INT'L. J. PSYCHIATRY IN MEDICINE, Vol. 7(4),1976-77
POSSIBLE SEQUELAE OF TRAUMA AND SOMATIC DISORDER IN EARLY LIFE
JEROME L. WEINBERGER, M.D. Psychiatrist Massachusetts General Hospital M A R T I N KANTOR, M.D. Attending Psychiatrist Beth Israel Hospital
ABSTRACT
All children experience trauma. The age, state of development and constitutional factors will determine whether some children will have a traumatic effect. Trauma occurring before the age of three, at a time when the ego has not developed its synthetic and integrative functions, may be reproduced in later life as an isolated symptom, by selected sensations involved in a sensory imprint or screen sensation of the trauma as a simple recording. After the age of three, under the influence of a more mature ego, excessive traumatic stimuli will be integrated and elaborated in symptom formations as phobias or other conditions and extended as part of the total personality. Recurrence in later life is triggered by events related not only to the original experience, but also to the content of its elaboration. The earlier in life the trauma occurs, the more likely that somatic imprints of primitive physiological symptoms would result as an archaic, biological defense 01 screen sensations. Recurrent sensory imprints or screens may appear as organic illness or functional somatic symptoms. Diagnostically, a detailed early life history is necessary to uncover the presence of a sensory screen memory of a trauma and SO avoid diagnostic medical search for organic causation. Case material illustrating the two groups are presented. Indications for psychoanalysis and for supportive psychotherapy are discussed from our theoretical framework as well as from the literature.
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Practically all children experience psychic trauma, but only some of these experiences result in pathologic formations. The events that are traumatic for some are experienced without ill effects by others. The age and stage of development of the child will determine, in a large measure, whether or not a given type of stimulus will have a traumatic effect. The susceptibility to trauma suggests the importance of constitutional factors and the role of past experience [ 11.
Literature Review The psychic apparatus maintains balance between external stimuli, tension within the organism, and discharge. When the inflow of a stimulus is too great and too rapid and is not assimilated, it may result in a traumatic state. Freud states [ 2 ] , “If there can be no reaction to a psychical trauma, it retains its original affect, and when someone cannot get rid of the increase in stimulation by abreacting it, we have the possibility o f . . . [it] remaining a psychical trauma. . . . A healthy psychical mechanism has other methods of dealing with the affect of psychical trauma even if the motor reaction and reaction by words are denied it-namely, by producing contrasting ideas.” Freud later elaborated on the mechanism of dealing with unassimilated excess of stimuli 131. He postulated the concept of mastery by repetitionchanging a passively experienced stimulus to actively repeating it. Trauma very early in life cannot be mastered by repetition or binding and neutralization of stimuli. Denial, inhibition of function, and regression are used [4]. Anna Freud stated in discussion of trauma, “Of significance . . . [is] Phyllis Greenacre’s statement that no truly traumatic experience [in childhood] is ever wholly digested, that increased vulnerability is left even if this hazard is restricted to those occasions where he is faced not only with a quantitative but with a qualitative repetition or near repetition of the original injury [ S ] .” Sylvester emphasizes that earlier trauma will have a profound and crippling effect of the development of the ego, whereas those traumata which occur after the consolidation of ego formation will affect ego functioning and object relations, rather than its development [ 6 ] .The use of gadgets for medical or surgical purposes, by altering channels for discharge, may further lead to regressive phenomena, resomatization, reversal of outgoing libidinal strivings, primitivization of ego functions and modes of object relationships. A stimulus exceeding the stimulus barrier disrupts normal perception, representation and memory trace formation and wakes defense survival mechanisms representing archaic functional organization. This regressive restructuring results in uncontrollable deviant functioning. As Lipin states: “Moreover, because such registration is produced by processes that do not employ mental representations, it is not available for recall [7] .” This
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statement would clearly suggest a mechanism for somatic sensory or vegetative imprint. Freud in discussing anxiety states, “Anxiety is not newly created in repression; it is reproduced as an affective state in accordance with an already existing mnemonic image [8]. If we go further and inquire into the origin of that anxiety-and of affects in general-we shall be leaving the realm of pure psychology and entering the borderland of physiology. Affective states have become incorporated in the mind as precipitates of primaeval traumatic experiences, and when a similar situation occurs, they are revived like mnemonic symbols.” In discussing the hypnoid state that Freud postulated, Loewald asserted that this state, freed of its naive implications of an obscure abnormal mental condition, reveals itself as the equivalent of the ego state corresponding t o the period of infantile sexuality [ 9 ] . This state has t w o characteristics: 1) n o associative absorption of sexual drive experiences is as yet possible because of the immature condition of the psychological functions, and 2) “traumatic” experiences at that period o f development are laid down as “unconscious memories,” in predominantly somatic “memory traces.” Greenacre elaborates a similar idea [ 101 : The earlier in life severe traumas occur, t h e greater are the somatic components in their imprints, owing t o the peculiar emotional somatic plasticity and responsive participation of the infant before the development of t h e ego with the special economizing and discharge functions associated with speech and with the development of conceptual memory. . . . Increased narcissism due t o earlier repeated overstimulation of the infant, such increase implies a prolongation and greater intensity of the tendency t o primary identification . . . and impairment of the developing sense of reality with the increased capacity for body responsiveness. . . . It may be that this latter is an important factor in the subsequent belief in magic, since the somatic elements in the identification give it greater force and semblance in reality. This may be observed . . . in the occurrence of highly specific physical illusory or objective symptoms, drawn from an early time in the patient’s life and repeated in the analytic situation. Neubauer enumerates types of trauma and classifies them by age of the infant, nature and effect [ I 11. Specifically, Neubauer’s salient assertion can be distilled into a two-fold Statement: 1) that a perceptual symptom is related t o the autistic phase and causes transitional disorders, and that 2) menlory imprints are related t o the symbiotic phase and result in fixation and regression with interruption of development. Hayman [12], Greenacre [13], Murphy [14], and Rosen [15] illustrate in their case material both the disruption of personality, as in borderline states, and the recovery of the early traumatic experience while unraveling the psychosomatic components of the symptom picture.
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Early Life Trauma and Somatic Symptoms In this paper, the imprint serves t o describe the traumatic event-in our cases, surgical-and its sensory imprint. Undoubtedly, some of these imprints are screen trauma for past traumatic experiences or telescoping of various early sensory traumata [14]. They also may refer to disturbed relationship with the mother and be the cause of strain trauma [16] or accumulative trauma [ 171, which can be crystallized by a less severe traumatic event [18]. The severity of the trauma, however, may leave its imprint into the second year before the full consolidation of speech or even later, depending on the magnitude of the trauma and its duration. In adults who survived the years in concentration camps, changes have been noted in ego and superego structures [19]. All of our patients who had traumatic experiences before the age of three had serious mental disturbances. Our historical material was limited to information at hospitalization in some of our cases. The earlier in life the trauma occurs, the more likely that somatic imprints or more primitively physiological symptoms would result, such as primitive, archaic, biological defense responses. The more prolonged and severe the trauma, the greater would be the interference with normal development and function. It seems that trauma of a certain magnitude and duration would leave an imprint well into the end of the second year or the first half of the third year. This paper proposes to call attention to a group of functional somatic symptoms which is not classifiable according to our usual criteria. These symptoms and symbolic representations do not represent true conversions, psychophysiological conversions, depressive equivalents, or somatic delusions, but appear to consist of a return of early somatic experiences of a traumatic nature. Careful historical evaluation suggests that the effects of illness, accident, surgery and anesthesia in childhood have persisted and are recurring later in life, reactivated under situations of stress. When these early traumatic experiences reappear, they mimic other types of psychosomatic reaction or surface as symbolic representations, but must be differentiated from these because of their different historical, dynamic and therapeutic implications. It is as if the original sensations have been stamped or “imprinted” or serve as screen sensations and are capable of revival later in life in stressful situations. For example, in evaluating recurrent numbness around the mouth we must consider that it may represent a return of sensations experienced during anesthesia for a tonsillectomy in early childhood or that recurrent bouts of abdominal pain may take root from early intra-abdominal disease.
