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PART Ⅰ GENERAL ASPECTS OF PSYCHOSOMATIC MEDICINE1

CHAPTER Ⅰ PSYCHOSOMATIC MEDICINE3

Psychosomatic Problems in the Practice of Medicine4

The Present Management of Psychosomatic Problems5

The Illness is＂Functional＂5

Suspicion of Physical Disease6

Pathologic Curiosities7

The Organic Tradition in Medicine7

Diagnostic Problems in Psychosomatic Medicine8

The＂Either-Or＂Concept9

Functional and Organic11

The Nature of Emotional Problems12

Psychosomatic Study in Illness12

Organ Language14

Sexual Factors15

Psychotherapy16

What is Psychotherapy？16

Major and Minor Psychotherapy17

Cost of Psychotherapy18

Emotional Illness and Public Health18

Summary19

CHAPTER Ⅱ PERSONALITY DEVELOPMENT AND PSYCHOPATHOLOGY21

Personality Development21

Psychopathology Established Early in Life22

Anxiety22

The Compulsive Personality27

Organ Language28

Sexuality29

Formation of a Phobia32

Other Manifestations of Anxiety32

The Hysterical Personality32

The Normal Personality33

Capacity for Love34

Adolescence35

Psychopathology37

Neurasthenia37

Hysteria38

Obsessional and Compulsion Neurosis41

Mental Elation and Depression (Manic-Depressive Personality)43

Schizophrenia44

Paranoia45

Differential Diagnosis46

Psychopathology of Psychosomatic Disorders47

Physiological Responses to Emotions47

Relation to Illness49

The Adaptation Syndrome50

Organ Neurosis51

Specificity51

Personality Trends52

The Lessons of Military Experience53

Incidence of Psychosomatic Reactions54

The Concept of Maturity56

Summary58

CHAPTER Ⅲ PSYCHOSOMATIC DIAGNOSIS59

The Psychosomatic Point of View60

Postulates for Psychosomatic Diagnosis62

Halliday＇s Six-Point Formula64

Some Background Factors68

Organ Neurosis68

Pseudoheredity70

Emotional Age70

History Taking71

Physician＇s Qualifications71

The Social Worker and Psychosomatic Diagnosis71

Criticism of Clinical Records72

The Person in the Patient74

Chronologic Development of the Life History77

Explaining＂Body Language＂to Patients77

The Case Illustration78

The Autobiography78

The Associative Anamnesis79

Definitive Psychosomatic Diagnosis79

Correlation of Life Situation and Symptom Formation80

The System Review82

The Past Medical History89

Family History97

The Summing Up98

Diagnostic Aids98

Casual Remarks98

The Patient＇s Ideas of the Illness99

Dreams as Diagnostic Aids100

Psychological Testing101

The Forces which Favor Psychotherapy106

Importance of Physical Examination108

Evaluation of the Findings108

CHAPTER Ⅳ TREATMENT－GENERAL PRINCIPLES OF PSYCHOTHERAPY109

Emotional Growth is Painful109

Emphasis on Organic Disease111

The Personality of the Physician111

Preparation for Psychotherapy112

The Physician as Educator113

Presentation of the Problem of Psychosomatic Illness to the Patient114

The Conversion of Emotion114

Discussion of Personality Disorders115

The Severity of the Neuroses115

Transference116

Psychopathic Personality116

Conversion Hysteria117

Neurasthenia118

Looking for Satisfaction119

The Meaning of Symptoms119

Anxiety Hysteria120

Compulsion Neuroses122

What Precipitates a Neurosis？125

Period of Life125

The Single Woman125

The Married Woman126

Relatives126

Career126

Menopause126

Neurosis in Men126

The Subtlety of the Onset of Neurosis127

Manic-Depressive Psychoses127

Depressive Phase127

Differential Diagnosis128

Suicide129

Convulsive Therapy (Shock Therapy)129

Childhood Background129

Personality Structure130

Treatment130

Schizophrenia131

Hypochondriacal Phase132

Treatment132

Psychopathic Personality133

Direct Expression of Hostility134

Surface Friendliness134

Clinical Considerations135

Ascetics and Eccentrics136

Neurotic Characters Who Cannot Stand Success136

Narcissistic Characters136

Alcohol and Drug Addicts136

Neurotic Criminals137

Character Disturbances in Parents137

Transference139

Repetition of Child-Parent Relationship139

Ambivalence140

Dynamic Factors in Psychotherapy141

Case Illustrating Transference141

National Health Problems and Psychosomatic Illness143

＂Fixing＂the Neurosis143

The Orthodox Approach to Psychosomatic Problems143

The Physician as a Pathogenic Agent144

The Cost of Psychotherapy144

The Cost of＂No Psychotherapy＂145

The Role of the General Physician145

General Principles of Management146

The Role of the Social Worker147

The Psychosomatic Concept in Social Case Work147

Cooperation of Physician and Social Worker148

Practical Suggestions149

Social Work as a Career150

CHAPTER Ⅴ TREATMENT－＂NORMAL＂PROBLEMS IN PSYCHOTHERAPY151

Problems of Growth and Adjustment151

Feeding Problems152

The Importance of Nursing152

Treatment153

Thumb Sucking154

Bowel and Bladder Training155

Management155

Enuresis156

Treatment156

Tantrums157

Treatment157

Sexuality of Childhood158

Genital Differences158

Infantile Masturbation159

