Theory
Psychother. Psychosom. 1979;31:9-17
A Reappraisal of Some Psychosomatic Concepts W.L.
Linford
Rees
St. Bartholomew’s Hospital, Department of Psychological Medicine, University of London, London Abstract The paper presents a critical reappraisal of some psychosomatic concepts which have become entrenched in the literature. The limitations of concepts of specificity relating to stimuli, emotional changes and various psychosocial stresses are discussed. The available evidence indicates the importance of the patient’s personality, but does not support the claims of specific personality types for each disorder. Concepts of aetiology are discussed. The importance of heterogeneity rather than homogeneity is stressed. Relationships between psychiatric and psychosomatic disorders are considered. The significance of somatopsychic as well as psychosomatic sequences of events arc emphasised, finally, the importance of multifactorial causation in psychosomatic disorders is underlined. Prof. W. Linford Rees, PRC Psych, MD, FRCP, FACP (Hon), DSc, St. Bartholomew’s Hospital, Department of Psychological Medicine, University of London, London (UK)
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Although physicians have realised from time immemorial that emotional and social factors may play a role in the development of disease, it is only in the last 40 years that serious research enquiries have been carried ouî into the relationship between psychological, social and biological variables influencing health and disease. The literature is indeed voluminous on studies on psychosomatic interactions and interrelationships and on the nature and effects of psychosomatic and somatopsychic sequences of events. Even though the importance of social and psychological factors in the understanding, prevention, diagnosis, management and treatment of all diseases has now achieved world-wide recognition, as has the importance of the psychological consequences of various illnesses which is an important aspect of liaison psychiatry, there is still considerable uncertainty and controversy about fundamental issues in the field, particularly regarding aetiology, pathophysiology. and pathogenesis. Rees 10 The modern pioneers in psychosomatic medicine in the 1930s and 1940s stimulated a great deal of interest and enthusiasm in the field. Their studies were dominated by psychoanalytic theory and therapy and were often on small selected groups of patients. There was no shortage of hypotheses, but the large number of hypotheses contrasted markedly to the paucity of scientifically established facts. Many of the hypotheses were not capable of scientific evaluation and refutation. Findings derived from selected groups of patients led to unwarranted assumptions and claims that the role of identified aetiological factors in these groups applied to the disorders in general. Inadequacies of methodology undoubtedly retarded the development of a scientifically established body of knowledge in the field. Very few studies attempted to obtain random representative samples of the disorder under investigation. Furthermore, very little attempt was made to compare the findings in patient groups with those of corresponding control groups derived from the general population. Specificity Hypotheses
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Alexander (1950) postulated a causal association between (^psycho-dynamic constellations formed in early life, consisting of and relating to unconscious conflicts, and of psychological defence methods utilised in response; (2) a precipitating life situation at the onset which immediately precedes the illness and which is of emotional significance to the patient and reactivates his underlying conflicts, and (3) the so-called ‘X’ factor, as a constitutionally determined organ vulnerability. A carefully executed study to evaluate experimentally Alexander’s specificity hypothesis as applied to seven diseases, namely, asthma, rheumatoid arthritis, ulcerative colitis, essential hypertension, neuro-dermatitis, thyrotoxicosis and peptic ulcer was carried out by the Chicago Institute of Psychoanalysis but the results failed to validate the specificity hypothesis. This does not mean that the psychodynamic factors so described are not important, but it means that they are not applicable to the disorders in general and are not specific for each disease. The specificity component of Alexander’s formulation aroused a great deal of controversy and resulted in overlooking the fact that his formulations were comprehensive and that he stated that the specific conflict operated in the presence of ‘X’ factors which, at that time were unknown, and were related to genetic, biochemical and physioA Reappraisal of Some Psychosomatic Concepts 11 logical attributes, and that the strong emotions accompanying the activated response to specific life situations were mediated by autonomic, hormonal or neuromuscular mechanisms to produce the lesion in the target organ. Personality Specificity Dunbar (1943), Hallíday (1948), and others proposed the hypothesis that for each psychosomatic disorder there were specific personality attributes. Various studies attempted to evaluate this whether in terms of traits of personality, constellations of traits, personality types or personality profiles, but have failed to support the claim that there are specific personalities correlated to specific psychosomatic disorders. This does not mean to say that personality disposition is not of importance in psychosomatic disorders. Most workers would agree that a patient’s personality is of paramount importance in so far as that it influences his reaction to environmental changes, psychosocial stresses