Case Material The authors studied a number of cases in which functional somatic complaints in adulthood seemed to reproduce somatic aspects of early
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traumatic experiences of illness, anesthesia, and accidental injury. Ten cases are presented to illustrate the process of the development of a traumatic insult in childhood into a functional somatic symptom later in life. The cases are divided into two groups. The first group shows what can happen when the trauma occurs very early, before the age of three, when the defenses available are primitive and limited and the stimulus threshold in the young child is lower and more easily breached. The effects of the traumatic experience remain isolated from the mainstream of psychic life and the traumatic experience tends to persist and recur in this isolated, walled-off, detached form, with n o apparent associative links. Typical late manifestations of this process include symptoms such as a floating sensation, feelings of unreality, numbness around the mouth, gagging, coughing, gastric discomfort and various bodily pains. The second group shows what can happen when the trauma occurs after the age of three, when the ego structure is more mature. Here the traumatic event becomes associatively linked and integrated with the mainstream of the psychic life (i.e., elaborated). For example, the effects of anesthesia for a tonsillectomy may become linked with castration fears [13, 20-251. What results is a complex of organic and psychological events which seems capable of existence as an entity and capable of revival in much the same way as the more isolated traumatic experience. As Freud put it, it is as if emotional symptoms are “twined around a pre-existing structure of organic connections much as festoons of flowers are twined around a wire [26].” Typical late manifestations of this process are phobias of illness with accompanying somatic distress and tic-like manifestations such as a cough, occurring in meaningful stressful situations.
THE FIRST GROUP The following illustrates the first group-from hospital, private practice and literature: those with an isolated, unelaborated symptom picture repeating trauma first incurred before the age of three, prior to the development of a mature psychic structure.
Case I-Greenacre [1,3] cites a patient who describes recurrent feelings of stiffness of her face during panic attacks. This symptom is interpreted as a reproduction of sensations experienced during frequent applications of a chloroform mask at age twenty-seven months. Case 2-A twenty-two-year-old white male had two operations for intussusception in infancy. The first operation was performed at five and onehalf months and another at three years of age. At nineteen, after attending special tutorial school near home, he was sent to college in Iowa. After a month in college he was sent home after being admitted to the infirmary for abdominal pains which were felt to be of emotional origin.
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Case 3-A twenty-two-year-old law student, a borderline patient, who previously had been seen in psychotherapy for anxiety dealing with his fears of his own aggression which alternated with fear of retaliation, was referred for analysis. His symptoms started at the age of fourteen, when he read in the newspaper of a boy who murdered his parents. He became obsessed with similar feelings. After a year he became anxious that he would be attacked by others and either be humiliated, beaten or injured. The patient was seen for a number of hours to determine his ability to be in analysis. When asked to use the couch, he brought the following dream: “In the first part I am talking to you (vis-a-vis) and I say how frightened I am of snakes. You seem sympathetic. In the second part, I am in your office and a boa constrictor wraps itself around my neck. You are unconcerned.” In association to this dream he related the intensely traumatic experience of being taken to and left in the hospital for a tonsillectomy and adenoidectomy (T and A) at age five. In the room with him was a child whose eyes were bandaged. He recalled being given anesthesia and awakening frightened. He states that he was told by his mother of a frightening episode at three years of age when an older boy, a neighbor, tied a rope around his neck and tied him to a tree. Another episode occurred when he was having a dental extraction at age eight. The dentist explained what he was going to do. As he was talking to the patient, he suddenly pushed the mask on his face. It was the unexpected suddenness of the dentist’s action that frightened him. In this case, since the traumatic experiences have been repeated, some elaboration has occurred. The initial trauma-being choked at age three-recurs symbolically represented in essentially isolated form in a dream (the boaconstrictor). But he was choked on three occasions and in the last two, the T and A and the dental work, symbolically castrated. The castration fears were further reinforced when after his surgery, he saw a crying child with bandaged eyes. As a consequence, much elaboration eventually occurred. Case 4-A nineteen-year-old married Jewish white female complained of inability to function for the past six months following an abortion about which she felt very guilty. In addition she complained a great deal of gagging, gastric distress, choking, nausea, dizziness and episodes of passing out. Of interest is that the anesthesia for the abortion was intravenous. Following the abortion she believed that she would die. She “couldn’t believe it” when she found she was still alive. When she got up from the anesthesia she felt as if she was “being reborn.” She “didn’t know where she was.” She “felt as if she had killed her baby.” On admission she felt that people could control her and that her fetus was trying to kill her. At the age of eleven an episode occurred during which the patient claimed she could not breathe. Thereafter she claimed to be dying and the mother recalls the patient’s thinking that her mother was going t o poison her.
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At the age of two, this patient had a T and A performed in a doctor’s office. It is presumed that the anesthesia was ether. All of her symptoms are oral in nature-and reconstruction appears to be descriptive of the symptoms resulting from the T and A and the anesthesia. It is of interest that they recur under stress at different periods of her life. This is a borderline patient with a symptom picture that may have had its origin in the T and A at the age of two. Case 5-This twenty-nine-year-old female had many fears after the birth of her third child. She became depressed and unable to care for her children, and at times extremely angry and irritable. During the sixth week of this third pregnancy, she had an appendectomy, after which she had right lower quadrant pain for eight weeks. After delivery, she became fearful of traffic and afraid that elevated trains would fall on her. Eight months after the delivery she developed severe facial pain. Workup on a neurosurgical service was negative. After psychiatric consultation, she was discharged with a diagnosis of “nonspecific facial pain.” The psychiatrist felt that her symptoms were similar to those which she had had four years before, at the age of twenty-five, when she had the first episode of facial pain after ovarian surgery. The ovarian surgery took place shortly after the birth of her second child. This patient is a twin, was delivered by forceps, and had a mark on her forehead from birth. She and her sister had frequent tonsillitis attacks, and both had tonsillectomies at age three. Although there is no direct relationship between the forceps delivery and the tonsillectomy and the facial pain, a connection may be suggested. A more detailed history would be needed to evaluate whether the anesthesia during the ovarian surgery was similar to the T and A procedure and to search for similar episodes of isolated facial pain. On a speculative level one might question whether the affective feelings of depression and feelings of unreality were also parts of the earlier T and A relating to the anesthesia and feelings of abandonment. In addition, it is possible that R.L.Q. pain after the appendectomy repeated the abdominal pain resulting from the bilateral ovarian cysts and the subsequent surgery. Case 6-A thirty-four-year-old male experienced in analysis sensations of “floating off the couch” whenever his associations implied matters of criticism, reproach or the real or fantasied possibility of bodily damage. Few associations to this feeling were forthcoming; it was experienced as isolated, unreal, and uncanny and had the quality of arising from the past. The patient would also experience faintness after novocaine anesthesia in the dentist’s office. A T and A had been performed at age two, under ether anesthesia. THE SECOND GROUP
The following illustrate the second group, from hospital and private practice: those with an elaborated symptom picture arising from trauma
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incurred after the age of three, during and after the development of a more mature psychic apparatus. Case 1 -A twenty-six-year-old mother of three, three months pregnant, complained of the panicky hypochondriacal fear that she or one of her children might develop leukemia. She was preoccupied with checking herself and her children for swollen glands and fever, and on several occasions came to the hospital anxiously requesting a white blood count. At age twelve the patient developed menorrhagia and metrorrhagia. Dilatation and curettage were performed several times in the next four years until the diagnosis of Idiopathic Thrombocytopenic Purpura was made at age sixteen. A splenectomy was performed and remission followed. When the patient was twenty-three her father developed chronic lymphatic leukemia. When she was twenty-five he became ill from an intercurrent pneumonia coincidental with her having a spontaneous abortion characterized by heavy vaginal bleeding. This ushered in the present illness. The patient unconsciously believed that she might pick up leukemia from her father by contact. She didn’t differentiate his leukemia from her Idopathic Thrombocytopenic Purpura. She felt that leukemia could be transmitted “by heredity” to her children because both she and her father had “something in common.” She reiterated how close she was to her father, how she, not her mother, took care of him, and how she was “his child.” She saw leukemia as her punishment for guilty wishes, and she compared her fate to that of a girlfriend who took away someone else’s husband, only to have the man die of leukemia. And, “Just as with me, my girlfriend developed the fear that her child might contract leukemia. That was her punishment for what she did.”
