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The Psychosomatic Arc in Therapy

Arno Remmers (Conference on Psychosomatic Treatment of WIP, Wroclaw 8. June 2018)

For clients and therapists it is helpful to have an easy to understand explanation of the reasons and treatment of psychosomatic disorders. In the following text i will show the “psychosomatic arc” in function, how it was called by Nossrat Peseschkian, who introduced 1988 his idea about that as an arc, painted on a flip chart in a post graduate seminar in the psychotherapeutic training center for psychotherapy in Wiesbaden, Germany. He marked the life event at the beginning of an arc, followed by the reaction of the central nervous system with an affective reaction. Consecutively neurotransmitters can change with the possibility to react with anxiety, aggression or depression in the next step. Afterwards the hormones influences followed by the vegetative nerve system can cause functional disorders, the psychosomatic symptoms. Finally the symptomatic body reaction at the end of the arc had been marked as an end point. At that time the neuroimmunological system had not been studied thoroughly enough to understand the regulation circles and neuromodulators. It was mainly a hypothesis of Nossrat Peseschkian about the interaction of the mentioned systems causing body dysfunctions or disorders, first published as a graphic in a book of N. Peseschkian in Bulgarian, developed and added by the editor A. Remmers.

Later some more research to explain the reactions within the psychosomatic arc could be added (Remmers A. 2008, 2010, 2011, 2013, Boncheva I. 2012). Starting point of any psycho-somatic activity is the perception of an event or a situation with our (preferred) senses, and this is very much depending on the personality as a “filter of perception” and on the underlying life experience. This specifically filtered information of the senses within less than 500 milliseconds causes a reaction of the brain stem and simultaneously goes to the brain. The brain stem reacts concerning to old memorised experiences within 0,5 seconds (!) affectively on the event, like in flight – fight – freeze schemes, resulting in fear – aggression – dissociation patterns. The brain has the possibility of a “veto” in the first second, not to think much about the consequences, because this needs more than a second, and will compare the event with concepts and memories typically, and even unique for this person. Upcoming conflicts between needs and limits, between values and expectations, safety and threat can influence the stress hormones and neuromodulators consecutively.

If there is any solution for the situation or conflict, or an understanding, meaningfulness and manageability (Antonovsky, Salutogenesis) in the observed, everything will be all right then, the mood will be balanced again. If the situation with its affective and emotional consequences continues, this information will influence neurotransmitters or neuromodulators, like they are called today. They will cause an affection, a specific mood – depressive, aggressive or anxious. A body reaction in mimic and skeletal tonus, in vegetative functions can be caused, a conflict reaction related to classical stress mechanisms. If the conflict situation continues, the autonomous system can create a specific change of the functions of the organs – somatoform autonom dysfunctional disorders, like described in ICD 10 as F45.3. Within these organic reactions of the individual reaction seem to be hidden subconscious meanings already as a pattern of possible body reactions, the suppressed “as if” reaction. This can be compared with what Alfred Adler had in mind with the “weak” organ that reacts – and the body “talks” with the symptom, concerning the subconscious needs of the person as a psychodynamic understanding of psychosomatic reactions in a specific cultural environment. “What somebody can and may feel... in a given situation, towards certain people or things, depends on social norms and rules. It is thus historically variable and open to change.” (Frevert, http://www.mpib-berlin.mpg.de/en/research/history-of-emotions)

If the “stress” or the inner conflict, or the challenging observation and its influence on concepts of this person goes on, it can become a “micro traumatic situation” (Peseschkian 1991) because of a continuing dissonance of perception and the formerly functioning old concepts. The neuro-immunological regulation system will change its activity using more than 60 different neuropeptides/immunopeptides, like different kinds of interleukin (IL1, IL6) or the tumour necrosis factor, TNF. These peptides are transmitting information between different immune cells, between immune cells and neurons, and also between neurons. This is the starting point of organic changes, like the described low immune activity in depression and grief, and as a consequence organic diseases of depressive persons more than in comparison to affective healthy persons. The opposite reaction is overreacting, or a one sided immune reaction, so that highly active auto immune processes might start destroying the own tissue – the auto immune disease can start on a basis of genetic vulnerability. This can influence many different kinds of organs like thyreoidea – M. Basedow, Hashimoto or others, Diabetes type 1, Colitis ulcerosa, Rheumatic diseases, M. Bechterew, Lupus Erythematodes. Lung, skin or eyes, all of them in a combination of genetic predisposition, environmental circumstances and actual start of auto immune activity are influenced by the affective status (mood, temperament) of the person, bonding/attachment experiences, and life events (trauma and emotional important events).

