A Study of the Psychodynamics of Duodenal Ulcer Exacerbations

With Special Reference to Treatment and the Problem of "Specificity1 AVERY D. WEISMAN, M.D.
tion of personality factors to measurable physiological processes, and the development of medical illness from deranged physiological functions. The present study is limited exclusively to the psychological area, and it attempts to evaluate emotional factors associated with exacerbations of symptoms of duodenal ulcer. The meaning of "specificity" is also investigated, in order to establish logical conditions which any etiologic theory must meet before it can be considered "specific." Finally, the implications for appropriate treatment in the light of current understanding of significant psychological findings are discussed.

J2/ARLY INVESTIGATORS in psychosomatic medicine believed that there were "personality types" which corresponded with specific bodily diseases. The ambitious, driving, responsible businessman was often assumed to be about to develop a peptic ulcer, if, indeed, he had not already done so. Patients with arterial hypertension were frequently described as having an outwardly calm but inwardly fuming type of personality. However striking these prototypes seemed to be in individual cases, clinical experience refuted the claim that "personality types" were predisposed to certain medical illnesses. As medicine advanced to include psychotherapy, and psychiatrists studied patients with medical ailments, it was realized that the clear understanding of a patient's personality depended upon an accurate psychodynamic appraisal of his life situation, his defense mechanisms, conflicts, impulses, and anxieties, rather than on a literary precis of certain behavioral patterns. Although the original character typologies have yielded to more sophisticated approaches, the quest for a "specific" psychological factor which determines whether a patient develops duodenal ulcer, atopic dermatitis, arterial hypertension, or other illnesses of obscure etiolgy has continued. In recent years, psychosomatic research4 has concentrated in three general areas: the exclusively psychological, the relaFrom the Department of Neurology and Psychiatry, Harvard Medical School, Boston, Mass., and the Psychiatric Service of the Massachusetts General Hospital and the Massachusetts General Hospital Division of the Hall-Mercer Hospital, Boston. Received for publication June n , 1954.

General Considerations
Selye's concept that all disease represents an effort by the organism to adapt to various kinds of stresses has stimulated much medical research.25 The hypothesis of the general adaptation syndrome provides a focal point for the investigation of their common effect on the human organism. The theory implies that man is in a state of continual disequilibrium, striving to modify and come to terms with stress from without and strain from within. The psychoneuroses and psychoses may be regarded as attempts to adapt to psychological stress. The ego, through its defense mechanisms and executant functions, makes this adaptation possible. If there is a disturbance of the adaptive functions, psychological symptoms result. For example, repression, denial, sublimation, substitute object choice, rationalization, and so on, are a few common dePSYCHOSOMATIC MEDICINE

WEISMAN fensive measures used by the ego to facilitate answer has ever been found, despite an adaptation to psychic stress. The processes of abundance of theories, varying from mutual learning and communication represent still independence (psychophysical parallelism) to other categories of the ego which may serve mutual identification (psychophysical interacadaptive functions. When faulty adaptive pat- tionism). In the medical realm, investigators terns develop, or psychic stress cannot be have been concerned with the problem of how managed by ordinary methods, secondary or "somatic" diseases can be influenced by tertiary responses in terms of symptoms or "psychological" factors. Distinctions between "functional" and "organic" illnesses have been character defects appear. In the investigation of the so-called psycho- drawn, despite Cobb's repeated demonstration somatic disorders, psychological stress is re- of their fallacy. All such problems arise from the presuppogarded as contributing to the development of disturbed adaptation (medical disease), but sition that there is a genuine distinction in other types of stress are not excluded. Hence, nature between the "psychic" and the it is unjustified to consider "psychosomatic "somatic," or between the "psychological" and diseases" as psychogenic (primarily deter- the "organic." Actually, the concepts on which mined by direct translation of psychic conflict these are based ("mental" and "physical") into the structural sphere, as, for example, in are pure abstractions which cannot be satisfactorily defined. Since no means can be dehysterical conversion symptoms). If psychosomatic disorders are related to the vised to solve them, they are, actually, pseudopsychoneuroses, psychoses, and other "psychi- problems. The unanswerability of questions such as atric" entities, it becomes necessary to explain why some patients have predominantly vis- the relation of mind and body, the influence ceral symptoms (psychosomatic) and others of emotion on organic disease, results from mainly psychological symptoms (psychoneu- the failure to distinguish clearly between the roses, etc.). Some patients, it is well known, method of investigation and the subject matmay actually alternate between attacks of ter investigated. Basically, the functioning asthma and psychosis.24 Similar observations unit is the organism. The various medical have been made in other psychosomatic dis- sciences study different aspects of the organorders.27 Such occurrences indicate that a ism. By determining separate functions and patient may have more than one way of relations within the organism, emphasizing adapting to psychological stresseither by some and disregarding others, the subject visceral pattern or by regression in the ego matter investigated is defined. to psychosis. Any theory of psychosomatic The operational viewpoint requires that the disease must provide the answer to three investigator distinguish between what is to be questions: ( i ) What determines the develop- studied and the means of studying it. For ment of a psychosis, psychoneurosis, or psy- example, hunger may be approached in varichosomatic disorder, if each is regarded as an ous ways. To the physiologist, hunger is repexpression of adaptation to psychological resented by an increase in gastric motility, stress? (2) What kinds of psychological stress blood, and the level of certain secretions. The awaken adaptive responses in the viscera? biochemist may regard hunger as a function (3) How can a visceral reaction pattern serve of insulin and blood sugar. The psychologist an adaptive function for psychological stress? approaches the same phenomenon as a maniThe preceding considerations are often festation of the "wish to eat," and studies made unnecessarily difficult by the uncritical its vicissitudes in terms of the importance of application of the ancient "mind-body" con- food to the psychic economy of the patient. cept of philosophy to current medical thought Similarly, weeping may be investigated as a about psychosomatic illnesses. The relation problem of lacrimation or as an expression of between "mind" and "body" has perplexed grief. From the operational viewpoint there philosophers for centuries. No satisfactory is no "mind-body" problem; there is only the VOL. xviii, NO. 1, 1956

DUODENAL ULCER EXACERBATIONS relation between psychology and physiology; i.e., methods of study. "Psychological" stress is actually stress studied by a psychiatrist or someone else who is aware of the effect of symbolic, emotional, or interpersonal factors on the organism. There is no factual distinction between psychosomatic and nonpsychosomatic disorders, since the organism is probably activated more or less completely by any stress. Emotional conflicts may be regarded as counterparts of disturbed physiological processes. Both may be conceived as a study in adaptation: normal processes with abnormal effects. "Psychosomatic medicine" deals with disorders which are adaptive responses to "psychological" stress. This means that "psychic factors" (those phenomena which a psychiatrist studies) are important in sustaining, relieving, or precipitating certain illnesses which can also be studied, finding significant variations from the normal by nonpsychological means. In summary, psychosomatic illness is a total adaptation of the organism which may be investigated from various points of view, including the psychological. In the following case presentations, 6 patients with recurrent exacerbations of duodenal ulcer are investigated from the viewpoint of significant concomitant psychological stress. Since cause is a statistical concept based on a high degree of probability and a knowledge of specific processes, the "cause" of duodenal ulcer is not under consideration here. or vascularity of the stomach or duodenum; and (c) that hyperactivity of the stomach or some other functional alteration leads to peptic ulcer." These premises are based on the hypothesis that there is a linear cause-effect relationship between personality, conflict situation, or "emotional status" on the one hand, and disturbed physiological processes in the stomach or duodenum on the other, which leads to ulceration. Peptic ulcer can also be understood as a problem of stress and adaptation, in which either an abnormal stress, impaired adaptation, or both, may culminate in a gastric or duodenal ulcer. On this basis the pertinent contributions are herein classified. Only a few theories favor the stress to the exclusion of the individual adaptive pattern, and vice versa. For the most part, the various theories are differentiated only by selective emphasis, rather than by exclusion of certain aspects. The most comprehensive hypotheses fully recognize qualitative and quantitative variations in both stress and adaptation. Abnormal Stress Environmental Factors

Internists who have worked with a large series of ulcer patients have often associated psychic stress with critical environmental events. Thus, Einhorn, Jankelson, and Emery and Monroe tend to minimize the importance of emotional factors. Others, such as Crile and Alvarez, have explained the periodicity of Review of the Literature ulcer symptoms by reference to events which Since von Bergmann enunciated his theory entail an abnormal degree of work, worry, or of the neurogenic factors in peptic ulcer, a fatigue. Davies and Wilson studied in detail voluminous literature has been accumulated. the external events and the reactions of paRecently this has been systematically evalu- tients to their work and environment precedated by Ivy, Grossman and Bachrach, who ing ulcer attacks. They discovered that some clarified the "three main premises upon which disturbing external event occurred in about the present day psychosomatic theory of the 85 per cent of their patients prior to initial etiology of peptic ulcer is based, viz.: (a) that ulcer symptoms and subsequent recurrences. most ulcer patients manifest a characteristic The situations centered in work, finances, personality pattern or conflict situation; (b) illness, and misfortune in the family. A shift that this emotional status is accompanied by of employment was the most frequent precipihypersecretion and hypermotility of the stom- tant in patients under 25, while in older paach or some other change in the secretions tients a change in financial status was the
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WEISMAN major environmental stress. Yet they conclude that "the seed is acute anxiety . . . the result of a reverse in fortune or increased responsibility." They predicted (but did not prove) that if anxiety were relieved the patient would be free of dyspepsia. These studies suffer from a lack of precision in definition and description. In an effort to discover common stressful factors, the various authors describe problems which periodically afflict all mankindwork, worry, fatigue, financial insecurity, illness, or misfortune in the familyand thus surrender any claim to having discovered the specific features, if any, in patients with peptic ulcer. Several studies of ulcer in military personnel appeared during World War II. Dunn noted that peptic ulcer developed in men who were mobilized for war but had little actual exposure to combat, and concluded that frustration and resentment were the important emotions. Cox and Junnila examined ulcer patients in a military hospital. They asserted that anxiety preceded epigastric symptoms in every instance. In their opinion, the anxiety was precipitated by combat conditions, family worries, and long periods overseas in unpleasant, uncomfortable surroundings with only male companionship. They followed patients with gastrointestinal symptoms, but without ulcer, to the stage where an ulcer was demonstrable by x-ray. The authors failed to define the term "anxiety," hence the statement that it is present prior to all ulcers loses value. Furthermore, the effects of emotions such as hostility, fear, and sadness were neglected. Halsted and Weinberg correlated aggravation of symptoms in a presumably active ulcer, or recurrence of activity in a previously quiescent one, with the nervous tension associated with going overseas. Active combat was not a precipitating factor. They concurred with Dunn in believing that the frustration of regimentation may be more traumatic to ulcer patients than are the dangers of combat. The various military studies, of which these are representative, added little to our understanding of the specific psychodynamic aspects of ulcer, presumably due to the difficulty of intensive psychiatric study in the military setting. HowVOL. xviii, NO. i, 1956 ever, they clearly documented the reputed rise in gastrointestinal disorders during the war, and indicated that, in certain instances, a common social and emotional stress may induce similar visceral responses. Emotional Factors General Emotogenic Factors: Ivy has made the felicitous suggestion that the term "emotogenic" be used to designate changes in gastric secretion and motility which occur as the result of certain affective states unrelated to eating or the conscious thought of food. In addition, "emotogenic" differentiates the affective elements from the ideational components in the emotional state of a patient with peptic ulcer. Mittlemann and Wolff reported that specific affects of anxiety, hostility, resentment, guilt, and frustration, which occurred in their patients, resulted in an increase in gastric motility, secretion, and blood, whereas fear and sadness diminished these functions. These findings were confirmed by Wolf and Wolff33 in their gastrostomized patient. Recently Wolf32 has experimentally studied several additional patients. He related periods of gastric hyperactivity, gnawing epigastric pain, and heartburn with anger and resentment. But, in contrast to the earlier work, the angry emotions are placed in the setting of the total personality and the individual's conflict concerning his need to be cared for and his determination to do something about the situational threat. In addition, Wolf related gastric hypofunction and nausea to situations in which the patient fails to accept the challenge of the situation and has given up all hope of a solution. Here the emphasis is placed on the conscious emotional response to challenging situations. The same investigators have indicated that the degree and duration of the gastric changes were proportional to the duration and intensity of the emotional reaction. Other workers have studied the physiological changes accompanying psychoanalytic investigation. Margolin and his associates discovered that unconscious mental content determines the physiological responses, and that unconscious conflicts are essentially independent of

DUODENAL ULCER EXACERBATIONS the conscious emotion which the patient expresses. Supplementing the views expressed by the preceding workers, Mahl adheres to the hypothesis that gastric hyperfunction is essential for peptic ulcer, and is positively associated with chronic anxiety. Moreover, if the two processes continue, an ulcer will develop, regardless of the source of the anxiety, whether conscious or unconscious, internal or external. Mahl's theory requires that the anxiety be chronic and unrelieved. Specific Conflicts: The application of psychoanalytic principles to the study of peptic ulcer was pioneered by Alexander. Since his initial report in 1934,1 his findings have been repeatedly confirmed, although his conclusions have been questioned. In 1950,2 he described two specific psychodynamic patterns in gastric hyperfunction. Both of these develop on the basis of prolonged frustration of oral-receptive longings. In one pattern, the oral-receptive tendencies, although repressed, continue, and induce gastric hyperfunction. In the other, the frustrated oral-dependent wishes are replaced by an oral-aggressive attitude which arouses guilt and anxiety, for which the patient overcompensates by successful accomplishments. But, as a result of the excessive independent effort, according to Alexander, the unsatisfied oral-receptive impulses are enhanced, and gastric hypersecretion follows. He regards the fact that only some patients with gastric neurosis or chronic functional hypersecretion develop ulcers as possibly due to "constitutional or acquired weakness of the stomach." Nevertheless, Alexander regards the repressed oral-receptive hypothesis as specific for peptic ulcer. A cornerstone for this theory is the supplementary view of Alexander that under the influence of frustrated oral-dependent trends the stomach is in a state of chronic hypersecretion, responding continuously as though food were about to be ingested. ent, responsible character. Alexander stresses the unconscious attitude and does not account for the various conscious affective states, regarding them as mere epiphenomena. Critical evaluation of the Alexander hypothesis has been provided by Ivy and Mahl. Alexander's hypothesis that peptic ulcer patients suffer from passivity, undue submission, and unsatisfied oral dependency wishes beneath a facade of resolute independence, has been elaborated by Angel Garma. Instead of merely longing for the nourishment of a mother's care and love, Garma asserts that the ulcer patient introjects the image of the frustrating mother who not only starves her child, but gives it harmful food (symbolically, excrement), and, herself, attacks it from within. Garma noted that certain genital frustrations were associated with regression to an oraldigestive phase of libidinal development, with reawakening of conflict concerning an aggressive, depriving mother. Zane has stressed the high standards which compel ulcer patients to strive for unattainable perfection. The fear and resentment which occur when the patient feels required to act in a certain prescribed manner, despite a conviction of failure, result in the dissociation of physiological functions necessary for the development of ulcer. Impaired Adaptation

Constitutional Draper and his associates have held that the ulcer patient is a person with essentially a female constitutional emphasis who is subject to unconscious fears that he will be unable to fulfill satisfactorily the masculine role, and so tends to struggle for independent achievement against his deeper insecurity. They regarded this as a factor in producing chronic fear. In an early work Wittkower reported that, for the individual patient, consistent changes The major defense mechanism of the first occur in gastric acidity, quantity or secretion, pattern is repression. Reaction formation to and motility, independent of the emotion oral-aggressive impulses and dependent urges which has been aroused. Gastric hypofunction dominates the second dynamic pattern and or hyperfunction thus is characteristic of the results in the development of the independ- patient, not directly related to the stress but
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WEISMAN more to the constitutional pattern of visceral response.

Socio-psychological

Ruesch and his co-workers evaluated a large group of male ulcer patients, not only from the viewpoint of conflicts, but also with regard to the sociological setting in which they were reared, particularly the familial relationships. They emphasized that ulcer patients displayed a lack of symbolic expression (infantilism), faulty channelization of energy, and paucity of social techniques in interpersonal experience. According to the authors, the outstanding behavior patterns in ulcer patients are motivated by a wish to maintain a source of dependence or to counteract the inner wish for such satisfaction. Thus, on the basis of certain sociological and developmental factors, the patients become particularly vulnerable to dependency conflicts through special adaptive predispositions. Protective Reaction Patterns Wolff34'35 has noted that the organism responds to certain stress situations by means of "protective reaction patterns." These consist of characteristic physiological reactions of various organs which respond as a unit to different types of stress, whether trauma, infection, intoxication, or psychological threat. There are several types of patterns which involve the stomach. In gastric hypofunction, nausea and a feeling of fullness, accompanied by vomiting, occur. The adaptive pattern characteristic of hypofunction is the reaction of riddance-rejection, in which the patient responds as though he had been poisoned. The pattern of gastric hyperfunction is associated with hunger, the wish to be fed and the need for sustenance. Thus, the emphasis is placed upon fixed, adaptive responses to specific but variegated threats. Yet, as the subsequent work of Wolf32 indicates, life experience tends to limit the types of psychological stress to which the patient's stomach and duodenum are most vulnerable. Psychosomatic Unit Although Deutsch0'10 has not emphasized
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peptic ulcer in his writings, his comprehensive concept of the "psychosomatic unit" is applicable to this problem as well as to others. The psychosomatic unit includes both an infantile organ dysfunction and repeated association with an instinctual conflict, which through regression and the repetition compulsion, is expressed in "organ language" during subsequent crises which activate it. Moreover, the significant early figures are symbolically represented in the sensations and parts of the body. The type of ego disturbance which ensues from the original conflict partially determines the subsequent defenses and adaptive measures. Repetition of the conflict is enforced by both ego defect and structural impairment, as well as by fortuitous social circumstances. Many of the previous theories are special cases and elaborations of Deutsch's hypothesis. Neither his concept nor Alexander's, however, satisfies all three of the Ivy premises, so that the psychosomatic unit remains as a model to be used in investigation, rather than as a resolution of the peptic ulcer problem.

