VOLUME XVI - NUMBER 4
FOURTH QUARTER, 1975
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Social Psychiatry and Psychosomatics JOHN J. SCHWAB,
M.D.,
Historically, the influence of sociocultural processes on psychosomatic illnesses was noted by Hippocrates in his treatise, Airs, Walers, and Places.! In that first essay on ecologic medicine, he described some specific psychosomatic afflictions and associated their frequency with child rearing practices and modes of living. For example. he related that the nomadic Scythians suffered from infertility. The men had a stout fleshy appearance, edema of the lower extremities, ill-marked joints, and diarrhea; the women's menstrual difficulties were severe. Hippocrates attributed these disorders, which occurred mainly among those who could afford horses and wagons, to their life style. The poor who walked or ran while the tribes moved had fewer of these health problems than the ones who spent long hours on horseback or were conveyed from place to place. Thus. 2500 years ago he pointed out that social factors were associated with psychosomatic illnesses. We are still evaluating such relationships in the hope that increased understanding will lead to amelioration and ultimately prevention. Our concerns hinge on two major factors to which Hippocrates alluded: (I) the unequal distribution of psychosomatic illnesses within populations, and (2) the influence of the social environment on the prevalence of these conditions. In their prospective stud:es, Hinkle and his colleagues~ have demonstrated that illness episodes of all types are not randomly distributed within groups. Instead, over a 20-year period, they found that 25 percent of the members in various groups experienced approximately 50 percent of all the illness episodes, while the healthiest 25 percent in the groups experienced less than 10 percent of the total illness episodes. This demonstration of the selective, not random, distribution of disease is particularly applicable to the psychosomatic illnesses, those bodily Presented at the Annual Meeting of the Academy of Psychosomatic Medicine, Scottsdale, Arizona, November 1720. 1974. Supported in part by NIMH Grant No. MH 15900·05-5. Dr. Schwab is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky 40201. October/November/December, 1975
AND RUBY
B.
SCHWAB
condtions which are produced, in Halliday's3 words, by a "synergy of causes," and are characterized by changing race, sex, and age ratios as certain sociodemographic groups are variably exposed to stressful or noxious forces. Even before psychiatry developed as a specialty in the early decades of the 19th century, physicians, scientists, and philosophers indicted social factors as causes of human distress and illness. Since then numerous investigators have studied the associations between the social environment and the prevalence of illness. The most consistent finding is the association between lower social status and an increased frequency of the mental disorders. 4 In our study of a random sample of 1,645 adults from the general population in a county in the southeastern United States, we found that, with few exceptions, the respondents with low incomes had more mental, psychophysiologic and somatic symptomatology than those in the middle- and upper-income groups. Low income has turned out to be the most statistically significant sociodemographic correlate of illness. We concluded that the configuration of human misery associated with poverty and deprivation, as well as social selection processes, leads to a piling up of the vulnerable, the disposed, and the afflicted among the poor. G' 7 But psychosomatic illnesses-in their magnitude, complexity, and variability-present certain exceptions to the association between poverty and the increased frequency of disease. Psychosomatic illnesses involve the interplay of complex intrapsychic as well as sociocultural processes. These include conation, 0 the r personality factors, elaborately developed defense mechanisms and symbolization, in addition to genetic factors, organ susceptibility, and exposure to stress. Certain psychosomatic illnesses, therefore, have sometimes been more frequent among middle-class and other groups than among those with low incomes. The magnitude of the problem of psychosomatic illness is revealed by the frequency of psychophysiologic symptomatology. Investigations of general populations, 151
PSYCHOSOMATICS
such as the Stirling CountyR and Midtown Manhattan Studies,9 indicate that as many as 60 percent of respondents had psychophysiologic complaints. Our study revealed that about 50 percent of the population suffered from at least one psychophysiologic symptom "regularly." Moreover, 17 percent reported that they had two or more psychophysiologic symptoms "regularly"; we labeled this group, 286 of our 1,645 respondents, as psychosomatically ill. The pervasiveness of psychosomatic symptomatology led us to conjecture that perhaps "as our sociotechnolog:c environment becomes more dehumanizing, the body protests".lfI Surveys of physicians' practices corroborate our concerns about the frequency of psychosomatic illnesses in general populations. In Western nations about onethird of all patients seen by physicians have psychophysiologic disorders. 