SOMATIZATION: A PERSPECTIVE FROM SELF PSYCHOLOGY

GARY M. RODIN, M.D.*

Somatization is a complex phenomenon that occurs in many forms and diverse settings. It is not necessarily path­ ological and may be found in a variety of psychiatric disor­ ders. Much of the psychiatric literature has focused on patients with conversion disorders and hypochondriasis. Psychoanalytic theories regarding such conditions were largely based upon concepts of drive, conflict, and de­ fense. The perspective from self psychology, with its em­ phasis on subjective experience and the sense of self, may further enhance the psychoanalytic understanding of so­ matization. Individuals with disturbances in the stability and organization of the self may present with somatic symptoms and disturbances in emotional awareness. So­ matization in such cases may be the experiential manifesta­ tion of a disturbance in the cohesion of the self and/or may result from defensive operations to ward off affect. The latter may be prominent when affective arousal triggers the psychological threat of fragmentation. Somatization may diminish in such individuals when a self-object relation­ ship is formed that bolsters and consolidates the sense of self. The integration of affect into ongoing subjective expe­ rience may also be an important aspect of psychoanalytic treatment in such patients. Somatization has been defined as the presence of somatic symp­ toms in the absence of organic disease (Kellner, 1986) or as the expression of emotional discomfort and psychosocial distress in the physical language of bodily symptoms (Barsky and Klerman, 1983). These definitions include states of bodily preoccupation and the tendency to experience one’s self in physical terms. Al­ though there are somatic manifestations of all emotional states, the term somatization seems most meaningful psychiatrically ♦Associate Professor, Department of Psychiatry, University o f Toronto; Psychiatrist-in-Chief, The Toronto Hospital. Journal of The American Academy of Psychoanalysis, 19(3), 367-384, 1991 © 1991 The American Academy of Psychoanalysis

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when used to refer to the tendency to be more aware of the physical than of the psychological aspects of emotional states. Until recently, the psychiatric literature on somatization has tended to focus on those patients who chronically seek medical attention and who demonstrate clinical features of hypochon­ driasis and conversion disorders (Brown and Vaillant, 1981; Engel, 1968; Lipsitt, 1974; Lowy, 1975). These conditions are categorized with the so-called somatoform disorders in both DSM-III and DSM-III-R. Attention to these syndromes is justifiable in terms of the clinical dilemmas and disproportionate health-care utilization associated with them. However, the focus of somatization on these disorders may have drawn attention from the broader implications of somatization in other clinical contexts. Recent studies emphasize that somatization and the tendency to amplify, bodily sensations (Katon, 1984) occur in a wide variety of clinical and nonclinical situations (Katon et al., 1984; Kellner and Sheffield, 1973; Slavney and Ifeitelbaum, 1985). Although the so­ matoform disorders represent striking examples of somatization, these conditions may account for no more than one-third o f the Axis 1 DSM-III psychiatric diagnoses in somatizing psychiatric patients (Katon et al., 1984; Slavney and Teitelbaum, 1985). In fact, somatization has been observed in almost the whole range of psychiatric disturbances (Slavney and Tbitelbaum, 1985). Further, although psychiatric disorders may be more common in patients who somatize (Slavney and Teitelbaum, 1985), a high proportion of normal individuals report at least one somatic symptom during any one-week period (Kellner and Sheffield, 1973). A reconsideration of psychoanalytic aspects of somatization may be timely for several reasons. First, psychoanalytic approach­ es, once prominent in this area, may now be underestimated within the psychiatric community. In this regard, recent psychiatric re­ views of somatization reflect the perception that psychoanalytic approaches to somatization are of limited or modest value in un­ derstanding or treating this clinical problem (Ford, 1983; Kellner, 1986; Lipowski, 1987). Second, disappointment with psychoana­ lytic approaches to somatization, particularly with the more severe or refractory cases, may have led to undue skepticism among prac­ ticing analysts about the suitability of, or benefits from, psychoan­ alytic treatment of somatizing patients. Recent texts on the princi­ ples of psychoanalytic psychotherapy (Luborsky, 1984; Paolino, 1981) tend not to address specifically the problem of somatization. Indeed, there are few practitioners today who share the enthusiasm

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evident several decades ago regarding the psychoanalytic treatment of somatizing patients. This more positive view was expressed over 40 years ago by Otto Fenichel (1945) regarding the psychoanalytic treatment of hysteria, a dramatic example of somatization. He said, Conversion hysteria is the classical subject matter of psychoanalysis. As a matter of fact the psychoanalytic method was discovered, tested and per­ fected through the study o f hysterical patients; the technique of psycho­ analysis still remains most easily applicable to cases of hysteria and it is psychoanalytic treatment o f hysteria that continues to yield the best thera­ peutic results, (p. 230)