Clinical Material
The present study is based on a series of 6 adult males with duodenal ulcer. They belong to a group of 65 patients, the majority of whom were interviewed on only 3 occasions. Because such meager contact usually emphasizes wide, superficial similarities between patients, rather than clarifying important psychodynamic differences, only those patients are reported who were interviewed at least 25 times, with the production of enough data to justify inferences, and with whom a therapeutic relationship was established. One patient (Case 1) was treated by psychoanalysis over a period of 3 years, totaling about 600 analytic hours. During this time about 25 well defined episodes of abdominal pain occurred. These were attacks of typical ulcer distress, which awakened the patient at night with epigastric pain, after a period of relative quiescence. The remaining patients were treated by means of psychoanalytic therapy. The patient

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in Case 2 was interviewed about 100 times; the patient in Case 3 had about 50 interviews, and the remaining 3 patients were seen between 25 and 30 times. Sufficient material was obtained during the sessions to warrant comparative study, although it was evident that certain conflicts in the patients who were seen on fewer occasions might have been clarified, had all been treated over a protracted period. The psychological stress associated with periods of relapse in ulcer symptoms is described in terms of the ego defenses (adaptive patterns), the predominant affects and anxieties, the conflicts, and the transference situation. Pertinent background material is presented in order to clarify the active psychological situation. Emphasis is also given to important persons and events with which the patient has been concerned, either directly in current events, or remotely through memories and dreams. penetrating duodenal ulcer. At the end of 3 years of analysis, no abnormality in the stomach or duodenum could be detected. Social He was born in a small New England town, the only son of a prosperous Catholic family. At an early age, he displayed unusual musical talent, in which his father found a vicarious revival of his own lost academic hopes. Hour upon hour was devoted to practice. Pleasure and play were forbidden; every move was supervised and for each error he was severely punished. In rebellion, he periodically ran away from home. Finally, his chief emotional outlet came through chronic, secret masturbation. While appearing to practice diligently, he would simultaneously masturbate, and satisfy himself rather than his father. But the price of such rebellion was guilt and intense anxiety. At the age of 12, he developed a paralysis of the right arm. His father surmised that the disability was a result of masturbation, and revealed this fact to all visitors to the household. Occasionally his mother attempted to mollify the father, but mostly she, too, reproached the patient for his offenses, warning him that his misbehavior would one day kill his father. Nevertheless, the patient retained a strong sense of affinity with his mother throughout the years. At 15, his conflicts led to scholastic failure. Periodically he would fall into trances, in which his surroundings became vague, distant, and meaningless. Gradually his intellect and sensorium became so confused that he permanently discontinued all musical activity when he was 16 and fled from his home. During the following years he constantly sought love and adoration. He became an actor and moved in theatrical circles. Although there was no lack of willing sexual partners, he was besieged with guilt, a sense of failure, and unyielding depression. He used alcohol and drugs to relieve these feelings which followed him like shadows. No matter where he took refuge, or how frantically he diverted himself with bizarre, exotic pastimes, a sense of incompleteness, failure, and shame clung to him. One elderly woman made him her protege and, subsequently, her lover. He reacted to this attention with horror and guilt. Later, he was adopted by a gifted homosexual. In order to accept this man's embraces, the patient went into an autohypnotic trance, in which he deliberately induced confusion, mumbled incoherently, and conjured up
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Case 1 History
The patient, a 35-year-old actor, presented himself for psychoanalysis because of an unrelenting, oppressive feeling of failure and tormenting dreams of impossible success and power. He had had a duodenal ulcer for many years, but denied that the abdominal pains with which he frequently suffered were influenced by his personality problems or life experiences. Medical Abdominal pain had begun in early childhood. He was forced to practice the piano for several hours each morning before breakfast. If he made mistakes, or did not perform as his father felt he should, the patient was punished by being forced to sit next to the table, watching the others eat, while he went without food himself. This form of punishment inflicted more suffering than the frequent beatings his father gave him. At the age of 25, the diagnosis of duodenal ulcer was confirmed by x-ray. He was placed on a diet, but failed to follow it. Vomiting was rare. There were no episodes of obstruction or bleeding, but he complained of frequent epigastric pain, mostly at night, throughout his adult life. An x-ray prior to psychoanalysis showed an old

WEISMAN
an image of the river that flowed past his family home. However, from passively submitting to this male lover he derived much satisfaction, feeling that at last he was really loved, and, in turn, was able to satisfy someone else. When the patient was 20, he defied his father and married a non-Catholic, despite a feeling that he was committing an unpardonable sin. He was convinced that in the end his father's prophecy of disaster would be fulfilled. Indeed, through his infidelity and alcoholism the marriage disintegrated, but not until he had forced his wife into the arms of another man. He could never resolve his conflicting attitudes toward her, and as years passed she became a living reproach. He felt that although his misdeeds had destroyed their marriage, she continued to love him. He was sure that one day he would leave his second wife and return to the first. And he was equally sure that she would receive him freely, as a mother might welcome a wayward child. Although the patient achieved moderate success in reality, he considered himself a failure. Unfaded dreams of glory as the musical virtuoso his father had intended him to be prodded him into fresh guilt and depression when realistic theatrical achievements gave him any slight satisfaction. He resented the drain and strain of everyday life which deprived him of artistic experiences. He exhausted himself daily through excessive responsibilities. His only pleasures were fleeting and sensual, always followed by oppressive guilt feelings and depression. He had suffered from periodic migraine attacks since early childhood. When in the presence of older men whom he categorically considered as potential enemies, he frequently noted twitches of the mouth and a tingling sensation around his lips. too much. He had rebelled, but at the price of failure as an artist. Not only through years of aimless alcoholism, but also as the family man and breadwinner, his talents had become dissipated and misdirected. Now he was dedicated to providing for others, rather than to developing and preparing himself for a career. Situations like the current one revived the patient's sense of guilt and shame with respect to his father. He reacted to his father's image in many older men and adopted either a receptive or placatory attitude toward them. The former was determined by his hunger, and indicated a wish to be loved and fed, taken care of and adored. But he was also afraid of the older men, whose love he wanted. This was expressed by an attitude of compliance, an inability to refuse any request put to him and a constant terror of ill will. He felt compelled to please, appease, and placate any older man in whom he could detect a threatening element. His attention was often focused upon older men who represented his father, and who contained possibilities of gratification. Then his rage and defiance faded into diligent, depleting obeisance, from which he periodically escaped into impersonal orgies of earing, drinking, and pregenital sexuality when his fear of helplessness became too intense. In situations which provoked feelings of blame or shame, the patient frequently reacted with painful, burning blushing. He described the sensation as similar to that of a child who has been bested by his elders and held up to scorn and derision. Analysis disclosed that the flushing appeared when his deeper, hidden feelings of militant defiance and insatiable hunger were in danger of exposure. Literally, the blush indicated that his true face was about to be unmasked. In this way, whenever he was forced to comply with or placate someone, as when he played the minor stage role, he felt guilt and shame. He was furiously envious and could not display his true attitude. He knew that he was an impostor and a failure. Another mask, developed to cover his inner rebellion and greed, was his great theatrical technique. Through its brilliance, his hunger and frustration were concealed. It was analogous to his childhood habit of deceiving his father by faultless dexterity in musical performance, while simultaneously masturbating. Technical skill in acting and in human relationships was the compromise between conformity and independence. External compliance covered his inner defiance. But a skillful deception also deprived him of rich, spontaneous artistic gratification, because

Exacerbations: I
Abdominal pains developed when patient was forced to accept a minor role in a play in which a colleague was starred. He was rankled by the situation, in which he became a secondary, almost insignificant, figure to someone else. Whenever some other artist achieved recognition or success, the patient reacted with resentment and guilt. He was reminded of his own failure to become the great musician his father had intended and repented because of his forfeited opportunities. Once upon a time he might have had acclaim and adulation, too, but his rather had demanded
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provided well for his family, rehearsed, studied, taught, and free associated. He was an enforced conformist, but only in order to retain and control an inner core of self-seeking independence and rebellion. Pseudocompliance and diversionary skill paralleled the obedience and performance which his father had demanded of him. 3. Hyperactivity and Overextension: The patient worked incessantly at numerous jobs and assignments. Many of these tasks were pointless and without benefit to him, yet he labored himself into exhaustion each day before feeling that he had earned the right to sleep. Investigation disclosed the fact that by working excessively he was able to prove to himself that he was not weak, that he was not passive or dependent, that actually he was strong, self-reliant, and independent. He could never refuse a request; he wanted Ego Defenses* always to please others. There were several de1. Diversionary Skill: The patient was protermining factors for this behavior. He hoped ficient in both theatrical and personal verbal perto awaken their love through gTatitude. Moreformance. Technical skill in acting and colorful over, he was afraid of the consequences of reconversation diverted attention from his inner, fusal: placation forestalls retaliation. Finally, by guilt-ridden self, which was often preoccupied a process of identification, he found vicarious with acquiring esteem and gratification, and with appeasement of his own hunger and wish to aggressive phantasies. The listener would admire have someone limitlessly caring for him. his professional technique and his conversational 4. Phantasy Formation: During moments of skill as well. In effect, he became a "star" in human relationships. Although he had many intense anxiety, the patient habitually lapsed loyal friends, he had fears that his aggression, into absorbing, vivid daydreams of limitless sexsexuality, and unceasing hunger would be dis- uality and power. The content included scenes covered. During the analysis he spoke in a tor- of exhibition and display, proficiency and achieverent of words. His associations often seemed ment. Whether he pictured himself participating more like exercises in rhetoric than like sponta- in protracted sexual activities, or performing beneous expressions of thoughts and feelings. It fore huge audiences, the chief pleasure was dewas difficult to interrupt him in order to convey rived from being singled out for admiration, an interpretation; his thoughts streamed on with- adulation, and applause. In effect, whenever he out hesitation about diverse and interesting topics, felt exhausted, humiliated, passive, or weak, he touching on important matters but scarcely paus- found relief in phantasies of strength. 5. Attitudes and Escapes: In addition to ing before he was off again. flight into gratifying phantasies, the patient had 2. Pseudocompliance: In an effort to retain formerly used alcohol, drugs, and promiscuous independence, control his impulses, and restrain sexual activity as avenues of escape. In a more hostile, punishing forces, the patient usually did subtle way, however, he would occasionally what was expected of him. He worked regularly, adopt certain conscious attitudes in an effort to achieve respite from the depletion of his custom* The term "ego defenses" designates certain ary routine. By thinking as he felt other people adaptive patterns by which the patient resolves, thought, his conflicts would automatically be allays, or avoids conflict. Such patterns may repre- solved. His psychological charades included the sent one or more general defense mechanisms (re- role of a mystic, a priest, an ascetic, a hobo, a pression, reaction formation, identification, etc.) simpleton, or merely a little boy. from which they must be distinguished. Inasmuch as there is no standard terminology for ego defenses Conflicts and no complete inventory of general defense mech1. Hunger: In Exacerbations: 1, the patient anisms, the following terms, referring to individual discloses his hunger for love, admiration and adaptive patterns, are purely descriptive.
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he knew that under the pretense of doing what was expected of him, he was actually a fraud who satisfied only himself. Following this period, in which he suffered from intense epigastric pain, the patient became restless and anxious. He began to rehearse various roles feverishly, as though he were himself the star in each. Simultaneously he lapsed into a hypnogogic state, filled with elaborate daydreams of enormous sexual prowess, or of performing in great plays, accompanied by tremendous applause. He worked unceasingly, ashamed of his need to rest and to eat. As he worked, rage surged through him. He wanted to flee from family responsibilities and find spontaneous expression in sex, alcohol, and gluttony. "One must perform in order to be fed," he asserted.

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acclaim. This is further clarified in Exacerbations: 11. 2. Father: Although he had rebelled against his father's depleting demands, the patient reflected his wish for father's approval and love in his guilt over failing to achieve and fulfill his father's ambitions for him. 3. Ohedience/Freedom*: This dilemma was implicit in most of his decisions and actions. Alternatively, it was expressed in the struggle between conformity/independence, compulsion/ spontaneity, intellect/impulse, monastic adherence to rules/the need for unlimited orgiastic discharge, and neverending study/the open expression of feeling.

11 dominal pain, he had the following dream: He is kissing his wife. Suddenly he stops, detaches his penis, and resumes the embrace. He associated this with self-reproach because he had neglected the offspring of his first marriage. But the principal complaint is fatigue, as if his marriages had caused him to give and to yield endlessly. "To be free of responsibility is like eating a fine meal by oneself. There is no one to please, no one else to think about!" This conflict was emphasized by repeated dreams in which he was exhausted beyond endurance, to the point of death, or was even killed outright by enemies. He thought of life as a struggle between exhausting forces and urges to attain gratification. The dread of exposure as being a hungry, passive little boy, and fear of insanity through the exacting, exhausting demands of psychoanalysis ("I must tell you everything, without reservation or control!") were concurrently expressed. After an analytic hour in which this conflict was unusually intense, the patient rebelled when he thought of returning home. Instead, he considered visiting two homosexual men friends, "to relax and eat with them." At least, he felt, they would not ask anything of him, in contrast to his wife and the analyst. Ruefully, he laughed and added. "Besides, I don't like my wife's cooking!" But habit overruled the impulse and he went home. During the night he experienced severe abdominal pain.

Predominant Affects
At this time he displayed fear of his father or of persons who stood in a similar relation to him. His father punished and destroyed through guilt. Constant shame was the price of disobedience. He was embarrassed, afraid of being unmasked; and forever afraid of disintegration by menacing father images, or through self-destructive actions.

Transference
His placatory, receptive attitude included the doctor, from whom he wanted help. Actually he wanted love and approval more than help, but his anxiety forced him to deny this wish. He alternately viewed the doctor as scornful, critical, and punitive (projection of hostile phantasies), but at other times he attempted to deny this by overestimating him as a sage and magic healer (projection of wish for ideal father). Although his transference feelings were actually ambivalent, the negative aspect emerged chiefly in dreams.

Ego Defenses
1. Avoidance and Social Isolation: During periods in which his wife was occupied in caring for the children, or displayed interest in other people, the patient developed an uncontrollable feeling of antipathy toward her, and resented her presence in the room, loathed everything she did, and rebuffed her approaches. This reaction could also be provoked when she was fatigued. He interpreted her concern with others and her occasional exhaustion at the end of the day as indication that "there was no more left for him." By not being the sole recipient of her interest, attention, or food, he automatically inferred rejection. Indeed, he complained that her breasts were not large enough to feed everyone, and that she was a poor cook. At such moments he withdrew all feelings except a sense of distant revulsion. He secluded himself and avoided all contact with the family and friends. In this way, social and emotional isolation served to prevent further depletion. 2. Denial by Word, Act, or Phantasy: Dur-

Exacerbations: II
Epigastric fain occurred as a culmination of intense conflict over the depleting demands of marriage and domesticity and the fear of submission and exhaustion entailed by the psychoanalytic process. The episode was heralded by complaints that his wife had too many mouths to feed other than his. Resentment was discharged in destructive dreams. His feeling of starvation was appeased by phantasies of boundless gratification with food and sex, where nothing was lost, and he was forever replenished. Several days prior to the exacerbation of ab* This sign ( / ) denotes the alternatives in a conflict and is translated "as opposed to."
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DUODENAL ULCER EXACERBATIONS

of the therapeutic situation, and ( 2 ) overestimation of him as a benevolent guardian with limitless wisdom. As a result, through placation, denial and isolation he separated himself from the threatening figure of the analyst. The homosexual phantasies involving the doctor were not expressed at this phase of the analysis.

ing this period he was also in conflict about submitting to the analytic process. In many dreams, the doctor was identified with fearful, sadistic, punitive figures. Consciously he maintained a rational attitude that the doctor was, after all, merely a fallible human being, with special knowledge that might help him. He found further solution to the conflict concerning submission by complete acquiescence, in which he denied fear, agreed uncritically with everything he was told, and idealized the analyst. In addition, he managed to conform (pseuaocompliance) and appeased his hunger by means of rich phantasies in which all weakness and subservience were denied.

