Every human illness is psychosomatic, since it affects a being whose body and mind are inseparable anatomically and functionally. For this reason, the expression psychosomatic illness is not very appropriate, since it implies that there are other illnesses that are not psychosomatic, that is, with a separation between the psyche and the soma. Body and mind are indivisible, and from this perspective, all illnesses are psychosomatic, because they affect both the psyche and the soma. However, in the biological view of current medicine and in the curricular structure of most medical schools, there is a fragmentation of the human being, who is studied in parts and systems, and not as a whole. Consequently, in this scenario, one learns to treat illnesses, and not sick people, who have a biological, psychological and social existence.

This article aims to highlight the importance of the emotional mechanisms involved in the genesis of illnesses and in the doctor/patient relationship, valuing the psyche and trying to understand in a global way what is happening to the patient in order to offer more effective treatment.

This more holistic view of the patient becomes essential in adolescence, as this is a period of many and great transformations, with the experience of new conflicts and the reactivation of old ones(7). In adolescence, in particular, a comprehensive view of the human being is essential.

It is necessary to emphasize that the disease has a social and cultural character, based not only on the social and economic conditions of the population, but on the social relations of production(5). Illness is also deeply influenced by sociocultural issues. Certain symptoms in one social class may not be considered as such in another. The perception of sensations is unequal in the different social classes. For example, the sensations that follow a large meal may represent discomfort, heaviness in the stomach for the upper classes, but, for the lower classes, they may mean postprandial euphoria, being full, satisfied (2).

The interpretation that individuals give to their disease and its symptoms differs according to moral, cultural and religious concepts. These cultural differences delimit ways of perceiving and interpreting conflicts, causing somatization in some and verbalization in others. Symptoms of diseases have different representations for each person. The individual’s relationship with their own body determines how they become ill and how they care for themselves.

When treating a patient, one must understand the possible meaning of the symptom presented. Illness does not happen by chance nor is it an isolated fact in the life of the individual. It occurs when the organism is vulnerable, due to personal history, genetic background, and social situation. The organism suffers aggressions from internal and external environments that disturb its homeostasis, thus generating the disease.

PSYCHOSOMATIC THEORIES

Several theories attempt to explain the relationship between biological and psychological manifestations. Didactically, we can say that two currents stand out. The first is based on the effect that emotions have on the organism through the nervous system and its neurotransmitters (psychophysiology). The second current is based on psychoanalytic theory, which attempts to clarify some psychological mechanisms involved in the genesis of diseases. Regarding

psychophysiology, the medical literature reports several studies. Some classic works, such as that of Cannon(6), prove the physiological changes in states of hunger, anger, and fear that occur due to the influence of the vegetative nervous system. Another theory, McLean’s(10), describes the reflex arc as a basic functional unit, which captures stimuli from the outside world through the afferent or sensory pathway, as well as from the inner world, and through the nervous center, which is distributed along the neuroaxis, reaches the efferent or effector pathway, which transmits impulses to the viscera, locomotor system and other regions. This set of structures was given the name of the limbic system, which comprises the cerebral cortex (temporal lobe and lower zones of the frontal lobe), the septal area, the amygdaloid complex, the hippocampus and the hypothalamus. The limbic system, upon receiving internal or external stimuli, transforms them into a somatic or physical activity (a scream, a facial expression, a sudden body movement, a circulatory or digestive change, etc.). The perception of the limbic system is not intellectual. It is the anatomical substrate that establishes the connection between affect, thought and the visceral system(9).