Case 2-A twenty-eight-year-old woman complained of infertility, sexual aversion, and anxiety, nausea, and vomiting when she went out socially with her husband. At age ten she developed bulbar poliomyelitis and experienced difficulty in swallowing and gagging. She recalled being in a hospital room with all boys and feeling embarrassed at being exposed. She couldn’t bring herself to use the bedpan because the boys were watching, and she developed abdominal distension from a full bladder. Her father had paranoid ideas that she and her siblings were indulging in sexual intimacies. He himself would get into bed with her and rub his genitals against her buttocks, when she was between nine and thirteen years old. During mealtimes he felt that the brother, sister and the patient were sending sexual signals to one another-and the patient recalls gagging at this time. From age thirteen to eighteen she was symptom-free. When she was eighteen years old, her father finally left her mother. Then the patient again became tense, nervous and could not eat at social gatherings, gagged, felt embarrassed, and had to excuse herself to go to the lavatory to vomit.
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Case 3-A forty-six-year-old woman complained of fear of losing control, floating away, choking to death, and fear of anesthesia. She also would become panicky when putting a skirt over her head. She suffered from an annoying cough which would recur whenever she tried to avoid a personal encounter. At the age of six she contracted scarlet fever which led to a middle ear infection that spread to the mastoid. The first of many operations on the mastoid bone was on the kitchen table at home. She soon became very fearful of the ether mask and would often hold her breath, nearly suffocating, in an attempt to avoid being put to sleep. She remembered two male attendants taking a vaginal smear which “caused her to lose her virginity.” Her father did nothing to “stop this” although he stood outside the room and she begged him to intervene. Her father, a physician, participated actively in the patient’s medical treatment, and frequently checked her physically. The patiect was very close to him and acted out her feelings about him in a relationship with a married man. Her father died, when she was forty-one, of esophageal cancer. He had many “dirty habits” that “irritated” her-particularly a recurrent cough, which she found especially annoying.
Case 4-A twenty-nine-year-old white, divorced, female complained of feelings of depression, loss of interest, isolation, fears of being “caged in” in a hospital, and fears of losing control. She expressed feelings of helplessness and a fear that she would not be able to satisfy any of her dependent longings. At age four she had a tonsillectomy. She yelled for her father but felt he wouldn’t come to her aid. She was an outgoing girl until this time, but then became very withdrawn and refused to talk to her parents for a few days. One week after the T and A she was rehospitalized because of bleeding from the operation site and became even more quiet and withdrawn. At age ten, after a crisis, she once again became withdrawn and negativistic. Later in life she persisted in the feeling that her parents had totally abandoned her and couldn’t be trusted.
Discussion
Our series of cases are in accord with the theoretical speculation that traumata occurring before the full development of the psychic organizationthat is, in the first three years of life-register but do not become associatively linked or integrated and that symptoms may arise from these traumata later in life under stressful situations. They may recur as isolated, single and simple symptoms, seemingly unconnected with and not related to the current life situation of the individual. They are not elaborated, but appear similar or identical to the original history of the trauma. We speculate that the traumata have left screen sensations or their equivalent, which can be reactivated later in life.
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In the later phases of development, with a mature psychic structure, trauma has a different effect from that of an isolated impression. With a developed psychic apparatus, magnification and elaboration seem t o occur. Consequently, when the original complex is reactivated later in life, what returns is not an isolated symptom but a pattern consisting of an admixture of the original trauma with subsequent developmental matters, fears of abandonment, or fears of physical mutilation, submission and helplessness. A phobia or psychotic symptom arises which, as Freud has suggested, is composed of emotional symptoms twined around a preexisting structure of organic connections [7,6-28]. The stressful situations that relight early (unelaborated) traumata seem t o be those associated with the nature and content of the original traumatic experience. The stressful situations that relight later (elaborated) traumata may be associated with the original traumatic event, with its initial or subsequent elaboration, or with both. There are two considerations of an additional and modifying importance. First, the intensity of the trauma must be considered. A very intense trauma occurring before the age of three can “spread” and become associatively linked t o some extent, where a mild trauma occurring after the age of three may be an “imprint” rather than an elaboration if it does not engage the psychic apparatus in symptom (defense) formation. Second, there is the apparent exception of the traumatic experiences of war. Here, an intense, overwhelming trauma occurs later in life but is not elaborated, as would be expected. Rather, it tends to recur (be dissipated) in the repetitive dreaming of the original traumatic experience [ 3 ] , with little modification and engagement b y the psychic apparatus. In the “survivors’ syndrome” related t o the concentration camp experience, the recurrent dreams and thoughts are apparently never fully dissipated by repetitive compulsion [3] . Niederland [ 191 suggests that massive continuous traumatic experiences disrupt ego organization, resulting in an altered sense of self and body image. We might infer that isolation of the traumatic experience may be a defense against regressive reactivation of castration anxiety in trauma of short duration as contrasted with the concentration camp experience. Our studies suggest that functional somatic symptoms are not always conversions, psychophysiological conversions, depressive equivalents, or somatic delusions. They may simply represent a revival of early traumatic experiences which have or have not come into connection with meaningful psychic events. Consequently, evaluation of a patient with a recurrent somatic symptom would then have t o include a search for an early history or similar sensations and experiences which may have been associated with bodily insult due to accident, disease, or surgery. The authors feel that this section of the psychiatric history is not adequately emphasized and would like t o call attention t o its importance.