Exacerbations: I I I Ulcer symptoms recurred during a weekend in which he felt lonely and deserted. The family went away on a weekend vacation, and the patient was alone and felt bereft. Impulsively he sought out a young girl who had admired him. Like him, she was an emotional waif who needed a father. Her appeal, however, Conflicts was that she asked nothing of him, but, instead, 1. Hunger and Starvation: In this second extended herself in order to gratify his hunger. exacerbation, the core conflict of exhaustion/ This form of escape was a relief from his usual restoration was clearly indicated. His fear of de- feeling of being the hungry man who must propletion and his wish for replenishment were vide for others. The feeling of desertion and often expressed, literally, as hunger and fear of neglect was temporarily alleviated in the atmosstarvation. Collaterally, the conflict was mani- phere of unrestrained admiration and sexual fested as a struggle between dominance/sub- gratification. Sexual intercourse was a source of pain and mission, activity /passivity, freedom/restriction, and integration with the group/isolation as a strain to the patient. When he could identify with the needy woman, he enjoyed his capacity separate unit. 2. Men and Women: Out of hunger, he to provide gratification and fulfillment. The turned to motherly women (wife), and consid- purely masculine role caused anxiety, because ered any diversion of interest as tantamount to even as he gave to the woman in need, he felt rejection and starvation. He had the phantasy, forced to yield. He felt that the woman sapped noted above, of resolving his fears of starvation, his strength for her benefit, leaving him weak, submission, and exhaustion by dining with two helpless, and enslaved. Actually, his ideal was male homosexuals. Gratification, then, must a motherly woman who would treat sex as one either come from men, or from women with no does food, giving freely, without condition or other children. But the price of such love was reservation, as a mother cares for her child. All submission, and this in itself was a grave threat, other women robbed him. He went home after visiting the girl to join because it implied an even greater depletion and surrender later. The struggle was only tempor- his family who, by that time, had returned. arily solved by phantasy formation or escapes. During the night, his infant son awakened and So he denied it by pseudocompliance, donning began to cry. The sound precipitated ulcer pains, the mask of subservience, altruism, and placation. because it signified another mouth waiting to be fed. Predominant Affects Ulcer pain frequently occurred on Sunday. Constant acquiescence and pretense inevitably All week he labored to feed others, forcing himself into activity and driving himself to exhausfailed, and fear of disintegration emerged. He was afraid of insanity and being driven beyond tion. His wish was for unconditional mother his limits into mental and physical collapse love. Thus, each workday meant a perpetuation (total depletion). Underneath his conscious ten- of his frustration; each Sunday he was consion and anxiety he concealed his resentment fronted with his failure, the countless hours of wasted energy and the prospect of another week and murderous impulses. of the same overextension, appeasement, and Transference pretense. Exhaustion and failure to receive help He continued with two conscious attitudes from those whom he felt he had a right to expect toward the analyst: ( i ) the highly rational view it from filled him with helpless rage.
PSYCHOSOMATIC MEDICINB

WEISMAN
Ego Defenses 1. Attitudes and Escapes: He relieved his feeling of loneliness and of being deserted by means of an impulsive, immediate sexual relationship with a needy young girl (Cf. infra, Predominant Affects). 2. Bisexual Identification: People in need, especially women, invariably awakened a response in which he felt compelled to offer himself to them. His wish to be the needy woman and to receive strength and support from a strong man resulted in a double identification with the woman, who receives, and with the masculine man, who gives. In this episode, he also identified himself with the hungry infant.

13 he expressed hatred and fear of people who, in the guise of understanding others, manipulated them. Exacerbations: IV Abdominal -pain appeared in conjunction with a reproach from his father. This aroused old resentment of his mother, who supported the father against him. Coincidentally, an older woman, who previously played a motherly role toward him, suddenly made demands upon him for the immediate performance of a task he had undertaken. He received a letter from his father, chiding him for a minor offense. To his mother, the father was always right, even though there was considerable conflict between them. She insisted that he obey his father at all times, regardless of his feelings or the unreasonableness of the demand. His old sense of resentment and enforced submission recurred. Failure to comply meant "blame and shame," he said, while obedience involved "drain and strain." The shame in refusing to submit to his father resembled the guilt associated with buccogenital activity which, to him, represented something evil and presaged the degeneration of a heterosexual relationship. At about the same time, a motherly woman who had commissioned him to carry out a certain task demanded that it be completed without further delay. He was outraged. Although he had accepted the offer with pleasure several months before because he would receive both acclaim and financial reward, he had done nothing about it. Now the request seemed sudden and unjustified. He was angry because, instead of giving to him, the motherly woman demanded that he fulfill his obligations. Ego Defenses 1. Pseudocompliance: Pseudocompliance frequently served to avoid competitive situations. The patient often accepted roles with less prestige value rather than place himself on a plane with an older actor. He underscored his part as the little boy who wanted to learn from the masters, rather than displace them. Such deference thus avoided the acknowledgment that he was actually in competition with his father for mother's affection and support. It can also be seen that by his feminine identification, as well as by pseudocompliance, he offered himself to his father.

Conflicts
By identifying with a needy woman, the patient awakened the masculine/feminine conflict. He wanted to be passive, receiving strength, security, and replenishment from a powerful father. But he anticipated being misused or controlled by such men as a consequence of yielding. He was afraid that, as a condition of such love, he would become in fact a woman. Accordingly, by yielding and giving to a deprived woman, he was also afraid of loss of strength and autonomy. In this connection we may recall the precipitating dream of Exacerbations: II, in which he removes his penis (masculinity) before he can embrace a woman.

Predominant Affects
In addition to feeling angry because he was deserted, he was anxious and afraid. This involved his wish to receive something for nothing, except that he feared having to repay it ultimately in complete dependence. This was illustrated during the period of Exacerbations: III, when he had a dream in which he was a pursued murderer who had killed both a man and a woman. His anger was associated with guilty feelings about his concealed needs and wishes. His sexual escapades were invariably followed by guilt. In this way he displaced his guilt onto a conscious misdeed, removing it from the deeper impulses which led him to dream of homicidal and homosexual experiences.

Transference
During this period he regarded the doctor as a man who would expiate his guilt and simultaneously release him from all restrictions and responsibilitiesa good mother-father who would feed him and ask nothing from him. Conversely,
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Conflicts
The conflict associated with the current ex-

14

DUODENAL ULCER EXACERBATIONS

same anxiety. The audience assumed the significance of the punitive father, whom he could defeat only by failure. Hence, conspicuous exposure contrived to inflict failure and humiliation. He experienced a relapse of arm pain, reminiscent of the paralysis of his adolescence, and expressive of both masturbation and professional conflicts. His ulcer symptoms, quiescent for several months, returned.

Ego Defenses 1. Phobic Reaction: This experienced actor's Again he was angry at "blaming" fathers and irrational fear of leading roles was clearly so ex"demanding" mothers. His resentment when the cessive that it could be considered a phobia. It was motherly woman suddenly demanded perform- based on the performances he had been required ance awakened him to the realization that her to give for his father, and his simultaneous fear gratuity was limited. of exposure as a masturbator. He noted restraint in rehearsing "stage business," clearly associating Transference it with a reluctance to move in a relaxed manner He wanted to have the analyst as both mother out of a conviction that such movements would and father, supplying him with limitless love, be noticeably sexual. As with other phobias, the kindness, support, and understanding, while he patient rationalized his difficulty, avoiding or Cthe patient) remained in the passive, supplicant postponing starring roles on transparently inadeposition. quate grounds. 2. Conversion: The recurrence of arm pain Exacerbations: V indicated a way in which he could resolve the Ulcer fains recurred prior to the opening of conflict through guilt-free refusal. If his arm were an important -play in which he was starred. His paralyzed, he obviously could not play the role. wish to please and he loved was nullified by 3. Avoidance and Diversionary Skill: During resentment over the strain and exhaustion of this period he wanted to flee the analysis as he rehearsals. did the play. His analytic hours consisted of For many years performance in a leading role rapid, abstract, rambling discourses on irrelevanhad caused the patient intense anguish. He ha- cies, as though he were afraid to face the pressing bitually became apprehensive, lost sleep, and psychological issues. worried to the point where every member of the audience became a potential enemy. Now he Conflicts was again immersed in painful preparation for a Although he wanted esteem and applause, dreaded ordeal. Several days earlier a gifted young love and admiration, appearing in public reman whom he had coached was said to act as minded him of the danger of performing at his well as he, the teacher. Instantly he felt neg- father's behest. It was an exhausting, hazardous lected and deprived. It reminded him of the task which exposed him to punishment. Because early days of his marriage, when his wife was of sexual misdeeds committed as a token of resexually indifferent, and he was forced to mas- bellious independence, he was afraid of discovturbate. Coitus under such circumstances was ery. Again, exhaustion and depletion marked the too exhausting; masturbation, at least, was for conflict and outweighed his yearning for approval his exclusive pleasure. Coitus and teaching were and acclaim. thus considered as depleting, fruitless tasks in which his strength flowed into others for their Predominant Affects aggrandizement. Masturbation, however pleasurThe anger originally associated with the father able, was associated with empty dreams, past who asked too much was revived. Yet he felt memories, and lost hopes. It was the only refuge guilty about the manner in which he defeated in his childhood that protected him from com- his father. The emotions precipitated by starring plete, passive submission to his father's ambition. performances were compounded of anxiety at Being singled out for attention in a leading role public exposure, anger at enforced obligations, thus entailed sexual guilt accompanied by the and a hunger for applause.

acerbation disclosed two aspects of his relationship with his mother. The central wish was to have mother's exclusive and undemanding love, but mother turned to father. It is noteworthy that in a triangle involving a woman and another man, he characteristically had the urge to make the woman fall in love with him, but usually manipulated matters so that the other man won out. The patient thus used feminine identification as a way out of the oedipal conflict.

Predominant Affects

PSYCHOSOMATIC MEDICINE

WEISMAN Transference
He wanted to please the teacher. However, in situations which required concentration and a measure of restriction, he suddenly felt stupid, "lost his intelligence," and wanted to run away. In psychoanalysis, flight from conflict was similarly expressed by pseudostupidity, thoughts of becoming insane, or more frequently in abstract, rapid speech filled with almost unintelligible generalities. Several other exacerbations are briefly summarized in the following section in order to emphasize the repetitive nature of the material:

15 associated him with a sadistic dentist who probes and hurts even as he helps. A phobia of losing his teeth during analysis was based on a fear of complete oral surrender, and becoming a sucking, helpless child. Exacerbations: VII Epigastric pain again appeared when he was given a secondary role. He was in conflict about a request to do a bit part in a play. (A dream occurred earlier in which he had an extra leg which was amputated.) After much indecision, the patient declined. That night he dreamed that a male friend, through the offices of psychiatry, "schizophrenized" someone into homosexuality. He reiterated an old belief that "homosexuals get that way by first submitting to the demands of an older man." A male acquaintance predicted that future technological advances would disrupt family life and women would take control of society. This enraged the patient and simultaneously his ulcer symptoms recurred. Ego Defenses 1. Pseudocompliance: His placatory attitude toward the man who invited him to take the bit part prevented his immediate refusal. The man who submits is identical with the passive homosexual who finds fulfillment only by attachment to a more powerful male figure. This was expressed in the dream where his homosexual conflict and passive tendencies "split" him, like a schizophrenic, and threatened his sanity. Playing a small part in a play where another man was starred implied castration, another dream indicated. In all his dreams women had penises. This reflected the wish to be a woman loved by a man and yet preserve his genitals.

Exacerbations: VI
He developed ulcer fains while struggling to complete the task which the motherly and beneficent woman had imperiously demanded several weeks previously. Although indignant at the abrupt transition which altered his relationship to the woman, he forced himself to work. He was afraid of becoming insane if he failed to complete the work. Beneath the hyperactivity was a wish for abject passivity which he simultaneously feared. All women contrive to exhaust men, his father had told him. He developed an unaccountable toothache during this period. Ego Defenses 1. Hyperactivity: This form of response invariably appeared when his passive wishes were frustrated, and his fear of submission was mobilized.

Conflicts
The struggle was between his wish to be succored and the fear of succumbing. Eating and sucking, manifested in obscure dental symptoms and labial twitches, were literal expressions of the conflict. Food meant sustenance but also subjugation.

Predominant Affects
His emotional response to the current predicament was characterized by ineffectual, impotent anger coupled with the anxiety contingent upon refusal to play the secondary role.

Predominant Affects
He was angry over unwarranted and unexpected demands placed upon him. Yet he could not protest because the woman's request was objectively reasonable. He was guilty over his wish to be mothered without obligation on his part. As he recognized his fear of submitting to superior power and subjective needs his anxiety increased.

Transference
The analyst, too, subjugated him and forced him into the feminine role.

Exacerbations: VIII
Abdominal distress recurred in response to renewed demands by his first wife that he maintain

Transference
He wanted the analyst to be his helper, but
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DUODENAL ULCER EXACERBATIONS

flicts appeared, but without ulcer symptoms. One night he had the following dream: A man is plowing the ground on his hands and knees, using his nose as a ploughshare. He spontaneously identified the man as himselfalways in the supplicant attitude, even at moments of backbreaking labor. By exhausting himself, he hoped one day to reap a harvest of the sustenance of which he had felt deprived. Again he reacted to his unending labors by engaging in a sexual escapade. This time, however, he felt no guilt, even though he recalled his father's admonition that women can ruin a man through sexual excesses. He concluded that men wanted him for their own use, and that their motives could be both good and evil. He had another dream in which an older, highly esteemed producer praised him highly. This period covered about i week, during which he worked unceasingly. Although exhausted and depleted to the point of physical pain, he failed to become depressed. He was explicit about wanting to escape to mother's bosom. His wish to be adored was again expressed in the familiar phantasies of glory. No evidence of anger appeared. Despite the presence of his ancient fears and conflicts, his ulcer was quiescent. Several contingent factors contributed to the absence of ulcer symptoms: 1. Period IX occurred just before the analyst went out of town and the analysis was to be interrupted for i week. The patient's ulcer Ego Defenses pains always remitted during the summer. In addition to the familiar observation that ulcer i. Bisexual Identification: By putting himactivity frequently has seasonal variation, part self in the role of the man who gives love to of the relief had also been attributed to his needy women, he found both vicarious satisfaclong vacation from regular duties. However, tion and a means of denying his feminine ulcer symptoms invariably recurred several strivings. days before psychoanalysis resumed, whether Conflicts after vacations or brief interruptions for other reasons. Dreams during this period were filled The homosexual/heterosexual conflict and his with struggle and conflict and usually involved wish for sustenance without exhaustion was again intense guilt feelings over homicidal thoughts. in the foreground. Just prior to interruptions the patient frePredominant Affect quently dreamed of finding a new analyst or a new restaurant. The affective tone of these He felt hopeless, helpless anger in the depletdreams was usually pleasant and optimistic. ing role which he had to fill. Such considerations indicate that the prospect Transference of a temporary interruption was greeted with relief from the intense conflict over depletion The analyst became the master teacher who and passivity. should help him solve all problems. 2. For several weeks prior to this period his Exacerbations: IX ulcer distress had been acute. He was anxious, In contrast to the -preceding exacerbations, duragitated, distraught and sleepless. In response, ing this period all of the patient's familiar conthe analyst changed from his regular procedure his obligations and increase the financial aid he had been giving. He became angry at the constant drain and indicated that he believed her real motive was to induce him to surrender everything and return to her. Whenever his first wife implied that she wanted more money, he inferred that not only did this represent a neverending financial drain, but that basically she wanted him to forsake his second wife and family and love her exclusively. He had never resolved his relationship with his first wife because he did not want to lose her love. When his second wife was in the hospital several years before, after giving birth to his youngest son, the patient impulsively told her about how unhappy he had been, and how frustrated and exhausted. In fact, he returned to the first wife and briefly felt that he was in love with her once more. At this time he expressed a belief that "insane children get that way because their mothers do not supply them with enough love, and their fathers want to destroy them out of jealousy." Generally, because he considered himself both "bad" and "needy," he identified with "bad" or "needy" women, and wanted to offer them love or sexual experience. Such feelings often resulted in escapades, particularly at moments when his need for love from an older man became acute and was repressed with difficulty. He was jealous when an older man loved someone else.
PSYCHOSOMATIC MEDICINE

WEISMAN
of listening and interpreting free associations. Hoping to supply a measure of emotional support during a difficult phase, he confined himself to observations which would have an egoenhancing value. As a result, the patient's epigastric symptoms had abated almost overnight. This episode indicates that the alleviation of symptoms occurred in response to the relief from analytic investigation. Although some guilt and anxiety persisted, he was enabled to master the anger which frequently accompanied ulcer exacerbations. The analyst ceased probing and instead, by emphasizing his strength rather than his weakness, implied approval, not criticism. This was apparently enough to allay the threat and drain of continued analytic production, but the analyst's subsequent return engendered enough fear of passivity once again to arouse anger. The following dreams, which occurred the night before the last analytic session, confirm this hypothesis: 1. He had begun to write a play in the familiar style of a certain homosexual playwright. His wife comforted him by saying, "Well, you can always put it away. . . ." 2. He was in a toilet with a young boy to whom he remarked, "Parents want you to urinate as often, as you can, to keep you from thinking about girls." The patient then urinated bloody feces. The first dream referred to the homosexual conflict which had been clarified in psychoanalysis and revived in the transference. An opportunity to turn away from it was afforded by the interruption. In the second dream the parent (analyst) decreed that he have nothing to do with girls (heterosexuality). A frequent response to homosexual conflicts had been heterosexual escapades. Moreover, urination and toilet training had often been associated with giving theatrical and psychoanalytic performance. Blood and feces were signs of struggle and suffering. The relative absence of anger during this period is significant, inasmuch as suppressed anger was often associated with a relapse of ulcer symptoms, especially when the patient was in conflict over passive homosexuality with reaction fear of depletion. It must be concluded, then, that the need for withdrawal from stress, which the anger usually served, was relieved by the interruption of the analysis and the supportive therapeutic measures concurrently provided by the analyst.
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17

