The Development of Psychosomatic Medicine

FRANZ ALEXANDER, M.D.

1 SYCHOTHERAPY of patients who aresuffering from organic diseases is not differ-ent from the psychotherapy of psychoneuro-ses. Its special feature is that it must bemeaningfully integrated with the somatictreatment. A bleeding ulcer, an acute attackof ulcerative colitis, or asthma require im-mediate medical attention. Psychotherapyduring such acute phases of the disease mustrestrict itself to the general management ofthe patient. Etiologically oriented long-termpsychotherapy can take place only when theacute local disease process is successfullybrought under control. Consequently, thecomprehensive treatment of organic diseasesin which emotional factors are significantconsists of teamwork between medical spe-cialists, the psychiatrist, and the nursingstaff. At present this is, however, still a pla-tonic ideal. Ideal collaboration betweenmedical specialists and psychiatrists wouldrequire on the part of the organicists an un-derstanding of the psychological compo-nents of chronic diseases, and on the part ofthe psychiatrist, an understanding of theirorganic implications. Mutual respect foreach other's contributions, which is so essen-tial in teamwork, can only accrue from mu-tual understanding. To my knowledge, thistype of ideal collaboration based on mutualunderstanding of and respect for each oth-er's specialized knowledge exists only spo-radically in a limited number of medicalcenters. That it exists at all in some places

This paper was delivered at the InternationalCongress for Psychotherapy, Vienna, Austria, Aug.22, 1961.

VOL XXIV, NO. I, 1962

is probably one of the significant advance-ments in modern medicine.

It was not long ago when a patient suffer-ing from an organic disease, in which emo-tional factors were suspected to have anetiological role had to go secretly to the psy-choanalyst, feeling that he had to hide thisfact from his treating physician so as not toarouse his ire; and vice versa, some psycho-analysts treating patients suffering fromchronic organic conditions frowned uponthe patient's continued contact with an or-ganicist as something which would interferewith the psychoanalytic treatment. Thisantagonism between the organicist and themedical psychologist is as old as written his-tory. It is one of the most common weak-nesses of the human mind to seek either/orsolutions: a disease must be either psycho-genie in its etiology. Fortunately, suchmonocausal explanations are gradually los-ing ground in all fields of medicine.

The prevailing trend in the United Statestoward the establishment of psychiatric de-partments in general hospitals is indeed en-couraging. Pioneering physicians in suchhospitals—psychiatrists as well as organicists—are frequently successful in bringingabout a meaningful integration of the so-matic and psychological management ofboth psychiatric and organic cases. Themental asylum which is isolated both geo-graphically and ideologically from the medi-cal centers is being looked upon by many asa residue of the past.

A brief historical review of this crucialproblem—the relation of the physical to the

14 PSYCHOSOMATIC MEDICINE

mental aspects of diseases—may be of inter-est.

Primitive man explained all events in na-ture psychologically. Thunder and light-ning were expressions of the ire of supernat-ural spirits, rain a gift of the gods Accord-ingly, primitive man could hope to influencenatural events only by psychological tech-niques, by appealing to the goodwill of thesesuperhuman spirits, by incantations orbribery or intimidation by the same meth-ods he used for influencing his fellow hu-man beings.

Primitive man did not know the laws ofphysics. He possessed, however, from hisown subjective experience a kind of primi-tive psychology. Psychological causality heknew introspectively. He knew whatprompted his own actions, how fear, rage,thirst for vengeance made him run away orattack his enemy. No wonder that he attrib-uted similar human-like motivations to allphenomena of nature, and dealt with themas if they were results of human-like motiva-tions, emotions, and desires

The principal accomplishment of the last300 years of our "scientific era" consisted inthe deanimation of nature, in the discoveryof physical causality, substituting for eviland benign spirits, "natural causes " Dur-ing the 19th century also biology and medi-cine came completely under the sway of thenatural sciences, and scientists hoped thatall the mysteries of life, just as those ofihe inanimate nature, could be solved byapplying to them the laws of physics andchemistry. The modern physician more andmore thought of himself as a mechanic, aglorified repairman of that complex physico-chemical apparatus—the human organismIt is this orientation to which modern medi-cine owed its great advancements. Para-doxically this same orientation retarded thedevelopment of medical psychology.

How this great propelling force in the de-velopment of medicine, the introduction ofthe methods and spirit of the natural sci-ences, could at the same time slow the prog-ress of one branch of medicine, that of psy-

chiatry, is an historical paradox which re-quires explanation.

