91. Исторический обзор психосоматической медицины. Э. Виттковер, Г. Уорнс (91. Historical Survey of Psychosomatic Medicine. Eric D. Wittkower and Hector Warnes)

McGill University, Montreal and Trinity College, Dublin

Introduction

Since time immemorial philosophers and physicians have pondered mind-body relationships. Socrates (496 BC-399 ВС), returning from army service, reported to his Greek countrymen that the barbarian Thraeians were in advance of Greek civilization insofar as they knew that the body could not be cured without concern for the mind. Hippocrates (466 BC-373 ВС) and his school established the rationalistic, mechanistic approach to medicine and his records showed an appreciation of the role of adaptive factors in health and disease; he emphasized not only the importance of the environment but also the relationship between physician and patient: "It is more important to know what sort of person has a disease than to know what sort of disease a person has". It was Galen (131 ВС-201 ВС) however, who underscored adaptive biology, in which diseases were due to a disturbance of the natural harmony of the body, especially of the four humours.

In the Dark Ages the search for naturalistic explanations were overwhelmed by a surge of primitive religious and metaphysical preoccupations which stifled progress for a dozen centuries. Science gradually gained the upper hand, with naturalism replacing demonology. The first sign of this trend occurred in the 13th century but did not gain real importance until the 17th.

A few progressive physicians such as Sydenham (1624-89) and others between the 17th and 19th centuries paid attention to the role of the mind in physical illness. For instance, Reil (1759-1813) in 1803 clearly recognized the mutual interaction between psychological and physical events. Heinroth (1773-1843) introduced the idea of internal conflict as a basis of mental disease and in 1818 was the first to use the term "psychosomatic". Carus (1789-1869) spoke of unconscious processes and believed in a rather vague manner that the unconscious animates all physiological processes. Francis Bacon (1605) put forward still valid speculations on psychosomatics: "For the consideration is double, either how, and how far the humour and affects of the body, do alter or work upon the mind; or again how and how far the passions and apprehensions of the mind, do alter or work upon the body" (p. 79)³². William Harvey (1649) describes an outstanding psychosomatic evolution: "I was acquainted with another strong man, who having received an injury and affront from one more powerful than himself, and upon whom he could not have his revenge, was so overcome with hatred and spite and passion, which he yet communicated to no one, that at last he fell into a strange distemper, suffering from extreme oppression and pain of the heart and breast, and... in the course of a few years... became rabid and died... His friends thought him poisoned by some maleficent influence or possessed with an evil spirit... In the dead body I found the heart and aorta so much gorged and distended with blood, that the cavities of the ventricles equalled those of a bullock's heart in size. Such is the force of the blood pent up, and such are the effects of its impulses..." (p. 130)³². Saver Walker (1796) astutely evaluated the onset of symptoms: "It is of some consequence to observe at what time the patient first discovered symptoms of lowness and dejection; whether these appeared after other nervous symptoms or preceded them. By attending to this circumstance, we shall be able to determine whether the state of the body is to be attributed to that of the mind, or the latter to the former. It is well known that any unpleasant affection of the mind, long continued, will have a very considerable influence on the state of the animal frame, and more particularly on the nervous system. On the other hand, it is equally true that different diseased states of the animal function will be productive of some affections of the mind. If, therefore, we can discover to which of these sources different symptoms are to be traced, we shall have a more clear indication of cure" (p. 552)³². ... "In order to do this we must endeavour, as much as possible, to prevent the recurrence of those circumstances, which by their association with their original cause of uneasiness, may serve to revive the recollection of it" (p. 553)³².

Psychotherapy for psychosomatic disorders has been recommended since antiquity but more cogently by Walter Cooper Dendy (1853): "The psychological and prophylactic, and, may we add, therapeutic influence of the mens sana are as clear as the pathological effect of mind"... "It is often deeply interesting to mark the salutary changes which result from the influence of a devout and philosophic spirit, and also of the lighter and more joyous states of the mind when brought to play even on structural disease. As we know that mental states induce disorder, we may also perceive, that prevention and cure may be effected simply by inducing a contrary condition of mind" (p. 1004)³². Unsurpassable observations on angina pectoris and life style came from Osier at the turn of the century: "А point that stands out prominently in my experience is the frequency of the disease in our profession..." "In a group of twenty men, every one of whom I knew personally, the outstanding feature was the incessant treadmill of practice; and yet if hard work, that "badge of our tribe" was alone responsible, would there not be a great many cases? Every one of these men had an added factor - worry; in not a single case under fifty years of age was this feature absent, except in Dr G..." "Listen to some of the comments I jotted down, of the circumstances connected with the onset of the attacks" and Osier goes on listing psychosocial life events preceding the onset of attacks and concludes: "At least six or seven men in the sixth decade were carrying loads light enough for the fifth, but too much for 240 a machine with an ever lessening reserve..." (p. 213)¹⁰. All their efforts, however, ran counter to accepted mechanistic views and thus fell largely on deaf ears.