and stimuli, and will govern his emotional reactions and arousal to such stimuli and will also influence the way in which he perceives such life changes and psychosocial stresses, and also the way with which he copes with these by a variety of different possible mechanisms which can influence the potentially damaging effect of such stresses. Personality factors will also influence the degree to which emotions are contained or adequately expressed in motor activity, speech or in other ways. Specificity of Life Events, Life Changes, and Psychosocial Stresses at the Onset Alexander (1950) and other authors have postulated a specificity of life circumstances associated with the onset of various emotional reactions. Undoubtedly, some of these specific formulations occur in some patients, but there is no evidence to support the view that they are applicable to the disease in general. In my studies of over 2,000 patients, I found that a variety of life events were associated with the onset of different psychosomatic disorders. Bereavement was the relevant factor in a proportion of all patients, and an equally prevalent and important life situation at the onset was one which was associated with a threat to the security of a loved person. In all groups, family and marital problems, sexual conflicts, sudden traumatic experiences, work problems, financial difficulties, and various conflict situations occurred in a proportion of patients. Therefore, although these
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conditions were relevant in some patients, there was no evidence of any specificity of life events for each form of psychosomatic illness. Rees 12 Stress The term ‘stress’ has been used in a variety of ways and has been applied to both external stimuli and environmental conditions and also to the effects such stimuli induced on the organism. The term stress is really an abstraction and is meaningless if the reaction of the organism to potentially damaging conditions is ignored. I propose to use the term stress as any stimulus or change in the external or internal environment of such a degree in terms of strength, intensity or duration as to tax the adaptive capacity of the organism to its limits and which, in certain circumstances, may produce a disorganisation of behaviour, maladaptation or dysfunction which may lead to disease. What may constitute a stress may consist of physical stimuli, infections (bacterial, viral, or fungal) allergic reactions, or may refer to a whole series of stimuli or changes in the social or psychological spheres of life, referred to as psychosocial stresses. The individual’s response to physical or psychosocial stresses will be influenced by genetic and constitutional factors and also by previous experiences, particularly in childhood. The damaging effects of psychosocial stresses will depend not only on the inherent threat, but also on the way the individual perceives and appraises the significance of the potentially challenging event, and the degree of damage resulting will be influenced by the way with which he copes with the stress, and whether he utilises various ego defences, such as denial, displacement, withdrawal, etc. The response will also be influenced by the cumulative effects of preceding psychosocial or physical stresses and by the existing physical and emotional state of the organism. Similarly, in some women who suffer from the premenstrual syndrome, reactions during this vulnerable time to a variety of stresses and problems are much greater than at other times during the menstrual cycle. Modifying the internal environment in these patients by hormonal means can ameliorate the degree of response to environmental and psychosocial stresses. Changes and mechanisms in reactions to psychosocial stresses involve emotions, arousal, perceptions and coping mechanisms. They may also involve endocrine processes, sympatheticoadrenal medullary, adrenocortical, thyroid activity, lymphatic and immunoreactive processes and other physiological changes. Thus, psychosocial stresses acting on the individual give rise to bodily changes involving the hypothalamic pituitary control of the adrenal cortex and medulla, the thyroid and other endocrine functions, and also a variety of biochemical and physiological changes which may constitute conditions which are conducive to the development of disease. Furthermore, changes in auto-nomic functioning and in the functions of the musculo-skeletal system can also A Reappraisal of Some Psychosomatic Concepts 13 play relevant and even dominant parts in the development of manifestations of different diseases. There is now well-established evidence that bereavement is followed by a tendency to increased morbiidity and mortality. The power of bereavement in affecting morbidity and mortality will be influenced by the way the person deals with his grief. It may be a normal grief reaction of limited duration which the patient satisfactorily works through with minimal damage. It may result in feelings of hopelessness and helplessness which many authorities have found to be important factors at the onset of many diseases. The damaging factors may not only lead to various
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