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The importance of identifying a “psychosomatic” symptom as belonging to the category of a late sequela of early trauma is twofold: diagnostic and therapeutic. DIAGNOSTIC IMPLICATIONS
We know that psychosomatic symptoms can often mimic organic symptoms. An early history of traumatic experiences similar or close to the present symptoms can assist in the differential diagnosis of functional from organic disease. Recurrent gastric pains, for example, may have their anlage in repeated surgery or illness in childhood, and this could focus attention away from intra-abdominal organic disease onto a psychological, functional process, and eliminate the necessity for repeated medical investigation and evaluation. THERAPEUTIC IMPLICATIONS
First, the dynamics of the formation of the symptom group described here are different from the dynamics of the formation of a conversion symptom or a somatic delusion. Psychotherapeutic considerations, as a consequence, would have to proceed along different lines. Second, a true conversion symptom, psychophysiological conversion, or somatic delusion does not include an “imprinted” organic component. This symptom group consists essentially of a structure based upon psychic representations-fantasies, wishes, fears, and so forth. The symptom group described here consists of both psychic representations (the “festooning”) and an organic, imprinted component (the “wire”). Loewald [9] postulates that the analytic task is to transform these unconscious memory traces into recollections (as opposed to reminiscences), to take them out of the realm of somatic response based on somatic, unconscious memory and to integrate them into “the great complex of associations . . . ranged alongside other experiences.” According to Lipin [ 7 ] , early intense experience may be brought back through analysis and integrated into higher levels. He states, “As a patient experiences his momentary mental state, he consciously, preconsciously, and unconsciously . . . perceives, iii status izascendi, various aspects of his momentary mental life and external environment. His perceptions are given conscious, preconscious and unconscious representations. These and their associations evoke complex responses that, sooner or later, usher in a new dominant organization of functioning, characteristic of the first phase of an experience complex.” This process is repeated phase after phase until the entire experience complex is lived through: “One observes that experimental stimuli of a current phase suddenly evoke ‘out of the blue,’ conscious representation . . . of a previously unremembered highly cathected experience [7] .”
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Inasmuch as psychodynamic treatment deals only with psychic representations, the component of a symptom which represents a “recurrent organic imprint” will not be affected by psychotherapy. While psychic representations and elaborations of the later period will be ameliorated by supportive therapy, psychoanalytic exploration may in some cases be the only means to alleviate and remove the symptoms. However we may view therapy, the earlier in life a traumatic experience occurs, the more disruptive it is of normal ego development. The task of restoring a normal ego and superego structure may, by the very nature of the ego impairment, be prevented. The measure of analytic therapy would therefore be the ability of the ego t o engage in a therapeutic alliance, and to recall and synthesize material from the past. In most cases of early impairment, supportive therapies may be our major resource. Later traumatic experiences after the age of three may be successfully treated by psychoanalysis [ 151 .
Summary and Conclusions We have presented the concept that traumata occurring in an individual may reappear later in life either as isolated symptoms without any involvement in the total relationships and life of the individual, or in an elaborated form as part of the content of phobias or other symptom pictures. If the trauma occurs before the age of three, when the psychic structure is not mature enough to integrate traumatic experiences, it may be reproduced in later life as an isolated symptom, unconnected and unelaborated-really as selected sensations involved in an imprint. It is almost as if there has been a simple recording of the traumatic experience. Recurrence in later life is ignited by experiences associated psychically with the original traumatic event. After the age of three, the more mature psychic structure may take the traumatic experience as the content of symptom formation of phobias or other psychiatric conditions, elaborating and extending them in the total life situation. This will only occur if the trauma is severe and sufficiently meaningful. Recurrence in later life is ignited by experiences associated not only with the original traumatic experience, but also with the content of its elaboration. Recurrent organic imprints sometimes mimic organic illness, or other types of functional somatic symptoms. Of crucial value in such situations is a detailed enough history to uncover the etiology of the recurrent imprint so as to understand the true meaning and source of the symptom. In certain instances this may eliminate the necessity for repeated medical investigations and evaluations, and in other instances it will serve as a guide for a suitable psychotherapeutic approach.
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ACKNOWLEDGEMENT
We wish t o acknowledge the kindness of Dr. Helen M. Herzan for contributing case 3, p. 345; and to thank Dr. Isidor Bernstein for his helpful criticisms and clarifications. REFERENCES
1. S. S. Furst, Psychic Trauma: A Survey in Psychic Trauma, Basic Books, Inc., New York, 1967. 2. S. Freud, (1893), On the Psychical Mechanism of Hysterical Phenomena, standard edition, Hogarth Press, London, 3, 37, 1955. 3. S. Freud, (1920), Beyond the Pleasure Principle, standard edition 18, Hogarth Press, London, pp. 1-64, 1955. 4. A. Freud, The Ego and the Mechanisms of Defence, International University Press, New York, 1946. 5. A. Freud, Comments on Trauma, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, New York, 1967. 6. E. Sylvester, Panel Report “Psychological Consequences of Physical Illness in Childhood,” reported by V. Calef, J. Amer. Psychoanal. Assoc., 7, pp. 155-162, 1959. 7. T. Lipin, The Repetition Compulsion and Maturational Drive-Representatives, Int. J. Psycho-anal., 44, pp. 389-406, 1963. 8. S. Freud, (1925), Inhibitions, Symptoms and Anxiety, standard edition, Hogarth Press, London, pp. 20, 93, 1955. 9. H. W. Loewald, Hynoid State, Repression, Abreaction and Recollection, J. Amer. Psychoanal. Assoc., 3, pp. 201-210, 1955. 10. P. Greenacre, Pregenital Patterning, Int. J. Psycho-anal., 23, pp. 4 10-415, 1952. 11. P. 3 . Neubauer, Trauma and Psychopathology, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, Inc., New York, 1967. 12. M. Hayman, Traumatic Elements in the Analysis of a Borderline Case, Int. J. Psychoanal., 38, pp. 9-21, 1957. 13. P. Greenacre, Trauma, Growth and Personality, Norton, New York, 1952. 14. W . P. Murphy, Character, Trauma and Sensory Perception, Int. J. Psychoanal., 33, pp. 1-14, 1958. 15. V. H. Rosen, The Reconstruction of a Traumatic Event in a Case of Derealization,J. Amer. Psychoanal. Assoc., 3, pp. 21 1-221, 1955. 16. J. Sandler, Trauma Strain and Development, in Psychic Trauma, S . S . Furst, (ed.), Basic Books, Inc., New York, 1967. 17. M. Khan and R. Masud, The Concept of Cumulative Trauma, in The Psychoanalytic Study of the Child, International Universities Press, New York, 18, pp. 286-306, 1963. 18. A. J . Solnit and M. Kris, Trauma and Infantile Experiences: A Longitudinal Perspective, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, Inc., New York, 1967.
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19. W. G. Niederland, Psychiatric Disorders Among Persecution Victims, J. Nerv. Ment. Dis.,139, pp. 458-474, 1964. 20. F. Deutsch, The Choice of Organ in Organ Neuroses, J. Psycho-anal., 20, pp. 1-1 1, 1939. 21. F. Deutsch, Symbolization as a Formative Stage of the Conversion Process, in On the Mysterious Leap f r o m the Mind to the B o d y , International Universities Press, Inc., New York, 1959. 2 2 . L. Jessner and S. Kaplan, Emotional Reactions to Tonsillectomy and Adenoidectomy: Preliminary Survey, in Problems of Infancy and Childhood, Josiah Macy Foundation, New York, 1949. 23. D. hl. Levy, Psychic Traumas of Operations in Children, Amer. J. Dis. Child., 69, pp. 7-25, 1945. 24. M. L. Miller, The Traumatic Effect of Surgical Operations in Childhood on the Integrative Functions of the Ego, Psychoanal. Quart., 20, pp. 77-92, 1951. 25. G. H. J. Pearson, Effect of Operative Procedures o n the Emotional Life of the Child, Amer. J. Dis.Child.,62, p. 716, 1941. 26. S. Freud, (1905), Fragment of an Analysis of a Case of Hysteria, standard edition 7, pp, 7-1 22, 27. H. Deutsch, Some Psychoanalytic Observations in Surgery, Psychosom. Med., 4 , pp. 105-1 15, 1942. 28. L. Jessner, G. Blom and S. Waldfogel, Emotional Implications of Tonsillectomy and Adenoidectomy o n Children, Psychoanal. Stud. of Child., 7, pp. 126-169.
