Proc. 4th Congr. Int. College Psychosom. Med., Kyoto 1977 Psychother. Psychosom. 31: 128-132 (1979)
Hebiatric Psychosomatic Medicine Mauricio Knobel Department of Psychological Medicine and Psychiatry, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas
Abstract. Adolescent diseases should not be considered as something similar to infan tile pathology or adult sicknesses. Special consideration must be given to the adolescent as such, taking into account the characteristics of adolescents as described in the ‘Normal Adolescence Syndrome’. Symptom formation follows the same pattern as described else where for children, adolescents and adults, but with very special differences in this stage of human development. Hysterical, hypochondriacal and psychotic types of psychosomatic illnesses can be described with the qualification of ‘adolescent type’. Hebiatric medicine must be the specialized approach to illnesses in this developmental stage and must define its study object: the adolescent. Interviewing, clinical examination, diagnosis treatment and prognosis are of a specialized kind and the psychosomatic approach is also different. There are some more typical hebiatric pathologies that must be considered properly.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Adolescence continues to be a puzzling phenomenon in the scientific field. The literature on the subject is constantly increasing, but the concepts are being repeated. The words change, as seen in the adolescent’s dictum, ‘We must change, but making sure that nothing will really change’. Medicine itself follows the same pattern, ‘We must consider the adolescent pathology’. Who? The general practitioner? The pediatrician? Or whoever may have an adolescent run to him for consultation? In a small survey 1 performed several years ago in different countries, I found that in medical practice there is no room for adolescents. The pediatric wards in general accepted children up to 12 or 13 years of age. The ‘other’ wards accepted only adults and occasionally a 16- or 17-year-old who either needed urgent hospital treatment or was a case of ‘scientific interest’. Nobody talks to the adolescents, most are afraid of them. They want them neither in the hospital wards nor in the outpatient departments because they are ‘troublesome’ and ‘never have really anything’. It is as if it were necessary to have a tumor, neurological defect or ‘serious’ diseases in order to deserve some sort of therapy.
129
I would like to put forward the questions, where does a sick adolescent obtain true medical assistance? And, who will provide for this type of assistance? The pediatrician would seem the most qualified professional to deal with this problem, however, to my understanding this is just looking for somebody who for mere chronological practice is apparently near the problem. Many adolescent sicknesses are like the adult except that the sick person is not an adult and, thus, is a different person from a psychosomatic point of view. A new field of medicine is now starting to be developed. ‘Hebiatric Medi cine’ is a true speciality with its own study object, the adolescent. The great French scholar of adolescence, Debesse (1961), stated that ‘Hebelogy’ started in the thirties with the study o f ‘diaries’, intimate confessions to oneself (but to me with a clear need to communicate with others and especially with parents); application of all kinds of psychological tests trying to ‘know’ how the adoles cent ‘really is’; first experiences with psychoanalytic therapy with adolescents; the most serious and scientific study of ‘juvenile delinquency’; and some new and specialized pedagogic methods with adolescents. It is my firm conviction that we are now in a position to claim as a medical specialty, ‘hebiatric medicine’ with its own well-trained specialist, the hebiatrician. He must be trained in pediatrics and have a profound knowledge of adolescent psychology and psychopathology. As the pediatrician he must know what are ‘normal adolescent crises’ and differentiate them from true pathological entities. We must be aware that even a ‘clinical history’ has its special difficulties with adolescents. The adolescent truly belongs to what may be called a ‘sub culture’ and at times a ‘counterculture’ that must be taken into consideration since the field of hebiatric medicine is the most notorious expression of psycho somatic medicine. That is why I state that we must emphasize, running the risk of a tautologic statement, that the professional working as an hebiatrician can be nothing more than a specialist in ‘psychosomatic hebiatrics’. It would sound ridiculous hearing a physician speaking to an adolescent in an adult manner or as with a young child. In addition the doctor must know the adolescents’ slang in his own culture if he wants to initiate a doctor-patient relationship. Language patterns are so important that the psychological studies performed in this field must be integrated into the practice of a ‘Hebiatric Psychosomatic Medicine’ (Nelsen and Rosenbaum, 1975). The problem of the ‘counterculture’ is more of a sociological nature but the hebiatrician must be aware of it (Cross and Lansing Pruyn, 1973). From psychosomatic practice we know how culture influences illnesses from their onset, during its course and its final resolution or ‘exit’. There is no doubt that