1I . 13 These are usually the "problem" patients, those whom Von Mering and EarleyH have labeled as having undifferentiated health aberrations. They suffer from admixtures of mental, phys.ical, and social distress which are ways of life, disturbances that can be neither diagnosed nor treated by modem technological medicine. The complexity of the problem of psychosomatic illaess, in addition to its magnitude, is highlighted by the appearance of epidemics. In his classic description of the Epidemics of the Middle Ages, Hecker l ;' mentioned that adverse social conditions, particularly the wretched and oppressed state of the populace-who were subjected to natural disasters, famines, baronial feuds, and corruption-were conducive to the development of the mental plagues of that day. He believed that the strange disorders spread by "morbid sympathy" until they became epidemic. Poetically. he stated that "imitation-compassion-sympathy, are imperfect designations for a common bond of union among human beings-for an instinct which connects individuals with the general body." Although psychophysiologic symptomatology is commonplace among the poor, epidemics of more discrete psychosomatic illnesses are also affecting numerous persons from the middle and upper classes, thus indicating that poverty is only one of the sociocultural processes associated with the occurrence of these illnesses. Some of the recent epidemics have been mild. For example, the Royal Free Hospital Epidemic in London. in which 300 overworked female staff members, not the patients, were afflicted with "Benign Myalgic Encephalomyelitis," produced no deaths but did necessitate closing the hospital for a number of months. 16 A review of IS such epidemics of this presumed viral disease has led to their reevaluation; the illness is now considered to be a psychosocial phenomenon which McEvedy and Beard l7 have renamed "Myalgia Nervosa." In an editorial entitled "Epidemic Malaise," the 152
British Medical Journal commented on McEvedy and Beard's review of these epidemics and pointed out the importance of hysteria and mental contagion in their genesis and spread. IIl Other epidemics are having dire consequences. Coronary heart disease (CHD) is now pandemic, at least throughout Western society. It is estimated that almost 600,000 Americans will die from it this yearY' In 1968 Hinkle 20 noted. ironically, that this disease appears to be "the outgrowth of several factors in our society which we regard as most desirable." These include a high standard of living with an abundant diet which is rich in fat and protein, a highly developed technology which reduces the demand for physical labor, a longer life expectancy with continued exposure to the abundant diet and lack of exercise. social mobility with its demands for alertness, and cigarette smoking to relieve consequent anxieties and tensions. Hinkle's comments about the relationship between our culture's valued objectives and the increased frequency of CHD are reminiscent of Hippocrates' description of certain psychosomatic illnesses among the Scythians who were wealthy enough to own horses and wagons. Furthermore, Friedman and Rosenman's2I Type A behavior pattern, which is associated with increased risk for CHD. consists of traits consistent with the Protestant ethic-striving for achievement, competitiveness, and impatience. Recently. in a comparative study of different nations and cultures, Appels 22 found a positive correlation between achievement orientation and the incidence of CHD. He sees the coronary patient as one who mirrors the charac:eristics of aggressive, competitive societies. The coronary-prone person. therefore, has been subjected to surplus repression, and has overly adapted to the society's precepts and values. In 1949, RedF:I postulated that an epidemic of mental or psychophysiologic illness does not occur unless there are social restraints to be reduced. This insight helps to explain that epidemics occur not only when unfavorable social conditions are conducive to their development, but also when repression is manifest. The epidemics of classical hysteria during the Victorian Era are an example of such miscarried revolts against the sexual repression of the time. Currently, the frequency of psychophysiologic symptoms and the appearance of epidemics such as CHD can be seen as evidence of psychosocial disequilibrium and of overadaptation. But such speculations can provide at best only partial interpretations of the nature of psychosomatic disorders. Other factors in the social environment besides poverty. repression, and overadaptation seem also to be contributory. One is the proliferation of technology and the consequent rapid rate of social change. Grotjahn 21 states that our "Life Volume XVI
SOCIAL
PSYCHIATRY~CHWAB AND
