The Predictive Value of Psychological Variables for Disease and Death there is a paper by Thomas (p. 653) that deserves thoughtful attention. A summary report of painstaking, diligent work extending over almost 30 years, it constitutes a major breakthrough in documenting prospectively what has long been postulated on the basis of retrospective studies, namely, that people with different disease predispositions also may differ among psychological and personality variables. In other words, psychological variables are not distributed randomly either between those with good as compared to poor health records or across all disease categories. Rather, not only are certain psychological patterns and constellations more prominent among individuals with greater predisposition to illness and death before age 50, but also these patterns may be different for different disorders. This would be in keeping with a long-held psychosomatic theory that psychological characteristics may directly or indirectly influence individual susceptibility to disease. Elucidation of the role of psychosocial variables in altering susceptibility to disease is the main task of psychosomatic research. It asks why, when exposed to similar pathogenic influences, some individuals manifest the disease and others do not. It investigates how psychological experiences may affect the development of the individual, how such experiences may become translated into altered physiologic states, and how in turn the interaction of such altered states with physiologic and biochemical responses independently induced by pathogenic stimuli determine the ultimate disease susceptibility of the individual. Ader (1) proposes that, given the presence of potentially pathogenic stimulation, conditions would be optimal for the manifestation of disease // there exists a biologic disposition, if the individual's personality structure is such that some change in the psychosocial environment is perceived as "stressful," and if the individual is unable to cope with the altered environmental circumstances. Like most research in medicine, psychosomatic studies began with empirical clinical observations. Astute clinicians, especially in the 19th century, commented not only on particular life settings in which people seemed more likely to become ill, but also on what they considered to be predisposing personality types and life styles for certain diseases, such as tuberculosis, cancer, and angina pectoris. In the 1930s these views received a powerful impetus from the psychoanalytic studies of Franz Alexander (2) and colleagues on patients with peptic ulcer, colitis, asthma, hypertension, rheumatoid arthritis, thyrotoxicosis, and neurodermatitis. From such studies evolved the specificity concept of "psychosomatic disease," namely, that a patient with biologic vulnerability of a specific organ or somatic system and a characteristic psychodynamic situation develops the corresponding disease when the turn of events in his life is suited to mobilize his earlier established central psychic conflicts and break down his defenses against them. After a period of great popularity, Alexander's views gradually fell into disrepute, chiefly for two reasons. First, IN THIS ISSUE
much research seemed to undermine the concept of specific "psychosomatic diseases," for numerous studies have indicated that a wide variety of illnesses, maybe even most illnesses, may have their onset in settings of life change or stress. Schmale (3), for instance, proposes psychological giving up as one such final common pathway to changes in health. Second, scepticism stemmed from the fact that the specificity concept was based on psychological data elicited from patients who already had the disease being investigated. This makes it impossible to eliminate either the effects of the illness itself on the person's psyche or the influence of bias on the part of the investigators. Over a period of time, the lack of success in devising adequate means of testing the theory gradually became misinterpreted to mean that the theory had been disproven. Indeed, most psychosomatic literature today relegates Alexander's specificity theory to the status of a historical curiosity. Actually, a more accurate perspective would suggest that both specific and nonspecific factors may be implicated. Indeed, a number of prospective studies lend support to the specificity perspective of Alexander, at least in its broader outlines. Thus, 20 years ago Mirsky (4) and associates were successful in predicting on the basis of premorbid psychological characteristics which army recruits with high serum pepsinogen levels would experience basic training as stressful and under such conditions develop active peptic ulcers. Psychological criteria for both the central psychodynamic conflicts and the specific way in which basic training might activate such conflicts were derived from Alexander's original work. The same investigators also were able to predict from psychological data which recruits would have high or low serum pepsinogen levels. And although all recruits were healthy at the time of study, the former were found to have psychological characteristics common among peptic ulcer patients, while the latter resembled, psychologically, patients with pernicious anemia. Another more familiar association having predictive value is Type-A behavior and coronary disease (5). Thomas' study is unique in that she undertook to collect certain psychological data on, and to follow longitudinally, a cohort of 1015 healthy young men, namely medical students in 17 successive classes (1948 through 1964), without any specific prediction as to how or whether subsequent health records might correlate with their psychological profiles. Hence, it is all the more impressive that not only did the youthful habits and family attitudes of the students who later developed or died from one of five disease states (hypertension, coronary occlusion, malignant tumor, mental illness, and suicide) differ from those of healthy classmates, but also group means of individual disorders were significantly different from each other. Thus the research gives powerful support to the theory that there is indeed some kind of relation between the pre-existing psychological experiences and characteristics of individuals and the time and the circumstances Editorials