From a broad perspective the whole his-tory of western thought consists indeed ina slow but relentlessly progressing deanima-tion of nature. This grandiose ideologicalmovement began with the Greek cosmolo-gists, who first tried to explain naturalevents from—no matter how primitive—physical principles, be it some all-pervadingbasic substance, such as water for Thales,air for Anaximenes, or four basic elements,air, fire, earth, and water, for Empedocles,Leucippus, and Pythagoras. Gradually thesematerialistic explanations were applied notonly to inanimate nature, but also to livingorganisms. In medicine the materialisticorientation remained a consistent trendsince Hippocrates declared that epilepsy isnot a sacred disease, but that it developsfrom natural material causes This trend,with some relapses into demonology, con-tinued through the Hellenistic period anddominated also Roman medicine.

The demons who governed all events innature were psychologically conceived, theiractions were prompted by human-like moti-vations. Consequently, in the relentlesswarfare of science against the demons in-evitably all psychology becomes suspect.Psychology, even if sober and empirical,nevertheless reminds scientists of the de-mons which, after centuries of patient ob-servation and reasoning, they finally haderadicated from western thought. One can-not see and measure the soul as one can ma-terial particles. To scientists the soul ap-peared but a relic of the mystical prescien-tific past, one which disturbed the unity ofscience and to which the well-proven meth-ods of physical sciences could not be ap-plied.

And yet, in spite of the persistent mecha-nistic striving for a unified materialistic-mechanistic picture of the universe, psycheresisted all efforts to be talked out of exist-ence. In ancient thought neither the fourelements of the cosmologists, nor the yellowand black bile, the dryness and moisture ofHippocrates, nor the discoveries of Hero-

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ALEXANDER

philus and Erasistratus in brain anatomycould eliminate the "ideas" which Platoconsidered the essence of reality or the"nous"—the intellect of divine origin—ofAristotle. Even in pragmatically orientedRome Cicero could ask poignantly, "why theart of curing and preserving the body shouldbe so much sought after and why the medi-cine of mind should be so neglected."8 Hebelieved in the psychological causation ofmelancholia, objecting to the black-bileconcept of Hippocrates. He said, referringto the Greek Hippocratic physicians, "whatwe call furor, they call melancholia, as if thereason were affected only by a black bileand not disturbed as often by a violent rageor fear or grief." The Roman physicians,Soranus and Caelius Aurelanius, in spite oftheir basically somatic orientation, never-theless practiced psychotherapy in order toalleviate the patients' suffering. All these,however, were faint beginnings and isolatedepisodes in the primarily somatically ori-ented Roman medicine.

After the collapse of the Greco-Romancivilization demonology returned with fullforce to interrupt for centuries the furtherdevelopment of the scientific outlook of theGreeks and Aristotle's first attempts towardsthe foundation of a biologically conceivedpsychology. During the Dark Ages, with thegrowing fear to face the instinctual forces ofman, the demons ruled unchallenged again.Man projected his unacceptable ego-alientrends into the world in the form of evilspirits. Demonology ruled again unchal-lenged until the 13th century, when with therediscovery of Aristotle's and Galen's writ-ings beginnings of a new search for naturalexplanations appeared. St. Thomas and theschoolmen succeeded, however, in emascu-lating Aristotle's teachings by subordinatingreason to revealed truth. Yet, they couldonly temporarily interrupt the relentless for-ward march of the naturalistic trend whichsince the Renaissance, persisted until ourpresent days. Eventually the scientific credogained the upper hand. The humanists re-discovered man as an individual person andthe Renaissance artists represented the hu-

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man body in all its dynamic manifestations.During the 17th century the scientific spiritsaw its greatest victories in the field of phys-ics and astronomy, and almost contempo-raneously in human anatomy.

It is quite natural that with the trium-phantly progressing scientific exploration ofnature, psychological interest receded intothe background, to become the concern ofthe man of letters. Serious scientists less andless considered psychological phenomenaworthy subjects for methodical exploration.Although 17th-century observationalisni wasmainly applied in the natural sciences, inLocke's and his followers' writings psychol-ogy, too, became empirical.

The influence of emotions upon bodilydisease was such a basic component of every-day experience that it could not be entirelyignored. Different outstanding medical au-thors of the grandc siecle, recognized the in-fluence of emotions upon the body. Thetwo greatest representatives of 17th-centurymedicine, Thomas Sydenham and WilliamHarvey, anticipated much of our presentpsychosomatic era. Sydenham stated in hisfamous epistle on hysteria that hystericalsymptoms may simulate almost all forms oforganic diseases. He boldly stated that hys-terical hemiplegia may proceed "fiom someviolent commotion of the mind." He spokeof hysterical headaches ending with vomit-ing and of psychogenic palpitation of theheart.17

