Canad. Med. Ass. 3. WrrrKowI.a: PSYCHOSOMATIC Disoiwi.

ms 1055
May 2, 1964, vol. 90

ABSTRACT SOMMAIRE
Goals, potentialities and limitations of L'auteur passe en revue les buts, los possi-
treatment of psychosomatic disorders are bilit6s et los limitations du traitement des
reviewed. Removal of a disturbing psycho- affections psychosomatiques. Tout cc qu'on
somatic symptom may be all that can be arrive parfois .i r6aliser est d'6liminer le
accomplished. The bulk of patients suffer- trouble cause par un sympt6me psycho-
ing from psychosomatic disorders should be somatique. La majorit6 des malades souf-
treated by physicians other than psychia- frant d'affections psychosomnatiques de-
trists. Difficulties arise, owing to differences vraient .tre trait6s par des g6n&alistes ou
in approach, when treatment is carried des m6decins qui ne soient pas des psy-
out by a general physician as well as a chiatres. Des difflcult6s naissent & cause
psychiatrist. In appraising the prospects of des diff6rences d'examen quand le traite-
treatment, the age on examination, intelli- ment est mend par un omnipraticien ainsi
gence, duration of illness, degree of insight, qu'un psychiatre. Pour estimer les perspec-
nature of illness, environmental stress and tives du traitement psychologique du ma-
personality structure of the patients should lade souffrant d'une affection psychosoma-
be considered. Psychiatric measures which tique, il faut tenir compte de nombreux
have been employed include: electroconviil- 6l.ments parmi lesquels figurent l'Age au
sive therapy, psychotropic drugs, hypnosis, moment de re.nen, la dur6e de Ia
drug abreaction, group therapy, supportive maladie, sa nature, le degr6 de la prise de
psychotherapy and psychoanalysis. Psycho- conscience et l'intelligence du sujet, los
analysis provides the best understanding of agressions n.es du milieu et la personnalit6
the psychodynamics of psychosomatic ill- profonde du malade. Les moyens d'action
ness but is, for a variety of reasons, applic- psychiatriques, employin$s pour traiter les
able only to a small number of patients. pathologies psychosomatiques sont: l'61ec-
Alterations and removal of disturbing symp- trostimulation, les m.dicaments psycho-
toms can be accomplished by the other tropes, l'hypnose, l'abr.action m&licamen-
therapeutic means. teuse, los psychoth6rapies collectives, la psy-
choth6rapie et la psycho-analyse auxiliafres.
La psycho-analyse est le meilleur moyen
de percer la psychodynamique de la mala-
die psychosomatique, mais elle n'est
malheureusement applicable qu'& un
nombre restreint de malades. La trans-
formation et l'6limination des sympt6mes
morbides peuvent .tre r.alis&s par los
autres moyens th&apeutiques.
 Canad. Med. Ass. J.
May 2, 1964, vol. 90

Balint's seminars for general practitioners at the

Tavistock Clinic in London, England, and similar
ventures at other centres are promising efforts in
this direction. Psychosomatic medicine is a stop-
gap and not a specialty; it will cease to exist if and
when its tenets have been absorbed by general
medicine. However, there is-and there will always
be-a group of psychosomatic patients who require
the help of a psychiatrist.
In many patients a combined approach is advis-
able. For instance, patients suffering from peptic
ulcer require a check-up at regular intervals and
frequently physical treatment while they are under-
going psychological treatment. No one would dare
to run the risk of a perforation for the sake of
proving that psychological treatment is effective.
Similarly, asthmatic patients are in need of pal-
liative treatment. They often develop severe attacks
and stay away when they come up against resis-
tances during their psychological treatment. How-
ever, co-operation between physician and psychi-
atrist who treat the same case is not always easy.
