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All aging is psychosomatic
Presidential Addresses Academy of Psychosomatic Medicine 29th Annual Meeting
All aging is psychosomatic FRED O. HENKER III, M.D.
All aging is psychosomatic. Such a statement might be difficult for some to accept, especially those who interpret "psychosomatic" to mean only imaginary physical complaints or emotionally-induced functional disturbances or even actual physical disease mediated by emotional tension. ' Nevertheless, the term is an appropriate one to describe both the process itself and a logical approach to medical care of aging people. We will cover the subject by first discussing the meanings of the two focal terms: "aging" and "psychosomatic"; then we will examine the four major categories of psychosomatic interaction in the light of the phenomena of aging. Aging First, let us consider aging-defined as a progressive loss of functional capacity after an organism has reached maturity, eventually resulting in death. 2 First signs begin to appear as early as the 30s. 3 The changes follow an insidiously progressive course, yielding annoying symptoms such as forgetting names of persons just met, need for bifocals, or falling hair during the 50s; gradually increasing through the 60s, 70s, and 80s until a state of incapacity or vulnerability is reached that is incomRead as the address of the President-Elect, 29th Annual Meeting of the Academy of Psychosomatic Medicine, November 19,1982, Chicago. Dr. Henker is professor ofpsychiatry and behavioral sciences at the University of Arkansas for Medical Sciences. Reprint requests to him there, 4301 W Markham, Lillie Rock, AR 72205. MARCH 1983 • VOL 24 • NO 3
patible with life. Individuals below age 75 who have not yet accumulated significant impairment are referred to as "young old" or said to manifest normal aging, while those above 75, the "old old," are in or nearing disabling impairment or pathologic aging. 4 The cause of this deterioration is physical-loss of cells. From age 35 to 75 the total number of cells in the human body diminishes by about 30%. Accordingly, there is a progressive loss of neurons at a rate of about 1% per year from prime development, around age 50, reaching 30% to 40% by old age, 85 to 90.5 This loss of neurons is not uniform. Some people lose more cells quicker than others and some brain regions suffer more drastically than others. For instance, the cells of the cerebral cortex are particularly vulnerable. The pattern of this deterioration is governed by two basic processes: primary aging and secondary aging.4 Primary aging sets the timing of decline, including rate and ultimate limits. It is genetically determined and generally fixed for each species, yet slight variations occur from individual to individual on a familial basis. For human beings the ultimate possible life span, before aging leads to death, falls in the early onehundreds, with a few possible exceptions such as the Abkhasians of the Georgian Republic of the U.S.S.R. We cannot simply say that this decline 'Just happens"; nor is the use of the label "old age" a sufficient answer. Numerous theories have been developed regarding the mechanism underlying aging. These include DNA chain breaks, random radiation impacts on the genetic apparatus, errors in RNA information transfer, cross 131
Aging is psychosomatic
linkage between polypeptide strands, and adverse antibody development, to list only a few. 6 Probably these mechanisms operate both singly and as multiples. Do what we may, we have not been able to extend the upper limit of primary aging during recorded history. Secondary aging, on the other hand, involves processes amenable to change, such as cell damage resulting from disease, trauma, and the way we live our lives. 4 Regulation of diet. tobacco, alcohol, drugs, and activities can help greatly here. Even if ultimate life expectancy has not been changed, the number of those approaching it has increased greatly. 'Psychosomatic' Now we come to the term "psychosomatic," a concept vitally important to all of medicine. The American Psychiatric Association glossary defines it as "the constant and inseparable relationship of p.~vche (mind) and soma (body).'" Though many use the word with widely different meanings, this interpretation is the most valid. Subsumed under it would be any somatic reaction or mobilization in response to any emotional state: mental distress precipitated by any somatic disturbance; mental disorder resulting from any organic brain impairment; and even mental tranquility associated with an optimal physical state.~ Clinically there are four main categories of psychosomatic interrelationship: • Organic mental disorders or psychic disturbances resulting from physical impairment of the brain • Psychological factors affecting physical condition, a category formerly called "psychophysiologic disorders" • Adjustment disorders, which are mental reactions precipitated by significant disturhances within the physical body or in its relationship with its environment • Subjective somatic complaints in the absence of somatic pathology Each of these categories will now be discussed briefly as it applies to aging. Organic mental disorders The appropriate question to ask is not "Does this aging person have organic mental disorder?" but "Is the amount of organic mental disorder he has significant?" Since all persons past their prime years are losing neurons, all have some degree of mental impairment. It may be so minimal as not to be detectable on ordinary examination, since cognition, performance, and social skills are shielded to a point by the brain's immense reserve capacity: nevertheless, imperceptible compromise exists and gradually increases. Adaptive reserve 232
