Br. J. med. Psychol. (1976), 49, 249-255 Printed in Great Britain
249
Psychopathology and psychotherapy in bronchial asthma* BY MURRAY JACKSONt
Writing about bronchial asthma eighty years ago Osler made the following comments: ‘One of the most striking peculiarities is the bizarre and extraordinary variety of circumstances which at times induce a paroxysm. . .Fright and violent emotions of any sort may bring on a paroxysm . . .We have no knowledge of the morbid anatomy of true asthma. Death during the attack is unknown ’ (Osler, 1892). It is instructiveto contrast these views with the present situation. Today a great deal is known about the relevant pathology, and death, far from being unknown, is a recognized hazard, partly attributable to the introduction of steroids (see Pinkerton & Weaver, 1970). Psychosocial factors are widely acknowledged amongst the ‘bizarre’ precipitants, and psychopathology has emerged as a discipline with a contribution to make to the understanding and management of the disease. The importance of infective and allergic factors has long been established and advances in understanding the chemistry of immune globulins is throwing light on the mechanisms that lead to bronchospasm. The role of genetic predisposition has been clarified, notably by the work of Leigh & Marley (1%7). The classic studies of Linford Rees (1956) demonstrated the high incidence of psychosocial stress in asthmatics. Despite all this progress there is little agreement about the nature and mode of operation of psychosocial factors in contributing to the asthmatic attack. Indeed, some recent research has been interpreted to indicate that asthmatics do not differ psychologically from the normal population (&alley, Aitken & Rosenthal, 1970) and it has been demonstrated by a long follow-up that asthmatics have no greater incidence of overt psychiatric disorder than the normal population (Benjamin, 1974). Since there is such a lack of agreement amongst experienced workers in the field it is not surprising that the place of psychotherapy in the treatment of asthma is an even more disputed subject. Opinions range from those who believe that it is often the most important approach (though by no means the only one) to those who would regard psychotherapy as having no part at all to play, except perhaps in the sense of a general supportive measure. With the extension of the psychiatric services into general hospitals, the psychiatrist will have many opportunities to explore the potentials of psychosomatic liaison activities (Jackson, 1973) which are likely to play an increasingly important part in his professional life (Lipowski, 1971). His help will be more often sought in the management of such ‘stress’ disorders as bronchial asthma and his expertise in psychopathology and psychotherapy will be in demand. THEORETICAL FRAMEWORK
Psychoanalytic theory provides a coherent framework for the understanding and psychotherapy of asthma and other stress disorders. Detailed exposition would be outside the scope of this paper. and only brief mention can be made of some key concepts. (1) The role of denial as a coping method in ego defence where denial is seen as a goal or strategy attained by many different defensive tactics (Hackett & Cassem, 1974). (2) The reciprocal relationship between the effectiveness of ego defence and neuroendocrine * Based on a paper read at the Annual Conference of the Society for PsychosomaticResearch, London, November 1974. t King’s College Hospital, Denmark Hill, London, S.E.5.
250
M. J A C K S O N
activation. As Reiser (1968) has pointed out, there is much evidence for the existence of such a reciprocal relationshipboth in conditionsof chronic sustained stress, and of acute psychological decompensation. It also seems clear that psychotic mechanisms may be as effective in containing conflict as are more healthy and socially adaptive ego activities. (3) The concepts of desomatization and resomatization (Schur, 1955)* and Engel’s addition of a ‘conservation-withdrawal’ mode to the familiar ‘flight-fight ’ response to stress (Engel, 1%2a; Schmale, 1972). The implications of these concepts is that when an individual fails to cope with stress, either because it is too overwhelming,or because he has failed to learn adequate coping methods, major biological arousals may occur. These arousals may be regarded as the somatic aspect of a regressive psychobiological response, whose psychic aspect is preverbal fantasy of a primitive and concrete kind. Complex determinants will decide the choice of target organ, and such factors as conditioning and secondary gain may be involved. In Engel’s terms, the mind has a buffering function for the body and conflict is expressed viscerally when it cannot be effectively confined to the ideational sphere. In practice the coping deficit typically appears as the inability to give adequate affective expression to distressing conflict, and in the case of asthma, the subsequent attack can at times be ascribed a meaningful content. Thus Hambling (1974) has reported the cathartic alleviation of attacks of asthma which he classified as the expression of a suppressed cry of grief (comparable to the familiar notion of the ‘cry for the mother’) or anger, or of sexual excitement. A further implication of the concept of ‘resomatization’ is, therefore, that where psychological stress is a factor in somatization, the process should be reversible, and it is this ‘desomatization’ that is the major goal in psychotherapy. ILLUSTRATIVE CASES
Two patients will illustrate these processes. The first, a brilliant and gifted artist of 40, had severe steroid-dependentasthma of many years duration, with recurrent episodes of status asthmaticus. An important factor in the precipitation of his attacks seemed to be the conflicts aroused within his intensely dependent tie to his wife, who was in the process of turning against him. He appeared as a subject at a clinical meeting with a selection of dramatic paintings mostly depicting incipient doom and the struggle between primordial forces of good and evil, whilst asserting that he was feeling reasonably calm. Psychotherapy was arranged and the initial contact was satisfactory. At this point his wife returned from abroad, rejected him, and he went into status. The psychotherapist did not hear of his admission, and he died in 24 hours. This event may be regarded as a catastrophic somatization which might have been avoided or mitigated. In Engel’s terms the patient was overwhelmed with hopelessness, was deprived of help, perhaps gave up the struggle and succumbed to the physiological consequences of a massive ‘conservation-withdrawal ’ reaction. The second patient was a woman of similar age and severity of asthmawho had spent 18 months in a psychotherapeutic group, when she found herself caught in a disturbing life-situation. She had made enough progress in the group to be able to try to give expression to her feelings, a capacity she had not had before. She arrived at a session wheezing, and rapidly developed severe respiratory distress. At the point where her life situation became the centre of the group’s attention she ran out of the room. At this point a female colleague, who knew the patient and happened to be on hand, simply put her arm round the patient and encouraged her to give in to her feelings. She burst into tears, and the respiratory obstruction rapidly diminished. She * According to these views mind and body as functioning entities differentiate out in the course of normal
ontogenetic development from an original psychosomatic unity. This ‘desomatization ’ process is never complete, may fail to varying degrees or be reversed under later stress (resomatization) (see Cameron, 1%3).
