizes scientific thinking. The need to feel known and understood manifests itself in the
continuity of human relationships and in the social complementarity between perceived helplessness and the
urge to help. Herein then converge the scientific and the caring (samaritan, pastoral) roles of the physician.22

This is the core of the biopsychosocial model. My father's caring lay at the heart of his insatiable passion to
know and understand. In reflecting on my father's life and work, our relationship, and my illusory memory
of his death, I now know and understand my father better. Even a brief exploration of memory, soul, mind-
body dualism, brain function, and human relationships underscores the critical importance of language and
relationship as means of access to essential, verifiable information. This may be my father's most important
legacy, one that enriches, broadens, and deepens the work of physicians as healers and investigators. In so
many aspects of his life, the soul of his work, his creativity, and his expansive thinking touched on this
unifying and illuminating gift that he leaves for us.

FIGURE 2. Eric, Anna, Julie, and Peter Engel celebrating grandpa's

84th birthday

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ACKNOWLEDGMENTS

The author deeply appreciates the thoughtful comments and suggestions from colleagues and friends. I am
particularly grateful to my wife, Anna Engel, MD who helped me to see the essential connections between
my father's life and work, and my relationship with him.
This essay draws upon the author's contributions to a memorial service for his father at the Interfaith Chapel,
University of Rochester, January 29, 2000. Portions of this tribute appeared in the April 2000 issue of the
Journal of Developmental and Behavioral Pediatrics, page 163.

REFERENCES

1. Engel GL: The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129–
136[Abstract/Free Full Text]

2. Grimby A: Bereavement among elderly people: grief reactions, post-bereavement hallucinations and
quality of life. Acta Psychiatr Scand 1993; 87:72–80[Medline]

3. Andrade C, Srinath S, Andrade AC: True hallucinations in non-psychotic states. Can J Psychiatry
1989; 34:704–706[Medline]

4. Corrigan FM: Parapsychotic grief, theory of mind and the concept of the soul. Med Hypotheses
1997; 49:301–302[CrossRef][Medline]

5. Engel GL: From biomedical to biopsychosocial: being scientific in the human domain.
Psychosomatics 1997; 38:521–528[Abstract/Free Full Text]

6. Schacter DL: Illusory memories: a cognitive neuroscience analysis. Proc Natl Acad Sci USA 1996;
93:13527–13533[Abstract/Free Full Text]

7. Daum I, Graber S, Schugens MM, et al: Memory dysfunction of the frontal type in normal ageing.
Neuroreport 1996; 7:2625–2628

8. Trott CT, Friedman D, Ritter W, et al: Item and source memory: differential age effects revealed by
event-related potentials. Neuroreport 1997; 15:3373–3378

9. Curran T, Schachter DL, Normal KN, et al: False recognition after a right frontal lobe infarction:
memory for general and specific information. Neuropsychologia 1997; 37:1035–1049

10. Mattioli F, Miozzo A, Vignolo LA: Confabulation and delusional misidentification: a four year
follow-up study. Cortex 1999; 35:413–422[Medline]

11. Joseph R: Frontal lobe psychopathology; mania, depression, confabulation, catatonia, perseveration,
obsessive compulsions, and schizophrenia. Psychiatry 1999; 62:138–172[Medline]

12. Burgess PW, McNeil JE: Content-specific confabulation. Cortex 1999; 35:163–182[Medline]

13. Engel GL: The death of a twin: mourning and anniversary reactions. Fragments of 10 years of self-
analysis. Int J Psychoanal 1975; 56:23–40[Medline]

14. Schacter DL: The seven sins of memory. Am Psychol 1999; 54:182–203[CrossRef][Medline]

15. Povinelli DJ, Preuss TM: Theory of mind: evolutionary history of a cognitive specialization. Trends
Neurosci 1995; 18:418–424[CrossRef][Medline]

16. Happe F, Ehlers S, Fletcher P, et al: "Theory of mind" in the brain. Evidence from a PET scan study
of Asperger syndrome. Neuroreport 1996; 8:197–201[Medline]
 17. Buck RW: The epistemology of reason and affect, in The Neuropsychology of Emotion, edited by
Borod JC. New York, Oxford, 2000, pp. 31–55

18. Devinsky O, Putnam F, Grafman J, et al: Dissociative states and epilepsy. Neurology 1989; 39:835–
840[Abstract/Free Full Text]

19. Saver JL, Rabin J: The neural substrates of religious experience. J Neuropsychiatry Clin Neurosci
1997; 9:498–510[Abstract/Free Full Text]

20. Greyson B: Varieties of near-death experience. Psychiatry 1993; 56:390–399[Medline]

21. Damasio AR: Descartes' Error: Emotion, Reason and the Human Brain. New York, Avon, 1994, p.
255

22. Engel GL: How much longer must medicine's science be bound by a seventeenth century world
view? in The Task of Medicine, Dialogue at Wickenburg edited by White KL. Menlo Park, CA,
Henry J. Kaiser Family Foundation, 1988, pp. 113–136, edited excerpt, pp. 124–125

CÃTRE O STRUCTURARE FILOZOFICÃ A PSIHIATRIEI

Kenneth S. KENDLER

Acest articol îsi propune sã contureze un cadru conceptual si filosofic pentru psihiatrie si abordeazã douã
întrebãri majore: care este relatia dintre minte si creier si cum putem integra multitudinea de perspective
implicate în explicarea bolii psihiice? Sunt avansate si sustinute opt afirmatii:
1) Psihiatria este ancoratã irevocabil în experientele mentale, individuale;
2) Dualismul cartezian este fals;
3) Epifenomenalismul este fals;
4) Atât relatia de cauzalitate creier › minte cât si relatia minte › creier sunt reale;
5) Tulburãrile psihice sunt complexe din punct de vedere etiologic si nu mai sunt de asteptat alte descoperiri
de tip „spirochete” care sã explice originea acestor tulburãri în termeni simpli;
6) Pluralismul explicativ este preferabil abordãrilor explicative moniste si în special reductionismului
biologic;
7) Psihiatria trebuie sã depãseascã etapa prestiintificã a „luptelor între paradigme”, sã îmbrãtiseze
complexitatea si sã sustinã modelele explicative pluraliste si riguros empirice;
8) Psihiatria ar trebui sã tindã cãtre un „reductionism fragmentar”, cu scopul de a ajunge la o „integrare
parcelarã” în efortul de a explica pas cu pas cãile etiologice complexe care duc cãtre boalã.
(Am. J Psychiatry 2005; 162: 433 – 440)

Multi psihiatri au spus cã nu vor sã ia asupra lor povara filosofiei... dar excluderea filosofiei ar... fi
dezastruoasã pentru psihiatrie.
K. Jaspers (1, p.769

Publicat initial în Statele Unite de American Psychiatric Publishing Inc., Washington D.C si London, UK.
Copyright 2005. Toate drepturile rezervate. First published in the United States by American Psychiatric
Publishing Inc., Washington D.C. and London, UK. Copyright 2005. All rights reserved.

PSIHIATRIA ESTE ANCORATÃ ÎN LUMEA MENTALULUI

Cadrul conceptual prezentat aici are la bazã ideea conform cãreia domeniul psihiatriei este profund si
ireversibil legat de lumea mentalului. Întrebãrile care au jucat un rol atât de proeminent în istoria psihologiei
– de tipul pot sau ar trebui sã fie studiate procesele mentale (2) – sunt pur si simplu irelevante pentru
psihiatrie. Scopul nostru major ca disciplinã medicalã este reducerea suferintei umane care este rezultatul
aparitiei unor modificãri disfunctionale în anumite arii ale experientelor individuale, subiective, cum ar fi
dispozitia, perceptia si cognitiile. Constructele noastre nosologice sunt formate în cea mai mare parte din
descrieri ale unor experiente la persoana întâi (de ex., dispozitie tristã, halucinatii, temeri irationale). Clinica
psihiatriei necesitã ca, în mod constant, noi sã evaluãm si sã interpretãm relatãrile la persoana întâi ale
pacientilor nostri. Multe din simptomele tintã pe care le tratãm pot fi evaluate doar dacã le cerem pacientilor
nostri sã ne vorbeascã despre experientele lor subiective. Nu vom putea beneficia de cele mai noi
descoperiri în domeniul neurostiintelor si biologiei moleculare în detrimentul ancorãrii în lumea suferintei
mintale umane.

ARUNCÂND LANTURILE LUI DECARTES

O primã sarcinã va fi confruntarea unei mosteniri istorice. Nici un concept filosofic nu a avut atât de multã
influentã în domeniul nostru sau nu a fost atât de pernicios în consecintele sale potentiale precum dualismul
cartezian. Chiar dacã anumiti psihiatri vor continua, din motive personale sau religioase, sã sustinã
dualismul minte-corp, a sosit timpul pentru psihiatrie sã declare fals dualismul cartezian. Trebuie sã
respingem definitiv credinta conform cãreia mintea si creierul reflectã douã „lucruri” fundamental diferite
si, în cele din urmã, incomensurabile. În locul acesteia si având suportul majoritãtii covârsitoare a datelor
clinice si stiintifice, ar trebui sã conchidem cã lumea experientelor subiective umane îsi are originea si este
în totalitate dependentã de functionarea creierului. Lumea mentalã nu existã independent de corespondentul
ei fizic din creier. Rejectarea dualismului cartezian (si acceptarea monismului, viziunea conform cãreia
procesele mintale si fizice sunt ambele reflectii ale unuia si aceluiasi fenomen) înseamnã sã nu mai
considerãm mentalul (sau functionalul) ca fiind fundamental diferit de biologic (sau organic). În aceastã
nouã viziune, mentalul si biologicul sunt doar moduri de întelegere diferite si/sau niveluri diferite de analizã
a sistemului minte – creier.

Rejectarea dualismului cartezian necesitã producerea unei schimbãri semnificative în modul nostru de a
gândi. Desi, oficial, o datã cu DSM IV (3), psihiatria americanã a abandonat dihotomia functional–organic,
unul dintre numeroasele ecouri ale dualismului cartezian, si în ciuda faptului cã un îndemn similar de
abandonare a dualismului a fost lansat de Kendel (4), gândirea si vocabularul dualist rãmân adânc ancorate
în felul în care abordãm problematica clinicã si de cercetare. De la modul în care ne structurãm prezentãrile
clinice si pânã la clasificãrile factorilor de risc, totul dovedeste cât de mult rãmânem tributari gândirii
carteziene care vede mintea si creierul ca reflectii ale douã sfere fundamental diferite ale realitãtii.