William Harvey also spoke unequivocal-ly of the effects of emotions upon heart ac-tion. In his De Motu Cordis he wrote:"Every affection of the mind that is attendedwith either pain or pleasure, hope or fear,is the cause of an agitation whose influenceextends to the heart. ." In 1649 Harveywrote: ". . . what indeed is more serving ofattention, than the fact that in almost everyaffection, appetite, hope or fear, our bodysuffers, the countenance changes, and theblood appears to course hither and thither?In anger the eyes are fiery and the pupilscontracted: in modesty the cheeks are suf-fused with blushes; in fear, and under asense of infamy and of shame, the face is

16

pale, but the ears burn as if for the evil theyheard or were to hear; in lust how quicklyis the member (penis) distended with bloodand erectedl"19

Harvey indicated in one place that hewould deal in more detail with the relation-ship of the mind and the body. It is not im-possible that he actually did. Much of hiscontributions were lost when a frenized mobburned his manuscript's because of hisroyalist leanings. In 1649, just 8 years beforehis death, he wrote about emotional factors:"Here I come upon a field where 1 mightroam freely and give myself up to specula-tion. And, indeed, such a flood of light andtruth breaks in upon me here; occasion of-fers of explaining so many problems, of re-solving so many doubts, of discovering thecauses of so many slighter and more seriousdiseases, and of suggesting remedies for theircure, that the subject seems almost to de-mand a separate treatise."111

But even if some of his more detailed con-tributions to this problem were lost, thehere-quoted passages from his writings suf-fice to justify considering him as one of thefathers of the modern psychosomatic era inmedicine.

But such flashes of insight as that ofSydenham and Harvey lay outside of themainstream of thought development. Theprogress in the exact sciences during the En-lightenment was staggering. The naturalscientist dealt with materials of nature, andphysicians similarly were looking for de-stroyed matter in the brain or disturbedphysiology to explain mental diseases. Thesoul and the animal spirits of nature weregradually going into oblivion. The ration-alist and observationalist heritage of the17th century continued to flourish, and bythe early 18th century in medicine too ex-perimentation was replacing abstract rea-soning.

With the pathological anatomical find-ings of Giovanni Battista Morgagni, theprecise localization of diseases in the differ-ent organs of the body became the rulingconcept. From then on up to our presentday physicians fought tiielessly to find the

PSYCHOSOMATIC MEDICINElocalization of mental diseases in the brain.Where organic changes were not found theyhad to be postulated by speculation whichlater appropriately was called "brain myth-ology."

Western man of the modern era went in-deed much too far in his effort to eliminatepsychology from the study of man and hisdiseases. After he had thoroughly eradi-cated from inanimate nature supernaturalspiritual forces he attempted now to deani-mate man himself. Since the study of per-sonality requires psychological methodswhich had been discredited by the spectacu-lar advancements of the physical sciences,the problems of personality had to be elimi-nated from a really scientific study of man.The study of personality had to be reducedto brain physiology to become a worthy sub-ject of science. It became relegated to thedomain of the men of letters. Yet, in the firsthalf of the 19th century, during the ro-mantic reaction to the unfulfilled hopes ofthe French Revolution, medical psychologyhad a short-lived revival.

The optimistic victorious spirit of ration-alism yielded rapidly to disillusionment.Reason was dethroned and the irrationaldepths of the human psyche were rediscov-ered. Philosophers of the Enlightenmentapplied to society the mechanistic world pic-ture which had proved so successful in theunderstanding of the physical universe. Thereformers and revolutionists believed thatsocial structure could be redesigned by so-cial engineering. After the fall of Napoleonthe spirit of the revolution, of which hemade an export article, had to be extin-guished. The Congress of Vienna attemptedto turn back the clock of history and restoreabsolutism, order, and religion. Politicaland social oppression blocked the bold out-ward-directed vistas of the Enlightenment,and the mind turned inward towards theonly remaining free outlet, the descent intothe depths of the inner life and glorificationof the historical past. This is the type of at-mosphere in which psychology, history, andidealistic philosophy nourish.

It is no wonder that for the history of psy-

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ALEXANDER

chiatry this first half of the 19th century wasof outstanding significance Psychiatry dealswith man as a person Its subject matter isthe mind. Psyche consistently refused to bereduced to physical mechanisms, which Hip-pocrates called humors, Morgagni, localizedprocesses in the brain, and which modernscience tried to describe by techniques ofhistology and chemistry. Throughout thehistory ol western thought the psyche re-appeared again and again. It appeared inPlato's world picture populated by "ideas/in St. Augustine's introspective revelations,in the humanists' emphasis on the individ-ual as a unique personality, in Sydenham'spsychogenic explanation of hysteria, inSpinoza's metaphysical thesis about the fun-damental identity of body and mind, inStahl's vital force, and in Pinel's "moraltreatment" of the insane.

