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Hypnosis in Psychosomatic Medicineby Gérard V. Sunnen, M.D.
The Group for the Advancement of Psychiatry Report, Psychopathological Disorders of Childhood: Theoretical Considerations and a Proposed Classification (1966), refers to these disorders as ones in which there is significant interaction between somatic and psychological components with varying degrees of weighting of each component.
This definition provides a concept of dynamism, of interactional interdependency between body and mind which very correctly identifies a central feature of psychophysiological illnesses.
Certain conditions have long been known to have strong psychogenic influence. This is the case for asthma, whose clinical description was so accurately noted in the time of early Greek physicians. In the 20th century and especially after 1940, a group of illnesses was identified as "psychosomatic" in response to widespread observations that the patient's emotional state had clear repercussions on the manifestations of the disease. In this group were placed conditions such as essential hypertension, asthma, ulcerative colitis, peptic ulcer, atopic dermatitis, and rheumatoid arthritis. Since then, many other conditions have been added to the list (from the APA, DSM-III): acne, allergic reactions, warts, urticaria, tension headaches skin diseases such as neurodermatitis, angina pectoris, coronary heart disease, diabetes mellitus, painful menstruation, obesity, migraine headaches, hyperthyroidism, and hypoglycemia among others.
With our increasing medical and psychological sophistication, however, we realize that more and more, if not all, diseases have some psychological components. Even the common flu, for example, is well known to be more virulent if the patient is depressed or stressed. The field of psychosomatic medicine is especially fascinating because it directly opens theoretical doors to issues concerning the relationship of the body to the mind.
Heinroth first used the word psychosomatic in 1817, applying it to problems of insomnia. Freud (1900) elucidated mechanisms whereby psychic conflicts expressed themselves in disorders of the voluntary nervous system--the conversion reactions. Ferenczi (1910) expanded the concept of conversion hysteria to apply it to the autonomic nervous system. Cannon (1927) showed how different emotions produced patterns of physiological alterations, emphasizing the importance of the autonomic network. Alexander (1934) stated that psychosomatic illnesses were mediated only through the autonomic nervous system--by definition--and that, in contrast to conversion hysteria, did not have specific symbolic meanings; rather, he felt they derived from chronic psychological states connected to unconscious drives in the context of constitutional predisposing factors. Dunbar (1936) suggested specific personality patterns to fit each psychosomatic disease; her approach, although intuitively attractive, did not bear conclusive results. Deutsh (1939) and Greenacre (1949) searched, equally inconclusively, for early putative traumatic experiences. Seyle (1950) described the stress syndrome, emphasizing the importance of hormonal factors. Wolff (1943) stated that physiological changes, if prolonged, could lead to organ damage. Horney (1939) and others postulated the importance of cultural influences. Grinker (1953) and Lipowski (1970) championed the comprehensive, multifactorial approach to psychosomatic disorders, viewing the patient in a holistic biopsychosocial context.
It is in this biopsychosocial concept of psychosomatic illness that hypnosis finds its niche. To the extent that it can influence the mind-body interaction, hypnosis can be utilized for the purpose of teaching the patient general relaxation, somatic and visceral, for working out conflicts and for modifying certain personality dynamics which may have aggravating influences.
Hypnosis has been used in the following psychosomatic conditions with varying degrees of success. It must be appreciated, however, that hypnotic success in this regard has less to do with the types of psychosomatic illnesses present than it does with the particular patient involved.
The activity of the gastrointestinal tract is intimately intertwined with emotional life, past and present. In our language, metaphors abound connecting its functions--ingestion, digestion, indigestion, elimination--with emotional states. "I can't stomach this fellow" or, "he has a lot of guts" are some of the many common expressions which attest to the role of emotions such as anger, sadness, loss, happiness, lust, and courage, among others, in the workings of our digestive systems. In endogenous depressions, there is lack of appetite, decreased salivation, and intestinal peristalsis, constipation, and weight loss. Angry states are sometimes accompanied by aerophagia, and anxious states are often associated with diarrhea. Some individuals under stress show vomiting reactions (psychogenic vomiting).
