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