Psyche's return at the beginning of the19th century, however, was more definitivethan in the psychological enterprises of for-mer times. This return was now at leastsomewhat enriched by the harvest of the17th century's observationalism and of therationalism of the enlightenment. It was areturn which set out to make psychiatry anintegral part of the whole of medicine.

In 1803 J Christian Reil, the son of a pas-tor, published the first systematic treatise onpsychotherapy, under the romantic title,"Rhapsodien ueber die Anwendung derpsychischen Cur-Methoden auf Geisteszer-ruettungen."20 His reasoning was still farfrom being founded on a comprehensivetheory of personality; his ideas about influ-encing by emotional devices the patient'spathological manifestations were naive andcrude. Significant was, however, his un-swerving conviction that mental disease is apsychological phenomenon, the cause ofwhich requires psychological methods oftreatment He states, "It is not since longthat one began to apply psychic treatmentmethods to the cure of menal disease, andthat one recognized that the latter must becured by such methods "

Reil clearly recognized the mutual inter-action between psychological and physi-

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ological events in the organism. He requiredthat not only physiology but also pathologyof the soul and also psychotherapy shouldbecome integral parts of the whole scienceof medicine. His attitude was outspokenlypsychosomatic, more consistently so thanthat of any of his predecessors. Reil's con-tribution was to outline a sound program.The time was not ripe to translate this the-oretically sound program into practice andbase it on a comprehensive view of the totalpersonality.

Yet, a number of romantic psychiatristsmade penetrating contributions towards adeeper understanding of the psychology ofmental symptoms, which they conceived asmanifestations of disturbances of the wholepersonality. One of the most outstandingamong them was Moreau, who energeticallypostulated that the basis of the psychologi-cal understanding of another person is in-trospection.58 To have a conception of pain,one must have experienced it. He main-tained that because the mentality of the in-sane is so foreign to the sane, the latter can-not understand the insane's mental processes.To know the thoughts of the insane, wemust have had similar thoughts ourselves,he concluded. This induced him to experi-ment on himself with hashish, anticipatingthose psychiatrists in our own days who weretaking, in self-experimentation, hallucino-genic drugs in order to have first-hand ex-perience with psychotic states. However,everybody dreams, and according to Mo-reau, dreams are made of the same stuff aspsychotic symptoms The dream thus offersa connecting link between the healthy per-son and the insane.

Among the other romantic predecessors ofFreud, Johann Christian Heinroth had aprofound intuitive grasp of mental conflicts.As a man deeply steeped in Lutheran tradi-tion, he expressed himself in religious termi-nology. The conscience to which he referredas the "super-us" (Uber-uns) was for himthe central core of those mental disturb-ances. He introduced a tripartite concept ofpersonality consisting of the basic self-cen-tered instinctual forces as the deepest level;

18

the ego, which functions through the guid-ance of the intellect and represents the indi-visible unity of body and psyche; and final-ly, the highest structure, the Uber-uns, therepository of moral principles. His interpre-tation of internal conflict as the basis ofmental disease is the more striking becauseHeinroth did not supply sufficient clinicalmaterial to substantiate his theory. Accord-ingly,, he offered no operational suggestionshow to help the mentally disturbed patientto achieve the desired internal harmony be-tween his selfish needs and the dictates of hisconscience.

Indeed, he was the first to use the term"psychosomatic"—in 1818 in his Lehrbuchdcr Stoerungen des Seelenlebens.15

In a sense, most modern among the ro-mantic physicians of the 19 century was theobstetrician, K. G. Carus. His book. Psyche,is perhaps the most consistent expose of theromantic position, not only in regard to thepsychology of mental disease, but also re-garding physiology and general pathology.7

The central axis of Carus's philosophy, likeFreud's, consists in his concept of the "un-conscious," which he equated with the crea-tive life-force similar to Freud's Eros andidentical with Groddeck's Id. There areislands of visionary insight in his book, sur-rounded by an ocean of vague and confusedgeneralization. We read in the introductionof his book the modern-sounding statement,"The key for the understanding of the es-sence of conscious mental processes lies inthe region of the unconscious. All the diffi-culties, nay, the seeming impossibility, tounderstand precisely the mysteries of themind becomes from this point of view un-derstandable. If it were really impossible tofind in consciousness the unconscious, oneshould resign ever to understand the psyche,that is to say, ever to understand one's ownself. However, should this impossibility beonly virtual, then the first aim of the scienceof psychology should be to determine inwhich way the human mind can descend in-to these depths."7 Indeed, Freud could havewritten something similar. Freud, however,actually discovered an operational method

PSYCHOSOMATIC MEDICINE

of penetrating the depth of man's personali-ty. Carus sets the problem correctly, butpitifully Jails to advance any methodologicaltools to achieve the goal which he statedwith admirable clairvoyance. And preciselyhere in this lack of operational knowledgelies the cardinal reason why the romanticmovement had to fail, to go into oblivionbefore a realistic depth psychology couldcome into existence.