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POSSIBLE SEQUELAE OF TRAUMA AND SOMATIC DISORDER IN EARLY LIFE
JEROME L. WEINBERGER, M.D. Psychiatrist Massachusetts General Hospital M A R T I N KANTOR, M.D. Attending Psychiatrist Beth Israel Hospital
ABSTRACT
All children experience trauma. The age, state of development and constitutional factors will determine whether some children will have a traumatic effect. Trauma occurring before the age of three, at a time when the ego has not developed its synthetic and integrative functions, may be reproduced in later life as an isolated symptom, by selected sensations involved in a sensory imprint or screen sensation of the trauma as a simple recording. After the age of three, under the influence of a more mature ego, excessive traumatic stimuli will be integrated and elaborated in symptom formations as phobias or other conditions and extended as part of the total personality. Recurrence in later life is triggered by events related not only to the original experience, but also to the content of its elaboration. The earlier in life the trauma occurs, the more likely that somatic imprints of primitive physiological symptoms would result as an archaic, biological defense 01 screen sensations. Recurrent sensory imprints or screens may appear as organic illness or functional somatic symptoms. Diagnostically, a detailed early life history is necessary to uncover the presence of a sensory screen memory of a trauma and SO avoid diagnostic medical search for organic causation. Case material illustrating the two groups are presented. Indications for psychoanalysis and for supportive psychotherapy are discussed from our theoretical framework as well as from the literature.
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Practically all children experience psychic trauma, but only some of these experiences result in pathologic formations. The events that are traumatic for some are experienced without ill effects by others. The age and stage of development of the child will determine, in a large measure, whether or not a given type of stimulus will have a traumatic effect. The susceptibility to trauma suggests the importance of constitutional factors and the role of past experience [ 11.
Literature Review The psychic apparatus maintains balance between external stimuli, tension within the organism, and discharge. When the inflow of a stimulus is too great and too rapid and is not assimilated, it may result in a traumatic state. Freud states [ 2 ] , “If there can be no reaction to a psychical trauma, it retains its original affect, and when someone cannot get rid of the increase in stimulation by abreacting it, we have the possibility o f . . . [it] remaining a psychical trauma. . . . A healthy psychical mechanism has other methods of dealing with the affect of psychical trauma even if the motor reaction and reaction by words are denied it-namely, by producing contrasting ideas.” Freud later elaborated on the mechanism of dealing with unassimilated excess of stimuli 131. He postulated the concept of mastery by repetitionchanging a passively experienced stimulus to actively repeating it. Trauma very early in life cannot be mastered by repetition or binding and neutralization of stimuli. Denial, inhibition of function, and regression are used [4]. Anna Freud stated in discussion of trauma, “Of significance . . . [is] Phyllis Greenacre’s statement that no truly traumatic experience [in childhood] is ever wholly digested, that increased vulnerability is left even if this hazard is restricted to those occasions where he is faced not only with a quantitative but with a qualitative repetition or near repetition of the original injury [ S ] .” Sylvester emphasizes that earlier trauma will have a profound and crippling effect of the development of the ego, whereas those traumata which occur after the consolidation of ego formation will affect ego functioning and object relations, rather than its development [ 6 ] .The use of gadgets for medical or surgical purposes, by altering channels for discharge, may further lead to regressive phenomena, resomatization, reversal of outgoing libidinal strivings, primitivization of ego functions and modes of object relationships. A stimulus exceeding the stimulus barrier disrupts normal perception, representation and memory trace formation and wakes defense survival mechanisms representing archaic functional organization. This regressive restructuring results in uncontrollable deviant functioning. As Lipin states: “Moreover, because such registration is produced by processes that do not employ mental representations, it is not available for recall [7] .” This
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statement would clearly suggest a mechanism for somatic sensory or vegetative imprint. Freud in discussing anxiety states, “Anxiety is not newly created in repression; it is reproduced as an affective state in accordance with an already existing mnemonic image [8]. If we go further and inquire into the origin of that anxiety-and of affects in general-we shall be leaving the realm of pure psychology and entering the borderland of physiology. Affective states have become incorporated in the mind as precipitates of primaeval traumatic experiences, and when a similar situation occurs, they are revived like mnemonic symbols.” In discussing the hypnoid state that Freud postulated, Loewald asserted that this state, freed of its naive implications of an obscure abnormal mental condition, reveals itself as the equivalent of the ego state corresponding t o the period of infantile sexuality [ 9 ] . This state has t w o characteristics: 1) n o associative absorption of sexual drive experiences is as yet possible because of the immature condition of the psychological functions, and 2) “traumatic” experiences at that period o f development are laid down as “unconscious memories,” in predominantly somatic “memory traces.” Greenacre elaborates a similar idea [ 101 : The earlier in life severe traumas occur, t h e greater are the somatic components in their imprints, owing t o the peculiar emotional somatic plasticity and responsive participation of the infant before the development of t h e ego with the special economizing and discharge functions associated with speech and with the development of conceptual memory. . . . Increased narcissism due t o earlier repeated overstimulation of the infant, such increase implies a prolongation and greater intensity of the tendency t o primary identification . . . and impairment of the developing sense of reality with the increased capacity for body responsiveness. . . . It may be that this latter is an important factor in the subsequent belief in magic, since the somatic elements in the identification give it greater force and semblance in reality. This may be observed . . . in the occurrence of highly specific physical illusory or objective symptoms, drawn from an early time in the patient’s life and repeated in the analytic situation. Neubauer enumerates types of trauma and classifies them by age of the infant, nature and effect [ I 11. Specifically, Neubauer’s salient assertion can be distilled into a two-fold Statement: 1) that a perceptual symptom is related t o the autistic phase and causes transitional disorders, and that 2) menlory imprints are related t o the symbiotic phase and result in fixation and regression with interruption of development. Hayman [12], Greenacre [13], Murphy [14], and Rosen [15] illustrate in their case material both the disruption of personality, as in borderline states, and the recovery of the early traumatic experience while unraveling the psychosomatic components of the symptom picture.
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Early Life Trauma and Somatic Symptoms In this paper, the imprint serves t o describe the traumatic event-in our cases, surgical-and its sensory imprint. Undoubtedly, some of these imprints are screen trauma for past traumatic experiences or telescoping of various early sensory traumata [14]. They also may refer to disturbed relationship with the mother and be the cause of strain trauma [16] or accumulative trauma [ 171, which can be crystallized by a less severe traumatic event [18]. The severity of the trauma, however, may leave its imprint into the second year before the full consolidation of speech or even later, depending on the magnitude of the trauma and its duration. In adults who survived the years in concentration camps, changes have been noted in ego and superego structures [19]. All of our patients who had traumatic experiences before the age of three had serious mental disturbances. Our historical material was limited to information at hospitalization in some of our cases. The earlier in life the trauma occurs, the more likely that somatic imprints or more primitively physiological symptoms would result, such as primitive, archaic, biological defense responses. The more prolonged and severe the trauma, the greater would be the interference with normal development and function. It seems that trauma of a certain magnitude and duration would leave an imprint well into the end of the second year or the first half of the third year. This paper proposes to call attention to a group of functional somatic symptoms which is not classifiable according to our usual criteria. These symptoms and symbolic representations do not represent true conversions, psychophysiological conversions, depressive equivalents, or somatic delusions, but appear to consist of a return of early somatic experiences of a traumatic nature. Careful historical evaluation suggests that the effects of illness, accident, surgery and anesthesia in childhood have persisted and are recurring later in life, reactivated under situations of stress. When these early traumatic experiences reappear, they mimic other types of psychosomatic reaction or surface as symbolic representations, but must be differentiated from these because of their different historical, dynamic and therapeutic implications. It is as if the original sensations have been stamped or “imprinted” or serve as screen sensations and are capable of revival later in life in stressful situations. For example, in evaluating recurrent numbness around the mouth we must consider that it may represent a return of sensations experienced during anesthesia for a tonsillectomy in early childhood or that recurrent bouts of abdominal pain may take root from early intra-abdominal disease.