From Virchovian Medicine to Psychosomatics

Science in medicine experienced great triumphs towards the end of the 19th century thanks to contributions from the fields of morbid anatomy, microbiology and biochemistry. The idea that disease was due to the faulty functioning of some organ, the result of damage to cellular structures, led readily to Virchow's principle of cellular pathology. In 1913 the spirocheta pallida was demonstrated in the brain of patients suffering from general paresis, through the work of Hideyo Noguchi. In 1929 Hans Berger developed the EEG, in 1940 Alexander Fleming discovered penicillin, and in the forties and fifties more effective methods to treat psychiatric illnesses were developed.

Precise descriptions of mental disorders were given by the beginning of the 20th century by Kraepelin, Bleuler, Bumke and others, and important discoveries in neuroanatomy and neurophysiology were made in the twenties and thirties. Although a structural explanation had been found for a few mental disorders, the psychological understanding of the mentally ill had made little headway and treatment was still largely organically based. Neurology and psychiatry were, in some quarters, combined - neurology as an "exact" science was considered superior to psychiatry and the cleavage between psychiatry (concern with the mind) and other medical specialties (concerned with the body) was wide.

Three eminent scientists paved the way for the introduction of the psychosomatic approach to and psychosomatic research in medicine: Freud (1856-1939), Pavlov (1849-1936) and Cannon (1871-1945). Freud turned against the localistic approach to disease which had led to narrow specialization, applied scientific reasoning to the study of personality and by discovery of the unconscious established the fundamental dynamic principles of psychological causality. Pavlov's explorations of the conditioned reflex provided a tool both for induction of stress and for measurement of emotions as correlates of physical stress. According to him, even the most complex of higher cerebral processes were elaboration of simple conditioned reflexes, and were thus subject to inhibition and enhancement. Ultimately, he arrived at the formulation of personality types within the framework of mechanistic reflexology. To Cannon emotions were energizers, such that situations evoking fear and rage could provoke important changes in the body (fight and flight reactions). He elaborated the complicated interaction between endocrine glands and vegetative functions, showed that emotional tension could be conducted to anspart of the body via cortico-thalamic and autonomic pathways, and developed the concept of homeostasis. The notion that excitation of the sympathetic nervous system together with adrenalin secretion in an emergency reaction 16. Бессознательное, II 241 led him to trace the interlocking mechanisms by which the organism maintains a dynamic equilibrium despite environmental changes.

By the beginning of the 20th century, therefore, a psychological as well as a neurophysiological model of the unity of the organism had been formulated; tools for measurement of emotions, and tools for access to repressed, unconscious psychological contents had been supplied.

The Psychosomatic Movement

In the second and third decade of this century the psychosomatic movement started in Germany and Austria as a reaction to what Weiss and English called the "machine age in medicine". Speculations, case histories and hypnosis research were presented by F. Deutsch in 1922, Groddeck in 1923, Heyer in 1925, Mohr in 1925, Schwarz in 1925, Fahrenkamp in 1926, Alkan in 1930, and von Weizsacker in 1933. In 1931, Wittkower submitted his thesis on "The Influence of Emotions on Bodily Functions" which appeared in 1935.

The publication of a book entitled "Psychosocial Medicine" by J. Halliday (1943), a Public Health Officer in Glasgow, threw new light on psychosomatic medicine. Smith Ely Jelliffe (1866-1945) - who Karl Menninger said saw no borderline between medicine, neurology, psychiatry and psychoanalysis - was one of the psychosomatic pioneers in the United States, but his early efforts were derided. Franz Alexander (1891-1964) brought to America the German interest in psychosomatic medicine. His forceful, though at times dogmatic, personality gave much impetus to the psychosomatic movement. Arriving in the United States in 1930, he founded the Chicago Psychoanalytic Institute and in 1939 initiated the first systematic collaborative research in psychoanalysis focused on psychosomatic problems. Concurrently, Flanders Dunbar (1902-1959) subjected large numbers of patients with organic diseases to psychodynamically oriented examination and in 1935 compiled her monumental book Emotion and Bodily Changes which in a most painstaking manner assembled worldwide observations regarding psychosomatic inter-relations. In retrospect, it appears likely that this book, enthusiastically received, not only stimulated interest in psychosomatic medicine but also by its very preparation indicated the growing interest in mind-body interaction existent at the time. When Flanders Dunbar visited London in 1938, she was at the height of her success - a brilliant, scintillating person, full of original ideas.

