The Psychoanalytic Approach to Psychosomatics and Eating Disorders

The Newsletter of the Psychosomatic Discussion Group of the American Psychoanalytic Association.

The Psychoanalytic Treatment of Patients with Inflamatory Bowel Disease

Charles C. Hogan, M.D., D.Med.Sc.
(New York)

Psychosomatic medicine is a descriptive term but is not a definition of causality. It implies neither a linear progression nor a temporal succession. It does imply a particular approach to the medical sciences. Medicine is both a demanding discipline and an academic exercise. Academically, the student is interested in accumulations of data and this data is available from two sources: the physical - with its anatomy, physiology, biochemistry, etc, and the subjective, the mind - with it's psychology, emotional conflicts, cognition, etc. These two areas of observation are not interactive, which means one does not cause the other. They are merely two separate sources of data. In the discipline of medicine some of us are interested in the treatment of patients with psychosomatic symptoms - that is, those patients whose physical symptoms obviously respond as correlates of emotional changes during treatment.

These patients almost universally present with pregenital defense pattems which include identifications based on primitive intemalizations of part objects. Such self perceptions in tum lead to primitive splitting, projection, projective identification and fragmentation of thought processes. As we know, these defensive maneuvers make for complex transference and counter transference problems. In bulimia-anorexia, for example, the patient's noisy provocative self destructive behavior can frequently move the physician or therapist to punitive medical actions or retaliatory interpretations. When the psychoanalyst treats inflammatory disease of the colon he can eventually recognize the above pregenital mechanisms, but discovers that they are used to create an obsessional denial that frequently manifests itself as a chronic nonchalance. Unfortunately, this has moved some observers to create a diagnostic category that they have labeled alexithymia. In terms of psychic reality, such massive denial is a defense against overwhelming rage and a sadistic fantasy life, that is in tum a response to painful deprivation, fear and humiliation.

I have noted in my work with these patients the ways in which this rigid denial influences the pre-analytic introduction to treatment. In the preliminary work, educational measures are frequently necessary to allow the patient to become aware of his punitive conscience, his shame and his fear of loss of control. As the patient feels freer to associate one can more clearly recognize the physical mechanisms of colonic activity that accompany the patient's intense unconscious rage and his unconscious fantasies of sadistic activity. As the conflicts become conscious and are resolved, there is a remission in the pathological physical symptoms.

Such processes can be illustrated by an abbreviated and condensed history of a patient with ulcerative colitis who's symptoms had progressed over several years and had resulted in a number of hospitalizations with medical treatments including steroids and antibiotics as well as hyperalimentation in the years before I was first consulted. He came to me as an altemative to a recommended colectomy. As with the usual colitis patient, I had to interest him in his own feelings by demonstrating that the exacerbations in his colitis occurred in conflictual family situations that might conceivably enrage someone else. As some of this was slowly acknowledged I went through the work of illustrating the severity of his conscience. His interest in the process allowed for a partial remission and a postponement of surgery. As a rule of thumb the analyst avoids early interpretations of preconscious aggression or libidinal interests. Early in treatment these patients cannot accept a recognition of such intolerable impulses. As he was able to accept this recognition of his severe conscience and with it an awareness of his subjective self, his reasonable ego could understand that his colonic activity paralleled his fantasy life, and that exacerbations accompanied sadistic rage. In time this man became quite verbal and consciously well aware of a remarkably conflicted emotional life. His early emaciated body regained it's vigor. He quite readily, but erratically, associated to an awareness of his perceptions of humiliation at the hands of a former girl friend, and acknowledged his intense fear of violent impulses towards this individual. The emotional confusion was immense and the patient had carried a weapon ostensibly for his own protection. As the analysis progressed, the associations led to his recognition of how this friend filled the places of intemal representations of various family members.

We do not know the neural pathways, the endocrine and immune activity that conceivably involved the hypothalamic adrenocortical axis, the neurophysiological or chemical end organs at the junction with the colon (the mechanical causal chain of physical events) that paralleled this man's intense subjective conflict. However, I do know that as this patient was able to verbalize the conflicts between his impulses, fears and reasonable ego, along with the accompanying fantasies, profound changes occurred in the progression of physical events. One year after entering treatment a man who had been unable to walk independently was driving himself to sessions. Within fifteen months he was gainfully employed for the first time in years. There was a prolonged remission in his colitis, which after some short exacerbations was followed by A complete remission which continues until today.