is a mechanized nightmare." Our culture can be described as a technoculture in which traditional bonds are being exploded. The modern family, for example, is no longer a production unit. In our technological society the stresses of employment, removed from the home and often highly specialized, cannot be communicated between husband and wife whose resulting emotional disturbances are frequently somatized, producing occupational illness in one and the "tiredhousewife syndrome" in the other. Another factor seems to be the relative loss of social support systems. At the turn of this century Durkheim~:; foresaw that the changing social structure was acquiring monistic, self-augmenting, impersonal characteristics. He deplored the loss of the secondary institutions-neighborhood clubs and churches and extended family relationships-and feared that as a consequence individuals would be compelled to relate to impersonal, distant bureaucratic organizations. The result would be stress, anomie, and individual and societal malaise. In our daily work we are observing countless patients whose rehabilitation is impaired by the absence of meaningful social support systems. These include: ( I) the numerous young people afflicted with personal and familial problems who are admitted to hospitalseither berserk or comatose-following drug use; (2) the host of alcoholics; (3) the many elderly who are living in isolation and deprivation; and (4) the appalling number who have made suicide attempts. Their life histories are characterized by alienation, despair, and an absence of meaningful familial and social structures. In a recent mortality study we found that 50 percent of the survivors were suffering from extended pathological grief reactions one year following bereavement. We concluded that a lack of social supports was probably responsible for their extended grief and that continued grieving might be the only meaningful emotion for individuals deprived of human contacts and supporting environmental systems. 26 As psychiatrists, we are in a position to develop constructive approaches to meet the problem of psychosomatic illness, in all of its magnitude, complexity, and variability. Such approaches will require that we acknowledge the pervasive influence of the social setting in which all illness develops. In this sense, we are called upon to realize, as Rabkin~j has stated, that the age of psychological man has ended and that we are now living in the era of social man in which illnesses can easily be spread, in Hecker's words, "on the beams of light-on the wings of thought." We need to adopt an orientation, psychosocial as we]] as psychosomatic, which focuses on society's values. Societal values are determinants of poverty, socially conditioned repression, the rate of social change, and social support systems-factors that we have discussed October/November/December, 1975
SCHWAB
in relation to psychosomatic illness. Values, after all, not only influence life styles which lead to health or illness, but also establish priorities for the quality and quantity of health care available to individuals and their families. In this respect we should recall Andriga Stampar's~8 statement that: "No matter what the number of physicians may be, they will never improve people's health by individual therapy." In commenting on Stampar's statement, Stallones~K emphasizes that the major health benefits of the last century "have resulted from the operation of undirected, nonspecific influences. Advances in medical knowledge and the decline of disease are simultaneous results of a general improvement in the quality of life." As psychosomaticists, therefore, we can no longer be content to serve only as custodians of the mentally ill or as counselors of the middle class. Instead, we will have to embrace programs which extend mental and physical health care to all groups in our society. Thus, in our personal and professional roles we will have to do our utmost to promote, in HalIiday's3 words, "social therapeutics-whose aim would be to alter etiologically relevant group characteristics and etiologically relevant factors so that reintegration could be secured and a sick society restored to health." And lastly, to take care of the psychosomatically ill in our society, many of whom are casualties of our technological era, we will have to rely on humanistic approaches, interactions, and therapies which go beyond the wizardry of our scientific techniques to reach the human heart. REFERENCES 1. Hippocrates: The Medical Works of Hippocrates. Trans. by J. Chadwick and W.N. Mann. Oxford, England: Blackwell Scientific Publications, 1950. 2. Hinkle, L.E., and Wolff. H.G.: Ecological investigations of the relationship between illness. life experiences. and the social environment, A 1111. Int. Md. 49( 6): 1374, 1958. 3. Halliday. J.L.: Psychosocial Medicille: A Stlldy of the Sick Society. New York: Norton, 1948. 4. Dohrenwend, B.P., and Dobrenwend, B.S. Social Staws alld Psychological Disorder: A Causallllquiry. New York: Wiley, 1969. 5. Schwab, J.J., and Warheit, G.J.: Evaluating southern mental health needs and services: A preliminary report, Fla. Med. J. 17-20, January, 1972. 6. Schwab, J.J., Holzer, C.E., and Warheit. GJ.: Depressive symptomatology and age, Psychosomatics 14(3): 135141, May-June, 1973. 7. Warheit, G.l., Holzer, C.E.. and Schwab. 1.1.: An analysis of social class and racial differences in depressive symptomatology: A community study, J. Health & Soc. Behav. 14, December, 1973. 8. Leighton, D.C., Harding, 1.S., Macklin, D.B., Macmillan, A.M., and Leighton, A.H.: The Character of Danger, Vol. 3 of The Stirling County Study of Psychiatric Disorder and Sociocultural Environment. New York: Basic Books, 1963.