In January 1939, prompted by growing interest in the field, under the editorship of Flanders Dunbar, the journal Psychosomatic Medicine came into being. Further milestones in the early development of American psychosomatic medicine included the publication of E. Weiss and O. Spurgeon English's Psychosomatic Medicine in 1943, of F. Alexander's book of the same title in 1950, and of R. Grinker's Psychosomatic Research in 1953.

In 1951, the editorship of Psychosomatic Medicine had been taken over by Carl Binger who brought to his job his wisdom, erudition and scholarly solidity. Diseases regarded previously as obscure of origin, we believed, had found an explanation, at least in part, and the prospects of treating them by psychotherapy appeared bright. Outstanding among the speakers were F. Alexander, Brady, R. Cleghorn, G. Engel, Gantt, Hinkle, Knapp, Kubie, Liddell, Margolin, Mason, Masserman, Mirsky, Reichsman, Reiser, Richmond, Rosenbaum, H. Wolff, St. Wolf.

In the Presidential Address to the American Psychosomatic Society in 1960, based on publications in Psychosomatic Medicine, Wittkower surveyed the progress of American psychosomatic medicine during the period from 1939 to 1959. At the beginning, the primary focus was on conceptualization of the psychosomatic attitude and on theoretical formulation of the development of psychosomatic disease. The research methods at this time consisted mainly of anamnestic and therapeutic studies. In time laboratory and clinical experimental studies increased. After an initial multiple approach, as inherent in the principles of the psychosomatic movement, the lion's share of psychosomatic research fell to psychiatrists and particularly psychoanalysts. By the late 1950's internists had practically abandoned the field. However, psychologists increasingly entered psychosomatic research. The focus turned from clinical observations to basic research. Important discoveries in the fields of neuroanatomy, neurophysiology and neuroendocrinology contributed to the understanding of the intricate relationships involved in visceral regulation. Areas covered during this research period include: (1) the role of the hypothalamus as part of a feedback system which mediates and regulates neural impulses concerned with emotions and neuroendocrine activity; (2) the limbic system which according to MacClean, mediates visceral rather than ideational functions; (3) the differentiation of noradrenaline from epinephrine; (4) the role of the adrenals and importance of corticoids in the defence against trauma; (5) the effect of adrenergic hormones in mobilizing those defences and (6) last, but certainly not least, the relevance of emotional factors to the aetiology of so-called psychosomatic disorders.

From 1959 to the Present

A follow-up covering the period from 1959 to the present shows that to some extent the trend prevailing in the previous survey has continued. More than in prior years, psychiatrists devoted interest to such problems as antecedents of psychosomatic disorders, the psychobiology of separation and Joss, the psychological effect of surgery, the epidemiology of psychosomatic disor-ders, doctor-patient relationships, the development of consultation psychiatry and psychopharmacology. Psychologists lost interest in validating psychoanalytic concepts in their application to psychosomatic problems. Instead, either alone or in co-operation with psychiatrists, they showed an increasing tendency towards isolating and quantifying objectively measurable variables of personality and opened up new areas of laboratory and experimental research including hypnotic experimental techniques, conditioning of biological functions in humans and investigations concerning the psychophysiological effects of sleep deprivation and of sensory input. Animal studies have been on the ascendance.

Consequently, with the growing emphasis on basic research, physicians - whether internists, psychiatrists or psychoanalysts - felt excluded from psychosomatic research. Understandably, as a countermove, organizations and journals developed bent on application of the psychosomatic approach to the practice of medicine. Examples in America are the formation of the Academy of Psychosomatic Medicine with its representative journal Psychosomatics and the publication of the journal Psychiatry in Medicine. With similar objectives, the International College of Psychosomatic Medicine has recently been founded. There are, of course, several clinically oriented psychosomatic societies and journals in Europe.

Semantic, methodological and conceptual progress and difficulties involved in psychosomatic research have been discussed by Reiser, Weinerand Wittkower. The predictive studies of Mirsky et al on serum pepsinogen as a predictor of future peptic ulcer, and of Alexander et al on increases in thyroid uptake of 131 I in subjects at risk for hyperthyroidism has vastly enriched psychosomatic research, although they have raised some objections.

Benedek and Rubinstein's studies on emotional and physiological interaction during the menstrual cycle has shown that the emotional manifestations of the female during the midfollicular phase is active, and heterosexual oriented while in the midluteal or premenstrual tends to be passive-receptive and retentive with a great deal of emotional tension. Thomas Holmes et al studied nasal response to threat and conflict. They concluded that humiliation, frustration and resentment may produce nasal responses consisting of redness of the mucous membrane of the nose, marked swelling of the nasal turbinais, profuse secretion and obstruction.

