90. Психосоматическое понятие специфичности. Г. Поллок (90. The Psychosomatic Specificity Concept. George H. Pollock)

Chicago Institute for Psychoanalysis, Northwestern University Medical School, USA

Although the field of psychosomatic medicine is ancient, the more or less systematic study of psychosomatic phenomena is but fifty years old. As our knowledge has increased, particularly in the basic sciences, we have moved away from the clinical aspects of psychosomatic disorders and have focused more on the biochemical, endocrinological, neurophysiological approaches on the one hand, and on the behavioral science and psychosocial considerations on the other. The result is a further specialization, and at times even a micro-fragmentation of our knowledge instead of the more holistic approach envisioned by the pioneers of this field of study.

As psychosomatic medicine has moved in many directions, it is now useful to synthesize the available information so that it can be applied by the deliverers of care, and used by the researchers employing one or another approach to further our knowledge. It is also essential that the clinicians who have direct contact with the patient, the family, the socio-economic-cultural milieu, be enlisted to provide input of data, ideas and speculations so that we can avoid the isolation and compartmentalization that characterizes the psychosomatic field today.

The psychosomatic specificity hypothesis had its origins in the clinic, not the laboratory or the research setting as such. From clinical observations, which could be replicated by others working with patients having similar diseases, common factors were detected. These were combined into more or less genera] formulations and then a theoretical conceptualization gradually evolved to explain the observations and correlations. If time and space allowed, it would be useful to trace the origins and developments of this psychosomatic specificity concept up to the present. Because of realistic limitations, I will present only a few highlights in order to set the stage for a compressed statement of our current and ongoing research. Before beginning, I wish to note that recently Rollins (1974) has reported on Soviet discussions of psychosomatic relationships. She notes that there is recognition of the significance of emotional factors and sets, both conscious and unconscious, in health and disease. She writes that "in considering the specificity of a psychic conflict in relation to a clinical syndrome, the problem of conversion in hysteria was separated from general psychosomatic relationships" (p. 304). This view is in accordance with that of our Chicago psychosomatic research group. As will be noted below, our work has related itself to the correlation of personality configuration patterns with psychosomatic disorders. Our findings are similar to those of some Soviet investigators who have studied "the balance between pathogenic influences and the quality of the defensive measures with which the organism responds" (p. 304). In accordance with the views of F. V. Bassin, we too find that conscious cognitive activity seems less effective in maintaining optimal homeostatic balance than unconscious psychic activity.

To return to psychosomatic specificity. The idea of specific humors as enunciated by Hippocrates and later modified by Galen were early theoretical attempts at understanding psychosomatic correlations. In a sense we see here the ancient precursors to the psychosomatic specificity concept. Galen frequently referred to physiological factors causing psychological symptoms as well as to psychological states causing physical symptoms.

I have discussed the history of psychosomatic concepts elsewhere (Pollock, 1968) and so shall limit myself here to an encapsulated condensed account of the development of the psychosomatic specificity hypothesis as it unfolded over the years.

In 1934, Alexander wrote a paper on psychological factors in gastrointestinal disturbances. He pointed out that on the basis of clinical work with patients diagnosed as having gastric neurosis, he found a constant relationship between gastric symptoms and certain emotional conflicts and situations. Many internists had recognized the importance of psychologic phenomena as causative agents in a great many disorders of the gastro-intestinal tract. Many organicists and psychoanalysts were aware "that the alimentary tract is a system which the psychic apparatus uses with great predilection to relieve different emotional tensions" (Alexander, 1934, p. 502). Among the analysts, Alexander noted the contributions of Freud, Abraham, and Jones, and the pioneering psychosomatic work of Groddeck, Felix Deutsch and Ernst Simmel. Especially emphasized was Deutsch's 1922 paper in which he clearly distinguished between initial disturbances and those morphological changes which could result following such a functional disturbance of long duration. This concept was of great importance as it called attention to the fact that organic damage could result from continued functional disturbance - a counterpart of Virchow's dictum that organic dysfunction was the result of cellular or organic damage. Today we are less inclined to make these distinctions between structural and functional disturbances as both components are present. However, what I wish to emphasize is the sequence of emotional response, functional reaction and subsequent organic structural alteration as contrasted with the reverse formulation of Virchow - namely, cellular pathology resulting in organic change and dysfunction. Both sequences can occur and emotion can serve as trigger or outcome.