and coping potential become eroded. New challenges and crises are met with increasing difficulty, depending on the weight of the demand on the psychic side and the extent of neuron loss on the somatic side. In less severe combinations, there is simply a reduction in happiness or security feeling; yet some impairment is there. In cases of increased severity there is increased anxiety, either experienced as adjustment disorder or else capable of precipitating any of the neurotic or psychotic disorders found in younger age groups. When deterioration is rapid, or in individuals who have undergone slow decline over a very long time, impairment of mental functions comes to interfere significantly with general adjustment and is termed "dementia." Fortunately, the incidence is surprisingly low. Less than 5% of those over 65 develop diagnosable senile dementia. 3 There are still other components of neuron loss, an important one being release and accentuation of the basic personality heretofore restrained in the interest of social adaptation. Losing varying degrees of formerly held control, these persons become more like their true selves. A quiet introvert becomes schizoid; a defensive, thin-skinned person becomes suspicious or even paranoid; and a free and easy conversationalist becomes a chatterbox. One special type of release applies to emotion, where frank expression of feelings, especially hostility and sadness, becomes increasingly difficulty to contain. All of these illustrate impairment of the psyche produced by aging of the soma, in particular the brain. An optimistic note here is that many of the destructive processes fall in the realm of secondary aging and some 100 of them are amenable to medical treatment. 9 Psychological factors affecting physical condition Practically any illness, when examined closely, can be seen to have psychic influence-through predisposing weakening, precipitating stress; adverse influence of somatic components of emotion; or aggravation from injudicious behavior. The aging are particularly susceptible. They may predispose themselves to illness through improper diet, inadequate protection from the elements, medication noncompliance, and poor hygiene. States of depression and hopelessness, when present, lower resistance and increase susceptibility to disease. 1O Because of the frustrating and adverse situations the elderly face, emotional tension is more likely to become elevated sufficiently to place them at greater risk for such classic disorders as hypertension, peptic PSYCHOSOMATICS
ulcer disease, colitis, rheumatoid arthritis, bronchial asthma, and coronary occlusion.s When such factors come to bear upon bodies already insulted by primary and secondary aging, we have fertile ground for the class of disorders now classified under "psychological factors affecting physical condition."
Adjustment disorders Personality disorders precipitated in ordinarily welladjusted individuals by obviously disruptive adversity are termed "adjustment disorders,"" another class of psychic disturbances produced by physical insult. Everyone has a breaking point, and the aging, because of their compromised coping potential and reduced adaptive reserve, are usually at greater risk than younger individuals. Furthermore, there is increased likelihood of adversity at this time. Physically there is the progression of chronic disease; decreased resistance to new pathology; degradation of body image; deterioration of organs, appendages, and functions; and the specter of approaching death. Situationally, the elderly face creeping loss of acclaim in a youth-oriented culture; loss of occupational meaning through retirement; loss of companionship through deaths of relatives, friends, and spouse; loss of financial security because of fixed income in an inflationary economy; and finally loss of home security through consignment to a nursing home. Current psychiatric nomenclature subclassifies adjustment disorders according to the delineating psychic manifestation: with depressed mood, with anxious mood, withdrawal, disturbance of conduct, and work inhibition. Aging patients occasionally report physical symptoms as a means of securing a physician's support in dealing with adjustment problems.
Subjective somatic complaints Elderly persons are notorious for somatic complaints for which no somatic explanation can be found. Current psychiatric nomenclature places such symptoms in the general category of somatoform disorders, which comprises the specific entities of (I) somatization disorder, (2) conversion disorder, (3) psychogenic pain disorder, and (4) hypochondriasis. I I Similar unfounded physical complaints occur in depression, schizophrenia, and paranoid disorders. The dynamics of this general class of symptoms vary widely but three psychological mechanisms are prevalent: (1) withdrawal of interest from other persons or objects and centering on oneself, one's body and its functioning; (2) shift of anxiety from a menacing area to a less threatening concern with body MARCH 1983 • VOL 24 • NO 3
disorder; and (3) use of physical symptoms as a means of self-punishment and atonement for unacceptable feelings toward associates. 4 As involvement in the fabric of life decreases, the aging have less and less to occupy their attention, leaving more and more space for concern with physical functions. Rational handling of such physical complaints will lead toward the underlying psychic disturbances and away from unnecessary diagnostic procedures and medication.
