Scott O. Lilienfeld and Candice Basterfield
Evidence-based therapies stemmed from the movement toward evidence-based medicine, and later, evidence-based practice (EBP) in psychology and allied fields. EBP reflects a progressive historical shift from naïve empiricism, which is based on raw and untutored observations of patient change, to systematic empiricism, which refines and hones such observations with the aid of systematic research techniques. EBP traces its roots in part to the development of methods of randomization in the early 20th century. In American psychology, EBP has traditionally been conceptualized as a three-legged stool comprising high-quality treatment outcome evidence, clinical expertise, and patient preferences and values. The research leg of the stool is typically operationalized in terms of a hierarchy of evidentiary certainty, with randomized controlled trials and meta-analyses of such trials toward the apex. The most influential operationalization of the EBP research leg is the effort to identify empirically supported treatments, which are psychotherapies that have been demonstrated to work for specific psychological conditions. Still, EBP remains scientifically controversial in many quarters, and some critics have maintained that the research base underpinning it is less compelling than claimed by its proponents.
Depression is defined in diagnostic literature as a mood disorder characterized by depressed mood, loss of interest or pleasure in activities, significant changes in weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, difficulty concentrating, and suicidal ideation and/or attempts. Research suggests a link between depressed mood and monoamine depletion, elevated cortisol, and inflammation, but existing laboratory evidence is inconclusive. Current treatments for depression include selective serotonin reuptake inhibitors (SSRIs), cognitive behavioral therapy (CBT), and lifestyle changes; however, more severe forms of the disorder can require other medication, sometimes in combination with electroconvulsive therapy (ECT).
Disagreement persists over how to define and classify depression, in part due to its ambivalent relationship to melancholia, which has existed as a medical concept in different forms since antiquity. Melancholia was reconfigured in 19th-century medicine from traditional melancholy madness into a modern mood disorder. In the early 20th century, melancholia gradually fell out of use as a diagnostic term with the introduction of manic-depressive insanity and unipolar depression. Following the publication of DSM-III in 1980 and the introduction of SSRIs a few years later, major depressive disorder became ubiquitous. Consumption of antidepressants have continued to rise year after year, and the World Health Organization notes depression as the leading cause of disability worldwide.
At present, internationally recognized systems of classification favor a single category for depressive illness (alongside a circular mood disorder, bipolar I and II), but this view is challenged by clinicians and researchers who argue for the reinstatement of melancholia as a separate and distinct mood disorder with marked somatic and psychotic features.
Psychosomatics concerns those physical disorders not caused by an organic event but caused by psychological events. These disorders, called “psychosomatic,” may involve different organs and systems and it is possible a wide range of cases of possible psychosomatic disorders.
The term psychosomatics itself represents all the complexity and tension of this discipline. It contains a dualism that contrasts with the theory at the heart of psychosomatic medicine—the functional and synergistic unitary nature of soma and psyche.
The psychosomatic problem represents the original nucleus at the inception of the psychoanalytic movement that concerns itself precisely with the physical disorders devoid of an anatomopathological substratum. With the development of the libido theory and the resulting hypotheses on the development of neurosis, Freud proposed a model that integrates the somatic, psychic, and social component, and it represents in a convincing way physical diseases that occur as a result of psychological events. Freud created two distinct approaches in the explanation of psychosomatic disorders: the first makes use of a system of conversion of the psychic into the somatic, and the second raises problems of biological nature, in the sense that a psychological factor (anxiety) would directly activate the sympathetic system and therefore the organic functions it controls.
The conflict theory was the first major paradigm of psychosomatic medicine, and most efforts by the first generation of psychosomatists aimed to test this hypothesis and identify psychological conflicts that were typical of patients suffering from diseases considered psychosomatic in nature. Some scholars—such as Federn, Goddeck, Deutsch, Dumbar and Alexander, Schultz-Hencke, von Weizsäcker, Schilder, Schur, de Mitsherlich, de Boor—starting from the Freudian psychoanalysis, emphasize a particular psychoanalytic mechanism interpreted as a cause of psychosomatic disorders. The panorama of contemporary psychosomatics is certainly much more varied than the classical one, and new proposals and conceptions have emerged alongside the psychoanalytic model. The main contemporary models aim to integrate the knowledge of medicine and psychoanalysis into a coherent and unitary theoretical whole. The goal is therefore the unification of the ontological and scientific dualism that sees the body of medicine as opposed to the psyche of psychoanalysis. The contemporary theories all converge in the analysis of the original mechanisms of formation and development of subjectivity that is named according to the search to address ego, self, or identity.