LOUIS A. GOTTSCHALK, M.D.

Psychosomatic medicinetoday: An overviewABSTRACT: The current status of several areas of interest in psy­chosomatic medicine, including specificity theory, life changes,and peptic ulcers, is reviewed, and their relevance to the practiceof psychosomatic medicine discussed. The importance of neuro­psychopharmacological research to psychosomatic medicine isstressed, and a perspective is given on the usefulness of drugs inconjunction with intensive psychotherapy.

"Psychosomatic" is now a part ofthe average person's vocabulary,and most educated laymen knowthe meaning of "psychophysiologi­cal" and "somatopsychic." Withouthaving words for the process, ev­eryone senses that mental processescan influence bodily functioning,and that the sick body can producea sick mind.

Some would like to reserve theterm "psychosomatic" for thosedisorders in which psychologicalRrocesses lead to visceral or somaticdysfunctions, and to limit the use ofthe term to certain conditions suchas essential hypertension, neuro­dermatitis, peptic ulcer, and rheu­matoid arthritis. Others wouldprefer to subsume a much broaderrange of illnesses and diseasesunder the term "psychosomatic"

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and include all medical disorders inwhich emotional or psychologicalfactors aggravate the medical con­dition in any way and to any extent.I will be using the terms "psycho­somatic" and "somatopsychic" inthe broader sense.

Etiological hypotheses

Because diagnosis, pathogenesis.and treatment are often linked to­gether with etiological theory, Iwould like to briefly review thevarious etiological hypotheses in­volving psychosomatic disorders.Most theoreticians agree that mul­tiple factors are involved in thepathogenesis of psychosomatic dis­orders. Thus, while genetic factorsmay predispose individuals to cer­tain kinds of disease or illness, en­vironmental factors, to varying ex-

tents, must come into operation inorder to bring out the phenotype.

Recently, Nemiah ' and Sifneos2

have proposed that individualswho are predisposed to psychoso­matic disorders are unable to ex­press their emotions and are, infact, unfamiliar with the subjectiveexperience of their emotions. Cer­tain French authors have elaborat­ed on this observation, and theystate that such individuals custom­arily use language to describe inpainstaking detail various situa­tions in which they or familymembers have been involved,while uniformly omitting emo­tional words; they have named thisphenomenon "pensee operatoire.")Sifneos has coined the word "alex­ithymia" for the phenomenon inwhich individuals systematicallyavoid expressing emotions, and heand his collaborators have enter­tained the notion that this condi­tion is heavily loaded towards agenetic predisposition.

Enough interest has been gen­erated in alexithymia so that theEleventh European Conference onPsychosomatic Research, in Hei-

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Psychosomatic medicine today

del berg, Germany in September1976, focused its attention on thisconcept. Preliminary data werepresented which suggested thatpsychosomatic patients (selectedfrom among the seven psychoso­matic disease entities studied by theChicago Institute for Psychoanaly­sis over a decade ago), in contrast toa matched control group, did in­deed use fewer emotionally-ladenwords in interviews.4 And an iden­tical twin study did suggest thatmonozygotic twins were morelikely to share alexit~ymic charac­teristics than dizygotic twins; but inthis study the twins were all rearedin the same family, so the differen­tial effects of nature and nurture onalexithymia were not c1ear.5

Many clinicians questionwhether alexithymic traits are nec­essarily associated more with psy­chosomatic disorders than with anyother medical or psychiatric dis­order. In any case, the concept ofalexithymia remains valuable forempirical reasons and will stimu­late interest in research with respectto how and whethe~ this condition,in its more extreme form, is relatedto bodily dysfunctions.

Specificity theory

Any consideration of psychoso­matic medicine must look at specif­icity theory, which holds that spe­cific psychodynamic conflicts orpsychosocial stresses lead to spe­cific psychosomatic disorders.6-9

Specificity theory has been mostclearly outlined by Alexander andhis associates.8 Alexander assertedthat psychological factors might beetiologically significan t in somediseases and less so in others. Hiscontention was that psychologicalfactors were conspicuously presentin a specific distribution in theseven disease entities that the Chi-

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cago Psychoanalytic Institute in­vestigated-namely, peptic ulcer,ulcerative colitis, essential hyper­tension, bronchial asthma, neuro­dermatitis, rheumatoid arthritis,and thyrotoxicosis.