Alexander (1968) conceptualized upper gastrointestinal disorders as connected, in mental life, to primitive conflicts surrounding the passive incorporative and aggressive biting stages. He also postulated a concomitant constitutional predisposition, as well as neuroendocrine factors, influencing gastric blood flow.
Several clinical conditions have received a lot of attention because of their psychological components. Indeed, when internists treat these disorders, recommendations are often made for adjunctive psychological and/or psychopharmacological treatment.
Peptic ulcer. This is manifested by chronic ulceration of the mucosa in the esophagus, stomach, and duodenum. Ulcers in the duodenum are more convincingly linked to psychological factors. It is said that the basic psychodynamic trend in the hypersecreter-duodenal ulcer group has to do with strong needs to be taken care of, to be nurtured, and to have close body contact. These needs may be compensated with a character armor of independence, self-reliance, and aggressiveness.
The hypnotherapist, in the evaluation of the duodenal ulcer patient, will want to gain an understanding of emotional dynamics as they relate to autonomic discharge. What unconscious emotions are experienced and how are they adapted to? What conditions make them flare up to the extent of actually injuring the gastric mucosa? What experiences--early and recent-contribute to the targeting of the stomach? Hypnotherapy is aimed at the experiential clarification of these issues and on visceral relaxation training. The patient is shown how to recognize putative emotions early on and how to process them more constructively, ie, through assertiveness training. Long-term hypnotherapy goals center on the resolution and maturation of needs and impulses--dependency, anger--and on the achievement of higher levels of personality integration.
Wennerstrand, the Swedish hypnotherapist, reported the healing of duodenal ulcers by the technique of prolonged "sleep" through hypnosis. This method is, of course, impractical in modern life, but it shows how hypnotically induced prolonged rest has antistress effects. Techniques such as autogenic training and meditation have also claimed success in treating this common psychosomatic condition.
Common lower intestinal psychologically influenced disorders include ulcerative colitis, regional ileitis, and the irritable bowel syndrome. The lower intestinal tract has rich connections to psychosexual development. Characterological traits, unconscious emotions, and intestinal symptoms may all be interwoven around issues of control versus lack of control, order versus disorder, giving versus withdrawing, infantile anger and fear of abandonment.
Ulcerative colitis. This is an inflammatory disease of the mucosa marked by remissions and exacerbations, diarrhea, bleeding, and possible complications in the colon and in other organ systems (hepatic, hematopoietic, renal). Investigations of its causes, which are still unknown, are focused on possible genetic, infectious, immunological, and psychosomatic factors.
Personality characteristics of the ulcerative colitis patient, although far from being universal, often sketch a patient who shows extreme sensitivity, low self-esteem, dependency, and conscientiousness.
Psychosocial stressors are well known to exacerbate the illness. Real or fantasized rejection, intense demands for performance--professionally or in a relationship--disapproval or criticism, especially from important figures, all can set the stage for a complex psychovisceral response which results in the engorgement and sloughing of the colonic mucosa.
Psychotherapy provides a context for hypnotherapy in such patients who, if willing, need longer-term explorative intervention. Hypnotherapy borrows from different strategies, from direct suggestion for symptom attenuation or removal, to the discharge of affect and abreaction, to relaxation, and finally to the long-term goal of personality maturation.
Hypnosis can provide some--usually small but nevertheless significant--positive influence on this complex psychosomatic condition which, for proper treatment, needs the combined attention to medical, psychological, and family-social dimensions of the patient's life.