153
PSYCHOSOMATICS 9. Langner, T.S., and Michael, S.T.: The Midtown Manhattan Stlldy: Life Stress and Mental Health, Vol. 2. New York: McGraw-Hill, 1963. 10. Schwab, J.J., Fennell, E.B., and Warheit, OJ.: The epidemiology of psychosomatic disorders, Psychosomatics 15:88-93, April-June, 1973. 11. Watts, C.A.H.: Psychiatric disorder, in Research Committee of the Council of the College of Oeneral Practitioners: Morbidity Statistics from General Practice, Stud. Med. PoplIl, SlIb;. 14(3) :35-52. London, England: H.M. Stationery Office, 1962. 12. Crombie, D.L.: The procrustean bed of medical nomenclature, Lancet 1: 1205-1209, 1963. 13. Finn, R., and Huston, P.E.: Emotional and mental symptoms in private medical practice, J. Iowa Med. Soc. 56: 138-143, 1966. 14. Von Mering, 0 .• and Earley, L.W.: Major changes in the western medical environment, Arch. Gen. Psychiat. 13:195-201,1965. 15. Hecker, J.F.C.: Epidemics of the Middle Ages. Trans. By B.O. Babington. London: Woodfall, 1844. 16. McEvedy, C.P., and Beard, A.W.: Royal free epidemic of 1955: A reconsideration, Brit. Med. J. 1:7, 1970. 17. McEvedy, C.P., and Beard, A.W.: Concept of benign myalgic encephalomyeltis, Brit. Med. J. 1: 11, 1970. 18. Epidemic malaise, Editorial in Brit. Med. J., 1(3): 1-2, 1970. 19. Mathers, D.H., and Eliot, R.S.: Predicting and preventing sudden death, in R.S. Eliot (Ed.) ACllte Cardiac Em-
ergency. Mt. Kisco, New York: Futura Publishing Co., loc., 1972. 20. Hinkle, L.E.: Relating biochemical. physiological, and psychological disorders to the social environment, Arch. Environ. Health 16:77, 1968.
21. Friedman, M., and Rosenman, R.H.: Type A behavior pattern-its association with coronary heart disease, Alln. Clin. Research 3:300, 1974. 22. Appels, A.: Coronary heart disease as a cultural disease, Psychother. Psychosom. 22:320-324,1973. 23. Redl, R.: The phenomenon of contagion and "shock effect" in group therapy, in K.R. Eissler (Ed.) Searchlighu on Delinqllellcy. New York: International Univ. Press, 1949. 24. Orotjahn, M.: The new technology and our ageless unconscious, The Psychoanalytic Forum 1:7-18. 1966. 25. Durkheim, E.: Silicide: A Stlldy ill Sociology. Toronto: The Free Press, 1966. 26. Schwab, U., Chalmers, J.M., Conroy, S.l., Farris, P.B., and Markush, R.E.: Studies in grief: A preliminary report, Presented at The Foundation of Thanatology Symposium on Bereavement, New York, November 2-3, 1973. 27. Rabkin, R.: Inner alld Ollter Space: llltrodllction to a Theory of Social Psychiatry. New York: W.W. Norton and Co., Inc., 1970. 28. Stallones, R.A.: Community health, Science 175 (4024) : 839,1972.
PROPOSED COSSTITUTIONAL AMENDMENT
The following amendment to Article VI, Section 1, #4, Page 5 of the Constitution of the Academy of Psychosomatic Medicine has been proposed. "The four past presidents, not counting the immediate past presidents, shall be members of the Executive Council for a period of four years with vote." Thomas C. Kalkhof, M.D.