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Hebiatric Psychosomatic Medicine
130
the adolescent lives in a different and very special world. The hebiatrician must become acquainted with it if he wants to know whether he is facing psycho logical reactions, somatizations, psychotic or neurotic traits and perhaps parti cular social problems. If he wishes to act as a physician he needs to have an holistic medical view of his patient. The critical phase of adolescence is not only due to the puberal phenom enon but to the fact that with it a whole psychosocial change takes place. As the most regressive, nondiscriminated part of the personality, which we may call the ‘psychotic’ or ‘sincretic’ part (Bion, 1957; Bleger, 1967), breaks the splitting barrier of the ‘normal’ or ‘neurotic’ part of the personality; ambiguity, con fusion, and a real fight for adjusting and identifying oneself begin. It is not easy for the adolescent nor it is easy for the adult to understand what is going on. According to my experience it is possible to speak of a ‘normal adolescence syndrome’, in which we must recognize true normal traits of behavior that, if unrecognized, can be easily labeled as pathological (Aberastury and Knobel, \916\ Knobel, 1968). During this adolescent process we may see what can be called ‘psychotic traits’ of personality. They are the result of the invasion of parts of the indiscriminated structure of the personality. I consider this a typical adolescent phenomenon. At that moment the individual is ambiguous; looks confused (but he is not); views reality from another, different vertex of life; and at times, very momentarily, may feel depersonalized. He soon recovers and is able to go on working, studying or just playing around with his group mates. The whole process involves a difficult mourning process if we look at it from a psychodynamic point of view. There is a threefold mourning process which leads to different kinds of behavioral manifestations: (1) mourning for the infantile body leading to the phenomenon of intellectualization on one side and to physical acting-out on another; (2) mourning for the infantile identity and role leading toward a psychopathic-like handling of affection and love, and (3) mourning for the childhood parents leading toward a distorted perception of reality with feelings of being displaced, abandoned and finding society as a whole as unjust {Abera stury and Knobel, 1976; Aberastury et al, 1972). That is why adolescence cannot be handled by those who do not know his clinical, psychological, and social reality. It is easy to get involved with the adolescent social problems. That is why I think that we can follow Caplan's (1974) ideas on ‘support systems’ and think that the adolescent will naturally seek his support systems in his peer group
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Knobel
Hebiatric Psychosomatic Medicine
131
which will enhance his ego (through a group-ego), will favor family separation in a developmental process leading to a healthier adult identity. The ‘support systems’ may be natural or artificially created. The task of the hebiatrician who understands the problem is not to take the adolescent away from his group, but to be able to create a more stable and reliable support system within the family. Adolescent illnesses will be better treated avoiding unnecessary infantile regression while fostering new support systems or strengthening the family as a nondemanding support system. If this factor is not considered the family will strengthen the adult-child relationship and interfere in the whole adolescent process, i.e., fixation of the normal adolescent syndrome as well as not allowing for the working-through of the mourning for childhood dépendance and ties to childhood parents. Hebiatric diagnosis is a psychosomatic task. That means, all factors shall be considered and a holistic approach to whatever problem must be taken. No preconceived, political opinions. None of ideologic preconceptions. Rather, in tegrated knowledge serving the adolescent, his family and society. The problem is that we now have enough tools to ask ourselves if the adolescent is sick or if his clinical picture corresponds to the ‘normal adolescent syndrome’ or to a failure in working-through his mourning processes or to a breakdown of one of his support systems, etc. That does not mean noninterven tion, but rather specialized, well-documented intervention. It is necessary to remain carefully looking for ‘normality’. There are also ‘normal somatizations’ in adolescence. Pains and aches of varied nature, occasional headaches and diz ziness, spleepiness and some dysmetric movements are normal somatic mani festations during adolescence; if they do not last long enough to require more careful examination. I spoke elsewhere on the hypochondriac, the hysteric and the psychotic types of somatization (Knobel, 1972,1974). We need specialists in adolescent pathology and psychosomatic hebiatrics. This is not just another name. It is the establishment of a clear-cut ideology that adolescents can be treated properly and that we must have well-trained profes sionals who will be able to perform the task. We have too much retoric and too little clinical practice. Let us go into a field which is calling for us as the future calls the adolescence.
