PSYCHOANALYSIS AND PSYCHOSOMATICS: A NEW SYNTHESIS GRAEME J. TAYLOR, M.D.*

Although psychoanalysis played an important role in the history of psychosomatic medicine during the first half of the present century, over the past 30 years it has had little impact on the field. Nowadays, it is unusual to find courses on psychosomatic medi­ cine in the training programs of psychoanalytic institutes, and articles reporting psychoanalytic treatments of physically ill pa­ tients are rarely published in the scientific literature. The drifting apart of psychoanalysis and psychosomatics is generally attributed to limitations in the early psychoanalytic theories of bodily disease and to advances in the biological sciences that strengthened physi­ cians’ allegiance to the traditional biomedical model of disease. In this article, I will attempt to restore the importance o f psy­ choanalysis to psychosomatic medicine by showing how some of the developments that have occurred within psychoanalysis over the past two decades can be integrated with new knowledge in developmental biology and the neurosciences and biomedical sci­ ences. In particular, I will focus on the increasing emphasis on affect development and affect regulation (Emde, 1988a; Krystal, 1988), as well as on the growing trend away from Freud’s oneperson exclusively intrapsychic, drive-conflict model toward the two-person, relational models that relate psychopathology to defi­ cits in psychic structure and functions (Mitchell, 1988). I will try to show how a synthesis of these modern psychoanalytic concepts with contemporary psychosomatic theories can provide psychoan­ alysts with a new theoretical model for working with physically ill patients. Let us begin by reviewing briefly the development and limita­ tions of some of the early psychosomatic models of disease that were derived from classical psychoanalysis during the 1940s and 1950s. Presented at the 34th Winter Meeting of the American Academy of Psycho­ analysis, December 1990. ♦Professor of Psychiatry, University of Tbronto; Staff Psychiatrist, Mount Sinai Hospital, Toronto, Ontario. Journal of The American Academy of Psychoanalysis, 20(2), 251-275, 1992 © 1992 The American Academy o f Psychoanalysis

252 TAYLOR

EARLY PSYCHOSOMATIC MODELS OF DISEASE In tracing the development of the early psychosomatic models of disease, it is useful to recall the important but frequently over­ looked distinction that Freud made in 1898 when he categorized neurotic disorders into two types—the actual neuroses and the psychoneuroses. Freud (1895) believed that the actual neuroses (anxiety neurosis and neurasthenia; hypochondriasis was added to the list in 1914) were not psychical in origin but caused by instinc­ tual tensions due to a lack of sexual satisfaction. Viewed as somat­ ic in origin, the actual neuroses were thought to have no primary psychological meaning and therefore to be unamenable to psycho­ analytic therapy. The psychoneuroses, on the other hand, were regarded as originating in psychic conflict over unconscious im­ pulses and fantasies from childhood and, as such, were treatable with psychoanalytic therapy. After Freud replaced his original “toxic” theory o f anxiety with his theory of signal anxiety in 1926, his concept of actual neurosis was almost completely discarded as his followers concluded that patients suffering from the bodily symptoms associated with panic attacks, neurasthenia, or hypochondriasis would ultimately reveal evidence of intrapsychic conflicts (Waelder, 1967). Apart from Glover (1939) and MacAlpine (1954), the psychoanalytic psychosomaticists of the 1940s and 1950s largely ignored Freud’s concept of the actual neuroses, and instead adopted his drive-conflict mod­ el of psychopathology, which they enthusiastically applied to pa­ tients suffering from bronchial asthma, essential hypertension, peptic ulcer, ulcerative colitis, thyrotoxicosis, rheumatoid arthritis, or neurodermatitis. These seven diseases subsequently came to be referred to as the “classical” psychosomatic diseases. As I have detailed in another contribution (Thylor, 1987), the early psychoanalytic psychosomaticists disagreed as to whether the symptoms of the psychosomatic diseases have primary Symbolic meaning, comparable to the symptoms of conversion hysteria (compare, for example, the specificity theory of Alexander [1950] with'the pregenital conversion theory of Deutsch [1959]), but the different theoretical disease models they developed were all based on the notion that intrapsychic (especially preoedipal) conflicts, and the emotions associated with them, play a central role in the pathogenesis of disease. Biological factors were also given an im­ portant role in these early psychosomatic models, but the models

PSYCHOANALYSIS AND PSYCHOSOMATICS 253

were based on a linear conception of causality (the so-called “mys­ terious leap from the mind to the body”) and psychoanalytic inter­ est was mainly in the psychogenesis of disease. These theoretical conceptions led to a therapeutic approach to physically ill patients that was virtually identical to that employed with psychoneurotic patients, namely, the interpretation and work­ ing through the drive-related conflicts. The outcome of this ap­ proach, however, was generally disappointing. While some patients responded favorably with a remission of their disease, others showed either no change or a worsening of physical symptoms and were found to benefit more from supportive psychotherapy and/ or behavioral interventions (Karush et al., 1977; Kellner, 1975; Lipowski, 1977; Reiser, 1978; Sifneos, 1975). These poor treat­ ment results suggested serious limitations to the conflict-based psychosomatic models of disease. The well-known investigations of Alexander and his associates (1968) provided some empirical support for an association between specific intrapsychic conflicts and specific psychosomatic diseases, but this support was seriously weakened by the subsequent discovery that many of the diseases that were investigated are heterogeneous, both physiologically and psychologically (Magni et al., 1986; Weiner, 1977). More recently, a meta-analytic review of published studies on the personality correlates of five diseases (bronchial asthma, pep­ tic ulcer, headache, rheumatoid arthritis, and coronary heart dis­ ease) found moderate support for the construct of a “disease-prone personality” that involves the affects of depression, anger/hostility, and anxiety (Friedman and Booth-Kewley, 1987). However, as there is yet no evidence that these affects are generated by intrapsy­ chic conflicts, alternative explanations for their origin must be considered. For example, as I have suggested previously (Taylor, 1992), high levels of anger and hostility, which are now regarded as the critical components of the Type A coronary-prone behavior pattern (Dembroski et al., 1985), might be explained by an im­ paired ego capacity for containing and modulating narcissistic rage and for tolerating frustration, rather than by conflicts over unconscious drive-related wishes. This speculation brings us to a consideration of the psychoana­ lytic view of affect development and affect regulation, and to recent psychosomatic research showing an association between somatic disorders and deficits in the cognitive processing of emo­ tions.

254 TAYLOR

AFFECT REGULATION IN HEALTH, ILLNESS, AND DISEASE In choosing to focus on unconscious conflicts as a risk factor for disease, the early psychosomaticists largely ignored the theo­ retical problems involved in emotions. They merely adopted the prevailing classical psychoanalytic view that emotions are drive derivatives that create bodily tensions and adverse physiological changes unless they are discharged regularly (Sandler, 1972). Dur­ ing the past two decades, however, clinical observations together with research in developmental psychology have led to important revisions in the psychoanalytic theory of affect development and affect regulation. While there is no general consensus about the definition of emotion, most contemporary theorists in psychoanalysis and psy­ chology agree with Freud’s (and Darwin’s) premise that emotions are innate biological phenomena that play a vital role in the exist­ ence and survival of living organisms (Buck, 1988; Emde, 1988a; Krystal, 1988; Schwartz, 1987; Thompson, 1988). Emotional arousal evokes not only the bodily sensations associated with acti­ vation of the autonomic nervous system, but also spontaneous motor behaviors such as facial expressions, gestures, and changes in posture and tone of voice (Ekman and Friesen, 1982; Thomp­ son, 1988). These physical signs of emotion appear to be prepro­ grammed genetically and based upon subcortical and paleocortical systems that tend to be right-lateralized in the brain (Buck, 1988; Schwartz, 1987). The highly evolved neocortex in the human organism adds a psychological dimension to emotions as this allows them to be processed cognitively (primarily in'the symbolism of language) and experienced subjectively as feelings. This subjective component, which is generally referred to as affects (Moore and Fine, 1968), allows humans to evaluate their emotional responses to both inter­ nal and external stimuli, and also intentionally to communicate emotions symbolically via language, images, and nonverbal behav­ iors that are learned during childhood and differ from culture to culture (Buck, 1984; Leff, 1977; Thompson, 1988). In addition, the cognitive processing of emotions and mental representation of affective experiences of the self interacting with others foster the creation of memories, fantasies, and dreams, which further help in containing and modulating states of emotional arousal; as these cognitive capacities mature, children generally become less deperi-

