PSOMAT Psychotherapy With Patients With Psychosomatic Disorders

Psychotherapy
with Patients with

Psychosomatic Disorders
GEORGE C. CURTIS
e-Book 2015 International Psychotherapy Institute
From The Theory and Practice of Psychotherapy With Specific Disorders by Max Hammer, Ph.D.
Copyright 1972 by Max Hammer, Ph.D.
All Rights Reserved
Created in the United States of America

Table of Contents
TYPES OF PSYCHOSOMATIC DISORDERS
PSYCHOSOMATIC ETIOLOGY
THERAPEUTIC CONSIDERATIONS
REFERENCES
www.freepsychotherapybooks.org 4
Psychotherapy with Patients with Psychosomatic Disorders
In approaching the treatment of psychosomatic disorders it is first
necessary to consider what a psychosomatic disorder is. This is by no means

simple. The expression psychosomatic does not refer to a discipline, a field
of study nor a medical subspecialty, but to a point of viewa way of thinking
about any process which involves the total human organism. This way of
thinking is synthetic and tries to apply all available information and methods
which might be useful, whether from psychodynamics, sociology,
anthropology, pathology, pharmacology, genetics, physiology, immunology,
medicine, surgery or related fields. In practice however, the elements for

synthesis vary not only with the problem under consideration but also with
the capacities and experience of the synthesizer. The term psychosomatic
has been criticized on the grounds that it implies a mind-body dichotomy

rather than unity of mind and body. In the present writers opinion, the term
and the viewpoint to which it refers are forerunners of a general systems

approach to health and disease.
One of the cardinal principles both in psychosomatics and in general
systems theory is that events within a system or level of description
psychological, social, anatomical, physiological and so forthmust be studied
by methods appropriate to that level and described in the language of that

level. Only after this has been done may events from two or more levels be
The Theory and Practice of Psychotherapy with Specific Disorders 5

correlated. Thus if we wish to study physiological changes in anxiety we
cannot use physiological data to infer the presence of anxiety; if we do, our
reasoning will be circular. If we wish to study psychodynamic patterns in
thyroid disease, we cannot use psychodynamic data to infer the presence of

thyroid disease nor medical data to infer the presence of psychodynamic
patterns. These statements may seem truisms, but their principles are
ignored with surprising frequency.
The term psychosomatic is also used in a more limited sense to refer
to a causal sequence from above downwardthat is, in which events at the
psychological-psychodynamic level appear to influence events at some lower
order of complexity, such as gastric motility or cardiovascular dynamics. This
usage is in contrast with the term somatopsychic which implies the

opposite causal sequence, such as the effect of brain damage on mental
function or psychological reactions to physical disease. Psychosomatic events
have somatopsychic feedback and vice versa, so that in a strict sense there are
no purely psychosomatic or somatopsychic sequences. Nevertheless the
distinction is convenient and necessary for ordering certain types of

observations.
When the term disorder is added to the term psychosomatic, one
ordinarily means clinical conditions in which psychosomatic causal

sequences are inferred. Some idea of the diversity of these conditions may be
conveyed by the following classification, which should be considered as
illustrative rather than definitive.
TYPES OF PSYCHOSOMATIC DISORDERS
Somatic Complaints of a Purely Ideational Nature
These are symptoms which express ideas and do not depend on
physical changes in the areas complained of. Needless to say, the ideas may
be, and often are, unconscious.
Somatic Delusions and Hallucinations
Although the idea expressed by these symptoms is conscious, it can and

usually does stand in the place of other ideas and feelings which are not
conscious. A patient may complain that he has pain and heaviness in his chest
because his heart has turned to stone or he has nausea and indigestion
because he is rotten inside. If the patient is grossly psychotic, the nature of
the complaint is quickly recognized. If his cognitive functions are relatively

intact and he has only an isolated somatic delusion, then its true nature is
easily missed. Being aware that people may think him crazy, he consults a
general physician complaining only of chest pain or indigestion. On finding
nothing wrong, the physician reassures him that his complaint is due to
nerves, and the patient seeks elsewhere for someone to soften his heart of

stone or to remove the rottenness inside. The examples chosen happen to be
ones which convey feelings of self-accusation, but this type of body
language may be used as well to express ideas related to other impulses and
feelings. This type of complaint must, of course, be distinguished from
delusional explanations erected on organically based symptoms, as for
example pains of angina pectoris1 interpreted as messages from heaven.
Obsessions About the Body
Somatic obsessions also express in body language ideas related to
unconscious wishes. However, the patient recognizes them as irrational, even
if this recognition does not bring relief of anxiety. As in the case of delusions,
the consciously expressed idea stands instead of unconscious ones.
Hypochondriasis
This term is used loosely to refer to multiple bodily complaints which

do not depend on physically based sensations. They are usually obsessional,
delusional or a mixture of the two.
Conversion Reactions (Hysteria)
Like somatic delusions and obsessions, conversion reactions also
express in body language ideas related to unconscious wishes. Instead of
appearing in conscious thought they appear involuntarily in charade or
pantomime in which the players are organ systems. In the early days of
psychoanalysis all psychosomatic disorders were assumed to be conversion
reactions, even those with marked tissue damage; ones blood pressure,
ulcers, bleeding from the bowel, etcetera, were all assumed to be symbolic
expressions of unconscious ideas. Following World War II, there was a

widespread reaction against this view. Many students of psychosomatics then
felt that unconscious ideas could be expressed only by the sensory and
voluntary motor symptoms and that the diagnosis of conversion reaction or

hysteria should be confined to symptoms in these systems. Despite explicit
statements of this sort, a number of symptoms involving involuntary systems
continued to be recognized as hysterical, such as vomiting and false
pregnancy (including cessation of menstruation). The earlier view was never

completely supplanted, and Sperling, for example, continued to regard
ulcerative colitis as a pregenital conversion in which bleeding from the bowel

symbolizes a traumatic separation in the form of an abortion.
More recently, Engel and Engel and Schmale have marshalled

substantial evidence that the conversion mechanism may underlie a wide
variety of involuntary symptoms. They further maintain that tissue damage
may occur as a complication of conversion reactions, although the damage
itself is not the conversion reaction and does not have primary psychological
meaning. Through the process of secondary symbolization the damage may,

of course, still acquire psychological meaning after it has developed.
Medical Consequences of the Patients Behavior
This is a heterogeneous group of disorders, some of which excite the

interest of psychosomatic workers and some of which do not. As a rule
interest in the damage caused by suicide attempts, hepatic cirrhosis2

following alcoholism or illnesses aggravated by heavy smoking is not
regarded as psychosomatic interest. Interest in obesity, on the other hand, is
regarded as psychosomatic interest. Most cases of obesity are caused by

eating more calories than are consumed by bodily activity. The mystery lies in
the reason for the dissociation between physiological need for food and
eating. It is generally recognized that neurotic and psychotic conflicts may

contribute to any of these behaviors, but there is no agreement as to whether
similar psychodynamic constellations underlie similar external behaviors.
Behavior which is not necessarily neurotic may also have medical
consequences, as for example, the eating of diets high in cholesterol which
seem to contribute to the development of coronary artery disease.
Psychophysiological Symptoms
In this category belong symptoms such as perspiration and pounding of

