Why doctors now study your mind to treat your body
It may be ulcers or migraine, warts, asthma, or heart trouble — one patient out of three, psychosomatic medicine has shown, is sick in the body because he is disturbed in the mind. This is one of the far frontiers of medical knowledge, and here is a report on how far the explorers have come
MOST MEDICAL HEADLINES — and there are plenty of them in these days of rapid scientific advance — are concerned with the physical side of medical research: another virus isolated; new bacteria spotted; a different kind of pathological tissue caught by the X ray. But as well as being days of science, these are days of stress, and emotional stress, as doctors are coming more and more to realize, plays a profoundly important part in a widely varied list of diseases. So that some of the most important research now going on. w'hich docs not make headlines at all. is concerned with things that cannot be seen under a miscroscope.
One branch of this research is "psychosomatic medicine” — the study that deals with bodily disorders caused by emotional disturbances — and the knowledge emerging from it is playing an increasingly important role in the way doctors are looking at their patients. About a third of those patients, it is now commonly agreed, are suffering from disorders that are distinctly psychosomatic in origin, of which bronchial asthma, essential hypertension, migraine headache and peptic ulcer (though none of those are necessarily psychosomatic) are most common. But so subtle is the interplay between the human mind and body that there is to some extent a psychic factor in all diseases and the fields of psychosomatic research now' extend from even before the cradle to very near the grave.
THE OLD MAN HAD AN UNSHAKABLE DEATH WISH...
One recent study at Dalhousie University in Halifax, for instance. concerned spontaneous abortion. There, Dr. Robert Weil, a psychiatrist, and Dr. Carl Tupper. a gynecologist, worked with eighteen pregnant women who were "habitual aborters” — each had lost at least three babies before taking part in the Dalhousie study and the eighteen had had a total of eighty-three spontaneous abortions. These women got weekly psychotherapy throughout their pregnancies. The psychotherapy amounted in the main to "an interested and understanding attitude on the part of the therapist, and guidance and support,” and it resulted — or something resulted — in the successful delivery of fifteen babies.
At the other end of the spectrum, there has been some recent work with what psychiatrists call "predilection to death.” One case, reported in the journal Psychosomatic Medicine last year, was that of a remarkable old man who was admitted to the Massachusetts General Hospital with nothing physically wrong with him but a broken leg. He was hawk-faced and robust, the journal reports, and he looked much younger than his eightv-six years. In the hospital, he joked with doctors, flirted with nurses, bragged of his background and of his years as a sailor and announced that, to his great relief, he was about to die. A psychiatrist discovered that the old man, a lifelong bachelor, had "at some point in his old age become preoccupied with a wish to die.” Unable, or unwilling, to commit suicide, he had tried to enlist an accomplice. He had tried to bribe a parking lot attendant to rig up a pipe from a car's exhaust and he had tried to hire someone to shoot him. He had started a rumor that he carried his life's savings around with him. But no one would do him in. He had suffered the broken leg that brought him to hospital when he was hit by a car — apparently in a genuine acci-
dent — and when he was in the hospital, the psychiatrist learned, he had decided that the surgeon who set the leg was to be his assassin. But he survived his simple operation. On awakening, he asked what sense there was in remaining in the world w'hen he had no more interest in it and. a w'eek after his operation, he suddenly died, of pulmonary embolism (a clot in the lung).
Interesting as these cases may be, to infer from them that all. or even many, spontaneous abortions can be stopped simply by a few understanding interviews, or even that one old man in a Boston hospital simply willed himself to die, is to go somewhat further than the most convinced psychosomaticist is prepared to lead. The true psychosomaticist emphasizes what he calls “multiple etiology” — meaning simply that diseases involve many factors, physical and psychic. The two Dalhousie doctors, for instance, even though they said flatly that they had proved “psychotherapy can prevent the abortive process from starting or continuing once started.” also took exquisite care to point out in their report that: "We are dealing with a multiplicity of more or less significant conditions.”
