Psychother. Psychosom. 30: 211-215 (1978)
Implications from an Unusual Case of Multiple Psychosomatic Illness Harold L. Levitan Queen Elizabeth Hospital, Montreal, Que.
Abstract. A 40-year-old patient who developed over her lifetime an unusually large number of psychosomatic illnesses is presented. She manifested in succession, bronchial asthma, peptic ulcer, regional ileitis and anorexia nervosa. In addition to the factor of multiplicity of illnesses, this series of illnesses is of special interest because the association of a classical psychosomatic illness with anorexia nervosa has not been reported previously. In order to take advantage of the unusual series of illnesses in one patient, I utilized a novel investigative approach. Basing myself upon the supposition that the fundamental make-up of the personality remains fairly constant over time, 1 criss-crossed bits of established knowledge from one illness to another. In this way, I was able to derive various implications with respect to the psychodynamic, the cognitive-perceptual and the hypothalamic levels of functioning in all the illnesses.
Introduction
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Patients who have developed several psychosomatic illnesses in succession provide the investigator with an important advantage. Given the essential unity of the personality over time it is likely that the same basic psychological factors have contributed to the production of all the illnesses. Thus it may be possible to cross-fertilize understanding of the illnesses by transferring insight from one to another. There can be no doubt at all regarding the legitimacy of this approach in cases involving simultaneous illnesses. Moschowitz and Roudin (1948), authors whose valuable studies are little consulted nowadays, were the first to utilize this unifying approach to the investigation of psychosomatic illness. They noted that it was precisely those illnesses which occurred in association with the same personality traits in different patients which tended to occur either successively or simultaneously in the same patient.
Levitan
212
In this paper, I apply this approach to a patient whose history contains an unusually long list of psychosomatic illnesses: she had developed in succession bronchial asthma, duodenal ulcer, regional ileitis and finally anorexia nervosa. For purposes of discussion, the three classic psychosomatic illnesses are treated as a unit in juxtaposition to the anorexia nervosa. Nemiah (1973) has drawn attention to the similarities in overall psychologi cal make-up which exist between patients with anorexia nervosa and patients with the classical psychosomatic illnesses. The circumstances of this case in which anorexia nervosa and the three classical psychosomatic illnesses occur in the same patient serves to underscore his point. However, this combination of illnesses is apparently very rare. A thorough search of the literature on anorexia nervosa turned up no other case which was associated with anyone of the three illnesses. In fact, I could find no case of anorexia nervosa which was associated with any psychosomatic illness. The Patient
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The patient is a 40-year-old mother of 4 children. At the time of writing, the anorexia nervosa is still present. In the periods prior to her hospitalizations her weight has dropped as low as 60 lb. On several occasions she has been discovered in coma due to the combined effect of hypoglycemia and dehydration. Data regarding her history and attitudes have been gathered slowly over several hospitalizations. She is a very reluctant informant who reveals almost nothing spontaneous ly. Often she becomes extremely irritated at my questions. Her anger is sharp but astonish ingly brief in duration. She is almost totally unaware of her own feelings. Often, when she is asked about her response to a particular life situation she replies by stating someone clse’s view of her response, such as ‘my children say 1 was very sad ...’. Her almost total refusal to eat began 4 years ago. Prior to this point, she did eat and drink regularly but only, as she puts it: ‘because everyone else in the family was doing it’. She claims that she has rarely if ever in her life experienced the feelings associated with appetite. She also claims that she has never experienced the feelings associated with sexual desire. Since the onset of the anorexia 4 years ago she has been totally amenorrheic. She demonstrates the behavioral features which are usually found in patients with anorexia nervosa. She abhors fatness in others and has a fear of gaining weight herself. She usually feels full after a single bite. If on occasion she does ingest more than the usual amount she immediately induces regurgitation. Like many patients with anorexia, she engages in shoplifting in food stores as well as elsewhere. This antisocial activity may represent a displacement of her oral aggressive trends. She has a grossly inaccurate concep tion of her body image: despite her extreme emaciation she does not consider herself a thin person. An atypical feature of her anorexia syndrome was its late onset at age 36. She suffered from moderately severe asthma from age 5 to age 29. At age 31, shortly after the birth of her second child, she developed a duodenal ulcer which was resistant to
Implications from an Unusual Case of Multiple Psychosomatic Illness
213
treatment for several years. Suddenly, at age 35, she presented with peritonitis due to rupture of the ileum. Pathological examination of the excised portion of the ileum disclosed acute regional ileitis. The anorexia nervosa began shortly after her recovery from the ileitis. It was not possible to relate the onset of her various illnesses to particular events in her life. Her history was marked by trauma from a very early age. Both her parents were irresponsible alcoholics with a strong proclivity to violence. Though the patient herself remained stubbornly silent on these matters, an older sibling portrayed in detail for us the chaotic circumstances surrounding her early years. Her parents finally separated when she was 10. At this point, she was placed in the first of a series of foster homes. At age 20, she married a much older man who became the father of her 4 children. The marriage, which has been extremely stormy, seems to repeat many features of the relationship between her parents.