Psychopathology and psychotherapy in bronchial asthma
25 1
returned to the group, verbalized her feelings of resentment against her husband, and within ten minutes her breathing was normal. Although there is nothing unusual about the relief of a single asthmatic attack through emotional catharsis, the effect of the physical contact was impressive, as was the fact that she had no further asthma for the next 12 months. By contrast to the first case this episode may be seen as a dramatically effective desornatization where the right help was provided at the right time in a patient in the throes of helplessness and progressive ‘conservation-withdrawal ’. PSYCHOSOCIAL STRESS AS A CAUSAL FACTOR IN ASTHMA
The opportunity to study 30 asthmatic patients in some depth has led me to the conviction that psychosocial factors are of paramount importance in the genesis of the asthmatic attack. Although this conclusion is not a particularly original one, and is derived from experience of a number of specially selected patients, it permits some commentson aspects that may not be widely recognized. Psychosocial factors in asthma are of the nature of contributory causes, neither necessary nor suficient. Whereas a healthy person may produce wheezing by voluntary activity, and an asthmatic may likewise produce an asthmatic attack, true asthma cannot occur unless the bronchial tree is physiologically labile (see Pinkerton, 1974).* Psychological factors in the personality may also be a consequence of the asthmatic attack (the somatopsychic direction) and it is well known that asthmatic children may learn to avoid emotional arousal of all sorts because they have discovered that any excitation may produce an attack. Such emotional inhibition may, however, be frequently encountered in late-onset cases, which may be seen to have had the same impoverishment of coping capacities for years or decades before their first attack. This may suggest that the familiar ‘bottling up’ of emotions is more relevant as an antecedent to the asthmatic attack than a consequence.
Pathogenic stress and the containment of conflict The nature of the pathogenicpsychosocial stress in asthma has been widely documented in terms such as the threat of loss or actual loss; of separation anxiety; of the threat of aggressivefeelings evoked within a dependent or symbiotic relationship with a mother figure; of the evocation of a specific alTective state of helplessness and hopelessness (Engel, 1%2b; Knapp, 1%9). These situations are all encountered in practice with varying frequency, and they have one thing in common, namely that they expose the person, of whatever age, to feelings that he cannot contain. The word ‘contain’ is introduced here to describe a mature capacity to experience, tolerate and give adequate expression to feelings. The word could be regarded as antithetical to ‘retain ’ in the sense of ‘bottling up ’ of emotions, a state widely regarded as characteristic of the ‘psychosomatic’ patient. The work of such psychoanalysts as Bion (1%2) and Winnicott (1958) suggeststhat if an infant and child does not have the experience of a mother figure who can herself contain strong emotions communicated by her infant, his ego development and thus his maturation will be impaired. The implication of these views is that a ‘good-enough’ mother (Winnicott’s term) is not only ‘caring’ in the sense of providing the necessary loving care and attention, but is also capable of ‘containing’ her infant’s feelings in the above sense. The ‘containment’ concept may also help in understandingthe mechanisms underlying certain phobias, which may have relevance to the psychopathology sometimes involved in asthma. A phobic object, such as an insect or animal, may at times be selected by chance alone, but at other
* The possibility that early life experiences from birth onwards may provide a psychogenic component to this constitutional vulnerability is a matter that has long preoccupied psychoanalysts, and is an extremely difficultsphere of research (Greenacre, 1953; French et al. 1941).