In development theory, according to psychoanalysis, an individual in the first year of life only reacts to external stimuli through the vegetative nervous system. He or she is not yet able to verbalize or express himself or herself through gestures, as he or she does not have the motor coordination to do so. Therefore, at this stage, communication is pre-verbal and vegetative functions are of great help in understanding psychosomatic processes. The possibility of somatizing is a defense mechanism established in the oral stage of development. Whenever the mother/child relationship is not good, the baby will react physically(8). This initial stage of human development, in which the mother/child relationship is fundamental, leaves marks for the rest of life. When an individual faces moments of crisis, he or she may react by reactivating psychosomatic processes with which he or she will resolve past problems. Spitz(12), in his work observing babies in the first year of life, drew attention to the psychosomatic reactions of babies who did not receive adequate care at this stage. Infantile eczema appears as a reaction to hostile and anxious maternal treatment, with anaclitic depression and marasmus being consequences of partial or total maternal deprivation. The author concludes that disturbances in the formation of the baby’s first object relations probably result in serious harm to the child’s future relationships in adolescence and adulthood.

Winnicott(14), with his extensive clinical experience and scientific research, emphasizes the importance of the baby’s early care in its future life. He emphasizes that a healthy development of the human psyche favors physical evolution and that emotional difficulties can generate serious somatic situations. According to Pierre Marty’s psychosomatic theory(3), the individual reacts to traumas according to his or her mental evolutionary organization. Each person has a peculiar way of reacting and somatizing traumas, depending on his or her life history and genetic background. The human being is a complex system of interactions that may or may not be in balance. An external trauma may be more disruptive for some than for others, depending on each person’s internal organization. When a person suffers a trauma, there is a movement of internal disorganization that first affects the most evolved structures, recently acquired during development. By knowing the psychosomatic economy of a person, we can predict their most likely mode of reaction to trauma and how they organize themselves later.

PSYCHOSOMATIC APPROACH The frequency of patients with symptoms called psychosomatic

in health servicesis large. According to Smith (11), the incidence of psychological problems among American adolescents reaches approximately 25% (anxiety, depression, eating disorders and somatizations). In Brazil, Crespin (1986), in a survey of 630 adolescents in private practice about the reasons for consultations, found that sociopsychosomatic complaints were the most numerous, representing 32.69% of the total.

However, even symptoms that are not called psychosomatic have a latent psychological content that is almost never externalized and whose understanding is desirable for the improvement of the disease. In the psychosomatic approach, the aim is to emphasize not only the symptoms that led the patient to the health service but also the understanding of their latent content.

When an important psychological component that aggravates the disease is identified, the health professional refers the patient to a psychiatrist or psychologist. Frequently, however, the person does not accept or pretends to accept such guidance and does not seek the psychotherapist. When the health professional listens to emotional issues, identifies some causes and allows the patient to understand that there are feelings linked to their symptoms, this attitude makes it more likely that they will accept the need to undergo psychotherapy. This behavior of the health professional already characterizes psychotherapy. Balint(1), in his book The Doctor, His Patient and the Disease , analyzes the doctor/patient relationship and notes that the most commonly used medicine in medicine is the doctor himself, who also needs to be familiar with his dosage, side effects and toxicity .

The anamnesis of the clinical consultation with a psychosomatic approach aims to learn as much as possible about the patient, his illness and also the environment in which he lives. Sometimes the patient gives reports that, apparently, have no relation to the illness, but later prove to be extremely important in understanding his clinical condition. Some data that are not normally privileged in the traditional clinical anamnesis should be valued in the psychosomatic approach, such as those listed below:

• ask the patient what he thinks he has, what the possible cause of his illness is;
• what he thinks makes his problems better;
• what consequences the disease has caused in your personal life;
• investigate the patient’s most significant bonds: mother, father, siblings, friends, girlfriends/boyfriends;
• ask about daily life at home, at school and in the community where you live;
• investigate the models of somatization and family organic disorder.

The collection of these data and the traditional anamnesis help to better contextualize the disease. The patient becomes co-responsible for the treatment, leaving behind a passive stance to actively act in the improvement and providing a lower cost of therapy, with fewer medications and complementary exams.