The relationship of somatic experience to the sense of self and the significance of somatic symptoms that emerge in response to disruptions in the transference relationship have been discussed in a previous publication (Rodin, 1984). The present article will ad­ dress the psychoanalytic treatment of patients who present with functional somatic complaints not necessarily associated with a clearly defined Axis 1 psychiatric disorder. Recent contributions from the study of self psychology, intersubjectivity, and the de­ velopment of emotional awareness will be discussed in terms of their relevance to the phenomenon of somatization. There is clear overlap between these and earlier theoretical formulations and a comprehensive review of all psychoanalytic approaches to somati­ zation will not be attempted here. Classical psychoanalytic ap­ proaches to somatization will be mentioned briefly but will not be discussed at length here. These concepts have already been well described in the literature (Engel, 1968; Fenichel, 1945; Schur, 1955). The more modest purpose of this article is to illustrate how some of the concepts noted above may enhance our psychoanalytic understanding and treatment of somatizing patients. A patient who presented with somatic complaints and who was treated with psychoanalysis will be described to illustrate these concepts and their implications for treatment. Numerous psychoanalytic formulations have been proposed to describe mental processes and to explain the origin and dynamics of psychopathology. However, a unifying theoretical model that is universally accepted within the field of psychoanalysis has not yet emerged. As several authors have recently emphasized (Cooper, 1985; Pine, 1988; Pulver, 1987), differing theoretical formulations influence both psychoanalytic understanding and practice. For de­ scriptive purposes, Pine (1988) recently delineated four discrete

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but overlapping psychologies that can be identified in psychoana­ lytic theory to date. These are the psychologies of drive, ego, object relations, and the self. Traditional psychoanalytic explana­ tions are based largely upon the psychology of drive, conflict, and defense. Subsequent formulations place more emphasis on the in­ dividual’s adaptation to the environment, early dyadic relation­ ships, and the consolidation of the boundaries and structure of the self. Self psychology and related areas of study including intersub­ jectivity, and the psychoanalytic study of infants and children, have also contributed importantly in this regard. The discussion will begin with a brief summary of somatization as understood by classical theory. This will be followed by a con­ sideration of somatization from the perspective of self psychology and subjective experience. SOMATIZATION AND CONFLICT THEORY Early in the history of psychoanalysis attention was directed to somatization in the form of hysterical conversion symptoms. Freud (1894) used the term conversion to refer to the process in hysteria whereby an “incompatible idea ia rendered innocuous by its sum of excitation being transformed into something somatic” (p. 49). Conversion symptoms were seen to arise in this model from the repression and distorted expression of instinctual im­ pulses. Freud was optimistic about the benefits o f psychoanalytic treatment in such cases. He observed that “each individual hysteri­ cal symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory o f the event by which it was provoked and in arousing its accompanying affect . . . ” (Freud, 1893, p. 6). There have been other psychoanalytic hypotheses based on the defensive function of somatic symptoms and the nature o f the repressed mental contents. Schur (1955) postulated that somatiza­ tion is associated with primary process thinking. He suggested that the sense of danger associated with sexual or aggressive wishes might result in regression with a resomatization of emotional re­ sponses. Freud (1914) distinguished conversion disorders from hy­ pochondriasis and suggested that the latter resulted from the with­ drawal of libido from the objects of the external world and the concentration of it upon internal organs. More recently, Arlow and Brenner (1969) argued that hypochondriasis, like conversion

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disorders, should be understood as a neurotic compromise forma­ tion. Broden and Myers (1981) support this view but suggest that whereas the conflict in conversion disorders is related to libidinal concerns, it is related to aggression in hypochondriasis. Wahl (1963) emphasized that somatic symptoms in the hypochondriac may serve an expiatory function related to guilt. He also drew' attention to the personal symbolic meaning o f the physical symp­ toms. Others have postulated that hypochondriasis may be related to more primitive psychological issues. For example, Rosenfeld (1958) suggested that temporary hypochondriasis might arise due to infantile psychotic anxieties and that chronic hypochondriasis might arise as a defense against confusional states, often of a schizophrenic nature. Others have viewed somatic preoccupation as a defense against depression (Dorfman, 1968) or as a response to the experience of loss (Mushatt, 1975). Brown and Vaillant (1981) suggest that hypochondriasis represents the transformation of reproach toward others first into self-reproach and then into complaints to others of pain or somatic illness. This latter view links the intrapsychic components of somatization with its inter­ personal manifestations in patients with hypochondriasis. A case is described below to illustrate some of the concepts described thus far: Mr. A is a 23-year-old single male university student who was referred by a neurologist for psychiatric assessment because o f physical com­ plaints th at had persisted during the preceding two years in the absence o f any identifiable organic disease. Specifically, he complained o f an inabili­ ty to concentrate and felt his mind to be in a “haze” or “fog.” He did not regard these symptoms to be related in any way to his emotions but wondered if they might be due to a “build-up o f sexual tension,” and he experienced some relief with m asturbation. He found these symptoms to be so troubling th at he could not continue with his university studies. In addition to his physical symptoms, Mr. A complained o f a tendency to feel confused and to experience doubt about whether his beliefs and goals em anated from within. A t times, he expressed strong opinions in discussions o f political or other subjects but felt unsure about his inner convictions and wondered if his firm stands on such matters merely served to establish his own sense o f identity through oppositionality. He was also uncom fortable with feelings o f dependency that seemed at odds with the im portance his father placed upon qualities o f stoicism and selfsufficiency. Em otional experiences were not discussed openly in the fami-