252
M. J A C K S O N
times may be selected as a symbolic container for parts of the self and inner world felt to be dangerous and destructive. The concept of projective identification introduced by Melanie Klein can enlighten this formerly obscure area of psychopathology (Segal, 1954, 1964). This work suggests that symbolization may be primary in some psychosomatic disorders [at least in those disorders of systems having apertural connexion with the outside world, and thus concerned in earliest perception and learning (see Kubie, 1953)], that the symptoms may thus be regarded as having a meaningful mental content, though of a very primitive and preverbal kind, and that the optimal aim of dynamic psychotherapy is to help this be integrated. Clinical experience suggests that phobic symptoms are relatively common in asthma [Pedder (1%9) has demonstrated this in a detailed survey of psychosomatic disorders], and a widely accepted explanation is that the repeated traumatic experience of respiratory oppression may give rise to claustrophobicanxieties. Whilst this is no doubt true, such symptomsare often encountered years or decades before the first onset of symptoms (in late-onset asthma). In such cases we may consider the possibility that such antecedent phobic symptoms are a dynamic precursor of, or alternative to, the somatic symptom, both of which may have meaningful psychic content. The disorder of ego function that may be involved in cases of severe asthma may also at times be encountered in other psychosomatic disorders, borderline states and anorexia nervosa. This disorder may be regarded as a failure in the development of psychological representation of states of body tension and sensation arising from birth onward (see Mchugall, 1974). Freud’s dictum ‘the ego is first and foremost a body ego ’ can be applied to the phenomena of somatization,which can be considered as in part the expression of mental (or more accurately psychobiological) processes of a primitive and preverbal kind, which have failed to be transformed into truly symbolic processes which can achieve psychological representation. [Wisdom (1959) has described an aspect of this impairment as the failure to shift from the kinaesthetic and proprioceptive to the visual representation sphere of imagery.] The normal ontogenetic desomatization has not been achieved, or has been lost under stress, and true ‘mentalization’has not been successfully established. In this context we can consider conflicts and confusions occurring in psychic reality over the retention and expulsion of good and benign and bad and dangerous objects and substances,with visceral spasm as its somatic concomitant. Such ideas may expand the psychological aspects of Engel’s concept of ‘ conservation-withdrawal ’. DENIAL AS A SPECIFW DEFENCE
An impaired capacity to contain and communicate feelings implies a degree of ego weakness in a personality that may sometimes in other respects be strong. This weakness involves the extensive use of denial as a defence. This denial can range from a conscious and fearful repudiation of emotion (where a person simply cannot think about his feelings) to a splitting or discontinuity within the personality such as is seen in major hysterical or borderline psychotic states. When denial is not deep-seated it may be easily reversible. As J. J. Groen (1974, personal communication) has pointed out, some people may be quickly helped by an accepting therapist to learn to express their feelings. This factor needs to be taken into account when explaining and evaluatingthe positiveresults of behaviour therapy and drug therapy (such as antidepressants) in some cases of asthma. When denial is very deep-seated it may appear to be irreversible,and associated with a peculiar impoverishment of vocabulary of ‘emotion’words. This has led Sifneos (1972) to coin the term alexifhymia (no word for feelings)and to suggest a maturationalfailure of limbic neural connexions as a possible explanation. Whilst environmentalfailure in the earliest critical periods of development may well be decisive for ego development, further exploration of the role of primitive
Psychopathology and psychotherapy in bronchial asthma
253
defensive operationsis needed before organicfactors can merit etiologicpriority (see McDougall, 1974). PROBLEMS OF ENGAGING THE PATIENT IN ~YCHOTHERAPY
Experience suggests that asthmatic subjects may be more difficult to engage in insight psychotherapy than neurotic patients, and this deserves comment. Apart from the obvious possibilities of poor selection and lack of therapist skill, there are factors in the patient and the setting that need examination in this respect. Where denial is being used as a main defensive method, insight is likely to be vigorously repudiated. Where the patient has been referred to the psychiatrist as a last resort, or because he has finally encountered a physician who is sympathetic to the psychosomatic approach, he may already have had long experience of a ‘medical’ (as opposed to a psychosomatic) model of his disorder, and this may have reinforced his defences of denial. Where the idea that referral of such cases to a psychiatrist carries the implication of mental disorder, it is not surprisingthat the patient’s natural wish to regard his disorder as an exclusively organic one may have become strongly reinforced. Another possible factor, although a speculative one, is that steroids, used in significant amounts over a long period, may cause mood change, short of the familiar steroid psychosis, which reinforce defences of a manic character. These various factors, singly or in combination, may greatly decrease the patient’s capacity to engage in the therapeutic task, whose first step is to increase the recognition of disturbing feelings, rather than to escape them. AIMS, TECHNIQUES AND OUTCOMES