Aberastury, A. and Knobel, M.: La adolescencia normal; 5th ed. (Paidos, Buenos Aires 1976).
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
References
Knobel
132
Mauricio Knobel, Department of Psychological Medicine and Psychiatry, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Rua José Theodoro de Lima 44 (Cambui), 13.100, Campinas, S.P. (Brazil)
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Aberastury, A.; Knobel, M., and Rosenthal, G.: Mourning as a way to maturity: thinking in normal and psychopathic adolescents. Psychoanal. Forum 4: 100-134 (1972). Bion, W.R.: Differentiation of the psychotic from the non-psychotic personalities. Int. J. Psycho-Analysis 38: 266-270 (1957). Bleger, J.: Simbiosis y ambigüedad. Estudio psicoanalítico (Paidos, Buenos Aires 1967). Caplan, G.: Support systems and community mental health, pp. 5 - 6 (Behavioral Publi cations, New York 1974). Cross, H.J. and Lansing Pruyn, E.: Youth and the counterculture; in Adams, Understanding adolescence. Current developments in adolescent psychology, pp. 339-374 (Allyn and Bacon, Boston 1973). Debesse, M.: Como estudiar a los adolescentes (Nova, Buenos Aires 1961). Knobel, M.: Psychotherapy and adolescence; in Riess, New directions in mental health, pp. 17-37 (Gruñe & Stratton, New York 1968). Knobel, M.: Patología psicosomática en la adolescencia. Minerva Psiquiát. Argent. 1: 51-58 (1972). Knobel, M.: Abnormality in normal development. A concept of symptom formation in childhood. Psychothcr. Psychosom. 23: 35-43 (1974). Nelsen, E.A. and Rosenbaum, E.: Language patterns within the youth subculture: develop ment of slang vocabularies, in Grinder, Studies in adolescence; 3rd ed., pp. 273-285 (Macmillan, New York 1975).
Hebiatric Psychosomatic Medicine Mauricio Knobel Department of Psychological Medicine and Psychiatry, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas
Abstract. Adolescent diseases should not be considered as something similar to infan tile pathology or adult sicknesses. Special consideration must be given to the adolescent as such, taking into account the characteristics of adolescents as described in the ‘Normal Adolescence Syndrome’. Symptom formation follows the same pattern as described else where for children, adolescents and adults, but with very special differences in this stage of human development. Hysterical, hypochondriacal and psychotic types of psychosomatic illnesses can be described with the qualification of ‘adolescent type’. Hebiatric medicine must be the specialized approach to illnesses in this developmental stage and must define its study object: the adolescent. Interviewing, clinical examination, diagnosis treatment and prognosis are of a specialized kind and the psychosomatic approach is also different. There are some more typical hebiatric pathologies that must be considered properly.
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Adolescence continues to be a puzzling phenomenon in the scientific field. The literature on the subject is constantly increasing, but the concepts are being repeated. The words change, as seen in the adolescent’s dictum, ‘We must change, but making sure that nothing will really change’. Medicine itself follows the same pattern, ‘We must consider the adolescent pathology’. Who? The general practitioner? The pediatrician? Or whoever may have an adolescent run to him for consultation? In a small survey 1 performed several years ago in different countries, I found that in medical practice there is no room for adolescents. The pediatric wards in general accepted children up to 12 or 13 years of age. The ‘other’ wards accepted only adults and occasionally a 16- or 17-year-old who either needed urgent hospital treatment or was a case of ‘scientific interest’. Nobody talks to the adolescents, most are afraid of them. They want them neither in the hospital wards nor in the outpatient departments because they are ‘troublesome’ and ‘never have really anything’. It is as if it were necessary to have a tumor, neurological defect or ‘serious’ diseases in order to deserve some sort of therapy.