PSYCHOANALYSIS AND PSYCHOSOMATICS 255

dent on parents for reducing psychic tension and regulating behav­ ior (Stern, 1985). There are individual differences, however, in the level of aware­ ness of inner states and in the ability to communicate emotions symbolically. Such differences are presumed to reflect variations in the complexity of cognitive schemata and linguistic and other sym­ bolic representations of emotions. This was recognized almost two decades ago by Krystal (1974), who extended an earlier contribu­ tion of Schur (1955) to propose an epigenetic sequence of affect development involving a progressive desomatization, differentia­ tion, and verbalization of emotions as cognitive capacities mature. Lane and Schwartz (1987) recently elaborated this model by inte­ grating psychoanalytic concepts of symbol formation with Piaget’s stages of cognitive development; they conceptualized a develop­ mental sequence of five levels of emotional awareness ranging from a simple awareness of undifferentiated bodily sensations only (Level 1) to an awareness of complex blends of feelings and a capacity to appreciate the emotional experience of others (Level 5). By linking the capacity for experiencing complex affects to ego development and ego functioning, these theorists all departed from the early classical psychoanalytic theory of affect, which emphasized the relation of affects to drives and the economic notion that affects accumulate and need to be “discharged” (Karush, 1989). Modern psychoanalytic theories emphasize the signal, integrative, and communicative functions of affects as well as the cognitive mechanisms involved in their regulation and mod­ ulation (Basch, 1976; Lichtenberg, 1983). While the psychoanalytic theory of affects has been evolving, research in the psychosomatic field has provided mounting evi­ dence that many somatic disorders are associated with emotions that have remained poorly differentiated and unregulated because of deficits in the capacity to form affect representations (Ihylor et al., 1991). Deficits in the cognitive processing of emotions among physically ill patients were first reported in 1948 by Ruesch, who regarded this pathology as “the core problem in psychosomatic medicine.” Ruesch’s observations were virtually ignored, however, until the 1970s, when Nemiah and Sifneos (1970; Nemiah et al., 1976) made systematic investigations of the cognitive/affective style of patients with classical psychosomatic diseases and intro. duced the construct of alexithymia. The salient features of this construct are (a) difficulty identifying and describing feelings; (b) difficulty distinguishing between feelings and the somatic concom­

256 TAYLOR

itants of emotional arousal; (c) constricted imaginative processes, as evidenced by a paucity of fantasies; and (d) an externally orient­ ed cognitive style (Thylor et al., 1991). Recent research using mea­ surement-based, construct-validational methodologies has provid­ ed considerable empirical support for the validity of this construct (Acklin and Bernat, 1987; Acklin and Alexander, 1988; Ihylor et al., 1990). Whereas the earlier, conflict-based psychosomatic models were restricted to the seven classical psychosomatic diseases, the alexithymia construct has been associated with a wide variety o f dis­ eases and illnesses including several so-called “functional” medical and psychiatric disorders. These “functional” disorders include hy­ pochondriasis and panic disorder, which Freud (1898, 1914) had originally categorized as actual neuroses. As I have outlined in previous contributions (Taylor, 1992; Ihylor et al., 1991), several investigators have hypothesized that the failure to process emo­ tions cognitively so that they are experienced as conscious feeling states leads to a focusing on and amplification of the somatic component of emotional arousal; this is thought to contribute to the development of hypochondriasis and somatization disorders (Barsky and Klerman, 1983; Lane and Schwartz, 1987). Similarly, the inability to modulate emotions through cognitive processes is thought to contribute to compulsive behaviors aimed at reducing unpleasant emotional tension, such as binge eating and the self­ starvation of anorexia nervosa. In addition, the failure to regulate and modulate distressing emotions at the cognitive level is thought to result in exacerbated physiological responses to stressful situa­ tions, thereby producing conditions conducive to the develop­ ment o f somatic disease (MacLean, 1949; Martin and Pihl, 1985; Papciak et al., 1985). Although research is in its early phases, studies examining the stress response patterns in normal individuals with high or low presence of alexithymic characteristics has provided some evidence that alexithymic persons manifest elevated levels o f sympathetic arousal, as well as a decoupling of the physiological response to stress from the subjective, affective response (Martin and Pihl, 1986; Papciak et al., 1985). There is also accumulating empirical evidence supporting an association between alexithymia and so­ matic illness. For example, investigators in India have demonstrat­ ed a significantly higher prevalence of alexithymia among patients with rheumatoid arthritis and patients with somatoform pain dis­ orders than among healthy control groups matched by age, sex,

PSYCHOANALYSIS AND PSYCHOSOMATICS 257

education, and marital status (Fernandez et al., 1989; Sriram et al., 1987). American investigators have compared four different groups of medical patients (low back pain, gastrointestinal disor­ ders, skin diseases, and migraine headache) with a reference group of nonpatients and obtained significantly higher rates of alexithymia in the somatically ill groups (Acklin and Alexander, 1988). And in our own research, my colleagues and I (Bourke et al., in press) found a prevalence rate of 77.1 % for alexithymia in a sample of women with anorexia nervosa (n = 48), compared with a preva­ lence of only 6.7 % in a control group of healthy women matched by age and education. However, prospective longitudinal studies have yet to be conducted to clarify the direction of causality be­ tween alexithymia and these various medical and psychiatric dis­ orders. While the etiology of alexithymia is not yet known, recent find­ ings from developmental psychology and neurobiology suggest the involvement of early developmental deficiencies as well as varia­ tions in brain organization. As Emde (1988b), Stern (1984), and other developmental psychologists have shown, the capacity to form affect representations and to self-regulate states of emotional arousal is acquired within the context of early social relationships. When the primary caregiver is emotionally unavailable, or when the child is repeatedly subjected to inconsistent responses because of parental “misattunements,” the child is likely to manifest abnor­ malities in affect development (Edgcumbe, 1984; Emde, 1984, 1988a, b; Furman, 1978; Osofsky and Eberhart-Wright, 1988; Stern, 1984, 1985). These abnormalities include emotional con­ striction, reduced playfulness, and a failure to acquire the sense of an “affective self.” As the individual progresses from infancy to childhood, the consistently faulty patterns of affective interchange with the caregiver are presumed to be internalized and to produce faulty internal representations of both self and object that reduce the ability to self-regulate states o f emotional arousal (Emde, 1988a, b). The idea that variations in brain organization might also con­ tribute to alexithymia is supported by Hoppe’s research (1977; IfenHouten et al., 1986) demonstrating a higher level of alexithy­ mia among cerebral commissurotomy patients than in normal con­ trol subjects, and by the recent demonstration o f a deficit in interhemispheric transfer in alexithymic men with posttraumatic stress disorder (Zeitlin et al., 1989). Impaired capacities to express emotion appropriately and/or to perceive the emotional states of