There are some experimental studies on the relationship between brain and viscera which yielded impressive results. Mahl demonstrated that fear is accompanied by increased HCl secretion in dogs, monkeys and humans. Porter et al showed in experiments of avoidance learning that 11 out of 19 monkeys developed lesions in the gastrointestinal tract. Brady in his famous experiments on the "executive monkeys" indicated that acidity did not increase while the monkey was pressing the lever to avoid shock, but during the rest period. Stress does not lead to ulceration in all animals. Susceptibility appeared to be related to sex, prenatal maternal handling, experiences in early life, whether the animal is housed alone or in a group, plasma pepsinogen level and degree of activity or immobilization. All these experiments confirming the psychosomatic view, along with those of Henry et al on hypertension, Luparello et al on bronchial asthma, and others were reviewed scholarly by Shagass. Measurements of biochemical "rebound" phenomena showed elevated plasma pepsinogen levels after the cessation of stress which raised the interesting question of delayed after-effects of stress. The studies of Friedman et al, Wolff et al and Knapp et al showed that in situations of acute and/or chronic psychological decompensation there is a reciprocal relationship between the effectiveness of ego-defensive operations and the level of adrenal and medullary hormone output. The concepts of schizokinesis and autokinesis in- troudced by Horsley Gantt,⁵⁹ the psychoendocrine⁴³, the experimental stress³⁸ and the social-environmental model³³ have made a great impact on medicine.

Psychosomatic Concepts

An account of the history of psychosomatic medicine would be incomplete without a review of its key concepts. Such concepts have been developed in psychoanalytic and non-psychoanalytic quarters. Because reviews of this kind have been presented by various authors and because serious doubts have been cast on the validity of some of them, the survey which follows will be brief.

Psychoanalytic Concepts

Freud never mentioned the term "psychosomatic medicine" in any of his writings. He restricted his theory that body changes have a symbolic meaning to conversion hysteria per se. Elaboration of psychosomatic concepts based on psychoanalytic theory was left to his co-workers and disciples (e. g. Groddeck, Ferenczi, and F. Deutsch). Ferenczi applied the conversion model to organ neurosis, but did not deal specifically with the problem of organ choice. Felix Deutsch, one of the first to work on this problem, theorized the development of organ neurosis as taking place at the focus of previous disease processes, a theory extended more recently by other investigators (Mirsky, Greene) to intrauterine processes of changed, increased or diminished functions of the fetus.

Melanie Klein, in contrast to Freud, postulated that superego conflict can occur at the level of the oral and anal stages of psychosexual development. She therefore felt that not only genital conversion but also pregenital conversion can occur in the form of an organ neurosis. Garma went a step further than Klein, assuming and demonstrating in his case material that regression might occur not only in the sphere of psychic events but also at the level of physiological events.' For instance, by means of a mental mechanism, such as introjection, anxiety about the image of an internalized aggressive mother could, through regressive fantasies, find symbolic expression in disturbed gastrointestinal function.

Dunbar studied large numbers of patients with organic diseases and noted marked similarities in the personality profiles of those suffering from the same disorder. She described the ulcer personality, the coronary personality, the arthritic personality and many others. She believed these personality profiles to be of diagnostic, prognostic and therapeutic significance.

Both she and Alexander refuted the symbolic significance of psychosomatic dysfunction and disorders, regarding them as affect concomitants. If emotions were inappropriately or inadequately expressed, chronic tension resulted with chronic concomitant vegetative innervations. As a result of this, morphological tissue changes occurred and disease set in.

In contrast to Dunbar, Alexander emphasized the relevance of psychodynamic conflict rather than personality profile to the nature of the psychosomatic disorder. According to him three variables - inherited or early acquired organ or organ system vulnerability, psychological patterns of conflict and defence formed early in life and a corresponding precipitating life situation - are operative in the aetiology of psychosomatic disorders. Based on the general direction of the conflicting impulses involved in the disturbances, Alexander distinguished three vectors: (1) the wish to incorporate, receive or take in; (2) the wish to eliminate , to give, to expend energy for attacking, for accomplishing something, or for soiling; and (3) the wish to retain or accumulate.

At the Chicago Psychoanalytic Institute, under his auspices, the diagnostic validity of these concepts was studied in a project extending over ten years. Patients suffering from the following disorders were examined: bronchial asthma, rheumatoid arthritis, ulcerative colitis, essential hypertension, neurodermatitis, thyrotoxicosis, and duodenal peptic ulcer. The results of this study have recently been published. The editors of this book, Alexander (posthumously), T. French and G. Pollock state: "On the whole, our extended statistical analysis seems to indicate that one can indeed differentiate between the seven specific diseases on the basis of the psychological patterns associated with each of them". D. T. Graham et al have reported on physiological response patterns specific to particular attitudes.