Discussion
It is convenient to conceptualize the factors which predispose to the production of psychosomatic illness in terms of the levels on which they operate. Three levels involving the central nervous system may be discerned: a psychodynamic level, a cognitive-perceptual level and a hypothalamic level. The Psychodymmic Level The role which psychodynamic factors play in the production of psychoso matic illness remains unsettled. At one point (Alexander, 1950), it was thought that each illness was correlated with a particular psychodynamic conflict. Our patient who developed so many illnesses in succession appears to refute this specificity hypothesis simply because it is highly unlikely that one patient could experience so many different conflicts. On the other hand, it seems reasonable to assume that a single conflict, possibly an oral conflict derived from the traumatic events which occurred during her early life, is relevant to all four illnesses.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
The Cognitive-Perceptual Level Many psychosomatic patients demonstrate an unawareness of their own on-going feelings. In an extreme instance, the patient who is crying may be aware only of ‘wet eyes’ rather than of sadness (Levitan, in press). In less extreme instances, the patient may vaguely sense some feeling but is unable to describe it well or to localize it within his body schema. Our present patient represents a rather extreme instance as indicated by the fact that it is often necessary for her to call upon an outside observer in order to know what she is
Levitan
214
feeling at a given time. The reasons for this failure of psychosomatic patients to become aware of their own feelings are not at all clear. Most workers in the field attribute it to the successful use of the defense mechanism of denial, other workers (Sifneos, 1974; Nemiah, 1973) attribute it to the presence of a neuro physiological deficit which interferes with the recognition and interpretation of internal signals. The inclusion of anorexia nervosa in the series of psychosomatic illnesses developed by our patient may shed some light on this issue. Our patient, like all anorexia nervosa patients, demonstrates fundamental perceptual abnormalities involving misperception of her body image and misinterpretation of her hunger stimuli. She therefore presents us with an instance in which a psychosomatic patient’s failure to become aware of feelings is definitely associated with failure to become aware of other internal bodily states. It is likely that the failures of perceptual function on the more fundamental levels are linked on an ascending continuum with the failure to perceive feelings. The presence in this case of the wide failure to perceive internal signals seems to favor a neurophysiological rather than a psychodynamic explanation of her failure to perceive her feelings. Recently, new techniques which enable precise measurement of the degree of distortion of the body image have become available. They have already been used to delineate the distorted perception of the body image in patients with anorexia nervosa (Slade and Russel, 1973; Crisp and Kalucy, 1974). An interest ing next step deriving from study of this case would consist in using the same techniques to test the accuracy of perception of the body image in psychosomat ic patients.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
The Hypothalamic Level The fact that in roughly 25% of cases the amenorrhea precedes the altera tions in eating habits has led to tire consideration of the possible role of a primary hypothalamic disturbance in the etiology of anorexia nervosa (Russell, 1970). Recent experimental work on the hypothalamic regulation of feeding and satiation behaviors in animals indicates that feeding behavior is correlated with activation of the noradrenergic and dopaminergic system and that satiation behavior is correlated with activation of the cholinergic system (Mawson, 1974). This set of findings suggests that anorexia nervosa which is a disorder charac terized by diminished pressure to feed and/or premature satiation is a disorder involving parasympathetic (cholinergic) predominance. The presence of asthma and ulcer which are also disorders involving parasympathetic predominance
Implications from an Unusual Case of Multiple Psychosomatic Illness
215
(hence the therapeutic usefulness of adrenalin and vagotomy, respectively) in a patient with anorexia nervosa tends to provide support for this new concept. It is not unlikely that a constitutional factor affecting the autonomic nervous system is present in this patient who developed so many illnesses which involve parasympathetic predominance. Moschowitz and Roudin (1948), after reviewing statistics of the frequency with which psychosomatic diseases precede each other, suggested that anyone particular psychosomatic illness may exert either a facilitating or an inhibitory effect on the development of other psychosomatic illnesses. Anorexia nervosa which usually has its onset relatively early in life, i.e. at puberty, appears to be one of those illnesses which inhibits the development of other psychosomatic illnesses. Perhaps it was only possible for it to occur in this patient in association with the other three psychosomatic illnesses because it occurred in middle life at the end of the series rather than at the beginning.