O consecintã pozitivã imediatã care ar decurge din abandonarea dualismului cartezian ar fi posibilitatea de a
confrunta neîntelegerile care apar ca urmare a observatiilor cã anumite procese suferã de ceea ce s-ar putea
numi o explicatie biologicã slabã. Rejectarea dualismului cartezian conduce la singura concluzie logicã si
anume cã toate tulburãrile psihiatrice sunt biologice. Desi nu ar trebui sã diminuãm importanta acestei
viziuni (care ar putea elimina, spre exemplu, cauzele în principal spirituale care conduc la aparitia
tulburãrilor psihiatrice), principalul pericol acum este tendinta contrarã de a exagera semnificatia acesteia.
Rejectând dualismul, acceptãm cã toate tulburãrile psihiatrice sunt biologice. Si la fel sunt, în general, toate
procesele mintale, patologice sau nu. Ubicuitatea acestei observatii privind slaba reprezentare a
componentei biologice a unor fenomene îi ascunde adevãrata însemnãtate. Dacã rejectarea dualismului
cartezin este corectã, atunci a constata cã o anumitã tulburare psihiatricã este biologicã este o tautologie si la
fel de informativã ca observatia „acest cerc este rotund”. O astfel de observatie nu aduce nimic nou fatã de
ceea ce se stia prin acceptarea viziunii moniste asupra functionãrii sistemului minte-creier.

DETRONAREA EPIFENOMENALISMULUI
Simpla rejectare a cartezianismului nu ne face sã ne simtim complet commfortabil din punct de vedere
filosofic. Un alt punct de vedere major în problema minte – creier ar avea, dacã ar fi dovedit ca fiind
adevãrat, un impact profund asupra domeniului de lucru al psihiatriei. Principala idee sustinutã de
epifenomenalism este cã lumea mentalã nu are eficientã cauzalã si cã viata noastrã mintalã este doar spumã
pe creasta valului sau aburul eliminat de motor. Gândurile sentimentele si impulsurile apar în câmpul
experientei noastre subiective, dar nu au nici o functie. Toate actiunile cu valoare de cauzalitate s-ar petrece
la nivelul functionãrii creierului. Oportunitatea si modul contracarãrii unei asemenea conceptii depãsesc
cadrul acestui articol. Pentru ceea ce ne-am propus, doresc doar sã afirm falsitatea acestei conceptii si sã
conchid cã gândurile, sentimentele si impulsurile sunt importante nu doar pentru cã sunt responsabile de o
parte imensã din suferinta umanã, dar si pentru cã ele sunt cauza altor fenomene.

ACCEPTAREA CAUZALITÃTII BIDIRECtIONALE MINTE – CREIER SI CREIER – MINTE

Acum cã am abandonat dualismul cartezian si am acceptat existenta unui sistem integrat minte – creier,
devine necesar sã acceptãm si o relatie de cauzalitate creier – spre – minte. Aceasta înseamnã cã modificãri
la nivelul creierului pot influenta direct functionarea mentalului. Prin rejectare epifenomenalismului,
devenim suporterii unei relatii de cauzalitate minte – spre – creier. Numeroase observatii pe care nu suntem
capabili încã sã le explicãm în totalitate ne aratã cã fenomene mentale subiective, experimentate la persoana
întâi au valoare de cauzalitate în lumea exterioarã. Ele au capacitatea de a influenta creierul si corpul si, prin
ele, lumea exterioarã. (Prin afirmarea valorii de cauzalitate pentru fenomenele mentale nu reintroduc
dualismul cartezian „prin usa din dos”. În concordantã cu alte câteva opinii filosofice similare – în special
materialismul nonreductiv [5,6] – sustin cã procesele mentale sunt purtãtoare de informatie cauzalã despre
comportamentul uman). Referintele 7 si 8 fac trimitere la douã recente si interesante luãri de pozitie în
aceastã problematicã.

Sã nu mai cãutãm explicatii simple, atotcuprinzãtoare

Dorintele noastre cele mai puternice îndreptate spre identificarea cauzei, acea cauzã care sã explice
manifestãrile tulburãrilor psihiatrice la nivel individual nu-si mai au locul si sunt contraproductive. De-a
lungul istoriei sale, psihiatria a fost martora identificãrii unui numãr mic de explicatii comprehensive. Cea
mai notabilã în acest sens este descoperirea implicãrii spirochetelor în aparitia paraliziei generalã
progresivã.

Este extrem de improbabil ca vor mai fi fãcute alte descoperiri de tipul spirochetelor, care sã explice aparitia
tulburãrilor psihiatrice majore. Am cãutat explicatii neuropatologice simple, comprehensive pentru
tulburãrile psihiatrice si nu le-am gãsit. Am cãutat explicatii neurochimice simple, comprehensive pentru
tulburãrile psihiatrice si nu le-am gãsit. Am cãutat explicatii genetice simple, comprehensive pentru
tulburãrile psihiatrice si nu le-am gãsit. Nivelul de cunostinte de care dispunem în prezent, desi incomplet,
ne conduce spre ideea, tot mai puternic sustinutã, cã toate tulburãrile psihice majore sunt complexe si
multifactoriale. Ceea ce putem spera, în cel mai bun caz, e sã gãsim numeroase explicatii mai mici
reprezentative pentru o varietate de perspective explicative, fiecare adresându-se unei anumite pãrti
componente a proceselor etiologice complexe care stau la baza tulburãrilor. Adevãrata provocare va fi sã
integrãm toate aceste mici explicatii si sã întelegem în ce fel acestea pot forma un tot unitar.

Suferintei de a fi nevoiti sã abandonãm ideea gãsirii unor explicatii comprehensive va trebui sã-i adãugãm si
pierderea sperantei în modele explicative simple, lineare. Nu va mai fi „ABCD”. Cãile etiologice vor fi
complexe si interactive, asemãnându-se mai degrabã cu o retea decât cu o cale simplã de tip linear.

ACCEPTAREA PLURALISMULUI EXPLICATIV

Introducere la conceptul de nivele explicative

Majoritatea fenomenelor naturale suportã perspective explicative multiple. Mai mult, pentru orice fenomen
dat, aceste perspective vor fi diferite în ce priveste gradul de informativitate si eficienta lor. Este posibil sã
studiezi probleme stiintifice din perspective care se pot dovedi nepotrivit de rudimentare sau nepotrivit de
abstracte. În contextul actual, a doua posibilitate este mai îngrijorãtoare si de aceea va face obiectul acestei
discutii. Conceptul „nivelelor explicative” are o importantã atât de mare pentru aceastã discutie, încât îl voi
ilustra prin urmãtoarele trei scenarii.

Scenariul 1
Jackie este fiziolog si studiazã mecanismele de reglare hormonalã. Ea acceptã cã moleculele pe care le
examineazã sunt alcãtuite din atomi care la rândul lor sunt alcãtuiti din particule care si ele au la bazã
particule subatomice. Cu toate acestea, în încercarea de a modifica anumite aspecte ale sistemului hormonal
pe care îl studiazã, ea ar putea cere sfatul unui biochimist sau unui farmacolog, dar nu si unui fizician
specialist în particule subatomice. De ce? Pentru cã tipul de efecte pe care vrea sã le producã – stimularea
unui anumit tip de receptor hormonal – rezultã din interactiunea unor molecule biologice mari. A sti ce fac
quark-ii în interiorul acestor molecule nu o va ajuta sã- si atingã scopurile.

Scenariul 2
Bill realizeazã o analizã statisticã pe computer si obtine rezultate eronate deoarece a fãcut o gresealã în
programul sãu statistic. Fiind un tip foarte pragmatic, Bill decide sã demonteze capacul din spatele
computerului sãu, sã demonteze placa de bazã si sã ia ciocanul de lipit în speranta de a gãsi o conexiune
dezlipitã pe care sã o repare. De ce este gresitã aceastã abordare? La urma urmelor, un computer este doar
un maldãr de circuite si electroni. A recurge la un ciocan de lipit în aceastã situatie este o solutie foarte
ineficientã deoarece este o interventie directionatã la un nivel explicativ inadecvat, în acest sistem complex.
Cauza disfunctiei se aflã la nivelul mai înalt al programãrii computerului si nu ar putea fi reperatã cu
usurintã sau reparatã la nivelul circuitelor din placa de bazã.

Scenariul 3
Lui Kathy, o tânãrã psihiatrã, i se solicitã un consult de cãtre o mamã îngrijoratã cã fiul sãu Brian tocmai a
decis sã abandoneze o carierã într-un domeniu stiintific pentru a îmbrãca rasa preoteascã. Mama insistã ca
Kathy sã solicite o examinare imagisticã, pentru a gãsi o cale de a-i schimba decizia fiului. „Trebuie sã fie
ceva în neregulã cu creierul lui, doamna doctor. Cum altfel ar putea sã arunce la gunoi o carierã atât de
promitãtoare?” Kathy îl consultã pe tânãr care pare o persoanã inteligentã si maturã. El îi descrie inspiratia
profundã si satisfactia pe care le resimte practivând religia catolicã. Este constient de greutãtile care îi stau
în cale, dar simte cã a luat o decizie corectã. Kathy îi comunicã mamei cã nu va solicita un examen RMN.
Nu existã nici o dovadã, afirmã ea, cã ar fi ceva în neregulã cu creierul tânãrului si nu sunt indicate în acest
moment nici un fel de interventii care ar actiona direct asupra creierului sãu. Simte cã tânãrul a luat aceastã
decizie într-o manierã rezonabilã, iar mama are toatã libertatea, dacã doreste, sã încerce sã-l convingã pe fiul
sãu sã renunte la decizia sa.

Ce se întâmplã de fapt în aceste trei scenarii? În fiecare caz avem de a face cu un sistem de un ordin
superior alcãtuit în întregime din elemente de ordin inferior. Cu alte cuvinte, macromoleculele lui Jackie
sunt formate din particule subatomice, computerul lui Bill este format din circuite si electroni, procesele
mintale ale lui Brian sunt exprimate în biologia creierului sãu. Cu toate acestea, o interventie la nivelul
elementelor de ordin inferior va fi probabil, în cel mai bun caz, ineficientã, iar în cel mai rãu, ineficace si
posibil nocivã.

