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ORIGINAL ARTICLE |
Address reprint requests to: John C. Nemiah, MD, 4 Rayton Road, Hanover, NH 09755-2214.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONNOTESREFERENCES |
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METHODS: The evolution of the psychodynamic formulation of psychosomatic symptom formation is described in a brief historical review.
RESULTS: There are two distinctly different pathways along which stress-induced psychological arousal is transformed into somatic symptoms.
CONCLUSIONS: Psychodynamic observations and theory have important implications for psychosomatic research and treatment.
Key Words: alexithymia • conversion • dissociation • egodeficit • psychodynamic conflict
Abbreviations: DSM = Diagnostic and Statistical Manual of Mental Disorders.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONNOTESREFERENCES |
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The latter definition reflects, of course, the emphasis in current psychiatric thinking on the phenomenological and biological aspects of mental disorders, a focus of interest that has allowed us in recent years to amass a wealth of important information about psychiatric illness in general and about the psychological complications of somatic illness in particular. However, the too-exclusive pursuit of research along biological and phenomenological lines in recent years has not only resulted in a paucity of psychodynamic studies of psychosomatic processes but has also led to a striking amnesia for the findings and concepts that had evolved over the earlier years of psychosomatic research. It is my purpose here briefly to review the history of that development and to indicate the potential value of those earlier inquiries for future psychosomatic investigations.
Although the origins of the psychodynamic view of the psychosomatic process stem from the psychological studies of Pierre Janet (4) at the end of the 19th century, for more than 100 years before that there had been a lively interest in the possible role of the human imagination as both a cause and a cure of somatic illness. The renowned English psychiatrist Daniel Hack Tuke admirably summarized the extensive literature that had accumulated concerning mind-body relationships during the previous 100 years in what may properly be called the first textbook of psychosomatic medicine. Published in 1873 and entitled Illustrations of the Influence of the Mind Upon the Body in Health and Disease Designed to Elucidate the Action of the Imagination (5), it recounts scores of telling examples of the effect of mental processes on somatic functioning, a phenomenon that, as Bate (6) has noted, Samuel Taylor Coleridge had already dubbed "psychosomatic" in the early years of that century.
Tuke, for instance, cites from the French literature the following startling "experiment": "The rejection of the contents of the stomach from a purely mental state is well exemplified in an experiment made upon 100 patients in a hospital and reported by Dr. Durand (du Gros) in his able work, ‘Essais de Physiologie Philosophique.’ The house surgeon administered to them such inert draughts as sugared water; then, full of alarm, he pretended to have made a mistake in inadvertently giving them an emetic instead of syrup of jam. The result may easily be anticipated by those who can estimate the influence of the imagination. No fewer than 80—four-fifths—were unmistakably sick."
That brief clinical vignette provides a striking illustration of Tuke’s basic view of the effect of the mind on the body. It serves also to epitomize his delineation of a focus of medical interest that had begun with Mesmer and when Tuke wrote was approaching a scientific dead end of sterile neurophysiological speculations, such as Carpenter’s (7) "unconscious cerebration."
It was Janet who found a way around that conceptual impasse with his recognition that suggestion and its effects on human subjects were psychological phenomena that could be described and understood only in psychological language. Within that frame of reference, Janet formulated his concepts of the psychological process of mental dissociation, the splitting of consciousness, and the transformation of subconscious ideation into hysterical symptoms. These basic conceptual guidelines are evident in Janet’s description of the clinical evaluation and treatment of his famous patient, Marie, a young woman with a variety of disabling somatic symptoms. Prominent among these was a profound disturbance in her menstrual functions.
"As her menses approached," Janet (4) wrote, "Marie’s character would change, she would become gloomy and violent 
and would suffer from nervous twitchings in all her limbs. Despite this, everything would go smoothly during the first day, but scarcely 20 hours after its appearance her menstrual flow would suddenly cease, and her whole body would be seized by a shaking chill followed by an acute pain starting in her stomach and rising to her throat, after which she would begin to have major hysterical crises. These convulsions never manifested characteristic epileptiform movements and were followed by a long and intense delirium. The episodes would end with copious vomiting of blood following which everything would return to normal.