Carus's unconscious comprises much morethan mental content which became uncon-scious sometime in the past. For him, justas for his modern reincarnation, Groddeck,the unconscious is practically equivalentwith the whole life process, both organic andmental. It is such an all-encompassing con-cept that it means everything and thus be-comes well-nigh meaningless. The uncon-scious animates all physiological processes,hence all organic illnesses are rooted in theunconscious mind.

Carus's medicine and psychiatry is the de-light of the metaphysician who wants tosolve the mysteries of life with a single prin-ciple, even if he has to disregard every detailthat our senses tell us about the world. It isat the same time a nightmare for the naturalscientist, who insists upon observing and ex-plaining the complexities of the world, nomatter how much he shares the metaphysi-cian's striving to reduce the basic principlesof his explanations to a minimal number ofindependent postulates. Unfortunately, thehistory of thought development stubbornlyoscillates between these extremes. Hyper-trophy of speculation and generalization arefollowed by a hypertrophy of compulsivegathering of details and their often mean-ingless classification. Psychiatry in the next50 years in the second half of the 19th cen-tury had to go through such a sterile era be-fore the dynamic integrative point of viewcould be again revived. However, when itwas revived it was tempered by the nowsolidly entrenched tradition of controlledobservation and rigorous reasoning. Freud'sgreatness lies just in a proper mixture of aspeculative and scientific genius which al-

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ALEXANDER

lowed him to accomplish a synthesis be-tween two extreme orientations.

It would take us too far to try to speculatewhy the pendulum of thought developmentreversed its direction in the middle of the19th century and why psychology as a medi-cal discipline again receded to the back-ground So much is certain—that by themiddle of the 19th century the industrialrevolution was full on its way and the engi-neer was becoming the hero of the day Theideal of the medical man was to become theengineer of the body. Psychiatrists of thisera were fascinated by the progress in brainanatomy and physiology and dreamed of astate of affairs in which their field wouldbecome equal to the other medical special-ties by substituting for the medieval conceptof the soul a solid knowledge of brain func-tions. Then the disturbances of the mindwould be treated with similar methods—physical and chemical, or perhaps even sur-gical—as were the disturbances of other or-gans.

Psychology began to slip back into thehands of philosophers and creative writers.

In the field of medicine, however, the con-fidence in making of medicine a natural sci-ence equal to physics and chemistry steadilygrew, and the psychological interest con-sistently ebbed away. No one was more in-fluential in this turn of thought develop-ment than Wilhelm Gnesinger (1817-1868),who visualized his role as the one who wouldemancipate psychiatry from the influence ofthe spiritualists and the romanticists andplace it on the sound basis of brain anatomy,pathology, and physiology. His spiritualsuccessor, Kraepelin, in theory completelyidentified himself with this theoretical posi-tion, yet felt that the chaotic picture whichthe great variety of mental disturbances of-fer required precise psychological descrip-tion and classification. His work, however,did not contribute in the least to a better un-derstanding of mental disturbances. In fact,it hindered the dynamic point of view whichthe romanticists began to introduce into thisfield. These beginnings went into completeoblivion under the shadow of the steadily

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advancing neurophysiological knowledge. Itso thoroughly disappeared that Freud wasunaware of the fact that his basic orienta-tion had been anticipated by the romanticssome 50 years before. This explains whyFreud's and his followers' contributionshave appeared to contemporaries as an al-most completely novel orientation. WhatFreud had to cope with was not only a "psy-chiatry without psychology,"22 but onewhich had not even workable and pertinentphysiological concepts for the understand-ing of those psychopathological phenomenawhich were described' and classified byKraepelin and his collaborators Freud wasobviously not acquainted with the writingsof the romantic psychiatrists, and had to re-discover their psychobiological orientation.It is only now, long after Freud's influencerevitalized psychiatry, that contemporaryhistorians begin to recognize the significanceof the psychiatrists of the romantic pe-riod.1*. 2i. 22

A reaction against this romantic episodewas unavoidable, the movement, with all itsstimulating flashes of imagination carried initself the seeds of its own decline: a hyper-trophy of speculation and the neglect of thearduously acquired fruits of 17th and 18thcentury empiricism and rationalism Whatwas veritably novel in Freud's approach wasnot his basic orientation, not even the postu-lation of unconscious mental processes, buthis developing an operational tool to studypsychological causal sequences and to mo-bilize repressed unconscious material in thetherapeutic situation This allowed him togo beyond a general abstract postulation ofthe unconscious and to study empirically itsinfluence upon behavior and physiology. Itled to the development of psychodynamicsas a basic science of psychiatry. Finally, itmade possible the development of whatmight be called the psychosomatic era ofmedicine.