The physician should keep strictly to his physical
approach, should refer emotional problems to the
psychiatrist and guard his words because patients
are apt to use not only their physical symptoms
but also utterances made by the physician as a
defence against a psychiatric approach. Under no
circumstances should patients be caught in a situa-
tion in which physician and psychiatrist psycho-
therapeutically pull in different directions. The
psychiatrist, on the other hand, is well advised not
to examine patients physically while they are
undergoing psychotherapy in view of the inevitable
transference implications and complications.
3. What type of psychosomatic patient should be
taken on for psychological treatment?
This question is difficult to answer. It may suffice
at this point to say that any patient in whom
psychosomatic diagnostic interview has established
beyond any doubt a definite etiological relevance
of emotional factors to the development of the dis-
ease, may be accepted for psychological treatment.
There are, however, certain reservations to this
statement which will be dealt with shortly.
4. What are the prospects of psychological treat-
ment in psychosomatic patients?
Factors which should be taken into consideration
in this respect are (a) age on examination, (b)
intelligence, (c) duration of illness, (d) insight,
(e) naturc of physical illness, (f) environmental
stress, and (g) personality structure of the patient
to be treated.
(a) Age on examination. It is generally agreed-
though not always true-that patients over 45 are
not easily amenable to psychotherapy. By that age
the structure of their personality has become so
rigid that it is difficult to bring about any modi-
fication.
Canad. Med. Ass. 3.
May 2, 1964, vol. 90
WIrricowER: Ps.ciosox.nc DIsoIWERS 1057

This statement is generally true, but there are

exceptions. Psychosomatic dysfunctions for a variety
of reasons 'may 'be intractable whereas structural
lesions may clear up under psychotherapy with
remarkable speed. For instance, the case of an
Australian surgeon comes 'to mind who, suffering
from ulcerative colitis, had been admitted to a
teaching hospital in London. By the time an
eminent physician 'had completed his examination
the patient was so weak that an operation was no
longer considered a reasonable risk. Most reluc-
tantly the physician called in a psychiatrist who
elicited the following story: Prior to 'his departure
from Australia the patient had 'been asked to
examine his mother, to whom he was greatly
attached. He had dismissed the lump, which she
had discovered on her breast, as 'benign and of no
importance. On receiving the news 'by cable that
she 'had an inoperable cancer he had his first attack
of bloody diarrhea. After a ventilation of his in-
tense feelings of guilt he recovered rapidly and
has remained well, as far as I know, ever since.
Hence the severity of the illness and of the struc-
tural lesion, with certain obvious exceptions, does
not necessarily militate against reversibility.
Moreover, as regards the nature of the illness,
the possibility of multiple causation and the rela-
tive significance of emotional factors in the sum
total of etiological factors should 'be borne in mind.
The concept of single-factor etiology of disease in
general and of psychosomatic disease in particular
has been generally abandoned and has been re-
placed by a recognition of the etiological relevance
of a combination of factors. Correspondingly, a
variety of therapeutic measures may lead to symp-
tomatic relief. For instance, drugs, desensitization
and psychotherapy may all diminish the frequency
and severity of asthmatic attacks. 'In fact, in aller-
gic patients it is considerably easier to remove a
noxious allergen from the patient's diet than to
enable him to tolerate it as a result of psycho-
therapy. However, it is obvious that removal of the
symptoms fails to remove the emotional conflict
which at least in part may have caused it.
(f) Envir&nmental stress. Another factor which
must be taken into consideration is environmental
stress. The reality and intensity of imposed frustra-
tions and deprivations must be appraised. and
'brought into relation with the patient's endurance
threshold for frustration, and the question of
transience versus persistence of environmental
stress must be considered. It is obvious that a
person under transient stress, however severe,
stands a better chance of recovery than a person
under prolonged unremovable stress which he is
unable to tolerate.
