Psychosomatic Medicine

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Psychosomatic MedicineAuthor(s): Edward WeissSource: The American Journal of Nursing, Vol. 45, No. 3 (Mar., 1945), pp. 189-193Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3416866 .

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Psychosomatic Medicine By EDWARD WEISS, M.D.

PSYCHOSOMATIC MEDICINE refers to the psyche, spirit, and the soma, body. In other words it has to do with the emotional-body relationships-the influence of the emotions upon the bodily functions. It is a new term for an old subject, because physicians have always known intuitively that there was some kind of a relation between emotions and illness. In recent years medicine has tried to substitute scientific principles for in- tuition and the result has been a rapidly growing body of medical knowledge now referred to as psychosomatic medicine. It is not a new specialty; it is an approach to medical problems that applies to all aspects of medicine and surgery.

It is generally acknowledged by the average physician that about one-third of the patients who consult him have no definite bodily disease to account for their illness. Recently, I have studied 200 consecutive private patients classifying them as follows: (I) those in whom the illness seemed to depend entirely on emotional problems; (2) those in whom the illness seemed in part dependent on emotional problems; and (3) those in whom an emotional problem did not seem to enter into the cause of the illness. Thirty-five per cent were placed in the first group, 33 per cent in the second, and 30 per cent in the last.

How does medicine of today deal with these patients-how are they studied and how are they treated? It is the purpose of this paper to discuss these questions briefly.

Quite commonly patients in Group I are told that there is no evidence of organic disease, that the trouble is "functional," and they are dis- missed without further attention only to land eventually in the care of some irregular practi- tioner or quack healer. Worse than that, physicians and nurses, too, sometimes take the attitude that the illness is imaginary, or that the patient is malingering, or assume that in some vague way the patient is deliberately responsible for the illness. For these reasons he is often referred to as a "damn neurotic" and gets the kind of care that must necessarily go with such a character- ization. The patient may also be told that the physician does not think anything is the matter, but suspicion is cast upon some organ or system which needs watching and care. This happens very frequently with regard to the symptom of fatigue and the suspicion of pulmonary tuberculosis and often results in a state of chronic invalidism. Lastly, following thorough study by means of medical history, physical examination, and laboratory investigation, some pathologic curiosity 1'

may be discovered which really has nothing to do with the illness. The patient is then treated as though organically diseased and is submitted to unnecessary medical or surgical treatment which, in many instances, intensifies the neurotic con- dition.

EMOTIONAL PROBLEMS

What is the matter with these patients and how should they be treated? They are suffering from disturbances in their emotional lives, that is, the illness is of emotional origin and can be satis- factorily studied and treated only from the psychologic standpoint. The ill health arises in a predisposed individual from long-standing dis- satisfactions in the business, social, or home life. This failure of adjustment to environment is manifested by a disturbance in some part of the personality, either as bodily symptoms of various kinds, capable of mimicking almost any disease, or as affections of the spirit resulting in attacks of anxiety, obsessions, phobias, depressions, and other disturbances of mood.

Why is it that so many physicians are unwilling to admit the psychologic basis for such illnesses, or if they do grudgingly concede that "a nervous factor is present," they believe it to be of secondary importance and probably the result of physical disease? In discussing a case of this kind they are apt to say, "But there must be something the matter," meaning that there must be a physical basis for the illness and that if they are just thorough enough in their investigations, "something" will be found. However, long-time follow-up studies on such patients fail to indicate that organic disease develops in any significant number; even when it does, we must not forget that a neurotic patient may develop an organic disease that is unrelated to his neurosis just as he similarly runs a chance of getting hit by a motor car.

Every physician freely acknowledges the relation of psychic causes to such physiologic phe- nomena as blushing, weeping, goose flesh, and even on occasions to vomiting, diarrhea, et cetera; but many, nevertheless, find it difficult to believe that more prolonged (chronic) disturbances of a physiologic nature can possibly be psycho- genic in origin.

This is due to the structural and physiologic training of modern medicine and came about in the following fashion.

The organic tradition in medicine.-The physician of ancient times was concerned with the spiritual

DR. WEISS is Professor of Clinical Medicine, Temple Uni- versity Medical School, Philadelphia, Pennsylvania.

I By pathologic curiosity is meant some congenital or ac- quired lesion that has no significance from the standpoint of health.