the heart in anxiety attacks, constipation and anorexia in depression, aching
muscles and joints resulting from chronic muscular tension, spastic colon,
emotional diarrhea, upset stomach due to emotional tension and so forth. The
complaints involve physical processes at the site of the symptoms. The heart
does usually beat more forcefully and rapidly during anxiety attacks. The
various digestive disturbances are related to changes in the function of the
gastrointestinal tract, and chronic muscular tension can be demonstrated by
electrical measurements. Though inappropriate to the situation, the
symptoms do not exceed the limits of normal physiological function, do not

involve structural damage to the tissues and usually subside with the
emotional state of which they are a part. It has not so far been possible to
make rigid connections between specific symptoms and specific types of

emotion, though some loose correlations, such as those mentioned above, do
seem to exist. One or more symptoms may appear in the absence of, or
instead of, more overt emotional displays. Such symptoms are often called
affect equivalents. It may be difficult to know whether one is dealing with a

normal but inappropriate affect equivalent or with a conversion in an
involuntary system, and there may indeed be no sharp separation. Physicians

other than psychiatrists often refer to symptoms in this category as
functional symptoms, indicating that they are generated by physiological

functions and that there is no identifiable disease.
Psychophysiological symptoms are produced by autonomic nervous
system discharges to heart, lungs, digestive glands, the adrenal medulla and

the digestive tract or by motor nerve discharges into skeletal muscles.
Physiological discharges in emotional states are not limited to the autonomic
and voluntary muscle systems but include the endocrine glands as well. The
biological effects of neuroendocrine secretions are so profound as to affect

the function of virtually every cell and tissue in the body. However, it is
doubtful whether the secretion of hormones during emotional discharges
gives rise to consciously perceived symptoms.
Psychic fatigue is a more complex symptom. Apparently it may be due in
part to the added work imposed on cardiovascular and muscular systems by

nervous discharge. Another contributing factor may be sleep loss. On the
other hand the sensation of fatigue may disappear suddenly with a change of
mood, suggesting that it also involves central perception and interpretation.
Psychic Aggravation of Existing Chronic Disease
It is sometimes unclear whether a particular disorder belongs in this
category or the following onePsychosomatic Diseaseswhich have

psychic components in their etiology. Where psychic factors are involved in
initial causation, they are usually also involved in subsequent aggravation.
However, the reverse need not be true. Psychic aggravation may be striking
and obvious in cases where psychic involvement in initial causation is more

difficult to establish.
Cardiovascular diseases are among those in which psychic aggravation
is clearest. Congestive heart failure or cardiac decompensation is an excellent
example. Persons whose hearts have been damaged in such a way as to
diminish permanently the working capacity of the heart are said to have
diminished cardiac reserve. By various combinations of medication, diet and
limitation of physical exertion, it is usually possible to keep the demands
upon the heart within its capacity to meet them. So long as this is the case, the
heart disease is said to be compensated. A compensated system
decompensates when the hearts work capacity is reduced further or when
fresh demands are placed upon and exceed its capacity. One of the most
common types of fresh demand is an emotional upset, the physiological

effects of which are similar to those of physical exertion. The symptoms of
cardiac decompensation are similar regardless of the cause and include
breathlessness, accumulation of fluid in the lungs and tissues, and a shortage

of oxygen in the tissues. Hospitalization, oxygen and additional medication
are often necessary in order to reestablish a state of compensation. In a study
of twenty-five consecutive hospital admissions for congestive heart failure

(cardiac decompensation) Chambers and Reiser found that emotional stress
was a major precipitating factor in 76 percent.
Another type of mismatch between supply and demand can occur when
the coronary arteries, which carry the blood supply to heart muscles, are
diseased. In the absence of physical or emotional stress, the diseased vessels

are often able to meet the heart muscles demands for the delivery of blood,
yet fail to meet the increased demands imposed by added emotional stress. In
this way emotional stress may precipitate attacks of angina pectoris3or even
ful-blown myocardial infardtions.4
In patients so disposed, emotional stress may also precipitate attacks of

irregular heartbeat, apparently mediated by emotional effects on the
autonomic nervous system. The heart is less efficient when beating
irregularly and this in turn may precipitate an attack of congestive heart
failure if cardiac reserve is already reduced by disease. The writer once had
the opportunity to observe a dramatic example of this in which a woman
suffered from obesity and severe rheumatic heart disease.5 Her disease was
adequately compensated until a rejection by her family precipitated an attack
of auricular fibrillation, one type of irregular heartbeat and congestive heart

failure. A successful physician-patient relationship was never established. The
auricular fibrillation and congestive heart failure proved refractory to
medical treatment and the patient eventually died. She did not reveal the
emotional rejection to her physicians, who learned of it through other sources
shortly before her death.
The emotional state can and frequently does alter the insulin
requirements of diabetics to such an extent that a previously well-regulated
patient is precipitated into an episode of diabetic6 acidosis7 or coma. The
other common precipitants of acidosis are infections, failure to take insulin
and departures from the diet.
Psychosomatic Diseases
In this category belong a number of physical disease entities, usually
with pathological tissue changes and always with functioning in some organ
system which is not only inappropriate but abnormal. In addition to the
impact of emotional factors upon the course of the illness once it is

established, there are further reasons to believe that emotional factors also
play a significant role in producing the illness. It would seem reasonable to
suppose that a period of functional disorder in an organ or system might
precede the onset of a psychosomatic disease. This has been shown to be true
of ulcerative colitis8 in which the onset of structural bowel changes is usually

preceded by years of functional bowel disturbances. As another example,
peptic ulcer9 is often preceded by acid indigestion. It is frequently difficult

to establish clinically the point at which one becomes the other. The onset of
essential hypertension10 is frequently preceded by labile blood pressure.

However, psychophysiological symptoms do not necessarily lead to
psychosomatic disease.
There is no rigorously established list of diseases which are and are not
psychosomatic. In several, however, psychic etiological factors have been

noted as especially prominent and are traditionally regarded as
psychosomatic. These include peptic ulcer,11 ulcerative colitis,12 essential
hypertension,13 thyrotoxicosis,14 migraine headaches,15 rheumatoid
arthritis16 and various allergic manifestations such as bronchial asthma, hay
fever, urticaria (hives) and eczema. There are also some grounds for
considering diabetes mellitus,17 pernicious anemia,18 coronary artery disease

and malignant lymphomas19 as partly psychogenic in etiology. The
appropriateness of dividing diseases into psychosomatic and non-
psychosomatic categories has been challenged and evidence introduced that
psychic factors may play a role in the development of any illness. It should be
understood, however, that at the present time only a very small minority of
workers consider any illness with pathological tissue changes to be purely

psychogenic. The majority hold that psychic and physical factors interact to
produce the disease.
PSYCHOSOMATIC ETIOLOGY
It is paradoxical that almost no one has serious doubts that