COMMON PSYCHOSOMATIC SYMPTOMS IN ADOLESCENCE

In adolescence, psychosomatic symptoms are frequently related to the stage of development. In the early phase (11 to 14 years), changes in the body, masturbation, and the definition of sexual identity are the main stressors. In middle adolescence (14 to 17 years), the conflicts that appear are related to attempts to become independent from the family and in relation to the beginning of romantic relationships. In the late phase (17 to 20 years), the main problems are related to starting a career, concerns about the future, and spiritual and philosophical issues. The most common psychosomatic

symptoms in adolescence are headache, chest pain, abdominal pain, and persistent fatigue (4,13). HEADACHE The usual clinical investigation should be carried out by ruling out any underlying disease, such as those with a neurological, ophthalmological, or otorhinolaryngological cause, etc. Headache without a well-defined organic cause is usually mild or moderate in intensity and does not prevent the adolescent from continuing to perform normal daily activities. It is often diffuse, chronic, intermittent, and occurs during the day or at the end of the day. The patient rarely wakes up with pain in the morning or in the middle of the night. It is common for the adolescent to relate the pain to tiredness, stress, or worry. In the diagnostic investigation, the health professional should check for the presence of something that is causing stress in the environments in which the adolescent lives: home, school, work. Another common finding is the presence of headaches in family members. Clinical consultation with a psychosomatic approach helps the patient understand the origin of the symptoms, and is a time when the patient has the opportunity to express his or her fears. This provides relief from his or her anxiety, since the adolescent often thinks he or she has a serious problem, such as a brain tumor. Treatment can also be done by controlling stress and administering analgesic, vasoconstrictor and antidepressant medications. CHEST PAIN

Common in anxious and depressed patients, it is generally unrelated to physical exertion or other associated cardiac or respiratory symptoms. The physical examination is normal. Pain accompanied by palpitations, which may indicate the presence of cardiac arrhythmia, should be carefully observed. When no other organic factors are found to justify the pain, issues related to certain types of stress that are not regularly reported, such as sexual abuse, fear of pregnancy, etc., should be investigated in greater depth. Sometimes the pain is similar to heart problems that have occurred in close family members. Treatment includes educating the patient about the possible origin of the symptoms, intervention in the environment to remove possible stressors, relaxation, psychotherapy, and anxiolytic or antidepressant medications in more severe cases.

ABDOMINAL PAIN

This is generally an ill-defined pain, with an imprecise location, unrelated to food intake or intestinal function. It is chronic, of mild to moderate intensity, and sometimes accompanied by paleness and headache. Pain usually improves with adequate rest, a healthy diet, guidance on quitting smoking, and controlling the use of chewing gum, soft drinks, and alcoholic beverages.

CHRONIC FATIGUE

Parents often complain about their adolescent children’s fatigue and excessive sleepiness. In these cases, the association with chronic infectious, immunological, and allergic problems should be investigated. The etiology, however, remains poorly defined, and some authors attribute such chronic fatigue to a latent depressive condition. Symptoms improve with guidance on changing lifestyle habits, resuming pleasurable physical activities, and using antidepressants in more debilitating situations.

FINAL CONSIDERATIONS

The psychosomatic approach focuses on the patient, not the disease, and attempts to understand its meaning. Relating a physical symptom to an emotional problem requires care and patience, and is rarely achieved in a first consultation. To do this, it is necessary to collect a detailed history, focusing the investigation on the patient, and not on their symptoms, and giving them a chance to express their feelings. Illness is often an escape from a conflict situation or appears due to the need for attention and affection, the need to be cared for. Some health professionals, when they identify that the origin of the patient’s symptoms is not an organic pathology, tend to classify the illness as psychological and undervalue it, not giving due attention to the patient’s suffering. It should be remembered that, even if there is no anatomical substrate that justifies the symptom, the patient feels it and needs help to get rid of it.

The psychosomatic approach reduces treatment time, avoids unnecessary additional tests, and shortens patient suffering.