Conclusion Thus, aging has been shown to be subject to every phase of psychosomatic interaction. It can be a very gratifying and productive period to a point for many, but it cannot be guaranteed to be a picnic for all. Through the psychosomatic approach to medicine we will do well for our profession and for our fellow human beings to: • Encourage preparation in early life for more enjoyable late life • Be alert for remediable secondary aging factors, which through proper care can yield longer normal aging before pathologic aging begins • Provide guidance in fullest realization of existing potential to sustain function as long as possible • In every case, provide adequate care for both the somatic and the psychic aspect of every aging patient • When pathologic aging has befallen the old-old, see that ample provisions are made for adequate, wholesome, hygienic, compassionate care until they experience death with dignity unhampered by heroic measures sustaining a vegetative existence. 0 Supported in part by N J M H grant M H05903·31.
REFERENCES 1. Henker FO: ConflicTing definilions of lhe term ·psychosomatic.· Psychosomatics 20:8-11. 1982. 2 Strehler BL: The BiOlogy of Aging. Washington. DC. American Institute of Biological SCiences. 1960. 3. Braumstein JT: Medical Applications of the Behavioral Sciences. Chicago. Yearbook Publishers. 1981 4. Busse EW: Behavior and Adaptation in Late Ufe, ed 2 Boston. Little. Brown, 1977. 5. Walsh TF: Steer your paTients to healthy old age. Patient Care 6 (June 15). 1972. 6. Verwoerdt A: Clinical Geropsychiatry. BalTimore, Withams & Wilkins. 1981 7. A Psychiatric Glossary. ed 5 Washington DC. American Psychiatric Association, 1980. 8. Eaton MT: Psychiatry. ed 4. Omaha, Medical ExaminaTion Publishing Company. 1981. 9. Special Report on Aging: 1979. US Dept of Health, Education, and Welfare publication No. (NIH) N080-1907, 1980. 10. SChmale AH: RelaTionship of separaTion and depreSSion to disease. Psychosom Med 20:259. 1958 11 Diagnostic and Statistical Manuat of Mental Disorders. ed 3 Washlnglon. DC. American PsychiatriC AssociaTion. 1980
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All aging is psychosomatic FRED O. HENKER III, M.D.
All aging is psychosomatic. Such a statement might be difficult for some to accept, especially those who interpret "psychosomatic" to mean only imaginary physical complaints or emotionally-induced functional disturbances or even actual physical disease mediated by emotional tension. ' Nevertheless, the term is an appropriate one to describe both the process itself and a logical approach to medical care of aging people. We will cover the subject by first discussing the meanings of the two focal terms: "aging" and "psychosomatic"; then we will examine the four major categories of psychosomatic interaction in the light of the phenomena of aging. Aging First, let us consider aging-defined as a progressive loss of functional capacity after an organism has reached maturity, eventually resulting in death. 2 First signs begin to appear as early as the 30s. 3 The changes follow an insidiously progressive course, yielding annoying symptoms such as forgetting names of persons just met, need for bifocals, or falling hair during the 50s; gradually increasing through the 60s, 70s, and 80s until a state of incapacity or vulnerability is reached that is incomRead as the address of the President-Elect, 29th Annual Meeting of the Academy of Psychosomatic Medicine, November 19,1982, Chicago. Dr. Henker is professor ofpsychiatry and behavioral sciences at the University of Arkansas for Medical Sciences. Reprint requests to him there, 4301 W Markham, Lillie Rock, AR 72205. MARCH 1983 • VOL 24 • NO 3
patible with life. Individuals below age 75 who have not yet accumulated significant impairment are referred to as "young old" or said to manifest normal aging, while those above 75, the "old old," are in or nearing disabling impairment or pathologic aging. 4 The cause of this deterioration is physical-loss of cells. From age 35 to 75 the total number of cells in the human body diminishes by about 30%. Accordingly, there is a progressive loss of neurons at a rate of about 1% per year from prime development, around age 50, reaching 30% to 40% by old age, 85 to 90.5 This loss of neurons is not uniform. Some people lose more cells quicker than others and some brain regions suffer more drastically than others. For instance, the cells of the cerebral cortex are particularly vulnerable. The pattern of this deterioration is governed by two basic processes: primary aging and secondary aging.4 Primary aging sets the timing of decline, including rate and ultimate limits. It is genetically determined and generally fixed for each species, yet slight variations occur from individual to individual on a familial basis. For human beings the ultimate possible life span, before aging leads to death, falls in the early onehundreds, with a few possible exceptions such as the Abkhasians of the Georgian Republic of the U.S.S.R. We cannot simply say that this decline 'Just happens"; nor is the use of the label "old age" a sufficient answer. Numerous theories have been developed regarding the mechanism underlying aging. These include DNA chain breaks, random radiation impacts on the genetic apparatus, errors in RNA information transfer, cross 131