psychophysiological complaints and psychosomatic diseases exist, yet there is
very little agreement as to how they are brought about. Of the various
theories of psychosomatic etiology, none has had sufficiently rigorous and

extensive validation to warrant final acceptance or rejection. The obstacles to
accomplishing these tasks are the familiar ones in psychiatric research:
complexity of the psychological data, confusion as to which psychic trait or
traits should be related to which illness or biological process, insufficient
precision and resolving power of the psychological methodology and
difficulty of obtaining adequate sampling of patients or adequate control of

contaminating variables.
One of the common themes running through all psychosomatic theory is
the issue of specificity versus non-specificity. Specificity implies that a specific
type of psychic event or process is related to a specific type of somatic event.
It has been suggested, for example, that compulsive personality goes with
ulcerative colitis20 ; that the emotion of anger is related to the secretion of the
noradrenalin, and fear or anxiety to the secretion of adrenaline; that intense
oral needs are related to the secretion of pepsinogen; that depressive illness
is related to depletion of brain catecholamines; and so forth. Non-specificity

implies that the quantity of psychic stress is related to the quantity of
physiological disturbance, but that the type or quality of one is unrelated to

the type or quality of the other. Most theories of non-specificity are not stated
in such extreme terms but tend in this direction. The following theories to be
discussed, and a number of others not considered here, combine specificity
and non-specificity in a variety of ways.
Pavlov

Pavlov was highly critical of psychological concepts, which he regarded
as unscientific. Nevertheless his work provided one of the first
demonstrations, in the modern scientific sense, that psychosomatic processes
are possible. In the course of research on the physiology of digestion he
discovered the conditioned reflex, demonstrating that a stimulus which
became a signal of food could produce physiological effects similar to those of
food itself. The secretion of saliva and gastric juices which he studied were
end results of parasympathetic nervous activity. Pavlov was mainly
interested in these responses as a method for studying the physiology of the
cerebral cortex, of the making and breaking of temporary connections
between stimuli, and of their facilitation and inhibition. He left to others the
main tasks of studying the peripheral effects of conditioned responses. The
specificity of his theory was higha specific stimulus, related to a specific
response, in an individual with a specific set of previous experiences.
Cannon
Cannons work was crucial in providing a comprehensive view of the

autonomic or involuntary nervous system with its two divisions, the
sympathetic and the parasympathetic. He suggested that the activity levels in
all branches of the sympathetic system rise and fall together, while the
activities of the different parasympathetic branches vary independently of

each other. This was expressed by the analogy of a piano in which the keys
represented different branches of the parasympathetic system and the loud-
soft pedal represented the sympathetic system. The parasympathetic system
promoted functions of reparation and reproduction such as digestion,
defecation, urination and copulation; it also inhibited functions promoted by

the sympathetic system. The sympathetic system discharged en masse during
fear and rage, making preparation for and supporting the metabolic
requirements of muscular exertion, fight and flight; these included

acceleration of the heart rate, shifting of blood from viscera to muscles,
mobilizing sugar into the bloodstream, accelerating the clotting of blood and
inhibiting most of the functions which are enhanced by the parasympathetic
system. Subsequent developments have supported most of his views but with
important exceptions. The sympathetic system has proved much more plastic
and flexible than he imagined, thus allowing it to participate with the

parasympathetic and endocrine systems in producing a great variety of
centrally programmed arrangements of cardiovascular, digestive and

metabolic function, both in preparation for anticipated events and in
response to current requirements. Consequently, the physiological changes in

fear and rage are much less stereotyped than he suggested.
One of the most striking departures from Cannons all-or-none view of

sympathetic function is Millers finding that autonomically mediated
functions may be modified by instrumental learning. By appropriate
contingencies of reward and punishment, rats whose skeletal muscle

responses had been paralyzed by curare were trained to raise or lower their
blood pressure, to increase or decrease intestinal motility or to modify blood
vessel tone unilaterally in one or the other ear. While the role of these
mechanisms in psychosomatic etiology is unclear, their discovery opens many

possibilities which were previously unsuspected and which may be of very
high importance.
Cannons influence on psychosomatic theory was enormous, especially
since the autonomic nervous system was in his time the only known pathway
by which the brain might influence involuntary body functions. For many
years it was known that the endocrine glands regulated important metabolic
and reproductive functions and that the pituitary gland regulated the other
endocrine glands. Only relatively recently was it recognized that the brain is
an important regulator of the pituitary.
Cannons theories were nonspecific psychologically. Fear, rage,
resentment, tension, pain or anxiety, or almost any emotional disequilibrium

might provoke a fight-flight physiological pattern. Physiologically they were
highly specific.
Selye
Selye proposed the concepts of stress and the general adaptation
syndrome, after Cannon had made major contributions but before the role of
the brain in pituitary regulation was recognized. His concepts were based on
the finding that a wide variety of injurious stimuliincluding but not limited
to toxins, burns, severe cold and mechanical injuryprovoked the release of
ACTH from the pituitary which in turn stimulated the release of corticoid
hormones from the adrenal cortex. Adrenal hormones influence a wide

variety of metabolic functions as well as biological defense reactions such as
inflammation and antibody production; without adrenal hormones it is
impossible to adapt to environmental changes and shifts in metabolic

demands. Any stimulus which provoked ACTH release was defined as a
stressor. Emotional distress was also found to provoke ACTH release and
thereby emotional stimuli were placed in a class with biologically injurious
ones. Selye recognized the psychosomatic implications of this concept and

proposed that a number of the traditionally termed psychosomatic illnesses
be called diseases of adaptation. He further suggested that they might be
caused by a disordered stress response in which there was an imbalance

between adrenal cortical hormones and somatatropic hormone.
Selyes theory, like Cannons, was psychologically nonspecific but highly

specific physiologically. Later work has confirmed and extended his finding
that emotional stimuli can provoke ACTH release. However, the stereotyped
regularity of ACTH release by emotional stimuli predicted by Selyes theory

has yet to be demonstrated. The suggestion that mild endocrine influences
due to psychic factors might contribute to physical illness remains plausible

but unproved. The element of preparation for anticipated events, which
figured so highly in Pavlovs and Cannons ideas, was absent from Selyes.
However, it has since become clear that the pituitary-adrenal axis does make
anticipatory responses.
Alexander
As mentioned previously, Alexander was instrumental in

deemphasizing the role of conversion reactions in systems which are
normally involuntary and hence in the production of organic disease. From
experiences of his own and his followers in psychoanalyzing patients with
psychosomatic diseases, he concluded that a specific nuclear unconscious

conflict is characteristic of patients with each disease, that the conflict
originated in early childhood and, in most cases, long antedated the onset of
the disease. The physiological by-products of unconscious strivings
associated with the conflict caused chronic hyperactivity in the appropriate

organ system and eventually led to a breakdown of normal structure and
function in it. For example, peptic ulcer21 patients were thought to have
especially intense but repressed passive oral and oral aggressive strivings
which were defended against by reaction formations resulting in overt
behavior of ambition, hard work, self-reliance and super-independence.