psychosomatic disorders, but also to physical or psychiatric illnesses, particularly if bereavement is not satisfactorily worked through. Family Influences Many psychosomatic disorders show a familial incidence. This may be due to a number of different factors including heredity, learning patterns of response from other afflicted members of the family or family influences producing emotional changes and feelings of insecurity. Studies, including my own, of asthmatic families reveal that no single pattern of family relationship exists. Mothers may be (1) over-protective, over-solicitous and over-anxious; (2) perfectionistic and over-ambitious for the child; (3) overtly dominant, rejecting or punitive, or (4) consistently helpful, supporting, accepting and from every point of view satisfactory for the emotional development of the child. A group of 170 asthmatic children were compared with a control group of 160 children of similar age, sex and social status. The asthmatic group had a much higher prevalence of parental attitudes classified as over-protective, perfectionistic and rejecting compared with the control group. Comparing asthmatic patients subjected to what were deemed to be satisfactory parental attitudes with those with unsatisfactory parental attitudes, it was found that the asthmatic group with unsatisfactory parental attitudes had a statistically significantly higher prevalence of individuals with traits rated as somewhat or very unstable, very meek, and somewhat or very sensitive and a greater frequency with which psychological factors precipitated attacks. 75% of maternal over-protective attitudes developed prior to the onset of asthma, and in those who developed these attitudes subsequently to the onset of asthma, 20% were considered to be mainly a reaction to the child’s asthma. The importance of faulty parental attitudes is attested by the marked improvement which occurs in the child when the parent, after psychotherapeutic guidance, is able to improve her attitude and mode of upbringing of the child. Certain parental attitudes are, therefore, of importance in producing conditions conducive to the precipitation of attacks of asthma but no one pattern of relationship is necessary or sufficient in the causation of the disorder. Rees 14 Aetiology There are innumerable possible causes to any event including an illness. As clinicians, we are concerned with the ascertainment and assessment of factors which are likely to be causal and relevant in the disorder, and we are particularly interested in any factors which lend themselves to modification or control as these will determine the feasibility of applying effective treatment and prophylaxis. Some causes are necessary or essential because without them the disorder could not develop. Other causes, although not necessary or essential, are sufficient causes because they enable the essential cause to be manifested in disease at a particular time. Necessary or essential causes are not always sufficient. Similarly, sufficient causes are not always necessary. Causes may also be classified into predisposing, initiating, sustaining and those which govern the termination of the illness. Predisposing factors include genetic and constitutional influences, im-munological reactions, hormonal changes, and biochemical and physiological processes. They may have their origin in past experiences or take the form of socio-cultural influences which may be both predisposing as well as precipitating factors. Another important predisposing factor is personality. It is clear that a multiplicity of causes operate in predisposition to any disease. It may also be concluded that psychological factors alone do not predispose to a disease, and no disease will develop in a
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
person predisposed to it unless the necessary causative factors are present. It is also clear that more persons are predisposed to a disease than actually develop it. There is now general agreement that the factors governing the onset of the disease as well as those controlling its course and outcome are always multiple. Homogeneity versus Heterogeneity The belief that various psychosomatic disorders are homogeneous has led to the unwarranted application of findings from small selected groups to the disease in general. What is now clear is that the majority of psychosomatic illnesses are, in fact, heterogeneous and that subgroups of illness occur which differ in aetiology, in their pathophysiology and in their pathogenesis. For example, in asthma only 30–50% have been proved to be allergic and in the remainder viral infections and psychological factors operate. Different constellations of aeti-ological factors and different pathophysiological mechanisms can produce the same disorder. A Reappraisal of Some Psychosomatic Concepts 15 Relationship between Psychiatric and Psychosomatic Disorders One of the hypotheses which has been put forward for many years is that there tends to be a reciprocal relationship between the manifestations of neuroses or psychoses and psychosomatic disorders. In other words when the psychosomatic disorder is being clinically manifested, the neurosis or psychosis tends to be in abeyance. In my observations of over 2,000 patients, I find that this relationship does occur, but this is quite exceptional. It is much more common for neurotic symptomatology or even manifestations of severe psychiatric illness, like depression, to vary concomitantly with the psychosomatic disorder. My studies are in agreement with those of Leigh and Marley (1976) and show a positive correlation between neurotic symptoms and psychosomatic disorders which tend to display a higher prevalence than corresponding control groups. Disorder of Regulation Many, if not all, psychosomatic disorders can be regarded as disorders of regulation, for example, in asthma the regulation of the patency of the bronchial tree is altered in the form of a tendency to broncho-constriction. Patency of the bronchi is usually maintained by a balance between Ø-adrenergic sympathetic mechanisms tending to cause dilation and α-adrenergic sympathetic and cholin-ergic mechanisms producing