Most psychosomaticists, in fact, don't even like being called psychosomaticists, for it is a w'ord implying specialization. If they are specialists in anything, they maintain, it is in not specializing at all. And spokesmen for the psychosomatic approach talk in terms of what they call “holistic medicine” — treatment, in other words, of the w'hole man. body and soul.
One of the most eloquent of these spokesmen is a Canadian: Dr. Eric Wittkower, a scholarly and affable psychiatrist in his early sixties who is an associate professor at McGill University and works at the Allan Memorial Institute of Psychiatry in Montreal. 'The. Allan, which is connected with both McGill and the Royal Victoria Hospital, has become, partly through Wittkower’s influence, one of the continent’s most important centres of psychosomatic research. Wittkower, who has been working in the field since the 1920s. is the author, co-author or editor of more than a hundred books, monographs and papers ranging in specific subject from the effect of anger on the bile flow to w'hat the general practitioner ought to know about psychiatry. In I960, he was elected president of the American Psychosomatic Society.
. . . BUT ALL THE ACTRESS HAD WAS AN ALLERGY
Wittkower, for all his eloquence in support of his field, has frequently warned of the dangers of concentrating so heavily on the psychic components of disease that the physical components are ignored. “To replace ‘bad" bacteria by ‘bad' emotions,” he has written. “falls short of doing justice to the complexity of the problem.” And of the many instances in medical literature of someone's failing to do that justice, few are simpler or more illustrative than a case Wittkower himself discussed in a paper he prepared a few' years ago on allergies and the psyche. It concerned an actress who suffered from severe asthmatic attacks every time she was about to appear on stage — a classic case of apparent, psychosomatic stage fright. Months later, with the actress nearly convinced she w'as a hopeless neurotic, a physiological test established clearly that her wheezing and sneezing were due to nothing more emotional than her reaction to one of the ingredients in her theatrical make-up.
There are, nevertheless, some disorders
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PSYCHOSOMATIC MEDICINE continued from page 16
Skin disease and baldness may be partly caused by emotions. And suggestion has cured countless warts
where the effects of ’’bad emotions” are quite obviously the vital factor — at least quite obviously to such convinced Freudians as Wittkower. One of these is the peptic ulcer. A basic premise of psychosomatic reasoning is that a disturbed function can be the cause of a disorder (as well as the result of one, the way a runny nose is the result of a cold). In the ulcer, this disturbed function is hyperacidity, which eventually can eat into the lining of the stomach. The digestive system is normally acidic and motile when it is preparing to receive food. One of the experiments the psychosomaticists quote to illustrate the chain of cause and effect in the ulcer is that of Silbermann’s dogs. Silbermann, a German doctor, cut holes into the esophagi of a group of dogs in such a way that any food the dogs snapped up would fall to the floor before it reached their stomachs. Sometimes, a dog would pick up the fallen food and repeat the process for as long as three quarters of an hour. Aside from what this exercise did for Dr. Silbermann’s popularity with dog lovers, it convinced him that this frustration — which, of course, kept the animals’ digestive systems in a sustained state of preparation for food — would lead “regularly” to ulcers. Putting their proposition into more human terms, the psychosomaticists quote the Freudian concept that under stress a person tends to return, unconsciously, to infantile characteristics, one of which is the equation of love and security with food. Thus, they say, certain emotional stresses of modern life (a failure to achieve security) can cause some people to simulate the chemistry of anticipating food — hyperacidity and hypermotility — which can lead to ulcers. Many experiments have seemed to bear this theory out; it has been discovered, for instance, that the amount of stomach acidity in ulcer patients tends to be significantly higher at night, when there is no anticipation of food, than it is in normal people. And a fairly common operation for ulcer cases is severance of the vagus nerve, which carries hunger stimuli to the stomach.