Nightmares160

Treatment160

Other＂Normal＂Problems of Childhood161

Adolescence161

Masturbation in Adolescence162

Prestige162

Emancipation from Parents163

Struggle with Religious and Ethical Concepts164

Codes for Sexual Behavior164

The Necessity for Cautious Management165

Parents＇ Concern over Adolescents165

Work Adjustment166

Counseling in Industry168

Courtship and Engagement170

Emotional Immaturity170

Marital Adjustments171

Incompatibility172

Hostility in Marriage Relationship172

Marriage for＂Therapeutic＂Reasons173

Education in Marriage174

The Sexual Relationship in Marriage175

Divorce176

Research on Divorce176

Marriage Counseling177

Psychotherapy179

Parenthood180

Emotional Background for Invalidism180

The Father as a Contributor to the Child＇s Emotional Growth181

Education181

Convalescence after Illness or Operation182

Unconscious Wish to Remain Ill182

The Authority of the Physician183

Psychology of Pregnancy and Parturition184

Vomiting of Pregnancy184

Pseudocyesis185

Delivery and Convalescence after Delivery185

Failure in Accomplishment186

Acknowledging Frustration187

Psychosomatic Problems of Aging187

The Role of Chronic Disease188

Old Age and Industry190

Mental Changes in Old Age190

Treatment191

CHAPTER Ⅵ TREATMENT－SPECIAL PSYCHOTHERAPEUTIC PROCEDURES193

Resistance to Treatment193

Suppressive Therapy194

Terrorism194

Placebos194

Rest195

Suggestion and Persuasion196

Hypnosis196

Religious Assurances198

Expressive Therapy198

Psychoanalysis198

Hypnoanalysis205

Transference and the Physician205

Mental Catharsis206

Psychiatric Counsel207

Group Psychotherapy213

Technic214

Group Psychotherapy as a Community Experiment215

CHAPTER Ⅶ TRAINING IN PSYCHOSOMATIC MEDICINE217

Ward Round Instruction217

The Psychosomatic Approach in Teaching219

Further Training in Psychosomatic Medicine224

The Specialist224

The General Physician225

PART Ⅱ．SPECIAL APPLICATIONS TO GENERAL MEDICINE AND THE SPECIALTIES227

CHAPTER Ⅷ THE CARDIOVASCULAR SYSTEM229

Anxiety and the Heart229

Anxiety and the Normal Heart (Cardiac Neurosis)230

Precipitating Factors230

Symptoms231

Treatment240

Practical Suggestions245

Case 1．Cardiac Neurosis246

Case 2．Cardiac Neurosis247

Low Blood Pressure (Hypotension)250

＂Neurocirculatory Asthenia＂250

Incidence in Military Service251

Clinical Picture251

The Development of the Syndrome252

＂Neurocirculatory Asthenia＂in Civil Life252

Differential Diagnosis256

Treatment259

Case 3．Neurocirculatory Asthenia262

Case 4．Neurocirculatory Asthenia265

CHAPTER Ⅸ THE CARDIOVASCULAR SYSTEM－EMOTIONAL FACTORS IN ORGANIC HEART DISEASE273

Importance of Emotional Factor273

Evaluating the Emotional Factor274

Problems of Coronary Occlusion275

Psychosis in Cardiac Disease276

Case 5．Congenital Heart Disease and Anxiety Neurosis277

Case 6．Mitral Stenosis and Anxiety Neurosis281

Case 7．Coronary Occlusion285

Case 8．Coronary Occlusion Preceded by Psychic Trauma288

Case 9．Cardiac Neurosis with Bundle Branch Block291

Case 10．Hypertensive-Arteriosclerotic Disease293

Case 11．Somatic Disease (Gastrointestinal and Cardiovascular)300

CHAPTER Ⅹ THE CARDIOVASCULAR SYSTEM－ESSENTIAL HYPERTENSION303

Importance of Hypertension304

Pathogenesis304

Psyche and Hypertension305

Experimental Observations306

Summary of Pathogenesis307

Clinical Picture309

The Problem in Medical Practice309

Psychosomatic Symptoms310

Treatment313

Psychosomatic Aspects of Treatment314

Personality Studies315

Hostility and Aggression316

Psychosomatic Observations316

On＂Bringing the Blood Pressure Down＂318

Redefining Objectives318

Some Practical Points318

Conclusions320

Case 12．Early Essential Hypertension．Recurrent Attacks of Acute Hypertension with Hypertensive Encephalopathy321

Case 13．Hypertension and Anxiety327

Case 14．Moderately Advanced Hypertensive-Vascular Disease330

Case 15．Advanced Hypertensive-Vascular Disease334

Case 16．Hypertension and Anxiety336

Case 17．Hypertension and Anxiety－Hypertensive Encephalopathy344

Case 18．Hypertension and Anxiety－Spontaneous Subarachnoid Hemorrhage347

CHAPTER Ⅺ THE GASTROINTESTINAL SYSTEM351

Functional Digestive Disturbances351

False Sense of Accuracy351

Organic Treatment352

Organ Language352

Emotional Trends353

Gastric Problems353

Bowel Problems354

Incidence of Functional Disturbances of the Gastrointestinal Tract355

Chronic Dyspepsia356

Psychosomatic Study358

The Approach to a Digestive Problem359

The Clinical Picture of Gastric Dysfunction361

Case 19．Constipation362

Case 20． ＂Nervous Indigestion＂364

Case 21．Syphilis of the Central Nervous System Thought to be＂Nervous Indigestion＂367

Nervous Vomiting369

Case 22．Nervous Vomiting369

Mental Depression with Digestive Symptoms372

Case 23．Two Attacks of Mild Depression with Digestive Symptoms372

Case 24．Castrointestinal Symptoms；Character Problem．Unsuitable for Psychotherapy374