258 TAYLOR

others have been demonstrated also in children and adults with evidence of lesions or other deficits in the right cerebral hemi­ sphere (Weintraub and Mesulam, 1983; Voeller, 1986). More re­ cently, my colleagues and I (Parker et al., in press) investigated a sample of young adults with intact brains and found an associa­ tion between alexithymia and left cerebral lateralization. Let us now consider how other recent developments in psycho­ analysis, especially the trend toward two-person, relational mod­ els, can be integrated with biological research findings and thereby contribute to our understanding of the psychosomatic process. RELATIONSHIPS AS PSYCHOBIOLOGICAL REGULATORS Psychosomatic investigators have studied the influence of inter­ personal relationships on physical health for several decades. Dur­ ing the 1950s and 1960s, for instance, Engel and Schmale (1967, 1972) observed a heightened susceptibility to disease in individuals who were unable to cope with separations and object loss. Such individuals developed a “giving up/given up complex” comprising the depressive affects of helplessness and hopelessness as well as a physiological conservation-withdrawal response that was thought to initiate changes in the autonomic, endocrine, and immune sys­ tems. Later research examining the effects of bereavement on health provided further evidence that the loss of a close relation­ ship can lead to increased morbidity and mortality (Klerman and Izen, 1977). Similar effects on the physical health of infants had been report­ ed during the 1940s by Spitz (1945; Spitz and Wolf, 1946), who observed that institutionalized infants with anaclitic depressions showed an increased susceptibility to infections and other diseases and a high mortality. Although Spitz (1960) appreciated the com­ plex nature of the infant’s dependency on the mother, he attrib­ uted the harmful consequences of maternal separation within the framework of traditional Freudian theory, namely, to the damming up of libidinal and aggressive drives. Following Bowlby’s (1969) observations on attachment behav­ ior, psychoanalysts and psychosomaticists have generally attrib­ uted the infant’s behavioral and physiological responses to separa­ tion to the emotional distress caused by the disruption of a strong social bond with the mother. This formulation is based on the

PSYCHOANALYSIS AND PSYCHOSOMATICS 259

assumptions that the infant’s homeostatic organization is a closed system and that the mental and bodily responses to separation and object loss are causally related. These assumptions have been chal­ lenged during the past decade by research in developmental biolo­ gy, which has shown that social relationships can alter bodily func­ tions independently of their effects on the emotions and on the mind. In a series of studies with rodents and primates, Hofer (1978) and other developmental biologists have demonstrated that hidden within the interactions between infant and mother are a number of sensorimotor processes whereby the mother can regulate aspects of the infant’s biology until the infant’s self-regulating mechanisms mature. Research has identified various “hidden” nutritional, olfactory, tactile, thermal, and vestibular processes whereby the mother “serves as an external regulator of the infant’s behavior, its autonomic physiology, and even the neurochemistry of its matur­ ing brain” (Hofer, 1983a, p. 199). By altering specific components of the animal mother-infant relationship, developmental biolo­ gists have been able to modify the infant’s responses to separation, thereby showing that the responses are caused not by the disrup­ tion of a common mechanism but by the withdrawal of multiple regulatory processes. For instance, the importance of body contact and tactile stimulation was demonstrated by the finding that a fall in the levels of growth hormone and the brain enzyme ornithine decarboxylase in separated rat pups can be prevented by stroking the pups’ skins with a brush (Evoniuk et al., 1979). A 30% reduc­ tion in heart rate following separation can be prevented only by providing the pups with graded amounts of feedings by stomach tube (Hofer, 1978). This effect is mediated by the autonomic and central nervous systems and not via the circulatory system. If the milk is delivered intermittently, in a pattern mimicking the rhythmicity of the normal mother-infant feeding relationship, then it is possible also to prevent the profound sleep disturbance that infant rats develop following premature separation. Further, the body temperature of infant rats, which is determined largely by the body temperature of the mother, has been shown to regulate levels of brain protein, nucleic acids, and catecholamines, all of which are reduced when infants are separated prematurely from their mother (Stone et al., 1976). . There is evidence also that olfactory stimuli are involved in the regulation o f crucial aspects of the attachment behavior of animals (Hofer, 1978). Infant rats, for example, are unable to locate and

260 TAYLOR

become attached to the nipple in the absence of a pheromone secreted from the mother’s areolar glands. The emission of this substance is regulated by the hormone oxytocin (not by its action on milk letdown), which, in turn, is released in the mother rat by suckling. These findings, along with results from other animal studies, provide evidence that the infant’s homeostatic organization is a relatively open system, rather than a closed system as previously thought, and that some of the infant animal’s responses to separa­ tion (especially the more slowly developing responses) are the result of withdrawal of biological regulators previously supplied by the mother-infant interaction rather than “part of the acute emotional response to disruption of attachment” (Hofer, 1983a, p. 199). While it is a long way from the animal laboratory to the human nursery, developmental biologists suspect that similar “hidden” regulatory processes are present also in the human mother-infant relationship. It is well known that the human infant regulates the flow of milk from the lactating mother, since suckling stimulates the release of the letdown hormone oxytocin. In turn, the mother may influence aspects of her infant’s attachment behavior; it has been demonstrated, for instance, that breastfeeding infants re­ spond preferentially to the breast odor from their own mother when paired with the breast odor from an unfamiliar lactating woman (Porter et al., 1988). Through her more obvious interac­ tions, the mother also plays an important role in the entrainment of such biological rhythms as the infant’s sleep/wake cycle and oral instinctual (feeding) cycle (Emde and Robinson, 1979). It appears likely that future research will identify specific stimuli and types of interaction within the human mqther-infant relationship that reg­ ulate or “fíne tune” a variety of other physiological and behavioral systems in the infant. The discovery that infant and mother are connected at the level of biological symbiosis, as well as by an emotional bond, is alter­ ing the traditional psychoanalytic and psychosomatic perspectives on attachment and separation in profound ways (Pipp and Har­ mon, 1987). No longer can the infant’s responses to separation be attributed simply to the breaking o f an attachment bond. Instead, we must view some o f the responses as resulting from the with­ drawal o f the biological and behavioral regulation previously sup­ plied by the mother (Hofer, 1983a). Further, the withdrawal of these “hidden” regulatory processes in early life might alter an individual’s homeostatic organization and thereby influence sus-

PSYCHOANALYSIS AND PSYCHOSOMATICS 261

ceptibility to medical and psychiatric disorders later in life (Hofer, 1983b). Even when mother and infant are together, physiological development in the infant may be modified if the mother is poorly attuned, as with a chronically anxious or depressed mother, who may fail to provide optimal levels of stimulation and arousal mod­ ulation (Field, 1985). The contributions from developmental biology can be integrat­ ed with the interactional models of the early mother-infant rela­ tionship provided by contemporary psychoanalysis and infant ob­ servation research. Self psychology, for example, conceptualizes the symbiotic mother-infant relationship as a self-selfobject unit in which mother and infant function as regulatory selfobjects for one another (Wolf, 1980). While Kohut (1977, 1984) emphasized the tension-regulating and self-esteem regulating functions of selfobjects, Hofer’s contribution indicates that selfobjects can function also as biological regulators via sensorimotor pathways. The psychoanalytic object relations theories of Mahler (1968), Winnicott (1975), and Bowlby (1988) enhance our understanding of how the infant normally progresses from a state of initial depen­ dency on the mother, as an external psychobiological regulator, to a state of relative independence and autonomous functioning. This is accomplished by maturational changes in organ systems and by the process of internalization, whereby the infant initially con­ structs simple cognitive schemata and eventually stable mental rep­ resentations of self and of object and of the pattern of interactions that have developed between them (Stern, 1983). These internal representations are presumed to provide important self-regulatory functions including affect regulation (which I discussed earlier), self-esteem regulation, and self-stimulation (deLissovoy, 1971; Schafer, 1968; Stierlin, 1970). Hofer (1984) and Pipp and Harmon (1987) have suggested that internal representations may function also as biological regulators, much the way the actual sensorimo­ tor interactions with the mother regulate aspects of the infant’s physiology and behavior. The process of internalization, and the emergence and matura­ tion of self-regulatory capacities in the child, are facilitated by the use of a transitional object, which comes gradually to represent the mother symbolically and to provide anxiety-regulating and other functions that previously required her presence (Winnicott, 1953). Initially, however, the transitional object functions merely as a sensation object that provides olfactory, tactile, and kinesthetic sensations that are reminiscent of early body contact with the