This same pattern, with variation, is evident in other psychosomatic disorders. If a man prepares for a fight, his blood pressure rises. If he does fight, it goes down. But in 1962 there aren't many people you can punch in the nose and get away with it. So that if a man is abnormally and habitually belligerent, his blood pressure is too often at an abnormally high level, and unless the emotional disturbance is relieved, the final effect is liable to be an organic disorder, in this case, hypertension.
Theorizing along these lines has led to some research into “personality profiles.” Arc certain types of people, in other words, prone to certain types of disorders? The answer the psychosomaticists give is a qualified yes. Some clinical studies have shown similar personality traits among people with similar disorders. In a 1957 study of eighteen rheumatoid arthritics, Wittkower and Dr. B. M. Cormier found that they were, as a group, “overactive as children but inhibited later in life (before the illness).” There are many other similar reports in many other areas of medicine; all the eighteen women in the Dalhousie study of habitual aborters were described as, in varying degrees, “aloof.” Many of these studies — enough to raise occasional questions even from firm believers in the psychosomatic approach — have been conducted without what some other disciplines would consider adequate “control” studies of unafflicted people. Control groups, of course, are not easily come by in psychoanalytic research—Wittkower and Cormier used the nearest brother or sister of their arthritic patients — because getting them usually requires subjecting groups of “normal” people to long and arduous sessions of analysis.
One attempt at establishing controls led to what is now probably psychosomatic medicine’s best-known concept in the field of personality profiles: accident-proneness. In a study of heart patients in a New York hospital. Dr. Flanders Dunbar worked with the patients in the accident ward as controls — and found common psychological
traits among them. It is now believed that some eighty percent of accidents are not really accidental at all, but are the results of inner turmoil. The same principle has led to research into such areas as venereal disease, where the psychosomatic theory is that indiscriminate promiscuity is symptomatic of emotional disorder and therefore VD has clear psychic components.
The qualifications of this personalityprofile idea lie in a newer trend to find patterns of conflicts, rather than of personalities. Certain forms of emotional tension, that is, are likely to have certain somatic effects, even in people who appear to be different in make-up. Thus a psychoanalytic study of twenty-three unmarried mothers showed that before conception all had suffered some form of what psychiatrists call “object loss,” varying, in this case, from the end of a love affair to the death of an earlier child.
One of the most significant recent experiments in the area of predictability of
disorders was conducted with all the 660 freshmen who enrolled at the University of Illinois College of Medicine from 1946 to 1949. All of them were given comprehensive medical examinations, psychiatric interviews and Rorschach ink-blot tests when they started college. In 1957, all those who had graduated were sent a detailed medical, personal and occupational questionnaire. Those who answered (nearly six hundred) showed a not-unusual incidence of classic psychosomatic ailments: 3.1 percent had duodenal ulcers; 4.7 percent had bronchial asthma: 4.9 percent had essential hypertension, and 6.3 percent had migraine headaches. When all the results »-'\Cerc in. the medical case histories were separated from the psychiatric data obtained a decade before and the psychiatric data alone was given to a psychiatrist. He was able, in the words of the report presented to the I960 annual meeting of the American Psychosomatic Society in Montreal, to predict with “an accuracy significantly higher than chance” which freshmen would come down with one of the psychosomatic disorders and which ones wouldn't.
Next to the four classic psychosomatic disorders suffered by the young doctors, diseases of the skin provide the most straightforward examples of the psychosomatic effect. “Irrespective of how many and which other factors are of relevance,” Wittkower has written, “eczema is a disease which occurs in emotionally insecure individuals.” Various kinds of suggestions have cured countless cases of warts and some writers have gone so far as to imply that suggestion is in fact the most important aspect of treatment of warts by X ray, drugs and even surgery. Similar conclusions. if not always so strongly stated, have been arrived at concerning all manner of skin diseases from hives to some kinds of baldness, although a recent article in the British medical journal The Lancet offered
a plea for not forgetting the purely physiological factors, and indeed quoted Wittkower to the effect that "in many skin conditions, psychological factors are of no importance."