Case 25．Pain Right Lower Quadrant；Extreme Fatigue；Low Fever of Obscure Origin377

CHAPTER Ⅻ THE GASTROINTESTINAL SYSTEM (Continued)383

Chronic Appendicitis383

Chronic Invalidism383

Significance of Acute Attack384

Case 26．＂Chronic Appendicitis＂385

Case 27．The Chronic Gastrointestinal Invalid395

Case 28．Mental Depression402

Case 29．Chronic Dyspepsia407

Case 30．Mucous Colitis (＂Irritable Colon＂)412

Ulcerative Colitis417

Emotional Factors417

Personality Study418

Dependency418

Relation to Psychosis419

Bereavement as Precipitation Factor419

Combined Therapy420

Physical and Emotional Immaturity420

Case 31．Ulcerative Colitis421

CHAPTER ⅩⅢ THE GASTROINTESTINAL SYSTEM (Concluded)424

Cardiospasm424

Prevailing Ideas of Etiology424

Personality Study424

The Specific Psychic Situation425

Psychosomatic Approach425

Case 32．Cardiospasm426

Anorexia Nervosa428

Case 33．Anorexia Nervosa428

Peptic Ulcer433

Prevailing Views433

Theories of Etiology434

Clinical Observations435

Experimental Observations435

Conscious Emotional Factors436

Unconscious Mental Forces in the Etiology of Peptic Ulcer438

Case 34．Duodenal Ulcer440

Case 35．Duodenal Ulcer442

Summary of Case Material445

Conflict over Marriage446

Relation of Psychic Forces of Ulcer Formation446

Principles of Psychotherapy in Ulcer Patients446

CHAPTER ⅩⅣ ENDOCRINE SYSTEM AND METABOLISM449

The Emotional Life and Ovarian Function450

Scientific Psychosomatic Study451

The Menopausal Syndrome453

The Menopause and the Climacteric453

Estrogenic Treatment454

Suggestion from Treatment455

Previous Personality Disturbances456

Need for Further Study456

Case 36．Psychic Factors in the Menopausal Syndrome457

Waiting Too Long for Help459

The Male Climacteric460

All Ill-defined Syndrome460

Need for Psychotherapy462

A Period of Adjustment463

Seeking Quick Cure463

Psychosomatic Observations464

Case 37．The Male Climacteric？465

Preadolescent Hypogonadism465

Puberty467

Case 38．Masturbation Problem in an Adolescent468

Chronic Masturbation470

Nightmares470

Anxiety Develops Early471

Case 39．Anxiety State of Puberty471

CHAPTER ⅩⅤ ENDOCRINE SYSTEM AND METABOLISM (Continued)473

The Relation of Disorders of the Thyroid Gland to the Emotions473

Preceding Emotional Disturbances473

Psychosomatic Observations474

Psychological Invalidism in Thyroidectomized Patients476

Case 40．Hyperthyroidism477

Case 41．Nodular Goiter with Anxiety Symptoms478

Case 42．Nodular Goiter；Thyroidectomy；Neurasthenia486

Case 43．Early Schizophrenia (？)；Anxiety Attacks491

Case 44．Neurotic Invalidism－Neurasthenia Following Childbirth496

Addison＇s Disease and the Adrenal Syndrome505

＂Low Blood Pressure＂505

Chronic Fatigue505

Case 45．Neurasthenia with Somatic Disease506

CHAPTER ⅩⅥ ENDOCRINE SYSTEM AND METABOLISM (Concluded)511

Anorexia Nervosa511

Simmonds＇ Disease511

Differential Features512

Functional Pituitary Depression512

Psychic Traits512

Clinical Findings513

Principles of Treatment513

Case 46．Anorexia Nervosa514

Diabetes Mellitus521

History522

Emotional Factors522

Expereimental Studies523

Personality Studies523

Psychologic Problems in Children528

Psychotherapy529

Case 47．Diabetes Mellitus531