According to Engel, Greene and Schmale, failure to accomplish the work of grief after object loss provokes a psychological state of hopelessness and helplessness ("giving up-given up") which provides conditions for the development of such psychosomatic diseases as ulcerative colitis. Engel's opinion that "no linear concept of aetiology is appropriate, but that rather the pathogenesis of disease involves a series of positive and negative feedbacks with multiple simultaneous and sequential changes potentially affecting any system of the body" leads to the multifactorial approach prevailing at present in psychosomatic medicine.

Other authors observed that object relationships of psychosomatic patients are characterized by a poverty of fantasies and mental representations and a lack of affective involvement with the object. They are often unable to describe the subtle nuances of affect and are often totally without words to express themselves in this respect (Sifneos' alexithymia). Their libidinal activity is invested and absorbed by the internalized object at the expense of the relationship with the external object and at the expense of the mental representation of the external object. Schur believed that the resomatization of responses is tied up with a regressive prevalence of primary process thinking and the failure of neutralization of primitive affective states.

Grinker and Margolin regard the relatively undifferentiated biological field as their starting point. Later, with the process of growth and maturation, the undifferentiated infantile patterns of hypersecretion, hypermotility and hyperemia are substituted by neural control methods, but the earlier mechanisms are not extinguished. As further maturation occurs, three broad streams of development may be recognized: the initial involuntary, these combined involuntary-voluntary, and the voluntary phases. Genetically, these three phases correspond to the libidinal stages of orality, anality and genitality. Should the organism meet a stimulus beyond its powers to master, regression to an earlier stage of development will occur. However, the total organism does not regress, only parts of it, and then only in varying degrees. On the basis of this conceptual model, psychosomatic symptoms are seen as a stress-determined regressive physiological de-differentiation of adult responses concomitant with a psychological regression. Grinker, Deutsch and Schur believe that specificity or organ-choice is determined by genetic factors or by early psychophysiological life experiences, which may have occurred at crucial developmental stages.

Alternative Models

The cortico-visceral approach prevalent in Eastern Europe and especially in the Soviet Union is based on Pavlovian neurophysiology and concerns itself predominantly with the mechanisms by which cortical impulses are transmitted to internal organs (exteroceptive conditioning) and by which impulses generated in internal organs are transmitted to the cortex (interoceptive conditioning). In the view of cortico-visceral theorists, psychophysiological disturbances may be caused by faulty exteroceptive signaling. They are said to be due to too much, too little or conflicting stimulation, to disorganization of cortical analysis and synthesis and to specific characteristics of interoceptive conditioning (Bykov, Kurtsin).

A considerable amount of experimentation has concentrated on interoceptive conditioning in the production of disturbed somatic functioning. Much of the research has been on animals. Myasnikov, Cernoruckij and Bulatov have successfully shown the applicability of cortico-visceral mechanisms in hypertension, peptic ulcer and bronchial asthma. Clinical, i. е., introspective studies with humans have received little attention although they seem to be in the ascendance. Constitution and predisposition are accepted as basic for the choice of organ in the development of cortico-visceral disease.

According to H. Wolff, psychosomatic disorders can be understood as adaptive biological responses to symbolic threats. Under stress, be it physical or symbolic, an individual reacts monotonously with swelling, hyperemia, hypersecretion and hypermotility. The stress is symbolized, and culture largely determines which organ will represent which symbol. Ruesch notes the immaturity of persons who develop psychosomatic disorders and attributes the development of the disorder to their inability to manipulate symbolic processes for the purpose of communication. Psychosomatic patients, in his view, communicate best at a preverbal level, i. е., via their autonomic nervous system.

Halliday and Mead, from the viewpoints of public health and anthropology, underscore the relevance of the socio-cultural environment to the frequency and nature of psychosomatic disorders. Halliday noted that economic stress and altered value systems were among the many factors which, during the last two generations, had changed the mother-child relationship. With these changes, he correlated the increased prevalence and incidence of such illnesses as rheumatism, peptic ulcer and angina pectoris in which psychological factors play such an important part. Margaret Mead correlated the type and incidence of psychosomatic disorders with the manner in which the early child-mother relationship was allowed to develop in different primitive cultures. Epidemiological and cultural research have yielded interesting observations reported elsewhere.

Hinkle and Lipowski, like Halliday and Mead, emphasize the adverse effects of the social environment on mind and body, especially in modern technological society. Salient features listed by them include conditions of work, urbanization, mass communication, noise and crowding. According to Lipowski, who has elaborated this model a great deal, both physical and social environment is relevant to psychosomatic relationships in four overlapping ways: (1) as a source of stimulus and information input; (2) as an instigator of goal-directed thought and action; (3) as a source of stimuli which give rise to somatic perceptions; and (4) as a source of factors which alter cerebral function and structure and thus impair adaptive capacities of the individual. Features of information input relevant to psychosomatics, he states, include subjective, conscious and unconscious meaning of the input for the recipient as well as quantity, novelty, clarity and attractiveness of information as experienced by its recipients.