MARCH 1945 189



90o The American Journal of Nursing basis of illness, but the structural concept intro- duced by Virchow led to the separation of illness from the psyche of man and a consideration of disease as only a disorder of organs and cells. With this separation of disease into many different ailments came the development of specialists to attend to all of these distinct diseases.

With the specialists came the introduction of instruments of precision, and the mechanization of medicine began. Medicine now contented itself with the study of the organism as a physiologic mechanism, impressed by blood chemistry, electro- cardiography, et cetera, but unimpressed and, indeed, often holding in contempt the investigation of the life situation of the individual, which was not considered as scientific as the results of laboratory studies. This period may in truth be referred to as the machine age in medicine. It is not to be denied that remarkable developments have occurred during this period of laboratory ascendency, but it also must be admitted that the emotional side of illness has been almost entirely neglected.

As a consequence of this structural and physiologic tradition in medicine and lack of training in medical psychology, a great many physicians pride themselves upon their unwillingness to concede the abscence of physical disease when dealing with an obscure illness. This failure to recognize neurosis, and treatment of the patient as organically diseased happens most frequently, as already sug- gested, because modern clinical medicine attempts to establish the diagnosis of a functional disorder by ruling out organic disease through medical history, physical examination, and laboratory investi-

gation. The point that I particularly wish to make is that the diagnosis of functional illness must be established not simply by exclusion of organic disease but on its own characteristics as well. In other words, neurosis has its own distinctive features to be discovered only by a study of the emotional life. Only in this way can serious errors in diagnosis and treatment be avoided. If this statement is admitted, it must naturally follow that personality study is just as important in the problem of chronic illness as laboratory investigation.

PSYCHOSOMATIC STUDY IN CHRONIC ILLNESS

Now the question is, "How do we proceed with this kind of a study?" For general purposes it may be stated that in addition to the physical study it consists simply in getting to know the patient as a human being rather than only as a medical case. Too often, as already stated, the patient is looked upon as a physiologic mechanism and is studied by means of medical history and physical examina- tions aided by "instruments of precision" and chemical tests. Tape measures and test tubes carry the erroneous notion of exactness and thorough- ness--erroneous because the emotional life of the

individual, which may hold the key to the solution of the problem, is not investigated or at best

inadequately so. In regard to the latter point, too many physi-

cians feel that they have done their duty to the

study of the emotional life if they ask the patient if he is worried about anything and receive a negative reply. They are the same physicians who are

apt to remark about a patient, "But he doesn't look neurotic," perhaps believing that such a patient should by his general apprehension or by evidences of physical nervousness betray the fact that he is neurotic.

Unfortunately, most neurotics do not betray any neurosis in their appearance, nor is the approach to their emotional problem so simple that the direct question: "Are you worried about anything?" will produce information of importance. Probably the best way to deal with these patients is first to satisfy ourselves and establish their confidence by a thorough medical history (which must contain more data concerning the social back-

ground of the patient that most of our present histories do), complete physical examination, and such laboratory tests as are necessary to exclude

organic disease. Having assured the patient that no

physical disease is present, or that symptoms are out of proportion to the physical disease that is

present, it is usually easy, by means of examples of

psychic causes for such physiologic disturbances as

blushing, goose flesh, palpitation, diarrhea, et cetera, to make the patient understand that a disturbance in his emotional life may be responsible for the symptoms. Then important clues to this disturbance can usually be found by encouraging a discussion of problems centering around voca- tional, religious, marital, and parent-child relation-

ships. This is usually best accomplished indirectly rather than by direct questions. In the case of adults, domestic problems and professional and business relationships play a large part in functional illness. In young unmarried people, family relationships, the choice of a career, and often

religious and sexual problems are important topics for discussion.

More important, however, than the actual life situation is the capacity of the patient to react to that life situation. In other words, besides exclud-

ing organic disease and besides the effort to connect the beginning of the illness with a particular life situation, it is of the greatest importance to know the patient's ability to adjust to such situations, his

pattern of reacting to them, the degree of anxiety in his make-up, and the nature and seriousness of his conflicts. It is not enough to ask, "Are you worried about anything?" as nine times out of ten the answer will be "No," in spite of the fact that all of us have problems that may disturb our bodily functions. The patient may feel that his particular problem has no bearing on his symptoms whereas

VOL. 45, No. 3



Psychosomatic Medicine 191

it may have everything to do with them although he is unaware of the connection.