154
Volume XVI
FOURTH QUARTER, 1975
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Social Psychiatry and Psychosomatics JOHN J. SCHWAB,
M.D.,
Historically, the influence of sociocultural processes on psychosomatic illnesses was noted by Hippocrates in his treatise, Airs, Walers, and Places.! In that first essay on ecologic medicine, he described some specific psychosomatic afflictions and associated their frequency with child rearing practices and modes of living. For example. he related that the nomadic Scythians suffered from infertility. The men had a stout fleshy appearance, edema of the lower extremities, ill-marked joints, and diarrhea; the women's menstrual difficulties were severe. Hippocrates attributed these disorders, which occurred mainly among those who could afford horses and wagons, to their life style. The poor who walked or ran while the tribes moved had fewer of these health problems than the ones who spent long hours on horseback or were conveyed from place to place. Thus. 2500 years ago he pointed out that social factors were associated with psychosomatic illnesses. We are still evaluating such relationships in the hope that increased understanding will lead to amelioration and ultimately prevention. Our concerns hinge on two major factors to which Hippocrates alluded: (I) the unequal distribution of psychosomatic illnesses within populations, and (2) the influence of the social environment on the prevalence of these conditions. In their prospective stud:es, Hinkle and his colleagues~ have demonstrated that illness episodes of all types are not randomly distributed within groups. Instead, over a 20-year period, they found that 25 percent of the members in various groups experienced approximately 50 percent of all the illness episodes, while the healthiest 25 percent in the groups experienced less than 10 percent of the total illness episodes. This demonstration of the selective, not random, distribution of disease is particularly applicable to the psychosomatic illnesses, those bodily Presented at the Annual Meeting of the Academy of Psychosomatic Medicine, Scottsdale, Arizona, November 1720. 1974. Supported in part by NIMH Grant No. MH 15900·05-5. Dr. Schwab is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky 40201. October/November/December, 1975
AND RUBY
B.
SCHWAB
condtions which are produced, in Halliday's3 words, by a "synergy of causes," and are characterized by changing race, sex, and age ratios as certain sociodemographic groups are variably exposed to stressful or noxious forces. Even before psychiatry developed as a specialty in the early decades of the 19th century, physicians, scientists, and philosophers indicted social factors as causes of human distress and illness. Since then numerous investigators have studied the associations between the social environment and the prevalence of illness. The most consistent finding is the association between lower social status and an increased frequency of the mental disorders. 4 In our study of a random sample of 1,645 adults from the general population in a county in the southeastern United States, we found that, with few exceptions, the respondents with low incomes had more mental, psychophysiologic and somatic symptomatology than those in the middle- and upper-income groups. Low income has turned out to be the most statistically significant sociodemographic correlate of illness. We concluded that the configuration of human misery associated with poverty and deprivation, as well as social selection processes, leads to a piling up of the vulnerable, the disposed, and the afflicted among the poor. G' 7 But psychosomatic illnesses-in their magnitude, complexity, and variability-present certain exceptions to the association between poverty and the increased frequency of disease. Psychosomatic illnesses involve the interplay of complex intrapsychic as well as sociocultural processes. These include conation, 0 the r personality factors, elaborately developed defense mechanisms and symbolization, in addition to genetic factors, organ susceptibility, and exposure to stress. Certain psychosomatic illnesses, therefore, have sometimes been more frequent among middle-class and other groups than among those with low incomes. The magnitude of the problem of psychosomatic illness is revealed by the frequency of psychophysiologic symptomatology. Investigations of general populations, 151
PSYCHOSOMATICS
such as the Stirling CountyR and Midtown Manhattan Studies,9 indicate that as many as 60 percent of respondents had psychophysiologic complaints. Our study revealed that about 50 percent of the population suffered from at least one psychophysiologic symptom "regularly." Moreover, 17 percent reported that they had two or more psychophysiologic symptoms "regularly"; we labeled this group, 286 of our 1,645 respondents, as psychosomatically ill. The pervasiveness of psychosomatic symptomatology led us to conjecture that perhaps "as our sociotechnolog:c environment becomes more dehumanizing, the body protests".lfI Surveys of physicians' practices corroborate our concerns about the frequency of psychosomatic illnesses in general populations. In Western nations about onethird of all patients seen by physicians have psychophysiologic disorders. 