constriction. The regulatory mechanisms are mediated by cyclic nucleotides and a shift in balance of their regulatory mechanisms would produce the bronchoconstriction tendency. Increased levels of cyclic GMP and decreased levels of cyclic AMP would produce a tendency to bronchoconstriction. It is on this tendency to bronchoconstriction that reflex neural mechanisms and the chemical mediators of allergic, infective, and psychological factors operate in producing asthmatic attacks. Despite the claims of immunologists that the release of chemical mediators of allergen-IgE antibody interactions are sufficient to produce bronchoconstriction, it has been shown that the immediate form of hypersensitivity, and also in experimental asthma in animals, bronchospasm and hyperventilation are mediated by vagal reflexes. Karczewski and Widdicombe (1969) showed that the intravenous injection of antigen into passively sensitised rabbits produced bronchoconstriction and hyperventilation. Cooling the cervical vagus inhibited these effects, and cutting the vagi prevented them. Similarly, Gold et al. (1972) demonstrated that the exposure of dogs to allergens to which they were sensitive raised airways resistance which could be prevented by afferent or efferent vagal blockade. Rees
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16 Somatopsychic Effects The problem which has faced researchers in the field of psychosomatic medicine is to what extent the psychological correlate of psychosomatic disorders may be a consequence of the disorder rather than the predisposing or contributory factor. There is no doubt that somatopsychic sequences of events are very important in influencing the degree of suffering and disability experienced by the patient and also in influencing the duration and the outcome of the illness. Studies I have carried out on over 800 asthmatics, comparing the prevalence of neurotic symptoms according to the duration of the illness, revealed, although there are significantly more frequent neurotic symptoms in the earlier stages of the illness than in the control groups, the longer the duration of the illness the greater is the prevalence of neurotic symptomatology. A carefully planned study on the relationships between breathlessness and anxiety in asthma and bronchitis were carried out in my hospital by Oswald et al. (1970). All categories of patients, whether suffering from asthma, bronchitis, or both, showed a greater tendency towards neuroticism, anxiety and introversion than normal control groups and neuroticism and anxiety increased with increasing respiratory disability. These studies indicate the importance of taking into account not only psychosomatic sequences of events, which are of course of paramount importance in the aetiology of psychosomatic disorders, but also paying due attention to somatopsychic reactions which are of vital importance in management and rehabilitation of patients and form the basis of liaison psychiatry. Conclusions Multifactorial causation is the rule in psychosomatic disorders with interaction and interplay between many forces rather than the operation of a single specific cause. A dynamic unifying concept of psychosomatic disorders would take into account such interaction of multiple forces in terms of adaptation to external forces and changes on the internal milieu to maintain homeostasis, a prerequisite for well being and health. Disease is characterised by a failure of adaptation and in the last analysis is a failure of homeostasi.s. Adaptive failure occurs when external forces and internal changes overwhelm the adaptive capacity of the organism. This can occur when the external events are severe and prolonged, or A Reappraisal of Some Psychosomatic Concepts 17 cannot be changed or avoided, or when the person’s adaptive capacity is limited by genetic, constitutional, physiological or psychological factors. Homeostasis is governed by regulating forces which may be physio-chemical, enzymatic, biochemical, endocrinal, autonomic and musculo-skeletal. The control of as many of the interacting causative factors as possible and the elimination or prevention of vicious circles interplaying between such factors appears the most effective means of helping our patients. References Alexander, F.: Psychosomatic medicine (Norton, New York 1950). Dunbar, H.F.: Psychosomatic diagnosis (Hoeber, New York 1943). Gold, W.M.; Kessler, G.R., and Yu, D.Y.C.: Role of vagus nerves in experimental asthma in allergic dogs. J. appl. Physiol. 33: 719 (1972). Halliday, J.L.: Psychological medicine (Norton, London 1948). Leigh, A.D. and Marley, E.: Bronchial asthma. Genetic, population and psychiatric studies (Pergamon, Oxford 1976). Linford Rees, W.: The significance of parental attitudes in childhood asthma. J. psychosom.
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Res. 7: 181–190(1963). Linford Rees, W.: The importance of psychological, allergic and infective factors in childhood asthma. J. Psychosom. Res. 7: 253–262 (1964). Linford Rees, W.: Trends and issues in psychosomatic medicine. Proc. 4th Wld Congr. Psychiat. Int. Congr. No. 150, pp. 563–565 (Excerpta Medica, Amsterdam 1966). Linford Rees, W.: A controlled epidemiological study of the role of psychological factors in migraine. Archs Neurobiol. 37: 243–251 (1974). Linford Rees, W.: Stress, distress and disease. Br. J. Psychol. 128: 3–18 (1976). Karczewski, W. and Widdicombe, J.G.: The role of the vagus nerves in the respiratory and circulatory reactions to anaphylaxis in rabbits. J. Physiol. 201: 293 (1969). Oswald, N.C.; Waller, R.E., and Drinkwater, J.: Relationship between breathlessness and anxiety in asthma and bronchitis. A comparative study. Br. med. J. it: 14–17 (1970).