Personality study is necessary if we are to establish a specific relationship of the psychic situation to the personality of the individual. Just as the typhoid bacillus is specific for typhoid fever, de- pending of course upon the susceptibility of the individual, so the psychic event must be specific for the personality structure of the person. To make such studies one must have some training in psychopathology. It is not enough to be just a sympathetic listener and it is certainly unwise and even dangerous for untrained or poorly trained people to try to give advice on important emotional matters.

There are no short cuts to involved emotional problems. You must know a great deal before you dare tamper with the urges and passions of human beings and my own experience is, the more you know the less you tamper. When psychopathology is given an equal place with tissue pathology in our medical curriculum, and is as well taught, we will finally realize that psychotherapy is an integral part of our medical discipline.

ORGAN LANGUAGE

I often tell my patients that if they cannot find an outlet for tension of emotional origin by word or action, the body will find a means of expressing this tension through a kind of "organ language."

For example, if a patient cannot swallow satis- factorily and no organic cause can be found, it may mean there is something in the life situation of the patient that he "cannot swallow." Nausea, in the absence of organic disease, sometimes means that the patient "cannot stomach" this or that environ- mental factor. Frequently afeeling of oppression in the chest accompanied by sighing respirations, again in the absence of organic findings, indicates that the patient has a "load on his chest" that he would like to get rid of by talking about his problems.

The patient who has lost his appetite and as a consequence has become severely undernourished (so-called "anorexia nervosa," which in its minor manifestations is such a common problem) is very often emotionally starved before he becomes physically starved. When he learns to taste life he will begin to taste food. The common symptom fatigue is very often due to emotional conflict which uses up so much energy that little is left for other purposes.

Again emotional tension of unconscious origin frequently expresses itself as muscle tension giving rise to aches and pains and sometimes these are represented by sharp pains such as atypical neuralgia. Thus, I suggest that atypical neuralgia of the arm or face may be due to focal conflict as well as "focal infection." An ache in the arm, instead of representing the response to a focus of infection,

may mean that the patient would like to strike someone but is prevented from doing so by the affection or respect that is mingled with his hostility.

Itching for which no physical cause is found very often represents dissatisfaction with the environment which the individual takes out upon himself; martyr-like, he scratches himself instead of someone else. "All-gone" feelings in the epigastrium, "shaky legs," and even vertigo, are common physical expressions of anxiety, and the anxiety attack, so frequently called a "heart attack," a gall bladder disturbance, hyperthyroidism, neurocircu- latory asthenia, hyperinsulinism, et cetera, is still far from being understood in general clinical medicine in spite of the fact that Freud described it more than forty years ago.

Many more examples could be given, but are unnecessary. Only one more point remains before concluding this part of the discussion and that is that the gastrointestinal tract is, above all other sys- tems, the pathway through which emotions are often expressed in behavior. Why this is so becomes appar- ent in the study of psychopathology but that is too large a subject to consider here. However, the abdomen has been aptly termed the sounding board of the emotions and the reasons go back to infancy and early childhood. The first contact that the infant has with the world is through its mouth so that the act of nursing and the emotions that go with it-love and affection, or anxiety and even hostility-are related one to the other. These emotions may become deeply buried in the unconscious mental life of the adult but nevertheless the processes of eating and digestion remain subject to disturbances in feeling in adult life because suste- nance and sensuality were so indissolubly related to the life of the infant. When things happen to people that disturb their emotions, old associations are awakened that result in a disturbance of the function of the gastrointestinal tract.

This whole approach can be summed up in the following fashion: Understanding illness and treating sick people consists of something more than a knowledge of disease; it necessitates looking upon illness as an aspect of behavior. It means that the nature of bodily disorders can only be appreciated when emotional factors are investigated in addition to physical factors. Such an approach can be applied to a wide variety of ailments and can be utilized very generally in talking with patients. Nor does it require a very high degree of intelligence on the part of the patient to follow this simple explana- tion. Patients in the clinic as well as those in private care can be dealt with in this fashion; they are just as susceptible to these psychosomatic disorders.