Case 2
History Medical
The patient was a 30-year-old newspaper reporter who sought psychiatric aid because of a persistent feeling of futility and mild, intermittent depression. Four years previously while in the navy, after a brief period of severe epigastric pain and vomiting the patient was found to have a duodenal ulcer. He followed the prescribed diet with only occasional infractions and his symptoms abated considerably. Until the stress of the year preceding psychiatric treatment, he was almost free of stomach distress. In certain situations he noticed that the epigastric symptoms returned for brief periods. However, so slight was his discomfort that he regarded the history of duodenal ulcer as entirely incidental to his other, more pressing problems. Social His mother died when he was 18 months old. Since his father was a traveling salesman who was unable to provide for him, he was boarded with various relatives until he was 13, when his father remarried. But instead of finding genuine security in the new home, there was only an unwilling dependence, since there was constant antagonism between the patient and his stepmother. At about the same age, he established a close relationship with an unmarried woman teacher 27 years his senior, which continued throughout the years. Although there had been no overt sexual contact with this woman, he still felt guilty when he later married, because he had deserted the one person who had been a mother to him, and to whom he had been the sole object of devotion. His father and stepmother were divorced several years after their marriage. Once again the patient was alone and adrift. He worked in restaurants, lumber camps, and carnivals, attending school sporadically until he joined the navy. He suffered his first significant depression while in military service. This was the first time that he had been forced to conform to regulations. Now, also for the first time, he associated with his contemporaries, having previously sought the company of older men and women exclusively. He married during the year preceding his military duty. His wife was the only daughter

18

DUODENAL ULCER EXACERBATIONS

to seek unhampered by family obligations. In contrast, the patient felt trapped and deprived, imprisoned, he asserted, "with emotional bread and water, for an indefinite period." The patient knew that he had married for security, not for love. His true wish, repudiated strongly, was to be supported and loved by his prosperous father-in-law. He felt he was a failure, and reproached himself for extensive literary ambitions. Actually, he was afraid of discovering his mediocrity, and so clung to an unhappy marriage. "The security of a comfortable existence is the hardest to take. I have always felt most alive when I've been least secure."

of a prosperous merchant for whom the patient had worked. She was 5 years older and had been recently divorced. A mutual interest in literature drew them together. Finally, a clandestine sexual relationship was formed from which the patient derived much satisfaction, feeling that he was truly appreciated and loved. For a short time he experienced complete security. However, after marriage and the birth of a child his wife's interest in him waned. She became more concerned with their child and with her son by her first marriage. The patient felt excluded and deprived of the sense of security she had once given him. The unhappy marital situation precipitated his enlistment in the navy, from which he was discharged within 1 year. He formed an attachment for a married woman and vindictively informed his wife of his infidelity. After, the anticipated arguments and recriminations, his wife decided never again to mention the affair. Instead, she maintained an aloof and resentful silence. Tension increased. Neither one discussed the subject, yet each was bitter and reproachful toward the other. He was determined to divorce his wife and resume his solitary life, but he struggled with indecision between a wish to find freedom and his self-disgust at maintaining a fagade. He felt intense guilt about his unappeased urges and his shortcomings. During this period, about 1 year preceding treatment, his quiescent ulcer again became active.

Exacerbations: II
He temporarily left the household, following which he developed severe abdominal pain. The constant discontent and domestic turmoil finally led him to rent a room where he could be alone, free from the distractions and demands of the household. He wanted to discover whether he was "really a man" and could take action, or must be resigned forever to a state of resentful, silent frustration. He recalled that he had ulcer pains while in service whenever he was compelled to conform to something in which he did not believe. He was always afraid of becoming like his devaluated fathera failure who stopped thinking, feeling, or believing. Unwittingly, however, he had followed the same pattern. His wife drained him, he believed, by relying upon him for performance he could not fulfill, and by her implied criticism for his shortcomings in this respect. "She needs no one but me. Yet, when I rely on her, I feel weak and self-indulgent. The lazy man in me likes it, but it seems cut off from reality. Half of me is dying when I am dependent; it invites further danger." He bitterly resented feeling weak and having nothing to give, and so he left the household. Ulcer symptoms recurred almost immediately. After a few days he and his wife effected a reconciliation and the abdominal symptoms abated.

Exacerbations: I
Ulcer pain recurred when a former girl friend visited the city. He was envious of unencumbered, privileged men. As he watched a male friend preparing to have lunch with a woman who had been friendly with the patient in years past, his ulcer pains returned. He was resentful, but realized that he could not frankly voice his wishes because he was a married man. Instead, his thoughts revolved about his constant conflicthis antipathy toward family responsibilities and his reluctance to escape from them. A short while later he met another acquaintance whom he envied. This man had a background quite different from his own. He had a home, generous parents, free access to education, and other privileges that the patient, through his own efforts, only partially attained. Abdominal pains became intolerable as he silently listened to his friend who was self-confidently expanding on his plans for the future, which he was free

Exacerbations: III
Ulcer pain followed several dreams, both frightening and pleasant. One night the patient had the following dreams: 1. A kindly boss told him that he worked harder than necessary. "You don't have to consume yourself!" 2. He worked in a paper mill for a thoughtful and indulgent employer.
PSYCHOSOMATIC MEDICINE

WEISMAN
3. He was a member of a large orchestra conducted by a despotic old man. The patient suddenly sounded a wrong note, and the entire auditorium burst into flame. At this moment he awakened with intense abdominal pain. His first associations were to his growing aversion toward sexual relations, which had become increasingly painful. He felt exhausted because the demands were too great. He was disgusted by his resemblance to his ineffectual father and yearned for the protection of a powerful and indulgent ideal father. Although his symptoms had been considerably relieved since entering therapy, this both pleased and frightened him, because he was afraid of being seduced into new obligations. He recalled that, when he was 9, his paternal grandfather, who also had an ulcer, fondled his genitals. "Eating is the only real satisfaction there is. Intercourse is only for unmarried adults; not for married people any more than for children." He had the phantasy of being a rich man's son. In this way he could be completely free, even though submissive and dependent upon his father. Ego Defenses 1. Pseudocompliance: Despite intense feelings of resentment and deprivation, the patient continued the pretense of being the devoted family man and reproached himself for not providing more adequately for his wife and children. 2. Avoidance and Social Isolation: In his early years he struggled to become self-reliant and independent. He mingled only with older people, was presumably self-sufficient, and avoided his contemporaries, leading the life of an itinerant student and worker. He sought the ideal home, but simultaneously fled from permanent attachments which could threaten him. His later tendency to withdraw into social isolation had a similar motivation. By this means he avoided further drain and allayed a fear of being consumed. His urge for independent self-expression, free from the requirements of family life, actually represented his conviction that his passive and dependent needs would never be fulfilled, and that in contrast he would be exploited to the point of disintegration. 3. Phantasy Formation: His overweening ambitions were a response to a sense of dependency and a fear of weakness. He wanted to become a great man, able to satisfy his needs without becoming diminished by exhausting efforts.
VOL.

19 4. Inhibition and Suppression: Both the patient and his wife restrained their emotions. Instead of the violent arguments which he pictured in his mind, they dealt with each other in terms of aloof and polite detachment, discussing their differences on an almost philosophical level.

Conflicts
He struggled with his partially repressed wishes to remain a little boy, cared for and supported by a loving father who would substitute for his dead mother. He resented other children who had not endured similar deprivations, and hungered for complete fulfillment by being fed, replenished, and loved with undivided devotion. Yet his fear of dependence and passivity was expressed in his lofty aspirations. His conviction of his own mediocrity indicated that he felt unable to rise above his fondness for dependency. Failure thus meant resignation to his passivity. When he reproached himself for being weak and self-indulgent, he also expressed resentment at his inability to accept full dependence without conflict. Marriage and the responsibilities of family life enraged him. Active participation in joint enterprises within the family was vitiated by his disinclination to surrender his right to exclusive attention and love.

Predominant Affects
Although the patient.sought psychiatric treatment because of recurrent depression, silent resentment characterized the exacerbations of his ulcer symptoms. He was afraid of being required to conform without protest, and to yield until exhausted. But whether or not he permitted himself complete indulgence or fought against passivity, the end stage in either case was helpless depletion. He was as angry with himself as with the people dependent upon him.

Transference
He established a ready relationship with the doctor and turned to him freely. Occasionally he expressed a wish for the therapist to be a social friend as well as a professional counselor. There was a tendency to deny the negative, mistrustful aspects of the transference. When he realized that he would not find the ideal father who would love and care for him, he complained that the doctor could only help him up to a point, and gradually began to disparage the entire therapeutic process.

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20 Case 3

D U O D E N A L ULCER

EXACERBATIONS

History The patient was a 30-year-old farm worker who was referred for psychiatric treatment because of persistent, severe anxiety attacks and a chronic duodenal ulcer. Three months before treatment began, while convalescing in a hospital after a minor back injury, the patient suddenly developed an alarming feeling in his chest, felt faint, and thought he was about to die. He had been suffering from intense ulcer pain, but when the axiety attack began the epigastric distress disappeared. Panicky, he thought that death was imminent, as though freedom from pain indicated the numbness before death. Anxiety attacks recurred on several occasions during the succeeding months. In each instance his ulcer pain abated, only to return when the palpitations, choking sensation, and faintness had passed. Medical Since the age of 15 the patient had complained of epigastric pain, vomiting, and anorexia. When he was 20 years old the diagnosis of duodenal ulcer was confirmed by x-ray. Even though symptoms were unusually severe, he failed to follow the recommended diet. He frequently could not eat at all because of vomiting immediately afterward. On 12 occasions he was hospitalized for treatment of symptoms. He had at one time been operated upon for a suspected perforation, but none was found. Periodic alcoholism since he was 21, together with disturbances in his work, environment, and emotional status, led to almost constant ulcer symptoms for about 10 years preceding psychiatric treatment. Although he usually suffered from chronic constipation, during spells of anxiety he complained of abdominal cramps and diarrhea. Social He was the youngest child of an alcoholic, improvident father and a promiscuous mother. His parents separated when he was 18 months old. He was consigned to a large state institution where homeless children were indiscriminately mingled with cretins, idiots, and deteriorated epileptics. Always nervous, he was easily startled, quick to anger and tears. He suffered from enuresis until he was 18. Discipline in the institution was severe and beatings were customary. When he first devel-

oped abdominal pain, fear of punishment prevented him from reporting it. He recalled that s o m e o f the feeble-minded boys ate in a revolting manner, drooling into their bowls. Often he became so angry and disgusted that he vomited, since more direct expressions of resentment were forbidden. If seen by an attendant he was punished by being forced to eat his vomitus. Finally, at the age of 19, he struck an attendant who had punished him. He was trying to kill the man when other guards intervened. He hid in a barn, but still enraged, set fire to it. A sympathetic judge who heard the case paroled him to a farm where he lived for 2 years. He left the farm at 21 in order to find his parents. His mother was readily located, but she had remarried and had had 14 more children. Even so, he remained with her for a short period. The household was dirty and vermin-ridden. Finally, his disgust at the filthy manner in which food was prepared led him to leave her. He then found his father, with whom he lived for about 6 months. His father was alcoholic. He required the patient to surrender his earnings which were promptly spent for whiskey. After a bitter argument in which he threatened to kill his father, the patient became a hobo, working intermittently and drinking heavily. He then worked for a farmer and his wife who had no children of their own. One evening, when he had been suffering with ulcer pains, the woman showed him sympathy, fed him milk, and sent him to see a doctor. For a long time after this his symptoms were relieved. He continued to work at the farm, felt as though he had finally found a home, and even began to call his benefactor "Mom." He was bitter when the farmer discharged him. Some day, he vowed, he would return and take his "mother" to live with him, inasmuch as she had confided to him that she was unhappy with her husband. In fact, several years later this promise was fulfilled. "Mom" left her husband to come to stay with the patient and his wife. When he was 25, the patient married a woman several years his senior. Almost immediately he was aware of her infidelity, but continued to live with her. He did not want to "lose his home." Many times during the marriage he was hospitalized for both ulcer symptoms and injuries sustained at work. Finally, after 18 months, he left his wife but did not sue for divorce. Once again he was depressed and lonely. His life consisted of more vagrancy and he worked
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only to buy alcohol. He had many heterosexual and a few homosexual experiences. One older prostitute supported him for a brief period, during which he was content and free of ulcer pain, happy in the feeling that this woman preferred him to all other men. After the attack on Pearl Harbor he enlisted in the Marine Corps, but was discharged after 2 months because of duodenal ulcer. During his brief service he was courtmartialed for striking a noncommissioned officer. Three years before psychiatric treatment the patient entered into a bigamous relationship with a farm girl. For several months they traveled aimlessly about the country without responsibility. He described this as one of the happiest periods of his life. Finally, he and this wife settled in New England. They started a small business, and for a time were fairly successful. Eventually the business failed, and the patient worked only sporadically at unskilled labor, while his wife went into office work. She received several promotions and pay increases, until her financial contributions supported the family. The patient drank excessively and was unfaithful to his wife on many occasions. Following such episodes he would be remorseful and insist on coming home, in tears, to confess every detail of the escapade to his wife. Just before the anxiety attacks began his wife lost patience and threatened to leave him.

21 that he could expect to be immobilized for an indefinite period. In addition, his wife failed to make her daily visit. He was apprehensive, fearing that she had been in an accident. "I can't bear the thought of being away from her. She babies me, buoys me up, tells me what I ought to do." Actually, he had some reason to wonder if she were going to visit him. While he had been working as a farm hand, she had been working in an office, and in a short time had received several raises in pay. She had spoken with great admiration of her employer. Lying in the hospital, he had pictured his wife going on to great success while he remained an invalid. "If I lost what little I have, especially my wife and children, I might do anything!" He entertained suicidal phantasies along with apprehension about his helplessness in the plaster encasement. He began to feel the imminence of death, which was almost synonymous with being deserted. In this setting he suddenly experienced the autonomic symptoms of acute anxiety. "If my wife left me I'd either drink myself to death or commit suicide. It doesn't take much to make me cry, even though I'm ashamed and try to hide it."

Ulcer Exacerbations
The patient was, surprisingly enough, aware of the emotions and situations which tended to increase his ulcer symptoms. He knew that periods of despondency and anger were more likely to induce pain than were dietary infractions. When his wife was pregnant his symptoms were intense. He drank excessively, sought out other women, and once gambled away their meager savings. He acknowledged his dependence upon her and was furious when her interest was divided by the children, his "mother," her employer, or her job. Ulcer attacks, he had observed, were most likely to occur when a situation angered him and there were insufficient avenues of expression. Indeed, when it was immediately possible to discharge his rage he could insure himself against pain. In some situations his anger was so mountainous as to exceed all possibilities of adequate expression. While in the Marine Corps he had a typical exacerbation of ulcer symptoms. He found military life exciting for a while, but he soon began to rebel at taking orders. "I had enough of that before I was nineteen!" He became chronically angry, with no opportunity to discharge this feeling. His curious, introspective capacity led him to recognize several levels of anger within himself. The superficial type of resentment caused

Anxiety Attacks
The patient's anxiety attacks afforded additional insight into his problem. It was a striking observation that when his anxiety was at its height the ulcer symptoms were relieved. This suggests that intense anxiety obliterates all other emotions, and that, in this patient at least, anxiety alone was not a precipitating emotion for his ulcer symptoms. For this reason it is of interest to compare the situations which provoked anxiety with those which accompanied exacerbations of his duodenal ulcer. He experienced his first anxiety attack while undergoing hospital treatment for a hack injury sustained at work. Several months previously he and his wife had failed in their business venture. He had returned to his familiar habits of drinking and loafing, while his wife had become increasingly impatient and critical. Under pressure, he had returned to farm work, but was injured and had been hospitalized. On the day of the first anxiety attack his physician had advised him that a plaster cast would soon be applied and VOL. xvin, NO. i, 1956

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character facades were employed. His ego defenses were primitive: phantasy, impulse and retreat, fight and flight, and parasitic attachments. 1. Impulsive Activity, Defiance, and Projection: Typically, the patient mistrusted the motives of other people. These were often persons upon whom he had come to depend or from whom he wanted something. In a more general way, they included individuals who had some authority over him or toward whom he had a vulnerable, passive relationship. Slight provocations often resulted in abrupt, brutal fist fights, frequently to his own surprise. The final break with his father was prototypical. His impulsive acts were invariably followed by intense guilt, even when he felt thoroughly justified on rational grounds. 2. Escapes: One of his outstanding characteristics was persistent avoidance of responsibility. Chronic alcoholism provided him with a ready escape. Gambling signified to him an urge to acquire great resources without effort or activity on his part. His heterosexual promiscuity had many meanings. It was both a quest for a woman who would love him exclusively, and a defense against his wish to be loved by, and submit to, a man. 3. Phantasy Formation: He lived out extensive daydreams, treating his phantasies as realities. These included his bigamous marriage, his adoption of a childless old lady as his "mother," and a conviction that his father would reform and become stable, loving, and supportive. So vividly did he depict himself as the hapless victim of adult brutality that the boundary between phantasy and reality was obscured. 4. Illness: The patient was accident prone and also in his many illnesses showed delayed recovery and symptoms far out of proportion to the evidence of bodily disease. 5. Confession: Habitually he resolved guilt feelings by telling his wife (later, the psychiatrist) about his various misdemeanors. His urge to confess resulted in intense masochistic satisfaction through belittling himself. He saw himself as one of the suffering, homeless children of the world. Whenever he read of someone's illness or need he usually wept, regardless of whether the person in trouble was a man or a woman.

little difficulty. He could "blow off steam" without precipitating symptoms. But the blinding rage that he felt welling up from deep inside, which burst forth in hot tears or in explosive assaults with his fists, often terminated in severe vomiting and epigastric pains. A particularly dominating sergeant wanted the patient to give him money. When he refused, the sergeant tormented him with extra duties, distasteful assignments, and unrelenting criticisms for minor infractions of rules. The patient struck his persecutor and beat him almost to the point of death. Subsequently he was courtmartialed, and finally discharged. Even so, the trial and final dismissal from service caused him less distress than being forced to restrain himself indefinitely. His ulcer symptoms had been agonizing during the few weeks of oppressive restrictions and silent submission to the coercive sergeant. After the assault the pains subsided and did not recur until long after his discharge. The situation in the service closely resembled his earlier life in the institution. Submission and obedience became symbolically equivalent to eating his own vomitus. The conflict included his wish to please people, particularly older men, but he was also afraid of being duped or mistreated. All the men he ever trusted, he declared, had failed him. "People I depend upon do me dirt!" Herein was the conflicta wish to be loved and a dread of the hazards of obedience and coercion. Similarly, he married his first wife in order to have a home. He tolerated her infidelity only because he was reluctant to surrender even the fiction that she cared for him. When they ceased living together he merely left and failed to get a divorce. During treatment it became clear that, in addition to his bigamous second marriage, he believed that the legal reality of his first marriage constituted a basis for a re-establishment of that relationship. Thus he felt justified in retaining his undivorced, though absent, first wife as a potential source of emotional support.

