Proc. 12th Eur. Conf. Psychosom. Res., Bod^ 1978 Psychother. Psychosom. 32: 2 7 -4 0 (1979)
Psychogenesis o f Somatic Disorders An Overview
R .A . Pierloot University o f Leuven, Leuven
Abstract. Psychogenesis, considered as a linear sequential process by which psycho logical influences lead to somatic disturbances, is only a link in a larger bio-psycho-social interactional field. Therefore, in practice, a multilateral approach o f the whole person, in his psychological, social and somatic aspects, in health and disease, in his habitual and his therapeutical contacts, should be stressed. It seems unlikely that the somatic symptoms we are confronted with can be considered as pure psychogenetically determined phenomena. This does not exclude that in the complex psychosomatic interaction, there exists at one or more stages a transition from the sphere o f psychological functioning to the somatic area, ending up in somatic symptoms. This process, which we call psychogenesis, is not a single event but should be considered as an abstraction, grouping a number o f component processes possibly occurring at different moments in the total system. We have distinguished four components: a psychopathological component, a psychophysiological component, a physiopathological component and a ‘somatic illness experience’ component. For each o f these components, a number o f conceptions are proposed according to the different theoret ical models o f psychosomatic connections. Most o f these formulations are largely hypo thetical or based only on fragmentary observations. Still, they offer guidelines for further research.
'Psychogenesis' or Psychosomatic Interaction In the last decades the scope o f psychosomatic medicine has been broadened. The need for a multilateral approach to the whole person, in his psychological, social and somatic aspects, in health and disease, in his habitual and his therapeutical contacts, has been stressed (Lipowski, 1977). In such a holistic, integrative view, psychogenesis remains an interesting, but not the only privileged topic of interest.
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The illness phenomena we are confronted with in clinical practice should be considered as a result o f a continuous interaction between psychological, social
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and somatic influences. In this complex, psychogenesis, considered as a linear sequential process by which psychological influences lead to somatic distur bances, is only a link in a larger bio-psycho-social interactional field. Different versions of these interactional processes have been conceived. Reiser (1975) has tried to integrate the most important contributions into a more comprehensive theory in which he distinguishes three phases in the genesis of a disease: the phase of programming the capacity for a specific disease, the actual onset or precipitation o f the disease, and the period following the establishment of the disease process. In the first phase, information transmitted in the genes, interacting with early experi ence, determines constitutional predispositions. This constitutional programming involves peripheral characteristics o f organ functioning and tissue response or modular central nervous system circuits, as well as ‘parallel’ central nervous system circuits and peripheral responses, linked by autonomic and endocrine effect or mechanisms. The programming finds its expression at the same time in behaviour patterns, enclosing typical needs and defence mechanisms, and in physiological functioning characteristics. This idea finds its support in the circular, somato-psycho-somatic theory o f Mirsky (1958) regarding the genesis o f duodenal ulcer. This concept postulates that the physiological and genetically-determined condition, necessary but not sufficient for the development o f the duodenal ulcer, is the hypersecretion o f pepsinogen into the blood. This inborn trait would through its influence on the m other-infant relationship, also play a central role in personality development and in determining the types o f conflict situation that will be pathogenic. In phase 2, the precipitation o f a disease in conjunction with psychosocial stress is taken into consideration. Psychosocial stress situations, overwhelming psychological defences, bring about an excessive non-specific psycho-ncuro-endocrine mobilization which can induce illnesses o f all sorts in all people. However, in some persons preprogrammed in phase 1, as described above, this psycho-neuro-endocrine change might facilitate altered states o f the central nervous system expressed in specific regressive psychological function ing, conceptualized as altered ego states, accompanied by an altered visceral function. This visceral dysfunction, combined with other factors such as allergens or somatic alterations, sets going the particular disease. In the third phase, when the disease has been established, non-specific as well as
In this conceptual scheme o f a three-phase genesis o f disease, the pheno menon of psychogenesis of somatic disturbances is situated at different places in the course and evolution o f a psychosomatic interaction system. Moreover, the possibility of different types and stages of psychogenesis, intervening in the different phases of pathogenesis, has been emphasized. This reminds us that the transition from events, understood in the psychological frame o f reference, to illness data, represented in a somatic terminology, is in itself a complex process.
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specific mechanisms can influence the course. At the same time, perception o f the altered organ functioning becomes elaborated in the individual’s self-image and incorporated into his mental life. Symbolic meanings associated with signs and symptoms become enmeshed in the patient’s intra-psychic conflicts and, in this way, the disease manifestations can appear as secondary symbolic conversion expressions.
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Different Components in 'Psychogenesis' of Somatic Disorders Many studies in psychosomatic medicine have demonstrated a coincidence of psychological or social factors and somatic disturbances, occurring within specified time intervals at a frequency beyond chance. These findings provide a stimulating background for a multilateral approach to the patients. However, they offer no sound basis for conclusions about the type o f relationship between the psychological or psychosocial characteristics and the somatic symptoms {Engel, 1967a). If we assume a continuous psychosomatic interaction system, there does not exist a one-way relationship. Indeed, it seems unlikely that the somatic symp toms we are confronted with in clinical practice can be considered as pure psychogenetically determined phenomena. But this does not exclude that in the complex psychosomatic interaction process, leading to the somatic clinical symptomatology, there exists at one or more stages a transition from the sphere o f psychological functioning to the somatic area, ending up in somatic symp toms. This leaves us the problem as to how an influence happening in the world o f meaningful and symbolic relations can produce a pathogenic effect in the physico-chemical bodily processes. A large number o f studies have been devoted to this problem. In their survey o f psychosomatic medicine, Brautigam and Christian (1973) have described 12 different
If we accept that psychosomatic symptoms are the result o f a string o f complex psychosomatic interactions, it seems likely that in this string psycho genesis is not a single event, but that it should rather be considered as an abstract concept, grouping a number o f component processes possibly occurring at different moments in the total system. As component processes we can define: (1) A qualitative or quantitative unusual process in the psychological or psychosocial functioning o f an individual. This is the psychopathological component. By the term ‘psychopathological’ , we mean a psychological or psychosocial factor contributing to the genesis o f illness phenomena and not a normative label. (2) This psychological or psychosocial process has a physiological counter part, which can be defined in terms o f physical and chemical changes in the body. This is the psychophysiological component.
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models o f psychogenesis: the characterological model, the conversion model, the objectintrojection model, the model o f de- and resomatization, the biphasic repression model, the ego-regression model, the model o f specific psychodynamic conflicts, the model o f specific somatic and psychic attitudes, the functional development model, the stress model, the learning theory model and the anthropological model.
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(3) These physical and chemical changes in the body produce dysfunctions or even organic lesions. Tliis is the physiopathological component. (4) The functional or organic disturbance is experienced by the individual as a somatic disease having no — or at least no conscious — meaning in his psycho logical functioning. Tliis is the ‘somatic illness experience’ component. Each of these components confronts us with specific problems; a theory of psychogenesis should offer an explanation on these different points. In our effort to elaborate the concept of psychogenesis, we shall analyse the solutions offered to these problems by the different models used in the classical psycho somatic studies as well as- some arguments and complements to these solutions, provided by the findings o f more recent research.