372 RODIN ly even though his m other seemed chronically withdrawn and unhappy. During the course o f treatm ent he came to believe that his m other had retreated from her unhappy state into secret alcoholism. His father was intelligent and well meaning but seemed wholly unable to communicate in emotional terms or to understand the difficulties o f others in the family. When interviewed, Mr. A presented as an intelligent, articulate young m an who was puzzled and distressed by his symptoms. He was introspec­ tive and tended to reflect upon philosophical questions regarding the purpose and meaning o f life. He appeared mildly anxious and depressed, which he attributed to worry about his physical symptoms. He denied vegetative symptoms o f depression, and there was no evidence o f cogni­ tive im pairm ent or o f any other psychiatric disturbance. He was prepared to entertain the possibility that his symptoms were emotional in origin although he did not experience them in this way. Most striking, however, were the large gaps in his recall o f his childhood and, in particular, the apparent absence o f emotionally significant memories. He was aware of no early experiences o f significant separation or loss in relation to his family. The self-absorption o f Mr. A ’s m other and the apparently limited capacity o f his father for em otional relatedness both seemed to contrib­ ute to Mr. A ’s sense o f isolation. His own feelings, wishes, and needs seemed burdensome to his m other and unacceptable to his father. His doubt about the legitimacy o f his feelings and needs was heightened by his perception that the needs o f his siblings were more tangible, more pressing, and more valid. The perceived unresponsiveness to and judg­ m ent o f his em otional experience seemed to interfere in this patient with the development o f emotional awareness and the capacity to integrate affective states into his experience. H e experienced affective arousal as threatening and associated with the risk o f psychic disorganization. A f­ fects tended to be split o ff from his experience, unrecognized and unac­ knowledged except in their somatic m anifestations and in intellectualized rum inations th at were several steps removed from the affective experience itself. Diagnostically, Mr. A dem onstrated some features o f hypochondriasis and o f a generalized anxiety disorder on Axis 1 and o f an avoidant personality on Axis II o f the DSM -III-R. However, his symptoms and presentation did not meet the full DSM -III-R criteria for any o f these conditions. The clinical picture was also suggestive o f a conversion disor­ der although this diagnosis can be ruled out in strict terms o f the DSMIII-R because o f the likelihood th at the physiological concomitants o f his anxiety contributed to his symptoms. His character structure, with his

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tendency toward rumination, emotional constriction, and isolation of affect may be regarded as obsessional in nature, although he did not meet DSM-III-R criteria for an obsessive compulsive personality disorder. Psy­ choanalytic treatment was considered suitable based on the usual criteria (Paolino, 1981) such as the presence of subjective distress, motivation for insight, the capacity to think in psychological terms, and the ability to form a therapeutic relationship as demonstrated over several assessment sessions. However, his difficulty identifying and communicating emo­ tional experience was noted as a possible limiting factor in treatment. COURSE OF TREATMENT Mr. A was distressed and was willing to accept psychoanalysis or any other treatment that might bring him relief. However, he was unsure as to whether his symptoms were physical or psychological in nature. He worried that psychoanalysis might cause him to become even more self-absorbed, confused, and disconnected from others. He feared that the therapy might cause him to “go crazy” or to become “lost” in his ideas. He also experienced a fear of psychic disorganization at other times of emotional arousal, such as during sexual excitement, and following separations from significant other, when he reported a “darkness” coming over him. He had not initially connected these experiences to his feelings and was puzzled on one occasion when the therapist used the phrase “sexual feelings,” stating that he had not considered sexual sensa­ tions to be associated with his feelings or emotions. Sessions during the early months of psychoanalytic treatment were characterized by his preoccupation with physical symptoms and by a marked tendency toward intellectualization. He contin­ ued to describe his symptoms in vague physical terms, “like waves,” and with metaphysical explanations, “like an energy force.” Al­ though he appeared to relate warmly to the therapist, he denied experiencing feelings o f closeness, because this was a “profession­ al” relationship. He made conscious efforts to be in tune with his emotions but felt that he could not muster any genuine feelings and that it was all “a fake.” The therapist initially found himself unwittingly drawn into seemingly fruitless intellectual discussions about affect. Yet, increasingly, it was possible to focus on felt emotional experiences, however momentary, that appeared during or outside of the sessions. It was often necessary for the therapist to draw upon his own emotional experience to identify the pa­ tient’s affective state. It became evident that the patient’s sense of