When the psychotherapist is asked to help in the management of an asthmatic patient, the obvious aim is alleviationof the symptom. The catharsisaccompanyingemotionalventilationmay achieve this, but the psychotherapist is more likely to be aiming for permanent structural change in the personality, which would represent a major achievement requiring adequate time and skill. Many techniques exist to approach these two goals, of symptom relief and personality change. The most fundamentalof these is formal psychoanalysis, which offers specific opportunities for treatment and research in appropriate subjects (see Liifgren, l%l). The practical difficulty of providing this treatment generally is well known, and modifications and applications of psychoanalytic methods are more widely available. One approach is to offer individual once-weekly sessions for a prolonged period, or to help the patient to a point where he can make good use of group therapy. Many patients cannot tolerate group therapy without a preliminary period of weeks or months preparation. This initial work is aimed at helping the patient recognize the connexion between his state of mind and his attacks of asthma, and to promote the capacity to investigate and think about feelings, a capacity which is often absent in the beginning. Once these goals are achieved, group therapy may offer more to the patient than once-weekly individual therapy (see Forth & Jackson, 1976). Modification of these familiar techniques are of considerable interest and may have a good deal to offer the patient. Psychodrama and encounter group methods in the right hands may offer a concrete experience that could be helpful to some asthmatics. The favourable results of group therapy reported by Groen & Pelser (1960)may in part be due to the physical medical care offered concurrently by the therapists, and it is interesting to consider that a large mutually caring patient group, the Nederlands Asthmatic Association, developed spontaneously from their therapeutic activities. An interesting modification is reported by Reckless (1972)whose unorthodox group method involves some limited physical contact when a patient is in the throes of an asthmatic attack, together with group pressure on the patient to examine and identify the relevant emotional state that precipitated it. This is an attempt to combine a reassuring physical contact with affective expression and psychodynamic insight which, at least in theory, seems a desirable aim. The use
254 M. JACKSON of hypnotism, biofeedback and new relaxation approaches are of great interest and importance and the psychotherapist may contribute to the evaluation of some of their successes in terms of the dynamics of transference and ‘containment’. CONCLUSIONS
Pinkerton (1974) makes a timely comment on the use of steroid therapy in asthmatic children: ‘. . .proper attention to emotional pathology in refractory asthma may obviate the need for steroid therapy, thereby reserving this potentially hazardous therapy for its proper indications - the physiologicallyseverecase ’. These cautionary words are equally applicable to the evaluation and management of the adult asthmatic. In this task the identification of the emotional pathology may be far from easy, and understanding of the defensive mechanisms of denial may be crucial. The majority of asthmatic subjects may well have no more than their normal share of emotional conflicts, apart from those engendered by the condition itself, but it is important for physicians to recognize that ‘pseudo-normality’ is a very real entity. Failure to recognize this may lead to a serious underestimation of the role of emotional factors in the genesis of asthma, and thus of neglecting the potential of psychotherapy in the treatment of this distressing disease. SUMMARY
The role of psychological factors in the genesis of bronchial asthma is much disputed, and hence the place of psychotherapy in its management is equally controversial. The opportunity to study a series of such patients and to attempt to provide psychotherapy for them has led the author to the view that significant psychopathology is more common in asthmatic subjects than is generally realized, and that psychotherapy has a vital part to play, in management. Some case material is presented to support this contention, and the application of psychoanalytic concepts, evaluation and treatment are discussed. ACKNOWLEDGEMENT
I am greatly indebted to Dr Philip Hugh-Jones, Director of the Pulmonary Research Unit, King’s College Hospital, for his invaluable cooperation. REFERENCES
BENJAMIN, S. (1974). Asthma and mental illness: A 15 year follow-up study. Paper read at loth European Conference on Psychosomatic Research, Edinburgh. BION, W . R. (1%2). Learning from Experience. London: Heinemann. CAMERON, N. (1963). Personality Development and Psychopathology, pp. 705-714. Boston: Houghton MiWin. ENGEL, G. L. (1%2a). Psychologicallkvelopment in Health and Disease. Philadelphia: Saunders. ENGEL,G. L. (1%2b). Anxiety and depressionwithdrawal; the primary affects of unpleasure. Int. J. Psycho-Anal. 43,89-97. FORTH,M. Bi JACKSON. M. (1976). Group psyche therapy in bronchial asthma. Paper read at 10th European Conference on Psychosomatic Research, Edinburgh. Br. J. med. Psychol. 49, 257260. FRENCH, T. M. et al. (1941). Psychogenic Factors in Bronchial Asthma. Psychosomatic Medical Monograph No. 2. GREENACRE, P. (1953). Trauma, Growth and Personality. London: Hogarth Press. GROEN,J. J. & PELSER,H. E . (1960). Experience with group psychotherapy in patients with bronchid asthma. J. psychosom. Res. 4, 191-205.