In psychosomatic research, psychopathological factors leading to somatic symptoms have been situated in the psychological development of early childhood and at the onset o f the symptoms (table I). In some models both types of psychopathological events are put together; in others one type has been particularly elaborated. In the conversion model, based on the observations o f Breuer and Freud (1895) with regard to sensori-motoric symptoms, non-resolved intrapsychic con flicts referring to infantile sexual drives and finding their origin in early child hood experiences, are considered as the basis o f somatic symptomatology. Groddeck (1926) applied this model to all sorts of somatic disorders but in later psychosomatic research only a few adherents subscribed to that theory. Nevertheless, in several research trends the patterning o f some typical psychological characteristics in early childhood remains the keystone in the genesis o f psychosomatic symptoms. Tliis patterning has been formulated in different ways according to the preconceived model. Some authors (Dunbar, 1943 ; Groen and Bastiaans, 1951) admit the mould ing of specific psychosomatic personality structures in childhood. In the ‘visceral neurosis’ theory o f Alexander (1950) the specific conflicts existing in psycho somatic patients find their origin in infantile fixations of dependency needs and aggressive tendences. Analogous fixations are supposed in the ‘ psychophysiologjcal regression’ (Margolin, 1953) and the ‘resomatization’ (Schur. 1955) models, but at the same time the primary process character and the more primi tive physiological components o f these regressive modes of functioning are pointed out. In the ‘specificity o f attitude’ theory of Grace and Graham (1952)
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The Psychopathological Component
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the structuring of typical ways o f perceiving threatening situations and reacting to them is assumed. In all these models the patterning of psychological characteristics pre disposing to somatic disorders is explained largely on the basis of typical inter actional experiences with the parental figures. However, we should not lose sight of the fact that these typical parent—child relationships are influenced by other factors. In the somato-psycho-somatic circular concept on duodenal ulcer, for mulated by Mirsky (1958), a genetic factor, determining the mother—infant relationship, has been formulated. On the other hand the socio-cultural context with its repercussion on parental attitudes must be taken into account. Other perspectives are offered by experiments concerned with the role and mechanisms o f the sensory input. From the psychological point of view Gardner et al. (1959) described perceptual-cognitive styles, characterized by specific ways of organizing the perceptual intake. Relations between differences in cognitive control and different physiological variables, e.g. galvanic skin response (Courier et a i, 1965), obesity (Karp and Pardes, 1965), fat mobilization (McGouch et a l, 1965), cardiac conditioning (Hein eta l., 1966) and anticipatory cardiac response (Israël, 1969) have been demonstrated. Learning theories, explaining the formation o f disturbing physiological reaction patterns in terms o f conditioning, find support in the findings that,
Table I. Psychopathological component
Psychological patterning in childhood
At the onset o f symptoms
By interactional experiences: - infantile sexual conflicts (conver sion model)
Frustration o f specific infantile needs
By constitutional factors - somato-psycho-somatic model - specific perceptual-cognitive style By conditioning (learning model)
Progressive disorganization; giving up-giver up, reactions to hostility, rejection, hope lessness, anxiety, helplessness, bereavement Cumulative affect o f life changes requiring adaptative behaviour Socio-culturally determined stress condi tioned factors Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 2/10/2018 11:29:14 PM
- specific personality structuring (psychosomatic personality) - fixation o f dependency needs and aggressive tendencies (visceral neurosis, psycho-physiological re gression, resomatization) - specific attitudes
Threatening experiences with regard to life, love, aspirations and needs in general
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during the maturation period, there exist critical stages in which the neuro végétative systems intervening in the regulation of visceral functions are particu larly sensitive to conditioning by external events (Hofer, 1970). Conditioning determines at the same time the nature o f the factors which will be provoking in the onset o f later symptoms. In the ‘stress-theory’ the psychological constellation at the onset of somatic symptoms has been elaborated. In the original formulation of Wolff (1950) threatening experiences with regard to life, love, aspirations and needs in general are preconceived as provoking factors o f psychosomatic disorders. In later research, controversies arose around the origin and type o f stress provoking the somatic symptomatology. In the above-described models of psychosomatic personality structure, visceral neurosis and psycho-physiological regression, frustration o f specific infantile needs in connection with the pre existing psychological patterning has been postulated. W olff (1950) as well as the ‘specificity of attitude’ adherents attach more importance to the manner of working up the stress than to its specific origin or nature. Marty (1968) described ‘progressive disorganization’ as a major process in the onset of somatic symptoms. A slight trauma can act as a narcissistic wound and incite the subject to give up certain emotional interests. This leads to a progressive chain destruction of the various cathected sectors o f the existing libidinal organization and to a depression introducing serious psychosomatic disturbances. In the same sense Engel (1967b) qualifies as ‘helplessnesshopelessness’ and ‘giving up—given up’ certain reactions to bereavement and real or symbolic object loss. Luborsky et al. (1973) performed a systematic review o f 53 studies on the onset conditions for psychosomatic symptoms. The psychological antecedents, in order o f rank with highest first, were hostility, rejection, hopelessness, anxiety, and helplessness. The stressing nature of life changes, requiring an adaptative behaviour o f the involved individual and their cumulative effect, has been demonstrated by Holmes and Rahe (1967). In a survey by Gwen (1970) the role of socio culturally determined stressors, described by many authors, is extensively analyzed.
This implies the definition o f physical and chemical changes in the body, considered as the somatic counterpart or consequence o f the psychopathological
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The Psychophysiological Component
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factors just described (table II). In a further step, these somatic changes con tribute to the genesis o f functional or organic disorders. In the conversion model the psychophysiological problem is more or less short-circuit ed by considering somatic symptoms as behaviour patterns expressing in a symbolic way some repressed infantile drives. Every behaviour pattern containing automatically a somatic component, the link between psychological meaning and somatic processes should not be different from the general psycho-physiological connections o f habitual behaviour.
However, in the majority o f the psychosomatic research studies more specific and defined psycho-physiological links have been explored. Since the original studies of Cannon (1928) physiological accompaniments, mostly vegeta tive and hormonal changes, o f emotional states in patients have been induced by hypnotic suggestion, by interviews, by staged situations, by test stimuli, by movies, by total or partial perceptual isolation and by conditioning procedures. Among the physiological variables studied in these induced situations, we mention skin potential and temperature, finger pulse volume, ECG and EEG curves, stomach and bowel functions, rate and type o f respiration, blood pres sure, muscle activity, hormone dosages and a number o f blood constituents. In general, most attention has been paid to peripheral physiological changes which could be directly connected with the clinical symptoms o f the different psychosomatic diseases. In the conflict-model o f Alexander, as well as in the stress-model o f Wolff, these physiological changes are conceived as fight—flight patterns consisting o f sympatho-adrenal or parasympathetic activation, character istic concomitants o f emotion in normal adult life. Engel (1967b) described the ‘conservation withdrawal’ reaction as a fundamental biological danger response state, apart from fight—flight responses. He assumes the physiological changes associated with such a response to be anabolic in contrast to the catabolic activation processes of the fight or flight reactions.