He argued that since these psy­chological phenomena antedatedthe appearance of the organicsymptoms, one faces one of onlytwo conclusions. Either these per­sonality phenomena contributed tothe etiology of the organic symp­toms or they were the psychological

The concept that anaccumulation ofadverse lifechanges and/or poor copingmechanisms predisposes toiUness and death has gainedmore anention.

expression ofcertain basic qualitiesof the organism that manifestedthemselves on the somatic side asan organic predisposition.

Other studies involving a dif­ferent approach to specificitytheory were carried out by Graceand Graham,6 working at the de­partment of medici!le, New YorkHospital-Cornell Medical Center,and these studies are typified by thepaper entitled "Relationship ofSpecific Attitudes and Emotions toCertain Boqily Diseases." Thestudies of these workers, along withthe studies of Harold Wolff andothers at the Cornell MedicalCenter constitute important contri­butions in the psychophysiology ofskin disorders such as pruritus, aswell as Raynaud's disease, gastricfunction, headache, upper respira­tory infections, and other condi­tions. 1o Harold Wolff and his asso­ciates were much more contentthan the psychoanalysts to deal

with manife.st emotions as theywere temporally associated withphysiological (somatic and visceral)changes, and they were consider­ably less concerned with underly­ing psychodynamic conflicts. Thearguments between the Alexanderand the Wolff groups have neverbeen clearly resolved with regard tothe nuances of the depth of specificpsychological correlates as precur­sors of physiological changes.

Engel and Schmale" have pro­posed that patients sharing thesame biological characteristics arepredisposed to similar develop­mental and psychological disordersin organic diseases. By means ofthis formulation, they have at­tempted to link various psychoso­matic and somatopsychic disorders,including blood dyscrasias andneoplasms, and explain similaritiesoften noted clinically in the psy­chological and somatic syndromesprecipitated initially by either psy­chosocial or biomedical stress.Schmale, Iker, and Engel '2-14 haveemphasized that one importantnonspecific situation contributingto the emergence ofdisease, thoughneither necessary nor sufficient forsuch, involves the affects of help­lessness and hopelessness.

Life changesGaining progressively more atten­tion in epidemiological studies ofpsychosomatic disease and illnesshas been the concept initially in­troduced by Holmes and Rahe l5

and subsequently elaborated con­siderably by Rahe,'6.'8 which statesthat an accumulation of adverselife changes and/or poor copingmechanisms predisposes to illnessand/or death. By use of a numberof questionnaires, including theSocial Readjustment Rating Ques­tionnaire and the Schedule of Re-

PSYCHOSOMATICS

cent Experiences, definitely signifi­cant but low correlations have beenobtained between the incidence ofcertain medical disorders and ad­verse life experiences and poorcoping mechanisms.l~

In a recent study, Rahe pre­sented data on 227 coronary heartdisease patients-I 13 who survivedan acute myocardial infarction, 65who died suddenly within onehour, and 49 who died between onehour and one month following anacute episode of myocardial infarc­tion. All three groups of patientshad no coronary heart disease priorto their myocardial infarction ordeath. A significant increase in re­cent life changes was seen over thesix to nine months prior to themyocardial infarction or abruptcoronary death. This build-up wasrelatively greater for the two deathgroups than for the myocardial in­farction survivors. Not all post­myocardial infarction patients re­port having experienced a recentlife-change build-up prior to theirinfarct. however. Only two thirds ofsubjects have indicated a moderateto substantial increase in recent lifechange experience over the six­month period prior to their myo­cardial infarction. Such a build-upof life changes has been found innearly three fourths of coronaryheart disease death subjects.

Trigger mechanisms

Other investigators, withoutespousing one hypothesis or an­other, have definitely demonstratedpsychosocial trigger mechanisms inthe physiological disorders of pa­tients.2o.23 The present author hasdemonstrated that even mild in­creases in subjects' anxiety, asmeasured from the content analysisof speech during an interview, aresignificantly associated with a de-

FEBRUARY 1978, VOL 19· NO 2

crease in skin temperature of thehands24 ; that (separation) anxietycan trigger genuine epileptic con­vulsions in certain susceptible indi­viduals25.26 ; and that anxiety whenawake27 and when dreaming,28 asmeasured from the content ofspeech or from the subject's reportof the content of a dream, is regu­larly associated with increases inplasma free fatty acids.