Taking exception with Deutsch's 1926 presentation in which Deutsch emphasized symbolic meaning, e.g. interpreting pulmonary hemorrhage as the direct expression of birth fantasies, Alexander suggested that even though the whole process might be initiated by a very specific psychological stimulus, i.e. specific fantasies of wishes, the end result, the hemorrhage, more than likely is the end result of a chain of organic processes. Alexander believed it was an error to attempt to interpret an organic symptom solely as a symbolic psychological phenomenon. Alexander was mindful that a specific psychological content could elicit direct vegetative expression, for example, blushing, perspiring, increased peristalsis; but a peptic ulcer could not be interpreted psychologically because it had no symbolic significance. "What can be interpreted as a direct effect of psychologic factors is the hyper- or hypo-secretion and the change in the motor activity and blood supply of the stomach", not the resulting peptic ulcer (Alexander, 1934,p. 505).

Extending the research from the systematic study of psychic factors in gastro-intestinal disturbances to the respiratory and circulatory systems, Alexander in 1934 first stated the guiding principles of these investigations as underlying theoretic concepts, later named the "specificity hypothesis". Alexander wrote:

"(1) Our first assumption or working hypothesis is that the psychic factors causative of the somatic disturbance are of a specific nature. They can be defined as certain emotional attitudes adopted by the patient toward his environment or directed toward his own person. An adequate knowledge of these causative factors can be obtained during the analytic treatment of the patients, and no other method-not even a careful psychiatric anamnesis-can be fully substituted for the analytic approach.

The patient's conscious psychologic processes play a subordinate role in the causation of somatic symptoms, since such conscious emotions and tendencies can be freely expressed and relieved through the voluntary system. Somatic changes, the influence of manifest anger, fear and similar violent and outwardly apparent emotions, are of an acute nature and have only a precipitating influence. Repressed tendencies, however, lead to chronic innervations causing chronic dysfunction of the internal organs.

The patient's actual life situation has usually only a precipitating influence on the disturbance. The understanding of the causative psychologic factors must be based on a knowledge of the development of the patient's personality, which alone can explain the reactions to acute traumatic situations" (Alexander, 1934, p. 506).

The issue of therapy is one that we may question today-in fact, Alexander himself changed his opinion later when he recognized the therapeutic benefit of psychotherapy as well as psychoanalysis in some of these conditions, but in the early thirties Alexander and the other members of the Chicago group derived most of their data from the clinical psychoanalytic situation and so were stressing this therapeutic approach.

Later research was expanded to include not only the respiratory system (bronchial asthma, hay fever), and the cardiovascular system (essential hypertension and migraine), but also endocrine-metabolic disorders (diabetes mellitus, hypoglycemia), skin diseases (eczema, neurodermatitis, urticaria, and pruritus ani), joints and skeletal musculature disturbances (rheumatoid arthritis). In 1948, a volume was published which contained the collected case reports, formulations and previously published papers on genera] principles and theory. I might add that of the psychosomatic specificity diseases investigated, six (duodenal peptic ulcer, ulcerative colitis, bronchial asthma, neurodermatitis, rheumatoid arthritis and essential hypertension) had already been studied in these early days. The research of Alexander, Ham and Carmichael (1951) on thyrotoxicosis later completed the seven diseases utilized in the Psychosomatic Specificity project (Alexander, French and Pollock, 1968).

As you will note in our research, we had the gastro-intestinal, respiratory, integumentary, cardiovasuclar, renal, endocrine and musculoskeletal systems represented. Rather than present the clinical formulations for each of these seven diseases which were crystallized at the start of our systematic study of psychosomtic specificity, I will refer the reader to the first volume reporting our methodology and results, published in 1968. In 1943, Alexander again discussed the problem of specificity of emotional factors. He discussed the criticism of the "non-specificity" school. They felt there was no specific correlation between emotional states and physiological disorders and instead focused on constitutional predisposition and the effect of early disease which increased vulnerability to later disease of the same organic system. In contrast, the Chicago group noted that physiological responses to different emotional tensions were individually constant, and they also differed from one disease cluster to the other. Furthermore, the vegetative dysfunctions arising from internal emotional conflict correlated with the specific physiological response expected from said emotion. For example, the physical response to rage was definitely different from that found associated with threat.

Actually, this premise was based on earlier work-Cannon's (1929) monumental research work on Bodily Changes in Pain, Hunger, Fear and Rage in which the physiological responses to various emotions were distinguished one from the other and demonstrated. In his later classic The Wisdom of the Body (1939), Cannon applied his concept of homeostasis to biological and social states. And it was even an earlier work of Claude Bernard on the constancy of the internal milieu that laid the groundwork for Cannon's later homeostatic principle. What Cannon did was to extend the homeostatic principle to psycho-social situations.