Table II. Psycho-physiological component Symbolic behaviour patterns (conversion) Peripheral physiological changes: - fight-flight patterns - conservation withdrawal reactions - regressive (resomatized) reactions - conditioned visceral responses
Physiological aspects o f afferent activity
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Central nervous system mechanisms: desynchronizing o f ultradian cycle
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Other researchers have questioned the equality of the physiological changes leading to psychosomatic disorders with normal concomitants of emotional reactions. They assume that, according to some form of preprogram ming in early childhood, the somatic changes elicited by the pathogenic psycho logical experiences are not the habitual but some specific physiological reactions. In the psycho-physiological regression and resomatization model the specific nature o f these physiological reactions is explained by fixation to primitive, unmodulated responses, typically found in very early childhood. Reactions to situations, experienced as frustrating or threatening, are characterized by the use of unneutralized, resomatized energy. According to learning theories, preprogrammed visceral responses have found their origin in conditioning processes. Demonstrations o f instrumental conditioning of autonomic responses (Miller, 1967) mean that the conditioning o f visceral changes is not limited to those that can be evoked by an uncondition ed stimulus, such as in classical conditioning. In later studies attention has been displaced from peripheral physiological reactions to central nervous system mechanisms. Recently Friedman (1978) described a psycho-physiological model proposing that desynchronized forms of the ultradian cycle are a precondition for the outbreak o f a psychosomatic disease. In predisposed individuals, chronic stress would lead to irregularity and shortening o f the cycle duration toward durations found in childhood. This effects dysfunctions of the autonomic nervous system, including excessive lability and range, plateaus of hyper- and hypoactivity and disturbances of integrative patterns. Similar features are found during rapid eye movement sleep and in the autonomic functioning in infants. In this manner, these findings are also in agreement with the resomatization and psycho-physiological regression ideas. A further link can be sought in the physiological aspects o f afferent activ ities. Analyzing these neurophysiological aspects, Weiner (1969) concludes that ‘all afferent activity, whether somatic or visceral, is superimposed upon or more accurately, interacts with an already existent neuronal activity. The presence of complex feedback controls on receptors and relay nuclei indicate that the nervous system actively regulates and modifies afferent input’ . The same sensory stimulus may cause desynchronization o f electrocortical activity, while causing synchronization of hippocampal activity. The findings, based on the use of cellular neurophysiological techniques, illustrate that we can no longer think about behaviour in terms of global states o f inhibition and excitation in the nervous system. Behavioral states such as sleeping and wakefulness are characterized by shifts in the pattern, not an overall increase or cessation of neuronal activity.
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The development o f new neurophysiological techniques, dosages of neurohormonal substances, progress in psycho-pharmacology will certainly in the near future add an almost incalculable amount o f new data to our knowledge on the connections between psychological experience and physiological changes.
The Physiopathological Component Altered physiological functioning, related to psychological experiences, belongs to everyday life. In general, the organism disposes o f sufficient capacities o f adaptation to neutralize the dysfunction. The question arises: why, in psycho somatic patients, does this dysfunctioning entail a definite somatic disorder? In most models o f psychosomatic psychogenesis the transition from physiological dysfunctioning to particular disease states has not been thoroughly elaborated (table III). In the visceral neurosis as well as in the stress theory, it has been assumed that long-lasting altered visceral function ends up in a definite disturbance o f a functional or even an organic nature. The different phases, described in the stress syndrome (Selye, 1956), leading to a final state o f exhaustion can be regarded as a prototype o f pathogenesis. Although it may contain some interesting starting-points, as a generalized explanation o f psychosomatic pathogenesis this theory seems untenable.
In the theories postulating some physiological reaction patterns preprogram med in infancy, the pathogenetic character o f these processes is implied in their impropriety to the adult physiological functioning. The evoked reactions are disorganizing by their primitive and massive nature. Often, the lack of knowledge on the pathogenetic aspect o f the psychophysiological reaction forms is made up by supposing other factors, o f an organic nature, to intervene in this stage. To arrive at a particular disease a complicating somatic factor is postulated as necessary. In this manner, Engel and Schmale (1968), although accepting conversion, and even pregenital conversion,
Table Ml. Physiopathological component
Long lasting altered visceral functioning
Complicating somatic factors: — specific (e.g. pepsinogen in blood) - aspecific: allergens, infections, circulatory adjustments etc.
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Regressive visceral functioning
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as a mechanism leading to somatic disease, regard disease as a complication of the conversion, having no primary symbolic or defensive function. In former conceptions these complicating somatic factors have been formulated in general terms, such as organ disposition or organ inferiority. In the circular somato-psycho-somatic formulations o f the genesis o f some psycho somatic diseases, a more defined constitutional factor has been indicated. For the development o f the duodenal ulcer, according to Mirsky, the hypersecretion of pepsinogen in the blood is a necessary but not sufficient condition. Research, done by Dongier et al. (1956) and Wallerstein et al. (1965), suggests that the high propensity o f the thyroid glands to incorporate 1-131 may serve as an indicator of potential vulnerability to later development o f thyrotoxicosis. The experiments of von E iff et al. (1967) indicate that in the pathogenesis o f essential hypertension a congenital sympathetic center hyperactivity should intervene. Besides these specific organic factors, all kinds o f somatic affections such as allergic reactions, infections, endocrine and circulatory adjustments etc. should be taken into account in the final pathogenesis o f a particular disease state.
It is an essential characteristic of psychosomatic disorders that the patient localizes the source o f his complaints in his body, denying at the same time any psychological meaning to this experience. This shift from the psychological to the somatic sphere has been a puzzling problem to both clinicians and research workers in psychosomatic medicine. In the notion of “conversion’ the transduction from psychological conflict to somatic dysfunction is included. Repression, considered as the abolition o f the psychological experience belonging to a behaviour reaction while the somatic component of this behaviour reaction is conserved, has served as a satisfying explanation in the classical hysterical conversion symptoms. Nemiah (1977) prefers to replace the term ‘conversion’ by ‘dissociation’ . Although resumed in psychosomatic theories, the concept o f repression has been subjected to different modifications (table IV). In the ‘visceral neurosis’ theory o f Alexander { 1950) repression refers to the affect connected with infantile needs and desires involved in ‘unresolved’ con flicts, in contrast to the hysterical conversion symptoms in which the ‘solution’ of an intrapsychic conflict remains unconscious by repression. Mitscherlich (1969) introduced the concept of biphasic repression. In a first
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Psychogenesis o f Somatic Disorders
Repression
Altered capacity to experience
In conversion (dissociation)
Resomalization
O f affect connected with infantile needs and desires
Operatory thinking Alexithymia
Biphasic
Altered ego-states
Provoked by socio-cultural pressure
Special type o f information processing
phase repression leads to a neurotic symptomatology. This being insufficient to cope with the underlying psychological conflicts, it is followed by a second phase characterized by a repression into the somatic sphere. In contrast to these conceptions attributing repression mechanisms in psychosomatic disorders to intra-psychic forces, some authors (Groen, 1970) have stressed the importance o f social and cultural influences in provoking the denial of psychological desires and problems. A more primary incapacity to experience specific feelings on a psychological level has been formulated in several theoretical concepts. According to the ‘resomatization’ theory of Schur (1955) psychosomatic reactions are characteriz ed by regression to primary process functioning including a dedifferentiation and generalizing o f affective responses. Marty and de M'Uzan (1963) first described a way o f mental functioning characterized by what they call operatory thinking, absence o f fantasy life and stereotyped perception o f other people. These ideas have been further elaborated by Marty et al. (1963) and in a later contribution by de M ’Uzan (1974). Similar findings have been reported by Nemiah and Sifneos (1970). They attributed difficulties to communicate with some patients suffering from psychosomatic disorders, to a difficulty o f expressing emotions appropriately and a poor fantasy life encountered in these patients (Sifneos, 1967). Using the term ‘alexithymia’ , Sifneos (1973) wanted to stress the inab ility to find appropriate words to describe feelings. A physiological starting-point can be found in the possible role o f desyn chronized forms o f the ultradian cycle in the genesis of psychosomatic disorders. These desynchronized forms, implicating so-called ‘altered ego states’ — a term referring at least partially to altered states o f consciousness - (Reiser, 1975), could be considered as the basis o f the altered emotional experience. Finally, an explanation has been offered on the basis o f variations in the information processing (Neisser, 1967). Psychosomatic patients are supposed to
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Table IV . ‘Somatic illness experience’ component
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stress a serial instead o f a parallel type o f information processing. ‘Such a tendency interferes with adequate contact with complex environmental vari ables, is accompanied by slow habituation to new stimuli, easily brings about physiological disruptions and amplifies the resulting bodily signals’ ( Vroon, 1975). Although none o f these new concepts, introduced to explain the somatic illness experience aspect in psychogenesis, has been sufficiently elaborated and verified by conclusive research, they offer interesting prospects for refining and differentiating the only too easily invoked notion of repression.