The important contributions of P. Schilder, M. Sperling, L. S. Kubie, J. Groen, A. Jores, A. Mitscherlich, T. von Uexkull, С. A. Seguin, M. Balint, J. Bastiaans, M. Boss, W. Brautigam and C. L. Cazzullo, to name just a few, have brought encouraging humanistic and psychodynamic trends to the practice of medicine and psychiatry. Lopez-Ibor has drawn attention to the "masked" depression or depressive equivalents underlying many pains and paraesthesias and in a number of patients suffering from disorders of a cyclic nature, such as in asthma, peptic ulcers, eczema, psoriasis, neurodermatitis, rheumatoid and neuralgic attacks.

Summary and Conclusions

A backward glance suggests that the advent of psychosomatic medicine in the nineteen thirties has been of major importance in the history of medicine. The human element had been reintroduced into medicine which, of course, has never been missing in good doctors. While this statement may appear trite, it can be grasped in its full significance only if one bears in mind the days when medicine had become mechanized, when young doctors flocked to the laboratories, when the approach to diseased persons was localistic and when patients were referred to as "an appendix" or "a case of tuberculosis". But has the stituation really changed fundamentally? In Wittkower and Cleghorn's book on recent developments in psychosomatic medicine published in 1956 the hope was expressed that the psychosomatic approach would be absorbed by medicine and they stated that (psychosomatic medicine) "is perhaps the only field of research and study in medicine dedicated to its own dissolution".

This certainly has not come about, though the psychosomatic approach has undoubtedly made an imprint on the practice of medicine and, as a field of research, it has gained coherence. Our hope of discovering an aetiollogy for diseases of previously unknown origin has not materialized to the extent we had hoped. The predisposing and precipitating role of emotional factors in these disorders has been convincingly demonstrated but owing to the significance of constitutional and acquired determining physical factors our assumption that psychosomatic disorders would be easily amenable to psychoanalysis and other forms of psychotherapy proved unwarranted. Consequently and regrettably, psychoanalysts increasingly withdrew from the psychosomatic area. The belief that, whenever possible, nonpsychiatrists should care for patients suffering from psychosomatic disorders led to a burgeoning of consultation/liaison psychiatry and of pharmacotherapy. Concomitant with a recent shift in many American psychiatric departments from the psychological and medical models of psychiatry to the sociological model, the ecological dimension of psychosomatic medicine, as Lipowski puts it, has come to the fore. But looking back, it appears regrettable that psychosomatic medicine, which started off as a reaction to prevailing laboratory orientation, at least in some aspects has gone full circle. Regarding psychosomatic theory, the evolution of a multitude of conceptual models indicates uncertainty of acceptance. At the 25th anniversary of the American Psychosomatic Society in 1964 many of its previous presidents attended its Annual Convention. There was a division between the older generation which adhered to the time-honoured conceptual models and the younger generation which discarded them. Specificity concepts generally have lost their appeal though, as stated before,. Alexander, French, and Pollock's recent work on psychosomatic specificity has submitted weighty evidence in favour of it.

References

1. Alexander, F: Psychosomatic Medicine: Its Principles and Applications. New York, W. W. Norton & Co. Inc., 1950.

2. Alexander, F., French, T. M., Pollock, G. H. (eds): Psychosomatic Specificity, Vol. 1: Experimental Study and Results. Chicago, the University of Chicago Press,. 1968.

3. Alkan, L: Anatomische Organkrankheiten aus seelischer Ursache. Stuttgart, Hippokrates Verlag, 1930.

4. Benedek, T. & Rubinstein, B: The Sexual Cycle of Women. Psychosomatic Medicine Monographs. 3. National Research Council, 1942.

5. Bulatov, P. K: The higher nervous activity in persons suffering from bronchial asthma, in Questions of the Interrelationship between Psyche and Soma in Psychoneurology and General Medicine. Tr. Inst. Bekhtereva (Leningrad) 29, 1963.

6. Bykov, К. M: The Cerebral Cortex and the Internal Organs. New York, New York Chemical Publishing Company, 1957.

7. Cannon, W. В: Bodily Changes in Pain, Hunger, Fear and Rage (2nd ed). New York, D. Appleton, 1929.

8. Carus, K. G: Psyche. Zur Entwicklung der Seele. Pforzheim, Flammer and Hoffman, 1841.

9. Cernoruckij, M. V: The etiopathogenesis of peptic ulcers, in Corticovisceral Pathology. Moscow, Publishing House of the U. S. S. R. Academy of Medical Science, 1949.