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disconnection from others and his “mental haze” was often trig­ gered by emotional arousal.. He feared a loss of his own sense of identity when he became attached to others but was even more threatened by the sense of isolation and disorganization that emerged when he felt disconnected from others. Mr. A’s reluctance to enter into a relationship was evident from the beginning of treatment. This reluctance seemed prominently related to the fear, in the absence of responsiveness from a signifi­ cant other, that the intensity of his feelings would cause him to lose his mind. The “mental haze” he described was a manifestation both of this perceived state of insanity and the defensive warding off of his emotional experience. As the therapeutic relationship deepened, Mr. A gradually became more aware of and more com­ fortable with emotional experience. He began to recall early emo­ tional experiences of various kinds. He cried for the first time in many years and reported feeling lonely, “screwed up,” and needing his mother. He identified himself with a boy in a movie who was crying because his mother never wanted him. He said, “In some ways, I feel really, really young and afraid of my parents leaving me.” He also recalled putting himself to sleep each night, as a child, by imagining situations of accomplishment, such as excel­ ling at sports, or of tragedy, such as the death of one of his parents, so that he might then, in fantasy, receive recognition or sympathy. He became aware of feeling frustrated with the therapist and others in his life for not doing more to help him. He said, “I feel anger toward you. Why can’t you do more? I’m not as con­ vinced as you are that talking will help.” In reference to the thera­ pist, he said, “I’m not sure of the reception I will get if I really let go. I fear or expect a clinical response.” As treatment progressed, the patient began to report that he felt more “real.” His somatic symptoms diminished and seemed to come less “out of the blue” although his somatic preoccupation and vagueness returned when he experienced the therapist as subtly rejecting or out of tune with him. On one such occasion, he said “I’m feeling spacy. It all starts to feel like words.” At other times, however, he experienced considerable relief when he could connect his thoughts and symptoms with his feelings and when he felt understood by the therapist. At such a time he said “I’m amazed that I never saw the tension as related to a build-up of feelings. I used to think of it as only physical. Now I feel a sense of peace. I’m aware of the world around me. It hit home.” This increased sense

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of the reality of his emotional experience was associated with a greater desire and capacity for closeness with his parents, whom he now actively struggled to reach, and with women whom he dated. DISCUSSION

Mr. A’s somatic symptoms may have arisen through multiple mechanisms and could be understood from many theoretical points of view. No attempt will be made here to discuss or even mention all possibilities. In part, the chronic state of physiological arousal associated with his anxiety may well have interfered with his capacity to concentrate, thereby contributing to the subjective experience of a mental “haze.” Further, there was evident second­ ary gain from his somatic symptoms; Mr. A had postponed diffi­ cult decisions regarding his career plans and had returned home to live with his family. His symptoms could also be viewed as a mani­ festation of a neurotic compromise formation involving sexual and other wishes and the defensive operations that had been called into play to reduce the associated anxiety. In part, he experienced sexu­ al feelings as threatening because they were associated with a po­ tential loss of control over his emotional life and with unaccepta­ ble and frightening wishes, such as dependency upon, merger with, and control over the exciting object. The concretization of his emotional concerns in his somatic symptoms served to express his sexual and other preoccupations but also to keep out of aware­ ness much of their unacceptable emotional significance. Similarly, his awareness of his mother’s emotional vulnerability may have contributed developmentally to increased guilt related to his hostile feelings. The course of treatment could also be understood in this patient in terms of a conflict-based model. Indeed, psychoanalytic treat­ ment helped bring to awareness Mr. A’s drive-related fantasies and the associated defensive operations. As interpretation and working through of the conflict progressed, his capacity to tolerate his emotional life improved, and the need for defensive operations diminished. Not only did this permit the “mental haze” to lift, but it also freed Mr. A from the generalized emotional inhibition and withdrawal that was so evident in his heterosexual relationships. However, attention to the interpersonal context of the patient’s symptoms, to deficiencies in affect discrimination and to the rela-

