Some current aspects of psychosomatic research.

PSYCHOSOMATIC medicine is involving a rapidly expanding research field. The concept of emotional disturbance contributing to bodily disease is not a new one; however, it has only undergone systematic study during the last few decades. Evidence providing impetus towards its more general recognition accumulated during World War II when large numbers of people, often under uniform circumstances, had real and neurotic emotional stresses inevitably imposed upon them and sometimes appeared to react somatically (Grinker and Spiegel, I945). Emotional disturbance is thought to play a varying and sometimes indirect part in many illnesses ranging from infectious diseases (when it may determine the individual's motivation to exposure to infection and also some part of his subsequent resistance to it), to accidents and early tooth decay (Grinker, I96I). These broader implications will not be considered here and the concept will be limited to include only those conditions involving the viscera, cardio-vascular system, endocrine system, skin, and musculoskeletal system in so far as they are influenced-via the autonomic nervous system, endocrine and general motor nervous systems-by the visceral brain (Maclean, 1954) and hypothalamus. The major diseases thus usually included are peptic ulcer, ulcerative colitis, essential hypertension, migraine, various gynacological disorders, urticaria, neurodermatitis, Raynaud's Disease, psoriasis, asthma, primary thyrotoxicosis, and rheumatoid arthritis. In 1943 Halliday defined six criteria distinguishing psychosomatic disease. They are: (i) The existence of an emotional disturbance as a precipitating factor; (2) Some of the conditions are associated with a particular personality type; (3) There is marked disproportion in the sex incidence in many of the conditions; (4) The different conditions are associated and might be found together, alternating, or in sequence in the same person; (5) There is often a family history of the same or similar disorder. (6) The course of an individual disorder tends to be phasic with periods of remission and relapse. It will be seen that these criteria apply equally to psychoneurotic illness. Many physicians have remained sceptical of psychosomatic concepts when presented with purely psychodynamic and symbolic formulations (Jelliffe, I922) and personality profiles (Dunbar, 1943) as the main vindication of psychosomatic theory. This early approach ensured that the general medical and psychiatric disciplinescould rarely overlap or unite in this field since most general physicians do not have the training necessary to evaluate these factors, whilst the psychiatrists concerned have been handicapped by their lack of scientific method, the speculative element in psychoanalytic theory and the inevitable subjectivity in clinical assessments of personality. They have also usually worked on small groups of patients, rarely on whole populations and very rarely with controls. (Examples of good controlled studies include one in primary thyrotoxicosis by Mandelbrote and Wittkower in I955, one in rheumatoid arthritis by King and Cobb in 1959, and one in peptic ulcer by Wretmark in I953.) This dichotomy of approach has led on the one hand to apparently authoritative reports such as that of the Empire Rheumatism Council (1950), a careful and controlled study by general physicians of 292 patients with rheumatoid arthritis in which they found no evidence of emotional stress as an atiological factor, a finding which carries very little conviction for many psychiatrists. There are, on the other hand, gross speculative unverifiable psychodynamic formulations such as Allendy's (1932) regarding a case of eczema about which he feels able to say' Her hands were diseased that she might not kill her father and her husband. Her eczema was a punishment for her desires to masturbate and her illness gratified her primary wish for idleness '.