10. Cushing, Harvey: The Liferof Sir William Osier, Vol. II, Oxford University Press, London, New York, Toronto, 1940.

11. Deutsch, F: Der gesunde und der kranke Korper in psychoanalytischer Betrachtung. Int. Zeit. Psa. 8: 290, 1922.

12. Dunbar, F: Emotions and bodily changes (4th ed). New York, Columbia University Press, 1954.

13. Dunbar, F. H. (ed): Synopsis of psychosomatic diagnosis and treatment. St. Louis. С. V. Mosby, 1948.

14. Engel, G. L: Selection of clinical material in psychosomatic medicine: the need for a new physiology. PsychDsom. Mad. 16: 333, 1954.

15. Fahrenkamp. K: Die psychophysischen Wechselwirkungen bei den Hypertonie Erkrankungen. Stuttgart, Hippokrates Verlag, 1926.

16. Ferenczi, S: The phenomena of hysterical materialization, in Further Contributions to the Theory and Technique of Psychoanalysis. Edited by Jones, E. London. The Hogarth Press, 1950, p. 89.

17. Freud, S: Collected Papers. London, Hogarth, 1924-50.

18. Friedman, S. B. et al: Urinary 17 Hydroxy-corticosteroid Levels in Parents of Children with Neoplastic Disease. Psychosomatic Med. 25: 364-376, 1963.

19. Galen: On the Passions and Errors of the Soul. Translated by Harkins, P. Columbus, Ohio State University Press, 1966.

20. Gantt, W. H. (ed): Physiological Basis of Psychiatry, Charles C. Thomas, Springfield, 111. 1957.

21. Garma, A: Peptic ulcer and psychoanalysis, (Nervous and Mental Disease Monographs No. 85). Baltimore, Williams and Wilkins Company, 1958.

22. Graham, David T: Psychosomatic Medicine in Handbook of Psychophysiology, edited by N. S. Greenfield and R. A. Sternbach. Holt, Rinehart & Winston, 1972.

23. Greene, W. A: Early object relations, somatic, affective and personal: an inquiry into the physiology of the mother-child unit. J. Nerv. Ment. Dis. 126: 225, 1958.

24. Grinker, R. R: Psychosomatic Research. New York, W. W. Norton and Co., 1953.

25. Groddeck, G: Das Buch vom Es. Internat. Psychoanal. Ferlag, 1923.

26. Halliday, J. L: Psychosocial Medicine. New York, Norton, 1948.

27. Heinroth, S. A: Lehrbuch der Storungen des Seelenlebens. Leipzig. F. С. W. Vogel 1818.

28. Heyer, G. R: Das korperlich-seelische Zusammenwirken in den Lebensvorgangen. Munich, S. F. Bergman, 1925.

29. Hinkle, L. E: Ecological observations of the relatiois of physical illness, mentaillness and the social environment. Psychosom. Med. 23: 298, 1967.

30. Hippocrates: The Genuine Works of Hippocrates. Translated by Adams F. London, Sydenham Society, 1848-50.

31. Holmes, Thomas, H. et al: Life situations, emotions and nasal disease. Psychosom. Med. 13: p. 71, 1971.

32. Hunter, Richard and Macalpine, IDA: Three Hundered Years of Psychiatry, Oxford University Press, London, New York, Toronto, 1970.

33. Insel, Paul M. and Moos, Rudolf H. (eds): Health and the Social Environment, Lexington Books, D. C. Heath and Co., Mass., Toronto, London 1974.

34. Jelliffe, Smith Ely: The psyche and the vegetative nervous system with special reference to same. NY Med. 115: 382-87, 1922.

35. Knapp, P. H. et al: Steroid excretion, emotion and asthmatic crises, Abstr. in Psychosom. Med. 26: 631, 1964.

36. Klein, M: Contributions to Psychoanalysis: 1921-45. London, Hogarth Press, 1948, p. 378.

37. Kurtsin, I. T: Vascular disturbances in cortico-visceral pathology. Sjezd Fiziol. Biokhim. Farmakol. Minsk 3: 114-118, 1959.

38. Levi, Lennart: Stress and Distress in Response to Psychosocial Stimuli, Pergamon Press, Oxford, New York, 1972.

39. Liowski, J: Psychosomatic medicine in a changing society: some current trends in theory and research. Comprehens. Psychiat. 14: 203-15, 1973.

40. Lopez-Ibor, J. J: Masked depressions, Brit. J. Psychiat. 120: 245-258, 1972.

41. Margolin, S. G: Genetic and dynamic psychophysiological determinants of pathophysiological process, in The Psychosomatic Concept of Psychoanalysis. Edited by Deutsch, F. New York, International Universities Press, 1953.