HACKEIT, T. P. & CASSEM,N. H. (1974). Development of a quantitativerating scale to assess denial. J. psychosom. Res. 18,93-100. HAMELING, H. J. (1974). Models for psychotherapy in respiratory disorders. Paper read at 10th European Conference of Psychosomatic Research, Edinburgh. JACKSON, M. (1973). Integration of psychosomatic medicine in a teaching hospital. Psychother. Psychosom. U ,205218. KNAPP, P. H. (1%9). The asthmatic and his environment. J. nerv. ment. Dis. 149, 133-151. KUEIE,L. S.(1953).The central representation of the symbolic process in relation to psychosomatic disorders. Psychosom. Med. 15(1), 1-7. LEIGH,D. & MARLEY, E. (1%7). Bronchial Asthma: A Genetic, Population and Psychiatric Study. Oxford: Oxford University Press. Z. J. (1971). Consultant-liaison psychiaLIPOWSKI, try in general hospitals. Compr. Psychiat. 12(5), 105-124. L~FGREN, J. B. (1961). A case of bronchial asthma with unusual dynamic features treated by psychotherapy and psychoanalysis. Znt. J. Psychoanalysis 42, 414-423. MCDOUGALL,Joyce (1974). The psyche-soma and
Psychopathology and psychotherapy in bronchial asthma the psychoanalytic process. Int. Rev. PsychoAnal. 1(4), 437459. O~LER (1892). The Principles and Practice of Medicine. Edinburgh, London: Pentland. PeDDeR, J. R. (1969). Psychosomatic disorder and psychosis. J. psychosom. Res. 13, 339-346. PINKERTON.P. (1974). In Munro (ed.), Psychosomatic Aspects of Asthma in Psychosomatic Medicine, pp. 17-30. Edinburgh: Churchill Livingston. P. & WEAVER,P. M. (1970). In D. W. PINKERTON, HiU (ed.), Modem Trends in Psychosomatic Medicine. London: Butterworths. RECKLESS, J. F. (1972). Groups, spouses and hospitalization as a trial of treatment in psychosomatic illness. Psychosomatics 13,353-357. REES, L. (1956). Physical and emotional factors in bronchial asthma. J. psychosom. Res. 1.98-1 14. REISER, M.F. (1968). Psychoanalytic method in psychosomatic research. Znt. J. Psycho-Analysis 49, 231-235. SCHMALE,(1972). Giving up as a final common
255
pathway to changes in health. Adv. Psychosom. Med., 8 , 20-40. SCHUR.M.(1955). Comments on the metapsychology of somatization. Psychoanal. Study Child 10. SEGAL,H. (1954). A note on schizoid mechanisms underlying phobia formation. Znt. J. PsychoAnalysis 35, 238-241. SEGAL, H. (1%). Introduction to the Work of Melanie Klein. London: Heinemann. Simeos, P. E. (1972). The prevalence of ‘alexithymic ’ characteristics in psychosomatic patients. Topics of PsychosomaticResearch. Basel: Karger. WINNICOTT, D. W. (1958). Collected Papers. lllrough Paediatrics to Psychoanalysis. London: Tavistock. WISDOM,J. 0.(1959). On a differentiating mechanism of psychosomatic disorder. Znt. J. PsychoAnalysis 40(2), 134-146. &ALLEY, A. K.,AITKEN, R. C. B. & ROSENTHAL, S. V. (1970). Asthma: a psychophysiological investigation. Proc. R. SOC.Med. 64, 825-829.
249
Psychopathology and psychotherapy in bronchial asthma* BY MURRAY JACKSONt
Writing about bronchial asthma eighty years ago Osler made the following comments: ‘One of the most striking peculiarities is the bizarre and extraordinary variety of circumstances which at times induce a paroxysm. . .Fright and violent emotions of any sort may bring on a paroxysm . . .We have no knowledge of the morbid anatomy of true asthma. Death during the attack is unknown ’ (Osler, 1892). It is instructiveto contrast these views with the present situation. Today a great deal is known about the relevant pathology, and death, far from being unknown, is a recognized hazard, partly attributable to the introduction of steroids (see Pinkerton & Weaver, 1970). Psychosocial factors are widely acknowledged amongst the ‘bizarre’ precipitants, and psychopathology has emerged as a discipline with a contribution to make to the understanding and management of the disease. The importance of infective and allergic factors has long been established and advances in understanding the chemistry of immune globulins is throwing light on the mechanisms that lead to bronchospasm. The role of genetic predisposition has been clarified, notably by the work of Leigh & Marley (1%7). The classic studies of Linford Rees (1956) demonstrated the high incidence of psychosocial stress in asthmatics. Despite all this progress there is little agreement about the nature and mode of operation of psychosocial factors in contributing to the asthmatic attack. Indeed, some recent research has been interpreted to indicate that asthmatics do not differ psychologically from the normal population (&alley, Aitken & Rosenthal, 1970) and it has been demonstrated by a long follow-up that asthmatics have no greater incidence of overt psychiatric disorder than the normal population (Benjamin, 1974). Since there is such a lack of agreement amongst experienced workers in the field it is not surprising that the place of psychotherapy in the treatment of asthma is an even more disputed subject. Opinions range from those who believe that it is often the most important approach (though by no means the only one) to those who would regard psychotherapy as having no part at all to play, except perhaps in the sense of a general supportive measure. With the extension of the psychiatric services into general hospitals, the psychiatrist will have many opportunities to explore the potentials of psychosomatic liaison activities (Jackson, 1973) which are likely to play an increasingly important part in his professional life (Lipowski, 1971). His help will be more often sought in the management of such ‘stress’ disorders as bronchial asthma and his expertise in psychopathology and psychotherapy will be in demand. THEORETICAL FRAMEWORK
Psychoanalytic theory provides a coherent framework for the understanding and psychotherapy of asthma and other stress disorders. Detailed exposition would be outside the scope of this paper. and only brief mention can be made of some key concepts. (1) The role of denial as a coping method in ego defence where denial is seen as a goal or strategy attained by many different defensive tactics (Hackett & Cassem, 1974). (2) The reciprocal relationship between the effectiveness of ego defence and neuroendocrine * Based on a paper read at the Annual Conference of the Society for PsychosomaticResearch, London, November 1974. t King’s College Hospital, Denmark Hill, London, S.E.5.