Response to stimuli, be they external or internal, physical agents or psycho-economic-social situations, induced a stress-strain on the integration of the organism. In order to cope with this dysequilibrium and so re-establish the constant or steady state, adaptive defenses or measures were called into play. These might include external reactions, e.g. fight or flight responses, or might involve many other internal defense mechanisms, some of which could be physical, e. g. coagulation of blood when injury occurred, or some could be psychological, e.g. denial, depression, etc. Once one accepts the principle of homeostasis the idea of a continuance from sub-cellular state to the universe can be conceptualized. System theory further helps us understand fundamental mechanisms of adaptive behavior and we can additionally envision defense-coping adaptive measures from newer perspectives.

Darwin's (1872) The Expression of Emotions in Man and Animals also dealt with the question of specificity of emotional expression, although Darwin limited his pioneering study to observations of external expressions in anxiety, grief, depression, dejection, shame, fear, despair, joy, elation, love, anger, contempt and many other states. None the less, Darwin's contribution must be considered as a major step in the evolution of specificity theory. Claude Bernard, Charles Darwin, Walter Cannon, along with Sigmund Freud and other psychoanalytic pioneers, were the giants on whose shoulders the psychosomatic specificity theories stood in the thirties, forties and fifties in order to extend their horizons further.

The clinical data presented in the early Chicago reports were convincing. The specificity hypothesis was very promising, although in 1943, as Alexander had stated many times before then and afterwards, research was needed to further test and clarify the relationship of clinical observations to clinical theory. "To what extent constitutional factors influence the picture, and to what extent a pre-existing organic pathology or sensitivity are responsible are questions to be decided by further careful clinical studies" concludes the 1943 report (p. 209). In his book on Psychosomatic Medicine (1950), Alexander defines specificity as the "physiological responses to emotional stimuli, both normal and morbid, [which] vary according to the nature of the precipitating emotional state" (p. 68). Thus "the vegetative responses to different emotional stimuli vary... according to the quality of the emotions. Every emotional state has its own physiological syndrome. For example, increased blood pressure and accelerated heart action are a constituent part of rage and fear" (p. 68). In this 1950 formulation of the hypothesis, Alexander suggests an etiologic formulation that is more precise than had heretofore been stated. He writes, "The following factors may be of etiological importance in disease:

D (disease) = f (function of) {a. b. c. d. e. g. h. i. j.

a. hereditary constitution

b. birth injuries

c. organic diseases of infancy which increase the vulnerability of ceratin organs

d. nature of infant care (weaning habits, toilet training, sleeping arrangements, etc.)

e. accidental physical traumatic experiences of infancy and childhood

g. accidental emotional traumatic experiences of infancy and childhood

h. emotional climate of family and specific personality traits of parents and siblings.

i. later physical injuries

j. later emotional experiences in intimate personal and occupational relations

These factors in different proportions are of etiological significance in all diseases. The psychosomatic point of view added the factors d., g., h., and j., to the other factors, which have long been given consideration in medicine. Only the consideration of all these categories and their interaction can give a complete etiological picture" (p. 52).

Furthermore, "The significant psychological influences, such as anxiety, repressed hostile and erotic impulses, frustration or dependent cravings, inferiority and guilt feelings, are present in all [the psychosomatic] disorders. It is not the presence of any one or more of these psychological factors that is specific but the presence of the dynamic configuration in which they appear. This type of specificity is found in stereochemistry. The constituent parts in the different organic compounds are the same atoms: carbon, hydrogen, oxygen, and nitrogen; they are combined, however, in a great variety of structural patterns, and each combination represents a substance of highly specific quality" (pp. 69-70). Thus there is similarly a psychological combinational specificity. Only the careful and detached comparative anamnestic and clinical study of a great number of patients suffering from the same type of disorder can yield the essential formulation for this disorder. Once such a formulation is available it can then be compared with detailed long-term data obtained from the psychoanalytic treatment of patients with this disorder. In this way predictive formulations for each disease can be constructed and then tested again to obtain greater depth and breadth. Today we include several other research populations-the study of children with one of the psychosomatic disorders along with the parallel study of key members of the nuclear family (this we have already done with a group of children with peptic ulcer disease and their families, some of whom were in concomitant treatment,) cross-cultural studies, urban-rural comparative studies, and different socioeconomic occupational category studies. These additional research populations along with twin studies can and do provide us with additional data to test our concepts.