1I . 13 These are usually the "problem" patients, those whom Von Mering and EarleyH have labeled as having undifferentiated health aberrations. They suffer from admixtures of mental, phys.ical, and social distress which are ways of life, disturbances that can be neither diagnosed nor treated by modem technological medicine. The complexity of the problem of psychosomatic illaess, in addition to its magnitude, is highlighted by the appearance of epidemics. In his classic description of the Epidemics of the Middle Ages, Hecker l ;' mentioned that adverse social conditions, particularly the wretched and oppressed state of the populace-who were subjected to natural disasters, famines, baronial feuds, and corruption-were conducive to the development of the mental plagues of that day. He believed that the strange disorders spread by "morbid sympathy" until they became epidemic. Poetically. he stated that "imitation-compassion-sympathy, are imperfect designations for a common bond of union among human beings-for an instinct which connects individuals with the general body." Although psychophysiologic symptomatology is commonplace among the poor, epidemics of more discrete psychosomatic illnesses are also affecting numerous persons from the middle and upper classes, thus indicating that poverty is only one of the sociocultural processes associated with the occurrence of these illnesses. Some of the recent epidemics have been mild. For example, the Royal Free Hospital Epidemic in London. in which 300 overworked female staff members, not the patients, were afflicted with "Benign Myalgic Encephalomyelitis," produced no deaths but did necessitate closing the hospital for a number of months. 16 A review of IS such epidemics of this presumed viral disease has led to their reevaluation; the illness is now considered to be a psychosocial phenomenon which McEvedy and Beard l7 have renamed "Myalgia Nervosa." In an editorial entitled "Epidemic Malaise," the 152
British Medical Journal commented on McEvedy and Beard's review of these epidemics and pointed out the importance of hysteria and mental contagion in their genesis and spread. IIl Other epidemics are having dire consequences. Coronary heart disease (CHD) is now pandemic, at least throughout Western society. It is estimated that almost 600,000 Americans will die from it this yearY' In 1968 Hinkle 20 noted. ironically, that this disease appears to be "the outgrowth of several factors in our society which we regard as most desirable." These include a high standard of living with an abundant diet which is rich in fat and protein, a highly developed technology which reduces the demand for physical labor, a longer life expectancy with continued exposure to the abundant diet and lack of exercise. social mobility with its demands for alertness, and cigarette smoking to relieve consequent anxieties and tensions. Hinkle's comments about the relationship between our culture's valued objectives and the increased frequency of CHD are reminiscent of Hippocrates' description of certain psychosomatic illnesses among the Scythians who were wealthy enough to own horses and wagons. Furthermore, Friedman and Rosenman's2I Type A behavior pattern, which is associated with increased risk for CHD. consists of traits consistent with the Protestant ethic-striving for achievement, competitiveness, and impatience. Recently. in a comparative study of different nations and cultures, Appels 22 found a positive correlation between achievement orientation and the incidence of CHD. He sees the coronary patient as one who mirrors the charac:eristics of aggressive, competitive societies. The coronary-prone person. therefore, has been subjected to surplus repression, and has overly adapted to the society's precepts and values. In 1949, RedF:I postulated that an epidemic of mental or psychophysiologic illness does not occur unless there are social restraints to be reduced. This insight helps to explain that epidemics occur not only when unfavorable social conditions are conducive to their development, but also when repression is manifest. The epidemics of classical hysteria during the Victorian Era are an example of such miscarried revolts against the sexual repression of the time. Currently, the frequency of psychophysiologic symptoms and the appearance of epidemics such as CHD can be seen as evidence of psychosocial disequilibrium and of overadaptation. But such speculations can provide at best only partial interpretations of the nature of psychosomatic disorders. Other factors in the social environment besides poverty. repression, and overadaptation seem also to be contributory. One is the proliferation of technology and the consequent rapid rate of social change. Grotjahn 21 states that our "Life Volume XVI
SOCIAL
PSYCHIATRY~CHWAB AND