References
Alexander, F. Psychosomatic medicine (Norton, New York 1950). Crisp, A.H. and Kalucy, R.S.: Aspects of the perceptual disorder in anorexia nervosa. Br. i. med. Psychol. 47: 349-361 (1974). Levitan, H.L.: Significance of certain dreams reported by psychosomatic patients. Psychother. Psychosom. (in press). Mawson, A.R.: Anorexia nervosa and the regulation of intake: a review. Psychol. Med. 4: 289 308 (1974). Moschowitz, E. and Roudin, M.B.: The association of psychosomatic disorders and their relation to personality types in the same individuals. N.Y. St. J. Med. 48: 1375 1381 (1948). Nemiah, J.D.: Psychology and psychosomatic illness: reflections on theory and research methodology. Psychother. Psychosom. 22: 106-111 (1973). Russell, G.F.M.: Anorexia nervosa: its identity as an illness and its treatment; in Price, Modern trends in psychological medicine, vol. 2. pp. 131-164 (Butterworths, London 1970). Sifneos, P.E.: A reconsideration of psychodynamic mechanisms in psychosomatic symptom formation in view of recent clinical observations. Psychother. Psychosom. 24: 151 — 155 (1974). Slade, P.D. and Russell, G.F.M.: Awareness of body dimensions in anorexia nervosa. Psychol. Med. 3: 188-199 (1973).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
Harold L. Levitan, MD, Queen Elizabeth Hospital, 2100 Marlowe Avenue, Montreal, Que. (Canada)
Implications from an Unusual Case of Multiple Psychosomatic Illness Harold L. Levitan Queen Elizabeth Hospital, Montreal, Que.
Abstract. A 40-year-old patient who developed over her lifetime an unusually large number of psychosomatic illnesses is presented. She manifested in succession, bronchial asthma, peptic ulcer, regional ileitis and anorexia nervosa. In addition to the factor of multiplicity of illnesses, this series of illnesses is of special interest because the association of a classical psychosomatic illness with anorexia nervosa has not been reported previously. In order to take advantage of the unusual series of illnesses in one patient, I utilized a novel investigative approach. Basing myself upon the supposition that the fundamental make-up of the personality remains fairly constant over time, 1 criss-crossed bits of established knowledge from one illness to another. In this way, I was able to derive various implications with respect to the psychodynamic, the cognitive-perceptual and the hypothalamic levels of functioning in all the illnesses.
Introduction
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
Patients who have developed several psychosomatic illnesses in succession provide the investigator with an important advantage. Given the essential unity of the personality over time it is likely that the same basic psychological factors have contributed to the production of all the illnesses. Thus it may be possible to cross-fertilize understanding of the illnesses by transferring insight from one to another. There can be no doubt at all regarding the legitimacy of this approach in cases involving simultaneous illnesses. Moschowitz and Roudin (1948), authors whose valuable studies are little consulted nowadays, were the first to utilize this unifying approach to the investigation of psychosomatic illness. They noted that it was precisely those illnesses which occurred in association with the same personality traits in different patients which tended to occur either successively or simultaneously in the same patient.