262 TAYLOR

mother (Gaddini, 1978; lUstin, 1981). These sensory experiences may also serve regulatory functions comparable to the “hidden” regulatory processes that have been discovered within animal mother-infant relationships. The relevance of these concepts for our work with patients is illustrated by the following brief clinical vignettes. One of my patients, a 21-year-old woman with panic disorder, who did not recall having a transitional object during childhood, discovered that she could abort her morning panic attacks by smelling the bedsheets that contained the residual odor of her husband after he had left for work. Another patient, a 74-year-old woman who developed a recurrence of panic disorder following the sudden death of her husband, found that she could modulate her panic attacks by inhaling the odor from one of her husband’s unwashed pyjama jackets. This woman was markedly alexithymie and was unable to recall dreams or create fantasies; whereas a photograph of her husband provided minimal solace, the tactile and olfactory sensations provided by the pyjama jacket evoked the illusion of his presence. While the fully individuated child no longer depends on regula­ tory interactions with the mother to help maintain homeostasis, self-regulation itself operates through a large number of individu­ ally distinct and hierarchically arranged mechanisms, some of which rely on social relationships and other environmental feed­ back (Hofer, 1984; Peters, 1971). In other words, it appears that we are never completely autonomous, a view shared by Kohut (1984) when he emphasized the regulatory function o f selfobject relationships throughout the entire life cycle. Evidence that social relationships have the potential to influence biological systems in adulthood comes from the observation that young women who live together soon menstruate in synchrony (Graham and McGrew, 1980; McClintock, 1971). This phenome­ non is thought to be mediated by a pheromone (McClintock, 1978; Preti et al., 1986). There is also preliminary evidence that women who are exposed regularly to pheromones from men have more regular menstrual cycles and a higher rate of ovulation than wom­ en who do not have regular physical contact with men (Cutler et al., 1986; Veith et al., 1983). And although the mediating mecha­ nisms remain unknown, research has shown that frequent social interaction among elderly people living in the same apartment building can effect several favorable endocrine and metabolic changes that do not occur in elderly tenants who remain socially

PSYCHOANALYSIS AND PSYCHOSOMATICS 263

isolated (Arnetz et al., 1983). Thus, while healthy adults are essen­ tially self-regulating, some of their biological systems may be more finely tuned by regulatory mechanisms that are “hidden” within their close relationships. PSYCHOBIOLOGICAL DISREGULATION: A NEW PSYCHOSOMATIC MODEL OF ILLNESS AND DISEASE The above synthesis of psychoanalytic relational models and modern theories of affect development with research findings in developmental psychology and developmental biology can be fur­ ther integrated with the work of several contemporary psychosomat­ ic investigators, who have recently proposed a disregulation model of illness and disease (Schwartz, 1983, 1989; Taylor, 1987, 1992; Weiner, 1989). This new, and still evolving, psychosomatic model is based on general systems theory, which conceptualizes the living organism as a continuum of hierarchically arranged subsystems that become more complex as we ascend from cells and organs to indi­ viduals, families, and societies (von Bertalanffy, 1968). An impor­ tant characteristic of systems is the reciprocal regulation that occurs between various subsystems. As Schwartz (1983) explains, “every [living] system is reciprocally regulated not only by its subsystems, but is simultaneously regulated by, and in turn actively regulates, systems in its external environment (of which it is part)” (p. 99). Thus, cells and organs regulate their own and each other’s activities and provide feedback to the brain, which functions as a superordi­ nate regulator by controlling neuronal and hormonal input to the cells and organs. The brain is itself subject to regulation by environ­ mental factors, factors that it can also modify. Recent advances in the neurosciences and biomedical sciences, in particular the discovery of more than 50 neuropeptides, have produced an explosion in knowledge of the complex network of regulatory mechanisms that operate bidirectionally between the brain and the various subsystems of the body (Dinarello and Mier, 1987; Krieger, 1983; Pert et al., 1985). For example, there is now extensive evidence that the neuroendocrine system and the immune system can regulate one another’s functions (Blalock, 1989); the regulatory mechanisms seem to include peptide hormones that are produced by both systems and interact with receptors that are common to the two systems (Smith and Blalock, 1986).

264 TAYLOR

According to this cybernetic model, a transition from health to illness or disease is likely to occur when there are perturbations in one or more components of the feedback loops o f the self-regulating system that lead to changes over time in the rhythmic function­ ing of one or more o f the biological subsystems (Schwartz, 1983, 1989; Ihylor, 1992; Weiner, 1989). Perturbations can arise at any level in the system, from the cellular or subcellular level (as with bacterial and viral infections, sensitivity to allergens, and varia­ tions in the expression of genes), to the psychological or social level (as with intrapsychic conflicts, attachment disruptions, and loss of self-esteem). Because the affected subsystem interacts with other subsystems, several physiological functions may become disregulated and lead to somatic symptoms and, in some instances, also to changes in bodily structure. This disregulation model o f illness and disease differs from pre­ vious psychosomatic models in several important ways. First, the concept of psychogenicity (“the mysterious leap from the mind to the body”) is replaced by a view o f the psyche as one component within a hierarchical arrangement of reciprocally regulating sub­ systems. While intrapsychic conflicts are still regarded as one pos­ sible source of pathogenic emotional states that might affect a person’s health, the emphasis is now on psychic deficits, including deficits in a person’s capacity cognitively to process and regulate emotions. Second, as Weiner (1989) has pointed out, the disregulation model eliminates the distinction between “organic” diseases and “functional” medical illnesses. With the emphasis on the function­ ing of biological systems rather than on the structure of cells and organs, many illnesses and diseases can be reconceptualized as disorders o f regulation that may or may not be associated with physical lesions (Schwartz, 1989; Thylor, 1987). These disorders include migraine headache, fibromyalgia, and irritable bowel syndrome, as well as the “classical” psychosomatic diseases (Moldofsky, 1989; Tilbe and Sullivan, 1990; Weiner, 1977). Finally, the disregulation model also eliminates the traditional distinction between medical disorders and psychiatric disorders, which can now all be viewed psychosomatically. This viewpoint was advanced initially by Grotstein (1986), who proposed a new paradigm for psychiatry and psychoanalysis in which all psycho­ pathology is reformulated as disorders of self-regulation or in­ teractional regulation involving “the failure o f inherent internal control-regulators and/or external object and selfobject modula­

PSYCHOANALYSIS AND PSYCHOSOMATICS 265

tors” (p. 104). Thus, major affective disorders, for example, may be triggered by object losses or by loss of self-esteem, but there is accumulating evidence for a trait vulnerability involving an insta­ bility in one or more neurotransmitter homeostatic regulatory mechanisms (Siever and Davis, 1985). Similarly, panic disorder may be initiated by object loss or by other stressful life events (Faravelli and Pallanti, 1989), but there is evidence also for a genet­ ic predisposition for this disorder involving a brainstem mecha­ nism that can be disregulated by various chemical agents including yohimbine, caffeine, sodium lactate, and carbon dioxide (Crowe, 1988; Gorman et al., 1989). While it is possible for somatic symptoms to become linked with psychological conflicts and thereby to acquire symbolic signifi­ cance, it will be evident to the reader that the disregulation model is more akin to Freud’s concept o f the actual neuroses in which the symptoms have biological origin and no primary psychological meaning. The concept o f psychobiological disregulation helps explain why some individuals seem more vulnerable than others to devel­ oping illness or disease. Whereas the early psychosomatic models linked increased susceptibility to disease with the presence o f neu­ rotic psychopathology, the disregulation model conceptualizes dis­ ease-prone individuals as people who have failed to achieve the usual and proper level of self-regulation (Weiner, 1982). Such peo­ ple are presumed to have suffered developmental arrests as a result of deficiencies in their earliest object relationships, that are reflect­ ed in the quality of their inner self and object representations and by impaired ego functioning. As noted earlier, deficiencies in the early childhood relationship with the primary caregiver might also have modified the genetic expression of neurotransmitters or other specialized chemicals that are involved in the homeostatic organi­ zation of biological systems. These individuals may compensate partly for their deficits in self-regulation by maintaining symbiotic selfobject relationships with other people; however, they are at greater risk for developing illness or disease following separation and object loss. This vulnerability was demonstrated during the 1950s by Engel (1955,1958) in his investigations of patients with ulcerative colitis. Engel observed that people most at risk for the initial onset or for a recurrence of colitis following an attachment disruption were those who had failed to individuate fully because of a pathologic symbiotic mother-child relationship; such people manifested ego