129
I would like to put forward the questions, where does a sick adolescent obtain true medical assistance? And, who will provide for this type of assistance? The pediatrician would seem the most qualified professional to deal with this problem, however, to my understanding this is just looking for somebody who for mere chronological practice is apparently near the problem. Many adolescent sicknesses are like the adult except that the sick person is not an adult and, thus, is a different person from a psychosomatic point of view. A new field of medicine is now starting to be developed. ‘Hebiatric Medi cine’ is a true speciality with its own study object, the adolescent. The great French scholar of adolescence, Debesse (1961), stated that ‘Hebelogy’ started in the thirties with the study o f ‘diaries’, intimate confessions to oneself (but to me with a clear need to communicate with others and especially with parents); application of all kinds of psychological tests trying to ‘know’ how the adoles cent ‘really is’; first experiences with psychoanalytic therapy with adolescents; the most serious and scientific study of ‘juvenile delinquency’; and some new and specialized pedagogic methods with adolescents. It is my firm conviction that we are now in a position to claim as a medical specialty, ‘hebiatric medicine’ with its own well-trained specialist, the hebiatrician. He must be trained in pediatrics and have a profound knowledge of adolescent psychology and psychopathology. As the pediatrician he must know what are ‘normal adolescent crises’ and differentiate them from true pathological entities. We must be aware that even a ‘clinical history’ has its special difficulties with adolescents. The adolescent truly belongs to what may be called a ‘sub culture’ and at times a ‘counterculture’ that must be taken into consideration since the field of hebiatric medicine is the most notorious expression of psycho somatic medicine. That is why I state that we must emphasize, running the risk of a tautologic statement, that the professional working as an hebiatrician can be nothing more than a specialist in ‘psychosomatic hebiatrics’. It would sound ridiculous hearing a physician speaking to an adolescent in an adult manner or as with a young child. In addition the doctor must know the adolescents’ slang in his own culture if he wants to initiate a doctor-patient relationship. Language patterns are so important that the psychological studies performed in this field must be integrated into the practice of a ‘Hebiatric Psychosomatic Medicine’ (Nelsen and Rosenbaum, 1975). The problem of the ‘counterculture’ is more of a sociological nature but the hebiatrician must be aware of it (Cross and Lansing Pruyn, 1973). From psychosomatic practice we know how culture influences illnesses from their onset, during its course and its final resolution or ‘exit’. There is no doubt that
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Hebiatric Psychosomatic Medicine
130
the adolescent lives in a different and very special world. The hebiatrician must become acquainted with it if he wants to know whether he is facing psycho logical reactions, somatizations, psychotic or neurotic traits and perhaps parti cular social problems. If he wishes to act as a physician he needs to have an holistic medical view of his patient. The critical phase of adolescence is not only due to the puberal phenom enon but to the fact that with it a whole psychosocial change takes place. As the most regressive, nondiscriminated part of the personality, which we may call the ‘psychotic’ or ‘sincretic’ part (Bion, 1957; Bleger, 1967), breaks the splitting barrier of the ‘normal’ or ‘neurotic’ part of the personality; ambiguity, con fusion, and a real fight for adjusting and identifying oneself begin. It is not easy for the adolescent nor it is easy for the adult to understand what is going on. According to my experience it is possible to speak of a ‘normal adolescence syndrome’, in which we must recognize true normal traits of behavior that, if unrecognized, can be easily labeled as pathological (Aberastury and Knobel, \916\ Knobel, 1968). During this adolescent process we may see what can be called ‘psychotic traits’ of personality. They are the result of the invasion of parts of the indiscriminated structure of the personality. I consider this a typical adolescent phenomenon. At that moment the individual is ambiguous; looks confused (but he is not); views reality from another, different vertex of life; and at times, very momentarily, may feel depersonalized. He soon recovers and is able to go on working, studying or just playing around with his group mates. The whole process involves a difficult mourning process if we look at it from a psychodynamic point of view. There is a threefold mourning process which leads to different kinds of behavioral manifestations: (1) mourning for the infantile body leading to the phenomenon of intellectualization on one side and to physical acting-out on another; (2) mourning for the infantile identity and role leading toward a psychopathic-like handling of affection and love, and (3) mourning for the childhood parents leading toward a distorted perception of reality with feelings of being displaced, abandoned and finding society as a whole as unjust {Abera stury and Knobel, 1976; Aberastury et al, 1972). That is why adolescence cannot be handled by those who do not know his clinical, psychological, and social reality. It is easy to get involved with the adolescent social problems. That is why I think that we can follow Caplan's (1974) ideas on ‘support systems’ and think that the adolescent will naturally seek his support systems in his peer group