Stresses usually arise from the family situation,
hence exploration of family interaction may pro-
vide major prognostic criteria for the outcome of
psychological and, for that matter, somatic treat-
ment of psychosomatic disorders. Not infrequently
the psychosomatic illness itself has enabled a kind
1058 WirricowErt: PSYCHOSOMATIC DIsoIuE1.s Canad. Med. Ass. J.
May 2, 1964, vol. 90

of precarious equilibrium to be established in the disease by surgical means. Margolin,'0 for instance,
reciprocal intrafamilial relationships, so that the describes the case of a patient in whom, following
successful treatment of the illness may create vagotomy and gastric resection, the preoperative
additional stress within the family rather than gastric symptoms reappeared and persisted. De-
relieve it. tailed investigation failed to disclose any pa-
(g) Personality structure. Last but not least, thological secretory, motor or anatomical findings
successful psychotherapy in psychosomatic dis- which would account for the symptoms in an organ
orders obviously depends on the level of emotional which "wasn't there". The diagnosis of "phantom
maturation reached by the sufferer previous to the organ" analogous to the phantom-limb syndrome
onset of the disease. It stands to reason that a was made. This state disappeared after psycho-
hysteric with hysterically determined organ symp- therapy.
tomatology is not more difficult to treat than any Seguin" therefore concluded that "a 'cure' can
other hysteric, but the closer the personality dis- only be declared when all stimuli altering the
order of a patient with a psychosomatic organ psychosomatic equilibrium of the organism have
dysfunction or structural lesion is to a psychosis, been taken into account and the total situation has
the more doubtful is the prognosis. been favourably modified, thus restoring the
Lindemann,8 Daniels,4' . Alexander2 and others equilibrium. This implies, naturally, knowledge
have stressed the weakness of the ego in patients of the physical, chemical and biologic resources
suffering from ulcerative colitis. Many of these which medicine makes available, but implies
patients have a tendency for paranoid projection; further the treatment of the personality and its
some of them belong to the group of borderline conflicts."
psychoses. Uncovering procedures in these cases
may lead to a release of repressed impulses which 5. What psychiatric measures should be used
their weak ego is unable to tolerate, and may result for the treatment of psychosomatic disorders?
in an aggravation of symptoms which may become The answer to this question cannot be dogmatic
unmanageable, if not in the development of a because in answering it every psychiatrist is of
psychotic episode. necessity influenced by his training and by his
A psychosomatic disease is a pathological affect- personal preferences.
discharge along autonomic pathways. If affect- (a) Electroconvulsive therapy. With very few
discharge along these channels is blocked by exceptions of patients who suffered *from gross
psychotherapy without resolution of the underlying depressive psychoses related or unrelated to the
emotional conflict, or by surgical procedures, an psychosomatic disorders, I have never used electro-
alternative outlet for emotional expression has to be convulsive therapy in the treatment of psycho-
found. As a result of this, after removal of the somatic patients. Even in these exceptional cases
disturbing somatic symptom, the patient may be the results obtained were by no means striking as
worse off than 'he was before. A most dramatic far as the psychosomatic symptoms were con-
example illustrating this mechanism is the case of cerned.
an asthmatic who had lost his asthmatic attacks on (b) Psychotropic drugs. Much research has been
suggestion therapy and wanted to have them back recently carried 'out into the effectiveness of
in lieu of the severe anxiety attacks which had psychotropic drugs in psychosomatic disorders. Our
taken their place. Similarly, Seguin reported the own investigations'8 regarding the effect of psycho-
case of a woman who on account of an obsessive tropic drugs on psychosomatic skin disorders, a
neurosis sought the attention of a psychiatrist. The douMe-blind study, have shown that these drugs
neurotic symptoms disappeared at the end of a are more effective than placebos, that their effec-
few months, but a "colitis" led the patient to tiveness depends on the presence or absence of
abandon the psychiatrist and resort to a physician psychiatric symptomatology, that preferential choice
until the colitis was cured and the patient, feeling of drug (chiorpromazine versus imipramine) de-
very grateful towards the physician, returned to the pends on the manifested psychiatric symptoma-
psychiatrist because her obsessive symptoms had tology, and that improvement in dermatological
reappeared. symptomatology corresponds to relief in psychiatric
Browning and Houseworth3 compared a series of symptomatology.