Conclusion In psychosomatic medicine, the conviction that there exists a constant interaction o f psychological, social and somatic factors in the illness process and that the approach to the patient should be multidimensional has grown more and more. In practice, this has made the notion o f psychogenesis, considered as a transition from psychological causes to somatic effects, less important. From a theoretical point o f view, however, this transition from the sphere of psychological experience to the area o f somatic disorder remains a puzzling process in which we have distinguished four aspects: a psychopathological com ponent, a psychophysiological component, a physiopathological component and a ‘somatic illness experience’ component. For each of these components, a number o f conceptions are proposed according to the different theoretical models of psychosomatic connections. Most o f these formulations are largely hypothetical or based only on fragment ary observations. Still, they offer guidelines for further research and, although we are far from an integrating model that embraces all aspects, new findings and insights o f the last years promise some interesting prospects for a better under standing o f the mysterious link between psyche and soma.
Alexander, F .: Psychosomatic medicine (Norton, New York 1950). Bräutigam, W. und Christian, P.: Psychosomatische Medizin (Thieme, Stuttgart 1973). Breuer, J . und Freud, S.: Studien über Hysterie (Deuticke, Leipzig und Wien 1895). Cannon, W.B.: The mechanism o f emotional disturbances o f bodily functions. New Engl. J. Med. ¡98: 877-895 (1928).
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References
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Courter, R .J.; Wattenmaker, R .A ., and A x , A .F .: Physiological concomitants o f psycho logical differentation. Psychophysiology I: 282-289 (1965). Dongier, M.; Wittkower, E .D .; Stephens-Newsham, L ., and Hoffman, M.: Psychological studies in thyroid function. Psychosom. Med. 18: 310-323 (1956). Dunbar, H .F .: Psychosomatic diagnosis (Hoeber, New York 1943). Engel, G .L .: The concept o f psychosomatic disorder. J . psychosom. Res. 11: 3 - 9 (1967a). Engel, G .L .: A psychological setting o f somatic disease: the ‘giving up-given up’ complex. Proc. R. Soc. Med. 60: 553-555 (1967b). Engel, G .L . et Schmale, A .H .: Théorie psychoanalytique du trouble psychosomatique. Rev. méd. Psychosom. 10: 195-216 (1968). Friedman, S.: A psychophysiological model for the chemotherapy o f psychosomatic illness. J . nerv. ment. Dis. 66: 110-116 (1978). Gardner, R.W .; Holzman, P.S.; Klein, G .S .; Linton, H .B ., and Spence, D .P.: Cognitive control: a study o f individual consistencies in cognitive behavior. Psychol. Issues 1: 1-185 (1959). Grace, W .J. and Graham, D .T .: Relationship o f specific attitudes and emotions to certain bodily diseases. Psychosom. Med. 14: 243-255 (1952). Groddeck, J .: The meaning o f illness (Hogarth Press, London 1977). Groen, J .J .: Influence o f social and cultural patterns on psychosomatic diseases; in Pierloot, Recent research in psychosomatics, pp. 184-215 (Karger, Basel 1950). Groen, J . en Bastiaans, J .: Over psychosomatische specificiteit; in Groen et al.,Grondslagen der klinische psychosomatiek, pp. 37-57 (Bohn, Haarlem 1951). Hein, P .L .; Cohen, S .L ., and Shmavonian, B.M .: Perceptual mode and cardiac conditioning. Psychophysiology 3: 101-108 (1966). Hofer, M .A .: Environmental influences in the early development o f autonomic cardiac regulation in the rat; in Pierloot, Recent research in psychosomatics, pp. 243-247 (Karger, Basel 1950). Holmes, T .H . and Rahe, R .H .: The social readjustment rating scale. J . psychosom. Res. 11: 213-218 (1967). Israël, N .L .: Leveling-sharpening and anticipatory cardiac response. Psychosom. Med. 31: 499-501 (1969). Karp, S .A . and Pardes, H.: Psychological differentiation (field dependence) in obese women. Psychosom. Med. 27: 238-244 (1965). Lipowski, Z .J.: Psychosomatic medicine in the seventies: an overview. Am . J . Psychiat. 134: 233-244 (1977). Luborsky, L .: Docherty, J.P ., and Penick, S.: Onset conditions for psychosomatic symp toms: a comparative review o f immediate observation with retrospective research. Psy chosom. Med. 35: 187-203(1973). Margolin, S .G .: Genetic and dynamic psychophysiological determinants o f pathophysiolog ical processes; in Deutsch, The psychosomatic concept in psychoanalysis, pp. 3 -3 6 (Int. Univ. Press. New York 1953).
Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 2/10/2018 11:29:14 PM
Marty,P. et de M’U zan.M .: La pensée opératoire. Revue fr. Psychoanal.2 7:1345-1354 (1963). Marty, P.; de M’Uzan, M., et David, C .: L ’investigation psychosomatique (P .U .F ., Paris 1963). Marty, P.: A major process o f somatization: the progressive disorganisation. Int. J . PsychoAnal. 49: 246-249 (1968).
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M cGouch, W .E.; Silverman, A .J ., and Bogdonoff, M .D.: Patterns o f fat mobilization in field-dependent (1965).
and
field-independent subjects. Psychosom. Med. 27: 245-255
Miller, N.: Learning o f visceral and glandular responses. Science 163: 43 9 -4 4 5 (1967). Mirsky, I.A .: Physiologic, psychologic and social determinants in the etiology o f duodenal ulcer. Am . J . dig. Dis. 3: 285-293 (1958). Mitscherlich, A .: The mechanism o f bi-phasic defence in psychosomatic diseases. Int. J . Psycho-Anal. 49: 236-240(1958). M’Uzan, M. de: Psychodynamic mechanisms in psychosomatic symptom formation. Psychother. Psychosom. 23: 103-110 (1974). Neisser, U .: Cognitive psychology (Appleton - Century Crofts, New York 1967). Nemiah, J . and Sifneos, P.: Psychosomatic illness. A problem o f communication. Psychother. Psychosom. 18: 154-160(1970). Nemiah, J .: Conversion: fact or chimera; in Lipowski et al., Psychosomatic medicine, pp. 132-137 (Oxford Univ. Press, New York 1977). Reiser, M .F .: Theoretical concepts in psychosomatic medicine; in Arieti, American hand book o f psychiatry, 2nd cdn., Vol. IV , pp. 47 7 -5 0 0 (Basic Books, New York 1975). Schur, M.: Comments on the metapsychology o f somatisation. Psychoanal. Stud. Child 10: 119-164 (1955). Selye, H.: Stress (Acta Inc., Montreal 1956). Sifneos, P.: Clinical observations on some patients suffering from a variety o f psychosomatic diseases; in Acta medica psychosomatica, pp. 4 52-458 (SJM P , Rome 1967). Sifneos, P.: The prevalence o f ‘alexithym ic’ characteristics in psychosomatic patients. Psychother. Psychosom. 22: 255-262(19 73). Von Eiff, W.: Essentielle hypertonie (Thieme, Stuttgart 1967). Vroon, P.A .: Psychosomatiek en cognitive processen. T . Psychotherapie 1: 195-210 (1975). Wallerstein, R .S .; Holzman, P .S.; V oth, H .M ., and Uhr, N.: Thyroid ‘hot spots’. A psychophysiological study. Psychom. Med. 27: 5 08-520 (1965). Weiner, H.: Some recent neurophysiological contributions to the problem o f brain and
Prof. Roland A. Pierloot, Universitaire St.-Jozefkliniek voor Psychiatric, Leuvenbaan 68, B -3 0 7 0 Kortenberg (Belgium)
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behavior. Psychosom. Med. 31: 4 57-473 (1969). Wolff, H .G .: Life stress and bodily disease - a formulation; in W olff, Life stress and bodily disease, pp. 1059-1094 (Williams and Wilkins, Baltimore 1950).