42. Marty, P, De M'uzan, M., David, C: L'Investigation Psychosomatique. Paris, Presses Universitaires, 1963.

43. Mason, John W: Organization of Psychoendocrine Mechanisms in Handbook of Psychophysiology. Edited by N. S. Greenfield and R. A. Sternbach. Holt, Rinehart and Winston, 1972.

44. Mead, M: The concept of culture and the psychosomatic approach. Psychiatry 10: 57-76, 1947.

45. Menninger, K: Sparks. Edited by Freeman, L. New York, Thomas Y. Crowell Co., 1973.

46. Mirsky, I. A: The psychosomatic approach to the etiology of clinical disorders. Psychosom. Med. 19: 424, 1957.

47. Mohr, F: Psychophysische Behandlungsmethoden. Leipzig, S. Hirzel, 1925.

48. Myasnikov, S. L: Hypertension. Moscow, Medgiz, 1954.

49. Macclean, P. D: Studies on limbic system (visceral brain) and their bearing on psychosomatic problems, in Recent Developments in Psychosomatic Medicine. Edited by Wittkower, E. D., Cleghorn, R. A. Philadelphia, J. B. Lippincott Co., 1956, pp. 101-25.

50. Nemiah, J. C., Sifneos, P. E: Affect and fantasy in patients with psychosomatic disorders, Modern Trends in Psychosomatic Medicine. By Hill, O. London, Butterworth, 1970.

51. Pavlov, I. P: Conditioned Reflexes and Psychiatry. Translated by Gantt, W. H. New York, International Publishers, 1941.

52. Porter, R. W. et al: Some experimental observations on gastrointestinal lesions in behaviourally conditioned monkeys. Psychosomatic Medicine 20: 379, 1958.

53. Reil, S: Rhapsodien uber die Anwendung der psychischen Curmethode auf Geisteszerruttungen. Halle Curt, 1803.

54. Reiser, M. F: Reflections on interpretations of psychophysiologic experiments in Psychosomatic Medicine 23: 430-439, 1961.

55. Ruesch, S: The infantile personality - the core problem of psychosomatic medicine. Pcychosom. Med. 10: 134-44, 1948.

56. Schmale, A. H: Relationship of separation and depression to disease: a report on a hospitalized medical population. Psychosom. Med. 20: 4, 1958.

57. Schur, Max: Comments on the metapsychology of somatization in The Psychoanalytic Study of the Child, 10: 119-164, New York, International Universities Press, 1955.

58. Schwarz, О. (ed) Psvchogenese und Psychotherapie korperlicher Symptome. Wien, J. Springer, 1925.

59. Shagass, G: Experimental neurosis in Comprehensive Textbook of Psychiatry II. Edited by A. M. Freedman, H. I. Kaplan and B. J. Sadock. Williams and Wilkins Company, Baltimore, pp. 428-444, 1975.

60. Socrates: Quoted from Charmides, section 156, in the Dialogues of Plato, Vol. I. Translated by Jowett, B. Vol. I, p. 6, New York, Random House, 1937.

61. Sydenham, T: The Works. Translated by Latham, R. F. London, Sydenham Society, 1848-50.

62. Von Weizsacker, V: Korpergeschehen und Neurose: Analytische Studie uber somatische Symptombildungen. Internat. Zsch. f. Psychoanal. 19: 16-116, 1933.

63. Weiner, Herbert: The status of psychosomatic research in Proceedings of the V World Congress of Psychiatry, Mexico, Vol. II (1971) Excerpta Medica, Amsterdam, 1973.

64. Weiss, E., English, O. S: Psychosomatic Medicine (2nd ed) W. B. Saunders Company. 1949.

65. Wittkower, E. D: Studies on the Influence of Emotions on the Functions of the Organs (including observations in normals and neurotics). J. Ment. Sei. (MonographSection) LXXXI: 533-682, July 1935.

66. Wittkower, E. D: Twenty years of North American psychosomatic medicine. Psychosom. Med. 22: 308-16, 1960.

67. Wittkower, E. D , and Warnes, H: Transcultural Psychosomatics. Canad. Psychiatric Assn. J., 20: 143-150, 1975.

68. Wolff, C. T. et al: Relationship between psychological defences and mean urinary 17 hydroxy-corticosteroid excretion rates. Psychosom. Med. I and II, 26: 575-591; 592-609, 1964.

69. Wolff, H. G: Life Stress and Bodily Disease - a formulation. Res. Publ. Assn. Nerv. Ment. Dis. 29: 3-1135, 1950.

70. Wittkower, E. D. and Lipowski, Z. J. Recent Developments in Psychosomatic Medicine, in Psychosomatic Medicine Vol. XXVIII, No. 5, 1966, p. 722.

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