LIMITELE REDUCTIONISMULUI BIO

Nu existã psihiatrie prea biologicã. E un nonsens.

S. B. Guze (9)
Ultimele decenii au fost martorele atingerii apogeului în domeniul psihiatriei a perspectivei reductionist
biologice. Sustinãtorii acestui punct de vedere afirmã cã procesele neurobiologice de bazã reprezintã singura
cale de urmat dacã dorim sã ne apropiem de întelegerea tulburãrilor psihice sau, într-un cadru mai larg, a
functionãrii psihologice (10). Modelele multisegmentare, în special cele care includ perspective explicative
mintale si sociale, sunt de obicei rejectate (uneori atasându-li-se epitetul de nestiintifice sau calificativul de
„teorii slabe”) sau acceptate sub premiza generalã cã „adevãratele” efecte cauzale se petrec de fapt la nivelul
biologic.

Aceastã pozitie ar putea pãrea cã decurge logic din respingerea dualismului cartezian. La urma urmelor,
dacã suntem de acord cã nu existã procese mintale independente de functionarea cerebralã, atunci nu
decurge cã toate cauzele tulburãrilor psihiatrice pot fi reduse la corespondentul lor la nivelul proceselor
cerebrale? Desi aceastã perspectivã reductionistã este de înteles în termeni sociologici ca o reactie la
programe anterioare radical mentaliste care au functionat în cadrul psihiatriei (de exemplu, anumite forme
de psihiatrie dinamicã) si atrage prin usurinta cu care se adecveazã modelului medical, aceastã abordare este
mult prea limitatã pentru a putea cuprinde marea varietate de procese cauzale care sunt prezente în cadrul
tulburãrilor psihiatrice. Limitele reductionismului biologic sunt ilustrate în cele trei scenarii descrise mai
sus. Contrar celor afirmate de Guze, psihiatria poate fi prea biologicã în acelasi fel în care ar fi fost o eroare
pentru Jackie sã se concentreze pe particule subatomice în cercetarea ei de fiziologie sau la fel cum ar fi fost
gresit ca Bill sã încerce sã-si rezolve problema de analizã statisticã apelând la ciocanul de lipit sau pentru
Kathy sã recurgã la psihofarmacologie pentru a schimba decizia de carierã a lui Brian. Notati, vã rog, cã nu
contest cã, la cel mai de bazã nivel, (în sensul de „biologie slabã”) toate bolile psihiatrice sunt biologice.
Ceea ce discutãm aici este nivelul optim din cadrul procesului cauzal care stã la baza tulburãrii psihiatrice
subiacente la care se poate face o interventie cât mai tintit si unde se poate obtine cel mai usor întelegerea.

Pluralismul explicativ
Urmând traditia altor comentatori de valoare (în special Engel [11] si McHugh si Slavney [12]), sustin
înlocuirea reductionismului biologic cu pluralismul explicativ (13-17) ca fiind abordarea cea mai potrivitã
pentru a putea întelege natura tulburãrii psihiatrice. Pluralismul explicativ presupune existenta mai multor
perspective reciproc informative cu ajutorul cãrora sã se facã abordarea fenomenelor naturale. În mod
obisnuit, aceste perspective diferã în privinta nivelului de abstractizare, folosesc unelte stiintifice divergente
si oferã moduri diferite si complementare de întelegere. Pluralismul explicativ se adecveazã în mod special
psihiatriei deoarece tulburãrile psihiatrice sunt în mod tipic influentate de procese cauzale care opereazã la
nivele diferite de abstractizare.

Un exemplu clar de pluralism explicativ vine din biologie, unde este util sã diferentiem între întrebãrile de
tip „cum” si întrebãrile de tip „de ce” (18). De exemplu, în examinarea cozii uriase si viu colorate a
pãunului mascul, am putea studia biologia dezvoltãrii ei, pentru a clarifica mecanismele fiziologice prin care
se poate dezvolta o asemenea coadã. În mod alternativ, am putea cãuta în istoricul de evolutie a pãunului un
rãspuns la întrebarea de ce si-a dezvoltat coada în acest fel. Rãspunsul stã probabil în mecanismele de
selectie sexualã. Nu se pune problema ca perspectiva cum / fiziologicã sã înlocuiascã perspectiva de ce /
evolutivã sau sã încerce sã o invalideze. Natura fenomenului este astfel încât este util din punct de vedere
stiintific sã fie abordat din douã perspective diferite. (Abordarea de tip pluralism explicativ descrisã în
aceastã lucrare preia perspectiva stiintelor naturale descrisã de Jaspers cu termenul de „explicatie”[1]. Nu
încerc sã ofer aici un rãspuns la o altã întrebare extrem de relevantã – care este relatia dintre informatia
obtinutã prin aceastã perspectivã si cunoasterea obtinutã prin empatie, în cadrul relatiilor interumane, prin
procesul numit de Jaspers „întelegere” [1]?)

Argumente în favoarea pluralismului explicativ si împotriva reductionismului biologic

În continuare, voi trece în revistã opt argumente în favoarea pluralismului explicativ si împotriva
reductionismului biologic sau altor perspective unimodale asupra bolii psihiatrice (incluzând aici teoriile
mentaliste radicale). Aceste argumente acceptã ceea ce este clar demonstrat în privinta rolului cauzal
semnificativ pe care anumite procese biologice manifeste, spre exemplu la nivel de factori de risc genetici
sau diverse modificãri neurochimice, îl au în aparitia tuturor tulburãrilor psihiatrice.

În primul rând, o traditie clinicã îndelungatã precum si numeroase dovezi empirice din ce în ce mai
riguroase din punct de vedere metodologic sustin importanta experientelor individuale în etiologia
tulburãrilor psihiatrice. Dintre multele studii de luat în consideratie, voi recurge la unul recent pentru a
ilustra acest argument (19). Acest studiu a analizat aparitia depresiei majore si a anxietãtii generalizate în
contextul evenimentelor traumatice severe la un lot de gemeni.

Descrierile evenimentelor traumatizante de viatã erau scorate în orb de evaluatori special formati sã ofere
note fiecãrei experiente, în functie de nivelul pierderii, al umilintei, al sentimentului de lipsã de alternativã
(entrapment) si al pericolului. Desi au fost luate în considerare doar evenimente de viatã care presupuneau
un grad mare de stress, scorurile acordate au corelat foarte bine cu riscul de a dezvolta depresie si anxietate.
Umilirea si sentimentul de pierdere sunt experiente subiective clasice pe care oamenii le pot recunoaste în
propriul istoric de viatã si în al altora. Desi sentimentul de umilire îsi are expresia cea mai de bazã în
activitatea cerebralã, aceasta nu înseamnã cã nivelul neurobiologic este si cel mai eficient nivel la care
aceastã experientã sã fie observatã.

A recurge la studiul biologiei cerebrale pentru a întelege sentimentul de umilire seamãnã cu încercarea lui
Bill de a rezolva problema de analizã statisticã cu ajutorul ciocanului de lipit. Este pur si simplu un nivel
explicativ gresit. Un al doilea argument se referã la datele consistente din literaturã care demonstreazã de o
manierã convingãtoare faptul cã procesele culturale au o influentã asupra tulburãrilor psihiatrice. De
exemplu, o meta-analizã recentã (20) a arãtat cã ratele pentru bulimie au crescut semnificativ în tãrile
vestice în ultimii ani. Mai mult, în ce priveste tãrile non-vestice, prevalenta bulimiei este într-o relatie de
dependentã foarte strânsã cu gradul de contact cu cultura vesticã (20). Un studiu realizat în Fiji (21) a
demonstrat o crestere substantialã a patologiei legate de tulburãrile de alimentatie la adolescente dupã
aparitia televiziunii si, asociat, dupã expunerea intensã la idealurile vestice referitoare la imaginea corporalã.
Aceste rezultate sugereatã faptul cã riscul de aparitie a bulimiei este strâns legat de modele culturale
privitoare la forma idealã a corpului. Chiar dacã ceea ce numim culturã reprezintã doar un sistem de
credinte internalizat la nivelul creierului fiecãrui individ care apartine unui grup cultural, este putin probabil
ca fortele culturale care modeleazã psihopatologia sã fie întelese eficient la nivelul biologiei cerebrale.

În al treilea rând, primele douã exemple demonstreazã faptul cã întelegerea pe deplin a etiologiei cel putin a
unei pãrti din tulburãrile psihiatrice va necesita luarea în consideratie, pe lângã factorii de risc
neurobiologici si genetici, si a factorilor psihologici si culturali. Totusi, ne-am asumat în mod naiv un model
în care factorii biologici, psihologici si culturali actioneazã independent în determinarea riscului de boalã.
Realitatea este însã mult mai complexã, ceea ce înseamnã si un numãr din ce în ce mai mare de dificultãti cu
care trebuie sã se confrunte modelul biologic reductionist. Impactul factorilor genetici asupra riscului de a
dezvolta o boalã psihicã sau abuz de substante poate fi modificat de mediul în care se produce dezvoltarea
individului (22, 23), de evenimetele traumatizante de viatã (24, 25) si de fortele culturale (26). Lucrãri
recente în domeniul bulimiei sugereazã cã aceastã tulburare apare ca urmare a unei combinatii între o
predispozitie biologicã/ geneticã si factori culturali care încurajeazã imaginea idealizatã a corpurilor slabe.
Actiunea factorilor biologici de bazã care creioneazã riscul de aparitie a unei tulburãri psihiatrice este
modificatã de forte care actioneazã la nivele superioare de abstractizare. Mai mult, expresia geneticã este
semnificativ modificatã de stimuli de mediu (27) atât din rândul celor foarte simpli (de ex., ciclul luminã -
întuneric) cât si din cei mai complecsi (de ex., sarcini de învãtare, separarea de mamã) si chiar aspecte
relativ grosiere ale anatomiei neuronale si cerebrale pot suferi modificãri sub influenta experientelor de
viatã (28). O abordare reductionistã rigidã de jos în sus ar fi lipsitã de substantã dacã ne gândim cã factorii
de risc neurobiologici de bazã sunt frecvent modificati de procese de ordin superior, incluzând aici
experientele de mediu, psihologice si culturale.