Psychotherapy, starting with accepting the symptoms in all its feelings and experiences can build up a trustful therapeutic relation. An ongoing process of labilization of old memories can change concepts of reactions in observed events, situations or feelings. On the basis of an emotionally corrective therapeutic experience in an emotional safe place a new kind of perception can start. Therapists different perception helps to widen the perception of the client. The former dysfunctional perception can be seen in its former meaningfulness for earlier experienced situations. Mentalisation of feelings will become possible with the help of the therapist by differentiation of contents and concepts. Re-connotation of meanings and values and a positive interpretation of the body symptoms as formerly useful reactions change the way of observation.

One of the most frequent difficulties in psychology, psychotherapy and medical treatment is to create a helpful therapeutic alliance with patients suffering from body complaints, often not feeling understood by the medical professionals when no body reasons are found. To take all symptoms very seriously, to understand them as a language of the patients body, to accept all kinds of description and language pictures is an important door to go to a healing process. Like in a good enough anamnesis the qualities of symptoms need to be found out until the patient gives a feedback, that the therapist really understood the way of individual experience. The way symptoms are expressed often show language pictures and subconscious meanings and values. Therapists can find language pictures, symbols or proverbs fitting the experienced situation to come to a common sense of understanding the way of suffering of the visitor.

In Psychosomatic Disorders the function of the disease is an interesting key to the next step of understanding the psychodynamic meaning. “To solve a problem we need to know first how to ask the question” (Cédric Villani 2013). So we need a simple structure for a question to be understood by the patient and the specialist as well. A first look to four areas of life, representing the balance model (slide), creates the question “What has changed after you have the symptom?”. Suffering and also the functions of the actual symptoms, the “positive interpretation” of the symptom are a possible result of this approach like described by N. Peseschkian 1977, 1991. S. Mentzos, German psychiatrist, calls it in his psychodynamic textbook the “functions of the dysfunctionality” (2010). The symptom can be seen as an expression of the organ, of the body in a language the patient does not understand. The vegetative or organ neurosis can be seen as a physiological side reactions of suppressed acting patterns and their emotional context continue to go on becoming chronic symptoms: a „mute“ pathophysiological fixation, concerning F. Alexander.

Listening exactly to the language of the patient brings out very often the hidden subconscious meaning of the symptom. Language pictures and sayings or proverb sometimes open the door to the patient’s fantasy (examples). So the next question might be “what is it about?” to find out the contents of the problem, the inner conflict, the inner dilemma, on which the body reacts. Positive psychotherapy found out of multicultural therapeutic interviews a list of typical capacities, called “actual capacities” because of their importance in the actual situation: “Secondary Capacities” as social norms on one side, “Primary capacities” on the other side as primary needs show the possible inner dilemma situation between internal needs and external expectations. These simple, understandable terms become now the basis for to understand the inner value conflicts, that cause finally the (in this case psychosomatic) symptoms.

A five step process is used in the positive psychosomatic treatment concerning N. Peseschkian (1991) and his co-workers. The actual life situation and way of suffering, and the function of the dysfunctionality of the symptoms can be discovered in a first step. The influence of the symptoms on everyday life can be discovered and understood as a function of the symptoms using the balance model, followed by understanding the values and value conflicts of the patient within the second step. Finding out the resources and actual coping strategies of the client in a third step becomes a basis for conflict solving, clearing or new interaction patterns trained with the therapist as a person in the fourth step, that includes to understand the inner conflict and basic conflicts causing the symptoms. In the therapeutic alliance it is possible to train patterns different from the former ones, this can create a new perspective. The therapeutic process causes first hope, even already when having the appointment for therapy, later an understanding of the situation, symptom function and reactions. Positive psychotherapy works with differentiation of contents and subconscious concepts. So the changed emotional atmosphere will change the immediate reactions of the brain stem not earlier than from 6 weeks on, as a reorganisation of the memories is needed. Brain stem parts help to memorise the new emotionally important encounters and events like the ones with the therapists, sometimes similar to re-parenting.

The effectiveness of the mentioned and herein used method “Positive Psychotherapy” (N. Peseschkian) in a realistic field situation was already under research with more than 30 therapists and more than 300 patients. It showed its long term effects on patients with affective, psychosomatic and anxiety disorders (Tritt K., Loew T. et al. 1999).