250
M. J A C K S O N
activation. As Reiser (1968) has pointed out, there is much evidence for the existence of such a reciprocal relationshipboth in conditionsof chronic sustained stress, and of acute psychological decompensation. It also seems clear that psychotic mechanisms may be as effective in containing conflict as are more healthy and socially adaptive ego activities. (3) The concepts of desomatization and resomatization (Schur, 1955)* and Engel’s addition of a ‘conservation-withdrawal’ mode to the familiar ‘flight-fight ’ response to stress (Engel, 1%2a; Schmale, 1972). The implications of these concepts is that when an individual fails to cope with stress, either because it is too overwhelming,or because he has failed to learn adequate coping methods, major biological arousals may occur. These arousals may be regarded as the somatic aspect of a regressive psychobiological response, whose psychic aspect is preverbal fantasy of a primitive and concrete kind. Complex determinants will decide the choice of target organ, and such factors as conditioning and secondary gain may be involved. In Engel’s terms, the mind has a buffering function for the body and conflict is expressed viscerally when it cannot be effectively confined to the ideational sphere. In practice the coping deficit typically appears as the inability to give adequate affective expression to distressing conflict, and in the case of asthma, the subsequent attack can at times be ascribed a meaningful content. Thus Hambling (1974) has reported the cathartic alleviation of attacks of asthma which he classified as the expression of a suppressed cry of grief (comparable to the familiar notion of the ‘cry for the mother’) or anger, or of sexual excitement. A further implication of the concept of ‘resomatization’ is, therefore, that where psychological stress is a factor in somatization, the process should be reversible, and it is this ‘desomatization’ that is the major goal in psychotherapy. ILLUSTRATIVE CASES
Two patients will illustrate these processes. The first, a brilliant and gifted artist of 40, had severe steroid-dependentasthma of many years duration, with recurrent episodes of status asthmaticus. An important factor in the precipitation of his attacks seemed to be the conflicts aroused within his intensely dependent tie to his wife, who was in the process of turning against him. He appeared as a subject at a clinical meeting with a selection of dramatic paintings mostly depicting incipient doom and the struggle between primordial forces of good and evil, whilst asserting that he was feeling reasonably calm. Psychotherapy was arranged and the initial contact was satisfactory. At this point his wife returned from abroad, rejected him, and he went into status. The psychotherapist did not hear of his admission, and he died in 24 hours. This event may be regarded as a catastrophic somatization which might have been avoided or mitigated. In Engel’s terms the patient was overwhelmed with hopelessness, was deprived of help, perhaps gave up the struggle and succumbed to the physiological consequences of a massive ‘conservation-withdrawal ’ reaction. The second patient was a woman of similar age and severity of asthmawho had spent 18 months in a psychotherapeutic group, when she found herself caught in a disturbing life-situation. She had made enough progress in the group to be able to try to give expression to her feelings, a capacity she had not had before. She arrived at a session wheezing, and rapidly developed severe respiratory distress. At the point where her life situation became the centre of the group’s attention she ran out of the room. At this point a female colleague, who knew the patient and happened to be on hand, simply put her arm round the patient and encouraged her to give in to her feelings. She burst into tears, and the respiratory obstruction rapidly diminished. She * According to these views mind and body as functioning entities differentiate out in the course of normal
ontogenetic development from an original psychosomatic unity. This ‘desomatization ’ process is never complete, may fail to varying degrees or be reversed under later stress (resomatization) (see Cameron, 1%3).
Psychopathology and psychotherapy in bronchial asthma
25 1
returned to the group, verbalized her feelings of resentment against her husband, and within ten minutes her breathing was normal. Although there is nothing unusual about the relief of a single asthmatic attack through emotional catharsis, the effect of the physical contact was impressive, as was the fact that she had no further asthma for the next 12 months. By contrast to the first case this episode may be seen as a dramatically effective desornatization where the right help was provided at the right time in a patient in the throes of helplessness and progressive ‘conservation-withdrawal ’. PSYCHOSOCIAL STRESS AS A CAUSAL FACTOR IN ASTHMA
The opportunity to study 30 asthmatic patients in some depth has led me to the conviction that psychosocial factors are of paramount importance in the genesis of the asthmatic attack. Although this conclusion is not a particularly original one, and is derived from experience of a number of specially selected patients, it permits some commentson aspects that may not be widely recognized. Psychosocial factors in asthma are of the nature of contributory causes, neither necessary nor suficient. Whereas a healthy person may produce wheezing by voluntary activity, and an asthmatic may likewise produce an asthmatic attack, true asthma cannot occur unless the bronchial tree is physiologically labile (see Pinkerton, 1974).* Psychological factors in the personality may also be a consequence of the asthmatic attack (the somatopsychic direction) and it is well known that asthmatic children may learn to avoid emotional arousal of all sorts because they have discovered that any excitation may produce an attack. Such emotional inhibition may, however, be frequently encountered in late-onset cases, which may be seen to have had the same impoverishment of coping capacities for years or decades before their first attack. This may suggest that the familiar ‘bottling up’ of emotions is more relevant as an antecedent to the asthmatic attack than a consequence.
