What's in a name? Psychosomatic medicine and biobehavioral medicine.

This issue marks the 70th anniversary of the founding of Psychosomatic Medicine. It is also the inaugural issue for adding, Journal of Biobehavioral Medicine as our new subtitle. Why, after 70 years of successful publication, does our journal now have a subtitle? Why was this particular subtitle chosen? And what does this change mean for the future of the journal? In their introductory editorial in January 1939 (1), Helen Flanders Dunbar and her associate editors noted that “psychosomatic medicine” was a new term that was not yet well known in the medical community. They expressed concern that it could lead to misconceptions and misunderstandings unless it was clearly defined. They defined it as the study of the “. . . interrelation [of] the psychological and physiological aspects of all normal and abnormal bodily functions . . ..” They rejected mind-body dualism in psychosomatic medicine, asserting that “. . . the complex neurophysiology of mood, instinct, and intellect differs from other physiology in degree of complexity, but not in quality,” and that “. . . psychic and somatic phenomena take place in the same biological system and are probably two aspects of the same process . . ..” The contents of the first issue of Psychosomatic Medicine reflected this perspective, and today’s readers would find that some of the articles in that issue concerned surprisingly contemporary topics. For example, it included an article on the role of hostility in essential hypertension (2) and a review of experimental research on the structure and functions of the hypothalamus (3). Thus, from its very beginning, Psychosomatic Medicine has been publishing articles on the roles of the central and peripheral nervous systems, and of psychological, behavioral, and social variables, in the development and progression of cardiovascular disease, diabetes, obesity, cancer, and other serious medical conditions. While rejecting mind-body dualism, the original editors embraced two other kinds of dualism. One of them pertained to the types of medical conditions and outcomes that were considered to be within the field’s and the journal’s domain. In addition to papers on relatively “hard” medical outcomes, such as cardiovascular disease, early volumes also included articles on “soft” outcomes, such as conversion hysteria and functional gastrointestinal complaints (4). In the ensuing years, many other papers also focused on similar problems, such as chronic pain, somatoform disorders, and unexplained somatic symptoms, such as chronic fatigue (5). The other kind of dualism concerned the psychiatric and psychological factors that were thought to be plausible explanations for the outcomes of interest. Some were observable phenomena, or at least were measurable via self-report questionnaires, psychophysiological instruments, human or animal experiments, or other objective techniques; were reasonably familiar to nonpsychiatric physicians and laypeople; and could be readily described in common sense terms. Examples included factors, such as hostility (2), frustration (6), tension (7), depression (7), and various types of overt behavior (8). Others were unobservable psychoanalytic constructs that were more obscure for nonpsychiatrists, such as intrapsychic conflict (9), oral dependence (10), and hypertrophied conscience (11). Over the years since our founding, the relatively soft and obscure strands of psychosomatic medicine have, unfortunately, helped to foster some of the misconceptions and misunderstandings that our founders hoped to prevent. The term “psychosomatic” has acquired a variety of meanings, and some of them are quite negative. For example, a 1994 survey of newspapers in the United States and the United Kingdom found that, out of 215 articles in which the word “psychosomatic” was mentioned, 34% used it in a stigmatizing, pejorative manner; it often connoted a symptom or condition that was considered to be imaginary, unimportant, malingered, or due to a character flaw (12). “Psychosomatic” also carries negative connotations for many laypeople (13) as well as for many physicians and nurses (14,15), especially in some countries and cultures. In addition, psychosomatic complaints figure prominently in a substantial proportion of the clinical encounters with which many physicians would rather not have to contend, i.e., those with “difficult patients,” “frequent attenders,” and “excessive utilizers” (15–23). Some patients who are dismissed as presenting baseless psychosomatic complaints, actually have unrecognized medical conditions, such as hypothyroidism (24), but this fact does little to burnish the image of psychosomatic disorders among physicians. Regardless of the negative reactions that these phenomena may elicit from some quarters, they continue to have a substantial impact on patients’ quality of life and on their patterns of healthcare utilization (25,26). We still publish some of the best articles on somatoform disorders, chronic fatigue syndrome, chronic pain, etc. (24,27,28), and will continue to do so. In recent years, however, interest in these disorders has been eclipsed by “hotter” topics, in terms of the manuscripts we receive, the ones we publish, and the ones that have the highest impact. For example, we have published numerous articles on the genetic substrates of psychological phenotypes, Franz Alexander (Associate Editor for Psychoanalysis), Dana W. Atchley (Internal Medicine), Stanley Cobb (Neurology), Hallowell Davis (Physiology), Clark L. Hull (Psychology), Howard S. Liddell (Comparative Physiology), Grover F. Powers (Pediatrics), and Theodore P. Wolfe (Reviews). In addition to serving as the first Editor-in-Chief of Psychosomatic Medicine, Dr. Dunbar was one of the founders of the American Psychosomatic Society, the journal’s owner. The full text of every issue of Psychosomatic Medicine, dating back to January 1939, is available online at www.psychosomaticmedicine.org. DOI: 10.1097/PSY.0b013e3181954848