Psychother. Psychosom. 1979;31:9-17
A Reappraisal of Some Psychosomatic Concepts W.L.
Linford
Rees
St. Bartholomew’s Hospital, Department of Psychological Medicine, University of London, London Abstract The paper presents a critical reappraisal of some psychosomatic concepts which have become entrenched in the literature. The limitations of concepts of specificity relating to stimuli, emotional changes and various psychosocial stresses are discussed. The available evidence indicates the importance of the patient’s personality, but does not support the claims of specific personality types for each disorder. Concepts of aetiology are discussed. The importance of heterogeneity rather than homogeneity is stressed. Relationships between psychiatric and psychosomatic disorders are considered. The significance of somatopsychic as well as psychosomatic sequences of events arc emphasised, finally, the importance of multifactorial causation in psychosomatic disorders is underlined. Prof. W. Linford Rees, PRC Psych, MD, FRCP, FACP (Hon), DSc, St. Bartholomew’s Hospital, Department of Psychological Medicine, University of London, London (UK)
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
Although physicians have realised from time immemorial that emotional and social factors may play a role in the development of disease, it is only in the last 40 years that serious research enquiries have been carried ouî into the relationship between psychological, social and biological variables influencing health and disease. The literature is indeed voluminous on studies on psychosomatic interactions and interrelationships and on the nature and effects of psychosomatic and somatopsychic sequences of events. Even though the importance of social and psychological factors in the understanding, prevention, diagnosis, management and treatment of all diseases has now achieved world-wide recognition, as has the importance of the psychological consequences of various illnesses which is an important aspect of liaison psychiatry, there is still considerable uncertainty and controversy about fundamental issues in the field, particularly regarding aetiology, pathophysiology. and pathogenesis. Rees 10 The modern pioneers in psychosomatic medicine in the 1930s and 1940s stimulated a great deal of interest and enthusiasm in the field. Their studies were dominated by psychoanalytic theory and therapy and were often on small selected groups of patients. There was no shortage of hypotheses, but the large number of hypotheses contrasted markedly to the paucity of scientifically established facts. Many of the hypotheses were not capable of scientific evaluation and refutation. Findings derived from selected groups of patients led to unwarranted assumptions and claims that the role of identified aetiological factors in these groups applied to the disorders in general. Inadequacies of methodology undoubtedly retarded the development of a scientifically established body of knowledge in the field. Very few studies attempted to obtain random representative samples of the disorder under investigation. Furthermore, very little attempt was made to compare the findings in patient groups with those of corresponding control groups derived from the general population. Specificity Hypotheses
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
Alexander (1950) postulated a causal association between (^psycho-dynamic constellations formed in early life, consisting of and relating to unconscious conflicts, and of psychological defence methods utilised in response; (2) a precipitating life situation at the onset which immediately precedes the illness and which is of emotional significance to the patient and reactivates his underlying conflicts, and (3) the so-called ‘X’ factor, as a constitutionally determined organ vulnerability. A carefully executed study to evaluate experimentally Alexander’s specificity hypothesis as applied to seven diseases, namely, asthma, rheumatoid arthritis, ulcerative colitis, essential hypertension, neuro-dermatitis, thyrotoxicosis and peptic ulcer was carried out by the Chicago Institute of Psychoanalysis but the results failed to validate the specificity hypothesis. This does not mean that the psychodynamic factors so described are not important, but it means that they are not applicable to the disorders in general and are not specific for each disease. The specificity component of Alexander’s formulation aroused a great deal of controversy and resulted in overlooking the fact that his formulations were comprehensive and that he stated that the specific conflict operated in the presence of ‘X’ factors which, at that time were unknown, and were related to genetic, biochemical and physioA Reappraisal of Some Psychosomatic Concepts 11 logical attributes, and that the strong emotions accompanying the activated response to specific life situations were mediated by autonomic, hormonal or neuromuscular mechanisms to produce the lesion in the target organ. Personality Specificity Dunbar (1943), Hallíday (1948), and others proposed the hypothesis that for each psychosomatic disorder there were specific personality attributes. Various studies attempted to evaluate this whether in terms of traits of personality, constellations of traits, personality types or personality profiles, but have failed to support the claim that there are specific personalities correlated to specific psychosomatic disorders. This does not mean to say that personality disposition is not of importance in psychosomatic disorders. Most workers would agree that a patient’s personality is of paramount importance in so far as that it influences his reaction to environmental changes, psychosocial stresses and