Levitan
212
In this paper, I apply this approach to a patient whose history contains an unusually long list of psychosomatic illnesses: she had developed in succession bronchial asthma, duodenal ulcer, regional ileitis and finally anorexia nervosa. For purposes of discussion, the three classic psychosomatic illnesses are treated as a unit in juxtaposition to the anorexia nervosa. Nemiah (1973) has drawn attention to the similarities in overall psychologi cal make-up which exist between patients with anorexia nervosa and patients with the classical psychosomatic illnesses. The circumstances of this case in which anorexia nervosa and the three classical psychosomatic illnesses occur in the same patient serves to underscore his point. However, this combination of illnesses is apparently very rare. A thorough search of the literature on anorexia nervosa turned up no other case which was associated with anyone of the three illnesses. In fact, I could find no case of anorexia nervosa which was associated with any psychosomatic illness. The Patient
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
The patient is a 40-year-old mother of 4 children. At the time of writing, the anorexia nervosa is still present. In the periods prior to her hospitalizations her weight has dropped as low as 60 lb. On several occasions she has been discovered in coma due to the combined effect of hypoglycemia and dehydration. Data regarding her history and attitudes have been gathered slowly over several hospitalizations. She is a very reluctant informant who reveals almost nothing spontaneous ly. Often she becomes extremely irritated at my questions. Her anger is sharp but astonish ingly brief in duration. She is almost totally unaware of her own feelings. Often, when she is asked about her response to a particular life situation she replies by stating someone clse’s view of her response, such as ‘my children say 1 was very sad ...’. Her almost total refusal to eat began 4 years ago. Prior to this point, she did eat and drink regularly but only, as she puts it: ‘because everyone else in the family was doing it’. She claims that she has rarely if ever in her life experienced the feelings associated with appetite. She also claims that she has never experienced the feelings associated with sexual desire. Since the onset of the anorexia 4 years ago she has been totally amenorrheic. She demonstrates the behavioral features which are usually found in patients with anorexia nervosa. She abhors fatness in others and has a fear of gaining weight herself. She usually feels full after a single bite. If on occasion she does ingest more than the usual amount she immediately induces regurgitation. Like many patients with anorexia, she engages in shoplifting in food stores as well as elsewhere. This antisocial activity may represent a displacement of her oral aggressive trends. She has a grossly inaccurate concep tion of her body image: despite her extreme emaciation she does not consider herself a thin person. An atypical feature of her anorexia syndrome was its late onset at age 36. She suffered from moderately severe asthma from age 5 to age 29. At age 31, shortly after the birth of her second child, she developed a duodenal ulcer which was resistant to
Implications from an Unusual Case of Multiple Psychosomatic Illness
213
treatment for several years. Suddenly, at age 35, she presented with peritonitis due to rupture of the ileum. Pathological examination of the excised portion of the ileum disclosed acute regional ileitis. The anorexia nervosa began shortly after her recovery from the ileitis. It was not possible to relate the onset of her various illnesses to particular events in her life. Her history was marked by trauma from a very early age. Both her parents were irresponsible alcoholics with a strong proclivity to violence. Though the patient herself remained stubbornly silent on these matters, an older sibling portrayed in detail for us the chaotic circumstances surrounding her early years. Her parents finally separated when she was 10. At this point, she was placed in the first of a series of foster homes. At age 20, she married a much older man who became the father of her 4 children. The marriage, which has been extremely stormy, seems to repeat many features of the relationship between her parents.
Discussion
It is convenient to conceptualize the factors which predispose to the production of psychosomatic illness in terms of the levels on which they operate. Three levels involving the central nervous system may be discerned: a psychodynamic level, a cognitive-perceptual level and a hypothalamic level. The Psychodymmic Level The role which psychodynamic factors play in the production of psychoso matic illness remains unsettled. At one point (Alexander, 1950), it was thought that each illness was correlated with a particular psychodynamic conflict. Our patient who developed so many illnesses in succession appears to refute this specificity hypothesis simply because it is highly unlikely that one patient could experience so many different conflicts. On the other hand, it seems reasonable to assume that a single conflict, possibly an oral conflict derived from the traumatic events which occurred during her early life, is relevant to all four illnesses.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