Psychogenesis o f Somatic Disorders An Overview
R .A . Pierloot University o f Leuven, Leuven
Abstract. Psychogenesis, considered as a linear sequential process by which psycho logical influences lead to somatic disturbances, is only a link in a larger bio-psycho-social interactional field. Therefore, in practice, a multilateral approach o f the whole person, in his psychological, social and somatic aspects, in health and disease, in his habitual and his therapeutical contacts, should be stressed. It seems unlikely that the somatic symptoms we are confronted with can be considered as pure psychogenetically determined phenomena. This does not exclude that in the complex psychosomatic interaction, there exists at one or more stages a transition from the sphere o f psychological functioning to the somatic area, ending up in somatic symptoms. This process, which we call psychogenesis, is not a single event but should be considered as an abstraction, grouping a number o f component processes possibly occurring at different moments in the total system. We have distinguished four components: a psychopathological component, a psychophysiological component, a physiopathological component and a ‘somatic illness experience’ component. For each o f these components, a number o f conceptions are proposed according to the different theoret ical models o f psychosomatic connections. Most o f these formulations are largely hypo thetical or based only on fragmentary observations. Still, they offer guidelines for further research.
'Psychogenesis' or Psychosomatic Interaction In the last decades the scope o f psychosomatic medicine has been broadened. The need for a multilateral approach to the whole person, in his psychological, social and somatic aspects, in health and disease, in his habitual and his therapeutical contacts, has been stressed (Lipowski, 1977). In such a holistic, integrative view, psychogenesis remains an interesting, but not the only privileged topic of interest.
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The illness phenomena we are confronted with in clinical practice should be considered as a result o f a continuous interaction between psychological, social
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and somatic influences. In this complex, psychogenesis, considered as a linear sequential process by which psychological influences lead to somatic distur bances, is only a link in a larger bio-psycho-social interactional field. Different versions of these interactional processes have been conceived. Reiser (1975) has tried to integrate the most important contributions into a more comprehensive theory in which he distinguishes three phases in the genesis of a disease: the phase of programming the capacity for a specific disease, the actual onset or precipitation o f the disease, and the period following the establishment of the disease process. In the first phase, information transmitted in the genes, interacting with early experi ence, determines constitutional predispositions. This constitutional programming involves peripheral characteristics o f organ functioning and tissue response or modular central nervous system circuits, as well as ‘parallel’ central nervous system circuits and peripheral responses, linked by autonomic and endocrine effect or mechanisms. The programming finds its expression at the same time in behaviour patterns, enclosing typical needs and defence mechanisms, and in physiological functioning characteristics. This idea finds its support in the circular, somato-psycho-somatic theory o f Mirsky (1958) regarding the genesis o f duodenal ulcer. This concept postulates that the physiological and genetically-determined condition, necessary but not sufficient for the development o f the duodenal ulcer, is the hypersecretion o f pepsinogen into the blood. This inborn trait would through its influence on the m other-infant relationship, also play a central role in personality development and in determining the types o f conflict situation that will be pathogenic. In phase 2, the precipitation o f a disease in conjunction with psychosocial stress is taken into consideration. Psychosocial stress situations, overwhelming psychological defences, bring about an excessive non-specific psycho-ncuro-endocrine mobilization which can induce illnesses o f all sorts in all people. However, in some persons preprogrammed in phase 1, as described above, this psycho-neuro-endocrine change might facilitate altered states o f the central nervous system expressed in specific regressive psychological function ing, conceptualized as altered ego states, accompanied by an altered visceral function. This visceral dysfunction, combined with other factors such as allergens or somatic alterations, sets going the particular disease. In the third phase, when the disease has been established, non-specific as well as
In this conceptual scheme o f a three-phase genesis o f disease, the pheno menon of psychogenesis of somatic disturbances is situated at different places in the course and evolution o f a psychosomatic interaction system. Moreover, the possibility of different types and stages of psychogenesis, intervening in the different phases of pathogenesis, has been emphasized. This reminds us that the transition from events, understood in the psychological frame o f reference, to illness data, represented in a somatic terminology, is in itself a complex process.
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specific mechanisms can influence the course. At the same time, perception o f the altered organ functioning becomes elaborated in the individual’s self-image and incorporated into his mental life. Symbolic meanings associated with signs and symptoms become enmeshed in the patient’s intra-psychic conflicts and, in this way, the disease manifestations can appear as secondary symbolic conversion expressions.
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Different Components in 'Psychogenesis' of Somatic Disorders Many studies in psychosomatic medicine have demonstrated a coincidence of psychological or social factors and somatic disturbances, occurring within specified time intervals at a frequency beyond chance. These findings provide a stimulating background for a multilateral approach to the patients. However, they offer no sound basis for conclusions about the type o f relationship between the psychological or psychosocial characteristics and the somatic symptoms {Engel, 1967a). If we assume a continuous psychosomatic interaction system, there does not exist a one-way relationship. Indeed, it seems unlikely that the somatic symp toms we are confronted with in clinical practice can be considered as pure psychogenetically determined phenomena. But this does not exclude that in the complex psychosomatic interaction process, leading to the somatic clinical symptomatology, there exists at one or more stages a transition from the sphere o f psychological functioning to the somatic area, ending up in somatic symp toms. This leaves us the problem as to how an influence happening in the world o f meaningful and symbolic relations can produce a pathogenic effect in the physico-chemical bodily processes. A large number o f studies have been devoted to this problem. In their survey o f psychosomatic medicine, Brautigam and Christian (1973) have described 12 different
If we accept that psychosomatic symptoms are the result o f a string o f complex psychosomatic interactions, it seems likely that in this string psycho genesis is not a single event, but that it should rather be considered as an abstract concept, grouping a number o f component processes possibly occurring at different moments in the total system. As component processes we can define: (1) A qualitative or quantitative unusual process in the psychological or psychosocial functioning o f an individual. This is the psychopathological component. By the term ‘psychopathological’ , we mean a psychological or psychosocial factor contributing to the genesis o f illness phenomena and not a normative label. (2) This psychological or psychosocial process has a physiological counter part, which can be defined in terms o f physical and chemical changes in the body. This is the psychophysiological component.
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models o f psychogenesis: the characterological model, the conversion model, the objectintrojection model, the model o f de- and resomatization, the biphasic repression model, the ego-regression model, the model o f specific psychodynamic conflicts, the model o f specific somatic and psychic attitudes, the functional development model, the stress model, the learning theory model and the anthropological model.
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(3) These physical and chemical changes in the body produce dysfunctions or even organic lesions. Tliis is the physiopathological component. (4) The functional or organic disturbance is experienced by the individual as a somatic disease having no — or at least no conscious — meaning in his psycho logical functioning. Tliis is the ‘somatic illness experience’ component. Each of these components confronts us with specific problems; a theory of psychogenesis should offer an explanation on these different points. In our effort to elaborate the concept of psychogenesis, we shall analyse the solutions offered to these problems by the different models used in the classical psycho somatic studies as well as- some arguments and complements to these solutions, provided by the findings o f more recent research.