peptic-ulcer patients treated by gastrectomy with a (c) Hypnosis. Many years ago 'I made wide use
control series of patients who had been treated of hypnosis for the removal of psychosomatic
along conservative lines. On follow-up the surgi- symptoms 'by direct suggestion as well as for
cally treated group revealed a significant increase abreactive purposes. The results obtained in cases
in other psychosomatic and psychoneurotic symp- of monosymptomatic hysteria were encouraging. In
toms. The medically treated control group, in patients with organ neuroses and in those with
which ulcer symptoms were not significantly psychosomatic structural diseases not much 'could
reduced in incidence or severity, revealed no such be expected.
redistribution of psychogenic symptoms following (d) Drug abretwticm. Drug abreaction has been
treatment. Other writers observed a "phantom used 'by Shorvon, Rook and Wilkinson'2 in the
syndrome" after abrupt removal of a psychosomatic treatment of psychosomatic skin disorders. Accord-
 Wirricowi.a.: PsYcHoso.nc Disoiu.s 1059

ing to their definition the term "abreaction" not reasons given, may be all that is needed. Yet
only is applied to the recalling and reliving of however desirable and 'however useful, like
repressed events 'but also includes the re-experience abreaction, it can never lead to a resolution of
of conscious experiences. 'In fact their case material basic conflicts.
suggests that *these authors confine themselves (g) Psychoanalysis. It is probably agreed that
exclusively to a reconstruction and to a revival of the psychoanalytical approach provides the 'best
events of the patient's recent past. understanding of the psychodynamics of psycho-
The techniques employed indude intravenous somatic illness. This, however, does not mean that
barbiturates, such as sodium amytal or thiopental every patient suffering from a psychosomatic illness
sodium, intravenous methedrine, ether inhalation should be submitted to full psychoanalysis. Even
and inhalation of carbon-dioxide mixtures. should 'this be feasible, indiscriminate application
The results obtained in a great variety of derma- of psychoanalytical treatment would not always be
tological patients were satisfactory. Of 50 patients in the interest of the patient, for reasons which
treated, 21 recovered completely as far as their will be discussed later.
skin lesion was concerned and 22 were improved.
In only seven patients was no change observed. 6. Which psychosomatic patients should be
According to these authors, barbiturates were of treated by psychoanalysis?
little value whereas ether, carbon-dioxide mixtures 'In theory those patients should be treated by
and methedrine brought about an intense excitatory psychoanalysis whose psychological disorder under.-
abreaction with the release of tension, anxiety and lying or accompanying the psychosomatic illness
aggression even in long-standing cases. is 'of such a nature as not to be amenable to minor
Abreaction of this kind, however, either under forms of psychotherapy. To decide whether or not
hypnosis or as the result of drugs, can hardly this is the case may require a trial analysis of a
come near to the underlying core conflict, which few weeks. More often than not this decision
consequently remains untouched. is reached after innumerable methods of physical
(e) Group therapy. Group therapy for psycho- and psychological treatment have been unsuccess-
somatic patients has been attempted at various fully attempted. In practice psychoanalysis is-.
centres, especially for patients suffering from an'd will be-a prerogative of those who can pay
obesity, diabetes mellitus, 'bronchial asthma and for it and it depends in its application on the
skin disorders. 'H. S. Klein,7 for instance, treated availability of trained psychoanalysts.