Because discharge of the repressed oral longings was blocked, they set up
chronic substitute discharges in the parasympathetic innervations of the
stomach similar to the preparations for feeding which Pavlov had
demonstrated. Essential hypertension22 was thought to be associated with
anxiety over repressed hostile competitive striving. The inhibited hostility

resulted in a substitution of chronic sympathetic nervous discharge along the
lines of the fight-flight reaction of Cannon. This in turn produced generalized
vasoconstriction, the release of adrenaline and elevation of the blood

pressure. Other formulations were proposed for migraine,23
hyperthyroidism,24 asthma, rheumatoid arthritis and ulcerative colitis.25 In
most of the formulations, pregenital and especially dependent and oral
conflicts were prominent. It was recognized that not every patient with the
appropriate conflict had the corresponding disease. Consequently, Alexander

postulated a somatic X factor which was also specific for each disease. Both
the conflict and the X factor were necessary to produce the disease, but
neither alone was sufficient. These hypotheses entailed high specificity at

both psychological and biological levels.
The psycho-analytic observations of Alexander and his followers have
proved hard to replicate and generalize. One difficulty is the sheer labor
involved in psychoanalyzing enough patients with each disease and
systematizing the material to provide an adequate and representative sample.

Another is the fact that those patients who can and will undergo
psychoanalysis already constitute a skewed sample. Yet another is that the
conflicts may not be so discreet and separable as they seem. For example,

persons who inhibit their oral strivings in one sphere of life may express
them in another, and many persons can be shown to have more than one of
the postulated conflicts. Smaller scale clinical studies have not uniformly
supported the findings. In one, for example, ulcer patients were found to
express their oral and dependent strivings quite freely and openly.
On the other hand, the gastric hypersecretion of hydrochloric acid and
gastric hyper-motility due to nervous factors are characteristic of peptic ulcer
patients. Hyper-salivation has also been reported, and it has been possible to
induce gastrointestinal ulcerations by chronic stimulation of the

hypothalamus in animals.
Hypersecretion of pepsinogen is also characteristic of ulcer patients

before, during and after the development of the disease. Pepsinogen is
secreted by the cells of the gastric mucosa and then enters the blood.
Hypersecretion of pepsinogen, therefore, has several features suggestive of a
somatic X factor for peptic ulcer and provided the basis for one of the few
successful predictive studies of psychosomatic illnesses. Serum pepsinogen
was measured in 2073 Army inductees, and a sample of those with the
highest levels were selected as a group with high probability of developing

ulcers during the stress of basic training. A sample with low values were
selected as low probability subjects. The two groups of subjects were then
given a battery of psychological tests, a medical questionnaire and a complete
radiologic examination of the upper gastrointestinal tract. At the initial
examination, a significantly greater number of ulcers was found in the high
pepsinogen group, and this group also developed a significantly greater
number of ulcers during the course of basic training. On the basis of a

prediction that evidences of orality, depression, dependence, anxiety over
expressing hostility and needs to please and placate in the psychological test
protocols would be characteristic of the high pepsinogen group, it was
possible to identify correctly 71 percent of the highs and 51 percent of the

lows. Especially strong psychological characteristics of the high pepsinogen
group were found in those who had or would develop ulcers. Other evidence
indicating that one may be a hyper-secreter from birth led Mirsky to suggest
that hypersecretion of pepsinogen may reflect a biological trait which
contributes to the development of strong oral needs and predisposes to the
development of peptic ulcers in situations of stress. Engel suggested that the
other psychosomatic illness may have analogous psychobiological

predisposing constellations and proposed the term somatopsychic-
psychosomatic disorder.
Schur
Schur finds all the claims of psychological specificity unconvincing and
argues that psychosomatic disorders tend to develop when defensive
equilibria breakdown and regression occurs. The particular kind of

regression producing psychosomatic disorders is regression to primitive
modes of ego functioning with resomatization of the channels for expression
of primitive affect.
Wolff
Wolff pointed out that biological threats provoke various automatic
biological protective patterns. Among these were the protective pattern of

offense involving eating, which is one of the infants earliest aggressive
patterns. This pattern included gastric hyper-function, increased blood flow
and salivation. Another pattern was the ejection-riddance reaction involving
the large bowel, the stomach and duodenum. This included vomiting and
diarrhea, which are nonspecific reactions of the infant to noxious agents even
when the gastrointestinal tract is not invoked. Another was the holding fast
reaction of skeletal muscles and large bowel. This was characterized by
constipation with tense, aching muscles and joints. Another was the
protective reaction of nose and airways with vasodilation, hypersecretion,
contraction of smooth muscle and occlusion of airways.
According to Wolff these patterns tend to be evoked in predisposed
individuals by nonspecific threats and to persist into adulthood in fragmented
form. Prolonged and persistent use of a pattern tends to irritate the systems
involved and predispose them to disease. The predisposition to a particular
pattern when threatened was considered to be geneticdue to stock
factorsand to be analogous to the running pattern in the horse, the
hoarding pattern of the squirrel or the retriever pattern of the dog.
Engel
On the basis of an extensive study of ulcerative colitis26 patients Engel

concluede that the disease tends to have its onset in the relationship, but only
if the subject reacts with feelings of helplessness and hopelessness. Later
work by Engel and various of his colleagues led to similar conclusions with
respect to malignant lymphomas,27 medical disease in general and

psychiatric illness. These findings also formed the basis for another of the few
successful psychosomatic predictive studies. Women entering the hospital for
biopsies of the uterine cervix were interviewed for evidence of object loss,
helplessness and hopelessness. The prediction was borne out that this state
would tend to identify those women whose cervical lesions would prove to be
malignant. The state has been termed the giving upgiven up complex and
is regarded as neither necessary nor sufficient for the development of disease

but as contributory.
As noted previously, Engels more recent theoretical interests have
turned to a more specific mechanismthe role of conversion in the
production of disease. Case material has been presented showing that a

sensory conversion may evoke appropriate biological protective patterns
similar to those described by Wolff. Engel describes a female patient who as a
child had been struck along with her mother by a hit-and-run driver on a
deserted street in the dead of winter. The child had been thrown into a snow
pile and not discovered for some time. As an adult, the resurgence of
ambivalent feelings toward her mother was associated with conversion
attacks in which she not only experienced a sensation of cold but had shaking
chills, chattering teeth and blanching of her hands and feet, which became
cold to the touch.
A conversion may also produce complications, as when a sensation of
breathlessness leads to over-breathing, which then results in respiratory
alkalosis.28 The associated tetany29 and sensations of tingling about the

mouth are due to alkalosis and not part of the conversion. Engel describes
other cases in which fantasies of punishment for sexual transgression had
determined the site of skin eruptions. A soldier developed an urticarial
eruption (hives) with a linear distribution which might have been produced
by a whipping on the back of his legs, thighs and buttocks. As a boy in a very
strict orphanage, he had been whipped for peeking in the windows of the
girls dormitory. The urticarial eruption developed about an hour after he had
been apprehended loitering on the grounds of the nurses dormitory on the
military post. An enlisted man, he had hoped to see one of the nurses whom
he wanted to date. The officer who apprehended him reprimanded him
severely and ordered him to his barracks.
Another patient, a young woman, developed an eczematoid skin