In our last published group study (1968), we described the careful and controlled method of testing the psychosomatic specificity hypothesis utilizing a team of internists and a team of psychoanalysts, each of whom attempted to make a medical diagnosis from what we believed to be almost only psychological interview material. Both analysts and internists used the same edited clinical protocols. The patients in this research were those actively ill with one of the seven diseases studied earlier. On the basis of this research we believe the validity of the specificity hypothesis was demonstrated and our statistical findings as well as our research methodology have been published (Alexander, French and Pollock, 1968). In the future, I hope to present the revised formulations and newer clinical insights we developed during the course of this research on the seven diseases for both men and women, and also our ongoing investigations of children ill with one of the Chicago Seven diseases. Before closing I wish to present Alexander's last thoughts on the specificity hypothesis that appeared potshumously in an unfinished essay prepared shortly before his death. Alexander's view that psychological factors play an important role in the etiology of the disease makes no claim for specificity of causation. He wrote:

"I assumed that in some cases the psychological factors may be etiologically significant, in others less so. My contention was only that they are conspicuously present in a specific distribution in the seven disease entities that the Chicago team has investigated. Moreoever, the reliability of the clinical approach is limited. Clinical observations can give good hunches, which, however, have to be checked by other methods. It is easy to select psychological configurations from the immense variety of psychological events and discover in every patient just the pattern one wants to discover. In spite of this skepticism, the investigators were increasingly confident in the validity of their psychodynamic formulations".

As the original clinical studies continued over more than seventeen years, the investigators became increasingly impressed with the consistent correlations between psychological and somatic findings. These studies indicated that some organic diseases have not only a specific pathophysiology, but possibly also a specific psychopathology. Independent of etiological speculations about which pathology is responsible for the other, the mere fact of their regular coexistence opens up a new chapter for medical research and theory.

The fact that the psychological phenomena antedate the appearance of the organic symptoms allows only two conclusions. Either these phenomena contribute to the etiology of the organic symptoms, or they are the psychological expression of certain basic qualities of the organism which manifest themselves on the somatic side as an organic predisposition. This does not preclude the possibility that the psychological features and the organic predisposition, even though they are parallel manifestations of the same underlying organismic quality, may have a mutual secondary influence upon each other. For example, in the case of duodenal ulcer Mirsky showed that the organic factor consists in hypersecretion but also confirmed the previously discovered psychological factor - the conflict about dependency needs (Wiener, Thaler, Reiser, and Mirsky, 1957). These two variables may both be contingent on a basic constitutional quality. This does not contradict the possibility that the oral conflict may influence stomach secretion, or that changes in stomach secretion may influence oral impulses.

While both of these theoretical possibilities were being considered, the need grew steadily to test the reliability of the underlying clinical observations. It made no sense to go on speculating about etiological problems before the basic facts were more solidly established.... To cope with this problem, a new research was designed. A plan was evolved to undertake a 'blind diagnosis' type of team investigation. If specific psychological features are characteristic for certain diseases, it should be possible to diagnose a given disease purely from psychological data. The problem was to find a method by which the reliability of psychodynamic formulations could be tested. Such a test requires two independent methods that can be checked against each other. An ulcer can be established by X-rays, with a high degree of certainty. The reliability of the claim that the presence of an ulcer can be concluded from psychodynamic formulations alone can be quickly checked by X-ray and by other non-psychological medical procedures.

In constructing this method the researchers were guided by three basic operational concepts that had been developed during the previous years of study.

The first is the psyehodynamic constellation, the central conflict pattern together with the primary defenses employed against it.

The second variable is the onset situation, the psychodynamic situation in which the patient found himself during the time his first symptoms developed. The onset situation includes the external life situation as it affects the patient. The same external life event may have different meaning for different persons. For example, being left by his wife may mean a great loss for one patient and a relief for another. The term 'onset situation' therefore refers to life conditions immediately preceding the illness as they affect the patient emotionally at that time. These conditions must be understood in terms of the genetic background of each patient, usually by the reactivation of old conflicts.

...It was necessary to postulate the existence of a third set of variables, the X factor, primarily because the same psychological pattern history and even the corresponding onset situation may be present in patients who do not develop organic disease. Some of these patients may never develop the disease, some may conceivably do so at some future date, and some may have it in a 'silent' form. There are many persons who have the type of defense against their hostile impulses that is found in hypertensives but never develop hypertension - even though their life situations stimulate aggressive impulses and at the same time prohibit their free expression. Those persons who may have, in addition to these psychological factors, a constitutional vulnerability of the vascular system (the X factor) may respond with hypertension.

