The Psychoanalytic Approach to Psychosomatics and Eating Disorders

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

Book Review

Psychocutaneous Disease
by Caroline S. Koblenzer, M.D.
New York: Grune & Stratton, 1987

The physicianly goal to treat the whole patient is rarely achieved. Although this may soon change dramatically, most physicians still specialize in part of the body, Journals compete for well established "facts" and "new research findings".

Caroline Koblenzer's book Psychocutaneous Disease is a welcome antidote to this narrow, costly medical vision which blankets health care. A Professor of Dermatology at the University of Pennsylvania and a psychoanalyst, Dr. Koblenzer has written a concise practical manual primarily for the dermatology resident and practicing dermatologist. While in need of a neurobiological update (the text was written 8 years ago), this is a volume rich with clinical examples on how to work with a range of troubled patients whose sometimes severe physical symptoms do not respond to physical remedies alone.

In Section 1, General Principles, Dr. Koblenzer reviews the history and classification of psychosomatic disease. Drawing from studies of matemal deprivation and the loss and bereavement literature, she suggests how overwhelmingly painful memories first "perceived" by the skin might reappear later as "physical disease". Hysterical conversion based on repression of an unacceptable idea, somatization, and secondary gain are other partial explanatory hypotheses for such disorders as alopecia areata, atopic dermatitis, and psychogenic purpura.

In a gem of a chapter on general principles of evaluation and treatment, Dr. Koblenzer's clinical wisdom brightly illuminates what might otherwise appear dry and mechanical. With an absence of jargon, she discusses how during history taking, the patient's behavior toward the physician can give useful information about his or her reaction to future care. She demonstrates the value of understanding that a patient's effort to demean or control the physician can be a defense against anxiety. There is also an excellent section helping physicians to recognize and manage their own feelings of anger, guilt, or failure when unable to reach their therapeutic goals.

The larger part of the book, Section 2, describes clinical syndromes grouped according to whether they are known psychiatric conditions manifest in skin disease, conditions where strong psychogenic factors are likely, and conditions whose outcome is often dependent on emotional factors.

In this section, Dr. Koblenzer discusses a number of the most unusual, puzzling, and difficult-to-treat mind-body problems affecting the skin; self-mutilating skin lesions of abused borderline children, Munchausen by proxy, inflictions perpetrated by parents on their children, monosymptomatic delusions of the dysmorphic syndrome, and the obsessive-bug infestation preoccupations in patients with parasitosis. Most of these disorders are given a clear clinical description followed by demographic data, discussions of etiology, pathophysiology, psychopathology, differential diagnosis, laboratory or biopsy findings, management, and prognosis.

The author is at her best when she writes "...we must have the courage to diagnose nondisease..." There are many fine clinical vignettes from Dr. Koblenzer's own practice illustrating how, with attention to timing and the strengths and weaknesses of the particular patient, she will confront them with the possibility that unseen, unfelt, and unspoken issues are contributing to their symptoms. Depending on how the patient reacts to her probing, she will follow up with further treatment recommendations. An example was a lonely, frightened woman with severe skin lesions and repetitive thoughts and behaviors she couldn't control. She had little capacity for psychological understanding and would have felt rejected if Dr. Koblenzer tried to refer her to a psychiatrist. Dr. Koblenzer willingness to listen to her story, help her to better locate her pain, and to offer understanding and comfort seemed exactly what this patient was able to use at the time.

Today's medical residents will have an increasing credibility problem with Dr. Koblenzer's description of the "neurosis" and its subdivisions since our medical/psychiatric colleagues have all but done away with such terminology in current data bases and the DSM IV. In fact a second of the four psychiatric categories Dr. Koblenzer uses, Organic Brain Syndrome, has also been discarded in an effort to reach a more unitary mind/brain classification system. Hopefully, discussions generated by Dr., Koblenzer's astute clinical observations could help refine those psychoanalytic concepts which continue to contribute to the doctor's understanding of the patient.

Dr. Koblenzer's book Psychocutaneous Disease is important and valuable and deserves a wide medical audience. It is a scholarly book about out the people undemeath their skin disease. It also demonstrates how a well trained and sensitive clinician can offer the best in psychological medicine to patients who deserve no less.

John L. Frank, M.D.


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