eruption around her neck where it was touched by the chain of a metal
crucifix which was given her at the time of her confirmation. She was
apprehensive about her confession, unsure whether she had sinned and felt
ashamed and unclean when the crucifix was placed around her neck. Later
eruptions occurred at the site of other metals contacting her skin if
associations of sexual guilt were aroused.
To account for the development of these lesions, Engel depends heavily
on experiments by Chapman, Goodell and Wolff. It had been known that the
pain, tenderness and inflammation following injury to the skin is enhanced

and sustained by antidromic (reverse direction) feedback activity along the
same nerve fibers which carry the nociceptive impulses. Chemical substances
(neurokinin, substance p) are released at the nerve terminals in the skin
which facilitate the local inflammatory response, lower the threshold for pain
and influence clotting mechanisms. The demonstration by Chapman et al. that
the same feedback system can be activated by hypnotic suggestion of injury to
the skin suggested to Engel that a similar mechanism might have operated in
the cases where conversion had determined the site of skin eruptions. In
these cases, skin eruptions would be complications of the conversion and not
the conversion itself, just as tetany30 is not a conversion but a complication of

hyper-ventilation. Engel suggests that similar processes might also produce
pathological lesions in other systems.
In applying this line of thinking, it is necessary to distinguish between
primary and secondary symbolization. Primary symbolization is the type
described by Engel, in which a fantasy is elaborated about a body part or
system before a pathological process develops in the tissue. Secondary

symbolization means the erection of fantasies about a pathological process
after it develops.
Comment
The view of the present writer is that claims of similar conflicts, similar
instinctual makeup, similar ego structure or similar personality makeup in
patients with similar symptoms are unconvincing. The common emphasis on

oral, dependent and pregenital mechanisms have developed in an era when
psychoanalysts are becoming increasingly aware of these impulses in all

areas of psychic development and in all symptom complexes including
classical hysterical, phobic and obsessive-compulsive neuroses. While their
role is being so extensively reevaluated, it seems premature to assign them
some special role in psychosomatics. The position of Schur would seem the
soundestnamely, that there is nothing psychologically specific about

psychosomatic illness, that it simply tends to be precipitated by psychological
regression and the breakdown of defenses. Furthermore, Engel would seem
to be entirely correct in observing that regression, disruption of defenses and
the giving upgiven up complex are most likely to occur when key object
relationships are threatened. The physiological pathways have yet to be

clarified in detail but almost certainly must involve combinations of
autonomic and neuroendocrine reactions together with local biological
defense reactions as outlined by Wolff and Engel.
THERAPEUTIC CONSIDERATIONS
With such a diverse group of disorders, there can hardly be a unitary
therapeutic approach determined by the fact that a psychosomatic disorder
exists. On the contrary, psychosomatic disorders present the entire gamut of
therapeutic problemsfrom grossly psychotic patients to healthy

neurotics. Hence they call for the entire repertoire of psychotherapeutic
approachesfrom supportive through classical psychoanalysis. The use of
behavior, group and family therapies has not been reported extensively in
these cases but undoubtedly each will eventually find its place in the
treatment of psychosomatic patients. Millers demonstration of operant
conditioning of discreet autonomic reactions is especially suggestive that
conditioning therapies might be effective in the treatment of some

psychosomatic symptoms.

Despite the diversity of psychosomatic disorders and of the
psychotherapeutic approaches to them, there are two central ideas of high
importance, around which any type of therapeutic approach can be organized.
They are (a) that the onset and exacerbations of both somatic and psychiatric
illnesses tend to occur in the setting of a real, fantasied or threatened
disruption of a key object relationship, which is accompanied by disruption of
defensive and adaptive patterns, psychological regression and feelings of

helplessness and hopelessness and (b) that physical illness per se tends to
induce psychological regression; this tendency sums with any other
regressive trends which the patient may bring with him to his illness.
The utility of the concept of the key relationship lies in its non-
specificity, its simplicity and its central importance in all psychic function.
None of the more complicated specificity hypotheses have been so well
documented and none are so readily verifiable in ones everyday clinical

work. Needless to say, this concept does not substitute for a full formulation
of the psychodynamics of an individual patient; it does, however, provide a

nodal point around which a more complete formulation may be organized.
Furthermore this concept does not preclude any of the more specific
formulations which might eventually be validated as characteristic of certain

disorders. In fact if any such formulation should be valid, the key relationship
concept provides a path for arriving at it. The fact that a threat to such a
relationship disrupts defenses, induces regression and precipitates illness is
already evidence that the relationship is invested with neurotic or psychotic
intensity derived from an object of early childhood, usually the mother. In fact
the current relationship involved in precipitating the illness is not
infrequently with the mother herself. In young adults the threat to the key
relationship is also likely to be rejection by a spouse or lover. In later life the
death or illness of a spouse is frequently the key precipitant of illnesses; in
this age range the maturation, separation or rebellion of offspring is also

often important.
It is not unusual to observe an acute rupture of a relationship, emotional

collapse and the first attack of a chronic medical illness all occurring within
hours. More frequent, however, is the onset of illness in a setting of gradual
deterioration of a relationship and gradual failure of coping mechanisms.
The psychological forces activated by physical illness have been simply
and profoundly described by Lederer. During the process of falling illthe
transition from health to illnessthe central experiences are pain,

discomfort, loss of strength and abilities, and anxiety. In addition to the
realistic fears about ones comfort and well-being, there are unconscious
anxieties, including fear of regression and passivity, fantasies that illness is a

punishment for transgressions and shame that ones weaknesses may be
exposed. At this stage one of the most potent provokers of anxiety is facing
the unknown. The nature of the illness and its implications are likely to be

unknown. Diagnostic equipment and procedures are often unintelligible and
mysterious. The language spoken by physicians, nurses and technicians is
strange. Particularly devastating at this time are signs of apprehension,
uncertainty or vacillation on the part of the physician. The lack of knowledge

is well designed to draw out fantasies from the patients unconscious. The
particular patients ways of dealing with anxiety and regressive urges are
likely to be activated. These may range from denial of illness, delay in seeking
treatment, aggressiveness and provocativeness to passivity, clinging and

compliance.
Those who can tolerate the necessary degree of regression and
dependence enter a stage of accepted illness. This is characterized by
egocentricity, preoccupation with body functions, constriction of interests

and a regressed dependent relationship with doctors and nurses which bears
the stamp of whatever the patients particular relationship had been with his
parental objects in early childhood. The same caretaking persons are likely to
be seen as omnipotent and idealized by one patient and as callous and
malevolent by another. Jealousy of a nurses or doctors attention may extend

to lengths entirely out of keeping with the patients personality when well.
Romantic heterosexual fantasies are fairly frequent. If defenses against the

necessary degree of regression and dependence are too elaborate, there may
be no stage of accepted illness and no secure emotional relationships with the
medical team. This interferes with the treatment regimen and with the
effectiveness of any treatment which he does receive. Such was undoubtedly
the case with the patient, cited earlier, in whom powerful medication was
ineffective against her auricular fibrillation and congestive heart failure.
Convalescence, the transition from accepted illness into relative health
and responsibility, is analogous to adolescence and often runs a similar

course. Doctors and nurses begin to lose their idealized qualities and may
appear somewhat depreciated, like the parents of an adolescent. Patients who
clung to the dependency on their parents may exhibit reluctance to give up
the role of sick person and the dependence to which it entitles them. This can
manifest itself in many ways such as reluctance to stop taking medicine,
reluctance to resume activity appropriate to the improved state of health or
actual recurrence of symptoms in the setting of discharge from the hospital.