Although in her normal waking state Marie could not connect her symptoms with any events in her life, under hypnosis she recalled, as Janet tells us.
...the exact memory of a scene she had never been aware of before except in the most incomplete fashion. At the age of 13 she had had her first period, but either as the result of some childish idea or of a conversation she had overheard and misunderstood, she got it into her head that there was something shameful about the process and tried to find a way of stopping the flow as quickly as possible. Approximately 20 hours after her period had started, she went out secretly and plunged herself into a tub of cold water. Her action was completely successful. Her period was suddenly arrested, and despite a severe shaking chill that followed she was able to return home. She was ill for some time thereafter, and for several days was delirious. Everything quieted down, however, and her periods did not recur for 5 years. When they did return, they were accompanied by the difficulties I have described. Thus, if one compares the sudden arrest of her menses and the shivering and pain she now experiences in her waking state with the account she gives under hypnosis (which, moreover, was independently confirmed), one arrives at the following conclusion. Each month the scene of the cold bath is repeated, leading to the same arrest of menses and delirium. In her normal state of consciousness, however, she knows nothing about that and is quite unaware that her shivering is brought on by a hallucination of cold. It is possible, therefore, that the scene occurs below consciousness and brings on all the rest of her difficulties in its train.
Janet’s formulation of mental dissociation and its central role in symptom formation was well known to Breuer and Freud (8) as they pursued their early investigation of hysterical phenomena. With reference to Janet’s findings, they commented, "The longer we have been occupied with these phenomena, the more we have become convinced that splitting of consciousness in the well known clinical cases under the form of ‘double conscience’ [dual consciousness] is present in a rudimentary degree in every hysteria, and that a tendency to such a dissociation and with it the emergence of abnormal states of consciousness is the basic phenomenon of this neurosis."
It should be noted, however, that although Freud agreed at this point with Janet that hysterical symptoms were the surface manifestations of unconscious dissociated traumatic memories, he disagreed with Janet’s explanation of the origin of dissociation itself. In Janet’s view, dissociation was the result of a deficiency of psychological energy ("la misère psychologique"). Normal persons, he proposed, have a sufficient quantity of such psychological energy to enable them to bind together all their mental functions into an organized unity under the control of the "ego," or self. In some individuals, however, either through heredity or as the result of emotionally exhausting traumatic stresses, the quantity of psychological energy is lowered below a critical point. As a consequence, the binding power of the ego is weakened, leading to the dissociation from consciousness of selected mental elements. The latter can now be represented in conscious awareness as automatisms taking the form of ego-alien symptoms. In Janet’s model of the mind, normal persons cannot be hypnotized. It is only those with a pathologically weakened ego who respond to hypnotic suggestion with an artificially induced mental dissociation.
By the same token, hypnosis becomes an effective therapeutic agent when applied to patients with pathological dissociative automatisms. For example, when Janet turned to the treatment of Marie’s menstrual disorder, he
was able to remove that idea [the dissociated memory of her aborted menarche] by a curious measure. It was necessary to bring her back to the age of 13 by hypnotic suggestion, to revive that earlier state of delirium, and then to convince her that her period had lasted for three days and had not been interrupted by any untoward occurrence. Once that had been accomplished, her next period arrived exactly on schedule, lasted three days without being accompanied by any interruption, any convulsions, or any delirium. It is now more than five months since that experiment was made, and Marie no longer presents the least sign of hysteria.
(Janet, it may be noted, used the therapeutic technique of cognitive restructuring nearly a century before the introduction of modern cognitive therapy.)
Freud’s explanation of dissociative splitting was radically different from Janet’s formulation. In Studies on Hysteria (8) he introduced the concepts of repression and psychological defenses. In hysterical patients, he proposed, the ego protects itself from the painful recollection of traumatic events by repressing both the associated memories and emotions from conscious awareness and by converting the painful affects into somatic symptoms symbolically representing the precipitating trauma.