Case Material The authors studied a number of cases in which functional somatic complaints in adulthood seemed to reproduce somatic aspects of early
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traumatic experiences of illness, anesthesia, and accidental injury. Ten cases are presented to illustrate the process of the development of a traumatic insult in childhood into a functional somatic symptom later in life. The cases are divided into two groups. The first group shows what can happen when the trauma occurs very early, before the age of three, when the defenses available are primitive and limited and the stimulus threshold in the young child is lower and more easily breached. The effects of the traumatic experience remain isolated from the mainstream of psychic life and the traumatic experience tends to persist and recur in this isolated, walled-off, detached form, with n o apparent associative links. Typical late manifestations of this process include symptoms such as a floating sensation, feelings of unreality, numbness around the mouth, gagging, coughing, gastric discomfort and various bodily pains. The second group shows what can happen when the trauma occurs after the age of three, when the ego structure is more mature. Here the traumatic event becomes associatively linked and integrated with the mainstream of the psychic life (i.e., elaborated). For example, the effects of anesthesia for a tonsillectomy may become linked with castration fears [13, 20-251. What results is a complex of organic and psychological events which seems capable of existence as an entity and capable of revival in much the same way as the more isolated traumatic experience. As Freud put it, it is as if emotional symptoms are “twined around a pre-existing structure of organic connections much as festoons of flowers are twined around a wire [26].” Typical late manifestations of this process are phobias of illness with accompanying somatic distress and tic-like manifestations such as a cough, occurring in meaningful stressful situations.
THE FIRST GROUP The following illustrates the first group-from hospital, private practice and literature: those with an isolated, unelaborated symptom picture repeating trauma first incurred before the age of three, prior to the development of a mature psychic structure.
Case I-Greenacre [1,3] cites a patient who describes recurrent feelings of stiffness of her face during panic attacks. This symptom is interpreted as a reproduction of sensations experienced during frequent applications of a chloroform mask at age twenty-seven months. Case 2-A twenty-two-year-old white male had two operations for intussusception in infancy. The first operation was performed at five and onehalf months and another at three years of age. At nineteen, after attending special tutorial school near home, he was sent to college in Iowa. After a month in college he was sent home after being admitted to the infirmary for abdominal pains which were felt to be of emotional origin.
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Case 3-A twenty-two-year-old law student, a borderline patient, who previously had been seen in psychotherapy for anxiety dealing with his fears of his own aggression which alternated with fear of retaliation, was referred for analysis. His symptoms started at the age of fourteen, when he read in the newspaper of a boy who murdered his parents. He became obsessed with similar feelings. After a year he became anxious that he would be attacked by others and either be humiliated, beaten or injured. The patient was seen for a number of hours to determine his ability to be in analysis. When asked to use the couch, he brought the following dream: “In the first part I am talking to you (vis-a-vis) and I say how frightened I am of snakes. You seem sympathetic. In the second part, I am in your office and a boa constrictor wraps itself around my neck. You are unconcerned.” In association to this dream he related the intensely traumatic experience of being taken to and left in the hospital for a tonsillectomy and adenoidectomy (T and A) at age five. In the room with him was a child whose eyes were bandaged. He recalled being given anesthesia and awakening frightened. He states that he was told by his mother of a frightening episode at three years of age when an older boy, a neighbor, tied a rope around his neck and tied him to a tree. Another episode occurred when he was having a dental extraction at age eight. The dentist explained what he was going to do. As he was talking to the patient, he suddenly pushed the mask on his face. It was the unexpected suddenness of the dentist’s action that frightened him. In this case, since the traumatic experiences have been repeated, some elaboration has occurred. The initial trauma-being choked at age three-recurs symbolically represented in essentially isolated form in a dream (the boaconstrictor). But he was choked on three occasions and in the last two, the T and A and the dental work, symbolically castrated. The castration fears were further reinforced when after his surgery, he saw a crying child with bandaged eyes. As a consequence, much elaboration eventually occurred. Case 4-A nineteen-year-old married Jewish white female complained of inability to function for the past six months following an abortion about which she felt very guilty. In addition she complained a great deal of gagging, gastric distress, choking, nausea, dizziness and episodes of passing out. Of interest is that the anesthesia for the abortion was intravenous. Following the abortion she believed that she would die. She “couldn’t believe it” when she found she was still alive. When she got up from the anesthesia she felt as if she was “being reborn.” She “didn’t know where she was.” She “felt as if she had killed her baby.” On admission she felt that people could control her and that her fetus was trying to kill her. At the age of eleven an episode occurred during which the patient claimed she could not breathe. Thereafter she claimed to be dying and the mother recalls the patient’s thinking that her mother was going t o poison her.
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At the age of two, this patient had a T and A performed in a doctor’s office. It is presumed that the anesthesia was ether. All of her symptoms are oral in nature-and reconstruction appears to be descriptive of the symptoms resulting from the T and A and the anesthesia. It is of interest that they recur under stress at different periods of her life. This is a borderline patient with a symptom picture that may have had its origin in the T and A at the age of two. Case 5-This twenty-nine-year-old female had many fears after the birth of her third child. She became depressed and unable to care for her children, and at times extremely angry and irritable. During the sixth week of this third pregnancy, she had an appendectomy, after which she had right lower quadrant pain for eight weeks. After delivery, she became fearful of traffic and afraid that elevated trains would fall on her. Eight months after the delivery she developed severe facial pain. Workup on a neurosurgical service was negative. After psychiatric consultation, she was discharged with a diagnosis of “nonspecific facial pain.” The psychiatrist felt that her symptoms were similar to those which she had had four years before, at the age of twenty-five, when she had the first episode of facial pain after ovarian surgery. The ovarian surgery took place shortly after the birth of her second child. This patient is a twin, was delivered by forceps, and had a mark on her forehead from birth. She and her sister had frequent tonsillitis attacks, and both had tonsillectomies at age three. Although there is no direct relationship between the forceps delivery and the tonsillectomy and the facial pain, a connection may be suggested. A more detailed history would be needed to evaluate whether the anesthesia during the ovarian surgery was similar to the T and A procedure and to search for similar episodes of isolated facial pain. On a speculative level one might question whether the affective feelings of depression and feelings of unreality were also parts of the earlier T and A relating to the anesthesia and feelings of abandonment. In addition, it is possible that R.L.Q. pain after the appendectomy repeated the abdominal pain resulting from the bilateral ovarian cysts and the subsequent surgery. Case 6-A thirty-four-year-old male experienced in analysis sensations of “floating off the couch” whenever his associations implied matters of criticism, reproach or the real or fantasied possibility of bodily damage. Few associations to this feeling were forthcoming; it was experienced as isolated, unreal, and uncanny and had the quality of arising from the past. The patient would also experience faintness after novocaine anesthesia in the dentist’s office. A T and A had been performed at age two, under ether anesthesia. THE SECOND GROUP
The following illustrate the second group, from hospital and private practice: those with an elaborated symptom picture arising from trauma
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incurred after the age of three, during and after the development of a more mature psychic apparatus. Case 1 -A twenty-six-year-old mother of three, three months pregnant, complained of the panicky hypochondriacal fear that she or one of her children might develop leukemia. She was preoccupied with checking herself and her children for swollen glands and fever, and on several occasions came to the hospital anxiously requesting a white blood count. At age twelve the patient developed menorrhagia and metrorrhagia. Dilatation and curettage were performed several times in the next four years until the diagnosis of Idiopathic Thrombocytopenic Purpura was made at age sixteen. A splenectomy was performed and remission followed. When the patient was twenty-three her father developed chronic lymphatic leukemia. When she was twenty-five he became ill from an intercurrent pneumonia coincidental with her having a spontaneous abortion characterized by heavy vaginal bleeding. This ushered in the present illness. The patient unconsciously believed that she might pick up leukemia from her father by contact. She didn’t differentiate his leukemia from her Idopathic Thrombocytopenic Purpura. She felt that leukemia could be transmitted “by heredity” to her children because both she and her father had “something in common.” She reiterated how close she was to her father, how she, not her mother, took care of him, and how she was “his child.” She saw leukemia as her punishment for guilty wishes, and she compared her fate to that of a girlfriend who took away someone else’s husband, only to have the man die of leukemia. And, “Just as with me, my girlfriend developed the fear that her child might contract leukemia. That was her punishment for what she did.”