is a mechanized nightmare." Our culture can be described as a technoculture in which traditional bonds are being exploded. The modern family, for example, is no longer a production unit. In our technological society the stresses of employment, removed from the home and often highly specialized, cannot be communicated between husband and wife whose resulting emotional disturbances are frequently somatized, producing occupational illness in one and the "tiredhousewife syndrome" in the other. Another factor seems to be the relative loss of social support systems. At the turn of this century Durkheim~:; foresaw that the changing social structure was acquiring monistic, self-augmenting, impersonal characteristics. He deplored the loss of the secondary institutions-neighborhood clubs and churches and extended family relationships-and feared that as a consequence individuals would be compelled to relate to impersonal, distant bureaucratic organizations. The result would be stress, anomie, and individual and societal malaise. In our daily work we are observing countless patients whose rehabilitation is impaired by the absence of meaningful social support systems. These include: ( I) the numerous young people afflicted with personal and familial problems who are admitted to hospitalseither berserk or comatose-following drug use; (2) the host of alcoholics; (3) the many elderly who are living in isolation and deprivation; and (4) the appalling number who have made suicide attempts. Their life histories are characterized by alienation, despair, and an absence of meaningful familial and social structures. In a recent mortality study we found that 50 percent of the survivors were suffering from extended pathological grief reactions one year following bereavement. We concluded that a lack of social supports was probably responsible for their extended grief and that continued grieving might be the only meaningful emotion for individuals deprived of human contacts and supporting environmental systems. 26 As psychiatrists, we are in a position to develop constructive approaches to meet the problem of psychosomatic illness, in all of its magnitude, complexity, and variability. Such approaches will require that we acknowledge the pervasive influence of the social setting in which all illness develops. In this sense, we are called upon to realize, as Rabkin~j has stated, that the age of psychological man has ended and that we are now living in the era of social man in which illnesses can easily be spread, in Hecker's words, "on the beams of light-on the wings of thought." We need to adopt an orientation, psychosocial as we]] as psychosomatic, which focuses on society's values. Societal values are determinants of poverty, socially conditioned repression, the rate of social change, and social support systems-factors that we have discussed October/November/December, 1975
SCHWAB
in relation to psychosomatic illness. Values, after all, not only influence life styles which lead to health or illness, but also establish priorities for the quality and quantity of health care available to individuals and their families. In this respect we should recall Andriga Stampar's~8 statement that: "No matter what the number of physicians may be, they will never improve people's health by individual therapy." In commenting on Stampar's statement, Stallones~K emphasizes that the major health benefits of the last century "have resulted from the operation of undirected, nonspecific influences. Advances in medical knowledge and the decline of disease are simultaneous results of a general improvement in the quality of life." As psychosomaticists, therefore, we can no longer be content to serve only as custodians of the mentally ill or as counselors of the middle class. Instead, we will have to embrace programs which extend mental and physical health care to all groups in our society. Thus, in our personal and professional roles we will have to do our utmost to promote, in HalIiday's3 words, "social therapeutics-whose aim would be to alter etiologically relevant group characteristics and etiologically relevant factors so that reintegration could be secured and a sick society restored to health." And lastly, to take care of the psychosomatically ill in our society, many of whom are casualties of our technological era, we will have to rely on humanistic approaches, interactions, and therapies which go beyond the wizardry of our scientific techniques to reach the human heart. REFERENCES 1. Hippocrates: The Medical Works of Hippocrates. Trans. by J. Chadwick and W.N. Mann. Oxford, England: Blackwell Scientific Publications, 1950. 2. Hinkle, L.E., and Wolff. H.G.: Ecological investigations of the relationship between illness. life experiences. and the social environment, A 1111. Int. Md. 49( 6): 1374, 1958. 3. Halliday. J.L.: Psychosocial Medicille: A Stlldy of the Sick Society. New York: Norton, 1948. 4. Dohrenwend, B.P., and Dobrenwend, B.S. Social Staws alld Psychological Disorder: A Causallllquiry. New York: Wiley, 1969. 5. Schwab, J.J., and Warheit, G.J.: Evaluating southern mental health needs and services: A preliminary report, Fla. Med. J. 17-20, January, 1972. 6. Schwab, J.J., Holzer, C.E., and Warheit. GJ.: Depressive symptomatology and age, Psychosomatics 14(3): 135141, May-June, 1973. 7. Warheit, G.l., Holzer, C.E.. and Schwab. 1.1.: An analysis of social class and racial differences in depressive symptomatology: A community study, J. Health & Soc. Behav. 14, December, 1973. 8. Leighton, D.C., Harding, 1.S., Macklin, D.B., Macmillan, A.M., and Leighton, A.H.: The Character of Danger, Vol. 3 of The Stirling County Study of Psychiatric Disorder and Sociocultural Environment. New York: Basic Books, 1963.