While Freud's psychoanalytic methodsmade possible the precise study of psycho-logical causal sequences, Cannon's animalexperiments, studying the adaptive bodilyresponses to fear and rage, prepared the way

20

for a systematic and controlled study of psy-chophysiological reactions.6

Until quite recently psychosomatic studieswere mainly clinically oriented. They dealtprimarily with the biographical reconstruc-tion ot emotional conflicts as they evolve inthe course of life and are revived by theevents immediately preceding the onset ofthe physical symptoms. The underlying hy-pothesis is that recurringorchronicemotion-al stress has a-cumulative physiological effectand eventually may produce chronic reversi-ble or irreversible organic dysfunction. Theprimary approach was the psychoanalyticobservation of patients suffering from differ-ent chronic organic diseases in which psy-chological factors were suspected. Studiesconducted in the Chicago Psychoanalytic In-stitute resulted in the description o£ char-acteristic emotional patterns which wereestablished in different organic conditions.There were seven psychodynamic patternsfound consistently in seven diseases: in duo-denal ulcers, in ulcerative colitis, in asthma,in essential hypertension, in rheumatoidarthritis, in thyrotoxicosis, and in neuroder-matitis.1-23-4 Our findings became knownunder the somewhat misleading term, "spe-cificity hypothesis." It is a misleading termbecause we did not postulate a one-sidedmonocausal etiology. Although these sevencharacteristic psychological patterns werefound with the greatest regularity in theseven chronic diseases, the same patternscould be observed also in patients who didnot suffer from any organic chronic disease.A multicausal explanation was offered Itwas assumed that only those individualswho have a specific organic vulnerabilitywhich they acquired earlier in life or whichwere genetically transmitted will developorganic symptoms under the influence ofspecific emotional stress situations. I calledthis specific organ vulnerability the "X"factor. In other words, it has been postulat-ed that patients suffering from certainchronic organic diseases have two kinds ofvulnerabilities: a specific emotional vulner-ability towards certain interpersonal stress

PSYCHOSOMATIC MEDICINEsituations and a specific organic vulnerabil-ity. The "onset situation" I defined as onewhich is particularly suited to produce thespecific emotional stress which has a specificaffinity to the vulnerable organ system.3

The effects of emotional stress upon theorganism can be studied not only by clinical-biographical methods, but more directly byexperiment. Cannon's classic experimentson the influence of rage and fear on thephysiology of animals paved the way. Thistype of experiment is not readily conductedon human subjects because of the great diffi-culty of reproducing in the laboratory thosecomplex life-stress situations which sup-posedly lead eventually to organic diseases.

Nevertheless, different devices have beenused in recent years to reproduce in the lab-oratory emotional stress situations and ob-serve their physiological effects. Hypnoticsuggestion has been widely used Wittkoweret al. observed physiological changes in stu-dents before and during examinations,9

Grinker studied physiological changes inparachutists which followed their jump,Funkenstein et al. gave the experimentalsubjects tantalizing tasks to perform, andridiculed their futile attempts. These areonly a tew examples of numerous experi-mental studies of this kind. They representd most valuable complement to the clinicalstudies in which the researcher makes use ofthe expei iments of nature.

In recent years in the Psychiatric andPsychosomatic Research Institute of MountSinai Hospital in Los Angeles we have de-veloped a technique which has proved to bepromising tor the experimental study ofemotional stress in a realistic lifelike setting.We are using different carefully selectedcommercial films, each representing a differ-ent kind of interpersonal stress situation cor-responding to those which were found char-acteristic for different diseases. In one filmfear for survival is the central topic. Thiswas found a typical stress precipitating thy-rotoxicosis 13 Another film revolves aroundrighteous indignation, picturing the violentfight of the hero with his oppressors. To this

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ALEXANDER

type of emotional stress, according to ourclinical findings, the hypertensive patient isspecifically vulnerable.1 Still another filmfeatures the competition of the modernwoman in the male world, revolving aroundthe emotional conflict usually referred to as"masculine protest reaction." This conflicthas been found conspicuous in arthriticwomen.16 Another film serves to mobilizethe "asthma conflict."10 It deals with a wom-an's desperate struggle to emancipate herselffrom the influence of an over-protectivemother, with whom she is unable to com-municate freely.