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under which some become ill while others remain well. Presumably, this is the case even among those exposed to the same biologic risk factors. Further, it restores confidence that Alexander's retrospectively derived data may indeed have reflected a genuine correlation, albeit probably not as highly specific as he had originally proposed. Some critics might be tempted to dismiss this work on the grounds that it is drawn from a skewed population (medical students), that the psychological tests lack sophistication, or that the psychological data are superficial and difficult to interpret. But such critics should be reminded that the basic design was established 30 years ago and, once established, could not be deviated from even as more elegant methods become available. Admirably, Thomas pursued the study so diligently even though fully aware that interpretable results would not be forthcoming for decades. In this era when grant renewal policies and personal ambition discourge long-term commitment to
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difficult research, such dedication to pursuit of knowledge is rare indeed. The work does much to restore confidence in the validity of psychological studies of those already ill and to justify intensification of efforts to understand more fully the influence of psychosocial variables on disease susceptibility. (GEORGE L. ENGEL, M.D., Departments of Psychiatry and Medicine, University of Rochester School of Medicine and Dentistry; Rochester, New York) References 1. ADER R: The role of developmental factors in susceptibility to disease. Int J Psychiatry Med 6:367-376, 1974 2. ALEXANDER F: Psychosomatic Medicine. New York, Norton, 1950 3. SCHMALE AH: Giving up as a final common pathway to changes in health. Adv Psychosom Med 8:20-41, 1972 4. MIRSKY IA: Physiologic, psychologic, and social determinants in the etiology of duodenal ulcer. Am J Dig Dis 3:285-314, 1958 5. FRIEDMAN M: Pathogenesis of Coronary Artery Disease. New York, McGraw Hill, 1969
much research seemed to undermine the concept of specific "psychosomatic diseases," for numerous studies have indicated that a wide variety of illnesses, maybe even most illnesses, may have their onset in settings of life change or stress. Schmale (3), for instance, proposes psychological giving up as one such final common pathway to changes in health. Second, scepticism stemmed from the fact that the specificity concept was based on psychological data elicited from patients who already had the disease being investigated. This makes it impossible to eliminate either the effects of the illness itself on the person's psyche or the influence of bias on the part of the investigators. Over a period of time, the lack of success in devising adequate means of testing the theory gradually became misinterpreted to mean that the theory had been disproven. Indeed, most psychosomatic literature today relegates Alexander's specificity theory to the status of a historical curiosity. Actually, a more accurate perspective would suggest that both specific and nonspecific factors may be implicated. Indeed, a number of prospective studies lend support to the specificity perspective of Alexander, at least in its broader outlines. Thus, 20 years ago Mirsky (4) and associates were successful in predicting on the basis of premorbid psychological characteristics which army recruits with high serum pepsinogen levels would experience basic training as stressful and under such conditions develop active peptic ulcers. Psychological criteria for both the central psychodynamic conflicts and the specific way in which basic training might activate such conflicts were derived from Alexander's original work. The same investigators also were able to predict from psychological data which recruits would have high or low serum pepsinogen levels. And although all recruits were healthy at the time of study, the former were found to have psychological characteristics common among peptic ulcer patients, while the latter resembled, psychologically, patients with pernicious anemia. Another more familiar association having predictive value is Type-A behavior and coronary disease (5). Thomas' study is unique in that she undertook to collect certain psychological data on, and to follow longitudinally, a cohort of 1015 healthy young men, namely medical students in 17 successive classes (1948 through 1964), without any specific prediction as to how or whether subsequent health records might correlate with their psychological profiles. Hence, it is all the more impressive that not only did the youthful habits and family attitudes of the students who later developed or died from one of five disease states (hypertension, coronary occlusion, malignant tumor, mental illness, and suicide) differ from those of healthy classmates, but also group means of individual disorders were significantly different from each other. Thus the research gives powerful support to the theory that there is indeed some kind of relation between the pre-existing psychological experiences and characteristics of individuals and the time and the circumstances Editorials
Downloaded from https://annals.org by Tulane University user on 01/17/2019
673
under which some become ill while others remain well. Presumably, this is the case even among those exposed to the same biologic risk factors. Further, it restores confidence that Alexander's retrospectively derived data may indeed have reflected a genuine correlation, albeit probably not as highly specific as he had originally proposed. Some critics might be tempted to dismiss this work on the grounds that it is drawn from a skewed population (medical students), that the psychological tests lack sophistication, or that the psychological data are superficial and difficult to interpret. But such critics should be reminded that the basic design was established 30 years ago and, once established, could not be deviated from even as more elegant methods become available. Admirably, Thomas pursued the study so diligently even though fully aware that interpretable results would not be forthcoming for decades. In this era when grant renewal policies and personal ambition discourge long-term commitment to
Downloaded from https://annals.org by Tulane University user on 01/17/2019
difficult research, such dedication to pursuit of knowledge is rare indeed. The work does much to restore confidence in the validity of psychological studies of those already ill and to justify intensification of efforts to understand more fully the influence of psychosocial variables on disease susceptibility. (GEORGE L. ENGEL, M.D., Departments of Psychiatry and Medicine, University of Rochester School of Medicine and Dentistry; Rochester, New York) References 1. ADER R: The role of developmental factors in susceptibility to disease. Int J Psychiatry Med 6:367-376, 1974 2. ALEXANDER F: Psychosomatic Medicine. New York, Norton, 1950 3. SCHMALE AH: Giving up as a final common pathway to changes in health. Adv Psychosom Med 8:20-41, 1972 4. MIRSKY IA: Physiologic, psychologic, and social determinants in the etiology of duodenal ulcer. Am J Dig Dis 3:285-314, 1958 5. FRIEDMAN M: Pathogenesis of Coronary Artery Disease. New York, McGraw Hill, 1969