Aging is psychosomatic
linkage between polypeptide strands, and adverse antibody development, to list only a few. 6 Probably these mechanisms operate both singly and as multiples. Do what we may, we have not been able to extend the upper limit of primary aging during recorded history. Secondary aging, on the other hand, involves processes amenable to change, such as cell damage resulting from disease, trauma, and the way we live our lives. 4 Regulation of diet. tobacco, alcohol, drugs, and activities can help greatly here. Even if ultimate life expectancy has not been changed, the number of those approaching it has increased greatly. 'Psychosomatic' Now we come to the term "psychosomatic," a concept vitally important to all of medicine. The American Psychiatric Association glossary defines it as "the constant and inseparable relationship of p.~vche (mind) and soma (body).'" Though many use the word with widely different meanings, this interpretation is the most valid. Subsumed under it would be any somatic reaction or mobilization in response to any emotional state: mental distress precipitated by any somatic disturbance; mental disorder resulting from any organic brain impairment; and even mental tranquility associated with an optimal physical state.~ Clinically there are four main categories of psychosomatic interrelationship: • Organic mental disorders or psychic disturbances resulting from physical impairment of the brain • Psychological factors affecting physical condition, a category formerly called "psychophysiologic disorders" • Adjustment disorders, which are mental reactions precipitated by significant disturhances within the physical body or in its relationship with its environment • Subjective somatic complaints in the absence of somatic pathology Each of these categories will now be discussed briefly as it applies to aging. Organic mental disorders The appropriate question to ask is not "Does this aging person have organic mental disorder?" but "Is the amount of organic mental disorder he has significant?" Since all persons past their prime years are losing neurons, all have some degree of mental impairment. It may be so minimal as not to be detectable on ordinary examination, since cognition, performance, and social skills are shielded to a point by the brain's immense reserve capacity: nevertheless, imperceptible compromise exists and gradually increases. Adaptive reserve 232
and coping potential become eroded. New challenges and crises are met with increasing difficulty, depending on the weight of the demand on the psychic side and the extent of neuron loss on the somatic side. In less severe combinations, there is simply a reduction in happiness or security feeling; yet some impairment is there. In cases of increased severity there is increased anxiety, either experienced as adjustment disorder or else capable of precipitating any of the neurotic or psychotic disorders found in younger age groups. When deterioration is rapid, or in individuals who have undergone slow decline over a very long time, impairment of mental functions comes to interfere significantly with general adjustment and is termed "dementia." Fortunately, the incidence is surprisingly low. Less than 5% of those over 65 develop diagnosable senile dementia. 3 There are still other components of neuron loss, an important one being release and accentuation of the basic personality heretofore restrained in the interest of social adaptation. Losing varying degrees of formerly held control, these persons become more like their true selves. A quiet introvert becomes schizoid; a defensive, thin-skinned person becomes suspicious or even paranoid; and a free and easy conversationalist becomes a chatterbox. One special type of release applies to emotion, where frank expression of feelings, especially hostility and sadness, becomes increasingly difficulty to contain. All of these illustrate impairment of the psyche produced by aging of the soma, in particular the brain. An optimistic note here is that many of the destructive processes fall in the realm of secondary aging and some 100 of them are amenable to medical treatment. 9 Psychological factors affecting physical condition Practically any illness, when examined closely, can be seen to have psychic influence-through predisposing weakening, precipitating stress; adverse influence of somatic components of emotion; or aggravation from injudicious behavior. The aging are particularly susceptible. They may predispose themselves to illness through improper diet, inadequate protection from the elements, medication noncompliance, and poor hygiene. States of depression and hopelessness, when present, lower resistance and increase susceptibility to disease. 1O Because of the frustrating and adverse situations the elderly face, emotional tension is more likely to become elevated sufficiently to place them at greater risk for such classic disorders as hypertension, peptic PSYCHOSOMATICS
ulcer disease, colitis, rheumatoid arthritis, bronchial asthma, and coronary occlusion.s When such factors come to bear upon bodies already insulted by primary and secondary aging, we have fertile ground for the class of disorders now classified under "psychological factors affecting physical condition."