This disorder, first called "nervous atrophy" by Rich Morton in 1689, and given its name by William Gull in 1874, is characterized by weight loss, intense fear of gaining weight, stubborn denial of the illness, peculiar handling of food, disorders of the body image with intense fear of becoming overweight, and often, hyperactivity. Gull recognized the influence of conflicts in anorexia nervosa and recommended that the patient be separated from the family. Theoretical approaches span from the purely psychological--the rejection of pregnancy wish, oral sadistic impulses, fears of sexuality--to purely genetic or biochemical ones, including hypothalamic disorders.
Treatment of anorexia nervosa is biological, nutritional, behavioral, family-oriented, and psychotherapeutic, and includes hypnotherapy. Only with this multi-modal comprehensive intervention can this potentially lethal disorder show positive response. Psychodynamic psychotherapy has not been shown to be effective (Rollins and Blackwell, 1968; Bruch, 1970). Crasileck and Hall (1975) report that more than half of 70 cases treated with hypnosis showed marked improvement. Initially, suggestions for increased food intake were given and once patients began to eat and to show stabilization of their medical condition, explorative and supportive psychotherapy using hypnosis was applied. In many patients with anorexia nervosa, however, there is no overt acknowledgment of the disease and no cooperation or motivation to work hypnotically.
The cardiovascular system has close, immediate responsivity to the manifestations of many emotions. Fright is accompanied by tachycardia, splanchnic vascular constriction, raised blood pressure, and blood engorgement of voluntary muscles. Anger, excitement, chronic anxiety and stress, elation, even love, have a direct bearing on the psychocardiovascular network. Internally generated imagery also has a direct effect on heart action. In hypnosis, where the experience of imagery is apt to be more intensively perceived, individuals may enhance or decrease cardiovascular responsiveness.
Essential hypertension. This is defined as blood pressure levels greater than 160 mm Hg systolic and 95 mm Hg diastolic and accounts for 90% of all hypertensive disorders. It appears at this time that there are likely to be several subtypes of essential hypertension; some hypertensive conditions seem to be more biologically mediated, while others are more dynamically connected to emotional responses.
Personality analyses have not yielded specific congregations of traits or intrapsychic conflicts peculiar to the hypertensive patient. The popular notion that repressed hostility plays a major role has not been experimentally substantiated, but there is ample clinical evidence that anger, guilt and fear, and issues of expressing emotions versus containing them, are operationally important. Hypertensive patients tend to respond with higher and more prolonged blood pressure rises than do normotensives. Stress is also implicated. Cobb and Rose (1973) found a high incidence of hypertension in air-traffic controllers exposed to the pressures of high air-traffic density.
As with other psychosomatic conditions, comprehensive treatment approaches derive from an awareness of the multi-causal nature of essential hypertension. While some cases may simply respond to weight control or salt restriction, others need additional measures such as pharmacotherapy and psychotherapy.
Psychotherapy aims to evaluate and constructively change the environmental impact, family interactions, intrapsychic conflicts, and behaviors which may contribute to this maladaptive response. Since the process of psychotherapy involves the unearthing of affect, care must be taken not to do this too quickly or too intensively before new coping skills are learned. Behavioral methods, including biofeedback, relaxation, meditation, and hypnosis, are increasingly being used for the control of hypertension (Shapiro et al, 1977). When using hypnosis, suggestions may be given for relaxation, calm, a sense of internal peacefulness, and ease of handling such emotions as anger. Imagery exercises may help the patient to visualize aggressive feelings flowing away and out of his system.
The breathing process represents a dynamic interplay between voluntary and involuntary influences, reflecting the involvement of all levels of the neuraxis from the medulla to the cortex. Emotions play directly into the rate, rhythm, and patterns of respiration. Sad or anxious individuals sigh; fear makes breathing shallow; relaxed states are associated with more abdominal breathing.