În al patrulea rând, sustinãtorii reductionismului biologic presupun cã factorii de risc neurobiologici care
stau la baza tulburãrilor psihiatrice opereazã pe cãi fiziologice „interne corpului”. Totusi, cercetãri recente
din ce în ce mai consistente sugereazã cã o asemenea asumptie este falsã. Parte din modul în care factorii
genetici influenteazã predispozitia la dezvoltarea unor tulburãri psihiatrice îl reprezintã cãi „exterioare
corpului”, prin modificarea probabilitãtii de expunere la medii de risc înalt. Spre exemplu, factorii genetici
care determinã riscul pentru depresia majorã cresc probabilitatea dificultãtilor interpersonale si maritale, la
rândul lor factori de risc recunoscuti pentru depresie (29). Aceasta nu este o problemã de teorie. Dacã
impactul factorilor de risc genetic este mediat prin intermediul proceselor de mediu, se deschid noi
posibilitãti pentru activitatea de preventie.

În al cincilea rând, modelele conservator reductioniste în stiintã cautã cu tot dinadinsul sã identifice relatii
de tip „unu-la-unu” între procesele bazale si variabilele luate în calcul. Astfel de relationãri simple nu sunt
plauzibile în psihiatrie. De exemplu, factorii de risc genetici individuali realizeazã probabil predispozitia
cãtre o varietate de tulburãri psihiatrice diferite, aparitia uneia sau alteia din acestea depinzând de alti factori
genetici, ontogenetici sau de mediu (30) si este posibil ca multe variante diferite de ADN sã predispunã
pentru aceeasi tulburare (31). Acest model de tip „multe-cãtre-multe” legãturi cauzale, fãcând legãtura între
procesele etiologice de bazã si variabilele studiate este mai compatibil cu modelele etiologice pluraliste
decât cu cele moniste. În al saselea rând, o serie de întrebãri importante în psihiatrie sunt de naturã istoricã
si nu e plauzibil ca rãspunsul la ele sã fie oferit prin explicatii biologice reductioniste. De ce sunt fiintele
umane predispuse la depresie atunci când sunt confruntate cu adversitatea socialã? De ce factorii genetici de
risc pentru schizofrenie persistã în populatia umanã? Similar problemei cozii pãunului, rãspunsul la aceste
întrebãri se gãseste mai degrabã la nivelul istoric / evolutiv decât la cel fiziologic.

În al saptelea rând, cum am putea defini disfunctia printr-o abordare de tip reductionist biologic (17)? Dacã
anumite simptome sunt probabil patologice la un nivel biologic de bazã (de ex., halucinatiile), multe alte
simptome sunt considerate disfunctionale numai în functie de contextul în care apar. La nivel fiziologic, un
atac de panicã care apare la un individ sãnãtos psihiatric în timpul unui accident aproape fatal de alpinism
sau un atac de panicã produs într-un mall la un pacient care suferã de agorafobie sunt probabil identice. Din
moment ce majoritatea tulburãrilor psihiatrice includ, prin definitie, un grad de disfunctie psihosocialã (32),
explicatiile mãrginite la nivelul biologiei vor oferi putinã satisfactie.

În al optulea rând, sistemele biologice în general si sistemul minte-creier în special au scopuri si genereazã
procese care sã rãspundã acestor scopuri, cum ar fi mentinerea tensiunii arteriale si a stimei de sine sau
achizitia de hranã sau de parteneri sexuali sau de status. Asa cum au sustinut în repetate rânduri Bolton si
Hill (7), aceste sisteme care se bazeazã pe informatie nu pot fi reduse la constituientii lor moleculari fãrã a
se pierde din puterea explicativã. La urma urmelor, biologia impulsului neuronal – influxul si efluxul de ioni
de sodiu, potasiu, calciu – este în mod esential aceeasi peste tot în creier. Aceste impulsuri au eficacitate
cauzalã specificã numai atunci cãnd activeazã anumite sisteme neuronale în cadrul cãrora se transmit.
Procesele cauzale de importantã criticã la nivelul sistemului minte-creier pot deveni comprehensive numai
dupã întelegerea nivelurilor de organizare superioarã a acestor sisteme orientate spre realizarea unor
scopuri.

De ce fel de pluralism explicativ avem nevoie?

Asa cum a fost expus într-un capitol extrem de revelator scris de Mitchell et al. (33), pluralismul explicativ
poate avea mai multe „arome”, dintre care douã prezintã interes pentru noi. Pluralismul compatibil
recunoaste existenta mai multor nivele de analizã distincte si independent semnificative. Totusi, din motive
stiintifice si/sau sociologice, cercetarea acestor nivele distincte se petrece în cea mai mare parte în izolare.
Dimpotrivã, în pluralismul integrativ se fac eforturi active pentru a încorpora niveluri divergente de analizã.
Aceastã abordare pleacã de la premiza cã, pentru majoritatea problemelor, analizele desfãsurate pe un singur
nivel vor oferi doar rezultate partiale. Cu toate acestea, pluralismul integrativ nu încurajeazã constructiile
teoretice uriase, favorizând mai degrabã crearea de mici arii „locale” de integrare între niveluri diferite de
analizã.

Domeniul nostru de activitate ar putea beneficia în mod special de pe urma adoptãrii pluralismului
integrativ, o perspectivã din care oamenii de stiintã ar putea, fãrã sã abdice de la rigoarea conceptelor, sã
traverseze granitele diverselor teorii etiologice sau, altfel spus, diverse nivele explicative. Astfel de eforturi
s-ar putea dovedi neasteptat de productive din punct de vedere stiintific si ar putea conlucra pentru
realizarea pas cu pas de paradigme explicative tot mai comprehensive. Exemple recente de pluralism
integrativ aplicat în cercetarea stiintificã psihiatricã ar putea fi includerea de cãtre Gutman si Nemeroff (34)
a evenimentelor traumatice timpurii în modelele neurobiologice ale depresiei sau eforturile realizate de
Caspi si colegii pentru includerea de genotipuri specifice într-un studiu epidemiologic care analiza
dezvoltarea comportamentului antisocial (35) si a depresiei (25) dupã expunerea la conditii adverse de
mediu.

PROBLEME LEGATE DE IMPLEMENTAREA PLURALISMULUI EXPLICATI

Mult prea adesea, în munca de cercetare realizatã în domeniul sãnãtãtii mintale, o anumitã orientare
explicativã este adoptatã din motive ideologice si nu empirice. În cea mai pesimistã dintre viziuni, domeniul
nostru ar fi alcãtuit din tabere teoretice izolate, mutual antagonice. Un mod de a aborda aceastã cacofonie de
abordãri explicative divergente ar fi impunerea rigidã a unei perspective metodologice unice, spre exemplu
impunerea reductionismului biologic. Totusi, o asemenea eventualitate este nefezabilã si sortitã de la început
esecului, chiar dacã s-ar încerca implementarea ei. Sarcina noastrã, indicibil de dificilã, este crearea unui loc
riguros metodologic, dar neamprentat de prejudecãti unde sã se desfãsoare jocul stiintific. Sustinerea
aplicãrii pluralismului explicativ la domeniul psihiatriei nu trebuie consideratã o invitatie stupidã la a
conferi egalã importantã tuturor metodologiilor. Factorii de decizie care ar trebui sã guverneze permanenta
competitie între diversele perspective divergente pentru resurse si cercetãtori nu ar lua în calcul orientarea
metodei, ci mai degrabã forta design-ului, replicabilitatea rezultatelor si relevanta lor pentru întelegerea
cãilor cauzale care conduc spre aparitia tulburãrilor psihiatrice.

Thomas Kuhn (36), faimosul filosof al stiintei care a relevat aspectul de activitate socialã al stiintei ar putea
sustine cã o astfel de agendã este o încercare zadarnicã. Ar sustine cã paradigmele stiintifice care
concureazã în cadrul psihiatriei sunt „incomensurabile” si cã sustinãtorii lor au puncte de vedere atât de
radical divergente încât aproape cã se poate spune despre ei cã trãiesc în lumi profesionale diferite. Mai
mult, el ar afirma cã datele stiintifice în domeniul nostru contin un procent mare de teorie si au la bazã
postulate teoretice. În astfel de circumstante, este extrem de dificil sã se stabileascã o comunicare eficientã
între paradigme si sã se identifice o zonã în care acestea sã se întâlneascã si sã competitioneze între ele cu
sanse egale.

Aceste contrargumente sunt foarte puternice. Îmi aduc aminte mult prea multe discutii sterile care aveau loc
la sfârsitul anilor ‘70 între psihanalisti, psihiatri sociali si psihiatri de orientare biologicã pentru a trece cu
usurintã peste aprecierile lui Kuhn referitoare la incomensurabilitatea diverselor perspective teoretice
diferite. Mai mult, îmi aduc aminte cu surprindere cum generatii anterioare de cercetãtori care aderau la
perspective diferite au pornit de la aceleasi date – de agregare familialã a schizofreniei – si au concluzionat
cã ele reprezintã dovada pentru teoriile etiologice biologice (37) sau familial-dinamice (38) pentru
schizofrenie. Cu toate acestea, perspectiva lui Kuhn s-ar putea dovedi prea pesimistã. Multi filosofi ai
stiintei dezaprobã versiunile mai radicale ale opiniilor sale (39). Nu este o sarcinã imposibilã sã determini
cercetãtori care îmbrãtiseazã perspective diferite sã cadã de acord asupra unor interpretãri în linii mari
similare ale acelorasi date.În ce priveste cercetarea, domeniul sãnãtãtii mintale este tot mai des martorul
discutiilor si colaborãrilor „între paradigme”. Ranchiuna ideologicã specificã dezbaterilor mai timpurii pare
sã scadã în intensitate, iar aceia dintre noi mai optimisti pun aceastã evolutie pe seama maturizãrii acestui
domeniu. Kuhn sustine cã pentru a se dovedi maturã, o stiintã trebuie sã subscrie la o paradigmã stiintificã
de bazã (36). Pe baza acestui criteriu, psihiatria s-ar afla într-o stare imaturã „preparadigmaticã”. Desi
suferind de o lipsã de specificitate si având nevoie sã fie „completat” în ce priveste diversele aspecte ale
fiecãreia dintre tulburãrile psihiatrice majore si tulburãrile legate de abuzul de substante, pluralismul
explicativ ar putea forma substratul acestei paradigme general împãrtãsite.