Ego Defenses
Significantly, the patient showed no overcompensation in the direction of hyperactivity. He was without ambition or sublimations. His life was a perpetual search for security. The underlying motive in all his relationships was to achieve a peaceful, enriching parasitism. He was direct in his approach to implusive discharge and instinctual satisfaction. No pseudocompliance or

Predominant Affects
His anxiety assumed many forms. He was afraid of death and of desertion by men or women upon whom he had become dependent.
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During much of his life he was afraid of attack and was preoccupied with extensive and elaborate masochistic phantasies of being killed, tortured, or mutilated. His overt anxiety attacks developed in situations which activated his fear of loss and desertion. His ulcer exacerbations were invariably accompanied by impotent rage.

23

Conflicts
The outstanding feature of his psychic life was a wish for a dependent relationship with a bountiful mother. Simultaneously, he was afraid of losing the woman. His need for security, when coupled with a wish for freedom, meant that whenever he acquired one, he lost the other. He was desolate when free and felt imperilled when he was most secure. Thus his life fluctuated between dependent family relationships and footloose vagabondage. Although he had many sexual experiences, he avoided permanent attachments, except that of a little boy with a protecting mother. His wish for a good father led him into precarious attachments to men. These relationships ended in explosive anger when his anxiety mounted and he feared becoming duped or victimized. He needed a protector, male or female, who would cherish and take care of him. But when he found one he felt vulnerable.

Transference
His relationship to the doctor was a reduplication of previous attitudes toward older men. At first he basked in a positive relationship. The therapist was regarded as the fulfillment of wishes for a strong and kindly father. Later he became mistrustful and afraid of the doctor's motives, seeking hidden meanings in everyday events. Thus he projected his fear of passivity. Simultaneously, he accused the doctor of losing interest in him, an expression of his disappointment that his needs were not to be completely gratified.

moved from his home town to a distant city to become the manager of a large department store. He was eager to succeed but was afraid of the increased responsibilities. As months passed, he became more irritable and suffered from intractable fatigue. He was tense and anxious, and ruminated over trivial details, constantly checking himself for possible errors or lapses. Principally he was afraid that the store would catch fire. He imagined that people would be killed in the ensuing stampede and that he would be held responsible. As his symptoms became more intense he avoided even minor decisions. Finally, he was convinced that he was completely inadequate and was a failure. He had vivid dreams in which fire, death, and accidents occurred in the store. These were accompanied by the recurrence of a lifelong dream, "As though someone was telling me an endless story." Six months after assuming the new position his chronic duodenal ulcer relapsed. Periodically for 17 years he had had epigastric pain which could be relieved by milk and eggs. This pain was more adversely affected by nervous upsets than by dietary indiscretion. He spontaneously observed that, following a disturbing experience, ulcer pain would continue unabated until he was reassured by an older person in authority. If no one was available, as in the new job, the pains persisted unrelieved. Social He was born and raised in a small New England city, the son of a wealthy chain store owner. Although his father was dominating, dogmatic, and intolerant, he was also kind and generous to the patient. His mother was a mild, acquiescent woman who suffered from periodic vomiting. She was affiliated with benevolent organizations and suffered vicariously from other people's misfortunes. Often she attended funerals of those whom she knew slightly, if at all, and wept profusely. She was constantly afraid that the family would lose its financial security and be plunged into poverty. The patient's older sister had been engaged in her younger years, but the father had disapproved of her fiance. After much dispute the engagement was broken. The sister developed into a bitter spinster, living in the family home, arguing almost constantly with the father, upon whom she blamed her unfortunate life. After the patient graduated from college he automatically joined his father in business. He had no interest in other fields, but even so he

Case 4 History
The patient was a 41-year-old manager of a department store who was referred for psychiatric treatment because of recent symptoms of anxiety and a duodenal ulcer from which he had suffered since the age of 24. Medical and Psychological Three years prior to treatment the patient
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that through his ineptitude a catastrophe would occur for which he would be blamed. He actually functioned effectively as an employer and did a good job; his subordinates were devoted to Exacerbations: I him. He rarely reproached others for mistakes, Ulcer symptoms recurred while living alone, preferring to take the blame himself. Seldom away from home, eager to succeed in a new job. could he express his feelings when he was angry. Shortly after graduation the patient was given All his life he had disguised his resentments a job as an assistant manager of a large metro- so well that often he himself was not aware of politan department store. Although his employer their intensity. Particularly was he aware, howwas kindly and helpful, in many respects he ever, of restraining his anger toward his father, was indifferent. For example, he permitted the with whom he had such a passive and dependent patient only short periods for meals. He often relationship. Gradually this original attitude deeppromised to return at a specific time but failed ened into a general emotional inhibition which to do so. As a result, the patient was frequently covered his feelings with a cloak of constraint. hungry and resentful, but afraid to protest. Even "My father is the opposite of me. He is a selfhis free time was uncertain because his em- made man, with lots of self-confidence. I am ployer was apt to assign a new task just before not. Without my father, I would be nothing. the patient was to go off duty. The patient said When my father bawled out employees I felt in retrospect, "If my boss had been tougher I sorry for them; I wanted to tell him to let them could have openly resented him and quit the alone, but didn't dare. He's always the boss. He job. Actually he was all right except about eat- doesn't care if he has enemies; I haven't any. ing hours. I never took more than fifteen minutes I obey all his rules whether I like it or not. My for any meal. I should have quit anyway but father thinks that all rules, except his own, are I felt obliged to carry on and succeed. Besides, made to be broken. I just don't dare to defy I didn't want to worry my mother; she might him in anything." have become sick herself. If my father had Still, the patient craved his father's respect known, he would have made me quit!" and understanding. In his phantasies he pictured During this period the patient developed con- himself as an outstanding success as a public stant epigastric pain and anorexia. After a few figureas measured by his father's standards. mouthfuls, food became revolting. He lost con- Even as he resented his father he admired him. siderable weight. Still he clung to the job, con- Although he felt humiliated when his father convinced that he could not get along without his trolled his activities, at such moments he also father's assistance. Finally, despite intense shame, experienced a strange sense of closeness to him. he quit and returned home. His ulcer symptoms The patient found that whatever the father diswere immediately relieved. approved of, he too would automatically feel was worthless, although he despised this reaction Exacerbations: I I in himself. "He doesn't read and it makes me Following a minor accident in the store, for feel that reading isn't worth-while. He has given which he assumed responsibility, abdominal pains me three cars, but never once has asked me what reappeared. kind I would like. He just gives them. That One day when the store was filled with humiliates me!" Actually he was humiliated by people, a large ventilating fan broke. The store his own compliant, passive attitude rather than began to shake and the customers rushed to the by his father's overbearing manner. street. The patient became panicky. He trembled violently, sweated profusely, and suddenly felt Exacerbations: III Ulcer pain developed concurrent with his responsible for the safety of the people, even though he realized that there was no actual mother's illness. His mother had suffered for many years with emergency. As soon as the excitement subsided and his anxiety diminished, his ulcer pains de- a "heart condition" for which no medical cause veloped. could be found. One day while she was ill he This episode demonstrated the general conflict saw a hearse drive past the store. Immediately from which the patient suffered. Insecurity and he thought that his mother was dead. In panic self-doubt habitually magnified minor episodes he ran several miles to her home, only to find into major misfortunes. He was always afraid that she was alive. While running, he felt severe could not have disputed his father's plans. Actually he felt incapable of getting a job without his father's influence, even in later years.
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abdominal pains which persisted until his mother had once again recovered. The mother was a nervous, apprehensive woman who had originally opposed his entering the department-store business. She was overly clean and hard working, and enjoyed waiting upon other people. The patient was her favorite. Similarly, he felt a unique attachment to her. "My father would take care of things for me, not letting me straighten them out for myself. My mother rarely stands up for herself either, but suffers inwardly as I do." He justified his acquiescence to father by believing that if they had argued his mother might have become ill. Whenever he saw his mother waiting upon his father he was bitter, angry, and humiliated. Whenever she developed various unexplained illnesses he blamed his father, and simultaneously ulcer pains would stab him. Frequently the mother expressed the wish that the father would die before she did, because he depended upon her so much and would not be able to get along without her. The patient agreedotherwise he would have had to take care of his father. Thus by identification with his mother he was encouraged to remain the passive little boy. By believing that he and his mother shared a mutual fate with respect to his father, he failed to realize that she had contributed to the situation by submitting and thereby facilitating domination by her husband. She tacitly discouraged her son's independent growth. Any resentment the patient felt, however suppressed, was directed toward the father. He did not realize that his mother had actually manipulated the situation.

25 the patient allied himself with his wife he was afraid he would lose father's guiding hand and that his responsibilities would close in on him. Thus he resisted feeling any dependence upon his wife. He maintained a facade of self-assurance and security which only resulted in a stiff formality between them. "When I had to discuss money with her, and I couldn't talk about it, my ulcer would always get worse." To his wife he maintained the pretense of being an independent, aggressive business man, and was afraid to disclose how acquiescent and uncertain he really felt. He was ashamed of his masquerade. When she wept openly on the day their daughter was injured, he realized how he had excluded her, out of deference to his father. But he was convinced that women could only love a man like his father, bold, ruthless, and self-confident. "If I were a women," he declared, "that is the cort of man I would love!"

Ego Defenses
1. Pseudocom-pliance and Compliance: The patient responded to many types of emotional stress with a deferential, ingratiating attitude. In order to ward off threatening elements and obtain benefits he would otherwise be denied, he became compliant and submissive. To a far greater extent, however, he was truly a passive participant in life rather than an active agent in search of achievement. Through true compliance he shunned competition and avoided all types of aggressive behavior. He was eager to please, and despite frequent discomfort adapted himself to the wishes of people with whom he was associated. His submissive patterns buffered him from both external threats and internal impulses. 2. Inhibition and Sufyression: He was a rigid, constrained man who shrank from active expression of his feelings. Out of fear of uncontrolled passion he preferred to suppress anger and withhold his impulses. Wary of all emotion, hesitating lest he err or offend, he exercised intellectual control and, as a consequence, developed a stereotyped response which was both friendly and arid, but devastating in its internal effect. 3. Phantasy Formation: His daydreams consisted of glorifying, noncompetitive, and unrealistic phantasies in which he was admired by everyone. The roles he filled were always those highly esteemed by his father. They enabled him to avoid positive independent action and helped him to deny both his passivity and sense of failure.

Exacerbations: IV
Exacerbation of ulcer symptoms followed a fire in the store. One night his store was destroyed by fire. During the ensuing insurance investigation he was afraid of being found negligent, although rationally he knew he was not at fault. As he anxiously awaited the results of the inquiry, his wife telephoned to tell him that his daughter had fractured her leg. He ran home, found his wife in tears, and immediately developed abdominal pain. The episode confronted him with an old conflict. He was on his own in business as well as in marriage, but instead of enjoying his freedom, he felt hopelessly inept and a complete failure at both. His marriage had been difficult because it frequently had tested his loyalty, which was divided between father and wife. If
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magic cure for his illness through submission.

4. Bisexual Identification: He progressed by clinging to his father, who decided major issues for him and determined his course of action. Conversely, he saw himself in the same relative position as his motherpassively controlling, submitting to father, plagued by illness, and suffering in silence. In the double identification he achieved some measure of control over aggressive independence. His masochistic surrender to both father and mother was thus complete. 5. Neurotic Symptoms: His prominent symptoms of fatigue, obsession with minor matters, and multiple phobias protected him from further conflict within himself as well as from open conflict with his father.

Case 5 History
The patient was a 30-year-old former professional athlete who was referred for psychiatric investigation of his duodenal ulcer.

Medical
About 2 years before, while on duty with the navy, the patient developed postprandial epigastric pain, accompanied by distention, occasional vomiting, and chronic anorexia. The symptoms increased when he went on sea duty and were unrelieved by food. He became tense, anxious, and tremulous; sleep was difficult and severe gastric symptoms made eating almost impossible. Between voyages, during short leaves at home, his appetite returned and the epigastric pain subsided. Finally, however, ulcer distress became so disabling and nervous tension reached such heights that he was sent to a naval hospital to await discharge from the service. He had had considerable combat experience, but noted no relation between fear, fatigue, or depression and relapses in his ulcer symptoms. His pains were controlled equally well by either whiskey or milk. Social He was raised in a small midwestern town, the only son of a middle class family. His father was a well-known local athlete and consequently was an early idol of his son. Although the family had only modest means, his father's reputation and the patient's own success as a high school athlete enabled him to associate with people of higher economic and social status. His mother was a sensitive, compliant woman who suffered from chronic vomiting. She was regarded as having "ulcers," although this was never verified. Following high school the patient played professional football and baseball. When he finally realized, however, that he could never become a major leaguer in either sport, he retired rather than accept mediocrity. He became a toolmaker and followed this trade until he enlisted in the navy. Even so, he never completely relinquished his athletic ambitions and had extensive daydreams in which he became a famous coach. Exacerbations: I Ulcer symptoms developed during sea duty as an enlisted man in the navy.
PSYCHOSOMATIC MEDICINE

Predominant Affects
Suppressed anger was the most dangerous, ever-present aspect of his emotional life. He was afraid that through uncontrolled discharge of his impulses he would be deprived of love, support, and gratification, and he would become helpless. "I shall be blamed for some catastrophe, I don't know what, even if I am not at fault!"

Conflicts
Despite superficial protests, his struggle against father's authority was reduced by a wish to be sheltered and loved exclusively. By submission, surrender, and acceptance of established authority and tradition, he hoped to guarantee a perpetual love relationship in which he was the passive recipient. This required that he forsake all impulses and actions except those approved by his father. He developed an abiding sense of failure and a conviction that his ideas, impulses, or plans were not to be trusted. He derived considerable vicarious gratification from his father's worldly success and domination, although consciously he decried it. Moreover, by surrendering to father as did his mother, he gained dignity and esteem through suffering and achieved success by default.