In general terms the operational hypothesis of this work can be reduced to the following statement: A patient with vulnerability of a specific organ or somatic system and a characteristic psychodynamic constellation develops the corresponding disease when the turn of events in his life is suited, to mobilize his earlier established central conflict and break down his primary defenses against it. In other words, if the precipitating external situation never occurs, a patient may, in spite of the presence of the predisposing emotional patterns and of organ vulnerability, never develop the disease.

These three variables - inherited or early acquired organ or system vulnerability, psychological patterns of conflict and defense formed in early life, and the precipitating life situation - are not necessarily independent factors. It is possible that constitution at least partially determines both the organ vulnerability and the characteristic psychological patterns. At present little is known about the inter-dependence of these two variables. There is strong indication, however, that the correlation between constitution and characteristic psychiatric patterns is not a simple one. Constitution alone without certain emotional experiences of early life, particularly the early mother-child relation, may not produce a consistent pattern.

Neither is the onset situation considered an entirely independent variable. It is not purely a chance factor. Patients with certain psychological predispositions may unconsciously seek out life situations which complement their predispositions. For exapmle, hypertensives who are characterized by the tendency to carry on their work dutifully even under difficult and harassing conditions are more apt to get into life situations in which they are exploited by their environment. Such a 'beast of burden' type of patient may subtly invite heavier and heavier loads just because he so patiently submits to indignities" (Alexander, French and Pollock, 1968, pp. 9-11).

Our research has been reported and as I have indicated we hope to publish additional aspects of our past study as well as our more current work. Alexander did not directly focus on the broader "specificity theory", which is of prime interest and significance to me and some of my colleagues. Alexander, in his last statement, focused on the interaction between the variables even though the variables are considered independently. This approach is very much in the forefront of science today. The interaction of psychological, endocrinological, physiological, and environmental factors involved in behavior has been the subject of intense investigation in recent years. Perhaps as we begin to apply such findings to the study of man, the notion of individuality and specificity will be considered along with the issue of universal response.

Summary

The psychosomatic specificity concept, now over forty years old, has gradually evolved from simple clinical observations to a more considered presentation of personality and psychosocial and psychobiological characteristics that are increasingly relevant in our understanding of the uniqueness of man. In this paper, the author attempts to trace the history of the concept, the various additions and amendations made over time, as well as the latest general formulation of the concept which can be applied to disease entities as well as to stress reactions that are not pathogenic. Increasingly, evidence is accumulating from other disciplines and fields of study that points to an extension of the psychosomatic specificity concept to a broader notion of the specificity of the individual as compared to the more general universality of response in man. Some allusion is briefly made to stimulus, response and stimulus-response specificity.

References

1. Alexander, Franz (1934), The influence of psychologic factors upon gastro-intestinal disturbances: a symposium. Psychoanalytic Quarterly, 3:501-539.

2. Alexander, Franz (1943), Fundamental concepts of psychosomatic research: psychogenesis, conversion, specificity. Psychosomatic Medicine, V/3:205-210.

3. Alexander, Franz; French, Thomas M. and Pollock, George H. (1968), Psychosomatic Specificity. Volume 1: Experimental Study and Results. Chicago and London: University of Chicago Press.

4. Alexander, Franz; Ham, G. C. and Carmichael, H. T. (1951), A psychosomatic theory of thyrotoxicosis. Psychosomatic Medicine, 13: 18-35.

5. Cannon, W. B. (1929), Bodily Changes in Pain, Hunger, Fear and Rage: An Account of Recent Researches into the Function of Emotional Excitement. (Second Edition, 1953). Boston: Charles T. Branford Campany.

6. Cannon, W. B. (1939), The Wisdom of the Body. New York: W. W. Norton and Co. (revised edition).

7. Darwin, Charles (1872), The Expression of the Emotions in Man and Animals. New York: D. Appleton and Company (reprinted, Chicago: University of Chicago Press, 1965).

8. Deutsch, Felix (1922), Biologie und Psychologie der Krankheitsgenese. Int. Ztschr. f. Psa., VIII: 290.

9. Deutsch, Felix (1926), Der gesunde und der kranke K?rper in psychoanalytischer Betrachtung. Int. Ztschr. f. Psa., XII: 489.

10. Pollock, George H. (1968), Psychosomatic illness. In: International Encyclopedia of the Social Sciences. New York: Macmillan Co. and the Free Press, pp. 135-144.

11. Rollins, Nancy (1974), The new Soviet approach to the unconscious. American Journal of Psychiatry, 131/3:301-304.