ACCEPTAREA UNUI REDUCtIONISM FRAGMENTAR CARE SÃ CONDUCÃ LA O

INTEGRARE PARCELARÃ
Care ar trebui sã fie obiectivele noastre în încercarea de a întelege retelele cauzale extraordinar de complexe
care formeazã sistemul minte-creier si modurile de interactiune cu mediul psihosocial care conduc la
aparitia tulburãrilor psihiatrice? O altã supozitie a sustinãtorilor reductionsmului biologic este cã valoarea
unei explicatii cauzale este direct proportionalã cu cât este directionatã mai la baza lantului cauzal – cu cât
mai bazalã si mai biologicã, cu atât mai valoroasã (10). Desi tentant, trebuie sã ne opunem acestui
„zeitgeist”. Ne putem ajuta de un experiment cognitiv. Sã ne imaginãm cã existã 15 niveluri discrete în
cadrul sistemului minte – creier, la un capãt având ADN-ul, iar la celãlalt manifestãrile clinice ale
schizofreniei. Cercetãtorul 1 conduce studii de linkeage si asociere al cãror obiectiv este sã punã în evidentã
o legãturã între nivelul 1 si nivelul 15, dar fãrã a oferi vreun insight pentru nivelele intermediare.

Cercetãtorul 2 încearcã sã înteleagã, la un nivel molecular de bazã, efectele unei posibile modificãri a
transcrierii genice, punând astfel în legãturã nivelul 1 cu nivelul 2 sau 3. În acelasi timp, cercetãtorul 3
încearcã sã înteleagã deficitele neuropsihologice din schizofrenie si sã clarifice legãtura dintre nivelul 13 si
nivelul 15. Desi reductionistii biologici ar gãsi cã munca cercetãtorului 2 este mai „stiintificã” si mai
valoroasã, deoarece este condusã la un nivel mai bazal, sper cã acest experiment cognitiv clarficã faptul cã
nu putem face astfel de judecãti a priori. Existã numeroase conexiuni în cadrul acestui lant, iar valoarea lor
definitivã si productivitatea lor din punct de vedere stiintific au prea putin de a face cu pozitia pe care o
ocupã în cadrul lantului (sau mai degrabã putem vorbi de o retea) cauzal.

Aceste experiment cognitiv ne conduce cãtre o ultimã concluzie. Desi dezvoltarea „marii teorii” este o cale
atrãgãtoare si ar putea sã ofere un cadru heuristic productiv, nu ne aflãm în acest moment aproape de
formularea vreunei retele cauzale complete pentru nici una din tulburãrile psihiatrice. Si acesta nu ar trebui
sã fie de fapt principalul nostru scop acum. În schimb, ar trebui sã ne multumim cu ceea ce am numit
eforturi „pas-cu-pas” spre un pluralism integrativ. Schaffner (40, p. 282) a exprimat o idee similarã prin ceea
ce el a numit „reductii fragmentare” într-o „structurã alcãtuitã din modele cauzale care se interpãtrund”. În
timp, este de asteptat ca astfel de eforturi sã aibe ca rezultat clarificarea mai multor zone din reteaua
cauzalã, moment în care am putea sã ne îndreptãm spre o întelegere etiologicã mai complexã a disfunctiilor
extrem de complexe ale sistemului minte – creier, adicã ceea ce noi avem responsabilitatea de a întelege si
trata.

INTEGRARE SI CONCLUZII

A lucra în domeniul psihiatriei presupune a te confrunta inevitabil cu unele din întrebãrile cele mai
importante si mai greu de rãspuns pe care si le-a pus rasa umanã. Douã sunt de o importantã covârsitoare
pentru domeniul nostru: cum interrelationeazã mintea si creierul si cum putem integra numeroasele
perspective explicative asupra bolii psihiatrice? Am încercat sã ofer variante de rãspuns la aceste întrebãri în
speranta cã ele ar putea oferi un cadru pragmatic integrativ cercetãrii psihiatrice. Este cazul sã abandonãm
dezbaterile sterile pe subiecte ideologice si sã ne axãm pe formularea creativã de probleme empirice, dintr-o
perspectivã criticã. Câtã fortã explicativã realã rezidã în numeroasele perspective etiologice posibile în cazul
unei tulburãri psihiatrice date? Cum am putea sã începem sã întelegem felul în care interrelationeazã
diversele perspective explicative între ele? Nu ne rãmâne decât sã sperãm în maturizarea stiintificã a
psihiatriei care sã ne permitã sã folosim si sã integrãm viitoarele progrese stiintifice. Aceastã eventualitate
necesitã ca noi sã lãsãm în urmã bagajul învechit si dificil de utilizat al dualismului cartezian. De asemenea,
nu ar trebui sã rejectãm nici sursele noastre fundamentale, adânc înrãdãcinate în sferele psihosociale si
mentale si nici sã capotãm în fata tentatiilor reductionismului simplist. Tulburãrile psihiatrice sunt, prin
natura lor, fenomene complexe multinivelare. Trebui sã nu pierdem niciodatã din vedere incredibila lor
complexitate si sã realizãm, cu umilintã, cã întelegerea lor pe deplin va necesita integrarea cu rigurozitate a
mai multor discipline si perspective. Primitã 4 Februarie 2004; revizie primitã 20 Martie 2004; acceptatã 3
Mai 2004. De la Virginia Institute for Psychiatry and Behavioral Genetics, Department of Psychiatry and
Human Genetics, Medical College of Virginia, Virginia Commonwealth University, Richmond VA. Adresa
de corespondentã si cererile pentru copii adresate la Dr. Kendler, Department of Psychiatry, P O Box
980126, Richmond VA 23298 – 0126; kendler@hsc.vcu.edu (email). Cu suportul unei burse a Fritz Redlich
de la Center for Advanced Study in the Behavioral Sciences si de la Rachel Brown Banks Endowment Fund.

Autorul multumeste lui Kenneth Schaffner, MD PhD si lui John Campbell, PhD pentru discutiile care au
contribuit la elaborarea acestui text. Putin din ceea ce este exprimat aici este original. Autorul se simte
îndatorat în special lucrãrilor lui Turkheimer (41), Schaffner (40, 42), Mitchell (13) si Zachar (14).

Traducere din limba englezã: Dr. Eugen Hriscu

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The Growth of George Engel's Biopsychosocial Model

Corner Society Presentation – May 24, 2000

By Theodore M. Brown
 I’ve set myself a very difficult task. Not only is George Engel’s “biopsychosocial model” a large and
challenging subject, but because it has been a central, indeed, defining feature of our medical school
curriculum for more than fifty years, many of you in the audience are intimately familiar with it in teaching
and practice settings.

What could I possibly add? I’ve only been in Rochester for the past 23 years, and although I got to know
Dr. Engel pretty well – even “rounding” with him in the early eighties and interviewing him on tape while
sipping tea at his home in the later eighties – I am an historian, not a physician, and most of my knowledge
comes from oral testimony and the written record, published and unpublished.

What I think I can add – and this is what historians do much of the time – is depth and perspective. I
have tried to take what I have learned from Dr. Engel and his writings and placed it against a background of
his entire, evolving career and of what else was happening in American medicine during the seven decades
when he was active in it.

Some of the story is, of course, familiar to you. Many of you doubtlessly heard from Dr. Engel – as I did
– on numerous occasions about certain key moments: how George started out under the long shadow of his
famous uncle Dr. Emanuel Libman (the L in George L. Engel) to become a very biomedically-oriented
investigator; how Dr. Soma Weiss of Harvard in the early forties cajoled George into reluctant collaboration
with the brilliant young psychiatrist John Romano; about the investigative work Romano and Engel began
together at Harvard and explored more fully at Cincinatti a few years later; about the curricular innovations
they experimented with at that medical school and then brought to ours in 1946 for much more extensive
development; about the linked growth of Dr. Engel’s Medical-Psychiatric “Liaison” fellowship training
program and the infusion of the Rochester medical curriculum with what for a long time were called
“psychosomatic” concepts and clinical examples; about the “Monica” studies beginning in the fifties and
their continuation and elaboration over many decades; about the group that coalesced in the fifties and
continued actively in the sixties with the contributions of Franz Reichsman, Bill Greene, Art Schmale and
Sandy Meyerowitz who, with Dr. Engel, made Rochester famous for studies on “conservation-withdrawal,”
“giving up-given up,” and the “helplessness/hopelessness” affect (“He-Ho”) as a “final common pathway”
to the onset or exacerbation of a wide variety of diseases; about the articulation of the “biopsychosocial
model” in the seventies and its achievement of world-wide recognition in the eighties; about the
development of the Program in Biopsychosocial Studies under the leadership of Tim Quill, Tony Suchman
and Rich Frankel in the nineties and the role it has played, with Dr. Engel’s encouragement and Dean
Hundert’s support, in the new “Double Helix” curriculum.
 Much of this, I suspect, is familiar to most of you in the room, so what I would like to do is take a few of
these familiar moments and explore them more fully. I hope to provide context and perspective as I have
already indicated, and in some cases I can provide depth derived from interviews, archival digging, and
focused reading in published sources.

Let me start with uncle Emanuel, a truly formidable figure.

Slide 1 – Libman on Time magazine cover

Libman was a world-famous medical scientist and clinician affiliated for most of his career with Mount
Sinai Hospital in New York City and renowned for several widely heralded discoveries. He was best known
for his pioneering work on the blood-culturing of bacteria and for identifying the condition of subacute
bacterial endocarditis, an insidious and complex infection of the membrane lining the cavities of the heart.

George grew up in Libman’s household in terror that he might one day embarrass “Uncle Manny,” so he
set out on the straight and narrow path of biomedical science. He majored in chemistry at Dartmouth
College, which he entered at age sixteen in 1930. He was strongly committed to the ideas of Jacques Loeb,
the famous “apostle of mechanistic conceptions in biology.” He obtained permission from the Dartmouth
biology to set up a small laboratory in which he worked with amoebae and paramecia, trying to duplicate
Loeb’s experiments on mechanistically-produced “tropisms.” In the same materialist and “anti-mystical”
spirit, George wrote his first college paper as an assault on intuitive and introspective psychology, “Thought
as a Product of Brain Metabolism.” In the summer between his junior and senior year, he obtained what in
those days was a very rare position for a college undergraduate, a research post at the Woods Hole Marine
Biological Laboratory, where he worked closely with Ralph Gerard, professor of physiology at the
University of Chicago and one of the pioneers of neurochemistry. George’s first major project, which led to
his first publication (in 1935, at age 21!), was a study of the distribution of organic phosphorus compounds
in the muscles of marine invertebrates.