stimuli, and will govern his emotional reactions and arousal to such stimuli and will also influence the way in which he perceives such life changes and psychosocial stresses, and also the way with which he copes with these by a variety of different possible mechanisms which can influence the potentially damaging effect of such stresses. Personality factors will also influence the degree to which emotions are contained or adequately expressed in motor activity, speech or in other ways. Specificity of Life Events, Life Changes, and Psychosocial Stresses at the Onset Alexander (1950) and other authors have postulated a specificity of life circumstances associated with the onset of various emotional reactions. Undoubtedly, some of these specific formulations occur in some patients, but there is no evidence to support the view that they are applicable to the disease in general. In my studies of over 2,000 patients, I found that a variety of life events were associated with the onset of different psychosomatic disorders. Bereavement was the relevant factor in a proportion of all patients, and an equally prevalent and important life situation at the onset was one which was associated with a threat to the security of a loved person. In all groups, family and marital problems, sexual conflicts, sudden traumatic experiences, work problems, financial difficulties, and various conflict situations occurred in a proportion of patients. Therefore, although these
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
conditions were relevant in some patients, there was no evidence of any specificity of life events for each form of psychosomatic illness. Rees 12 Stress The term ‘stress’ has been used in a variety of ways and has been applied to both external stimuli and environmental conditions and also to the effects such stimuli induced on the organism. The term stress is really an abstraction and is meaningless if the reaction of the organism to potentially damaging conditions is ignored. I propose to use the term stress as any stimulus or change in the external or internal environment of such a degree in terms of strength, intensity or duration as to tax the adaptive capacity of the organism to its limits and which, in certain circumstances, may produce a disorganisation of behaviour, maladaptation or dysfunction which may lead to disease. What may constitute a stress may consist of physical stimuli, infections (bacterial, viral, or fungal) allergic reactions, or may refer to a whole series of stimuli or changes in the social or psychological spheres of life, referred to as psychosocial stresses. The individual’s response to physical or psychosocial stresses will be influenced by genetic and constitutional factors and also by previous experiences, particularly in childhood. The damaging effects of psychosocial stresses will depend not only on the inherent threat, but also on the way the individual perceives and appraises the significance of the potentially challenging event, and the degree of damage resulting will be influenced by the way with which he copes with the stress, and whether he utilises various ego defences, such as denial, displacement, withdrawal, etc. The response will also be influenced by the cumulative effects of preceding psychosocial or physical stresses and by the existing physical and emotional state of the organism. Similarly, in some women who suffer from the premenstrual syndrome, reactions during this vulnerable time to a variety of stresses and problems are much greater than at other times during the menstrual cycle. Modifying the internal environment in these patients by hormonal means can ameliorate the degree of response to environmental and psychosocial stresses. Changes and mechanisms in reactions to psychosocial stresses involve emotions, arousal, perceptions and coping mechanisms. They may also involve endocrine processes, sympatheticoadrenal medullary, adrenocortical, thyroid activity, lymphatic and immunoreactive processes and other physiological changes. Thus, psychosocial stresses acting on the individual give rise to bodily changes involving the hypothalamic pituitary control of the adrenal cortex and medulla, the thyroid and other endocrine functions, and also a variety of biochemical and physiological changes which may constitute conditions which are conducive to the development of disease. Furthermore, changes in auto-nomic functioning and in the functions of the musculo-skeletal system can also A Reappraisal of Some Psychosomatic Concepts 13 play relevant and even dominant parts in the development of manifestations of different diseases. There is now well-established evidence that bereavement is followed by a tendency to increased morbiidity and mortality. The power of bereavement in affecting morbidity and mortality will be influenced by the way the person deals with his grief. It may be a normal grief reaction of limited duration which the patient satisfactorily works through with minimal damage. It may result in feelings of hopelessness and helplessness which many authorities have found to be important factors at the onset of many diseases. The damaging factors may not only lead to various
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