In psychosomatic research, psychopathological factors leading to somatic symptoms have been situated in the psychological development of early childhood and at the onset o f the symptoms (table I). In some models both types of psychopathological events are put together; in others one type has been particularly elaborated. In the conversion model, based on the observations o f Breuer and Freud (1895) with regard to sensori-motoric symptoms, non-resolved intrapsychic con flicts referring to infantile sexual drives and finding their origin in early child hood experiences, are considered as the basis o f somatic symptomatology. Groddeck (1926) applied this model to all sorts of somatic disorders but in later psychosomatic research only a few adherents subscribed to that theory. Nevertheless, in several research trends the patterning o f some typical psychological characteristics in early childhood remains the keystone in the genesis o f psychosomatic symptoms. Tliis patterning has been formulated in different ways according to the preconceived model. Some authors (Dunbar, 1943 ; Groen and Bastiaans, 1951) admit the mould ing of specific psychosomatic personality structures in childhood. In the ‘visceral neurosis’ theory o f Alexander (1950) the specific conflicts existing in psycho somatic patients find their origin in infantile fixations of dependency needs and aggressive tendences. Analogous fixations are supposed in the ‘ psychophysiologjcal regression’ (Margolin, 1953) and the ‘resomatization’ (Schur. 1955) models, but at the same time the primary process character and the more primi tive physiological components o f these regressive modes of functioning are pointed out. In the ‘specificity o f attitude’ theory of Grace and Graham (1952)
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The Psychopathological Component
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the structuring of typical ways o f perceiving threatening situations and reacting to them is assumed. In all these models the patterning of psychological characteristics pre disposing to somatic disorders is explained largely on the basis of typical inter actional experiences with the parental figures. However, we should not lose sight of the fact that these typical parent—child relationships are influenced by other factors. In the somato-psycho-somatic circular concept on duodenal ulcer, for mulated by Mirsky (1958), a genetic factor, determining the mother—infant relationship, has been formulated. On the other hand the socio-cultural context with its repercussion on parental attitudes must be taken into account. Other perspectives are offered by experiments concerned with the role and mechanisms o f the sensory input. From the psychological point of view Gardner et al. (1959) described perceptual-cognitive styles, characterized by specific ways of organizing the perceptual intake. Relations between differences in cognitive control and different physiological variables, e.g. galvanic skin response (Courier et a i, 1965), obesity (Karp and Pardes, 1965), fat mobilization (McGouch et a l, 1965), cardiac conditioning (Hein eta l., 1966) and anticipatory cardiac response (Israël, 1969) have been demonstrated. Learning theories, explaining the formation o f disturbing physiological reaction patterns in terms o f conditioning, find support in the findings that,
Table I. Psychopathological component
Psychological patterning in childhood
At the onset o f symptoms
By interactional experiences: - infantile sexual conflicts (conver sion model)
Frustration o f specific infantile needs
By constitutional factors - somato-psycho-somatic model - specific perceptual-cognitive style By conditioning (learning model)
Progressive disorganization; giving up-giver up, reactions to hostility, rejection, hope lessness, anxiety, helplessness, bereavement Cumulative affect o f life changes requiring adaptative behaviour Socio-culturally determined stress condi tioned factors Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 2/10/2018 11:29:14 PM
- specific personality structuring (psychosomatic personality) - fixation o f dependency needs and aggressive tendencies (visceral neurosis, psycho-physiological re gression, resomatization) - specific attitudes
Threatening experiences with regard to life, love, aspirations and needs in general
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during the maturation period, there exist critical stages in which the neuro végétative systems intervening in the regulation of visceral functions are particu larly sensitive to conditioning by external events (Hofer, 1970). Conditioning determines at the same time the nature o f the factors which will be provoking in the onset o f later symptoms. In the ‘stress-theory’ the psychological constellation at the onset of somatic symptoms has been elaborated. In the original formulation of Wolff (1950) threatening experiences with regard to life, love, aspirations and needs in general are preconceived as provoking factors o f psychosomatic disorders. In later research, controversies arose around the origin and type o f stress provoking the somatic symptomatology. In the above-described models of psychosomatic personality structure, visceral neurosis and psycho-physiological regression, frustration o f specific infantile needs in connection with the pre existing psychological patterning has been postulated. W olff (1950) as well as the ‘specificity of attitude’ adherents attach more importance to the manner of working up the stress than to its specific origin or nature. Marty (1968) described ‘progressive disorganization’ as a major process in the onset of somatic symptoms. A slight trauma can act as a narcissistic wound and incite the subject to give up certain emotional interests. This leads to a progressive chain destruction of the various cathected sectors o f the existing libidinal organization and to a depression introducing serious psychosomatic disturbances. In the same sense Engel (1967b) qualifies as ‘helplessnesshopelessness’ and ‘giving up—given up’ certain reactions to bereavement and real or symbolic object loss. Luborsky et al. (1973) performed a systematic review o f 53 studies on the onset conditions for psychosomatic symptoms. The psychological antecedents, in order o f rank with highest first, were hostility, rejection, hopelessness, anxiety, and helplessness. The stressing nature of life changes, requiring an adaptative behaviour o f the involved individual and their cumulative effect, has been demonstrated by Holmes and Rahe (1967). In a survey by Gwen (1970) the role of socio culturally determined stressors, described by many authors, is extensively analyzed.
This implies the definition o f physical and chemical changes in the body, considered as the somatic counterpart or consequence o f the psychopathological
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factors just described (table II). In a further step, these somatic changes con tribute to the genesis o f functional or organic disorders. In the conversion model the psychophysiological problem is more or less short-circuit ed by considering somatic symptoms as behaviour patterns expressing in a symbolic way some repressed infantile drives. Every behaviour pattern containing automatically a somatic component, the link between psychological meaning and somatic processes should not be different from the general psycho-physiological connections o f habitual behaviour.
However, in the majority o f the psychosomatic research studies more specific and defined psycho-physiological links have been explored. Since the original studies of Cannon (1928) physiological accompaniments, mostly vegeta tive and hormonal changes, o f emotional states in patients have been induced by hypnotic suggestion, by interviews, by staged situations, by test stimuli, by movies, by total or partial perceptual isolation and by conditioning procedures. Among the physiological variables studied in these induced situations, we mention skin potential and temperature, finger pulse volume, ECG and EEG curves, stomach and bowel functions, rate and type o f respiration, blood pres sure, muscle activity, hormone dosages and a number o f blood constituents. In general, most attention has been paid to peripheral physiological changes which could be directly connected with the clinical symptoms o f the different psychosomatic diseases. In the conflict-model o f Alexander, as well as in the stress-model o f Wolff, these physiological changes are conceived as fight—flight patterns consisting o f sympatho-adrenal or parasympathetic activation, character istic concomitants o f emotion in normal adult life. Engel (1967b) described the ‘conservation withdrawal’ reaction as a fundamental biological danger response state, apart from fight—flight responses. He assumes the physiological changes associated with such a response to be anabolic in contrast to the catabolic activation processes of the fight or flight reactions.
Table II. Psycho-physiological component Symbolic behaviour patterns (conversion) Peripheral physiological changes: - fight-flight patterns - conservation withdrawal reactions - regressive (resomatized) reactions - conditioned visceral responses
Physiological aspects o f afferent activity
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Central nervous system mechanisms: desynchronizing o f ultradian cycle
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Other researchers have questioned the equality of the physiological changes leading to psychosomatic disorders with normal concomitants of emotional reactions. They assume that, according to some form of preprogram ming in early childhood, the somatic changes elicited by the pathogenic psycho logical experiences are not the habitual but some specific physiological reactions. In the psycho-physiological regression and resomatization model the specific nature o f these physiological reactions is explained by fixation to primitive, unmodulated responses, typically found in very early childhood. Reactions to situations, experienced as frustrating or threatening, are characterized by the use of unneutralized, resomatized energy. According to learning theories, preprogrammed visceral responses have found their origin in conditioning processes. Demonstrations o f instrumental conditioning of autonomic responses (Miller, 1967) mean that the conditioning o f visceral changes is not limited to those that can be evoked by an uncondition ed stimulus, such as in classical conditioning. In later studies attention has been displaced from peripheral physiological reactions to central nervous system mechanisms. Recently Friedman (1978) described a psycho-physiological model proposing that desynchronized forms of the ultradian cycle are a precondition for the outbreak o f a psychosomatic disease. In predisposed individuals, chronic stress would lead to irregularity and shortening o f the cycle duration toward durations found in childhood. This effects dysfunctions of the autonomic nervous system, including excessive lability and range, plateaus of hyper- and hypoactivity and disturbances of integrative patterns. Similar features are found during rapid eye movement sleep and in the autonomic functioning in infants. In this manner, these findings are also in agreement with the resomatization and psycho-physiological regression ideas. A further link can be sought in the physiological aspects o f afferent activ ities. Analyzing these neurophysiological aspects, Weiner (1969) concludes that ‘all afferent activity, whether somatic or visceral, is superimposed upon or more accurately, interacts with an already existent neuronal activity. The presence of complex feedback controls on receptors and relay nuclei indicate that the nervous system actively regulates and modifies afferent input’ . The same sensory stimulus may cause desynchronization o f electrocortical activity, while causing synchronization of hippocampal activity. The findings, based on the use of cellular neurophysiological techniques, illustrate that we can no longer think about behaviour in terms of global states o f inhibition and excitation in the nervous system. Behavioral states such as sleeping and wakefulness are characterized by shifts in the pattern, not an overall increase or cessation of neuronal activity.