Case 2-A twenty-eight-year-old woman complained of infertility, sexual aversion, and anxiety, nausea, and vomiting when she went out socially with her husband. At age ten she developed bulbar poliomyelitis and experienced difficulty in swallowing and gagging. She recalled being in a hospital room with all boys and feeling embarrassed at being exposed. She couldn’t bring herself to use the bedpan because the boys were watching, and she developed abdominal distension from a full bladder. Her father had paranoid ideas that she and her siblings were indulging in sexual intimacies. He himself would get into bed with her and rub his genitals against her buttocks, when she was between nine and thirteen years old. During mealtimes he felt that the brother, sister and the patient were sending sexual signals to one another-and the patient recalls gagging at this time. From age thirteen to eighteen she was symptom-free. When she was eighteen years old, her father finally left her mother. Then the patient again became tense, nervous and could not eat at social gatherings, gagged, felt embarrassed, and had to excuse herself to go to the lavatory to vomit.
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Case 3-A forty-six-year-old woman complained of fear of losing control, floating away, choking to death, and fear of anesthesia. She also would become panicky when putting a skirt over her head. She suffered from an annoying cough which would recur whenever she tried to avoid a personal encounter. At the age of six she contracted scarlet fever which led to a middle ear infection that spread to the mastoid. The first of many operations on the mastoid bone was on the kitchen table at home. She soon became very fearful of the ether mask and would often hold her breath, nearly suffocating, in an attempt to avoid being put to sleep. She remembered two male attendants taking a vaginal smear which “caused her to lose her virginity.” Her father did nothing to “stop this” although he stood outside the room and she begged him to intervene. Her father, a physician, participated actively in the patient’s medical treatment, and frequently checked her physically. The patiect was very close to him and acted out her feelings about him in a relationship with a married man. Her father died, when she was forty-one, of esophageal cancer. He had many “dirty habits” that “irritated” her-particularly a recurrent cough, which she found especially annoying.
Case 4-A twenty-nine-year-old white, divorced, female complained of feelings of depression, loss of interest, isolation, fears of being “caged in” in a hospital, and fears of losing control. She expressed feelings of helplessness and a fear that she would not be able to satisfy any of her dependent longings. At age four she had a tonsillectomy. She yelled for her father but felt he wouldn’t come to her aid. She was an outgoing girl until this time, but then became very withdrawn and refused to talk to her parents for a few days. One week after the T and A she was rehospitalized because of bleeding from the operation site and became even more quiet and withdrawn. At age ten, after a crisis, she once again became withdrawn and negativistic. Later in life she persisted in the feeling that her parents had totally abandoned her and couldn’t be trusted.
Discussion
Our series of cases are in accord with the theoretical speculation that traumata occurring before the full development of the psychic organizationthat is, in the first three years of life-register but do not become associatively linked or integrated and that symptoms may arise from these traumata later in life under stressful situations. They may recur as isolated, single and simple symptoms, seemingly unconnected with and not related to the current life situation of the individual. They are not elaborated, but appear similar or identical to the original history of the trauma. We speculate that the traumata have left screen sensations or their equivalent, which can be reactivated later in life.
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In the later phases of development, with a mature psychic structure, trauma has a different effect from that of an isolated impression. With a developed psychic apparatus, magnification and elaboration seem t o occur. Consequently, when the original complex is reactivated later in life, what returns is not an isolated symptom but a pattern consisting of an admixture of the original trauma with subsequent developmental matters, fears of abandonment, or fears of physical mutilation, submission and helplessness. A phobia or psychotic symptom arises which, as Freud has suggested, is composed of emotional symptoms twined around a preexisting structure of organic connections [7,6-28]. The stressful situations that relight early (unelaborated) traumata seem t o be those associated with the nature and content of the original traumatic experience. The stressful situations that relight later (elaborated) traumata may be associated with the original traumatic event, with its initial or subsequent elaboration, or with both. There are two considerations of an additional and modifying importance. First, the intensity of the trauma must be considered. A very intense trauma occurring before the age of three can “spread” and become associatively linked t o some extent, where a mild trauma occurring after the age of three may be an “imprint” rather than an elaboration if it does not engage the psychic apparatus in symptom (defense) formation. Second, there is the apparent exception of the traumatic experiences of war. Here, an intense, overwhelming trauma occurs later in life but is not elaborated, as would be expected. Rather, it tends to recur (be dissipated) in the repetitive dreaming of the original traumatic experience [ 3 ] , with little modification and engagement b y the psychic apparatus. In the “survivors’ syndrome” related t o the concentration camp experience, the recurrent dreams and thoughts are apparently never fully dissipated by repetitive compulsion [3] . Niederland [ 191 suggests that massive continuous traumatic experiences disrupt ego organization, resulting in an altered sense of self and body image. We might infer that isolation of the traumatic experience may be a defense against regressive reactivation of castration anxiety in trauma of short duration as contrasted with the concentration camp experience. Our studies suggest that functional somatic symptoms are not always conversions, psychophysiological conversions, depressive equivalents, or somatic delusions. They may simply represent a revival of early traumatic experiences which have or have not come into connection with meaningful psychic events. Consequently, evaluation of a patient with a recurrent somatic symptom would then have t o include a search for an early history or similar sensations and experiences which may have been associated with bodily insult due to accident, disease, or surgery. The authors feel that this section of the psychiatric history is not adequately emphasized and would like t o call attention t o its importance.