Spontaneous Hypoglycemia (Hyperinsulinism)534

Psychic Manifestations535

Case 48．Diabetes with Anxiety Attacks，Thought to be Hypoglycemia535

Case 49．Functional Hypoglycemia536

Obesity539

Intake of Food539

Personality Studies541

Psychological Aspects of the Treatment of Obesity542

Case 50．Obesity and Reduction Problem545

CHAPTER ⅩⅦ THE GENITO-URINARY SYSTEM AND THE SEXUAL FUNCTION552

Instinctual Forces552

Genital Functioning553

Education in Sexuality553

Frigidity and Impotence554

Thwarted Sexual Development554

Marriage and the Sexual Function554

Psychosomatic Background of Impotence and Frigidity555

Orgastic Pleasure556

Causes of Frigidity and Impotence560

The＂Clumsy Male＂562

Hostility Toward the Partner562

Conflicting Loves (Usually Unconscious)564

Psychosomatic Problems of Frigidity566

The Abuse of Surgery566

Emotions and Menstruation567

Menstrual Taboos568

Anxiety and Superstition568

Childhood Fantasies569

Effect on Children569

Hostility570

Dysmenorrhea570

Clinical Aspects570

A General Problem571

Psychological Study571

Nature of Sexual Fantasies572

Premenstrual Tension572

Case 51．Premenstrual Tension573

Amenorrhea574

Unconscious Influences575

Leukorrhea575

Psychological Factors576

Functional Urinary Disturbances576

A Substitute for Sexual Activity577

Aggressive Component577

Lack of Emotional Control577

CHAPTER ⅩⅧ THE GENITO-URINARY SYSTEM AND THE SEXUAL FUNCTION (Concluded)579

Treatment579

Disturbances of Sexual Functioning579

Eliciting History579

Physician＇s Attitudes580

Contraception581

The Fallacy of Pregnancy as a Cure for Neurosis584

Reeducation584

Psychological Factors in Urological Disorders587

Dysmenorrhea589

Case 52．Dysmenorrhea589

Case 53．Frigidity in a Patient without Deep Conflicts591

Case 54．Frigidity with Severe Neurosis，Demanding Longer Therapy593

Case 55．Impotence595

Case 56．Impotence597

Case 57．Premature Ejaculation600

Case 58．Premature Ejaculation，Needing More Intensive Therapy601

CHAPTER ⅩⅨ THE RESPIRATORY SYSTEM603

The Effect of Emotions on Breathing603

Analogy to Gastrointestinal Tract603

Neurosis and Respiratory Tracings604

Sighing Respirations in Anxiety States605

Physiological Mechanisms606

Functional Respiratory Disorders607

Case 59．Neurotic Dyspnea607

Case 60．Anxiety Attacks；Hyperventilation610

Emotional Factors in Common Colds612

More Complex Psychological Problems613

Anxiety and Depression614

＂Feeding to Cold＂614

Relation to allergy614

Emotional Factors in Pulmonary Tuberculosis615

High Incidence of Neurosis615

Personality Study616

Social Work and Tuberculosis617

Case 61．Tuberculophobia－Healed Tuberculosis618

Case 62．Tuberculophobia－Fatigue and Slight Fever625

CHAPTER ⅩⅩ THE RESPIRATORY SYSTEM (Concluded)627

Bronchial Asthma627

Diagnosis627

Etiology627

Emotional Factors in Bronchial Asthma628

Personality Structure of Children Suffering from Asthma629

The Site of Selection for Organ Neuroses631

Parent-Child Relations632

Further Psychoanalytic Observations632

Summary634

Case 63．Asthma635

Case 64．Bronchial Asthma640

CHAPTER ⅩⅪ THE CENTRAL NERVOUS SYSTEM645

Insomnia645

Insomnia and Anxiety645

Insomnia Not an Isolated Symptom646

Treatment646