If one compares these two models of symptom formation, the differences are readily apparent. Whereas Janet conceived of an ego too weak to maintain its functional integrity, Freud viewed the ego as being strong enough to preserve its normal functions and its emotional equanimity by exercising an active control over the range and quality of the contents of conscious awareness. In that latter formulation were born the concepts of psychological conflict and psychological structure that remained thereafter the bedrock of the psychoanalytic understanding of mental functioning. It is not surprising, therefore, that when psychoanalytically trained physicians turned to a study of the possible role of psychological factors in the causation of medical diseases, they invoked the mechanism of conversion that had initially been formulated in connection with the somatic symptoms of hysterical patients. In the early 1920s, for example, Deutsch (9) commented, "The concept of the conversion process is now gaining in importance because similar transformation processes from psychic into organic phenomena can be observed also in diseases which by no means appeared to be psychogenic ones. Thus Freud’s concept of conversion may be carried beyond its original meaning. A considerable part of organic symptomatology will then be recognized as a result of the conversion process."
In the course of additional psychoanalytic investigations of patients suffering from what were increasingly referred to as psychosomatic illnesses, it became evident that generalizations such as that set forth by Deutsch were unsubstantiated. Psychological exploration of psychosomatic patients rarely disclosed conversion mechanisms underlying their symptoms. As Alexander (10) commented in a summary of the extensive clinical observations that had accumulated during the decade or two after Deutsch’s formulation,
It seems advisable to differentiate between hysterical conversion and vegetative neurosis (i.e., a psychosomatic condition). Their similarities are rather superficial: both conditions are psychogenic, that is to say, they are caused ultimately by a chronic repressed or at least unrelieved emotional tension. The mechanisms involved, however, are fundamentally different both psychodynamically and physiologically. The hysterical conversion symptom is an attempt to relieve an emotional tension in a symbolic way; it is a symbolic expression of a definite emotional content. This mechanism is restricted to the voluntary neuromuscular or sensory perceptive systems whose function is to express and relieve emotions. A vegetative neurosis consists of a psychogenic dysfunction of a vegetative organ which is not under control of the voluntary neuromuscular system. The vegetative symptom is not an expression of the emotion, but its natural physiological concomitant.
Although Alexander made a sharp distinction between the specific psychodynamic mechanisms underlying the production of a conversion and a psychosomatic symptom, he attributed both to a repression of affects. In so doing, he adhered firmly to the basic psychoanalytic concept of psychological conflict. At the same time, however, he highlighted a striking aspect of the mental functioning of psychosomatic patients, who exhibit marked behavioral defects in their affective and cognitive functions. Those characteristics subsequently became the explicit focus of interest of several investigators of psychosomatic illness, such as Ruesch (11) in the United States and Marty (12) in France, whose description and analysis of their nature went far beyond Alexander’s brief passing mention.
Foremost among those investigators is Sifneos (13), who in 1967 called attention to the remarkable difficulty of many psychosomatic patients in finding words to describe feelings. In a subsequent, more detailed investigation of a series of patients with psychosomatic disorders, Nemiah and Sifneos (14) delineated the characteristics of a prominent behavior pattern for which Sifneos (15) ultimately coined the term "alexithymia" (no words for feelings). Alexithymic patients, they reported, manifest two basic characteristics. First, they are unable to describe or to differentiate among fundamental human feelings, such as anxiety, sadness, or anger. Second, their cognitive thought content is characterized by a preoccupation with the details of external events and a complete absence of fantasies referable to inner drives and affects. The origin of this characteristic pattern of behavior is not fully known. Apart from the possible causal role of genetic and early developmental factors, Krystal (16) has found that many persons exposed to the chronic horror of concentration camp life developed characteristic alexithymic behavior, a result Krystal attributed to a regressive dedifferentiation and resomatization of affects to a state of affective functioning characteristic of the early phases of life.
Whatever the ultimate explanation of alexithymia proves to be, it is clear from its behavioral manifestations that the mechanisms of somatic symptom formation in alexithymic patients are quite different from those found in the production of conversion symptoms. A conversion symptom is the end result of processes occurring in a complex structure of psychological mechanisms that transform stress-induced arousal into a somatic dysfunction symbolically representing the original stressful situation. In the alexithymic individual, on the other hand, stress-induced arousal undergoes no psychic elaboration and is directly transformed into a somatic dysfunction. Despite those differences, however, from a conceptual point of view, both models of symptom formation are psychological in nature. Both use a psychological model that conceives of symptoms as the end result of stress-induced internal psychic arousal into peripheral somatic manifestations. There are, in other words, two radically different psychological pathways leading to clinical symptoms, one associated with the mechanism of conversion, the other with alexithymia.