The most common psychosomatic respiratory illness is asthma. Marked by recurrent bronchial constriction, edema, and excessive secretion, the clinical picture is manifested by recurrent attacks of dyspnea and prolonged expirations with wheezing and coughing. During the attack, the patient usually is tense, anxious, and frightened in the face of experiencing a lack of availability of vital air. Symptoms may be mild and infrequent or severe and life-threatening (status asthmaticus). Several subtypes of bronchial asthma are being investigated. Some tend to be more clearly mediated by specific immunological mechanisms and others by a wide range of irritants.
Psychoanalytic investigations have been enlightening in showing the complexities of psychological factors contributing to asthma. Although no single personality type is singled out, investigators have emphasized the importance of the unconscious fear of the loss of the nurturing mother and have noted the influence of antecedent feeling states of a sexual or hostile nature.
The symptoms in some asthmatic patients are much more responsive to psychological influences than in others. While in some, the exposure to an allergen produces wheezing regardless of mental state, in others, stress or upset is all that is needed to precipitate an attack. The famous case of the glass rose, the sight of which alone brought on asthmatic symptoms, attests to this phenomenon. Although uncontested explanations for the effectiveness of hypnosis in asthma are lacking, clinically and pragmatically, hypnosis has had clear success in this disorder. Many asthmatics suffer from anticipatory fear of the next attack and, while in the throes of an attack, are panic stricken with fears of choking and dying. Hypnosis is helpful in alleviating both anticipatory anxiety and attack panic. It may, at some level, actually increase bronchiolar dilatation and decrease airway resistance (Edwards, 1960). As with other psychosomatic conditions hypnosis, on a longer-term basis, can be applied to the problems of personality integration and family adjustment.
The relationship of emotions to skin health and distress is well known. This clear and, in some patients, very direct pathway from the mind to the skin can be illustrated by the production, through suggestion during the hypnotic trance, of erythema, blisters, and urticaria. The literature also contains numerous studies dealing with the hypnotically induced disappearance of warts. Experimental evidence suggests that skin resistance to noxious stimuli--such as heat or irritants--may be intensified through hypnotic suggestion, or decreased, with greater vulnerability. Besides its applications in the treatment of warts and burns, hypnosis has found usefulness in conditions such as ichthyosis, atopic eczema, contact dermatitis, neurodermatitis, psoriasis, and acne rosea (Scott, 1960).
COMMENTARIES ON TREATMENT OF PSYCHOSOMATIC DISORDERS
We have seen how psychosomatic disorders, in their close connections to the mind-body interface, are determined by a multiplicity of factors. Emotions--most commonly anxiety, depression, sadness, hostility, and guilt--have intimate influence on remissions and exacerbations of these illnesses. Characteristically, however, the complaints of psychosomatic patients remain physical rather than psychiatric.
The comprehensive psychomedical treatment of these disorders recognizes the multifactorial nature, the uniqueness of individual expression, and the necessity for a combined approach to therapy. While in the acute stages of psychosomatic illness, medical treatment is a mainstay, psychotherapeutic measures are important to provide emotional ventilation, reassurance, and support.
In this phase, hypnosis can be applied directly to symptom relief. In the chronic phases or during remissions of the illness, psychotherapeutic interventions assume primary importance, with goals centering on the discovery of feelings, conflicts, needs, mood states, and personality dynamics which, if worked through, can disconnect the somatization process.
Difficulties in psychotherapy have to do with patient resistance on several levels. The hardest part of treatment may be obtaining the acknowledgment from the patient that psychological dimensions need to be attended to. Other difficulties include a tendency to "think somatically," a dependency on secondary gains of symptoms, and in some patients, a possible aggravation of symptoms and dropping out of therapy with the uncovering of affects.
Psychological treatment, while rarely curative, may significantly change the pattern of psychosomatic illness. Diabetics, for example, can be more smoothly stabilized with the acceptance of diet and the regulation of exercise; hypnotic treatment has, in some cases, led to decreased insulin requirements. Hypertensives may similarly need lower doses of medications and asthmatics less steroids or bronchodilators.