Case 65．Insomnia647

Weakness and Faintness649

Significance of the Symptoms649

The Mechanism of Syncope650

Vasodepressor Syncope650

Hysterical Fainting651

Case 66．Hysterical Fainting651

Case 67．Weakness and Fainting652

Headache653

Etiology654

Mechanism of Headache656

Intracranial Pressure657

Arterial Pulsation657

Muscular Contractions657

Character of Pain658

Diagnostic Test658

Case 68．Headache of Emotional Origin661

Migraine663

Clinical Features664

Mechanism664

Personality Features665

Emotional Immaturity665

Relation to Hypertension666

Psychoanalytic Observations666

Rorschach Tests667

Medical Observations667

Case 69．Migraine；Thought to Be Allergic；Good Response to Psychotherapy668

Case 70．Migraine；Childhood Asthma；Psychological Conflict in Regard to Mother670

Epilepsy672

Predisposition673

Treatment673

Marriage in Epilepsy674

Heredity675

Case 71．Epilepsy676

Delirium677

Symptoms678

Electroencephalographic Study678

Treatment678

Organic Brain Disease Simulating Neurosis679

Case 72．Brain Tumor and Functional Symptoms679

Case 73．Organic and Psychic Disease Coexisting685

CHAPTER ⅩⅫ EAR AND EYE688

Psychosomatic Aspects of Ear Disorders688

Vertigo688

Case 74．Vertigo689

Case 75．Vertigo697

Ocular and Visual Disturbances698

Anxiety and the Eyes698

Asthenopia699

Night-blindness699

Miners＇ Nystagmus700

Central Angiospastic Retinopathy700

Glaucoma701

Treatment702

CHAPTER ⅩⅩⅢ SKIN DISORDER AND ALLERGIES704

Psychosomatic Aspects of Skin Disorders704

Attitude of Dermatologists704

Concepts of Multiple Causation704

Neurodermatitis705

Case 76．Neurodermatitis；Good Response to Psychotherapy708

Case 77．Severe Acne－Improvement with Psychotherapy710

Urticaria712

Pruritus712

Pruritus Ani713

Hostility and Skin Disorders713

Necessity for Psychotherapy714

The Relations Between Emotion and Allergy715

The Psychosomatic Point of View716

The Common Cold716

Hay Fever717

Asthma719

Urticaria719

Exhibitionism719

General Theory719

The Child＇s Longing for the Parent720

Personality Trends721

Cooperative Therapy723

Conclusions723

CHAPTER ⅩⅪⅤ DENTISTRY，ARTHRITIS AND ORTHOPEDIC PROBLEMS725

Psychosomatic Aspects of Dentistry725

Dental Problems of Childhood725

Thumb-Sucking726

Relation of Dentistry to Emotional Aspects of Surgery726

Psychologic Preparation for Surgical Operations728

Atypical Neuralgia729

Personality Structure729

Chronic Arthritis731

Focal Infection732

Polypharmacy732

Social Implications of Chronic Arthritis734

Clinical features734

Sociological Factors735

The Social Worker and Arthritis737

Emotional Factors738

Personality Studies738

Rorschach Studies739

Summary740

Osteoarthritis740

Nonarthritic Rheumatism (＂Fibrositis＂)741

Clinical Findings741

Psychological Symptoms741

Psychodynmaics742

Previous Studies742

Orthopedic Problems743

The Low Back Problem744

Intractable Pain Syndromes746

The Accident Habit748

Case 78．A Purposeful Accident749

Case 79．Low Back Problem751

Psychosomatic Aspects of Physical Medicine752

Spas753

Physician Relationships753

Practical Suggestions754

APPENDIX (Orientation Chart for Teaching Psychosomatic Medicine)755

REFERENCES759

SELECTED REFERENCES770

INDEX773