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tionship of affect to self experience helped to illuminate further the psychological basis of this patient’s somatic symptoms. Some of these concepts will be discussed below. SOMATIZATION AND DTADIC RELATIONSHIPS

In classical theory, neurotic symptoms were seen to arise in the crucible of early family relationships. Also, Freud (1926) empha­ sized the repetition in the transference relationship of instinctual conflicts related to parental figures. In recent years, however, more attention has been paid to early dyadic relationships and to the nondefensive or restitutive nature of transference relationships. This is implicit in Winnicott’s concept of the “holding environ­ ment” (1976) and in Kohut’s subsequent elaboration of the self­ object transference (1977). In these terms, the therapeutic relation­ ship is seen to bolster the sense of self in individuals whose capaci­ ty for autonomous self-regulation is deficient. It has been suggested by some (Gaddini, 1978; Kestenberg and Weinstein, 1978) that psychosomatic'symptoms belong, like Winnicott’s (1951) transitional object to an area of experience that is important in terms both of its symbolic relationship to the moth­ er and its physical reality. Kestenberg and Weinstein (1978) suggest that body memories may form part of this intermediate area of experience based on “yearning for past intimacy, and the recreation of past togetherness” (p. 90). In a similar vein, Gaddini (1978) suggests that when there have been experiences of loss or separa­ tion, the infant seeks in the somatic symptom a semblance of reunion with the mother. Similarly, in the psychotherapeutic situa­ tion, functional somatic symptoms may be related to a need for responsiveness from the therapist (Rodin, 1984). This wish to es­ tablish a particular role relationship (Sandler, 1976) in which the therapist provides relief from physical distress may be regarded as an example of “actualization” of the transference, that is, the expe­ rience of the patient that an unconscious fantasy is being partially fulfilled by the therapist (Boesky, 1989). It is perhaps not surprising that somatic symptoms should have particular significance in the therapeutic dyad because physical experience and somatic distress are so intertwined with parental care and attention early in life. In general terms, the health-care setting recapitulates certain aspects of the parent-child relation-

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ship in that the need for emotional support may be legitimized by physical distress. Like the suicidal expressions o f some patients, somatic symptoms may represent manifestations o f inner distress that cannot easily be disentangled from the presumed or fantasied response of the significant other. In the case described, the patient felt neither sufficiently aware of nor comfortable with his own emotional life to permit him to share this experience directly. His physical symptoms were an area of subjective experience that could be shared with the therapist. In this context, he recalled that, in his childhood, he would evoke fantasies of some unhappy event befalling him so that he could then imagine receiving sympathy and attention from others. In the therapeutic situation, the physi­ cal symptoms served not only to insure the continued interest of the therapist but also to ward off fears of abandonment. SOMATIZATION AND THE SELF Recent psychoanalytic developments regarding the so-called psychology of the self and the relationship of self experience to affectivity may further contribute to the understanding of somati­ zation. Heinz Kohut contributed most to the elaboration of the psychoanalytic psychology of the self although he was reluctant to define the self, which he felt was “not knowable in its essence” (1977). Building upon Kohut’s work, Atwood and Stolorow (1984) defined the self as a psychological structure through which experi­ ence acquires cohesion and continuity. More specifically, Stern (1985) has delineated the following senses of self as essential to daily social interactions: the sense of agency, the sense of physical cohesion, the sense of continuity, the sense of affectivity, the sense of a subjective self that can achieve intersubjectivity with another, the sense of creating organization, and the sense of transmitting meaning. Body experience, as several investigators have recently asserted, is the core around which these senses of self develop (Bauman, 1981; Lichtenberg, 1978; Stern, 1985). This concept was advanced earlier by Freud who asserted that “the ego is first and foremost a bodily ego” (1923). In certain states in adult life, particularly following stress-induced regression, self experience may be pre­ dominantly somatic. This is strikingly evident, as Kohut (1984) ob­ served, in association with the psychological threat of fragmenta­ tion of the self. He regarded the anxiety related to the threat of fragmentation or disintegration as the deepest anxiety that