13 patients suffering from neurodermatitis. He
adopted a more or less didactic attitude during the 7. Are there any shortcuts to psychoanalysis in
first few sessions, which were devoted to discussion dealing with psychosomatic disorders?
of emotions and bodily changes with special refer-
ence to blushing, sweating and other psycho- Freud originally argued that the only means of
physiological phenomena. He regarded these shortening a psychoanalysis is to improve ones
preliminary discussions as essential in view of the psychoanalytical technique. Since then various
fact that for many years these patients had been psychotherapeutic procedures *have been worked
instilled with the idea that their condition was due out which are based on psychoanalytical principles;
to various physical irritants. Afterwards the psychi- for instance, brief psychoanalysis of Alexander at
atrist assumed an interpretive role. Not only the al.1 Felix Deutsch's6 sector therapy and Sydney
relationship between patient and therapist, 'but also Margolin's9"0 anacitic treatment.
between the patients themselves, and between the Of these, I shall briefly describe Margolin's
patient and nursing staff were interpreted. The anacitic therapy which regards as its objective
results obtained with these 13 patients were en- the induction of a physiological change-a remis-
couraging, especially from the point of view of sion of the disease in association with objective
recovery from the dermatitis. The satisfactory re- changes in mood and a clearly observable altera-
sults were attributed to the establishment of a tion in the patient's transference 'behaviour. Its goal
good transference relationship. In achieving a posi- is therefore symptom-directed or disease-directed;
tive 'transference the therapist was enabled to and not directed, at least not primarily, towards
assume the role of the "good" father and became, a change in personality structure. The term
as it were, a kind of auxiliary super-ego. In this "anaclitic", meaning "leaning on", is derived 'from
way his permissiveness offset the patient's original Freud, who used it to designate that transference
strict and punishing conscience and thus lessened behaviour which repeats certain aims of the infant's
guilt and tension. From this it follows that the relationship to the mother. Although for the most
greater part of the improvement depended on the part anaclitic treatment is widely practised as
stability of the transference. "superficial psychotherapy", the concept "anacitic"
(f) Supportive psychotherapy. Supportive psy- is used to differentiate its psychoanalytic applica-
chotherapy, from an attentive, well - meaning tion.
listener, as reassurance, as environmental manipu- Anaclitic therapy consists of three phases. The
lation or even as hospitalization, may be all that first phase exploits the patient's unconscious ten..
can be offered and in certain cases, for the dency to drive to a level of regression which re-
1060 WITTKOWER: PSYCHOSOMATIC DISORDERS Canad.
May Med. Ass.
2, 1964, J.
vol. 90

enacts the infantile conflict that is genetically The second phase of the anaclitic therapy aims
related to his disease. This regression permits an at reversing the psychological regression. During
attitude of dependency which favours external it, verbal interpretations are given, although Mar-
help. During this phase the therapist assumes a golin emphasizes that the verbal exchange between
role of total permissiveness and does not thwart therapist and patient in the first and second phases
the regression. Instead of formal daily scheduled of therapy is not directed at psychological insight
interviews, the therapist seeks the hospitalized but at physiological remission, which never occurs
patient out wherever he is, several times a day. without a mood change. Phase 2 extends over a
The guiding principle of this frequency is analo- period of three or four months.
gotis to that of the "demand feeding" schedule. More often than not, according to Margolin,
Food is prepared and provided by the therapist, patients suffering from various psychosomatic dis-
usually in the form of high-calorie milk mixtures. eases experience a complete remission during this
It is available to the patient on demand and given period. It may have to be followed by a character
to him by the therapist. Hints of the efficacy of analysis which constitutes phase 3.
the therapy come from the degree of the patient's Margolin does not claim that anaclitic therapy
relaxation, drowsiness and wish to sleep. The pa- is a panacea for the treatment of psychosomatic
tient is touched and handled; areas of pain and disease; he does not even claim that it is a novel
discomfort are massaged and stroked. The therapist method of treatment, but he submits the view that
deliberately adopts and maintains an attitude of his concepts have provided a framework which
omniscience and omnipotence. The activities of allows one to understand and to conceptualize
nurses and other attendants fall into line and are measures intuitively adopted by many practitioners.
represented as being under the direct control and
supervision of the therapist. Usually within a week SUMMARY
or two the patient has passed into a state of An outline of problems arising from the management
dependency and attachment to the therapist, char- of patients suffering from psychosomatic disorders has
acterized by infantile features. been given. Goals, possibilities, potentialities and limi-
In the process of the psychological backward tations of the treatment of psychosomatic disorders
movement, patients may abandon interest in their have been discussed.
environment and may display, in a childlike manner, RF:FERENCES
marked self-centredness. Psychotic symptoms may 1. ALEXANDER, F. et al.: Psychoanalytic therapy; principles
appear. Sooner or later, however, the patient's and application, Ronald Press Go., New York, 1946.