Pathogenic stress and the containment of conflict The nature of the pathogenicpsychosocial stress in asthma has been widely documented in terms such as the threat of loss or actual loss; of separation anxiety; of the threat of aggressivefeelings evoked within a dependent or symbiotic relationship with a mother figure; of the evocation of a specific alTective state of helplessness and hopelessness (Engel, 1%2b; Knapp, 1%9). These situations are all encountered in practice with varying frequency, and they have one thing in common, namely that they expose the person, of whatever age, to feelings that he cannot contain. The word ‘contain’ is introduced here to describe a mature capacity to experience, tolerate and give adequate expression to feelings. The word could be regarded as antithetical to ‘retain ’ in the sense of ‘bottling up ’ of emotions, a state widely regarded as characteristic of the ‘psychosomatic’ patient. The work of such psychoanalysts as Bion (1%2) and Winnicott (1958) suggeststhat if an infant and child does not have the experience of a mother figure who can herself contain strong emotions communicated by her infant, his ego development and thus his maturation will be impaired. The implication of these views is that a ‘good-enough’ mother (Winnicott’s term) is not only ‘caring’ in the sense of providing the necessary loving care and attention, but is also capable of ‘containing’ her infant’s feelings in the above sense. The ‘containment’ concept may also help in understandingthe mechanisms underlying certain phobias, which may have relevance to the psychopathology sometimes involved in asthma. A phobic object, such as an insect or animal, may at times be selected by chance alone, but at other
* The possibility that early life experiences from birth onwards may provide a psychogenic component to this constitutional vulnerability is a matter that has long preoccupied psychoanalysts, and is an extremely difficultsphere of research (Greenacre, 1953; French et al. 1941).
252
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times may be selected as a symbolic container for parts of the self and inner world felt to be dangerous and destructive. The concept of projective identification introduced by Melanie Klein can enlighten this formerly obscure area of psychopathology (Segal, 1954, 1964). This work suggests that symbolization may be primary in some psychosomatic disorders [at least in those disorders of systems having apertural connexion with the outside world, and thus concerned in earliest perception and learning (see Kubie, 1953)], that the symptoms may thus be regarded as having a meaningful mental content, though of a very primitive and preverbal kind, and that the optimal aim of dynamic psychotherapy is to help this be integrated. Clinical experience suggests that phobic symptoms are relatively common in asthma [Pedder (1%9) has demonstrated this in a detailed survey of psychosomatic disorders], and a widely accepted explanation is that the repeated traumatic experience of respiratory oppression may give rise to claustrophobicanxieties. Whilst this is no doubt true, such symptomsare often encountered years or decades before the first onset of symptoms (in late-onset asthma). In such cases we may consider the possibility that such antecedent phobic symptoms are a dynamic precursor of, or alternative to, the somatic symptom, both of which may have meaningful psychic content. The disorder of ego function that may be involved in cases of severe asthma may also at times be encountered in other psychosomatic disorders, borderline states and anorexia nervosa. This disorder may be regarded as a failure in the development of psychological representation of states of body tension and sensation arising from birth onward (see Mchugall, 1974). Freud’s dictum ‘the ego is first and foremost a body ego ’ can be applied to the phenomena of somatization,which can be considered as in part the expression of mental (or more accurately psychobiological) processes of a primitive and preverbal kind, which have failed to be transformed into truly symbolic processes which can achieve psychological representation. [Wisdom (1959) has described an aspect of this impairment as the failure to shift from the kinaesthetic and proprioceptive to the visual representation sphere of imagery.] The normal ontogenetic desomatization has not been achieved, or has been lost under stress, and true ‘mentalization’has not been successfully established. In this context we can consider conflicts and confusions occurring in psychic reality over the retention and expulsion of good and benign and bad and dangerous objects and substances,with visceral spasm as its somatic concomitant. Such ideas may expand the psychological aspects of Engel’s concept of ‘ conservation-withdrawal ’. DENIAL AS A SPECIFW DEFENCE
An impaired capacity to contain and communicate feelings implies a degree of ego weakness in a personality that may sometimes in other respects be strong. This weakness involves the extensive use of denial as a defence. This denial can range from a conscious and fearful repudiation of emotion (where a person simply cannot think about his feelings) to a splitting or discontinuity within the personality such as is seen in major hysterical or borderline psychotic states. When denial is not deep-seated it may be easily reversible. As J. J. Groen (1974, personal communication) has pointed out, some people may be quickly helped by an accepting therapist to learn to express their feelings. This factor needs to be taken into account when explaining and evaluatingthe positiveresults of behaviour therapy and drug therapy (such as antidepressants) in some cases of asthma. When denial is very deep-seated it may appear to be irreversible,and associated with a peculiar impoverishment of vocabulary of ‘emotion’words. This has led Sifneos (1972) to coin the term alexifhymia (no word for feelings)and to suggest a maturationalfailure of limbic neural connexions as a possible explanation. Whilst environmentalfailure in the earliest critical periods of development may well be decisive for ego development, further exploration of the role of primitive
Psychopathology and psychotherapy in bronchial asthma