The subjects watching the films becomeemotionally involved and their physiologi-cal reactions while they are watching are re-corded by electronic devices. Heart activity,muscle tonus, respiration, galvanic skin re-sistance, blood pressure, and changes in thy-roid functions are continuously recorded ona tape which is synchronized with the soundrecord of the film.5 This method allows oneto observe in a continuum physiologicalchanges which take place under these differ-ent types of emotional stress situations. Afterthe patients have seen the film they are sub-jected to psychological tests and a psychi-atric interview by which we try to establishnot only the physiological but also the psy-chological events which took place concur-rently with their exposure to the stressorfilm.

A first pilot study on thyrotoxicosis hasshown that patients suffering from an acuteattack of thyrotoxicosis react to the stressorfilm dealing with threat to biological sur-vival with changes in thyroid function.Treated and euthyroid patients did not re-act the same way.5

While the experimental study of psycho-physiological reactions is still in its infancy,the clinical knowledge of the typical emo-tional patterns has already proved of greatvalue in our therapeutic work. Knowing thespecial emotional vulnerabilities of patientssuffering from different diseases enables usto approach their conflicts more directly,without having to discover anew the nuclearconflict in each case. Moreover, the knowl-

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edge of these nuclear conflicts greatly facili-tates the general clinical management ofthese patients. We know, for example, thatulcer patients cannot freely gratify their de-pendent needs because accepting help fromothers mobilizes shame and guilt. There-fore, such patients react favorably to au-thoritative management: The therapist or-ders them to rest, this relieves their guilt andshame for renouncing .their responsibili-ties. Equally helpful is the knowledge thatasthma patients are inhibited in communi-cating freely their conflicts because of adeeply rooted fear of rejection acquired ininfancy as a result of an early, disturbedmother-child interaction. Asthma, indeed,is a disease of communication. It attacks theorgan of communication—the expiratoryphase of respiration. The knowing thera-pist, by proving himself uncritical, permis-sive, and understanding often succeeds inrapidly establishing a confidential climatewhich alone may terminate attacks of manyyears standing Knowing the hypertensivepatient's inclination to submit himself—be-cause of an exaggerated loyalty and over-conscientiousness— to unrewarding andstrenuous life situations which he inwardlyresents is useful if one is to teach him toavoid these types of stress-provoking life cir-cumstances

In other words, in addition to the pro-longed psychoanalysis and psychotherapy,which attempt to bring about changes inthe patient's internal emotional economy,the precise knowledge of the psychophysio-logical interaction characteristic of differenttypes of patients, allows their purposeful to-tal management.

Many years of experience have taught methat there are different avenues towardbringing about a proper adaptive balancebetween the person and his environment.Prolonged and not always successful psycho-analytic and psychotherapeutic attempts toeffect a radical change in the total emotionaldynamics is not the only approach. It ap-pears to me that in recent years we went toofar in calling "neurotic" all deviations froman imaginary, mainly culturally determined

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norm. Neurosis is a relative term. The sameperson may be well-adjusted in one situa-tion and not in another. Neurosis is not anabsolute attribute of a person. It has nomeaning without considering the field inwhich the person operates. Only in the mostsevere cases is a person's general adaptabilityso uniformly disturbed that he fails in prac-tically all life situations. All of us who wereactive on military selection boards duringthe last war remember well psychopathicpersonalities who slipped through thescreening procedures and became war he-roes, only to become "sociopaths" again af-ter they returned to civilian life. Obviouslytheir personality disorder was especiallysuited to front-line service. Had they livedin a society in which war is a chronic state ofaffairs they would never have been consid-ered neurotics. Many adult immigrantstaught us a similar lesson. Many of themwere especially well-adapted to their nativeculture and became neurotic only in theirnew environment in which they felt frus-trated As a result they regressed to less ma-ture behavior patterns and developed trueneurotic symptoms. It is noteworthy thatsome of these immigrants failed in readjust-ing to their new environment just becausethey were so firmly adjusted to their origi-nal milieu.