psychosomatic disorders, but also to physical or psychiatric illnesses, particularly if bereavement is not satisfactorily worked through. Family Influences Many psychosomatic disorders show a familial incidence. This may be due to a number of different factors including heredity, learning patterns of response from other afflicted members of the family or family influences producing emotional changes and feelings of insecurity. Studies, including my own, of asthmatic families reveal that no single pattern of family relationship exists. Mothers may be (1) over-protective, over-solicitous and over-anxious; (2) perfectionistic and over-ambitious for the child; (3) overtly dominant, rejecting or punitive, or (4) consistently helpful, supporting, accepting and from every point of view satisfactory for the emotional development of the child. A group of 170 asthmatic children were compared with a control group of 160 children of similar age, sex and social status. The asthmatic group had a much higher prevalence of parental attitudes classified as over-protective, perfectionistic and rejecting compared with the control group. Comparing asthmatic patients subjected to what were deemed to be satisfactory parental attitudes with those with unsatisfactory parental attitudes, it was found that the asthmatic group with unsatisfactory parental attitudes had a statistically significantly higher prevalence of individuals with traits rated as somewhat or very unstable, very meek, and somewhat or very sensitive and a greater frequency with which psychological factors precipitated attacks. 75% of maternal over-protective attitudes developed prior to the onset of asthma, and in those who developed these attitudes subsequently to the onset of asthma, 20% were considered to be mainly a reaction to the child’s asthma. The importance of faulty parental attitudes is attested by the marked improvement which occurs in the child when the parent, after psychotherapeutic guidance, is able to improve her attitude and mode of upbringing of the child. Certain parental attitudes are, therefore, of importance in producing conditions conducive to the precipitation of attacks of asthma but no one pattern of relationship is necessary or sufficient in the causation of the disorder. Rees 14 Aetiology There are innumerable possible causes to any event including an illness. As clinicians, we are concerned with the ascertainment and assessment of factors which are likely to be causal and relevant in the disorder, and we are particularly interested in any factors which lend themselves to modification or control as these will determine the feasibility of applying effective treatment and prophylaxis. Some causes are necessary or essential because without them the disorder could not develop. Other causes, although not necessary or essential, are sufficient causes because they enable the essential cause to be manifested in disease at a particular time. Necessary or essential causes are not always sufficient. Similarly, sufficient causes are not always necessary. Causes may also be classified into predisposing, initiating, sustaining and those which govern the termination of the illness. Predisposing factors include genetic and constitutional influences, im-munological reactions, hormonal changes, and biochemical and physiological processes. They may have their origin in past experiences or take the form of socio-cultural influences which may be both predisposing as well as precipitating factors. Another important predisposing factor is personality. It is clear that a multiplicity of causes operate in predisposition to any disease. It may also be concluded that psychological factors alone do not predispose to a disease, and no disease will develop in a
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/17/2019 1:56:52 PM
person predisposed to it unless the necessary causative factors are present. It is also clear that more persons are predisposed to a disease than actually develop it. There is now general agreement that the factors governing the onset of the disease as well as those controlling its course and outcome are always multiple. Homogeneity versus Heterogeneity The belief that various psychosomatic disorders are homogeneous has led to the unwarranted application of findings from small selected groups to the disease in general. What is now clear is that the majority of psychosomatic illnesses are, in fact, heterogeneous and that subgroups of illness occur which differ in aetiology, in their pathophysiology and in their pathogenesis. For example, in asthma only 30–50% have been proved to be allergic and in the remainder viral infections and psychological factors operate. Different constellations of aeti-ological factors and different pathophysiological mechanisms can produce the same disorder. A Reappraisal of Some Psychosomatic Concepts 15 Relationship between Psychiatric and Psychosomatic Disorders One of the hypotheses which has been put forward for many years is that there tends to be a reciprocal relationship between the manifestations of neuroses or psychoses and psychosomatic disorders. In other words when the psychosomatic disorder is being clinically manifested, the neurosis or psychosis tends to be in abeyance. In my observations of over 2,000 patients, I find that this relationship does occur, but this is quite exceptional. It is much more common for neurotic symptomatology or even manifestations of severe psychiatric illness, like depression, to vary concomitantly with the psychosomatic disorder. My studies are in agreement with those of Leigh and Marley (1976) and show a positive correlation between neurotic symptoms and psychosomatic disorders which tend to display a higher prevalence than corresponding control groups. Disorder of Regulation Many, if not all, psychosomatic disorders can be regarded as disorders of regulation, for example, in asthma the regulation of the patency of the bronchial tree is altered in the form of a tendency to broncho-constriction. Patency of the bronchi is usually maintained by a balance between Ø-adrenergic sympathetic mechanisms tending to cause dilation and α-adrenergic sympathetic and cholin-ergic mechanisms producing