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man can experience. Kohut (1971) and others (Stolorow, 1977) have considered hypochondriacal anxiety as a manifestation of the perceived threat of psychological fragmentation or disintegration. In such views, hypochondriasis is regarded not as a defensive oper­ ation but as the experiential manifestation of an endangered self. The technical approach that might follow from the latter concep­ tualization would emphasize the self-object experience that is nec­ essary to consolidate the sense of self. The empathic availability of the therapist is important in such cases to provide the self-object experience and to facilitate the integration o f affect into subjective experience. Stern (1985) has emphasized that parental attunement to the subjective experience of the infant facilitates the development of a subjective sense of self and of “core relatedness” that permits com­ munication in more than physical terms. Greenspan (1981) has similarly delineated the development progression from somatic to consequential to representational-structural learning. He suggests that somatic patterns become organized at the representational level so that somatic experience is perceived on an ongoing basis in light of the representational structures. This would support the observation that emotional experience is closely tied to intrapsy­ chic representations (Krystal, 1975) and that somatization may be associated with disturbances in the sense of self (Rodin, 1984). SOMATIZATION AND EMOTIONAL AWARENESS The developmental progression o f affects from somatic to ver­ bal experience has been widely discussed (Atwood and Stolorow, 1984; Krystal, 1975; Lane and Schwartz, 1987). Lane and Schwartz (1987) propose a classification of emotional awareness with emo­ tions that are experienced in more differentiated, attenuated forms at higher levels and those that are experienced as body sensations and action tendencies at lower levels of emotional awareness. This classification acknowledges that somatic symptoms may arise as a manifestation of a relative deficiency in emotional awareness. In such cases, the somatic symptoms may be devoid of symbolic meaning but associated instead with an impoverished fantasy life (Stephanos, 1975). Stolorow et al. (1987) suggest that the developmental integration of affective states into psychological structures depends upon the caregiver’s ability to identify and verbalize affects. This assistance with the integration of affect into subjective experience contrib-

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utes, they suggest, to the organization and consolidation of the self. Observational research (Greenspan, 1981) similarly suggests that the capacity for somatopsychic differentiation, that is, to dis­ tinguish somatic from psychological experience, depends, at least in part, upon the differential responsiveness of parental figures t o , somatic and emotional states. When such responsiveness is not available, infants may learn to respond somatically to situations in which it would be more appropriate to respond socially (Green­ span, 1981). This development may contribute to the tendency toward somatization in adults who have been described as “dis­ affected” (McDougall, 1984), alexithymie (Taylor, 1977), or mani­ festing the so-called “pensée opératoire” (Marty and De M’Uzan, 1963). Whereas it was initially suggested that alexithymia is charac­ teristic of so-called psychosomatic illness (Nemiah and Sifneos, 1970), it has since been shown that this characteristic is associated more broadly with the tendency to report functional somatic symptoms (Lesser et al., 1979; Shipko, 1982). In the case of Mr. A, the association of somatization with a disturbance in emotional awareness and in virtually all of the sens­ es of self delineated by Stern (1985) is evident. Most striking in his developmental history was the disjunction in what Atwood and Stolorow (1984) refer to as the “intersubjective field.” In this con­ text, Mr. A did not often experience with his parents a sense of acceptance, recognition, or confirmation of his own subjective experience. He could not recall much of his early emotional life and now experienced considerable doubt about his identity and his subjective experience. As a child, he had often found it difficult to get on “the same track” as his mother and now felt “dead” or “flat” when he experienced a similar state of disconnection from the therapist. He said, “I can’t connect my rational thoughts with what I feel. I can see things sometimes piece by piece, but not the overall picture.” In the therapeutic situation it was important for him to feel that the therapist was actively present and that his own subjec­ tive experience was understood. Mr. A’s somatic symptoms were the initial focus for his wish for understanding and involvement from the therapist. He needed to feel that the therapist understood the nature, intensity, and perva­ siveness of his somatic symptoms. Only gradually was he able to accept that his physical symptoms were related to his emotional experience. He reported initial disbelief and subsequent “ecstasy” when this association became apparent during the course o f treat­ ment. As therapy progressed, his increasing awareness of his emo­ tional experience was associated with a heightened sense of subjec-