Silbergeld and associates29 haveshown that anxiety, as measured

Even mild increases inanxiety are associated with adecrease in skin temperatureofthe hands. A nxiety is alsoassociated with increases inplasma free fatty acidswhether the patient is awakeor dreaming.

from the content analysis of speechby the method of Gottschalk andGieser, is significantly associatedwith increases in serum dopaminebeta-hydroxylase. Moreover,Gottschalk and associates30 havedemonstrated significant correla­tions between anxiety and hostilityscores from the content analysis ofspeech and various cardiovascularchanges as measured by echocar­diography. The relationship ofarousal of various emotions andgastrointestinal disorders has beendemonstrated in great detail.

Peptic ulcer

The physiological conditions thatfoster peptic ulcer are fairly wellunderstood. Gastric acid and pep­sin must be present for an ulcer todevelop. In most duodenal ulcerpatients, the body mechanism con­trolling gastric acid productionseems to produce greater than nor-

mal amounts of the acid. Severaldrugs have been developed that re­duce the production of gastric acid.One of the newer such drugs, cime­tidine, blocks the histamine acid­triggering mechanism, thus depriv­ing the peptic ulcer of one of theconditions it requires.

The decrease in the incidence ofduodenal ulcers over the past 20years raises a number of tantalizingquestions. It is believed that such arapid change has resulted from anenvironmental factor, and it hasbeen proposed that peptic ulcer is a"transitional disease," one of the"diseases of civilizatior" that mayaccompany the beginnings of ur­banization.

I still favor the hypothesis pro­posed by Alexander and asso­ciates,S that the mobilization of de­pendency that cannot be gratified,either for external reasons, such aspoverty, or because of internalizedinterdictions. such as shame in ex­pressing dependency need, plays akey role in the psychophysiology ofpeptic ulcer development, espe­cially in male patients.

Neuropsychophannacology

Like psychosomatic medicine,neuropsychopharmacology dealswith multiple factors, as these playroles in the final common path of aclinical effect. We now know thatthe effects of a psychoactive drugare considerably influenced by thebiomedical and psychosocial his­tory of the individual to whom thedrug is administered. The mea­surement of psychosocial phenom­ena, for which we need more sensi­tive and better quantifiableinstruments, is important in psy­chosomatic research and practice.The development of such measure­ment instruments, which includesdoing reliability and validity stud-

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Psychosomatic medicine today

ies, can be considerably enhancedby psychopharmacological studies.Such psychoactive drugs as seda-

.. tive-hypnotics, mild tranquilizers,opiates, and psychotomimetics arecapable of strongly influencing theoutput of our central nervous sys­tem, as reflected not only in generalbehavior, but also in the content ofspeech, as well as in the expressionof emotions.

The measurement instrumentsused in psychosomatic research, aswith neuropsychopharmacologicalresearch, include self-report scales,rating scales by outside observers,and psychological assessmentthrough the content analysis of theindividual's speech. Psychophar­macological studies can help cali­brate the psychosocial measure­ment instruments we are using byallowing us to administer specificamounts of antianxiety, antihostili­ty, or antipsychotic drugs and ob­serving the effects of not only thedoses of these drugs, but also therelationships of the blood levelsand half-lives achieved in each in­dividual by such drug administra­tion to the dependent behavioralvariables being measured.

NeurotransmittersMoreover, we now believe thatmany of the intervening variablesbetween stressful precipitants ex­ternal to the human body and in­ternal physiological effects involvesynapses and neurotransmitters,both in the central nervous systemand peripheral nervous system, andthese intervening variables areequally involved in psychosomaticdisorders as well as in disorders inwhich psychopharmacologicalagents are typically administered.For these reasons, current researchand discoveries in the nature ofneurotransmitters and factors that

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lead to their ebb and flow arehighly germane to both psychoso­matic and psychopharmacologicalresearch.