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PSYCHOSOMATICS 9. Langner, T.S., and Michael, S.T.: The Midtown Manhattan Stlldy: Life Stress and Mental Health, Vol. 2. New York: McGraw-Hill, 1963. 10. Schwab, J.J., Fennell, E.B., and Warheit, OJ.: The epidemiology of psychosomatic disorders, Psychosomatics 15:88-93, April-June, 1973. 11. Watts, C.A.H.: Psychiatric disorder, in Research Committee of the Council of the College of Oeneral Practitioners: Morbidity Statistics from General Practice, Stud. Med. PoplIl, SlIb;. 14(3) :35-52. London, England: H.M. Stationery Office, 1962. 12. Crombie, D.L.: The procrustean bed of medical nomenclature, Lancet 1: 1205-1209, 1963. 13. Finn, R., and Huston, P.E.: Emotional and mental symptoms in private medical practice, J. Iowa Med. Soc. 56: 138-143, 1966. 14. Von Mering, 0 .• and Earley, L.W.: Major changes in the western medical environment, Arch. Gen. Psychiat. 13:195-201,1965. 15. Hecker, J.F.C.: Epidemics of the Middle Ages. Trans. By B.O. Babington. London: Woodfall, 1844. 16. McEvedy, C.P., and Beard, A.W.: Royal free epidemic of 1955: A reconsideration, Brit. Med. J. 1:7, 1970. 17. McEvedy, C.P., and Beard, A.W.: Concept of benign myalgic encephalomyeltis, Brit. Med. J. 1: 11, 1970. 18. Epidemic malaise, Editorial in Brit. Med. J., 1(3): 1-2, 1970. 19. Mathers, D.H., and Eliot, R.S.: Predicting and preventing sudden death, in R.S. Eliot (Ed.) ACllte Cardiac Em-
ergency. Mt. Kisco, New York: Futura Publishing Co., loc., 1972. 20. Hinkle, L.E.: Relating biochemical. physiological, and psychological disorders to the social environment, Arch. Environ. Health 16:77, 1968.
21. Friedman, M., and Rosenman, R.H.: Type A behavior pattern-its association with coronary heart disease, Alln. Clin. Research 3:300, 1974. 22. Appels, A.: Coronary heart disease as a cultural disease, Psychother. Psychosom. 22:320-324,1973. 23. Redl, R.: The phenomenon of contagion and "shock effect" in group therapy, in K.R. Eissler (Ed.) Searchlighu on Delinqllellcy. New York: International Univ. Press, 1949. 24. Orotjahn, M.: The new technology and our ageless unconscious, The Psychoanalytic Forum 1:7-18. 1966. 25. Durkheim, E.: Silicide: A Stlldy ill Sociology. Toronto: The Free Press, 1966. 26. Schwab, U., Chalmers, J.M., Conroy, S.l., Farris, P.B., and Markush, R.E.: Studies in grief: A preliminary report, Presented at The Foundation of Thanatology Symposium on Bereavement, New York, November 2-3, 1973. 27. Rabkin, R.: Inner alld Ollter Space: llltrodllction to a Theory of Social Psychiatry. New York: W.W. Norton and Co., Inc., 1970. 28. Stallones, R.A.: Community health, Science 175 (4024) : 839,1972.
PROPOSED COSSTITUTIONAL AMENDMENT
The following amendment to Article VI, Section 1, #4, Page 5 of the Constitution of the Academy of Psychosomatic Medicine has been proposed. "The four past presidents, not counting the immediate past presidents, shall be members of the Executive Council for a period of four years with vote." Thomas C. Kalkhof, M.D.
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