SEXUAL FACTORS

This again is a subject that cannot be treated in detail, but one point of importance does deserve

MARCH I945



192. The American Journal of Nursing consideration at this juncture and that is the relation of sexuality to neuroses.

Ever since the introduction of the epoch- making studies of Freud to the problems of neurosis, medicine has misunderstood his conception of sexuality. He has often been quoted to the effect that disturbances in genital activity are the sole cause of the neuroses. This is very far from the truth. It is rather that difficulty in the sexual sphere appears as a revealing index to a neurotic personality and can be looked upon in that light. In other words, in much the same manner that urea retention serves as an index to an impending uremia, so do disturbances in the sexual life of the individual, such as varying degrees of frigidity in the female and varying degrees of impotence in the male, serve as a reliable index to the kind of personality that is very apt to develop a neurosis.

Sexual difficulties are rarely in themselves the cause of the kind of the illress under consideration; when they are important and the patient has a satisfactory relationship to the physician, sufficient confidence will eventually be gained to permit discussion of these intimate matters. In women questions regarding menstruation and childbearing will often lead naturally to such a discussion.

In this connection let me suggest a cautious attitude in regard to marital maladjustments, which are often in the background of obscure illnesses. The better these problems are understood from the standpoint of personality study the clearer it becomes that serious emotional maladjustment is behind the marital problem. Consequently, casu- ally to give advice regarding marriage and childbearing, divorce and extramarital relationships as short cuts to involved emotional problems is to assume knowledge beyond present human understanding.

PSYCHOTHERAPY

And now to come to a question frequently raised regarding these matters: "Suppose you do find something of importance in the emotional life of a patient, some conflict that is causing illness, what g?od does it do the patient to know? What can you do about it?"

First of all, it is often a great help to the patient to know that the ailment is not organic but is due to a disturbance in his emotional life. When a neurotic symptom is divorced from a fear of organic disease--cancer, for example--it loses its force, whereupon the slogan "carry on in spite of symptoms" often helps the patient a great deal. This is especially true if the psychological approach which we have discussed is a part of the study and the emotional background of the illness is made clear to the patient. Secondly, such knowledge and such an approach will frequently save the patient unnecessary, troublesome, and expensive medical or surgical treatment with a resulting further degree of

invalidism. Often just the talking out of the problem with the physician will alleviate symptoms, and frequently some simple adjustment will ac- complish real help. However, it is a good rule for the physician to listen rather than talk; giving advice on important emotional matters is dangerous.

The same thing applies to the nurse. Repeatedly patients will unburden themselves to the nurse when they will not to the doctor. They feel on closer terms with the nurse. They find her more friendly, more sympathetic, et cetera, or they may believe, as many patients do, that these personal problems have nothing to do with their illness and therefore are not subjects to be discussed with the physician in his hurried rounds, accompanied by a retinue of associates. Now the advice, "listen, rather than talk," applies to the nurse as she realizes that these emotional matters are related to illness and anything that she may say or do may influence the patient for better or worse. There- fore the best thing to do is to listen attentively and sympathetically and then to report the material to the doctor in charge. If he has the correct psychosomatic approach, he will be properly appreciative.

Again and again I have received information from the nurse concerning psychosomatic relationships that has been of the greatest value. Indeed I make it a rule to ask the nurse in charge of the ward or in charge of the individual patient "What is your impression about this patient?" Often I have sought the nurse's aid by suggesting that I would like her to talk to the patient about this or that matter in the hope that she can furnish me with material that will be helpful in my understanding of the patient and, of course, in the last analysis to the patient in understanding himself. As long as the proper relationship exists among the three parties-patient, nurse, and doctor-there can be no question about violating a confidence. These matters, intimate as they may be, are just a part of behavior in the same way that illness is a part of behavior and they must be treated with the same scientific detachment.

The kind of patients about whom I am speaking, when requiring nursing care for any reason, may be demanding, cantankerous, or ungrateful, but they also may be especially considerate and appreciative. In either case they require patient and kindly treatment to help them recover their emotional balance. They may behave with extreme childishness but the wise nurse knows this is a part of their illness and should be handled with tact. The patient who is weakened by organic disease or neurotic illness slips back to the behavior typical of his earliest years. The nurse who realizes this will not become antagonistic to or irritated by her patient. It may be that by her sympathetic handling she can be of great value to the physician in hasten- ing the recovery of the patient.

Just as there is major and minor surgery, so there

VOL. 45, No. 3



Psychiatric Nursing in the General Hospital

Psychiatric Nursing in the General Hospital By EDITH PATTON, R.N.