Transference
His attitude toward the doctor was one of affable acquiescence. He found no reason to dispute, accepted all interpretations without question, and persisted in his polite, restrained manner. The therapist was regarded as a good father-mother who placed him in a central noncompetitive role for special attention. There was no consciously expressed fear of coercion or domination. He tended to identify passively with the doctor and hoped to acquire strength and a

WEISMAN
The patient was on board about a week when he felt a gradually increasing, scarcely tolerable rage developing within him. He hated everyone, and even wished a torpedo would sink the ship, not only to relieve his suffering, but also as a means of destroying every person on the ship. Rigorous discipline precluded even mild expressions of resentment. Restraint became more and more difficult. Finally he begain to vomit after every meal and suffered almost unremitting epigastric pain. Prior to enlistment he had been able to discharge his aggressive, competitive feelings through vigorous athletics. He was a hard loser, playing each game as though it were a decisive test of one man against another. Socially, he had also been concerned with proving himself as good as any other man, and struggled against defeat or humiliation. As a child he repeatedly fainted at the sight of blood. He interpreted this as a sign of weakness and lack of manhood. He was less afraid of death than of defective virility and humiliation. When he joined the navy he was galled by his inferior status as an enlisted man. The officers, he felt, looked down on him. Particularly did he resent WAVE officers. "They may outrank me but they are not my superiors!" This feeling was rooted in many episodes in the past when he had been irked by women in positions of authority: a high-school editor, the manager of a factory, and so on. The upsurge of abdominal pain on shipboard followed a dispute with a WAVE who was his immediate superior. He had been assigned to the same type of hospital duty as were WAVES and resented the implied humiliation. In the past his self-esteem had been amplified when women admired him for athletic prowess. Now that he was thrust into an inferior position he felt vulnerable. His manhood was in question and he felt helplessly enraged. Exacerbations: I I Following an argument with his family, epigastric distress returned. Several years before, the patient's father had developed a brain tumor. It was successfully removed but his personality was altered. No longer was he the vigorous, friendly man his son had admired, but instead had become seclusive, depressed, and had several convulsions. His gradual deterioration caused the patient considerable anguish because, as a youth, he had esteemed his father, not only as an outstanding athlete but also for his "will power" and his capacity to
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27 overcome many obstacles through sheer determination. One day while home on furlough, fed up with his father's indolence and depression, the patient exploded and informed the family that unless the father returned to work he would not come home again. It was too humiliating. His onetime idol had become an aimless and apathetic shell. He argued further with his sister who reproached him for his belligerent attitude. The next day he experienced a recurrence of ulcer pain. Following the family quarrel he assumed an attitude of indifference and henceforth became reserved and cautious in all dealings with his parents. With his father's deterioration the patient felt that he too had suffered a loss of status. Exacerbations: I I I His wife requested a divorce, after which he had recurrence of abdominal symptoms. The patient had been in a naval hospital for several weeks undergoing treatment for his ulcer. He was discharged as "recovered" and was given a short leave prior to official separation from the service. Although free of abdominal complaints, the patient brooded over the treatment he had received. He felt that the doctors were contemptuous and, as a result, neglected him. "They seemed to feel that if I were a man I'd be back on active duty." But he did not want to return to duty because once again he would be assigned to work with WAVES. "All I needed was a skirt and I'd have been a woman!" In this disconsolate mood he visited his wife who greeted him by demanding a divorce. Immediately, his epigastric pain, heartburn, vomiting, and anorexia returned. He became agitated and distraught. "I was shocked when she told me about a divorce. I wandered around and couldn't sleep. I got nervous and had terrible stomach pains. I felt as if I could vomit even before I started to eat!" He returned to his station without settling the question of divorce. After a few days he received an encouraging letter from his wife. He showed the letter to a friendly physician who assured him that his wife evidently loved him very much. His ulcer symptoms subsided almost immediately. Shortly after he joined the navy the patient had married a girl from his home town. She belonged to the higher social stratum in which he had moved but to which he did not belong. Her parents objected and refused to attend the wedding. Humiliated, the patient had resolved to retaliate by becoming an outstanding success.

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DUODENAL ULCER EXACERBATIONS

to accepting a lesser role. His compliant tendencies were minimal. Pseudocompliance was practiced only under extreme protest; it was not the familiar pattern that it had been in the previous patients. 6. Escapes: Alcohol afforded some surcease from his chronic feeling of failure. On rare heterosexual adventures, despite his braggadocio, he was invariably impotent.

Although both he and his wife wanted children, she did not become pregnant. After an examination the patient was told' that he had "bad sperm," and that this accounted for his wife's failure to conceive. This was ostensibly the reason she requested the divorce, although the patient wondered if she had not met another man. After the humiliating experience with WAVES and his impending discharge from the service, the divorce became additional evidence of his failure both as a man and a husband, and a confirmation of the objections of his in-laws. Ego Defenses 1. Emotional Inhibition: To him, display of emotion was a sign of weakness. When his father became depressed and unable to carry on as the vigorous and decisive person whom the patient had admired, he wanted to reject him completely. Fainting, crying, and fatigue were similarly repudiated. 2. Denial hy Word, Act, or Phantasy: He allayed the anguish of feeling weak, unimportant, or inferior by creating an image of himself as a superman. He dreamed of great success beyond realistic possibilities. "Will power," "strength of character" and "social status" were the hallmarks of manhood. This demanded that he reject his shortcomings and limitations and adopt the facade of complete adequacy in all spheres of life. In his psychiatric treatment he frequently shielded himself from unpleasant disclosures by suppression, evasion, and direct misstatements. 3. Avoidance and Social Isolation: Regarding himself as a man of ability and accomplishment, he frequently shunned situations which challenged his precarious adjustment or confronted him with his mediocrity. Thus he avoided unacceptable evidence of his weakness or failure. 4. Bisexual Identification: Through vicarious participation in the success of prominent athletes, the patient retained a remnant of his own lost hopes and eased the humiliation of being a lesser person. His social aspirations, his resentment when he was assigned to an inferior station in the navy, and repudiation of his family when his father became ineffectual indicated his fear of being looked down upon or ignored. His strong aversion to female sailors signified a deeper feminine orientation which was managed by counterphobic mechanisms. 5. Hyperactivity and Defiance: His competitive attitude was determined to a considerable degree by his fear of defeat and being only second best. He vigorously and defiantly objected

Predominant Affects
Ulcer exacerbations were uniformly characterized by an upsurge of rage which he was forced to conceal. He was constantly preoccupied with fears of humiliation, so that the precipitating situations associated with recrudescence of ulcer symptoms always involved humiliation followed by suppressed anger.

Conflicts
His most important conflict challenged his ideal of being a strong, independent man and threatened to thrust him into a feminine role. He resented women who achieved equal status because his own feminine strivings, envy, and fears were thus exposed. Associated with this was a wish to be admired and esteemed by a strong man, an athlete, naval officer, doctor, or social leader. There was rivalry with women in the home as well as in the service. His impotence was one manifestation of this conflict. His father, with whom he had early identified, had once been a powerful masculine figure whom illness had transformed into a depressed, dependent invalid. He regarded his father's illness and defeat as an augury of his own future.

Transference
Cautious and evasive with the therapist, he was afraid that if he confessed his weakness without the counterbalance of tales of prowess and strength he would be regarded with contempt. The doctor recognized this and not only treated him with extreme courtesy but also displayed appreciation and interest in his achievements. As a result, the patient reciprocated with a slight relaxation of his guard. Still, when situations developed which he feared would put him in an unfavorable light, he withdrew into polite taciturnity. No overtly hostile feelings toward the therapist were ever expressed.

Case 6 History
The patient was a 30-year-old merchant seaPSYCHOSOMATIC MEDICINE

WEISMAN
man who was referred for psychiatric study of a chronic duodenal ulcer. Medical and Psychological For 6 years he had suffered with postprandial midepigastric pain, often associated with nausea. He complained of severe distention and punctuated his conversation with loud and abrupt gaseous expulsion. Certain foods and alkalis afforded some temporary relief. Under emotional stress however pain, heartburn, and distention were almost unremitting. The patient resisted psychological investigation of his life experiences and personal background. Although conceding that fatigue, agitation, and particularly anger were apt to precede aggravations of his gastric complaints, he was unwilling to disclose details of his life to the physician. He limited communications to brief, factual responses to direct questions, so that his early history was only cursorily outlined. Not until later was it possible to reconstruct the actual sequence of events prior to the onset of his ulcer symptoms, and to understand some of the psychodynamics of individual relapses. In the following report the initial half-truths, untruths, evasions, and distortions are omitted. The history and conflictual situations surrounding the separate exacerbations are presented in their final, clarified form. Social He was born of a Catholic father and a Protestant mother, the second son among 11 siblings. The father was a decorator who required absolute obedience from his sons, all of whom were expected to work for him. In addition, the father periodically used alcohol to excess, at which times he abused his wife and children and often was destructive. The mother was a large, lenient person who tended to protect her children. The patient was proud of being the "good son" who did errands, visited elderly relatives, and assisted his mother in general, trying to win her approval. But with so many brothers and sisters, most of them younger, he found himself struggling fruitlessly to gain her attention, and often felt isolated. Later, after most of his siblings were married and had children, the patient still remained aloof from the family, feeling that his unmarried state deprived him of full participation in their mutual intimacy. Failing in his classes, he left school at an early age. He preferred to work for his demanding, exacting father rather than be disgraced by being held back in school. Almost daily his father upVOL. XVIII, NO. i, 1956

29 braided him for inefficiency, but the patient was afraid to protest. However, at times he felt consumed with rage and an urge to retaliate. He continued to live in a tense household rather than leave home. There was a peculiar attachment to father which led him to resent his demands but also to seek his approval.

Exacerbations: I
A love affair ended tragically because of his indecision and ambivalent attitude toward his father. His ensuing sense of guilt and self-rebuke were elaborated into paranoid rage which altered the course of his life. Finally, as his resentment burst forth, he developed severe ulcer symptoms which persisted intermittently for several years. When the patient was 20 his girl friend became pregnant. He had wanted to marry her for a long time but had hesitated because his father objected to the girl's religion. The conflict was again revived when the pregnancy was discovered. He fluctuated between his wish to marry the girl and his fear of alienation from his father. After considerable indecision the girl arranged for an abortion herself, which was performed with his consent. Afterward he became depressed and hated himself, feeling as though he were a murderer. Within a few weeks the girl turned from him and married another man. Following this he became desperate, constantly chiding himself for weakness and vacillation. He threw himself into a life of all-night parties, alcohol, and promiscuity in order to escape from his guilt and self-derogation. He slept but little, worked only occasionally, and argued incessantly with his father for the first time. One night after a party he was arrested for drunken driving. Out of his overwhelming guilt came the thought that he was being framed and unjustly persecuted by the police. His resentment became a fixed conviction. He repeatedly provoked altercations with the police in a vain effort to achieve revenge for the shame he felt had been thrust upon him. He was irritable, suspicious, and isolated, constantly brooding and carrying a grudge against all men. His father, who had also been drinking, demanded one morning that the patient go to work immediately and moreover work longer hours. His long-smoldering resentment exploded into a brutal argument in which both men threatened each other. Suddenly he experienced severe abdominal pain and nausea and vomited precipitously. He collapsed and took to his bed. "There was no one to take care of me. Relatives expect

30

DUODENAL ULCER EXACERBATIONS

His reaction was one of complete surprise and humiliation. He insisted, in retrospect, that his sole motive in pursuing her was pity, but after her repudiation he felt even less like the manly man he wanted to be. His ulcer symptoms flared up in an exacerbation which exceeded even his shipboard experiences. He quit work and roamed aimlessly about the city, agitated, suspicious, and afraid of losing his mind. At this point he entered the hospital for psychiatric treatment.

too much . . . and for no pay!" The diagnosis of duodenal ulcer was made shortly thereafter. Following several weeks of incapacitating illness his symptoms remitted. He stopped working for his father but did not leave the household. Each succeeding job, however, lasted only a short time. He regarded his employers as incompetent, punitive exploiters who asked too much, gave too little, and invariably made him feel "in the wrong." He argued with everyonebosses, family, and former friends. "All I thought about was hate . . . hate . . . hate!" he recalled. When the abdominal pains returned the patient noted that his constant feeling of anger subsided. It was actually a relief to experience gastric pain and heartburn instead of the gnawing pains of diffuse resentment. When the army later rejected him because of his ulcer, his sense of humiliation, guilt, and anger made it impossible for him to remain in his home community. He joined the merchant marine, hoping to avoid the persistent feeling of being persecuted and dominated by hostile powers. But he found himself doing menial kitchen work while others did "men's work." He was obliged to clean the officers' mess, sweep the floors, wash dishes, and act as cook's helper. His ulcer symptoms nagged him incessantly. Again he felt that others less capable than he were using him to their advantage. While ashore his pains subsided, only to return when he shipped out again.

Ego Defenses 1. Pseudocom-pliance and Pseudodefiance: The patient resisted all efforts to enlist his cooperation. This included not only psychotherapy but any situation in which he feared being "ordered around." Yet when confronted with even mildly positive opposition he tended to wilt and, muttering belligerently, he regularly backed down. On other occasions, fortified by alcohol and agitated by a heightened conflict over fancied wrongs, he fought back. The bellicose manner covered fear of being exploited or maneuvered into a helpless position. His pugnacious, defiant attitude was actually a counterphobia. 2. Avoidance and Social Isolation: He withdrew into a mood of silent rebellion in situations which made compliance inevitable. Rather than be forced to acquiesce, he left home and wandered aimlessly, preferring painful isolation to subjugation by father. 3. Denial by Word, Act, or Phantasy: This was illustrated by his repeated statement: "NothExacerbations: II ing can bother me!" Even in the face of suffering His ulcer rela-psed after rejection by another and frustration he assumed a boastful, nonchalant attitude and rejected any suggestion that he girl. For several years after his discharge from the had problems other than those thrust upon him merchant marine the patient worked at odd jobs, by unfair people. So great was his need to prove dissatisfied with himself, blaming others for neg- himself a strong, capable man that he attempted lecting him, and feeling alone, weak, humiliated, to act the role in the exaggerated manner of a and rebellious. Finally he returned home to work confused adolescent, with braggadocio and posfor his father, who had become somewhat less turing. The situation was reminiscent of Aesop's exacting with the passing of time. At once his fable, "The Ass in the Lion's Skin": appetite returned and his abdominal pain abated. An Ass, finding the skin of a Lion, put it With the improvement in family relations his on and roamed about, frightening all the chronic anger decreased. silly animals he met with. Seeing a Fox, he At length he met a girl who was reputedly a tried to alarm him also; but the Fox, having "man hater." He resolved to woo her in order to heard his voice before, said, "Well, to be show her "what a man was really like." His aim sure! And I should have been frightened was to gain her love and esteem after she realized too, if I had not heard you bray!" how superlative a man he was. He actually did not care very much for the girl and so was per- The patient told a similar fable in his phanplexed when he found himself constantly seeking tasies. He believed that eunuchs were the most her company, courting her, and finally proposing powerful of men. Instead of being crippled by their castration, such men increased in size and marriage. She rejected him emphatically.
PSYCHOSOMATIC MEDICINE

WEISMAN
compensated for their lack of sexual life by acquiring prodigious physical strength. Thus, for his audience, he attempted to evoke the image of a powerful man instead of the confused, somewhat helpless, unhappy little boy he actually approximated. Other expressions of his use of denial appeared in suppression, dissimulation, evasions, and halftruths which distinguished many of the therapeutic interviews. 4. Projection: Others were blamed for his misfortunes and shortcomings. He felt persecuted by men in authority and reacted to his inferior status by devaluating them. In a similar way he belittled the girl who repudiated him. He was convinced that doctors and nurses in the hospital were submitting him to various tests in an attempt to prove him insane, when actually he questioned his own sanity. His truculent suspicions were motivated by a fear of being misused by men in authority. He felt that instead of giving him what he wanted they would exploit him and leave him helpless. 5. Attitudes and Escapes: His overbearing, bellicose, contrary attitude has been described under Denial. In addition, after the long period of vacillation prior to the abortion, he used alcohol excessively in response to guilt and humiliation. He was also sexually promiscuous and provoked fights, as though by gargantuan exploits he could neutralize his feeling of weakness and unworthiness with respect to his father. 6. Illness: When ulcer symptoms were most acute, his partially restrained hostile impulses subsided and he felt entitled to ask for the help which otherwise he was certain would be refused.

31 from home and remaining painfully dependent upon his father. He could achieve independence only at the price of rejection. Although he wanted to be close to a strong, reliable man, he was also afraid of complete helplessness. In such a situation his sense of borrowed strength was impaired by a fear of being exploited and drained without attaining the replenishment he needed. This was consciously experienced in situations where he felt neglected by his employers or other superiors who failed to take care of him adequately. The uncertain masculine status was also reflected in his relationship with women. The two women to whom he was closest, aside from mother, rejected him. In both instances he was "not enough of a man." Thus, to overcome his sense of weakness and passivity Chis feminine wishes) he fought, drank, boasted, and copulated promiscuously. In a specific campaign to establish his manhood, the patient tried to win over a "manhating" woman, even though he was not in love with her. He was bewildered at both his efforts and her refusal. The situation may be understood if we translate the relationship as follows: he was unconsciously the "man-hating" woman or, more accurately, the "man-fearing" woman. He reacted to his unconscious sense of femininity by eulogizing eunuchs and through constant efforts to pose as an aggressive, virile fellow. Toward the girl he played the role of a benign and loving father. In this way he tried to realize vicariously the fulfillment of his own wishes to be loved by his father. Inasmuch as he identified himself with a "man-fearing" woman it was inconceivable that she should fail to carry out her role in the charade by rejecting him. Thus his passive conflict was renewed.

Predominant Affects
The patient described his mood as "inside hate." Although periodically explosive, his resentment was usually either restrained or displaced to trivial situations. Beneath the belligerence several fears were recognizable. In order to bolster his precarious self-esteem he needed constant appreciation and deference. He was afraid that if he expressed his needs he would be refused and might even have a new burden thrust upon him. He felt that through unwilling submission his own will would become ineffectual and only depletion, exhaustion, and humiliation could result.