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tive reality. Affect more often came, as Stolorow et al. (1987) suggest, to organize and integrate self experience. It may be interesting to speculate about the factors that contrib­ uted to the timing of the onset of Mr. A’s symptoms. The upsurge of sexual feelings in late adolescence and the phase-specific tasks of young adulthood most likely played some role. The need to establish his own identity separate from his family and to embark upon a career path undoubtedly triggered profound anxiety in Mr. A. For reasons described above, Mr. A may have been ill-equipped to identify, tolerate, and integrate these disturbing affects. Affec­ tive arousal that could not be contained then seemed to lead to fears of psychological disorganization or fragmentation. The ve­ neer of self-sufficiency, stoicism, and strong beliefs masked, in this patient, a precarious self-structure that left him vulnerable to expe­ riences of fragmentation when intense affects were aroused. Somatic preoccupation may also arise de novo during the course of psychoanalytic treatment. In fact, Kohut (1984) suggested that the “pathognomonic regression” of patients with narcissistic disor­ ders during psychoanalytic treatment involves increased bodily awareness with “regression to bodily tensions.” Stolorow and Lachman (1980) similarly postulate that hypochondriacal and death anxiety may serve a signal function in response to a threat to the integrity of the self representation. In this case, the somatic symp­ toms represent both the experience of injury as well as the wish for a healthy response from a significant other. Somatic symptoms arising during the course of psychotherapy may have such dual meanings and may be an important indicator of a disruption in the therapeutic relationship (Rodin, 1984).'Although hostility is con­ sidered by some to be inherent in somatizing disorders, when it is prominent in the treatment situation, the possibility should always be considered that it is a secondary reaction to misattunement of the therapist or empathic failure perceived by the patient. A PERSPECTIVE ON PSYCHOTHERAPEUTIC APPROACHES TO SOMATIZATION A variety of psychotherapeutic approaches have been recom­ mended with somatizing and hypochondriacal patients. Most of­ ten, as Kellner (1986) suggests, supportive-directive techniques are indicated including persuasion, reassurance, explanation, accep­ tance, and empathy. Psychoanalytic psychotherapy is likely indi­ cated in only a small proportion of somatizing patients depending

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upon the usual criteria such as the presence of subjective distress, the capacity to form a therapeutic relationship, psychological mindedness, and motivation for insight. Psychoanalytically in­ formed therapeutic interventions may include interpretation of un­ conscious conflict, exploration of the symbolic and interpersonal significance of symptoms, and the identification, confirmation, and validation of emotional experience. This article has emphasized the relationship of somatization to disturbances in emotional awareness and the sense of self. Individu­ als who present with somatization and with disturbances in emo­ tional awareness may suffer from a relative developmental arrest in terms of their capacity for affect regulation and/or may defensively ward off affect for a variety of reasons. In some cases, as in the patient described here, affect may be warded off because of the fear that it will result in fragmentation or disorganization of the psycho­ logical sense of self. Fragmentation anxiety, as Kohut (1984) ob­ served, may be the most profound anxiety that can be experienced. It may be difficult to determine, at the time of initial assessment of the somatizing patient, to what extent those with emotional constriction are likely to be responsive to psychoanalytic treat­ ment. In cases in which there is a more severe developmental dis­ turbance in emotional awareness, psychoanalytic treatment may not be possible or may require a relatively prolonged initial phase directed toward identifying and labeling emotional experience. Other patients who present with prominent somatic symptoms may have more ready access to their emotional life once a thera­ peutic relationship is formed in which they feel understood. The establishment o f a therapeutic relationship in which emotional experience can be shared and understood may alleviate distress and assist in the translation of emotional experience from the somatic to the psychological realm. This may help to resolve what Winnicott (1966) referred to as the "split” between the psyche and the soma in psychosomatic illness. Patients with extreme limitations in emotional awareness require of their therapists a special tolerance for emotional deprivation from their patients and a capacity for empathic understanding and access to fantasy life even when there is little verbal communica­ tion of affect. Sifneos (1975) considered alexithymia, an extreme manifestation o f a disturbance in emotional awareness, to be a contraindication to dynamic psychotherapy. Others who have not shared this view have nevertheless vividly described the frustrations and countertransference difficulties that are prone to arise in the