After Dartmouth, George attended the Johns Hopkins Medical School. It was the obvious place to go for
an aspiring biomedical scientist. During his pre-clinical years, George was, in fact, a scientific celebrity. As
a result of his continuing association with Ralph Gerard, he was asked by the Rockefeller Foundation to
spend two months during the summer of 1935 at the Leningrad Institute of Experimental Medicine in the
laboratory of Alexander Gurwitsch, a Russian physiologist working on “mitogenetic radiation” and a
colleague of Ivan Pavlov. Since, by coincidence, the XV International Physiological Congress took place
that summer in Moscow and Leningrad, Congress participants – including several Hopkins physiology
instructors – were treated to tours of Institute labs by George serving as tour-guide and translator (his
Russian was very good).

Slide 2 – Engel photo of Pavlov

His Hopkins reputation thus assured, George was also acknowledged in his clinical years for his ferociously
Libman-like diagnostic prowess. Moreover, uncle Manny arranged for him to work during the summer of
1937 at Boston City Hospital where he met Soma Weiss, soon to become Harvard’s Hersey Professor of the
Theory and Practice of Physic and physician-in-chief of the Peter Bent Brigham Hospital.
 After medical school graduation in 1938, George began his postgraduate training at Mount Sinai Hospital
in New York City. Mount Sinai was an intense, high-energy place that modelled itself to a large extent on
the Johns Hopkins Hospital and was still very much in the Libman mode. Indeed, uncle Manny was a
“consulting physician” until his death in 1946 and in the late thirties still published occasionally in the
scientifically prestigious Journal of the Mount Sinai Hospital. The chief of medicine during Engel’s house
officership, Dr. Eli Moschowitz, moved, however, in certain new, dramatically different directions.
Moschowitz was, in fact, part of the “psychosomatic” wave that was sweeping through American medicine
at that time.

Slide 3 – title page of Dunbar’s “Emotions and Bodily Changes” (1935)

Slide 4 – Cannon on “Role of Emotion” in 1936 Annals of Int. Med.

Slide 5 – title page of Psychosomatic Medicine (1939)

Moschowitz was interested in the role of emotions in essential hypertension, Graves Disease, and
ulecerative colitis and was open to the ideas of psychoanalysis. In fact, while George worked on his medical
service, psychoanalytically-based psychiatrists rapidly expanded their presence in the outpatient department
and on the floors of the hospital. In 1939, in a major reorganizational move, the well-known psychoanalyst
Lawrence Kubie moved from Columbia to Mount Sinai as Asssociate Psychiatrist and as head of a new
“psychosomatic” service. Kubie described the move a few years later as part of the “invasion of a general
hospital by ... [a] large group of psychiatrists” and as an effort to create “a profound and rapid change in the
practice of medicine itself.”

George, however, remained skeptical and aloof. He dismissed most of what psychoanalytic psychiatrists
had to say as “laughable” and as “hogwash” and continued to focus on physiological and biochemical
investigations. He worked, for example, on “the signficance of the carotid sinus reflex in biliary tract
disease” and on “‘epinephrine shock’ as a manifestation of a pheochromocytoma of the adrenal medulla.”
When George did collaborate with a young Mt. Sinai psychiatrist, Sydney Margolin, he continued to
maintain a reductionist point of view, trying to link neuropsychiatric symptoms to the precise tracings of the
electroencephalograph and insisting on explaining them as the mere consequence of “altered physiologic or
biochemical reactions.” Perhaps modelling his approach on Soma Weiss’ vitamin therapy in cardiovascular
disorders, he attempted to correct neuropsychiatric symptoms in organic disease with vitamins and other
metablolic adjustments. And by 1941, George eagerly prepared to leave Mount Sinai and its
psychosomaticists behind, so that he could return to Boston and work again with Soma Weiss.
 George apparently did not realize that Weiss had shifted his focus in some subtle but important ways.
Although he still actively pursued the studies in pathophysiology, pharmacology and pharmacotherapy that
had brought him fame and universal admiration, Weiss had also moved with the times and become
interested in the emotional dimensions of clinical medicine. In 1940 he published in the Journal of the
American Medical Association an Alpha Omega Alpha address on “The Medical Student Before and After
Graduation” in which he pointedly told his student audience that “social and psychic factors play a role in
every disease, but in many conditions they represent dominant influences” and that “mental factors
represent as active a force in the treatment of patients as chemical and physical agents.”

When George arrived at the Brigham in 1941 he was shocked to discover that Weiss had introduced
some dramatic changes since the summer of 1937. He had invited a young psychiatrist, John Romano, to
join the Department of Medicine and help teach the emotional and psychological dimensions of patient care.
Fully integrated into Weiss’ medical service, Romano conducted rounds at patients’ bedsides, where he
would pull up a chair and listen at length to their stories just as he would on a psychiatric ward. George
watched as Romano, with Weiss’ blessing, placed the patient’s narrative of his life and illness experience in
a central position in clinical evaluation. To add to Engel’s shock, Weiss also strongly encouraged him to
work collaboratively with Romano on a research project focused on delusional patients. Engel would study
them with precise electroencephalographic techniques while Romano would investigate their mental states
in psychological detail, after which the two investigators would compare their independent observations.
Even though Engel “condescended” to learn the mental status exam and approached Romano in a
“patronizing” manner, the unlikely collaborators found, as Weiss very likely suspected they would, that the
features of the EEG very closely correlated with the clinically determined mental states.

George had another major shock in January, 1942, when Weiss died suddenly of an unsuspected
intracranial aneurysm. Romano had already accepted a position as Professor and Chair of the Department of
Psychiatry at the University of Cincinnati College of Medicine and promptly offered George the opportunity
to join him in that department. George at first refused but was persuaded to move by Eugene Ferris, one of
Weiss’ former fellows and collaborators who was now in the Department of Medicine at Cincinnati, where
he also offered George a position. George thus came to Cincinnati in 1942 with appointments in both
Medicine and Psychiatry and found in each of the departments an extraordinary group of individuals. Ferris
and Arthur Mirsky were the standouts in Medicine, while Romano, Milton Rosenbaum, and Maurice Levine
made Psychiatry equally stimulating. George found the Cincinnati group “the most exciting I’d ever
encountered, before or since.”

For George, the single most important event in Cincinnati was the abandonment of his resistance to
psychological factors in medicine. At first, he tried to ignore the psychosomatic buzz in the Cincinnati air as
he set out to trip up the psychiatrists by demonstrating somatic clinical findings they had missed. Gradually,
however, he let down his guard. Ferris was instrumental as he took a broadly clinical approach to the wide-
ranging studies of high altitude decompression sickness with which the Cincinnati group was deeply
involved. Instead of sticking to physiological observations, Ferris led the group in watching a broad
spectrum of clinical behavior, which left considerable room for psychological observations. In addition,
Rosenbaum persuaded or perhaps manipulated George into doing psychotherapy with a patient who had
complex reactions to pain. While supervising him in that psychotherapy experience over the course of a
year, Rosenbaum helped Engel overcome his “stubborn resistance” to psychological matters and
introduced him to the writings of Sigmund Freud.

George served as an attending in the Department of Medicine and was responsible for a full range of
medical patients, but he also undertook collaborative research in which he now explored in imaginative and
open-ended ways the psychological as well as the medical dimensions of his clinical cases. With Romano,
for example, Engel returned to one of his long-standing interests, syncope, only now with an important new
psychological perspective. No longer keeping Romano and his psychological insights at a disdainful
distance, Engel enthusiastically studied psychogenic fainting and distinguished between two basic types:
vasodepressor syncope as an emotionally-precipitated, physiologically-based “vegetative neurosis,” and
hysterical fainting in which loss of consciousness serves as a “substitutive or symbolic expression of
emotion” unaccompanied by demonstrable changes in circulatory dynamics or EEG-measured brain
metabolism. He had thus adopted exactly the distinction between two types of psychogenic disorder that the
emigre psychoanalyst and psychosomatic leader Franz Alexander had recently made popular.

Slide 6 – Franz Alexander

Significantly, Engel and Romano presented their findings on fainting to the American Psychosomatic
Society while Alexander sat in the audience and published them in the Society’s official journal,
Psychosomatic Medicine, on whose editorial board Alexander served.

In Cincinnati George developed important new interests in medical education. He participated in

psychosomatic conferences in which a psychiatric resident was paired with a medical resident in case
presentations attended by medical students and house staff. Under the inspiration of John Romano, he also
conceived dramatically expanded and far more ambitious teaching possibilities. It was Romano’s strong
conviction that “psychiatry should be taught in each year of the curriculum” and that “skilled psychiatrists
should be assigned to teaching posts, not as occasional visitors but as intimate coworkers to the other
teaching services of the hospital.” Engel and Romano called for a “more comprehensive frame of reference
or conceptual scheme of disease [than that] with which the student had heretofore been ... familiar ... [a]
conceptual scheme ... in which psychologic and social factors exist or coexist with more impersonal
biologic factors, eventually to cause, provoke, or otherwise modify variations in the total human biologic
behavior.” This was, obviously, an early statement of the “biopsychosocial model.”

Before Romano and Engel got much further along, however, the Cincinnati chair of Medicine proved
“somewhat resistant.” Romano soon afterwards decided to leave Cincinnati for Rochester, formally
announcing his move in January, 1946. He had been given the opportunity to shape a brand new department
of psychiatry, just then forming at Rochester. With the enthusiastic support of Rochester’s Chair of
Medicine William S. McCann, Romano now had the chance to develop the training program that had been
stymied in Cincinnati. He offered Engel an assistant professorship in the Department of Psychiatry with a
specific invitation to play a major role in Rochester’s “psychosomatic” teaching, and McCann offered
George an assistant professorship in Medicine. This time, Engel did not hesitate to join Romano.

