Am

J Psychiatry

Severe BY

135:8,

August

1978

Hypertension

FRANK

CLINICAL

Treated

SUMMERS,

Successfully

by Marital

of this

investigators

disorder.

have

Despite

found

the fact

it to be useful

that

some

in some

cases

the predominant view of practitioners appears to be that medication alone is a sufficient treatment (3). However, there are cases that are controlled only with

(2),

great

difficulty

on not

at all by medication,

and

in such

be considered as a treatment option. The purpose ofthe present report is to advance the thesis that psychotherapy can be of value in pacases

tients

psychotherapy

who

are

may

refractory

to medication

by

presenting

Ms. A, a 64-year-old obese mother of nine, had been marned for 47 years at the time of consultation. In the 2 years she had been attending a hypertension clinic, her blood pressure readings were generally 280-300 systolic and I 10-120 On

several

occasions

the

systolic

pressure

was

too

high to measure. Her treatment regimen consisted of methyldopa, 500 mg q.i.d. ; propranolol hydrochloride, 120 mg b.i.d. ; hydrochloride, 100 mg t.i.d. ; furosemide, 120 mg q.A.M. ; and hydrochlorthiazide, 50 mg q.A.M. Despite this intensive treatment, Ms. A had shown no noticeable consistent reduction in blood pressure since she began attending the clinic. She reported that she felt well both physically and mentally. She was considered free ofpsychiatnic difficulty by both her physician and herself, and she had no psychiatric history or previous treatment. The psychological consultation was performed on the request of the therapist, whose interest was piqued by the high blood pressure readings and the inability of the patient to profit from high doses of five powerful antihypentensive agents. Ms. A appeared to be a nice, quiet, cooperative, affable, neatly dressed woman who looked younger than her stated age. The initial interview consisted of general, open-ended questions regarding her life situation. She did not hesitate to

report

was

Psychotherapy

to me frustrations

in her

relationship

with

her

hus-

band. She stated that her husband was arrogant, insensitive, hypercritical,jealous, and unable to listen to her. She elaborated that his personality had been more bothersome to her recently since her youngest child had left home. She felt that she was now more dependent on her husband than at any previous time in their relationship. Ms. A was also upset by what she felt was an insufficient amount ofcontact with all of her children. She reported feeling lonely and isolated since her last child left home and wished her children would initiate more contact with her. Ms. A depended heavily on reli-

clear

that

this

quiet,

unassuming,

an was deeply depressed felt empty and alone,

about rejected

apparently

the marital relationship, counseling was in order. band’s potential compliance initial

interview.

He

calm

worn-

her current life situation. by her husband, and

doned by her children. She gave Because her difficulties tended

wife also wife

Report

diastolic.

REPORTS

gion and expected her husband, who was a minister, to help her see the ‘ ‘goodness of the Lord,’ ‘ but she was frustrated in this expectation. Ms. A requested further interviews and was seen individually in once weekly psychotherapy for several weeks. Much of the content of these interviews centered around hen frustration in attempting to communicate with her husband and her tolerance ofwhat she felt to be his constant abuse. It

an

one such case. Case

RESEARCH

PH.D.

Since the work of Alexander (1), a major controversy in psychosomatic medicine has centered around the role of psychological factors in the etiology and treatment ofhypertension. One ofthe major issues in this area is the efficacy of psychotherapy in the

treatment

AND

She aban-

no indication of anger. to be concentrated around

Ms. She

A and I agreed that marital was dubious about her husbut prevailed on him to attend quickly displayed the qualities his

had ascribed to him. Mr. A, a short, round man appeared younger than his stated years, attacked for not listening to him, accused her of infidelity

having a ‘ ‘mean temper,’ ‘ and gave reply. He insisted that his wife agree superior education and ‘ ‘understanding stressed to the therapist that his wife

tempered,”

and

he

attributed

who his and to

her little opportunity with him because of his of psychology. ‘ ‘ He was “evil” and “mean-

these

traits

to

her



‘going

through the change of life. ‘ ‘ Ms. A offered little in reply cxcept to state quietly and rather hopelessly that these charges were unfair. Initially, the focus of the therapy was on providing an atrnosphere in which Ms. A could tell her husband how his accusations make her feel. By the second session, she began to do this and, concurrently, to complain to Mr. A of the difficulties she had stated previously to me. This increased the tension in their relationship temporarily, but it also provided a more balanced conflict. The therapeutic focus could now shift to fostering awareness in each party of how his or her attacks made the other feel. Beginning with the fourth conjoint session, Mr. A acknowledged that his complaints about his wife made her feel bad. Ms. A grudgingly came to a similar awareness. Even as Mr. A insisted on the truth of his allegations, he began to feel accountable for his wife’s responses to them. According to both parties, Mr. A reduced his attacks on his wife considerably after the fourth session. After this session, Ms. A’s blood pressure fell for the first time since her treatment at the clinic had begun. This decline continued until it reached a steady level of 190-200 systolic and 90-95 diastolic. There were no changes in medication or

frequency

of medical

continued

for 4 months,

contacts.

The

at which

continue the treatment, to his wife’s tinued to see me on an individual sions. at which time I left the mained at the same level after and conjoint sessions.

marital

time

Mr.

sessions A decided

were to dis-

displeasure. Ms. A conbasis for five more ses-

clinic. Her termination

blood pressure reof both individual

REFERENCES Dr. Summers stitute

Erie St. chiatry,

of ,

is Clinical Psychiatry,

Chicago, Northwestern

Psychologist, Northwestern

Sustaining Memorial

Care

Program,

Hospital,

Ill. 60611, and Associate, Department University Medical School.

0002-953X/78/0008-0989$0.35

301

InEast

of Psy-

© 1978

I . Alexander sentation 1939

American

F: Emotional of a tentative

Psychiatric

factors hypothesis.

