Psychosomatic Medicine 18:2-42 (1956)
© 1956 American Psychosomatic Society

A Study of the Psychodynamics of Duodenal Ulcer Exacerbations

With Special Reference to Treatment and the Problem of "Specificity"

¹ Department of Neurology and Psychiatry, Harvard Medical School Boston, Mass., Psychiatric Service of the Massachusetts General Hospital and the Massachusetts General Hospital Division of the Hall-Mercer Hospital, Boston

Six male patients with exacerbations of chronic duodenal ulcer have been studied in order to elicit the concomitant psychological factors. The major symptom was essentially similar in all patients: epigastric pain, usually nocturnal, relieved by ingestion of food, but reappearing within several hours. The investigative method included psychoanalysis and psychoanalytic psychotherapy.

The formulation of the emotional state at the time of relapse includes both descriptive and psychodynamic observations regarding the nuclear conflict, predominant affects, ego defenses, and transference situation.

In all 6 patients the nuclear conflict consisted of variations in the passive/active antinomy. Struggle over dependence/independence, however frequent, was regarded as a special case of the larger problem of passivity/ activity. The ulcer recurrence invariably developed in an atmosphere in which the patient vacillated between active seeking and passive yielding. The stress of the conflict could be brought about in three ways: by a lack of fulfillment of passive-receptive wishes, by a transgression of the exaggerated ego ideal, and by fear of passivity itself.

The basic affects were restrained resentment, angry guilt, and guilty fear. The patients were afraid of becoming helpless and submissive through a narcissistic injury, by depleting demands, or by loss of a source of strength or support.

Ego defenses included compliance and defiance; inhibition and suppression; denial by word, act, or phantasy; avoidance and social isolation; phantasy formation; bisexual identification; and the secondary adaptive measures of various neurotic symptoms. Phobic and obsessional symptoms were frequent, but depression was strikingly absent during the ulcer exacerbations.

The transference relationship to the doctor was distinguished by its excessive ambivalence. The therapist represented either an ideal, beneficent parent, or a demanding, exploiting, relentless, coercive force. In many respects the transference neurosis reflected the patient's relationship with the significant figures in his life.

The ego ideal was excessive in that the patients expected more from themselves than they were capable of fulfilling. It represented the ideal parent in the superego and the wish for complete identification with this parent. Fundamentally the underlying motivation of these patients was for the right to be passively loved and sustained with a unique, noncompetitive, inexhaustible devotion.

Ulcer symptoms recurred most often when the threat of depletion exceeded the promise of replenishment and the resulting angry protest was restrained.

The ulcer exacerbation was associated with no single factor operating alone, but required the integrated presence of the nuclear conflict, basic fear, special ego defenses, and ambivalent interpersonal relationships.

The meaning of specificity is discussed. The logical requirements for specificity are described in terms of equivalent and conditional forms and a distinction is made between disorder specificity and stress specificity. The specific psychosomatic formulation of the various categories of psychological factors is regarded as conditional stress specificity because a similar formulation may exist without necessarily entailing the development of duodenal ulcer. It is therefore to be differentiated from equivalent stress specificity where a specific psychosomatic formulation may be applied if, and only if, a duodenal ulcer is present. Parallel psychological observations in other diseases are necessary in order to determine disorder specificity, which similarly may be either conditional or equivalent.

The application of these observations to the management of ulcer recurrences has been discussed.

This article has been cited by other articles:

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