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psychotherapeutic treatment of such patients (Krystal, 1979; Tay­ lor, 1977). Krystal (1979) suggests that psychodynamic psychother­ apy in such patients should begin with a preparatory phase directed toward improving the patient’s capacity to verbalize, desomatize, and tolerate affect. In this phase, therapists need to rely upon non­ verbal cues and upon their own subjective experience and fantasies. Sometimes a shared understanding may develop with such patients before it can be explicitly defined or communicated. Finally, it has been emphasized that somatization may occur in a variety of clinical and nonclinical situations. By itself, this phe­ nomenon should suggest neither refractoriness nor suitability for psychoanalytically oriented psychotherapy. The indications for such treatment are similar to those that apply in any other patient population. Psychoanalysis or psychoanalytically oriented therapy is likely indicated in only a small proportion of somatizing pa­ tients. However, unwarranted generalizations about the refractori­ ness of somatizing patients to psychoanalytic treatment may de­ prive some individuals who are deeply distressed and likely to benefit. References Arlow, J. A., and Brenner, C. (1969), The psychopathology of the psychoses, Int. J. Psychoanal., 50, 5-14. Atwood, G. E ., and Stolorow, R. D. (1984), Structures o f Subjectivity: Explorations in Psychoanalytic Phenomenology, Lawrence Erlbaum, Hillsdale, NJ. Barsky, A. J., and Klerman, G. L. (1983), Overview: Hypochondriasis, bodily complaints, and somatic styles, A m . J. Psychiat., 140, 273-283. Bauman, S. (1981), Physical aspects o f the self: A review o f some aspects o f body image development in childhood, Psychiat. Clin. North America, 4 , 455-470. Boesky, D. (1989), Acting out: A reconsideration o f the concept, Int. J. Psychoanal., 63, 39-55. Broden, A. R., and Myers, W. A. (1981), Hypochondriacal symptoms as derivatives of unconscious fantasies of being beaten or tortured, J. A m . Psychoanal. Assoc., 29, 535— 557. Brown, H. N., and Vaillant, G. E. (1981), Hypochondriasis, Arch. Int. Med., 141,723-726. Cooper, A. M. (1985), A historical review of psychoanalytic paradigms, in A. Rothstein (Ed.), Models o f the Mind: Their Relationship to Clinical Work, International Universi­ ties Press, Madison, CT, pp. 5-20. Dorfman, W. (1968), Hypochondriasis as a defense against depression, Psychosomatics, 9, 248-251. Engel, G. L. (1968), A reconsideration of the role of conversion in somatic disease, Comp. Psychiat., 9, 316-326. Fenichel, O. (1945), The Psychoanalytic Theory o f Neurosis, W. W. Norton, New York. Ford, C. V. (1983), The Somatizing Disorders, Elsevier, New York. Freud, S. (1893), On the psychical mechanism of hysterical phenomena: Preliminary com­ munication, Standard Edition, Vol. 3, Hogarth Press, London.

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384 RODIN Paolino, T. J. (1981), Psychoanalytic Psychotherapy: Theory, Technique, Therapeutic Rela­ tionship and Treatability, Brunner/Mazel, New York. Pine, F. (1988), The four psychologies of psychoanalysis and their place in clinical work, J, A m . Psychoanal. Assoc., 36, 571-596. Pulver, S. E. (1987), Epilogue, in “How theory shapes technique: Perspectives on a clinical study,” Psychoanal. Inq., 7, 289-299. Rodin, G. (1984), Somatization and the self: Psychotherapeutic issues, A m . J. Psychother., 55,257-263. Rosenfeld, H . (1958), Some observations on the psychopathology of hypochondriacal states, Int. J. Psychoanal., 3 9 ,121-124. Sandler, J. (1976), Countertransference and role-responsiveness, Int. Rev. Psychoanal., 3, 43-48. Schur, M. (1955), Comments on the metapsychology of somatization, Psychoanal. Study Child, 10, 119-164. Shipko, S. (1982), Alexithymia and somatization, Psychother. Psychosom., 3 7 ,193-201. Sifneos, P. E. (1975), Problems of psychotherapy of patients with alexithymic characteris­ tics and physical disease, Psychother. Psychosom., 26, 65-70. Slavney, P. R., and Teitelbaum, M. L. (1985), Patients with medically unexplained symp­ toms: DSM-III diagnoses and demographic characteristics, Gen. Hosp. Psychiat., 7, 2125. Stephanos, S. (1975), A concept of analytical treatment for patients with psychosomatic disorders, Psychother. Psychosom., 2 6 ,178-187. Stern, D. (1985), The Interpersonal World o f the Infant: A View fro m Psychoanalysis and Developmental Psychology, Basic Books, New York. Stolorow, R. D. (1977), Notes on the signal function o f hypochondriacal anxiety, Int. J. Psychoanal., 58, 245-246. Stolorow, R. D., Brandchaft, B., and Atwood, G. E. (1987), Psychoanalytic Treatment: A n Intersubjective Approach, Analytic Press, Hillsdale, NJ. Stolorow, R. D., and Lachman, F. M. (1980), Psychoanalysis o f Developmental Arrests, International Universities Press, New York. Thylor, G. J. (1977), Alexithymia and the counter-transference, Psychother. Psychosom., 28, 141-147. Wahl, C. W. (1963), Unconscious factors in the psychodynamics of the hypochondriacal patient, Psychosomatics, 4, 9-14. Winnicott, D. W. (1951), transitional object and transitional phenomena, in Collected Papers: Through Paediatrics to Psychoanalysis, Basic Books, New York, 1958, pp. 229■ 242. Winnicott, D. W. (1966), Psycho-somatic illness in its positive and negative aspects, Int. J. Psychoanal., 47, 510-516. Winnicott, D. W. (1976), The theory of the parent-infant relationship, in The Maturational Processes and the Facilitating Environment, Hogarth Press, London, pp. 37-55.

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