constriction. The regulatory mechanisms are mediated by cyclic nucleotides and a shift in balance of their regulatory mechanisms would produce the bronchoconstriction tendency. Increased levels of cyclic GMP and decreased levels of cyclic AMP would produce a tendency to bronchoconstriction. It is on this tendency to bronchoconstriction that reflex neural mechanisms and the chemical mediators of allergic, infective, and psychological factors operate in producing asthmatic attacks. Despite the claims of immunologists that the release of chemical mediators of allergen-IgE antibody interactions are sufficient to produce bronchoconstriction, it has been shown that the immediate form of hypersensitivity, and also in experimental asthma in animals, bronchospasm and hyperventilation are mediated by vagal reflexes. Karczewski and Widdicombe (1969) showed that the intravenous injection of antigen into passively sensitised rabbits produced bronchoconstriction and hyperventilation. Cooling the cervical vagus inhibited these effects, and cutting the vagi prevented them. Similarly, Gold et al. (1972) demonstrated that the exposure of dogs to allergens to which they were sensitive raised airways resistance which could be prevented by afferent or efferent vagal blockade. Rees
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16 Somatopsychic Effects The problem which has faced researchers in the field of psychosomatic medicine is to what extent the psychological correlate of psychosomatic disorders may be a consequence of the disorder rather than the predisposing or contributory factor. There is no doubt that somatopsychic sequences of events are very important in influencing the degree of suffering and disability experienced by the patient and also in influencing the duration and the outcome of the illness. Studies I have carried out on over 800 asthmatics, comparing the prevalence of neurotic symptoms according to the duration of the illness, revealed, although there are significantly more frequent neurotic symptoms in the earlier stages of the illness than in the control groups, the longer the duration of the illness the greater is the prevalence of neurotic symptomatology. A carefully planned study on the relationships between breathlessness and anxiety in asthma and bronchitis were carried out in my hospital by Oswald et al. (1970). All categories of patients, whether suffering from asthma, bronchitis, or both, showed a greater tendency towards neuroticism, anxiety and introversion than normal control groups and neuroticism and anxiety increased with increasing respiratory disability. These studies indicate the importance of taking into account not only psychosomatic sequences of events, which are of course of paramount importance in the aetiology of psychosomatic disorders, but also paying due attention to somatopsychic reactions which are of vital importance in management and rehabilitation of patients and form the basis of liaison psychiatry. Conclusions Multifactorial causation is the rule in psychosomatic disorders with interaction and interplay between many forces rather than the operation of a single specific cause. A dynamic unifying concept of psychosomatic disorders would take into account such interaction of multiple forces in terms of adaptation to external forces and changes on the internal milieu to maintain homeostasis, a prerequisite for well being and health. Disease is characterised by a failure of adaptation and in the last analysis is a failure of homeostasi.s. Adaptive failure occurs when external forces and internal changes overwhelm the adaptive capacity of the organism. This can occur when the external events are severe and prolonged, or A Reappraisal of Some Psychosomatic Concepts 17 cannot be changed or avoided, or when the person’s adaptive capacity is limited by genetic, constitutional, physiological or psychological factors. Homeostasis is governed by regulating forces which may be physio-chemical, enzymatic, biochemical, endocrinal, autonomic and musculo-skeletal. The control of as many of the interacting causative factors as possible and the elimination or prevention of vicious circles interplaying between such factors appears the most effective means of helping our patients. References Alexander, F.: Psychosomatic medicine (Norton, New York 1950). Dunbar, H.F.: Psychosomatic diagnosis (Hoeber, New York 1943). Gold, W.M.; Kessler, G.R., and Yu, D.Y.C.: Role of vagus nerves in experimental asthma in allergic dogs. J. appl. Physiol. 33: 719 (1972). Halliday, J.L.: Psychological medicine (Norton, London 1948). Leigh, A.D. and Marley, E.: Bronchial asthma. Genetic, population and psychiatric studies (Pergamon, Oxford 1976). Linford Rees, W.: The significance of parental attitudes in childhood asthma. J. psychosom.
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Res. 7: 181–190(1963). Linford Rees, W.: The importance of psychological, allergic and infective factors in childhood asthma. J. Psychosom. Res. 7: 253–262 (1964). Linford Rees, W.: Trends and issues in psychosomatic medicine. Proc. 4th Wld Congr. Psychiat. Int. Congr. No. 150, pp. 563–565 (Excerpta Medica, Amsterdam 1966). Linford Rees, W.: A controlled epidemiological study of the role of psychological factors in migraine. Archs Neurobiol. 37: 243–251 (1974). Linford Rees, W.: Stress, distress and disease. Br. J. Psychol. 128: 3–18 (1976). Karczewski, W. and Widdicombe, J.G.: The role of the vagus nerves in the respiratory and circulatory reactions to anaphylaxis in rabbits. J. Physiol. 201: 293 (1969). Oswald, N.C.; Waller, R.E., and Drinkwater, J.: Relationship between breathlessness and anxiety in asthma and bronchitis. A comparative study. Br. med. J. it: 14–17 (1970).