266 TAYLOR

deficits that they attempted to compensate for by remaining exces­ sively dependent on the support of others. Similar observations of ego deficits and developmental arrests among patients with ulcera­ tive colitis or other physical diseases were reported by Sperling (1960, 1978) and Mushatt (1975, 1989). An in-depth study of pa­ tients with chronic ulcerative colitis subsequently demonstrated that patients who were unable to progress from symbiotic attach­ ments to a more autonomous level of functioning responded poor­ ly to the traditional psychoanalytic approach of interpreting defenses and unconscious drive-related conflicts (Karush et al., 1977). Surprisingly, neither Engel nor any of the other psychoanalysts engaged in this research attempted to formulate their observations within the conceptual framework of the various psychoanalytic object relations theories that were emerging at the time as alterna­ tives to drive psychology. Consequently, they were unable to devise psychoanalytic techniques that might repair defective psychic structure and ego functions and thereby reduce a person’s vulnera­ bility to object loss and the possible onset of disease. Observing that such patients tend to transfer their dependent needs onto their therapist or physician, Engel, for the most part, advocated an ongoing supportive psychotherapy for patients suffering from so­ matic diseases. Nowadays, we can see that Engel’s description of the highly dependent relationships that ulcerative colitis patients establish with certain “key figures” anticipated Kohut’s conception of patho­ logic relationships with selfobjects. As Engel (1955) wrote, “the patient appears to depend on the key figure as part o f his equip­ m ent for dealing with the external world” (p. 234; my italics). He also referred to the continuing need o f children with ulcerative colitis “to utilize others as ‘external* egos” (p. 253; my italics). However, Engel did not adequately formulate a model o f these patients’ internal object relations. Such a model was partly con­ structed many years later by Ammon (1979), who reported similar psychic deficits in psychosomatic patients and referred to their “rigid dependency upon an external object, or upon a group of external objects that are experienced as the representation of an internal object and function as the external stabilizers of an ego threatened with disintegration . . . ” (p. 118). McDougall (1974) offered a similar conceptualization when she compared these pa­ tients to alcoholics and drug addicts, who “attempt to make an external agent behave like a symbolic one and thus repair a psychic

PSYCHOANALYSIS AND PSYCHOSOMATICS 267

gap” (p. 455). More elaborate formulations of the ego deficits and inner object relations of physically ill and disease-prone persons have begun to appear in the literature as psychoanalysts increasing­ ly shift away from Freud’s drive-conflict-defense model of the mind and apply the models of the mind offered by self psychology and object relations theory (Lefebvre, 1980; Levitan, 1989; Rodin, 1984; Thylor, 1987). Empirical research evaluating the proposed association between the nature of a person’s inner object world and his or her suscepti­ bility to disease is difficult to conduct because of the need for prospective studies and problems in operationalizing the construct of mental representations. The development of a Rorschach Inter­ action Scale, however, and its application in a long-term prospec­ tive study of Johns Hopkins medical students, has shown that the development of cancer later in life is associated with mental repre­ sentations that reflect unstable patterns of attachment as well as poor affect modulation (Graves et al., 1986). Psychoanalysts are all too familiar with the influence that the internalized representa­ tions of a person’s early object relations can have on his or her current relationships. The impact of current social relationships on health, however, is much easier to investigate scientifically than the influence of the inner object world. Indeed, research has now provided strong empirical evidence that people’s health is influ­ enced by the availability and quality of their interpersonal relation­ ships (House et al., 1988). There is even preliminary evidence sug­ gesting that the beneficial effect on cardiovascular health of modifying Type A behavior is through an improvement o f the coronary-prone patient’s social relationships (Orth-Gomer and Unden, 1990). A great deal more research is needed, however, to establish the validity of the psychobiological disregulation model. CLINICAL IMPLICATIONS What then are the implications of the psychobiological disregu­ lation model for the psychoanalytic therapy of physically ill pa­ tients? As I have argued in other contributions (Thylor, 1987, 1992), the basic aim of psychoanalytic therapy should be to en­ hance these patients’ self-regulating capacities. This may be ac­ complished by facilitating the process of separation-individuation and the associated progression from the paranoid-schizoid posi­ tion of mental functioning toward the depressive position of stable

268 TAYLOR

mental representations (Brown, 1987). As with characterologically disturbed patients, this requires careful analysis o f the physically ill patient's unconscious internal object relations as these are ex­ ternalized in the transference relationship. The resolution of inter­ personal and intrapsychic conflicts, and the unification of split “good” and “bad” representations o f self and object, enhance also the quality o f the patient’s intimate and social relationships that potentially provide mature selfobject and other interactive experi­ ences that complement his or her self-regulating capacities. While the emergence of a selfobject transference can be expected to help stabilize the patient’s medical condition, further analysis should be guided by the formulations and techniques o f self psychology that are aimed at facilitating an internalization o f the regulating com­ ponents of the therapeutic relationship. The somatically ill patient’s capacity to experience and express emotions appropriately may improve as other developmental ar­ rests are resolved. However, alexithymic deficits in affect regula­ tion often require more specialized psychotherapeutic techniques that attempt to elevate emotions from the primitive sensorimotor level of experience to a mature representational level where they can be valued for their signal function and modulated through imaginative processes and by communication with others (Krystal, 1982/1983; Robbins, 1989; Ihylor, 1987). Psychoanalysis or psychoanalytic psychotherapy with a physi­ cally ill patient is usually a lengthy process during which the thera­ pist must function like the “good-enough mother,” who contains and transforms her infant’s primitive anxieties and facilitates the emergence of transitional activities and other self-regulating ca­ pacities. The hoped-for outcome is a strengthening of the patient’s resistance to disease. SUMMARY The usefulness o f psychoanalysis to psychosomatic medicine has been limited by the longstanding assumption that the psycho­ logical disorder in psychosomatic patients resembles the conflictbased psychopathology that Freud identified in psychoneurotic patients. Recent investigations of the alexithymia construct, and the discovery that social relationships can influence health over the entire life span, have challenged this assumption and created an opportunity for a new and active involvement of psychoanalysis with psychosomatic medicine.