Transference
The patient's need to prove himself a man in other men's eyes was carried into his relationship with the physician. His transference attitudes went through several phases. Initially he treated his physician with disparagement. The doctor was either wrong, stupid, or dealt with trivialities, while he, the patient, knew all the answers. Later his fear of domination emerged and he became suspicious of the doctor's motives, wondering if he were being used for needless experimentation. Ultimately he regarded the psychiatrist as a punitive avenger. In a dream during this final period the doctor appeared both as a detective who caught a murderer and as the

Conflicts
The patient vacillated between running away VOL. xviii, NO. 1, 1956

32

DUODENAL ULCER EXACERBATIONS

A 31-year-old unmarried seamstress complained of anxiety attacks whenever she noticed that the spoon in a sugar bowl was pointed directly at her. Her eyes crossed as she attempted to focus Discussion on the handle, and on each occasion felt palpitations, faintness and intense anxiety. In no other Specificity situation, to her knowledge, did such anxiety The long-argued question, "Is there speci- occur. ficity in psychosomatic disorders?" is meanAnother patient suffers from a certain disingless. Instead, we must ask, "What kinds of specificity are there and what is specific in order and no other, in response to more than psychosomatic disorders?" In this form, the one, but not every, stress. question is significant, but requires an underA 25-year-old teacher noticed that her mucous standing of the meaning of specificity, the colitis was more severe when she felt exploited conditions by which specificity may be deter- and angry, or was in a period of sexual frustramined, and the basic elements in psychoso- tion. Other types of emotional stress were managed differently. matic disorders. The most general statement about speciSimilar stresses may induce a certain disficity is the following: For a given patient, a order in one patient and quite a different certain disorder occurs in response to a limited response in a second patient. Loss of money number of stress-stimuli. Thus, there are three may be catastrophic to a financier but a matter variables: ( i ) the patient as a personality, of indifference to a philosopher. social creature, and functioning organism; (2) the disorder of adaptation, also called disease; Disorder Specificity and (3) the stresses which disturb the pa- This refers to the adaptive disorders which tient's equilibrium. occur in conjunction with a variety of stresses. Three types of specificity may be defined It may designate a symptom, a disturbed on the basis of these variables: physiological function, or an actual lesion, depending upon the method of investigation. Patient Specificity The sociological background and constitu- In the following patient, several distinct tional structure of a given patient are recog- stresses provoked a similar disturbance of nized by all investigators as essential elements adaptation. of both his personality and his predisposition A 47-year-old housewife suffered with recurto adaptive disorders. The problem of identi- rent periorbital urticaria. The disorder appeared fying these elements, however, is the concern whenever she was faced with the unpleasant of the sociologist and the biologist, rather prospect of visting her mother-in-law, but also than of the psychiatrist. Nevertheless, it developed after using a certain brand of lipstick should be recognized that the importance of or being exposed to smoke from a wood fire. certain psychological stresses is at least partially determined by the social and constitu- Stress Specificity tional background of the individual organism. A single stress may disturb the organism's Clinically, we find that similar stresses may equilibrium in a number of ways. For exambe associated with different disorders in dif- ple, loss of a loved one may arouse depression, ferent patients, while different stresses fre- weeping, diminished gastric responses, insomquently induce similar reactions in others. nia, social withdrawal, hypermotility of the The different combinations of stress and dis- colon, or many other forms of adaptation, order may be illustrated by clinical examples. both physiological and psychological. For the following patient, there is an apparent specificity of both stress and disorder, since Determination of Type the specific stress does not induce a similar A specific psychosomatic formulation is one reaction in other patients. which describes an emotional state at the
murderer himself, who dissected helpless women victims. Thus the patient again disclosed the extent o his feminine identification.
PSYCHOSOMATIC MEDICINE

WEISMAN time of an increase in symptoms or a disturbance of physiological activity. The symptoms or disorder must vary with the emotional stress. If any component of the psychodynamic situation is lacking, there are no symptoms. If only a single component is present, there will be no symptoms. But if all the components are operating together, the disorder must occur or the formulation cannot be called "specific." Without further differentiation, we cannot determine whether disorder specificity or stress specificity has been established. Therefore the conditions for determining the type of specificity must be further defined. Where a stress regularly is associated with an adaptive disorder and with no other disorder, and where, in every case, this disorder involves the same stress, the situation may be designated as equivalent specificity. Equivalence then, represents the coincidence of both stress specificity and disorder specificity, where one form of stress never exists without a certain disorder, and where the adaptive response occurs if, and only if, a certain stress is in operation. The other forms of specificity may be called conditional. There is stress specificity associated with many different responses, and disorder specificity associated with several different stresses. To summarize: specificity refers to a constant relationship between an emotional constellation and a physiological disturbance. Conditional specificity means that, given a certain stress, a variety of adaptive disorders may ensue (stress specificity); or that a more or less fixed type of adaptive disorder may occur with stresses of several kinds (disorder specificity). Equivalent specificity requires that a certain adaptive process is in operation only when the emotional constellation is also active, and that the emotional constellation is active only when the adaptive disorder is present.

33

chosomatic formulation can be described? Much of the dispute encountered in the literature has arisen from ambiguities in terms and one-sided generalizations. For example, "anger" may have different consequences in different people because of different ideational elements associated with the anger, rather than because of the emotion itself. Isolated statements that certain psychosomatic symptoms are caused by "anxiety" actually assert little more than that the patient is "tense" or "nervous." The most satisfactory definition of "emotion" includes its subjective, behavioral, and reflex aspects. This problem has been discussed elsewhere from the neurological viewpoint, with particular reference to peptic ulcer.30 It has been clinically convenient to describe and compare the emotional constellations operating in these patients at the time of exacerbation of ulcer pain, in the following psychological terms: conflicts, predominant affects and fears, ego defenses, and transference. From these four categories, or psychological terms, the specific psychosomatic formulation can be derived.

Conflicts A conflict consists of a pair of antithetical alternatives, each of which entails both pleasurable possibilities and painful consequences. The patient vacillates between the hope of fulfillment and the fear of disaster. Such alternatives were expressed in various ways by the 6 patients. Obedience/freedom, heterosexuality/homosexuality, dependence / independence, exhaustion/replenishment, passivity/activity, masculinity/femininity, indulgence/discipline, security/exposure, acquiescence/authority, attachment to father/reliance upon mother, compliance/defiancethese represented most of the antinomies and were reducible to a single basic formulation. All the patients displayed initial passive and receptive urges which gradually yielded to active seeking. The so-called "independent Specific Psychosomatic Formulation striving" was secondary, although it often The foregoing considerations define the was the only aspect of the conflict which was logical forms of specificity. What are the basic conscious. The original passive orientation psychological terms by which the specific psy- was more difficult to establish but could be VOL. xviii, NO. i, 1956

34

DUODENAL ULCER EXACERBATIONS dependency is not a striking issue. Indeed, dependency/independency may be regarded as a special case of the passivity/activity conflict. Patient 3 developed acute anxiety when his source of dependence was threatened, but his ulcer exacerbations occurred in situations where he was helpless to avert the passive role and became enraged, not only by the anticipated deprivation, but by his inability to cope with the stress. The fear of vulnerability was as prominent as the fear of desertion. The two concepts of passivity and dependency may certainly coincide. We find that the loss of a dependent relationship as a result of passive fears was so often a source of conflict that one is tempted to infer that when dependency becomes conflictive the patient also demonstrates a protest against his passive role. However, this does not imply an identity. A man who is being whipped is obviously in a passive position, but hardly dependent. Passivity refers to an attitude, where the person is acted uponsomething is done to him. Dependency describes a relationshipsomething is done for him. Predominant Affects and Fears The many exacerbations were characterized by three affective states: restrained, ineffectual anger; guilt associated with anger (angry guilt); and guilty fear. The latter was less frequent, but even so, successive recurrences of ulcer symptoms suggested that a hostile element was also present. Smoldering resentment was almost universal. Complete discharge of anger usually relieved or forestalled an ulcer attack. Even when guilt followed in its wake no gastrointestinal symptoms developed. Patient 6 described himself as filled with "inside hate," and periodically erupted in impulsive rages as he nomadically avoided human contacts. His restrained resentment was not unlike that in Case 1 where a cultured, urbane, placatory manner and effective performance as father and breadwinner for a large family contrasted dramatically with violent dreams of blood, feces, death, and murder. Szasz and his colleagues have regarded hosPSYCHOSOMATIC MEDICINE

clearly recognized. The transformation from passive to active was determined by 3 factors: 1. Lack of fulfillment of passive-receptive wishes. 2. Fear of passivity itself, which resulted from (a) homosexual fears and feminine identification. (b) fear of weakness, depletion, and helplessness. 3. Conflict with the ego ideal. The patient in Case 3 suffered actual deprivation of parental love and protection and became a vagrant, seeking an ideal mother and father. The patient in Case 4 experienced enforced passivity under the influence of a successful, aggressively benevolent father and a long-suffering, yielding mother. He dreaded the weakness implicit in being protected and controlled and resolved his problems only in phantasies. The patient in Case 1 was forced into premature activity by his father's artistic ambitions for him. He rejected both independent self-reliance and unlimited love and support, even as he hungered for them. To him passivity meant depletion, helplessness and homosexual fears, particularly with respect to older men. The patient in Case 2 was not only without adequate parental care, but in later life resisted situations in which such gratification could be at least partially fulfilled. The patients in Cases 5 and 6 both struggled with doubts of their masculinity and measured success by the degree to which they could separate themselves from female figures with whom they had withal closely identified. Characteristically, all the patients fluctuated between active seeking and passive yielding, being drawn first to one and then to the other. This seemed to be the nuclear conflict. The assertion that the conflict, passivity/ activity, was present in the 6 patients under investigation naturally raises the question of whether the accepted hypothesis of oraldependency conflict cannot also be generally applied to these patients. The view proposed here is that passivity is a wider concept than dependencythat is, that the passivity/activity conflict can be aroused in situations where

WEISMAN tility as a "potential pathogenic agent." There is an equation, according to these investigators, between anger (crying) and receiving food on the one hand, and fear and what is feared (not receiving food) on the other. The implication is that anger in an ulcer patient is a significant factor only when it occurs in response to frustration of oral needs. They indicate that erosion of the stomach and duodenum are directly related to only one parameter: hypersecretion of hydrochloric acid, stimulated by an upsurge of hostility. It is important, from the perspective of the passivity conflict, to note that their patient was described as "resistant to interviewing . . . behavior characterized by a very striking passivity . . . sullenness and an air of hostility." Thus, is anger in ulcer patients specifically related to not being fed? Perhaps this is an instance where dependency and passivity coincide. People may become angry when others do not perform in a desired manner, but not always because they are not being fed or having their own dependency satisfied. From the passive/active viewpoint, anger occurs in response to a narcissistic threat. If the anger in ulcer exacerbations is subject to restraint the source of suppression must be determined. In the 6 patients both guilt and fear were responsible. The guilt resulted from the peculiar type of ego ideal which will be discussed below. The fears associated with recurrences took several forms. Emphasized were fear of exposure, depletion and exhaustion, coercion and desertion, along with less frequent fears of humiliation and depreciation. By exhaustion and depletion the patient would be forced into a helpless, submissive position. Desertion by a source of love or support foreboded a loss of strength, again with vulnerable consequences. The fear of humiliation was based upon a reluctance to recognize passive dispositions. If a basic fear can be determined from the diverse forms of anxiety manifested during ulcer exacerbations, it has this form: a fear of being helpless and submissive, with defenses torn away by narcissistic injuries, by exhausting, unreasonable demands, or by loss of strength or support. This, when coupled VOL. xvni, NO. i, 1956

35 with imfotent rage, distinguished the ulcer exacerbation from other emotional crises. In the 6 patients, when the threat of depletion exceeded the promise of replenishment and the angry protest was restrained by guilt or fear, ulcer symptoms recurred. Ego Defenses The vicissitudes which the nuclear conflict and basic fear undergo during exacerbations can be explained by the system of ego defenses. 1. Compliance and Defiance: Several of the patients (Cases 3, 5, and 6) openly opposed coercion by active resistance, even including homicidal attempts. Others were more restrained and rebelled only in a disguised way. Patient 1 was typical in his persistent overextension, placation, and obedience. Yet, however supplicant the attitude, the underlying feelings of protest against subjugation were clear to the patient. Thus the conformity was "pseudocompliance" and differed from true reaction formation, in which the underlying attitude is largely unconscious. The inhibited patients adapted to the stress of the conflict by surrender, acceptance, and silent protest; the impulsive, defiant patients often projected their hostility, blamed others for their misfortunes, and shunned threatening situations. 2. Inhibition and Suppression: Patient 4, a man dominated by his father, restrained all independent activities, constantly holding himself in check. Unlike the others, there were no periodic outbursts of self-assertion and no substitute avenues of discharge. Only Patient 3 allowed himself full indulgence of his phantasies of dependence and was openly belligerent in passive situations. The other patients demonstrated inhibition and suppression in varying degrees. Each had a limited tolerance of impeding, restraining forces before mounting anxiety and anger resulted in overt protest. 3. Denial by Word, Act, or Phantasy: In the mildest form, denial was expressed in verbal assent, unquestioning acquiescence, or spurious idealization of personal and social pressures. In the most extreme form, denial almost completely replaced reality testing as

36

D U O D E N A L ULCER

EXACERBATIONS

a means of coping with conflict. Patient i adopted certain approved attitudes and behavior other than his own, creating the effect of a charade. The patient in Case 5 regarded himself as a superlative specimen of manhood, beyond the facts, in order to deny his uncertain masculine status. Patient 6 huffed and puffed, as if to blow away his feelings of inadequacy, and when this proved ineffective he reacted with persecutor)' ideas. It is noteworthy that the impulsive patients tended to use denial by word, act, or phantasy more frequently than did the inhibited, pseudocompliant patients. 4. Avoidance of Social Isolation: Troublesome situations were frequently avoided by withdrawal into seclusion in order to be protected against depleting, threatening circumstances. "If I am by myself, nothing further can happen to me!" Yet none of the patients was content in this solitary state. After a short time they gradually returned to their customary milieu, usually with misgivings, but also with renewed hope of fulfillment of their need for love, sustenance, acceptance, and support. 5. Phantasy Formation: This differed from denial by phantasy in that the patients were aware of the palliative nature of their daydreams. It did not cloud recognition of their true reality status. Exaggerated dreams of acclaim and prestige were marked in Cases 1, 2, 4, and 5. Patient 3 sometimes confused facts with fancies in his quest for an ideal dependent relationship. Significantly, all such phantasies had a common themea setting in which the patient basked in an atmosphere of unsolicited, unshared adulation. Their fancied achievements represented the high standards, requirements, and ambitions of their parents. Although such phantasies relieved distress, of which the patient was fully aware, it did not serve to deny reality. 6. Bisexual Identification: The patients placed a high value upon independent and masculine self-reliance. However, in their relations with people they repeatedly found themselves thrust into a feminine role. Patient 1 disclosed both wishes for and fears of an older man's love. Patient 2 had repeated

dreams of feminine orientation. The patient in Case 4 identified with a weak, submissive mother who achieved her status through taking care of the aggressive father. Patient 5 was thrust into a rage when, in the service, he was given "women's work." Patient 6 suffered an ulcer exacerbation when he attempted unsuccessfully to play the protective masculine role to a woman whose life and family situation were similar to his own. The masculine/ feminine conflict was prominent in all patients; moreover, bisexual identification served an adaptive purpose. If they could achieve the feminine role without anxiety and not yield to the pressure of passivity, many of their conflicts with men could be dispelled. They envied the privileged status of self-reliant women, and in many instances were jealous when certain older men in authority turned their attention toward women. Feminine identification led in Cases 1, 4, and 6 to overextension by protecting and offering love to deprived women. Under these circumstances, when it was also possible to assume the masculine role, bisexual interests could be simultaneously fulfilled. In the language of the libido theory, the patients had phantasies of being both phallic-submissive and phallic-aggressive women. 7. Neurotic Symptoms: When the usual ego defenses were unable to cope with the situational stresses, the patients were subject to a variety of secondary symptoms and attitudes. Secondary gain was prominent in Cases 1, 3, 4, and 6. When abdominal pain recurred, Patient 6 discovered that he became less hostile, and more docile and tractable. He preferred ulcer symptoms to his truculent suspicious, isolated existence which forced him to avoid the persons whose devotion and attention he most wanted. Patient 3 was accident prone, and had a prolonged convalescence with each of his many illnesses. Phobic reactions were observed in Cases 1, 3, 4, and 5. Cases 1 and 5 occasionally showed development of conversion symptomsarm paralysis, fainting, and psychic impotence. Patient 3 suffered with acute anxiety attacks almost as frequently as he did with ulcer symptoms. Patients 2 and 4 were often dePSYCHOSOMATIC MEDICINE

