Book Review

Mind, Body, and Medicine: An Integrative Text

N Engl J Med 2002; 346:70-71January 3, 2002

Article

Mind, Body, and Medicine: An Integrative Text
By Raphael N. Melmed. 424 pp. New York, Oxford University Press, 2001. $49.95. ISBN: 0-19-513164-9

The belief of the Greek philosophers in the separateness of mind and body, although challenged from the beginning, has its counterpart in medicine. The importance of a holistic approach to a patient would seem to be self-evident, but the separation of psychiatric and somatic medicine occurred during the early 20th century and has been reinforced by the rapid development of biologic knowledge and ever-increasing specialization. The generalist movement, sustained by economic pressures, may be seen as medicine's challenge to the belief in the separateness of mind and body.

Mind, Body, and Medicine: An Integrative Text is a timely contribution to the reconciliation of body and mind in medicine. As Melmed points out, the title may be misleading because what he really attempts is “an integrative text” of mind and body in medicine. The first part of the book deals with somatization (why and how some patients express emotional stress through somatic symptoms), doctor–patient communication, the role of stress, the somatic expression of anxiety, and mechanisms of disease control. In the second part, Melmed deals with some specific clinical presentations, such as chronic pain syndromes, including visceral and thoracic pain, respiratory and cardiovascular expressions of anxiety, chronic fatigue, and depression. The last section discusses specific approaches for dealing with the psychosomatic aspects of disease: drugs, stress management, behavioral intervention, and relaxation.

The book is very well written and extremely well referenced. Melmed does not hesitate to use older references, which is welcome in these hectic times of progress and pseudoprogress in medicine. The chapters dealing with challenges in doctor–patient communication, hyperventilation, stress, and relaxation (and many others) are a pleasure to read.

It is evident that a textbook of 400 pages that attempts to integrate somatic and psychological presentations of disease will not satisfy everyone. Some readers will be disappointed by the absence of discussions of eating disorders, drug abuse, and sexual dysfunction. Others may be critical of Melmed's tendency to switch rapidly from very detailed and somewhat cumbersome biologic data to almost exclusively behavioral explanations and treatment proposals. A chapter about the newly rediscovered narrative medicine would have been welcome, and some reference to the old Freudian analytic approach would have been useful. The repetitions can be irritating, and some explanations in the text could have been summarized in figures (e.g., neurobiologic pathways) or tables (e.g., dosages and side effects of antidepressant drugs). This would have made the book more accessible to the hurried practitioner or resident.

It sometimes seems as if Melmed fears the final step — approaching the patient from the beginning in a truly holistic manner. Why should doctors first exclude somatic disease and only then consider an emotional process? It is well known that, with such a unilateral approach, more anxiety may be produced by clinical tests with false positive results. For most doctors, a negative result is still less exciting than finding a rare disease. An integrative approach should consider emotional and somatic disease together, right from the first encounter with the patient. Furthermore, some reflection on what is truly somatic and what is psychological would have been interesting. Fatigue is considered a somatic symptom. But is it really? As the author points out, depression causes many somatic symptoms, and upper respiratory tract disease may be followed by depression. A truly integrative writer on the mind–body connection should challenge the often artificial classification of diseases as psychiatric or somatic entities.

Does Melmed reach his goal, which he states is “to convince medical practitioners, whether primary care physicians or medical specialists, that the great majority of psycho-physiological processes may be relatively easily understood and effectively managed”? Maybe not; neurobiologic and psychobiologic pathways are as complicated as the patients who suffer from psychosomatic diseases. However, despite some deficiencies, the book can be recommended to physicians who want a wide view of psychosomatic diseases as seen through the eyes of an erudite internist and behaviorist and to residents who, during their training, may not have been introduced to these problems.

Hans Stalder, M.D.
Hôpitaux Universitaires de Genève, 1211 Geneva, Switzerland
hans.stalder@hcuge.ch