PSYCHOANALYSIS AND PSYCHOSOMATICS 269

In this contribution, I offer a synthesis of contemporary psy­ choanalytic observations and theories with concepts and research findings from developmental psychology, developmental biology, and the biomedical sciences. The proposed synthesis is consistent with the view that living organisms are self-regulating cybernetic systems; it also extends an evolving new psychosomatic model that conceptualizes illnesses and diseases as disorders of psychobiological regulation. A modern psychoanalytic approach to physically ill and disease-prone individuals focuses less on the resolution of neurotic conflicts, and more on correcting deficits in these pa­ tients’ self and object representations and capacity cognitively to process emotions. References Acklin, M. W., and Alexander, G. (1988), Alexithymia and somatization, J. Nerv. M ent. D is., 176, 343-350. Acklin, M. W., and Bemat, E. (1987), Depression, alexithymia, and pain prone disorder: A Rorschach study, J. Pers. A ssess., 5 1 ,462-479. Alexander, F. (1950), Psychosom atic M edicine: Its Principles and Applications, Norton, New York. Alexander, F., French, T. M., and Pollock, G. H . (1968), Psychosom atic Specificity, Vol. I: Experim ental Study and Results, University of Chicago Press, Chicago. Ammon, G. (1979), Psychoanalysis and Psychosom atics, Springer, New York. Arnetz, B. B., Theorell, T., Levi, L., Kallner, A ., and Eneroth, P. (1983), An experimental study of social isolation of elderly people: Psychoendocrine and metabolic effects, Psychosom. M ed., 45, 395-406. Barsky, A. J., and Klerman, G. L. (1983), Overview: Hypochondriasis, bodily complaints, and somatic styles, A m . J. Psychiat., 140,273-283. Basch, M. F. (1976), The concept of affect: A re-examination, J. A m . Psychoanal. A ssoc., 24, 759-777. Blalock, J. E. (1989), A molecular basis for bidirectional communication between the immune and neuroendocrine systems, Physiol. Rev., 6 9 ,1-32. Bourke, M. P., Tkylor, G. J., Parker, J. D., and Bagby, R. M. (in press), Alexithymia in women with anorexia nervosa: A preliminary investigation, Brit. J. Psychiat. Bowlby, J. (1969), A ttachm ent and Loss, Vol. I: Attachm ent, Basic Books, New York. Bowlby, J. (1988), Developmental psychiatry comes of age, A m . J. Psychiat., 145, 1-10. Brown, L. J. (1987), Borderline personality organization and the transition to the depressive position, in J. S. Grotstein, M. F. Solomon, and J. A. Lang (Eds.), The Borderline Patient, Vol. 1, Analytic Press, Hillsdale, NJ, pp. 147-180. Buck, P. (1984), The Communication o f E m otion, Guilford Press, New York. Buck, P. (1988), Nonverbal communication, A m . Behav. Sci., 3 1 ,341-354. Crowe, R. R. (1988), Family and twin studies o f panic disorders and agoraphobia, in M. Roth, R. Noyes Jr., and G. D. Burrows (Eds.), H andbook o f A nxiety, Vol. 1: Biological, . Clinical, and Cultural Perspectives, Elsevier, New York, pp. 101-114. Cutler, W. B ., Preti, G., Krieger, A ., Huggins, G. R ., Garcia, C. R ., and Lawley, H . J. (1986), Human axillary secretions influence women’s menstrual cycles: The role o f donor »[tract from men, H onn. Behav., 2 0 ,463-473.

270 TAYLOR deLissovoy, V. (1971), Foreword, in D. N. Walcher and D. L. Peters (Eds.), The D evelop­ m ent o f Self-Regulatory Mechanisms, Academic Press, New York. Dembroski, T. M ., MacDougall, J. M., Williams, R. B., Haney, T., and Blumenthal, J. A. (1985), Components of Type A, hostility and anger-in. Relationship to angiographic Endings, Psychosom. M ed., 4 7 ,219-233. Deutsch, F. (1959), On the M ysterious Leap fro m the M ind to the Body, International Universities Press, New York. Dinarello, C. A ., and Mier, J. W. (1987), Lymphokines, New Engl. J. M ed., 317, 940-945. Edgcumbe, R. M. (1984), Modes of communication: The differentiation o f somatic and verbal expression, Psychoanal. Study Child, 3 9 ,137-154. Ekman, P., and Friesen, W. V. (1982), Em otion in the H uman Face (2nd ed.), Cambridge University Press, Cambridge. Emde, R. N. (1984), The affective self: Continuities and transformations from infancy, in J. D. Call, E. Galenson, and R. L. Tyson (Eds.), Frontiers o f Infant Psychiatry, Basic Books, New York, pp. 38-54. Emde, R. N. (1988a), Development terminable and interminable. 2. Recent psychoanalytic theory and therapeutic considerations, Int. J. Psychoanal., 69, 283-296. Emde, R. N. (1988b), Development terminable and interminable. 1. Innate and motiva­ tional factors from infancy, Int. J. Psychoanal., 6 9 ,23-42. Emde, R. N., and Robinson, J. (1979), The first two months: Recent research in develop­ mental psychobiology and the changing view of the newborn, in J. D. Noshpitz (Ed.), Basic H andbook o f Child Psychiatry, Vol. I, Basic Books, New York, pp. 72-105. Engel, G. L. (1955), Studies of ulcerative colitis: III. The nature o f the psychologic process, A m . J. M ed., 1 9 ,231-256. Engel, G. L. (1958), Studies of ulcerative colitis: V. Psychological aspects and their implica­ tions for treatment, A m . J. Dig. D is., 3, 315-337., Engel, G. L ., and Schmale, A. H . (1967), Psychoanalytic theory o f somatic disorder: Conversion, specificity and disease onset situation, J. A m . Psychoanal. A ssoc., IS , 344365. Engel, G. L., and Schmale, A. H . (1972), Conservation-withdrawal: A primary regulatory process for organismic homeostasis, in Physiology, Em otion and Psychosom atic Illness, Ciba Foundation Symposium 8, Elsevier, Amsterdam, pp. 57-85. Evoniuk, G. E ., Kuhn, C. M ., and Schanberg, S. M. (1979), The effect o f tactile stimula­ tion on serum growth hormone and tissue ornithine decarboxylase activity during mater­ nal deprivation in rat pups, Communicat. Psychopharmacol., 3, 363-370. Faravelli, C ., and Pallanti, S. (1989), Recent life events and panic disorder, A m . J. Psychiat., 146,622-626. Fernandez, A ., Sriram, T. G., Rajkumar, S., and Chandrasekar, A. N. (1989), Alexithymic characteristics in rheumatoid arthritis: A controlled study, Psychother. Psychosom ., 51, 45-50. Field, T. (1985), Attachment as psychobiological attunement: Being on the same wave­ length, in M. Reite and T. Field (Eds.), The Psychobiology o f A ttachm ent and Separa­ tion, Academic Press, Orlando, FL, pp. 415-454. Freud, S. (1895), On the grounds for detaching a particular syndrome from neurasthenia under the description “anxiety neurosis,” Standard E dition, Vol. 3, pp. 90-115. Freud, S. (1898), Sexuality in the aetiology o f the neuroses, Standard E dition, Vol. 3, pp. 263-285. Freud, S. (1914), On narcissism: An introduction, Standard E dition, Vol. 14, pp. 67-102. Freud, S. (1926), Inhibitions, symptoms, and anxiety, Standard E dition, Vol. 20, pp. 87156.