The hanging on reaction tends to be intensified by long periods of
hospitalization. Thomas Manns novel The Magic Mountain deals with such a
reaction in a patient hospitalized for tuberculosis. On the other hand, patients

who broke away from their families abruptly and prematurely during
adolescence are likely to follow the same pattern with their physicians during
convalescence. Patients who separated from their parents gradually but
smoothly and progressively during adolescence are likely to have a smooth

and uneventful convalescence. The more psychosomatic the disorder, the
more likely are complications in the progression of the psychological stages of
the illness and the more likely are these complications to feed back upon the

medical course of the illness.
During the stage of acute illness one faces a patient whose outbreak of
symptoms was probably precipitated by the loss of an important source of
dependent gratification, whether recognized or not, followed by disruption of
defenses, regression, helplessness and hopelessness. The illness itself will

have induced further regression. The situation is ripe for the development of
rapid and intense transference relationships. Many perceptive nonpsychiatric
physicians are very aware of these matters and handle them skillfully. Others
are totally oblivious and hence unaware of the enormous effect of their
behavior upon the course of the illness. During the acute phase of the illness,
the psychological task is to effect some temporary restitution of the
threatened object relationship, partially by replacing it with the naturally

developing transference relationship to the physician and, if practical, by
facilitating repair of the rupture with the key person. Uncovering
psychotherapy during this phase is often impractical, but proper attention to

developing good patient-physician rapport will usually facilitate the
outpouring of a great deal of material which otherwise would be heavily
defended. This readiness, even eagerness, of acutely ill patients to share
heavily charged material has been noted repeatedly. Listening to this material
and gently encouraging its revelation helps to cement the therapeutic
relationship necessary for recovery. Several years ago, Margolin advocated a
very exaggerated form of inducing this early attachment by means of
anaclitic therapy. In this approach the physician assumed a totally giving
and totally omnipotent role toward the patient, remaining available to him at
any and all times, feeding him, stroking and massaging painful areas and
attending to all minor details of physical care. This procedure was often life-
saving but is very taxing for medical personnel to keep up for any length of
time. Equally good results can usually be obtained less dramatically by merely
being aware of the patients likes, dislikes, dependent needs and conveying
this awareness to him along with a sense of personal interest. It cannot be
emphasized strongly enough that the success or failure of this relationship
can and does spell the difference between effectiveness and ineffectiveness of
very powerful drugs or even surgical operations. If the psychotherapist enters
the case at this point, one of his major services may be to help restore a
deteriorating relationship between patient, ward personnel and physician-in-

charge.
Beyond the acute phase of illness the problems to be considered are

whether psychotherapy offers the hope of sufficient emotional maturation to
free the patient from the more neurotic aspects of his dependence on key
objects and his vulnerability to the threat of separation. In arriving at this
decision, his ego strengths, capacity for relationships and capacity for insight
will be weighed in the usual manner. Also to be considered are the questions
whether the vulnerability of his ego and his diseased organ systems can
withstand the moderate but unavoidable degrees of frustration inherent in

insight giving techniques. The alternative is to establish and maintain a
supportive relationship either with the general physician or the
psychotherapist which may have to be maintained almost indefinitely, though
with dilution during times of well-being and intensification during times of

difficulty. The effectiveness of ostensibly medical visits scheduled mainly for
psychological reasons is incomprehensible to many general physicians until
they see it for themselves.
Whatever techniques are chosen, care must be taken that the general
physician keep up his contact with the patient at a sufficient level to minimize
feelings of rejection and abandonment by him during the transition period
when the psychotherapeutic relationship is being built. Once the patient is
established in psychotherapy, the problems of transference,

countertransference, resistance, hostility and dependency differ in no
characteristic way from the therapeutic problems with other patients.
However, the vulnerability of the organ systems to separation and threats of

separation must be borne in mind. During vacations and other interruptions
one must anticipate the possibility not only of anxiety, depression and
hostility but also of gastrointestinal bleeding, asthmatic attacks or whatever
the particular somatic vulnerability happens to be. Even though the therapy
seems to have gone well, additional exacerbations may occur around the time
of termination. A gradual stepwise termination with a gradually decreasing
frequency of visits is probably desirable. It is often best not to terminate
officially at all but to act as though one assumes that the patient will call
periodically for appointments.
Our prognostic abilities for psychosomatic patients are even less than
for neurotic and psychotic patients. In general the presence of schizophrenia,
serious ego impairment, secondary gain from illness and intense strivings
toward passivity and helplessness tend to signal a poor prognosis in
psychosomatic disorders as well as in psychiatric ones. Other traits which
may be characterized generally as maturity and ego strength tend to indicate
a favorable prognosis in both the psychic and somatic spheres. With

successful psychotherapy and substantial maturation of the personality, even
fairly severely diseased organ systems may return to normal structure and
function, provided there had been no irreversible tissue damage prior to

therapy. The psychotherapist, however, should not entertain the illusion that
the vulnerability of the organ system has been removed. His contribution has
been to reduce the impact of emotional stress on this vulnerability.

Unfortunately, life provides no security against object loss or further
psychological stress. Hence the therapist must be prepared for exacerbations
and should work to prevent unrealistic illusions either in himself or in his
patient. This is not to deny that the gains through psychotherapy may spell
the difference between a productive life and invalidism, but the removal of
the organ vulnerability is probably a remaining task for biological research.