George’s first major assignment as Assistant Professor of Psychiatry and of Medicine at Rochester was to
organize a “liaison program,” which meant establishing himself as an attending on the inpatient medical
service, supervising fellows jointly appointed in Psychiatry and Medicine, conducting “ward walks and
conferences on the medical divisions,” and introducing a once-a-week elective “Psychosomatic Clinic” for
third- and fourth-year students and house officers. In 1947 Engel added a required course in
“Psychopathology” for second-year medical students, in which he offered “consideration of the concepts of
health and disease, with study of morbid psychologic experiences occurring at various life periods.” This
course also introduced students to the clinical skills and theoretical principles involved in medical
interviewing “as they relate to history taking and to psychotherapy.” In the early fifties arrangements were
made for Engel and his expanding group of liaison fellows and junior faculty to conduct required weekly
liaison conferences during the medical clerkship on each of the four inpatient floors. Unlike other liaison
programs, an important feature of Rochester’s was its staffing largely by internists, which gave members of
the liaison group credibility with their medical colleagues and allowed them to serve as effective role-
models for the students.

George also became a convert to psychoanalysis during his early years at Rochester. He began his
personal analysis with Sandor Feldman in August, 1946 and used the experience to explore such long-
resisted personal issues as the peculiarity of his family constellation dominated by Uncle Manny, the role of
his mother (Manny’s sister) in the daily household drama as a “classic hysteric,” and the identity-shaping
significance of being an identical twin.

Slide 7 – Engel family diagram

 Slide 8 – Engel twins (George and Frank)

George then pursued a training analysis at Franz Alexander’s Chicago Institute for Psychoanalysis (he
regularly commuted), where he learned the latest in psychoanalytic and psychosomatic theory, which he
eagerly incorporated into his work. But George did not absorb Alexandrian approaches uncritically and
remained an original and intellectually independent investigator. In 1953 he received a major research grant
from the United States Public Health Service and another from the Foundations’ Fund for Research in
Psychiatry. In 1954 he was elected president of the American Psychosomatic Society. The Liaison Group
had grown large enough to allow the redistribution of many of his responsibilities and to free up more of his
time for research. With a burst of energy, George undertook an ambitious new program of investigation,
with three major and overlapping areas of study: ulcerative colitis, psychogenic pain, and depression and
gastric secretion in a child with a gastric fistula, the famous “Monica” studies. Let’s focus on the latter.

These began when George and Franz Reichsman were fortuitously presented with a naturalistic
experiment on a infant, “Monica,” who was admitted to the Pediatric service of Strong in 1953. Monica had
been born with a congenital atresia of the esophagus, which required that two fistulas be established, one in
her neck to drain anything she took by mouth and one in her stomach through which she could be fed.
Monica was discharged from the hospital ten days after her initial surgery and for a while did well at home.
But when her home situation changed drastically, she failed to thrive, then dramatically declined, and was
eventually readmitted to Strong at fifteen months in a dangerously marasmic and developmentally retarded
condition. After she was nursed back to health and during a protracted hospitalization, Engel and
Reichsman undertook a series of studies on Monica. They believed that they had near perfect study
conditions to explore the connections between Monica’s behavioral responses, “object relationships,” and
gastric secretory activity. Their access to Monica’s detailed case history and multiple opportunities for
behavioral and physiological observation in the hospital let them probe and test various current
psychoanalytic theories of psychobiological development and depression.

Engel and Reichsman were especially struck by Monica’s characteristic reactions in the presence of new
experimenters (“strangers”) in stark contrast to her reactions in the presence of her favorite, familiar one
(Reichsman). In the first instance, Monica quickly lapsed into extreme motionlessness and inactivity, lying
flat on the bed with flaccid muscles, ultimately passing into a state of “depression-withdrawal” and then
sleep. In the latter instance, Monica quickly displayed unmistakable signs of pleasure. In each instance, her
gastric activity was characteristically different and fully integrated with her total behavior. During the
depression-withdrawal state and sleep, Monica’s hydrochloric acid production was markedly reduced and
almost ceased entirely. During pleasure, it was just as markedly elevated, especially during reunion with her
favorite experimenter.
 Slide 9 – Monica composite

Engel and Reichsman drew far-reaching conclusions from their experimental findings: “These data
suggest that in this infant ... the processes whereby relationship with objects in the external world are
established include a general intaking, assimilative organization in which the stomach participates as if the
intention is also to take objects into it.” They also concluded that their findings lent strong support to current
psychoanalytic theory: “From this it appears that the genesis of early object relations includes an
assimilative process, largely orally organized. The processes concerned in establishing mental
representations of objects and their libidinal and/or aggressive cathexes involve an essentially oral, intaking
model.” Most generally, they saw in Monica’s behavior evidence that “two basis processes contribute to the
development of a nuclear psychodynamic constellation which is potentially depressogenic. ... there is not
only the active, oral, introjective anlage emphasized in classic theory, but also an inactive, pre-oral, pre-
object anlage. ... Monica’s reaction of depression-withdrawal, including gastric hyposecretion ... [is]
representative of the inactive, pre-oral phase, while the response to the return of the ‘good’ object, with its
associated massive gastric secretion, provides the basis for a future introjective pattern.”

In 1954 and 1955 Engel and Reichsman made several major presentations of their Monica findings and
conclusions, which often included filmed highlights of their subject’s behavior. Their two most notable
presentations were on successive days in May, 1955 to the American Psychosomatic Society and the
American Psychoanalytic Association. At the latter meeting, their work was the focus of an all-day
symposium, with panel discussions featuring several of America’s leading psychoanalysts. One stated that
the study opened a new field of psychoanalytic research “through which visceral processes throw light on
mental events which could not be understood otherwise.” Another noted that the Engel-Reichsman
investigation “brings several aspects of psychoanalytic theory into sharper focus.” A third reported the
symposium in the Journal of the Psychoanalytic Association, concluding that “surely this work of Engel
and Reichsman (with the infant Monica) is and will remain a classic.”

Generalizing from his Monica studies and other clinical investigations, Engel soon led his colleagues in
the Liaison Group to a distinctive “Rochester style” of psychosomatic research. He first inspired William
Greene, who in the early fifties had begun general, somewhat diffuse studies of “psychological factors” in
patients with lymphomas and leukemias. In 1954-1955 he participated in a year-long “working conference”
that had been organized and directed by Engel “to consider the dynamics of separation and depression.”
After that experience, Greene summarized his principal conclusions in sharp and precise terms: “The
occurrence of various types of losses, separations, or threats of separation in a period of 4 years prior to the
apparent onset of lymphoma or leukemia is described. These included the loss of a significant person such
as the mother, father, husband, or child by death or illness ... Half of such separations or losses during the 4-
year prodromal period occurred during 1 year prior to the apparent onset. ... The majority of patients showed
an affect of sadness or hopelessness for weeks or months prior to the apparent onset.

Arthur Schmale also participated in Engel’s separation-depression conferences and became a major
contributor for several very productive years. In 1955 he began “a survey of the psychobiological problems
on a medical floor” which he completed two years later, demonstrating “a high incidence of separation and
depression preceding illness.” He reported that “31 of the 42 patients experienced the onset of disease
within a week after the final significant change in relationship” and that “24 patients and/or family members
... reported feelings of helplessness as the last predominant affect prior to the onset of the disease and
another 10 patients who had given up completely ... reported feelings of hopelessness.” Schmale cautiously
but provocatively concluded as follows: “The relatively short period of time between the final feelings of
helplessness and hopelessness and the onset of the medical disease ... suggests that there are changes in
biological activities related to these psychic reactions to unresolved loss. ... The exact influence of such
psychic giving-up on resistance, immunity, organ dysfunction, and cell growth and multiplication awaits
further study.”

Building on this increasingly sophisticated and suggestive work of the fifties, Engel and his Liaison
Group colleagues felt ready in the sixties to stride onto the national and international stage. Recognized at
the beginning of the decade with a Career Research Award from the National Institute of Mental Health,
Engel remained the central figure, contributing significantly to two major areas: the specialized field of
psychosomatic research and general internal medicine. Within the psychosomatic field, Engel developed
new theories of hysterical conversion phenomena and the disease onset situation and offered them as
alternatives to the (primarily Alexandrian) psychosomatic orthodoxies of the day. Within medicine more
broadly, he roamed widely, from critiques of current educational methods to searching examinations of the
deficiencies in contemporary clinical practice.

Engel foreshadowed much of this new work in 1962 when he published Psychological Development in
Health and Disease, a monograph outlining his own psychoanalytically-grounded psychobiological system.
Psychological Development was also a textbook based on his lectures – now considerably refined and
expanded – regularly delivered to second year medical students. The meatiest parts of the book were the last
two chapters, on the somatic consequences of “compensated” and “decompensated” psychological states,
about which Engel presents a complex and original synthesis of ideas derived from Freud, Walter Cannon,
Hans Selye, and the Rochester Liaison Group.

Engel then put these ideas on the national and international stage, beginning in 1965 and 1966. At
meetings of the American Psychoanalytic Association, the American College of Physicians, the Royal
Society of Medicine in London, among others, he presented papers exploring his new ideas about
conversion and the disease onset situation. He drew upon his own clinical work plus a careful review of the
literature to probe more deeply into the ways in which conversion mechanisms are not, as for Alexander,
“bounded by neuroanatomy” but may involve any parts or systems of the body having the “capability to
achieve mental representation.” Engel included clinical cases involving the skin, the upper respiratory tract,
and the upper and lower gastrointestinal tract to illustrate how remembered “perceptual gestalts” could be
the symbolic core of conversion reactions, often determining the timing and location of a broad range of
somatic manifestations. In many instances, these somatic manifestations might be complicated by associated
physiological or biochemical events following as natural but psychologically meaningless sequelae.

Engel also relied on his own and Schmale’s work to help sort out the psychological circumstances or
“life settings” in which diseases generally had their origin. Rejecting Alexander’s personality-based
“specificity” notions, he focused instead on a non-specific onset situation, a psychological complex of
“giving up-given up” characterized by the affects of helplessness and hopelessness, which significantly
“contribut[es] ... to the emergence of somatic disease ... if the necessary predisposing factors are also
present.” After real, threatened or symbolic psychic losses, many but not all patients experience feelings of
helplessness and hopelessness and, when they do, diseases or exacerbations of various kinds often soon
follow. Presumably because the psychobiological mechanism leading to further, as yet unspecified
physiological and biochemical consequences has already been triggered, persons who “give up” become
more vulnerable to pathogenic influences in the external environment or derangements in the internal one.