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The development o f new neurophysiological techniques, dosages of neurohormonal substances, progress in psycho-pharmacology will certainly in the near future add an almost incalculable amount o f new data to our knowledge on the connections between psychological experience and physiological changes.
The Physiopathological Component Altered physiological functioning, related to psychological experiences, belongs to everyday life. In general, the organism disposes o f sufficient capacities o f adaptation to neutralize the dysfunction. The question arises: why, in psycho somatic patients, does this dysfunctioning entail a definite somatic disorder? In most models o f psychosomatic psychogenesis the transition from physiological dysfunctioning to particular disease states has not been thoroughly elaborated (table III). In the visceral neurosis as well as in the stress theory, it has been assumed that long-lasting altered visceral function ends up in a definite disturbance o f a functional or even an organic nature. The different phases, described in the stress syndrome (Selye, 1956), leading to a final state o f exhaustion can be regarded as a prototype o f pathogenesis. Although it may contain some interesting starting-points, as a generalized explanation o f psychosomatic pathogenesis this theory seems untenable.
In the theories postulating some physiological reaction patterns preprogram med in infancy, the pathogenetic character o f these processes is implied in their impropriety to the adult physiological functioning. The evoked reactions are disorganizing by their primitive and massive nature. Often, the lack of knowledge on the pathogenetic aspect o f the psychophysiological reaction forms is made up by supposing other factors, o f an organic nature, to intervene in this stage. To arrive at a particular disease a complicating somatic factor is postulated as necessary. In this manner, Engel and Schmale (1968), although accepting conversion, and even pregenital conversion,
Table Ml. Physiopathological component
Long lasting altered visceral functioning
Complicating somatic factors: — specific (e.g. pepsinogen in blood) - aspecific: allergens, infections, circulatory adjustments etc.
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Regressive visceral functioning
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as a mechanism leading to somatic disease, regard disease as a complication of the conversion, having no primary symbolic or defensive function. In former conceptions these complicating somatic factors have been formulated in general terms, such as organ disposition or organ inferiority. In the circular somato-psycho-somatic formulations o f the genesis o f some psycho somatic diseases, a more defined constitutional factor has been indicated. For the development o f the duodenal ulcer, according to Mirsky, the hypersecretion of pepsinogen in the blood is a necessary but not sufficient condition. Research, done by Dongier et al. (1956) and Wallerstein et al. (1965), suggests that the high propensity o f the thyroid glands to incorporate 1-131 may serve as an indicator of potential vulnerability to later development o f thyrotoxicosis. The experiments of von E iff et al. (1967) indicate that in the pathogenesis o f essential hypertension a congenital sympathetic center hyperactivity should intervene. Besides these specific organic factors, all kinds o f somatic affections such as allergic reactions, infections, endocrine and circulatory adjustments etc. should be taken into account in the final pathogenesis o f a particular disease state.
It is an essential characteristic of psychosomatic disorders that the patient localizes the source o f his complaints in his body, denying at the same time any psychological meaning to this experience. This shift from the psychological to the somatic sphere has been a puzzling problem to both clinicians and research workers in psychosomatic medicine. In the notion of “conversion’ the transduction from psychological conflict to somatic dysfunction is included. Repression, considered as the abolition o f the psychological experience belonging to a behaviour reaction while the somatic component of this behaviour reaction is conserved, has served as a satisfying explanation in the classical hysterical conversion symptoms. Nemiah (1977) prefers to replace the term ‘conversion’ by ‘dissociation’ . Although resumed in psychosomatic theories, the concept o f repression has been subjected to different modifications (table IV). In the ‘visceral neurosis’ theory o f Alexander { 1950) repression refers to the affect connected with infantile needs and desires involved in ‘unresolved’ con flicts, in contrast to the hysterical conversion symptoms in which the ‘solution’ of an intrapsychic conflict remains unconscious by repression. Mitscherlich (1969) introduced the concept of biphasic repression. In a first
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Psychogenesis o f Somatic Disorders
Repression
Altered capacity to experience
In conversion (dissociation)
Resomalization
O f affect connected with infantile needs and desires
Operatory thinking Alexithymia
Biphasic
Altered ego-states
Provoked by socio-cultural pressure
Special type o f information processing
phase repression leads to a neurotic symptomatology. This being insufficient to cope with the underlying psychological conflicts, it is followed by a second phase characterized by a repression into the somatic sphere. In contrast to these conceptions attributing repression mechanisms in psychosomatic disorders to intra-psychic forces, some authors (Groen, 1970) have stressed the importance o f social and cultural influences in provoking the denial of psychological desires and problems. A more primary incapacity to experience specific feelings on a psychological level has been formulated in several theoretical concepts. According to the ‘resomatization’ theory of Schur (1955) psychosomatic reactions are characteriz ed by regression to primary process functioning including a dedifferentiation and generalizing o f affective responses. Marty and de M'Uzan (1963) first described a way o f mental functioning characterized by what they call operatory thinking, absence o f fantasy life and stereotyped perception o f other people. These ideas have been further elaborated by Marty et al. (1963) and in a later contribution by de M ’Uzan (1974). Similar findings have been reported by Nemiah and Sifneos (1970). They attributed difficulties to communicate with some patients suffering from psychosomatic disorders, to a difficulty o f expressing emotions appropriately and a poor fantasy life encountered in these patients (Sifneos, 1967). Using the term ‘alexithymia’ , Sifneos (1973) wanted to stress the inab ility to find appropriate words to describe feelings. A physiological starting-point can be found in the possible role o f desyn chronized forms o f the ultradian cycle in the genesis of psychosomatic disorders. These desynchronized forms, implicating so-called ‘altered ego states’ — a term referring at least partially to altered states o f consciousness - (Reiser, 1975), could be considered as the basis o f the altered emotional experience. Finally, an explanation has been offered on the basis o f variations in the information processing (Neisser, 1967). Psychosomatic patients are supposed to
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Table IV . ‘Somatic illness experience’ component
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stress a serial instead o f a parallel type o f information processing. ‘Such a tendency interferes with adequate contact with complex environmental vari ables, is accompanied by slow habituation to new stimuli, easily brings about physiological disruptions and amplifies the resulting bodily signals’ ( Vroon, 1975). Although none o f these new concepts, introduced to explain the somatic illness experience aspect in psychogenesis, has been sufficiently elaborated and verified by conclusive research, they offer interesting prospects for refining and differentiating the only too easily invoked notion of repression.