Adjustment disorders Personality disorders precipitated in ordinarily welladjusted individuals by obviously disruptive adversity are termed "adjustment disorders,"" another class of psychic disturbances produced by physical insult. Everyone has a breaking point, and the aging, because of their compromised coping potential and reduced adaptive reserve, are usually at greater risk than younger individuals. Furthermore, there is increased likelihood of adversity at this time. Physically there is the progression of chronic disease; decreased resistance to new pathology; degradation of body image; deterioration of organs, appendages, and functions; and the specter of approaching death. Situationally, the elderly face creeping loss of acclaim in a youth-oriented culture; loss of occupational meaning through retirement; loss of companionship through deaths of relatives, friends, and spouse; loss of financial security because of fixed income in an inflationary economy; and finally loss of home security through consignment to a nursing home. Current psychiatric nomenclature subclassifies adjustment disorders according to the delineating psychic manifestation: with depressed mood, with anxious mood, withdrawal, disturbance of conduct, and work inhibition. Aging patients occasionally report physical symptoms as a means of securing a physician's support in dealing with adjustment problems.
Subjective somatic complaints Elderly persons are notorious for somatic complaints for which no somatic explanation can be found. Current psychiatric nomenclature places such symptoms in the general category of somatoform disorders, which comprises the specific entities of (I) somatization disorder, (2) conversion disorder, (3) psychogenic pain disorder, and (4) hypochondriasis. I I Similar unfounded physical complaints occur in depression, schizophrenia, and paranoid disorders. The dynamics of this general class of symptoms vary widely but three psychological mechanisms are prevalent: (1) withdrawal of interest from other persons or objects and centering on oneself, one's body and its functioning; (2) shift of anxiety from a menacing area to a less threatening concern with body MARCH 1983 • VOL 24 • NO 3
disorder; and (3) use of physical symptoms as a means of self-punishment and atonement for unacceptable feelings toward associates. 4 As involvement in the fabric of life decreases, the aging have less and less to occupy their attention, leaving more and more space for concern with physical functions. Rational handling of such physical complaints will lead toward the underlying psychic disturbances and away from unnecessary diagnostic procedures and medication.
Conclusion Thus, aging has been shown to be subject to every phase of psychosomatic interaction. It can be a very gratifying and productive period to a point for many, but it cannot be guaranteed to be a picnic for all. Through the psychosomatic approach to medicine we will do well for our profession and for our fellow human beings to: • Encourage preparation in early life for more enjoyable late life • Be alert for remediable secondary aging factors, which through proper care can yield longer normal aging before pathologic aging begins • Provide guidance in fullest realization of existing potential to sustain function as long as possible • In every case, provide adequate care for both the somatic and the psychic aspect of every aging patient • When pathologic aging has befallen the old-old, see that ample provisions are made for adequate, wholesome, hygienic, compassionate care until they experience death with dignity unhampered by heroic measures sustaining a vegetative existence. 0 Supported in part by N J M H grant M H05903·31.
REFERENCES 1. Henker FO: ConflicTing definilions of lhe term ·psychosomatic.· Psychosomatics 20:8-11. 1982. 2 Strehler BL: The BiOlogy of Aging. Washington. DC. American Institute of Biological SCiences. 1960. 3. Braumstein JT: Medical Applications of the Behavioral Sciences. Chicago. Yearbook Publishers. 1981 4. Busse EW: Behavior and Adaptation in Late Ufe, ed 2 Boston. Little. Brown, 1977. 5. Walsh TF: Steer your paTients to healthy old age. Patient Care 6 (June 15). 1972. 6. Verwoerdt A: Clinical Geropsychiatry. BalTimore, Withams & Wilkins. 1981 7. A Psychiatric Glossary. ed 5 Washington DC. American Psychiatric Association, 1980. 8. Eaton MT: Psychiatry. ed 4. Omaha, Medical ExaminaTion Publishing Company. 1981. 9. Special Report on Aging: 1979. US Dept of Health, Education, and Welfare publication No. (NIH) N080-1907, 1980. 10. SChmale AH: RelaTionship of separaTion and depreSSion to disease. Psychosom Med 20:259. 1958 11 Diagnostic and Statistical Manuat of Mental Disorders. ed 3 Washlnglon. DC. American PsychiatriC AssociaTion. 1980
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