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The importance of identifying a “psychosomatic” symptom as belonging to the category of a late sequela of early trauma is twofold: diagnostic and therapeutic. DIAGNOSTIC IMPLICATIONS
We know that psychosomatic symptoms can often mimic organic symptoms. An early history of traumatic experiences similar or close to the present symptoms can assist in the differential diagnosis of functional from organic disease. Recurrent gastric pains, for example, may have their anlage in repeated surgery or illness in childhood, and this could focus attention away from intra-abdominal organic disease onto a psychological, functional process, and eliminate the necessity for repeated medical investigation and evaluation. THERAPEUTIC IMPLICATIONS
First, the dynamics of the formation of the symptom group described here are different from the dynamics of the formation of a conversion symptom or a somatic delusion. Psychotherapeutic considerations, as a consequence, would have to proceed along different lines. Second, a true conversion symptom, psychophysiological conversion, or somatic delusion does not include an “imprinted” organic component. This symptom group consists essentially of a structure based upon psychic representations-fantasies, wishes, fears, and so forth. The symptom group described here consists of both psychic representations (the “festooning”) and an organic, imprinted component (the “wire”). Loewald [9] postulates that the analytic task is to transform these unconscious memory traces into recollections (as opposed to reminiscences), to take them out of the realm of somatic response based on somatic, unconscious memory and to integrate them into “the great complex of associations . . . ranged alongside other experiences.” According to Lipin [ 7 ] , early intense experience may be brought back through analysis and integrated into higher levels. He states, “As a patient experiences his momentary mental state, he consciously, preconsciously, and unconsciously . . . perceives, iii status izascendi, various aspects of his momentary mental life and external environment. His perceptions are given conscious, preconscious and unconscious representations. These and their associations evoke complex responses that, sooner or later, usher in a new dominant organization of functioning, characteristic of the first phase of an experience complex.” This process is repeated phase after phase until the entire experience complex is lived through: “One observes that experimental stimuli of a current phase suddenly evoke ‘out of the blue,’ conscious representation . . . of a previously unremembered highly cathected experience [7] .”
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Inasmuch as psychodynamic treatment deals only with psychic representations, the component of a symptom which represents a “recurrent organic imprint” will not be affected by psychotherapy. While psychic representations and elaborations of the later period will be ameliorated by supportive therapy, psychoanalytic exploration may in some cases be the only means to alleviate and remove the symptoms. However we may view therapy, the earlier in life a traumatic experience occurs, the more disruptive it is of normal ego development. The task of restoring a normal ego and superego structure may, by the very nature of the ego impairment, be prevented. The measure of analytic therapy would therefore be the ability of the ego t o engage in a therapeutic alliance, and to recall and synthesize material from the past. In most cases of early impairment, supportive therapies may be our major resource. Later traumatic experiences after the age of three may be successfully treated by psychoanalysis [ 151 .
Summary and Conclusions We have presented the concept that traumata occurring in an individual may reappear later in life either as isolated symptoms without any involvement in the total relationships and life of the individual, or in an elaborated form as part of the content of phobias or other symptom pictures. If the trauma occurs before the age of three, when the psychic structure is not mature enough to integrate traumatic experiences, it may be reproduced in later life as an isolated symptom, unconnected and unelaborated-really as selected sensations involved in an imprint. It is almost as if there has been a simple recording of the traumatic experience. Recurrence in later life is ignited by experiences associated psychically with the original traumatic event. After the age of three, the more mature psychic structure may take the traumatic experience as the content of symptom formation of phobias or other psychiatric conditions, elaborating and extending them in the total life situation. This will only occur if the trauma is severe and sufficiently meaningful. Recurrence in later life is ignited by experiences associated not only with the original traumatic experience, but also with the content of its elaboration. Recurrent organic imprints sometimes mimic organic illness, or other types of functional somatic symptoms. Of crucial value in such situations is a detailed enough history to uncover the etiology of the recurrent imprint so as to understand the true meaning and source of the symptom. In certain instances this may eliminate the necessity for repeated medical investigations and evaluations, and in other instances it will serve as a guide for a suitable psychotherapeutic approach.
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ACKNOWLEDGEMENT
We wish t o acknowledge the kindness of Dr. Helen M. Herzan for contributing case 3, p. 345; and to thank Dr. Isidor Bernstein for his helpful criticisms and clarifications. REFERENCES
1. S. S. Furst, Psychic Trauma: A Survey in Psychic Trauma, Basic Books, Inc., New York, 1967. 2. S. Freud, (1893), On the Psychical Mechanism of Hysterical Phenomena, standard edition, Hogarth Press, London, 3, 37, 1955. 3. S. Freud, (1920), Beyond the Pleasure Principle, standard edition 18, Hogarth Press, London, pp. 1-64, 1955. 4. A. Freud, The Ego and the Mechanisms of Defence, International University Press, New York, 1946. 5. A. Freud, Comments on Trauma, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, New York, 1967. 6. E. Sylvester, Panel Report “Psychological Consequences of Physical Illness in Childhood,” reported by V. Calef, J. Amer. Psychoanal. Assoc., 7, pp. 155-162, 1959. 7. T. Lipin, The Repetition Compulsion and Maturational Drive-Representatives, Int. J. Psycho-anal., 44, pp. 389-406, 1963. 8. S. Freud, (1925), Inhibitions, Symptoms and Anxiety, standard edition, Hogarth Press, London, pp. 20, 93, 1955. 9. H. W. Loewald, Hynoid State, Repression, Abreaction and Recollection, J. Amer. Psychoanal. Assoc., 3, pp. 201-210, 1955. 10. P. Greenacre, Pregenital Patterning, Int. J. Psycho-anal., 23, pp. 4 10-415, 1952. 11. P. 3 . Neubauer, Trauma and Psychopathology, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, Inc., New York, 1967. 12. M. Hayman, Traumatic Elements in the Analysis of a Borderline Case, Int. J. Psychoanal., 38, pp. 9-21, 1957. 13. P. Greenacre, Trauma, Growth and Personality, Norton, New York, 1952. 14. W . P. Murphy, Character, Trauma and Sensory Perception, Int. J. Psychoanal., 33, pp. 1-14, 1958. 15. V. H. Rosen, The Reconstruction of a Traumatic Event in a Case of Derealization,J. Amer. Psychoanal. Assoc., 3, pp. 21 1-221, 1955. 16. J. Sandler, Trauma Strain and Development, in Psychic Trauma, S . S . Furst, (ed.), Basic Books, Inc., New York, 1967. 17. M. Khan and R. Masud, The Concept of Cumulative Trauma, in The Psychoanalytic Study of the Child, International Universities Press, New York, 18, pp. 286-306, 1963. 18. A. J . Solnit and M. Kris, Trauma and Infantile Experiences: A Longitudinal Perspective, in Psychic Trauma, S. S . Furst, (ed.), Basic Books, Inc., New York, 1967.
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19. W. G. Niederland, Psychiatric Disorders Among Persecution Victims, J. Nerv. Ment. Dis.,139, pp. 458-474, 1964. 20. F. Deutsch, The Choice of Organ in Organ Neuroses, J. Psycho-anal., 20, pp. 1-1 1, 1939. 21. F. Deutsch, Symbolization as a Formative Stage of the Conversion Process, in On the Mysterious Leap f r o m the Mind to the B o d y , International Universities Press, Inc., New York, 1959. 2 2 . L. Jessner and S. Kaplan, Emotional Reactions to Tonsillectomy and Adenoidectomy: Preliminary Survey, in Problems of Infancy and Childhood, Josiah Macy Foundation, New York, 1949. 23. D. hl. Levy, Psychic Traumas of Operations in Children, Amer. J. Dis. Child., 69, pp. 7-25, 1945. 24. M. L. Miller, The Traumatic Effect of Surgical Operations in Childhood on the Integrative Functions of the Ego, Psychoanal. Quart., 20, pp. 77-92, 1951. 25. G. H. J. Pearson, Effect of Operative Procedures o n the Emotional Life of the Child, Amer. J. Dis.Child.,62, p. 716, 1941. 26. S. Freud, (1905), Fragment of an Analysis of a Case of Hysteria, standard edition 7, pp, 7-1 22, 27. H. Deutsch, Some Psychoanalytic Observations in Surgery, Psychosom. Med., 4 , pp. 105-1 15, 1942. 28. L. Jessner, G. Blom and S. Waldfogel, Emotional Implications of Tonsillectomy and Adenoidectomy o n Children, Psychoanal. Stud. of Child., 7, pp. 126-169.
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