Psychological factors are of great importance in diseases of the heart. Several studies have found that emotional stress — particularly of occupational origin — is far more important in the pattern leading up to heart attacks than heredity, diet, tobacco consumption or exercise. One of the most striking of these studies was presented to the American Psychosomatic Society in I960. It was a survey of more than twenty-five hundred American physicians, working in four fields. The fields were rated according to “stressfulncss." General practitioners, judged to be under the greatest stress, were fourni to suffer three times as many heart attacks as dermatologists, at the bottom of the stress scale. Anesthesiologists, under the second greatest amount of stress, had more than twice as many coronary attacks as the dermatologists.
In an area of disease where psychosomatic factors might not be so obvious to the layman, a study of tuberculosis published in Psychosomatic Medicine in I960 concluded with a confirmation of "previous clinical reports which have associated fast recovery among tuberculosis patients with the overt expression of hostility, while slow recovery occurs more readily among patients who bottle up their anxiety and superficially appear to be 'good' patients." Wittkower has written: "It is agreed that emotional disturbances often precede — and probably precipitate — the onset of tuberculosis . . Writers have often stressed the
function of this illness as a means for a flight from frustration and the responsibilities of life, and for self-punishment ultimately in the form of organic suicide."
What of cancer? Here, the evidence is not so clear, nor are the implications so strong. In 1959. two U. S. doctors, George Perrin and Irene Pierce, presented in Psychosomatic Medicine a review of much of the literature then available on the psychosomatic aspects of cancer. After casting some doubts on the scientific validity of some oi the research, they offered, somewhat grudgingly, such conclusions as: "Published studies suggest a slightly higher cancer death rate in hospitalized psychotic pa tients than in the normal population: the reason for this . . . may well be due to the inadequacy of the statistics. . . . Some authors . . . believe that cancer appears in patients with specific immature types of personalities. . . . One group reports that established cancer grows more slowly in less inhibited individuals." But some correspondents thought Perrin and Pierce had been too hard on what research they had examined—and pointed out that they had missed some. One pair of critics of Perrin and Pierce listed eight different researchers who had. they said, come "to accept psychological factors as of major importance in the development and pathogenesis of cancer." In a reply to their critics published in the same journal last year. Perrin and Pierce, while admitting that they had not covered all the most recent work, offered what may well be the most significant statement yet on this aspect of medicine: "We might point out that there was at one time a much greater unanimity of opinion about the value of bleeding as a practically universal medical procedure than there ever has been about the ps>chological influences in cancer."
What there is unanimity about—at least among the psychosomaticists—is the need to further the theory that is at the bottom of all their research: the theory of holistic medicine. Por all the obscure corners of medical knowledge into which the psychosomatic researchers probe—and no
report of this kind could even list them— what they are getting at is the fact that you can't separate the disease from the man who has it. And as medicine, under an avalanche of new' and ever more precise physical data, grows more and more specialized, too many doctors, the psychosomaticists feel, arc treating too many patients as the mechanical sums of occasionally defective parts. As Wittkower said in his presidential address to the APS: “Despite the popularity among the lay public of the term ‘psychosomatic.’ there is no evidence on the Canadian scene—
and to a large extent this is no different across the border—that the psychosomatic approach has been fully accepted by our colleagues in medicine, surgery and other medical specialties."
To combat this trend, or lack of it, the psychosomaticists would like to see every doctor given enough psychiatric training that he could at least discern when there was a possibility of emotional factors in a disorder, and they would like to convince every doctor that he should listen to his patient. Perhaps more important, they would like all patients to tell their doctors
more about what’s been worrying them, even when they don't sec any possible relationship between, say. their digestive troubles and their marital woes.
“Psychosomatic medicine,” Wittkower told the World Congress of Psychiatry in Montreal last June, "has undoubtedly rendered an extremely valuable service by doing away with the arbitrary and unsound distinctions between so-called organic and so-called functional disease. We still have a long way to go before the term psychosomatic may be superseded by such terms as comprehensive medicine." if