Hypnotic influence may be applied, in the context of medical and psychosocial treatment, to anyone or all levels of the psychosomatic continuum--from organ dysfunction to higher personality integration. To general visceral relaxation, we may add the hypnotic effect on specific organ systems. There is ample evidence that the psyche, through pathways tapped into by hypnosis, yoga, autogenic training, and biofeedback, among others, can positively modify the physiological functions of specific organs, ie, the heart, skin, etc. On a different level, hypnosis can be applied to the discovery and healthful expression of subconscious affects which directly and symbolically alter--and destroy--specific organs. Finally, in combination with supportive or insight oriented psychotherapy, hypnosis may help both to accelerate the global maturation process and to transcend the funneling of psychological energies into the soma.
SUGGESTED READING AND REFERENCES
Alexander F, French TM, Pollock GH: Psychosomatic Specificity: Experimental Study and Results. Chicago, University of Chicago Press, 1968. Bruch H: Psychotherapy in primary anorexia nervosa. J Nerv Ment Dis 1970;150:51. Cannon WB: The Wisdom of the Body. New York, WW Norton, 1932. Cobb S, Rose RM: Hypertension, peptic ulcer, and diabetes in air traffic controllers. JAMA 1973;224:489. Crasileck HB, Hall JA: Clinical Hypnosis: Principles and Practice. New York, Grune & Stratton, 1975. Dally P, Gomez J: Anorexia Nervosa. London, Heinemann, 1979. Deutsh F: The Choice of organ in organ neurosis. Int J Psychoanal 1939;20:1. Dunbar F: Emotions and Bodily Changes. New York, Columbia University Press, 1954. Edwards F: Hypnotic treatment of asthma. Br Med J 1960;2:492. Engel G: The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137(5):535. Ferenczi S: Further Contributions to the Theory and Technique of Psychoanalysis. London, Hogarth Press, 1926. Freud S: Fragment of an analysis of a case of hysteria, in Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 7. London, Hogarth Press, 1953, p 40. Greenacre P: Trauma, Growth and Personality. New York, WW Norton, 1953. Grinker R: Psychosomatic Research. New York, WW Norton, 1953. Group for the Advancement of Psychiatry: Psychopathological Disorders in Childhood: Theoretical Considerations and a Proposed Classification. New York, Group for the Advancement of Psychiatry, 1966. Gull W: Anorexia nervosa (apepsia hysterica, anorexia hysteria). Trans Clin Soc London 1874;7:22. Heinroth JC: Lehrbuch der Storungen des Seelenlebens oder der Seelenstorunger under ihrer, in Behandlung, part 2, Leipzig, Vogel, 1818, p 76. Horney K: The Neurotic Personality of Our Time. New York, WW Norton, 1937. Lipowski ZJ: Psychosomatic perspectives. Can Psychiatry Assoc J 1970; 15:515. Morton R: Phthisiologia--or a Treatise of Consumption, ed 2. London, Smith, 1720. Rollins N, Blackwell A: The treatment of anorexia nervosa in children and adolescents: Stage I. J Child Psychol Psychiatry 1968;9:81. Scott MJ: Hypnosis in Skin and Allergic Diseases. Springfield, Ill, Charles C Thomas, 1960. Seyle H: The Physiology and Pathology of Exposure to Stress. Montreal, Acta, 1950. Shapiro AP, Schwartz GE, Ferguson DCE, et al: Behavioral methods in the treatment of hypertension. Ann Intern Med 1977;86:626. Thakur KS: Treatment of anorexia nervosa with hypnotherapy, in Wain HJ (ed): Clinical Hypnosis in Medicine. Miami, Symposia Specialists, 1980, p 147. Wolff S, Wolff HG: Human Gastric Function. New York, Oxford University Press, 1943.
Gérard V. Sunnen M.D. 200 East 33rd St. New York, NY 10016 212/679-0679 (voice) 212-679-8008 (fax)