Diseases of the gut have been a common coin in literature and myth since the dawn of history The first known medical description of enterocolitis was the contribution of Morgagni in 1769: De Sedibus et Causis Morborum (The Seats and Causes of Disease). The association of abdominal pain and discomfort with episodes of acute emotional distress is as ancient as the awareness of intestinal action. But the scicntific recognition that psychic conflict was an integral accompaniment of inflammatory disease of the bowel began with the investigation of Cecil Murray who published two very important papers in 1930. His examination of a series of cases and his detailed attention to the psychotherapy and psychodynamics of one of those patients are classics in the clinical studies of psychosomatic conditions Other important studies include those of Weinstock (1962) who reported on the results of treatment with psychoanalysis and psychoanalytic psychotherapy in 28 cases of severe ulcerative colitis .

Many of the conclusions in the medical literature are contradictory while simultaneously being absolute and arbitrary. Cloaked in the use of the adjective "scientific" some investigators disavow any observations that do not involve mechanical chains of events confined to the realm of physical sources of data. Another group of authors believes that an attempt at numerical tabulations, however forced, guarantees a study's scientific objectivity. As a common corollary, the interactive arguments about causality (emotional or physical etiology) are a frequent subject of debate in both academic and clinical literature.

I recognize the seeming complications involved in recognizing that thinking is a process that is parallel to accompanying neural activity, or that the subjective experience of anxiety is accompanied by parallel physical tachycardia. The parallel nature of these phenomena, as opposed to one causing another, is an observation of tremendous importance to our understanding of all disease as well as to our understanding of psyche and soma. In my recent book (1995)1 note that Graham (1967) approached this same subject in his paper on linguistic parallelism. I have gone a step further in recognizing the dual parallel sources of data and that an identity of physical and mental processes can be inferred when both sets of data are simultaneous. All of the habitual wishes to separate and place the mind above the brain or the mind beyond the brain in complexity, or related attempts to place the brain in a temporal causal succession with the mind are inherently erroneous and can only lead to confusion. The seemingly parsimonious monism of the interactionist "mind-is- afunction- of- brain" construction is an illusion.

I have spent over thirty years in the psychoanalytic exploration of patients with psychosomatic symptoms and along with a number of colleagues I have observed a number of cases of inflammatory bowel disease that have gone into complete remission, as did the patient discussed above. A substantial number have maintained these remissions over many years. We have been impresscd by the acute development of symptoms during appropriate emotional regressions in the psychoanalysis of the coordinate personality disorders (parallel subjective conflicts). We have noted the remission of symptoms with appropriate psychoanalytic interpretations of subjective conflict in almost all patients in treatment, including those who showed improvement but for one reason or another did not continue their therapy until prolonged remission was possible.

Our years of practice have led us to the firm conclusion that we are dealing with severe life threatening symptomatology that is the parallel accompaniment of a demonstrably clear cut psychological personality disorder. It is apparent that with the successful treatment of the subjective unconscious conflicts we are repeatedly able to obtain reversals in the parallel physical symptomatology.


Graham,D T (1967), Health,disease, and the mind-body problem: Linguistic parallelism. Psychosom.Med., 29:52

Hogan,C (1995), Psychosomatics, Psychoanalysis, and Inflammatory Disease of the Colon. Madison, Ct: Int. University Press.

Morgagni, G. (1769), De Sedibus et Causis Morborum per Anatomen Indagatis Libri Quinque. New York:Hafner, 1960..

Murray, C.D. (1930a) Psychogenic factors in the etiology of colitis and bloody diarrhea. Amer. J. Med. Sci., 180:239

(1930b), A brief psychological analysis of a patient with ulcerative colitis. J. Nerv. & Ment. Dis., 72:617

Weinstock, H.I. (1962), Successful treatment of ulcerative colitis by psychoanalysis. A survey of 28 cases with follow-up. J. Psychosom. Res., 6:243.

Discussion by Marilia Aisenstein (Paris)

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