PSYCHOANALYSIS AND PSYCHOSOMATICS 271 Friedman, H. S., and Booth-Kewley, S. (1987), The “disease-prone personality,” A metaanalytic view o f the construct, A m . Psychol., 42, 539-555. Furman, R. A. (1978), Some developmental aspects o f the verbalization of affects, Psychoanal. Study Child, 3 3 ,187-211. Caddini, R. (1978), Transitional object origins and the psychosomatic symptom, in S. A. Grolnick, L. Barkin, and Muensterberger (Eds.), Between Reality and Fantasy: Transi­ tional O bjects and Phenomena, Aronson, New York, pp. 111-131. Glover, E. (1939), Psychoanalysis, Staples Press, London. Gorman, J. M ., Liebowitz, M. R., Fyer, A. J., and Stein, J. (1989), A neuroanatomical hypothesis for panic disorder, A m . J. Psychiat., 1 4 6 ,148-161. Graham, C. A ., and McGrew, W. C. (1980), Menstrual synchrony in female undergraduates living on a co-educational campus, Psychoneumendocrinology, 5 ,245-252. Graves, P. L ., Mead, L. A ., and Pearson, T. A. (1986), The Rorschach interaction scale as a potential predictor of cancer, Psychosom. M ed., 48, 549-563. Grotstein, J. S. (1986), The psychology o f powerlessness: Disorders o f self-regulation and interactional regulation as a newer paradigm for psychopathology, Psychoanal. In q ., 6, 93-118. Hofer, M. A. (1978), Hidden regulatory processes in early social relationships, in P. G. Bateson and P. H. Klopfer (Eds.), Perspectives in Ethology, Vol. 3, Plenum, New York, p p . 135-165. Hofer, M. A. (1983a), On the relationship between attachment and separation processes in infancy, in R. Plutchik (Ed.), Em otion: Theory, Research and Experience: Vol. II. Em o­ tions in Early Developm ent, Academic Press, New York, pp. 199-219. Hofer, M. A. (1983b), The mother-infant interaction as a regulator o f infant physiology and behavior, in L. Rosenblum and H. Moltz (Eds.), Sym biosis in Parent-O ffspring Interactions, Plenum, New York, pp. 61-75. Hofer, M. A. (1984), Relationships as regulators: A psychobiologic perspective on bereave­ ment, Psychosom. M ed., 46, 183-197. Hoppe, K. (1977), Split brains and psychoanalysis, Psychoanal. Q uart., 4 6 ,220-244. House, J. S., Landis, K. R., and Umberson, D. (1988), Social relationships and health, Science, 241, 540-545. Karush, A. (1989), Instinct and affect, in A. M. Cooper, O. F. Kernberg, and E. S. Person (Eds.), Psychoanalysis: Toward the Second Century, Yale University Press, New Haven, pp. 76-90. Karush, A., Flood, C., and O’Connor, J. F. (1977), Psychotherapy in Ulcerative C olitis, Saunders, Philadelphia. Kellner, R. (1975), Psychotherapy in psychosomatic disorders: A survey of controlled stud­ ies, Arch. Gen. Psychiat., 3 2 ,1021-1028. Klerman, G. L., and Izen, J. E. (1977), The effects of bereavement and grief on physical health and general well-being, Adv. Psychosom. M ed., 9, 63-104. Kohut, H. (1977), The Restoration o f the Self, International Universities Press, New York. Kohut, H. (1984), How Does Analysis Cure?, University of Chicago Press, Chicago. Krieger, D. T. (1983), Brain peptides: What, where, and why?, Science, 222,975-985. Krystal, H. (1974), The genetic development of affects and affect regression, A nn. Psy' choanal., 2, 98-126. Krystal, H. (1982/1983), Alexithymia and the effectiveness of psychoanalytic treatment, " Int. J. Psychoanal. Psychother., 9, 353-378. Krystal, H . (1988), Integration and Self-Healing: A ffect, Houma, Alexithym ia, Analytic Press, Hillsdale, NJ.

272 TAYLOR Lane, R. D., and Schwartz, G. E. (1987), Levels of emotional awareness: A cognitivedevelopmental theory and its application to psychopathology, A m . J. Psychiat., 144, 133-143. Leff, J. (1977), The cross-cultural study o f emotions, Cult. M ed. Psychiat., 1, 317-350. Levebvre, P. (1980), The narcissistic impasse as a determinant o f psychosomatic disorder, Psychiat. J. Univ. Ottawa, J, 5-11. Levitan, H. (1989), Failure o f the defensive functions of the ego in psychosomatic patients, in S. Cheren (Ed.), Psychosom atic Medicine: Theory, Physiology, and Practice, Vol. I, International Universities Press, Madison, CT, pp. 135-157. Lichtenberg, J. D. (1983), Psychoanalysis and Infant Research, Analytic Press, Hillsdale, NJ. Lipowski, Z. J. (1977), Psychosomatic medicine in the seventies: An overview, A m . J. Psychiat., 134, 233-244. MacAlpine, I. (1954), Psychosomatic symptom formation, The Lancet, 1 ,278-282. MacLean, P. D. (1949), Psychosomatic disease and the “visceral brain,” Psychosom. M ed., 11, 338-353. Magni, G., Di Mario, F., Rizzardo, R., Pulin, S., and Naccarato, R. (1986), Personality profiles of patients with duodenal ulcer, A m . J. Psychiat., 1 4 3 ,1297-1300. Mahler, M. S. (1968), On H uman Sym biosis and the Vicissitudes o f Individuation, Interna­ tional Universities Press, New York. Martin, J. B., and Pihl, R. O. (1985), The stress-alexithymia hypothesis. Theoretical and empirical considerations, Psychother. Psychosom ., 4 3 ,169-176. Martin, J. B., and Pihl, R. O. (1986), Influence o f alexithymie characteristics on physiologi­ cal and subjective stress responses in normal individuals, Psychother. Psychosom ., 45, 66-77. McClintock, M. K. (1971), Menstrual synchrony and suppression, Nature, 229, 244-245. McClintock, M. K. (1978), Estrous synchrony and its mediation by airborne chemical communication (Rattus norvegicus), H o rn . Behav., 1 0 ,264-276. McDougall, J. (1974), The psychosoma and the psychoanalytic process, Int. Rev. Psy­ choanal., 1, 437-459. Mitchell, S. A. (1988), Relational Concepts in Psychoanalysis: A n Integration, Harvard University Press, Cambridge, MA. Moldofsky, A. (1989), Sleep-wake mechanisms in fibrositis, J. Rheum atol. (Suppl. 19), 16, 47-48. Moore, B. E ., and Fine, B. D. (1968), A Glossary o f Psychoanalytic Terms and Concepts (2nd ed.), American Psychoanalytic Association, New York. Mushatt, C. (1975), Mind-body-environment: Tbward understanding the impact o f loss on psyche and soma, Psychoanal. Q uart., 4 4 ,81-106. Mushatt, C. (1989), Loss, separation, and psychosomatic illness, in C. P. Wilson and I. L. Mintz (Eds.), Psychosom atic Sym ptom s: Psychodynamic Peatm en! o f the Underlying Personality Disorder, Aronson, Northvale, NI, pp. 33-61. Nemiah, J. C., Freyberger, H ., and Sifneos, P. E. (1976), Alexithymia: A view of the psychosomatic process, in O. W. Hill (Ed.), M odern P ends in Psychosom atic M edicine, Vol. 3, Butterworths, London, pp. 430-439. Nemiah, J. C ., and Sifneos, P. E. (1970). Affect and fantasy in patients with psychosomatic disorders, in O. W. Hill (Ed.), M odern P ends in Psychosom atic M edicine, Vol. 2, But­ terworths, London, pp. 26-34. Orth-Gomer, K., and Unden, A. (1990), Tÿpe A behavior, social support, and coronary risk: Interaction and significance for mortality in cardiac patients, Psychosom. M ed., 52, 59-72.