Notes
1 Pain, usually in the mid-chest or left arm, occurring when diseased but still functioning coronary
arteries are temporarily unable to supply enough blood to the heart muscle to meet its
requirements. Pain is usually precipitated by exertion, emotion, a heavy meal or
exposure to cold or rarefied air and relieved by eliminating the precipitating factor or by
drugs which enlarge the lumen of the coronary artery.
2 Gradual progressive destruction of liver tissue in severe chronic alcoholism. Death eventually results
if the process is not arrested.
3 Pain, usually in the mid-chest or left arm, occurring when diseased but still functioning coronary
arteries are temporarily unable to supply enough blood to the heart muscle to meet its
requirements. Pain is usually precipitated by exertion, emotion, a heavy meal or
exposure to cold or rarefied air and relieved by eliminating the precipitating factor or by
drugs which enlarge the lumen of the coronary artery.
4 Irreversible blocking of a coronary artery so that a portion of the heart muscle is permanently
deprived of its blood supply. Symptoms of pain and breathlessness resemble the
symptoms of angina pectoris but are usually more severe and are not reversed by drugs
or by removing a precipitating factor. The affected area of heart muscle dies and is
replaced by scar tissue. During the acute stage of the illness the patients survival may be
in doubt.
5 Damage to heart valves which is sometimes an aftermath of rheumatic fever. If the damage is severe
enough, diminished cardiac reserve results, and the patient becomes subject to episodes
of cardiac decompensation or congestive heart failure.
6 In diabetes mellitus a deficiency of insulin secretion by the pancreas is the central feature of the
disease, but many other factors are involved. The naturally occurring disease is often
much more severe than that caused by total removal of the pancreas. There may possibly
be several types of diabetes mellitus. Diabetes insipidus is an entirely different disorder.
7 An abnormally acid condition of the blood resulting from the accumulation of improperly
metabolized materials. This occurs when insulin requirements exceed the insulin dose
by too much for too long. Coma results when the condition is severe, and death will then
follow if treatment is not prompt and vigorous.
8 A generalized disease of unknown cause. Some of the outstanding symptoms are fever and bloody
diarrhea or sometimes constipation. Ulcers form in the inner lining and muscular walls
of the large intestine (colon) and may become secondarily infected by bacteria which
inhabit the bowel. The disease is usually chronic and episodic, often leading to extensive
scar formation in the large intestine. Occasionally the course is rapid and progressive,
resulting in death.
9 A disease of unknown cause involving the lower stomach or upper duodenum. Outstanding
symptoms in uncomplicated cases include burning and cramping in the mid or upper
abdominal area, usually when the stomach is empty. Some relief is often afforded by the
intake of milk or mild anti-acids. In the affected area a single craterlike ulcer erodes the
inner lining of the stomach or duodenum and into the muscular wall. Motility and acid
secretion by the stomach and duodenum are usually increased.
10 Abnormally elevated blood pressure (hypertension) in the absence of any known cause, such as
impaired kidney function or hormone-secreting tumors. If prolonged and severe, the
complications may include overworking of the heart or damage to the blood vessels of
brain, heart or kidney.
resulting in death.

14 Also called Graves disease, Basedows disease and hyperthyroidism. Its cause is unknown. The
central feature of the disorder is overproduction of thyroid hormones which are
responsible for many of the symptoms, which include enlargement of the thyroid gland
(goiter), general acceleration of the metabolic rate, intolerance to warm temperatures,
restlessness, rapid heartbeat, perspiration and sometimes protrusion of the eyeballs.
Rather similar symptoms may be produced by hormone secreting tumors of the thyroid,
but the mechanism of these disorders is different.
15 Episodic headaches, usually severe, throbbing and confined to one side of the head. They are often
preceded by various visual phenomena and followed by nausea and vomiting. The pre-
headache phenomena are associated with constriction and the headache with dilation of
cranial arteries. During the headache, the tissues surrounding cranial arteries on the
involved side are swollen and tender.
16 A disease of unknown cause which is usually chronic and recurring. Its outstanding feature is
inflammation of the lining membranes of various joints which causes pain, swelling and
redness over the area. In the advanced stages there may be destruction of joint cartilage,
scar tissue formation and fusion of joints.
17 In diabetes mellitus a deficiency of insulin secretion by the pancreas is the central feature of the
disease, but many other factors are involved. The naturally occurring disease is often
much more severe than that caused by total removal of the pancreas. There may possibly
be several types of diabetes mellitus. Diabetes insipidus is an entirely different disorder.
18 Anemia due to deficiency of vitamin B12. It results from failure of the stomach to secrete enough of
a material which enables the intestine to absorb dietary vitamin B12.
19 A collective term referring to various malignant disorders involving spleen, lymph nodes and other
lymphatic and related tissues. These disorders include Hodgkins disease, lymphatic
leukemia and lympho sarcomas.
resulting in death.
23 Episodic headaches, usually severe, throbbing and confined to one side of the head. They are often
preceded by various visual phenomena and followed by nausea and vomiting. The pre-
headache phenomena are associated with constriction and the headache with dilation of
cranial arteries. During the headache, the tissues surrounding cranial arteries on the
involved side are swollen and tender.
24 Also called Graves disease, Basedows disease and hyperthyroidism. Its cause is unknown. The
central feature of the disorder is overproduction of thyroid hormones which are
responsible for many of the symptoms, which include enlargement of the thyroid gland
(goiter), general acceleration of the metabolic rate, intolerance to warm temperatures,
restlessness, rapid heartbeat, perspiration and sometimes protrusion of the eyeballs.
Rather similar symptoms may be produced by hormone secreting tumors of the thyroid,
but the mechanism of these disorders is different.
resulting in death.

resulting in death.
27 A collective term referring to various malignant disorders involving spleen, lymph nodes and other
lymphatic and related tissues. These disorders include Hodgkins disease, lymphatic
leukemia and lympho sarcomas.
28 Alkalosis (the opposite of acidosis) refers to any state in which the blood is abnormally alkaline. In
respiratory alkalosis the primary cause is over-breathing, which drives the carbon
dioxide level in the blood (and thereby the carbonic acid level also) to abnormally low
levels. In alkaline blood the solubility of calcium compounds (and hence the serum
calcium concentration) is reduced. This causes a condition known as tetany.
29 A syndrome which includes extension of the extremities with a characteristic flexion of the ankles
and wrists known as carpopedal spasm. There is also twitching of the extremities and
sensations of tingling about the mouth. The cause is low serum calcium concentration.
30 A syndrome which includes extension of the extremities with a characteristic flexion of the ankles
and wrists known as carpopedal spasm. There is also twitching of the extremities and
sensations of tingling about the mouth. The cause is low serum calcium concentration.
REFERENCES
Adamson, J. D., and Schmale, A. H., Jr.: Object loss, giving up, and the onset of psychiatric disease.
Psychosom Med, 27:557-576, 1965.
Alexander, F.: Psychosomatic MedicineIts Principles and Applications. New York, W. W. Norton &
Company, Inc., 1950.
Cannon, W. B.: Bodily Changes in Pain, Hunger, Fear and Rage. Boston, Charles T. Branford
Company, 1953.
Chambers, W. N., and Reiser, M. F.: Emotional stress in the precipitation of congestive heart
failure. Psychosom Med, 25:38-60, 1953.
Chapman, L. F., Goodell, Helen, and Wolff, H. G.: Augmentation of the inflammatory reaction by
activity of the CNS. Arch Neurol, 1:557-572, 1959.
Engel, G. L.: Selection of clinical material in psychosomatic medicine: The need for a new
physiology. Psychosom Med, 16:368-373, 1954.
Engel, G. L.: Studies of ulcerative colitis: III. The nature of the psychologic processes. Am J Med,
19:231-256, 1955.
Engel, G. L.: Studies of ulcerative colitis: V. Psychological aspects and their implications for
treatment. Am J Dig Dis, 3:315-337, 1958.
Engel, G. L.: Psychological Development in Health and Disease. Philadelphia, W. B. Saunders