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defensive operationsis needed before organicfactors can merit etiologicpriority (see McDougall, 1974). PROBLEMS OF ENGAGING THE PATIENT IN ~YCHOTHERAPY
Experience suggests that asthmatic subjects may be more difficult to engage in insight psychotherapy than neurotic patients, and this deserves comment. Apart from the obvious possibilities of poor selection and lack of therapist skill, there are factors in the patient and the setting that need examination in this respect. Where denial is being used as a main defensive method, insight is likely to be vigorously repudiated. Where the patient has been referred to the psychiatrist as a last resort, or because he has finally encountered a physician who is sympathetic to the psychosomatic approach, he may already have had long experience of a ‘medical’ (as opposed to a psychosomatic) model of his disorder, and this may have reinforced his defences of denial. Where the idea that referral of such cases to a psychiatrist carries the implication of mental disorder, it is not surprisingthat the patient’s natural wish to regard his disorder as an exclusively organic one may have become strongly reinforced. Another possible factor, although a speculative one, is that steroids, used in significant amounts over a long period, may cause mood change, short of the familiar steroid psychosis, which reinforce defences of a manic character. These various factors, singly or in combination, may greatly decrease the patient’s capacity to engage in the therapeutic task, whose first step is to increase the recognition of disturbing feelings, rather than to escape them. AIMS, TECHNIQUES AND OUTCOMES
When the psychotherapist is asked to help in the management of an asthmatic patient, the obvious aim is alleviationof the symptom. The catharsisaccompanyingemotionalventilationmay achieve this, but the psychotherapist is more likely to be aiming for permanent structural change in the personality, which would represent a major achievement requiring adequate time and skill. Many techniques exist to approach these two goals, of symptom relief and personality change. The most fundamentalof these is formal psychoanalysis, which offers specific opportunities for treatment and research in appropriate subjects (see Liifgren, l%l). The practical difficulty of providing this treatment generally is well known, and modifications and applications of psychoanalytic methods are more widely available. One approach is to offer individual once-weekly sessions for a prolonged period, or to help the patient to a point where he can make good use of group therapy. Many patients cannot tolerate group therapy without a preliminary period of weeks or months preparation. This initial work is aimed at helping the patient recognize the connexion between his state of mind and his attacks of asthma, and to promote the capacity to investigate and think about feelings, a capacity which is often absent in the beginning. Once these goals are achieved, group therapy may offer more to the patient than once-weekly individual therapy (see Forth & Jackson, 1976). Modification of these familiar techniques are of considerable interest and may have a good deal to offer the patient. Psychodrama and encounter group methods in the right hands may offer a concrete experience that could be helpful to some asthmatics. The favourable results of group therapy reported by Groen & Pelser (1960)may in part be due to the physical medical care offered concurrently by the therapists, and it is interesting to consider that a large mutually caring patient group, the Nederlands Asthmatic Association, developed spontaneously from their therapeutic activities. An interesting modification is reported by Reckless (1972)whose unorthodox group method involves some limited physical contact when a patient is in the throes of an asthmatic attack, together with group pressure on the patient to examine and identify the relevant emotional state that precipitated it. This is an attempt to combine a reassuring physical contact with affective expression and psychodynamic insight which, at least in theory, seems a desirable aim. The use
254 M. JACKSON of hypnotism, biofeedback and new relaxation approaches are of great interest and importance and the psychotherapist may contribute to the evaluation of some of their successes in terms of the dynamics of transference and ‘containment’. CONCLUSIONS
Pinkerton (1974) makes a timely comment on the use of steroid therapy in asthmatic children: ‘. . .proper attention to emotional pathology in refractory asthma may obviate the need for steroid therapy, thereby reserving this potentially hazardous therapy for its proper indications - the physiologicallyseverecase ’. These cautionary words are equally applicable to the evaluation and management of the adult asthmatic. In this task the identification of the emotional pathology may be far from easy, and understanding of the defensive mechanisms of denial may be crucial. The majority of asthmatic subjects may well have no more than their normal share of emotional conflicts, apart from those engendered by the condition itself, but it is important for physicians to recognize that ‘pseudo-normality’ is a very real entity. Failure to recognize this may lead to a serious underestimation of the role of emotional factors in the genesis of asthma, and thus of neglecting the potential of psychotherapy in the treatment of this distressing disease. SUMMARY
The role of psychological factors in the genesis of bronchial asthma is much disputed, and hence the place of psychotherapy in its management is equally controversial. The opportunity to study a series of such patients and to attempt to provide psychotherapy for them has led the author to the view that significant psychopathology is more common in asthmatic subjects than is generally realized, and that psychotherapy has a vital part to play, in management. Some case material is presented to support this contention, and the application of psychoanalytic concepts, evaluation and treatment are discussed. ACKNOWLEDGEMENT
I am greatly indebted to Dr Philip Hugh-Jones, Director of the Pulmonary Research Unit, King’s College Hospital, for his invaluable cooperation. REFERENCES
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