2. ALEXANDER, F.: Psychosomatic Medicine, w. W. Norton
productions and behaviour indicate a wish to re- & Go., Inc., New York, 1950, p. 122.
3. BROWNING, J. S. AND HOUSEWORTH, J. H.: Psychosom.
enact his own genetic development; that is, he Med., 15: 328, 1953.
4. DANIELS, G. E.: New Eag. J. Med., 226: 178, 1942.
begins to manifest a wish to assume certain of his 5. Idem.: Gastroenterology, 10: 59, 1948.
6. DEITTSCIT, F.: Applied psychoanalysis; selected objectives
functions which had been delegated to the thera- in psychotherapy, Grune & Stratton, Inc., New York,
1949.
pist. This spontaneous development is analogous 7. KLEIN, H. S.: Brit. J. Med. Psychol., 22: 32, 1949.
8. LINDEMANK, E.: Arch. Neiool. Psychiat. (chicago), 53:
to the process of maturation in the growing infant. 322, 1945.
9. MARGOLIN, S. G.: Genetic and dynamic psychophysiologi-
The therapist then proceeds to "frustrate" the pa- cal determinants of pathophysiological processes. In:
The psychosomatic concept in psychoanalysis, edited
tient by changing the mode of gratification to by F. Deutsch, International Universities Press, Inc.,
which the patient has become conditioned. This New York, 1953, p. 3.
10. Idern: Psychotherapeutic principles in psychosomatic
is done by offering a verbal interpretation of the practice. In: Recent developments in psychosomatic
medicine, edited by E. D. Wittkower and H. A. Gleg-
patient's wish to be looked after while gratifying it. horn, Sir Isaac Pitman & Sons, Ltd., London, 1954,
p. 134.
This procedure, if successfully applied, becomes 11. S.euixv. C. A.: Psychosom. Med., 11: 305, 1949.
12. SHORvON, H. J., RooK, A. J. AND WILaINsoN, D. S.:
the nodal point which ushers in the second phase Brit. Med. J., 2: 1300, 1950.
13. WITTKOWER, B. D. AND LESTER, B. P.: Psychosomatic
of treatment. By then evidence of symptomatic aspects of skin disorders: Dv: Acta Psychosomatica,
Documenta Geigy, No. 5, British Series, 1962, p. 1.
improvement is usually noticeable. 14. XVITTKOWER, B. D.: Psychosoia. Med., 22: 308, 1960.

PAGES (JUT OF TI-IE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO
THE BEST HOLIDAY thought have time to recuperate, not-let us hope-by
One of the characteristics and charms of university life lying fallow, but by being cultivated in other directions.
is its division into terms and sessions, each with its definite For with the brain, as with the body, the best holiday is a
work apportioned to it, and each at once complete in change of work.
itself, and yet forming part of the great whole, which The weeks of vacation go quickly by, and almost before
constitutes the full curriculum. At the completion of each we realize ft we stand again, as we do to-day, on the
session, when the strain of teaching and of studying, of threshold of a new session. This time too brings with it
examining and being examined, is over, we suddenly its own peculiar sense of exhilaration. We return mentally
relax, and with a comfortable feeling of leaving behind! and physically fit. Tasks which seemed a burden a short
us the year's work well done, and of taking away with us three months ago can now be cheerfully faced. We are
something new added to our store of knowledge, we enjoy eager for work, and can look forward with confidence to
our holiday as few others can. Brains exhausted and staled the future-B. P. Watson, Gonad. Med. Ass. 1., 4: 469,
by close application to a more or less limited field of 1914.