At a more refined level, there ismore precise information nowavailable about the mind-body re­lationship. Teyler and associates) I

have demonstrated that when anindividual thinks of different words(and even the same word, such as"hound" as noun and verb), dif­ferent evoked electrical potentialsappear from surface scalp elec­trodes for each word. This phe­nomenon illustrates that there are

Current research anddiscoveries in the nature ofneurotransmitters are highlygermane to bothpsychosomatic andpsychopharmacologicalresearch.

specific electrical processes in thebrain (and, by inference, concomi­tants of biochemical processes), as­sociated with every thought orword, expressed or unexpressed.These findings help demonstratethe continuing link between exter­nal phenomena or life events andsomatic and visceral changes oc­curring in the body.

Finally, psychopharmacologicaldata and clinical work enhance ourtreatment approaches in psychoso­matic medicine. The pure psycho­logical approach to psychosomatictreatment often assumes that ca­tharsis improves a physiologicalcondition and disorder, but this ap­proach loses sight of the fact that, insome instances, autonomic andother somatic concomitants stirredup by the arousal of disturbingmemories may aggravate psycho-

somatic disorders. Hence, auto­nomic blockers, tranquilizers, seda­tive-hypnotics, and antidepressantdrugs may be useful adjuvants inpsychosomatic treatment.

Psychosomatic management

As in the past, there tends to be anoversimplification of the type ofpsychotherapy that might be mostadvantageous for various types ofpatients with psychosomatic dis­orders. Today, we have availableindividual and group (includingfamily) types of psychotherapy,both for prevention and treatmentof psychosomatic disorders. Therecent delineation of the phenome­non of alexithymia-the inhibitionof the expression of emotions­would erroneously lead one to be­lieve that every psychosomatic dis­order would be improved if theindividual expressed emotionsmore freely. In many instances andwith certain patients, however, theproblem is not so much the expres­sion of too little or too much emo­tion, but that irrational and abnor­mal emotions are aroused becauseof misperceptions and misapprai­sals of various life situations due tolack of differentiation by the indi­vidual between past life experi­ences and current life situations.

Modification of such syndromes,which are technically labeledneuroses, psychoses, or characterdisorders, is not brought about bygetting the patient to express moreemotions or suppress emotions, orby use of drugs that stimulate orinhibit affects. These conditionscan only be ameliorated by inten­sive psychotherapy designed tohelp the patient discern that certainpsychological reactions and memo­ries are being incorrectly mobilizedin response to current life situationsthat are only vaguely similar to the

PSYCHOSOMATICS

Dr. Gottschalk is professor and chairman, department of psychiatry and humanbehavior, at the University of California, Irvine. Reprint requests to Dr. Gottschalk,University of California Irvine Medical Center, /OJ City Drive South, Orange, CA92668.

past, and to discern that this futileand erroneous arousal of past reac­tions to the present situation is abasic problem that triggers andsustains the disturbing psychoso­matic disorder.

In closing this discussion of the

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looked by such an approach, whichmay cancel out the beneficial ef­fects of the drugs. but the capacityof the patient to remember or oth­erwise make use of some psycho­therapeutic understanding may beblocked by the overuse ofotherwisevery useful sedative-hypnoticagents. such as the benzodiaze­pines. which in small doses are ca­pable of producing amnesic ef­fects. 32.33 0

ifications of the oropharyngeal bacterial w~hChanges in the psychodynamic state. Psy­chosom Med 20:314-320. 1958.

23. Gottschalk LA: Sell-induced visual imagery,affect arousal, and autonomic correlates.Psychosomatics 15:166-169.1974.

24. Gottschalk LA. Gieser GC: The Measurementof Psychologic States Through the ContentAnalysis ot Verbal Behavior. Los Angeles,University of California Press, 1969.

25. Gottschalk. LA: Psychologic conflict andelectroencephalographic patterns. ArchNeurol Psychiatry 73:656-662, 1955.

26. Gottschalk LA: The relationship of psycho­logic state and epileptic activity. Psychoan­alytic Study of the Child. New York. Interna­tional Universities Press. 1956. vol II.

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29. Silbergeld S. Manderscheid RW, O'Neill PH,et al: Changes in serum dopamine-beta-hy­droxylase activity during group therapy. Psy­chosom Med 37:351-359. 1975.

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31. Teyler TJ, Roener RA, Harrison TF, et al:Human scalp recorded evoked potential cor­relates of linguistic stimuli. Bulletin of Psy­chonomics Society 1:333-334,1973.

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