Conclusion In psychosomatic medicine, the conviction that there exists a constant interaction o f psychological, social and somatic factors in the illness process and that the approach to the patient should be multidimensional has grown more and more. In practice, this has made the notion o f psychogenesis, considered as a transition from psychological causes to somatic effects, less important. From a theoretical point o f view, however, this transition from the sphere of psychological experience to the area o f somatic disorder remains a puzzling process in which we have distinguished four aspects: a psychopathological com ponent, a psychophysiological component, a physiopathological component and a ‘somatic illness experience’ component. For each of these components, a number o f conceptions are proposed according to the different theoretical models of psychosomatic connections. Most o f these formulations are largely hypothetical or based only on fragment ary observations. Still, they offer guidelines for further research and, although we are far from an integrating model that embraces all aspects, new findings and insights o f the last years promise some interesting prospects for a better under standing o f the mysterious link between psyche and soma.
Alexander, F .: Psychosomatic medicine (Norton, New York 1950). Bräutigam, W. und Christian, P.: Psychosomatische Medizin (Thieme, Stuttgart 1973). Breuer, J . und Freud, S.: Studien über Hysterie (Deuticke, Leipzig und Wien 1895). Cannon, W.B.: The mechanism o f emotional disturbances o f bodily functions. New Engl. J. Med. ¡98: 877-895 (1928).
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References
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Courter, R .J.; Wattenmaker, R .A ., and A x , A .F .: Physiological concomitants o f psycho logical differentation. Psychophysiology I: 282-289 (1965). Dongier, M.; Wittkower, E .D .; Stephens-Newsham, L ., and Hoffman, M.: Psychological studies in thyroid function. Psychosom. Med. 18: 310-323 (1956). Dunbar, H .F .: Psychosomatic diagnosis (Hoeber, New York 1943). Engel, G .L .: The concept o f psychosomatic disorder. J . psychosom. Res. 11: 3 - 9 (1967a). Engel, G .L .: A psychological setting o f somatic disease: the ‘giving up-given up’ complex. Proc. R. Soc. Med. 60: 553-555 (1967b). Engel, G .L . et Schmale, A .H .: Théorie psychoanalytique du trouble psychosomatique. Rev. méd. Psychosom. 10: 195-216 (1968). Friedman, S.: A psychophysiological model for the chemotherapy o f psychosomatic illness. J . nerv. ment. Dis. 66: 110-116 (1978). Gardner, R.W .; Holzman, P.S.; Klein, G .S .; Linton, H .B ., and Spence, D .P.: Cognitive control: a study o f individual consistencies in cognitive behavior. Psychol. Issues 1: 1-185 (1959). Grace, W .J. and Graham, D .T .: Relationship o f specific attitudes and emotions to certain bodily diseases. Psychosom. Med. 14: 243-255 (1952). Groddeck, J .: The meaning o f illness (Hogarth Press, London 1977). Groen, J .J .: Influence o f social and cultural patterns on psychosomatic diseases; in Pierloot, Recent research in psychosomatics, pp. 184-215 (Karger, Basel 1950). Groen, J . en Bastiaans, J .: Over psychosomatische specificiteit; in Groen et al.,Grondslagen der klinische psychosomatiek, pp. 37-57 (Bohn, Haarlem 1951). Hein, P .L .; Cohen, S .L ., and Shmavonian, B.M .: Perceptual mode and cardiac conditioning. Psychophysiology 3: 101-108 (1966). Hofer, M .A .: Environmental influences in the early development o f autonomic cardiac regulation in the rat; in Pierloot, Recent research in psychosomatics, pp. 243-247 (Karger, Basel 1950). Holmes, T .H . and Rahe, R .H .: The social readjustment rating scale. J . psychosom. Res. 11: 213-218 (1967). Israël, N .L .: Leveling-sharpening and anticipatory cardiac response. Psychosom. Med. 31: 499-501 (1969). Karp, S .A . and Pardes, H.: Psychological differentiation (field dependence) in obese women. Psychosom. Med. 27: 238-244 (1965). Lipowski, Z .J.: Psychosomatic medicine in the seventies: an overview. Am . J . Psychiat. 134: 233-244 (1977). Luborsky, L .: Docherty, J.P ., and Penick, S.: Onset conditions for psychosomatic symp toms: a comparative review o f immediate observation with retrospective research. Psy chosom. Med. 35: 187-203(1973). Margolin, S .G .: Genetic and dynamic psychophysiological determinants o f pathophysiolog ical processes; in Deutsch, The psychosomatic concept in psychoanalysis, pp. 3 -3 6 (Int. Univ. Press. New York 1953).
Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 2/10/2018 11:29:14 PM
Marty,P. et de M’U zan.M .: La pensée opératoire. Revue fr. Psychoanal.2 7:1345-1354 (1963). Marty, P.; de M’Uzan, M., et David, C .: L ’investigation psychosomatique (P .U .F ., Paris 1963). Marty, P.: A major process o f somatization: the progressive disorganisation. Int. J . PsychoAnal. 49: 246-249 (1968).
Pierloot
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M cGouch, W .E.; Silverman, A .J ., and Bogdonoff, M .D.: Patterns o f fat mobilization in field-dependent (1965).
and
field-independent subjects. Psychosom. Med. 27: 245-255
Miller, N.: Learning o f visceral and glandular responses. Science 163: 43 9 -4 4 5 (1967). Mirsky, I.A .: Physiologic, psychologic and social determinants in the etiology o f duodenal ulcer. Am . J . dig. Dis. 3: 285-293 (1958). Mitscherlich, A .: The mechanism o f bi-phasic defence in psychosomatic diseases. Int. J . Psycho-Anal. 49: 236-240(1958). M’Uzan, M. de: Psychodynamic mechanisms in psychosomatic symptom formation. Psychother. Psychosom. 23: 103-110 (1974). Neisser, U .: Cognitive psychology (Appleton - Century Crofts, New York 1967). Nemiah, J . and Sifneos, P.: Psychosomatic illness. A problem o f communication. Psychother. Psychosom. 18: 154-160(1970). Nemiah, J .: Conversion: fact or chimera; in Lipowski et al., Psychosomatic medicine, pp. 132-137 (Oxford Univ. Press, New York 1977). Reiser, M .F .: Theoretical concepts in psychosomatic medicine; in Arieti, American hand book o f psychiatry, 2nd cdn., Vol. IV , pp. 47 7 -5 0 0 (Basic Books, New York 1975). Schur, M.: Comments on the metapsychology o f somatisation. Psychoanal. Stud. Child 10: 119-164 (1955). Selye, H.: Stress (Acta Inc., Montreal 1956). Sifneos, P.: Clinical observations on some patients suffering from a variety o f psychosomatic diseases; in Acta medica psychosomatica, pp. 4 52-458 (SJM P , Rome 1967). Sifneos, P.: The prevalence o f ‘alexithym ic’ characteristics in psychosomatic patients. Psychother. Psychosom. 22: 255-262(19 73). Von Eiff, W.: Essentielle hypertonie (Thieme, Stuttgart 1967). Vroon, P.A .: Psychosomatiek en cognitive processen. T . Psychotherapie 1: 195-210 (1975). Wallerstein, R .S .; Holzman, P .S.; V oth, H .M ., and Uhr, N.: Thyroid ‘hot spots’. A psychophysiological study. Psychom. Med. 27: 5 08-520 (1965). Weiner, H.: Some recent neurophysiological contributions to the problem o f brain and
Prof. Roland A. Pierloot, Universitaire St.-Jozefkliniek voor Psychiatric, Leuvenbaan 68, B -3 0 7 0 Kortenberg (Belgium)
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behavior. Psychosom. Med. 31: 4 57-473 (1969). Wolff, H .G .: Life stress and bodily disease - a formulation; in W olff, Life stress and bodily disease, pp. 1059-1094 (Williams and Wilkins, Baltimore 1950).