The Cognitive-Perceptual Level Many psychosomatic patients demonstrate an unawareness of their own on-going feelings. In an extreme instance, the patient who is crying may be aware only of ‘wet eyes’ rather than of sadness (Levitan, in press). In less extreme instances, the patient may vaguely sense some feeling but is unable to describe it well or to localize it within his body schema. Our present patient represents a rather extreme instance as indicated by the fact that it is often necessary for her to call upon an outside observer in order to know what she is
Levitan
214
feeling at a given time. The reasons for this failure of psychosomatic patients to become aware of their own feelings are not at all clear. Most workers in the field attribute it to the successful use of the defense mechanism of denial, other workers (Sifneos, 1974; Nemiah, 1973) attribute it to the presence of a neuro physiological deficit which interferes with the recognition and interpretation of internal signals. The inclusion of anorexia nervosa in the series of psychosomatic illnesses developed by our patient may shed some light on this issue. Our patient, like all anorexia nervosa patients, demonstrates fundamental perceptual abnormalities involving misperception of her body image and misinterpretation of her hunger stimuli. She therefore presents us with an instance in which a psychosomatic patient’s failure to become aware of feelings is definitely associated with failure to become aware of other internal bodily states. It is likely that the failures of perceptual function on the more fundamental levels are linked on an ascending continuum with the failure to perceive feelings. The presence in this case of the wide failure to perceive internal signals seems to favor a neurophysiological rather than a psychodynamic explanation of her failure to perceive her feelings. Recently, new techniques which enable precise measurement of the degree of distortion of the body image have become available. They have already been used to delineate the distorted perception of the body image in patients with anorexia nervosa (Slade and Russel, 1973; Crisp and Kalucy, 1974). An interest ing next step deriving from study of this case would consist in using the same techniques to test the accuracy of perception of the body image in psychosomat ic patients.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
The Hypothalamic Level The fact that in roughly 25% of cases the amenorrhea precedes the altera tions in eating habits has led to tire consideration of the possible role of a primary hypothalamic disturbance in the etiology of anorexia nervosa (Russell, 1970). Recent experimental work on the hypothalamic regulation of feeding and satiation behaviors in animals indicates that feeding behavior is correlated with activation of the noradrenergic and dopaminergic system and that satiation behavior is correlated with activation of the cholinergic system (Mawson, 1974). This set of findings suggests that anorexia nervosa which is a disorder charac terized by diminished pressure to feed and/or premature satiation is a disorder involving parasympathetic (cholinergic) predominance. The presence of asthma and ulcer which are also disorders involving parasympathetic predominance
Implications from an Unusual Case of Multiple Psychosomatic Illness
215
(hence the therapeutic usefulness of adrenalin and vagotomy, respectively) in a patient with anorexia nervosa tends to provide support for this new concept. It is not unlikely that a constitutional factor affecting the autonomic nervous system is present in this patient who developed so many illnesses which involve parasympathetic predominance. Moschowitz and Roudin (1948), after reviewing statistics of the frequency with which psychosomatic diseases precede each other, suggested that anyone particular psychosomatic illness may exert either a facilitating or an inhibitory effect on the development of other psychosomatic illnesses. Anorexia nervosa which usually has its onset relatively early in life, i.e. at puberty, appears to be one of those illnesses which inhibits the development of other psychosomatic illnesses. Perhaps it was only possible for it to occur in this patient in association with the other three psychosomatic illnesses because it occurred in middle life at the end of the series rather than at the beginning.
References
Alexander, F. Psychosomatic medicine (Norton, New York 1950). Crisp, A.H. and Kalucy, R.S.: Aspects of the perceptual disorder in anorexia nervosa. Br. i. med. Psychol. 47: 349-361 (1974). Levitan, H.L.: Significance of certain dreams reported by psychosomatic patients. Psychother. Psychosom. (in press). Mawson, A.R.: Anorexia nervosa and the regulation of intake: a review. Psychol. Med. 4: 289 308 (1974). Moschowitz, E. and Roudin, M.B.: The association of psychosomatic disorders and their relation to personality types in the same individuals. N.Y. St. J. Med. 48: 1375 1381 (1948). Nemiah, J.D.: Psychology and psychosomatic illness: reflections on theory and research methodology. Psychother. Psychosom. 22: 106-111 (1973). Russell, G.F.M.: Anorexia nervosa: its identity as an illness and its treatment; in Price, Modern trends in psychological medicine, vol. 2. pp. 131-164 (Butterworths, London 1970). Sifneos, P.E.: A reconsideration of psychodynamic mechanisms in psychosomatic symptom formation in view of recent clinical observations. Psychother. Psychosom. 24: 151 — 155 (1974). Slade, P.D. and Russell, G.F.M.: Awareness of body dimensions in anorexia nervosa. Psychol. Med. 3: 188-199 (1973).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:19 PM
Harold L. Levitan, MD, Queen Elizabeth Hospital, 2100 Marlowe Avenue, Montreal, Que. (Canada)