WEISMAN pressed. Obsessive compulsive symptoms in the form of ruminations and rituals occurred prominently in Cases i and 4. Impulsive outbursts and antisocial "acting out," as a form of escape and resolution, periodically occurred in Cases 1, 3, 5, and 6. Alcohol and sexual promiscuity were similarly used in Cases 1, 2, 3, 5, and 6, and constituted a major problem in Cases 3 and 6. Only the inhibited Patient 4 avoided these refuges. As in all humanity, the 6 patients could generally be described as inhibited, independent, and impulsive. Some were acutely depressed at times, but never during an ulcer exacerbation. Indeed, the inverse relationship between depression and ulcer symptoms was impressive. Periodic attempts at emotional discharge by means of hyperactivity, alcoholic orgies, or fisticuffs usually occurred in response to enforced passivity, when fear of surrender dissolved their urge for succor and compliance was replaced by combat. Transference In the patient's transference relationship to the doctor the general character of the neurosis was reflected. Thus the transference assumed two general forms. The doctor was regarded as an ideal parent, both mother and father, strong, benevolent, accepting, and replenishing; but he was also viewed as a person who subjugated and coerced, a heartless manipulator of human feelings, a relentless Javert, or even as a murderer before whom the patient was abjectly helpless. The positive attitude was expressed in unrealistic overestimation, as in Case 1, where the patient regarded the doctor at times as a magic healer or omniscient teacher. In Cases 2 and 3 he was considered an ideal father-friend. Patient 4 treated the doctor deferentially, agreeing uncritically with all his statements. The negative attitude predominated in Cases 5 and 6, in which the patients came into therapy fresh from humiliating wartime experiences. Patient 5 was cautious and evasive, while at times Patient 6 was openly paranoid. The positive component of the transference was rarely if ever expressed. Even though most of the patients initially VOL. xviii, NO. t, 1956

37

regarded the therapeutic relationship as a potential fulfillment of their unsatisfied needs and reacted positively, their ambivalence was not difficult to perceive. The defense mechanisms of denial, repression, projection, displacement, and isolation were frequently employed to avoid recognition of the ambivalence. Patient 4 persisted in his docile acquiescence as he had with his father, consistent with his belief that in submission he would find strength. In Cases 1, 2, and 6 the patients were able to dream about their hostility'and fear regarding the therapist. Patient 2 turned away when he realized that the doctor would not exclusively love and care for him, and so began to disparage the therapeutic process on intellectual grounds. Patient 3 became increasingly suspicious, seeking hidden meanings in neutral events, and finally accused the doctor of losing interest in him. Patient 5 succeeded in isolating his transference feelings, seeking merely to impress the therapist with his accomplishments in a bid for favor. The belligerent Patient 6, who early belittled the doctor, subsequently through suspicious distortions disclosed his underlying fear of domination, and finally in dreams revealed his terror of the murderer-doctor. Significant Figures Father: None of the patients had a satisfactory relationship with his father. The father was either absent (Case 3), menacing (Cases 1, 4, and 6) or devaluated (Cases 2 and 5). Yet each one yearned for a close attachment to an older man who would embody strength, benevolence, and vigilant protection. In later life, ineffectual older men were regarded with contempt; men in authority were feared as coercive. Mother: With the exception of Cases 2 and 3, where the mother was absent, the patients universally had weak, compliant, selfsacrificing mothers with whom they felt a close affinity. Most of the mothers has gastrointestinal symptoms, frequently chronic vomiting. When the patient failed to gain complete acceptance by his father, he consoled himself by attempting to be a dutiful son. Failing this, he would feel guilty. He blamed the

38

DUODENAL ULCER EXACERBATIONS gratification of his dearest wishes and realization of his infantile phantasies. In the ulcer patients the ego ideal was inaccessibly high, even in those without remarkable ambitions or talents. Singularly, this made them vulnerable to a feeling of failure, shame, or guilt when actual events forced them to settle for less than their ideal demanded. Patients 1 and 2 needed to be superlative artists; Patient 5 wanted to be an athletic champion. But this represented more than occupational success; it was imperative for their self-esteem. Ulcer patients, tradition asserts, are hyperactive, driven, and ambitious and regard fatigue as surrender and contentment as illusion; the patients who had exaggerated ego ideals were like this. They were manifestly self-sufficient but haunted by the shadow of passive wishes for unearned satisfaction. The reason why such patients always are doomed to a sense of failure is that the basic ambition is not for independent achievement and success, but for the right to be passively loved and admired with a singular, noncompetitive devotion. Patient 1 wanted to be the most eminent actor, Patient 2, the outstanding novelist of his time; Patient 3 cherished the hope of being loved by all women; Patient 4 spun away hours of dreaming of himself in heroic roles, as did Walter Mitty; Patient 5 still yearned to be at least the coach of champion athletes; and Patient 6 wanted to be the strong, self-sufficient man of all men. Independence and ambition in ulcer patients signifies both dissatisfaction with what reality has provided by way of passive satisfactions and a persistent pursuit of that which they must always be denied. Treatment

father for mother's suffering and identified with her as a passive victim. Much of his solicitude for mother's welfare was also determined by the hope of winning her exclusive devotion. Garma's hypothesis of the "poisonous mother" was not confirmed. Patient 3 had a disreputable, indifferent, slovenly mother, but, as noted, he subsequently adopted a more bountiful substitute. Wife: All but Patient 6 were married. In Cases 1, 2, 3, and 5 the patients turned to other women when they felt too drained by the mutual interchange demanded in marital life. Always this represented a symbolic attempt to achieve an ideal, restorative relationship, rather than one primarily sexual. Several patients had ulcer exacerbations in connection with the wife's pregnancy, apparently because it represented a potential threat to their own unique status. Desertion by the wife was feared not only as a loss of love but also as a narcissistic blow. This was true also for Patient 6, who suffered an ulcer relapse when a girl friend rejected him. Significance of Food Case 1 exemplified the symbolic importance of food to the ulcer patient. His symptoms often appeared when he felt there were too many mouths to feed besides his own. At least 4 patients had dreams in which food represented a basic relationship with both men and women. Traumatic conditioning experiences with food were encountered in Case 1 in the form of punishment by starvation and in Case 3 by being forced to eat vomitus. In Cases 4 and 5 the mothers were chronic vomiters. Aside from this, no early feeding history was elicited. Ego Ideal The ego ideal represents the patient's model image of himself in the light of his own expectations and of his superego. The kind of action and thought and the degree of accomplishment which the individual is compelled to follow to avoid a sense of failure is a reflection of his ego ideal. In fulfilling his psychological mission, the patient expects to attain

Inasmuch as the cause of duodenal ulcer is unknown, treatment necessarily consists of management of recurrences. No single, specific factor has been found which accounts either for the frequency or duration of exacerbations of a peptic ulcer or for the length of symptom-free intervals. Anatomical factors alone (the size of the ulcer, its rate of healing or degree of bulbar deformity) fail to account
PSYCHOSOMATIC MEDICINE

WEISMAN for the frequency of remission or predisposition to relapse. Treated cases, however, have fewer recurrences than do untreated ones. Especially well protected are those patients who are able to live on a strict regimen, including both careful eating and living habits. Hospitalization also decreases the incidence of relapses. In the large majority of cases symptoms rapidly abate when bed rest in a hospital is ordered. No data are available regarding the various active emotional factors in operation during the medical management of routine patients with ulcer exacerbations, since psychological investigation is perforce limited. Palmer believes that an important therapeutic factor is the patient's knowledge that he is being scrupulously cared for. Whether or not this exists cannot be ascertained except in the rare individual case. Presumably such awareness will influence the course of convalescence. Therefore it is difficult to compare the results obtained in a clinic patient, who has been routinely given a perfunctory set of instructions, with the private patient whose therapeutic regimen includes careful evaluation and management of the emotional stresses. Medical Regimen The data from this study justify.the following therapeutic conclusions: Enforced rest or hospitalization frequently relieves the conflict between active striving and passive goals. Sometimes, however, if the patient permits himself complete rest, outside pressures (financial worries, family needs, job requirements, etc.) may augment his inner conviction of weakness and symptoms, will persist. If the decision for hospitalization or rest is taken away from the patient, the responsibility for giving in to passive-receptive needs is assumed by the doctor. Less anxiety will develop if the patient's fear of being helpless is also avoided. Thus the emphasis is placed on rest, diet, controlled living arrangements, and so on, but only as benevolently enforced regulations designed to fortify the patient for further independent efforts after hospitalization. The maxim, "once an ulcer patient, always an
VOL. XVIH, NO. i, 1956

39 ulcer patient," is often interpreted as an indication of inherent weakness and permanent restriction. By shifting emphasis, the doctor who enables the patient to realize that proper adherence to certain measures will not deplete or weaken him but, in fact, help him to become even more effective, is operating in accordance with the psychodynamic observations. The accent is thus placed on potential health rather than on chronic vulnerability. This must be attained in an atmosphere of paternal decisiveness. Too strict supervision and uncompromising demands may incite the patient's rebellion or a feeling that too much is being asked of him. Release of Anger The controlled release of restrained anger is also an important aspect of the management of ulcer exacerbations. If the patient is approached too abruptly, the anger may be displaced to the doctor. Frequently, unless the area of resentment is tactfully broached, the patient will completely deny all conflict and present himself as a singularly able and responsible individual, in keeping with his lofty self-image. Moreover, denial by word, act, or phantasy is so common that one may expect ulcer patients to avoid crucial issues in this way and find solutions to problems in daydreams. Ego Enhancement Investigation of emotional factors is often handicapped by the patient's fear of weakness, impaired masculinity, or submission. Some observers16 have noted that the ulcer patient frequently agrees to psychiatric investigation only when convinced that he is helping the doctors, rather than because of his own needs. Thus, during the early interviews only egoenhancing confrontations should be made to the patient. Much attention is given to the patient's actual accomplishments, meager though they might seem. The exhausting conditions under which he has been struggling should be fully recognized. The doctor appreciates the patient's high ideals and his need for self-esteem. By avoiding any implication of "failure" or "breakdown" he indi-

40

DUODENAL ULCER EXACERBATIONS In all 6 patients the nuclear conflict consisted of variations in the passive/active antinomy. Struggle over dependence/independence, however frequent, was regarded as a special case of the larger problem of passivity/ activity. The ulcer recurrence invariably developed in an atmosphere in which the patient vacillated between active seeking and passive yielding. The stress of the conflict could be brought about in three ways: by a lack of fulfillment of passive-receptive wishes, by a transgression of the exaggerated ego ideal, and by fear of passivity itself. The basic affects were restrained resentment, angry guilt, and guilty fear. The patients were afraid of becoming helpless and submissive through a narcissistic injury, by depleting demands, or by loss of a source of strength or support. Ego defenses included compliance and defiance; inhibition and suppression; denial by word, act, or phantasy; avoidance and social isolation; phantasy formation; bisexual identification; and the secondary adaptive measures of various neurotic symptoms. Phobic and obsessional symptoms were frequent, but depression was strikingly absent during the ulcer exacerbations. The transference relationship to the doctor was distinguished by its excessive ambivalence. The therapist represented either an idea], beneficent parent, or a demanding, exploiting, relentless, coercive force. In many respects the transference neurosis reflected the patient's relationship with the significant figures in his life. The ego ideal was excessive in that the patients expected more from themselves than they were capable of fulfilling. It represented the ideal parent in the superego and the wish for complete identification with this parent. Fundamentally the underlying motivation of these patients was for the right to be passively loved and sustained with a unique, noncompetitive, inexhaustible devotion. Ulcer symftoms recurred most often when the threat of depletion exceeded the promise of replenishment and the resulting angry protest was restrained. The ulcer exacerbation was associated with
PSYCHOSOMATIC MEDICINE

cates the likelihood that "any man would probably have had difficulties under similar circumstances." Conduct of Therapy Admonitions are usually given about too vigorous probing of the patient's emotional situation. However, careful, sensitive questions may be successful in tapping into sources of resentment, frustration, and conflict, even in the first interview. In such instances the patient can be encouraged to discuss himself as completely as possible. This is advisable because, even under the most auspicious circumstances, most ulcer patients "rebound" into resistant silence, denial, and avoidance when interviewed a second time. Where the defenses are impenetrable, persistent interrogation may be interpreted as an aggressive act designed to injure the patient and may place the doctor permanently in the role of the coercive, unsympathetic father by arousing the hostile side of the transference. Modification of life patterns, emotional conflicts, and ego defenses is a matter for more or less prolonged psychotherapy. Regulation by fiat is likely to have an impermanent influence, especially in older patients. The results of systematic psychotherapy and psychoanalysis in ulcer patients need further clarification with larger groups of patients before their specific value in maintaining symptom-free intervals can be established.26

Summary
Six male patients with exacerbations of chronic duodenal ulcer have been studied in order to elicit the concomitant psychological factors. The major symptom was essentially similar in all patients: epigastric pain, usually nocturnal, relieved by ingestion of food, but reappearing within several hours. The investigative method included psychoanalysis and psychoanalytic psychotherapy. The formulation of the emotional state at the time of relapse includes both descriptive and psychodynamic observations regarding the nuclear conflict, predominant affects, ego defenses, and transference situation.

WEISMAN no single factor operating alone, but required the integrated presence of the nuclear conflict, basic fear, special ego defenses, and ambiva- 10. lent interpersonal relationships. The meaning of specificity is discussed. 11. The logical requirements for specificity are described in terms of equivalent and conditional forms and a distinction is made between 12. disorder specificity and stress specificity. The specific psychosomatic formulation of the vari- 13. ous categories of psychological factors is regarded as conditional stress specificity because a similar formulation may exist without neces- 14. sarily entailing the development of duodenal ulcer. It is therefore to be differentiated from 15. equivalent stress specificity where a specific psychosomatic formulation may be applied if, and only if, a duodenal ulcer is present. Paral- 16. lel psychological observations in other diseases are necessary in order to determine disorder 17. specificity, which similarly may be either conditional or equivalent. 18. The application of these observations to the management of ulcer recurrences has been 19. discussed.

41 concept in medicine. Bull. ]ohns Hofkins Hosp. 80:71, 1947. DEUTSCH, F. Basic psychoanalytic principles in psychosomatic disorders. Acta Psychotherapeutica 1:102, 1953.
DRAPER, C., and TOURAINE, G. The man-

environment unit and peptic ulcer. Arch. Int. Med. 49:616, 1932. DUNN, W . Gastroduodenal disorders: An important wartime medical problem. War Med. 2:967, 1942. EINHORN, M. The role of psychic load in recurrent attacks of gastroduodenal ulcer. New Eng. ]. Med. 2oS:68i, 1933.
EMERY, E., and MONROE, R. Peptic ulcer:

Nature and treatment based on a study of 1435 cases. Arch. Int. Med. 55:271, 1935. GARMA, A. Internalized mother as harmful food in peptic ulcer patients. Int. ]. Psychoanal. 34:102, 1953.
HALSTED, J., and WEINBERG, H. Pentic ulcer

among soldiers in the Mediterranean Theater of Operations. New Eng. J. Med. 234:313, 1946.
IVY, A. C , GROSSMAN, M. I., and BACHRACH,

W. H. Peptic Ulcer. Philadelphia, Blakiston, 1950. JANKELSON, I. Causes of peptic ulcer recurrences and their prevention. Rev. Gastroenterol. 5:170, 1938. MAHL, G. Anxiety, hydrochloric acid secretion and peptic ulcer etiology. Psychosom. Med. 12:158, 1950.
MARGOLIN, S., ORRINGER, D., KAUFMAN, M.,

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H., STEIN, A., and LEVY, M. Variations in 1. ALEXANDER, F. The influence of psychologic gastric functions during conscious and unconfactors upon gastrointestinal disturbances: Genscious conflict states. Res. Pub. A. Res. Nerv. eral principles, objectives and preliminary re& Ment. Dis. 29:656, 1950. sults. Psychoanal. Quart. 3:501, 1934. 21. MITTLEMANN, B., and W O L F F , H. Emotions 2. ALEXANDER, F. Psychosomatic Medicine. New and gastroduodenal function. Psychosom. Med. York, Norton, 1950, p. 8. 4:5, 1942. 3. ALVAREZ, W . Nervousness, Indigestion and 22. PALMER, W . "Peptic Ulcer." Ch. 22 in Pain. New York, Hoeber, 1943, p. 17. PORTIS, S. (Ed.): Diseases of the Digestive 4. ASSOCIATION FOR RESEARCH IN NERVOUS AND System (ed. 3 ) . Philadelphia, Lea, 1953, p . MENTAL DISEASE. Life Stress and Bodily Dis461. ease (Res. Pub. Vol. 29). Baltimore, Md., 23. RUESCH, J., CHRISTIANSEN, C , DEWEES, S., Williams & Wilkins, 1950. HARRIS, R., JACOBSON, A., and LOEB, M. Duo5. COBB, S. Foundations of Neuropsychiatry. denal Ulcer: Sociapsychological Study of Naval Baltimore, Md., Williams & Wilkins, 1948, p. Enlisted Personnel and Civilians. Berkeley, 99Calif., Univ. California Press, 1948. 6. Cox, T., and JUNNILA, B. Relationship be24. SABBATH, J., and LUCE, R. Psychosis and

tween anxiety neurosis and duodenal ulcer. Calif. & West Med. 64:240, 1946. 7. CHILE, G. "Peptic Ulcer." Ch. 8 in Diseases Peculiar to Civilized Man. New York, Macmillan, 1940, p. 95.
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Physicians Placement
The Council on Medical Service of the American Medical Association has issued a booklet, Physicians Placement. This offers a brief history and description of the services available in locating physicians and in assisting communities to secure their services. Information may be had from Ralph A. Johnson, M.D., Chairman, Committee on Medical and Related Facilities, American Medical Association, 535 North Dearborn Street, Chicago 10, 111.

PSYCHOSOMATIC MEDICINE