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Knobel
Hebiatric Psychosomatic Medicine
131
which will enhance his ego (through a group-ego), will favor family separation in a developmental process leading to a healthier adult identity. The ‘support systems’ may be natural or artificially created. The task of the hebiatrician who understands the problem is not to take the adolescent away from his group, but to be able to create a more stable and reliable support system within the family. Adolescent illnesses will be better treated avoiding unnecessary infantile regression while fostering new support systems or strengthening the family as a nondemanding support system. If this factor is not considered the family will strengthen the adult-child relationship and interfere in the whole adolescent process, i.e., fixation of the normal adolescent syndrome as well as not allowing for the working-through of the mourning for childhood dépendance and ties to childhood parents. Hebiatric diagnosis is a psychosomatic task. That means, all factors shall be considered and a holistic approach to whatever problem must be taken. No preconceived, political opinions. None of ideologic preconceptions. Rather, in tegrated knowledge serving the adolescent, his family and society. The problem is that we now have enough tools to ask ourselves if the adolescent is sick or if his clinical picture corresponds to the ‘normal adolescent syndrome’ or to a failure in working-through his mourning processes or to a breakdown of one of his support systems, etc. That does not mean noninterven tion, but rather specialized, well-documented intervention. It is necessary to remain carefully looking for ‘normality’. There are also ‘normal somatizations’ in adolescence. Pains and aches of varied nature, occasional headaches and diz ziness, spleepiness and some dysmetric movements are normal somatic mani festations during adolescence; if they do not last long enough to require more careful examination. I spoke elsewhere on the hypochondriac, the hysteric and the psychotic types of somatization (Knobel, 1972,1974). We need specialists in adolescent pathology and psychosomatic hebiatrics. This is not just another name. It is the establishment of a clear-cut ideology that adolescents can be treated properly and that we must have well-trained profes sionals who will be able to perform the task. We have too much retoric and too little clinical practice. Let us go into a field which is calling for us as the future calls the adolescence.
Aberastury, A. and Knobel, M.: La adolescencia normal; 5th ed. (Paidos, Buenos Aires 1976).
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
References
Knobel
132
Mauricio Knobel, Department of Psychological Medicine and Psychiatry, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Rua José Theodoro de Lima 44 (Cambui), 13.100, Campinas, S.P. (Brazil)
Downloaded by: King's College London 137.73.144.138 - 3/5/2018 8:47:00 PM
Aberastury, A.; Knobel, M., and Rosenthal, G.: Mourning as a way to maturity: thinking in normal and psychopathic adolescents. Psychoanal. Forum 4: 100-134 (1972). Bion, W.R.: Differentiation of the psychotic from the non-psychotic personalities. Int. J. Psycho-Analysis 38: 266-270 (1957). Bleger, J.: Simbiosis y ambigüedad. Estudio psicoanalítico (Paidos, Buenos Aires 1967). Caplan, G.: Support systems and community mental health, pp. 5 - 6 (Behavioral Publi cations, New York 1974). Cross, H.J. and Lansing Pruyn, E.: Youth and the counterculture; in Adams, Understanding adolescence. Current developments in adolescent psychology, pp. 339-374 (Allyn and Bacon, Boston 1973). Debesse, M.: Como estudiar a los adolescentes (Nova, Buenos Aires 1961). Knobel, M.: Psychotherapy and adolescence; in Riess, New directions in mental health, pp. 17-37 (Gruñe & Stratton, New York 1968). Knobel, M.: Patología psicosomática en la adolescencia. Minerva Psiquiát. Argent. 1: 51-58 (1972). Knobel, M.: Abnormality in normal development. A concept of symptom formation in childhood. Psychothcr. Psychosom. 23: 35-43 (1974). Nelsen, E.A. and Rosenbaum, E.: Language patterns within the youth subculture: develop ment of slang vocabularies, in Grinder, Studies in adolescence; 3rd ed., pp. 273-285 (Macmillan, New York 1975).