"PSYCHIATRIC NURSING? Oh no, I would not be interested in that. I could have elected a psychiatric affiliation if I had wanted to, but I knew I could not stand being with those insane people all the time. Excuse me, I must see what ails Mrs. Jones this time-her light is always on-first she has a headache, then her feet are cold, then she feels nauseated-it is all in her mind--she just likes attention and this time I may tell her so. Keep an eye on Mr. Smith, will you? He is de- termined to get out of bed, get his clothes, and go home, although he is a bad cardiac-I guess we shall have to restrain him." And off goes the busy nurse in a general hospital.

While the foregoing bit of conversation is fic- tional, it is unfortunately representative of the attitude of many nurses today. Interpreting psychiatric nursing as a rather vague art which is prac- ticed only in mental hospitals with psychotic patients, they often fail to recognize the less obvious but more prevailing psychiatric problems which they encounter in the general hospital.

The fault, however, is not theirs, but lies in the fact that our concept of psychiatric nursing is in need of more reflective consideration. At this particular time, when interest in this field seems to be steadily increasing, it is appropriate to emphasize that the care of the psychotic patient in a mental hospital represents only one application of psychiatric nursing. All patients are in need of psychiatric nursing care, if we interpret that term to mean an appreciation of the personality factors operative in illness.

The individual who must reorganize his life within the limitations of a chronic disease-the young woman who must adjust to the handicap of an amputated leg '-the patient undergoing a serious operation who is faced with the possibility of dying-all these represent psychiatric problems which the nurse is constantly encountering. In

addition to these problems of personality adjustment we find other more specific conditions in which the influence of psychiatric factors is significant. Unless the nurse has some knowledge of the basic principles of psychiatric nursing, she will not be able to give these patients the nursing care which they require. A full consideration of the many such psychiatrically-conditioned pictures is not within the scope of this article, but a few of the most prevalent conditions should be reviewed.

THE PSYCHONEUROSES

The psychoneurotic patient is perhaps the most poorly understood and most maligned individual in the general hospital today. Usually her story reveals that she has travelled from doctor to doctor, hospital to hospital, only to be told, "There is nothing wrong with you-all our tests are negative -it is all your imagination--just your nerves-get your mind off yourself." In the hospital, she pre- sents a picture familiar to all nurses. She has many complaints of physical discomfort, she is over- apprehensive, often she is irritable and faultfinding. The nurse's reaction is usually summed up in the contemptuous statement, "Just another neu- roticl" and she resents her taking up the time she should be giving patients who are "really" sick. And the patient? She still has her symptoms, re- gardless of their cause-the palpitation, the gastric discomfort, the feeling of panic. Telling her the symptoms are "in her mind" does not cause them to disappear; she continues uncomfortable and distressed, and probaftly resentful of the seeming lack of consideration on the part of the staff.

Miss Morgan was just such a case. At the age of thirty-nine her pattern of life was suddenly dis- rupted by the death of her mother who had been a chronic invalid for many years. During this time, Miss Morgan had been the devoted, unselfish daughter; she had refused to marry, and any feelings of resentment she may have had toward her mother were quickly repressed. Now she was free- EDITH PATTON (Frances Payne Bolton School of Nursing,

Cleveland, Ohio; B.A., Smith; M.N., Western Reserve) is assistant director of nursing in charge of education, Norwich (Connecticut) State Hospital.

1 GIMORE, MARY E.: An Amputated Leg at Twenty-one; Am. J. Nursing, Vol. 44, pp. 120-121 (Feb.) 1944.

MaRcH 1945

'93 exist major and minor forms of psychotherapy, and while the average physician should not attempt major forms of psychotherapy, he must be able to recognize the severe neuroses so that he may refer them elsewhere for treatment. He should be able to deal with the simpler neuroses not only for the purpose of helping such patients in a positive way but also to save them from unnecessary medical and surgical treatment and exploitation by quacks and irregular practitioners.

In closing I should like to emphasize that along with this approach physical factors remain just as important as ever and cannot be neglected by the psychological enthusiast. There are people who become so interested in the psychological approach that they forget there is'a body, just as there are organically minded physicians and nurses who forget that there are feelings. Psychosomatic medicine applies to both-it does not mean to study the soma less, it means to study the psyche more.



Psychosomatic Medicine

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