PSYCHOANALYSIS AND PSYCHOSOMATICS 273 Osofsky, J. D., and Eberhart-Wright, A. (1988), Affective exchanges between high risk mothers and infants, Int. J. Psychoanal., 69, 221-231. Papciak, A. S., Feuerstein, M., and Spiegel, J. A. (1985), Stress reactivity in alexithymia: Decoupling of physiological and cognitive responses, J. Human Stress, 11, 135-142. Parker, J. D. A ., Thy)or, G. J., and Bagby, R. M. (in press), Relationship between conjugate lateral eye movements and alexithymia, Psychother. Psychosom. Pert, C. B., Ruff, M. R., Weber, R. J., and Herkenham, M. (1985), Neuropeptides and their receptors: A psychosomatic network, J. Im m unol., 135 (Suppl.), 820-826. Peters, D. L. (1971), Epilog, in D. N. Walcher and D. L. Peters (Eds.), The D evelopment o f Self-Regulatory M echanisms, Academic Press, New York. Pipp, S., and Harmon, R. J. (1987), Attachment as regulation: A commentary, Child Dev., 5 8 ,648-652. Porter, R. H ., Balogh, R. D., and Makin, J. W. (1988), Olfactory influences on motherinfant interactions, in C. Rovee-Collier and L. Lipsitt (Eds.), Advances in Infancy Research, Vol. 5, Ablex, Norwood, NJ, pp. 39-68. Preti, G., Cutler, W. B., Garcia, C. R., Huggins, G. R., and Lawley, H. J. (1986), Human axillary secretions influence women’s menstrual cycles: The role o f donor extract of females, H o rn . Behav., 2 0 ,474-482. Reiser, M. (1978), Psychoanalysis in patients with psychosomatic disorders, in T. B. Karasu and R. I. Steinmuller (Eds.), Psychotherapeutics in M edicine, Gruñe and Stratton, New York. Robbins, M. (1989), Primitive personality organization as an interpersonally adaptive mod­ ification of cognition and affect, In t. J Psychoanal., 7 0 ,443-459. Rodin, G. (1984), Somatization and the self: Psychotherapeutic issues, A m . J. Psychother., 38, 257-263. Ruesch, J. (1948), The infantile personality, Psychosom. M ed., 1 0 ,134-144. Sandler, J. (1972), The role o f affects in psychoanalytic theory, in Physiology Em otion and Psychosom atic Illness, Ciba Foundation Symposium 8, Elsevier, Amsterdam, pp. 31-56. Schafer, R. (1968), A spects o f Internalization, International Universities Press, New York. Schur, M. (1955), Comments on the metapsychology of somatization, Psychoanal. Study Child, 1 0 ,110-164. Schwartz, A. (1987), Drives, affects, behavior and learning: Approaches to a psychobiology of emotion and to an integration o f psychoanalytic and neurobiologic thought, J. A m . Psychoanal. Assoc., 3 5 ,467-506. Schwartz, G. E. (1983), Disregulation theory and disease: Applications to the repression/ cerebral disconnéction/cardiovascular disorder hypothesis, Int. Rev. AppL Psychol., 32, 95-118. Schwartz, G. E. (1989), Disregulation theory and disease: Ibward a general model for psychosomatic medicine, in S. Cheren (Ed.), Psychosomatic M edicine: Theory, Physiolo­ gy, and Practice, Vol. 1, International Universities Press, Madison, CT, pp. 91-117. Siever, L. J., and Davis, K. L. (1985), Overview: Tbward a dysregulation hypothesis o f depression, A m . J. Psychiat., 1 4 2 ,1017-1031. Sifneos, P. (1975), Problems o f psychotherapy o f patients with alexithymic characteristics and physical disease, Psychother. Psychosom ., 2 6 ,65-70. Smith, E. M ., and Blalock, J. E. (1986), A complete regulatory loop between the immune and neuroendocrine systems operates through common signal molecules (hormones) .and receptors, in N. P. Plotnikoff, R. E. Faith, A. J. Murgo, and R. A. Good (Eds.), Enkephalins and Endorphins: Stress and the Im m une System , Plenum, New York, pp. 119-127. Sperling, M. (1960), Symposium on disturbances of the digestive tract: II. Unconscious

274 TAYLOR phantasy life and object relationships in ulcerative colitis, In t. J. Psychoanal., 41, 450455. Sperling, M. (1978), Psychosom atic Disorders in Childhood, Aronson, New York. Spitz, R. A. (1945), Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood, Psychoanal. Study Child, 1 ,53-74. ; Spitz, R. A. (1960), Discussion of Dr. Bowlby’s paper, Psychoanal. Study Child, 15, 85-94. Spitz, R. A ., and Wolf, K. M. (1946), Anaclitic depression, Psychoanal. Study Child, 2, 313-342. Sriram, T. G., Chaturvedi, S. K., Gopinath, P. S., and Shanmugam, V. (1987), Controlled study o f alexithymic characteristics in patients with psychogenic pain disorder, Psychother. Psychosom ., 47,11-17. Stem, D. N. (1983), The early development o f schemas o f self, other, and “self with other,” in J. D. Lichtenberg and S. Kaplan (Eds.), Reflections on S e lf Psychology, Analytic Press, Hillsdale, NJ, pp. 49-84. Stem, D. N. (1984), Affect attunement, in J. D. Call, E. Galenson, and R. L. Tyson (Eds.), Frontiers in Infant Psychiatry, Vol. 2, Basic Books, New York, pp. 3-14. Stem, D. N. (1985), The Interpersonal World o f the Infant, Basic Books, New York. Stierlin, H . (1970), The functions o f “inner objects,” In t. J. Psychoanal., 51, 321-329. Stone, E. A ., Bonnet, K. A ., and Hofer, M. A . (1976), Survival and development of maternally deprived rats: Role of body temperature, Psychosom. M ed., 3 8 ,242-249. Taylor, G. J. (1987), Psychosom atic M edicine and Contemporary Psychoanalysis, Interna­ tional Universities Press, Madison, CT. Thylor, G. J. (1992), Psychosomatics and self-regulation, in J. W. Barron, M. N. Eagle, and D. L. Wolitzky (Eds.), The Interface o f Psychoanalysis and Psychology, American Psy­ chological Association, Washington, DC. Thylor, G. J., Bagby, R. M., and Parker, J. D. A. (1991), The alexithymia construct: A potential paradigm for psychosomatic medicine, Psychosomatics, 3 2 ,153-164. Thylor, G. J., Bagby, R. M., Ryan, D. P., and Parker, J. D. A. (1990), Validation o f the alexithymia construct: A measurement-based approach, Can. J. Psychiat., 3 5 ,290-297. TenHouten, W. D., Hoppe, K. D., Bogen, J. E., and Walter, D. O. (1986), Alexithymia: An experimental study of cerebral commissurotomy patients and normal control subjects, A m . J. Psychiat., 143, 312-316. Thompson, J. G. (1988), The Psychobiology o f E m otions, Plenum, New York. Tilbe, K., and Sullivan, S. (1990), The extracolonic manifestations o f the irritable bowel syndrome, Can. M ed. A ssoc. J., 142, 539-540. ' TUstin, F. (1981), A utistic States in Children, Routledge and Kegan Paul, London. Veith, J. L., Buck, M ., Getzlaf, S., van Dalfsen, P., and Slade, S. (1983), Exposure to men influences the occurrence o f ovulation in women, Physiol. Behav., 31, 313-315. Voeller, K. K. S. (1986), Right-hemisphere deficit syndrome in children, A m . J. Psychiat., 143, 1004-1009. von Bertalanffy, L. (1968), General System s Theory, Braziller, New York. Waelder, R. (1967), Inhibitions, symptoms, and anxiety: Forty years later, Psychoanal. Q uart., 3 6 ,1-36. Weiner, H . (1977), Psychobiology and H uman Disease, Elsevier, New York. Weiner, H . (1982), The prospects for psychosomatic medicine: Selected topics, Psychosom. M ed., 4 4 ,491-517. Weiner, H . (1989), The dynamics o f the organism: Implications of recent biological thought for psychosomatic theory and research, Psychosom . M ed., 5 1 ,608-635. Weintraub, S., and Mesulam, M. M. (1983), Developmental learning disabilities o f the right hemisphere, A rch. N eurol., 3 8 ,463-468.

PSYCHOANALYSIS AND PSYCHOSOMATICS 275 Winnicott, D. W. (1953), Transitional objects and transitional phenomena, Int. J, Psychoanal., 34, 89-97. Winnicott, D. W. (1975), Collected Papers: Through Pediatrics to Psychoanalysis, Hogarth Press, London. Wolf, E. S. (1980), On the developmental line of selfobject relations, in A. Goldberg (Ed.), Advances in S e lf Psychology, International Universities Press, New York. Zeitlin, S. B., Lane, R. D., O’Leary, D. S., and Schrift, M. J. (1989), Interhemispheric transfer deficit and alexithymia, A m . J. Psychiat., 146, 1434-1439.

600 University Avenue, Room 933 Toronto, Ontario Canada M5G 1X5

Psychoanalysis and psychosomatics: a new synthesis.

The usefulness of psychoanalysis to psychosomatic medicine has been limited by the longstanding assumption that the psychological disorder in psychoso...
1MB Sizes 0 Downloads 0 Views