Company, 1962.
Engel, G. L.: The psychoanalytic approach to psychosomatic medicine. In Modern Psychoanalysis,

edited by J. Marmor. New York, Basic Books, 1968.
Engel, G. L., and Schmale, A. J. Jr.: Psychoanalytic theory of somatic disorder: Conversion,
specificity, and the disease onset situation. J Am Psychoanal Assoc, 15:344-365,
1967.
French, J. D., Porter, R. W., Cavanaugh, E. B., and Longmire, R. L.: Experimental gastroduodenal
lesions by stimulation of the brain. Psychosom Med, 19:209-220, 1957.
Funkenstein, D. H., King, S. H., and Drolette, M. E.: Mastery of Stress. Cambridge, Harvard
University Press, 1957.
Greene, W. A., Young, L. E., and Swisher, S. N.: Psychological factors and reticuloendothelial
disease: II. Observations on a group of women with lymphomas and leukemias.
Psychosom Med, 18:284-303, 1956.
Jenkins, C. D. (with cooperation of Rosenman, R. H., and Friedman, M.): Components of the
coronary-prone behavior pattern: Their relation to silent myocardial infarction and
blood lipids. J Chronic Dis, 19: 599-609, 1966.
Kaplan, S. M., and Curtis, G. C.: Reactions of medical patients to discharge or threat of discharge

from a psychosomatic unit of a general hospital. In Mental Patients in Transition,
edited by M. Greenblatt, D. J. Levinson, and G. L. Klerman. Springfield, Charles C
Thomas, 1961.
Kapp, F. T., Rosenbaum, M., and Romano, J.: Psychological factors in men with peptic ulcers. Am J
Psychiatry, 103:700-704, 1947.
Lederer, H. D.: How the sick view their world. J Soc Issues, 8:4-15, 1952.
Mann, T.: The Magic Mountain. New York, Knopf, 1945.
Margolin, S.: Round table. Bull Am Psychoanal Assoc, 8:170-180, 1952.
Miller, N. E.: Learning of visceral and glandular responses. Science, 163:434-445, 1969.
Mirsky, I. A.: Physiologic, psychologic, and social determinants in the etiology of duodenal ulcer.
Am J Dig Dis, 3:285-314, 1958.
Pavlov, I. P.: Lectures on Conditioned Reflexes. New York, International Publishers, 1928.
Schachter, S.: Obesity and eating. Science, 161:751-756, 1968.
Schildkraut, J. J., and Kety, S. S.: Biogenic amines and emotion. Science, 156:21-30, 1967.
Schmale, A. H. Jr.: Relationship of separation and depression to disease. Psychosom Med, 20:259-
277, 1958.
Schmale, A. H. Jr., and Iker, H. P.: The affect of hopelessness and the development of cancer: I.
Identification of uterine cervical cancer in women with atypical cytology.
Psychosom Med, 28:714-721, 1968.
Schur, M.: Comments on the metapsychology of somatization. The Psychoanalytic Study of the
Child, 10:119-164. New York, International Universities Press, 1955.
Selye, H.: The Stress of Life. New York, McGraw-Hill, 1956.
Sperling, M.: Symposium on disturbances of the digestive tract: II. Unconscious fantasy life and
object relationships in ulcerative colitis. Int J Psychoanal, 41.450-455, 1960.
Stunkard, A.: Obesity and the denial of hunger. Psychosom Med, 21: 281-289, 1959.
Stunkard, A., and Koch, C.: The interpretation of gastric motility: I. Apparent bias in the reports of
hunger by obese persons. Arch Gen Psychiatry, 11:74-82, 1964.
Szasz, T. S.: Psychosomatic aspects of salivary activity: I. Hyper-salivation in patients with peptic
ulcer. Res Nerv Ment Dis Proc, 29:647-655, 1950.
Weiner, H., Thaler, Margaret, Reiser, M. F., and Mirksy, I. A.: Etiology of duodenal ulcer: I. Relation
of specific psychological characteristics to rate of gastric secretion (serum
pepsinogen). Psychosom Med, 19:1-10, 1957.
Wolff, H. G.: Life stress and bodily diseasea formulation. Res Nerv Ment Dis Proc, 29:1059-1093,
1950.

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What is a psychosomatic disorder?

What is a psychosomatic disorder?

What are some examples of psychosomatic etiology discussed?

What are some examples of psychosomatic etiology discussed?

Psychotherapy

with Patients with

Copyright 1972 by Max Hammer, Ph.D.

All Rights Reserved

Created in the United States of America

TYPES OF PSYCHOSOMATIC DISORDERS

In approaching the treatment of psychosomatic disorders it is first

necessary to consider what a psychosomatic disorder is. This is by no means

of study nor a medical subspecialty, but to a point of viewa way of thinking

anthropology, pathology, pharmacology, genetics, physiology, immunology,

medicine, surgery or related fields. In practice however, the elements for

the capacities and experience of the synthesizer. The term psychosomatic

has been criticized on the grounds that it implies a mind-body dichotomy

and the viewpoint to which it refers are forerunners of a general systems

One of the cardinal principles both in psychosomatics and in general

systems theory is that events within a system or level of description

psychological, social, anatomical, physiological and so forthmust be studied

by methods appropriate to that level and described in the language of that

The Theory and Practice of Psychotherapy with Specific Disorders 5

reasoning will be circular. If we wish to study psychodynamic patterns in

thyroid disease, we cannot use psychodynamic data to infer the presence of

ignored with surprising frequency.

The term psychosomatic is also used in a more limited sense to refer

to a causal sequence from above downwardthat is, in which events at the

psychological-psychodynamic level appear to influence events at some lower

order of complexity, such as gastric motility or cardiovascular dynamics. This

usage is in contrast with the term somatopsychic which implies the

function or psychological reactions to physical disease. Psychosomatic events

distinction is convenient and necessary for ordering certain types of

When the term disorder is added to the term psychosomatic, one

ordinarily means clinical conditions in which psychosomatic causal

TYPES OF PSYCHOSOMATIC DISORDERS

Somatic Complaints of a Purely Ideational Nature

These are symptoms which express ideas and do not depend on

Somatic Delusions and Hallucinations

Although the idea expressed by these symptoms is conscious, it can and

the complaint is quickly recognized. If his cognitive functions are relatively

The Theory and Practice of Psychotherapy with Specific Disorders 7

feelings. This type of complaint must, of course, be distinguished from

delusional explanations erected on organically based symptoms, as for

example pains of angina pectoris1 interpreted as messages from heaven.

Obsessions About the Body

Somatic obsessions also express in body language ideas related to

unconscious wishes. However, the patient recognizes them as irrational, even

This term is used loosely to refer to multiple bodily complaints which

delusional or a mixture of the two.

Conversion Reactions (Hysteria)

Like somatic delusions and obsessions, conversion reactions also

express in body language ideas related to unconscious wishes. Instead of

psychoanalysis all psychosomatic disorders were assumed to be conversion

expressions of unconscious ideas. Following World War II, there was a

voluntary motor symptoms and that the diagnosis of conversion reaction or

statements of this sort, a number of symptoms involving involuntary systems

continued to be recognized as hysterical, such as vomiting and false

pregnancy (including cessation of menstruation). The earlier view was never

ulcerative colitis as a pregenital conversion in which bleeding from the bowel