An introverted, poetically inclined personmay have been considered a misfit in anAmerican frontier town a hundred yearsago. He was exposed to ridicule, was of nouse in clearing the woods or killing IndiansFrustrated in self-expression, he withdrewfrom human contacts and today he wouldprobably be diagnosed as a schizoid person-ality. In a literary society the same personmay have become a luninary

Every neuiosis consists in an adaptivefailure resulting from the discrepancy be-tween a person's adaptive capacity and theenvironment in which he finds himself. Thepersonality patterns we found etiologicallysignificant in chronic organic diseases com-prise the whole gamut of human conflicts.They are well-nigh universal Shame at be-ing helpless, mobilizing the urge to over-

PSYCHOSOMATIC MEDICINE

compensate by a display of toughness andefficiency, repression of hostile feelings inorder to be loved, the urge to deny fear bycontraphobic defenses—by whistling in thedark—and to conceal one's feelings for fearof rejection, are universal dynamisms. Anyof these patterns or all of them may be pres-ent in traces in one person and be central inanother. There is no doubt that psycho-analysis and deep psychotherapy sometimessucceed in modifying, at least to some de-gree, these idiosyncratic qualities. In ourhighly diversified Western culture, however,with its immense variety of subcultural en-vironments, many of these patterns have anadaptive value in one or another profession-al and subcultural milieu. Our heterogene-ous culture can use a great diversity of per-sonality types. Which of these personalityconfigurations should be considered neu-rotic largely depends upon the specific valuesystem which prevails in a given subculturalenvironment.

This relativistic view of neurosis broadensour therapeutic perspective. The currentnaive, often fanatical insistence upon tryingto reconstruct radically the patient's per-sonality to fit an imaginary norm will haveto yield to a more seasoned and realistic psy-chiatric wisdom which operates with a newdiagnostic dimension. This dimension con-sists in asking in each individual case thequestion: How can the discrepancy betweenpersonality structure and environment bestbe reconciled, by changing the person or bychanging his environment.

The hard-driving business executive,ready to take on more and more responsi-bilities, who is married to an infantile, de-manding, clinging-vine type of wife, maymore easily relieve his chronic ulcer symp-toms by resolving this marital incompati-bility by a divorce and by marriage with amaternal type of woman, than by a pro-longed analysis which tries to reduce his"orality." He may bear his professional re-sponsibilities without somatic symptoms ifhe is relieved on one front—namely, in hispersonal life—from the excessive demandsof a nongiving wife. A person is not neces-

PSYCHOSOMATIC MEDICINE

ALEXANDERsanly neurotic per se. The diagnostic term"neurotic'' must be qualified by addingwhere and when a person is neurotic. Notonly the person, but also the field in whichhe finds himself must be considered. Thefully analyzed normal person is one of thosefictions which at present is retarding the de-velopment of psychiatry. The furor analy-sandi took the place of the juror operandi ofthe preceding era.

And yet, looking back on the history ofpsychotherapy, there is no reason for dis-couragement. In all areas of knowledge thefirst phase of development consists in specu-lations about the phenomena in nature:thinking and talking about them instead ofmethodically observing them. Only grad-ually is speculation replaced by methodicalobservation and rigorous reasoning. TheGreeks speculated about matter and Leucip-pus and Democritus finally postulated theexistence of the atom. Democritus' atom,however, had little to do with Dalton's atomwhich could be measured because it enteredinto chemical compounds according to defi-nite weight ratios. Hippocrates' speculativehumors have been replaced today by chem-ically analyzed and frequently even synthe-sizable endocrine secretions.

Methodical observation and close reason-ing, to replace the generalities of common-sense psychology, were introduced muchlater into psychology and psychotherapy.The science of personality in this operation-al sense is only 6 decades old. The soul, theanimal spirits, yielded to the concept of themental apparatus which functions accord-ing to empirically established laws of psy-chodynamics. The psychotherapist is nolonger interested in an abstract "human na-ture" but in the concrete individual personwhom he studies with improved methods ofcommunication—namely, by free associa-tion in the nonjudgmental climate of thetherapeutic situation. Also, the abstractplatonic thesis that the mind rules over thebody is being replaced by controlled psycho-physiological experiments. And finally, an-other fictitious abstraction, "the individualperson," who can be studied as an isolated

VOL. xxiv, NO 1, 1962

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unit, is beginning to yield to a moie leahsticview, which maintains that the person canonly be understood within the cultural fieldin which he grows up and operates Thephysiological, the psychological, and the so-ciological approaches thus begin to be in-tegrated into a comprehensive understand-ing of man. Future advancements of psycho-therapy will evolve from such an integratedcomprehensive approach to man as a bio-logical organism, a personality, and a mem-ber of a social system. Neglecting any ofthese three major parameters results in adistorted and operationally unsatisfactorypersonality theory and therapy.

The developments of the last 60 years inour field consist precisely in applying to per-sonality research the same principles—con-crete, systematic observation and close rea-soning—which enabled man to gain greatercontrol over his physical environment andhis body. The next step which contempo-rary man is in the process of undertaking isto gain a similar mastery over his personali-ty and his social destiny.

Mt. Sinai Hospital8720 Beverly Blvd.

Los Angeles 48. Calif

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