In 1967 George gave the keynote address to the annual meeting of the European Psychosomatic Society
and used the occasion to advertise the work of the Rochester group on the “chronological relationship ...
between disease and a psychological complex we are calling ‘giving up-given up.’” He identified the work
in which he and his colleagues were engaged as potentially the most fruitful that could be pursued in the
psychosomatic field.

For the time being I believe the most useful access to the psychosomatic interface is through
discovery of simultaneity or sequence of psychic and somatic phenomena, inadequate as that
may be. And the most pressing task is to study with the greatest care and in the finest detail
the characteristics of the psychic processes occurring in such time periods of simultaneity or
sequence. ... Accordingly, at this time I think refinement of psychological techniques is much
more important for us than refinement of physiological techniques. The less instrumentation
we place between ourselves and our patients at this time the better, for it serves to complicate
the relationship and blur psychological observation.
 Speaking before a larger and more general audience the following year, on April 4, 1968 George
delivered the William Menninger Award Lecture to the annual meeting of the American College of
Physicians, held that year in Boston in conjunction with the Royal College of Physicians of London. Soon
published in the Annals of Internal Medicine as “A Life Setting Conducive to Illness: The Giving-Up –
Given-Up Complex,” Engel’s Menninger Lecture broadcast his ideas of disease onset in internist-friendly
and psychoanalytically muted terms.

Slide 10 – Engel’s paper in Annals

It is no wonder that Chase P. Kimball, in his overview of “Conceptual Developments in Psychosomatic

Medicine: 1939-1969" published two year later in the Annals, called Engel and the Rochester group one of
the major “schools” in modern psychosomatic medicine and devoted a full quarter of his review article to
detailing its clinical and conceptual work.

George drew confidence for his appearances in the national and international medical spotlight from his
solid grounding in Rochester, which grew even more solid in the sixties. As in the fifties, the teaching of
interviewing skills was still begun in the first year of the medical curriculum, and Engel’s course on
“Medical Psychology and Psychopathology” was a mainstay of the second year. But a reform of third year
teaching implemented in 1966 institutionalized George’s psychobiological approach even more completely
in the Rochester curriculum. This was the development of a General Clerkship as an innovative,
interdepartmental introduction to the series of departmentally-based clerkships that defined the third year.
Spearheaded by Dr. William Morgan, recruited to the Department of Medicine in 1962, and by Engel, the
complex and faculty-intensive new course consisted of two major phases of closely supervised training.
During the first, five-week phase students learned techniques of physical examination and history taking;
during the second, six-week phase they progressed to “graduated patient responsibility” under the guidance
of a preceptor. Especially important in the new clerkship were the expanded role of the Liaison Group and
the corresponding emphasis on interviewing, psychological parameters of illness, and the process of clinical
reasoning. Morgan and Engel produced a new teaching manual for the clerkship emphasizing these skills,
which was first available in mimeographed form and subsequently published in 1969 as The Clinical
Approach to the Patient. Well beyond the weekly liaison rounds still run by Engel’s fellows during the
medical clerkship, all students were now thoroughly exposed at the gateway to clinical medicine to “the
numerous psychological facets of illness among the nonpsychiatric population.” In Rochester, Engel’s
psychologically-oriented approach was so thoroughly integrated into the curriculum that it was
indistinguishable from learning clinical medicine as such.
 When the seventies began, George was thus in very high gear. The Clinical Approach to the Patient
received a dual rave review in the Annals of Internal Medicine, where it was praised by one reviewer as “a
milestone in clinical medicine” and by the other (an editor of the journal) as a “medical classic.” George
was much in demand as a distinguished lecturer. He was, for example, the Edward Weiss Lecturer at Temple
University School of Medicine in 1975, and the Samuel Novey Lecturer at Johns Hopkins in 1976. Engel
used these occasions to address fundamental clinical issues such as the need for closely attentive and
rigorously scientific observation of the individual patient’s psychodynamics and the importance of
psychological stress in variously precipitating, in different patients, vasodepressor syncope, life-threatening
cardiovascular episodes, or sudden death. He also discussed these and related issues as a keynote speaker
and named lecturer at medical society meetings and in other honorific settings.

As the seventies unfolded, however, the ground under Engel began to shift. Notable changes overtook
several major fields of medicine, and these changes had important effects on George’s work and influence.
Most significantly, psychiatry and internal medicine underwent dizzying and dramatic shifts. In psychiatry,
the seventies were marked by the rapid decline of psychoanalysis (which really began in the sixties), the rise
of the neurosciences, and the general advance of an aggressive new biological psychiatry.

Slide 11 – Solomon Snyder’s diagram in Scientific American

In internal medicine, several large, interrelated shifts also became apparent. Departments of medicine felt
themselves reeling in “future shock” as they struggled with unsettling changes in size, subspecialty
fragmentation, geographic dispersion, and administrative balkanization. Tied to these changes were further
transformations: the displacement of physician-investigators by Ph.D.-trained biomedical scientists; the
refocusing of research from human subjects and disease processes to “basic” and increasingly molecular
events; and the alteration of study designs from selected patient cases to biostatistically refined clinical
trials. The cumulative impact of all these changes was readily apparent in the medical textbooks of the
seventies, especially in chapters on diseases long thought to have particularly clear psychosomatic
components. A comparison of the chapters on asthma and ulcer in the 1971 and 1979 editions of the Cecil-
Loeb Textbook of Medicine, for example, readily reveals a dramatic decline in psychosomatic orientation
distilled into the following comment in the 1979 edition: “Much has been written about a possible
psychogenic basis for asthma. More often than not, however, emotional problems prove to be a result rather
than a cause of the disease.” In short, the audience in mainstream medicine for Engel’s clinical and
scientific work shrank dramatically as the seventies progressed and seemed threatened with disappearance
by the decade’s end.
 George was also denied the opportunity to retreat to the “safe haven” of psychosomatic medicine,
because that field, too, was undergoing disconcerting changes. From Engel’s point of view, the problems of
psychosomatic research – already evident in the sixties – deepened in the seventies as animal “models,”
“stress” studies, and psychoendocrine bench research took over a larger and larger portion of the field and
tended to displace earlier, psychoanalytically-grounded clinical studies. During Herbert Weiner’s tenure as
editor of Psychosomatic Medicine from 1972 to 1982, the journal published many more studies of the kind
George found disconcerting. Moreover, Weiner’s 1977 Psychobiology and Human Disease emerged as the
dominant book in American psychosomatic studies of the decade, and its approach – based largely on
neuroscience – gave little solace to Engel, none of whose recent work shared this characteristic.

Slide 12 – Weiner’s 1977 Psychobiology

Because by the latter part of the seventies he was no longer at the forefront of clinical and scientific
research in medicine, psychiatry, or even psychosomatics, George increasingly assumed a new role. He
became primarily a spokesman for what Alvan Feinstein in 1970 had labeled “clinical exhortation,” that is,
the principled assertion of “the importance of patients and of attention to clinical phenomena in the medical
world of modern science.” Feinstein introduced this sardonic terminology after reviewing marked trends
toward basic and molecular research at the annual meetings of the American Society for Clinical
Investigation and the Association of American Physicians in the period 1953-1969 and noticing the
disconnect between what research papers actually contained and what leaders of these organizations said in
their presidential addresses. Papers were becoming narrower and more reductionist, but presidents were
waxing eloquent about old-fashioned clinical virtues.

With the changes underway in the seventies, George steadily assumed or was pushed into the role of
“clinical exhortor.” Then, in 1977, he heightened the intensity of his exhortation by beginning to appeal to a
comprehensive, “biopsychosocial model” as an alternative to the narrow and restrictive “biomedical
reductionism” that had become dominant in medicine.

Slide 13 – Engel’s 1977 Science paper

As he had done earlier in his career but now with a greater sense of urgency, Engel challenged reigning
medical orthodoxy – governed, he claimed, by a “paradigm” that had hardened into a “dogma.” He called
for the adoption of a broadly inclusive, “systems”-based, intellectual framework that legitimated, among
other things, the paying of close attention to the patient’s social needs and emotional realities and the
training of a new generation of “biopsychosocial” clinicians.

Slide 14 – Engel’s 1980 “Clinical Application” paper

 Although he struck a resonant chord with many and got considerable praise and attention for his
biopsychosocial model, George’s new exhortatory role had its limitations. He was still highly visible and,
by some, even more enthusiastically applauded than before, yet his strongest sympathizers acknowledged
that his alternative model sometimes received “lip service” rather than true support and predicted that real
acceptance “may be long in coming.” All this was made abundantly clear in the ulcerative colitis chapter in
the 1979 edition of the Cecil-Loeb Textbook of Medicine. In contrast to the chapter in the 1971 edition
which still gave considerable credence to George’s ideas, the chapter in the later edition dismissed his
approach with the comment: “[R]ecently, these [psychosomatic] concepts have been both challenged and
ignored by workers in the field.” Adding insult to injury, the author of the 1979 chapter misspelled Engel’s
name twice. Yet Engel’s “Biopsychosocial Model” was a rallying cry for many, not least in Rochester,
where it stood for the best in humanistic and psychosocially sensitive medical education and
multidimensional clinical care.

But it is fair to note that, even in Rochester, the Biopsychosocial Model has had some difficult moments
in the 21 years since George stepped down as Director of the Medical-Psychiatric Liaison Group. On the
one hand, the development of psychoneuroimmunology by Bob Ader, Nick Cohen, David Felten and others
has provided a brilliant new research foundation for many of the clinical insights of the biopsychosocial
approach.

Slide 15 – Ader’s 1981 PNI book

The approach has also remained firmly ensconced in first and second year teaching, even if it has lost some
ground in the General Clerkship and in the third and fourth year clinical curriculum more broadly. Yet the
Liaison fellowship program disappeared from Strong in the eighties and was only resurrected, after a
struggle and in modified fashion, at Genesee and Highland hospitals. In the early nineties, Tim Quill, Tony
Suchman and Rich Frankel built a new Program in Biopsychosocial Studies around that revived and
remodeled fellowship program, and in the later nineties members of the Program played a very active role in
the Medical School curriculum, both before and after the adoption of the “Double Helix” innovations. The
Biopsychocial Model has come a long way from its psychoanalytic and psychosomatic roots, but it seems
destined to stay as part of Rochester’s medical environment. George would be proud.

Copyright: The Author

Department of History
University of Rochester

Rochester, N. Y.

http://www.history.rochester.edu:80/history/fac/brown.htm

brown@prevmed.rochester.edu