Association

in essential hypertension: prePsychosom Med I: 173-179,

989

CLINICAL

AND

RESEARCH

2. Wolff H, Wolff Hypertension:

5: The management of hypertensive patients, A Symposium. Edited by Bell E. Minneapolis,

Psychoanalytic BY

LEON

Observations WALLACE,

effects,

treatment

on

in

are

Marijuana

others

during

in whom

use of marijuana

After

has

revealed no other reports of this kind. The limitations of psychoanalytic investigations are well known. The focus on therapeutic goals has limiton data

collection,

and

the

analysis

may

in-

fluence responses to the drug. However, if these limitations are kept in proper focus, scientific knowledge about marijuana may be increased by such studies. I will focus particularly on the immediate aftereffects of marijuana.

a

success

achieve

with

laborer,

neurosis.

some

goal

after

time

he had

professional

symptoms reaction,

college

or to begin

Mr. A reported years,

often

joints His

a day, use

on

that a daily

although

of marijuana

ment progressed. order to tolerate

self-treatment with cal responses which A did not immediately the

He then reported coworkers to join pliance

was

been

associated

about

managed

were

team.

to

offered

He

subdued. were

1955

a career

and

basis.

He

was

eager

marijuana

a

immedi-

he generally

smoked as the

boredom chronic

was then

10

smoked

somewhat

psychoanalytic

pervaded boredom

Later ical

into

the

marijuana however,

of

investigation.

a great deal of social pressure them in smoking marijuana. with

his

hunger

for

Dr. Wallace is Assistant Clinical Professor, try, University of California, Los Angeles, dress reprint requests to him at 3400 Lomita

from his His corn-

acceptance

by

Department of PsychiaSchool of Medicine. AdBlvd.

,

Torrance,

Calif.

90505. 0002-953X/78/0008-0990$0.35

His

effects

he reported

for his wife

ambition

he might

in the treatment,

Mr.

and

spend

drive

as well were

as also

the rest ofhis

A reported

of marijuana-intense

that the to repeat

tolerate

life as

delays

was

another

daydreams a let-down

associated

fantasies were unreal. The the high. This decreased

involved

in pursuing

Mr. A completely

psycholog-

during with

high. recog-

result was an his motivation

his goals

discontinued

the the

imto

in reality.

marijuana

use for

some time, he experienced increasing psychic discomfort that reached a peak in about 4 days. During this time he ruminated about the various frustrations and insults suffered at different times in his life and experienced virtually uninterrupted feelings of rage. This gradually tapered offto his ‘normal’ state by the 9th or 10th day.

Discussion

I observed this

in he

to be a form

analytic

the drug’s

of affection

intense.

and he feared

result

less. treat-

a tranquilizer that inhibited psychologineeded to be investigated. Although Mr. discontinue his marijuana use, the dissubject

the

two

every activity of his as a major symptom.

interpreted

disliked

for help.

for about

occasionally

of the group.

he intensely

a laborer.

patient.

© 1978

two First,

consequences

of marijuana

the

high

immediate

use

contributed

in an

intense quality to his daydreaming that substituted for the pursuit of satisfaction in reality and provided a temporary escape from internal conflict. Second, the aftereffects during the subsequent 24 hours had both pleasant and unpleasant qualities. The immediate postintoxication period was characterized by

fatigue,

lethargy,

and

a feeling

that

time

dragged.

The next day, however, there was a noticeable consistent tranquilizing effect, and all affects were diminished. This was an important reason for his regular use of marijuana. I have observed this tranquilizing effect in several other patients, sometimes lasting 2 or 3 days. Marijuana

990

Churchill,

like a member

that

idealized

Feelings less

decreased,

When

that he was getting an A was He had been unable to gradu-

he had used

him to feel

however,

he no longer

anger

to fail.

he had been

At first he said that he needed the boredom of his job. Soon,

The use of marijuana

brought

had

athletic

decreased

acknowledged that life, thus establishing

cussion

Press, 1951 Pressure. London,

1978

that immediately following the high he would become lethargic and tired, making his work much more difficult. This contradicted his earlier statement that the drug helped him to tolerate hisjob. Mr. A also observed that on the day after he used marijuana, all affects, both pleasant and unpleasant,

nition pulse

be described

of generalized weakness, an apand was dropped from the team.

A statement from a professor followed by inability to study. ate from

he

somehow

long preparation

a major

ately developed parent conversion

had what could

Each

career

For example, contract

permitted

The next day there

Report

Mr. A, a 32-year-old as

August

men at work and that marijuana helped him to ward off feelings of hatred. Before long the analysis helped him to recognize that he was intensely angry most of the time. A major function of the marijuana was to reinforce his defenses against the anger.

psychoanalytic

regular

and

He acknowledged,

is an incidental observation. The analysis of unconscious resistances should lead to more accurate descriptions of the effects of marijuana than are generally available. A review of the psychoanalytic literature

Case

of Minnesota G: High Blood

135:8,

Use

of regular users of marijuana, to a better understanding of the possible

of patients

ing effects

University Pickering

3.

J Psychiatry

M.D.

In-depth investigations which could contribute drug’s

Am

REPORTS

was

used

to try

to relieve

his painful

bore-

dom as well as to reinforce his defenses against anger. It was evidently particularly attractive because it worked in the same manner as a major psychic defense by suppressing all affects. In that sense, it may have American

Psychiatric

Association

Severe hypertension treated successfully by marital psychotherapy.

Am J Psychiatry Severe BY 135:8, August 1978 Hypertension FRANK CLINICAL Treated SUMMERS, Successfully by Marital of this investigators...
429KB Sizes 0 Downloads 0 Views