That duality of pathways has numerous implications for the investigation of psychosomatic disorders and for the treatment of patients who suffer from them. Clinical observations made since Alexander’s investigations, for example, have shown that his rigid distinction between a conversion and a psychosomatic symptom is by no means absolute and that the psychological process of conversion may lead to symptoms mediated by the autonomic ("vegetative") pathway. Marie is a case in point, with her neuroendocrine menstrual disturbance arising from a highly structured, unconscious psychological conflict.
Similarly, in a psychodynamically oriented study of the results of psychotherapy in a group of patients with ulcerative colitis, Karush et al. (17) found that 20% of their population manifested psychoneurotic conflicts responsive to dynamic psychotherapy. The vast majority (80%), however, showed a behavior pattern strongly suggestive of alexithymia. They were emotionally restricted, unresponsive to insight-oriented psychotherapy, and required supportive psychotherapeutic measures.
Karush et al.’s findings seem to be consistent with observations reported earlier by Lindemann (18) in a remarkable but little known paper describing a clinical study of 87 patients hospitalized with acute ulcerative colitis. In this group, Lindemann observed that the onset of symptoms was associated with the rupture of a relationship with a person on whom the patient was deeply dependent. Furthermore, Lindemann found that the acute symptoms were dramatically reduced when he substituted himself for the lost person in a therapeutic relationship, a therapeutic technique he termed "psychological replacement therapy."
Studies such as these emphasize the importance of psychodynamic concepts for the theoretical understanding, clinical evaluation, and treatment of patients with psychosomatic illnesses. They point to the significant role of psychodynamic processes in the production of psychosomatic illness and indicate the clinical necessity of determining the exact nature of those processes in psychosomatic patients as a guide to appropriate therapy. They emphasize, too, the fundamental value of psychodynamically oriented research, a form of investigation that is now out of fashion. Indeed, there is currently a need for sophisticated psychological studies designed, for example, to cast light on the still profoundly mysterious nature of the relationship between one human being and another that in the setting of support groups significantly prolongs the life of persons with metastatic carcinoma (19) or can dramatically abort a life-threatening exacerbation of ulcerative colitis with psychological replacement therapy (18). Or, we might with profit explore the remarkable power of therapeutic suggestion, which is not only able to transform a word into an emetic for an entire ward of patients (5) but is perhaps at the heart of much of "alternative medicine," an area, Dimsdale (20) reminds us, that is seriously wanting in testable hypotheses. We might also anticipate that a difference of such magnitude as that which exists between the psychological constellations associated with conversion on the one hand and alexithymia on the other would be mirrored by differences in brain functioning of sufficient degree to be detectable by the increasingly sensitive techniques of modern brain imaging.
Finally, it should be emphasized that the historical information presented here is of more than mere antiquarian interest. On the contrary, it reveals a large body of empirically derived psychodynamic fact and theory that, although largely disregarded in our current preoccupation with the biology of psychiatric disorders, constitutes a major element of what Engel (21) has termed the "biopsychosocial" model of human illness. In sum, as history teaches us, psychodynamic psychiatry has made important contributions to the understanding of psychosomatic illness, and it has many more to add in the years ahead to an integrated concept of human illness that, as Weiner (22) has cogently demonstrated, is unique to psychosomatic medicine.
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NOTES |
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TOPABSTRACTINTRODUCTIONNOTESREFERENCES |
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Received for publication June 11, 1999.
Revision received October 18, 1999.
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This article has been cited by other articles:
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  R. M. Gottlieb Psychosomatic Medicine: the Divergent Legacies of Freud and Janet J Am Psychoanal Assoc, September 1, 2003; 51(3): 857 - 881. [Abstract] [PDF]
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 F. Lamprecht and M. Sack Posttraumatic Stress Disorder Revisited Psychosom Med, March 1, 2002; 64(2): 222 - 237. [Abstract] [Full Text]
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