A study of parent-child relationships in patients with peptic ulcer and bronchial asthma as revealed by projective techniques

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A STUDY OF PARENT-CHILD RELATIONSHIPS IN PATIENTS WITH PEPTIC ULCER AND BRONCHIAL ASTHMA AS REVEALED BY PROJECTIVE TECHNIQUES

A Dissertation Presented to the Faculty of the Department of Psychology The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

by Gideon Barto Stone II June 1950

UMI Number: DP30398

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This dissertation} written by Gixieon-Bar.tx3..3.tQnfi..II................

under the guidance of hi-S—~ Faculty Committee on Studies, and approved by all its members, has been presented to and accepted by the Council

,

on Graduate Study and Research in partial fu l­ fillment of requirements for the degree of D O C T O R OF P H IL O S O P H Y ...

Committee on Studies

ACKNOWLEDGMENTS

I wish to express my gratitude to the many individuals who have been both helpful and essential in the preparation of this study. Foremost are Dr, S. M. Wesley who served as a stimulating consultant throughout the research and subsequent preparation of the paper; and Dr, G. H, Seward, who gave many helpful suggestions in planning the methodology of the experi­ ment, and in reading the manuscript, I wish to thank Dr, R. S. Tolman, Dr, F. J, Kirkner and DR, H.S. Grayson, for making available the facilities of the Veterans Administration general hospitals, and for their aid in making the collection of the data possible. Finally, I wish to acknowledge my in­ debtedness to Dr, A, S, Friedman, Dr, P. A, Goodwin and Dr. S. D. Prince, the other members of the group research project of which this study has been one part. G. B. Stone

TABLE OF CONTENTS CHAPTER I.

PAGE

THE PROBLEM AND DEFINITIONS OF TERMS USED . . .

1

The problem • • • • • • • • • • • • • • • • •

2

Statement of the problem

• • • • • • • • •

2

Importance of the study • • • • • • • • • •

3

Definitions of terms used . . • • • • • • • •

4

Parent-child relationships

• • • • • • • •

4

• • • • • • • • • • • • •

5

• • • • • • • • • • • • • • •

5

Bronchial asthma Peptic ulcer Psychosomatic II.

REVIEW OF THE LITERATURE

5 . .

..............

7

General considerations in psychosomatic research

• • • • • • • • • • • • • • . • •

Social and Cultural considerations

• • • •

7 20

Evidence of Cultural influence in Psychosomatic disorders • • • • • • • • * Studies on Bronchial Asthma ................ Psychoanalytic studies

................

Psychiatric studies Psychometric studies Summary

32 32 35

• • • • • • • • • • •

................................

Studies on Peptic Ulcer • • • • • • • • • • • Psychoanalytic studies

27

40 43 44

• • • • • • • • • •

46

Psychiatric studies • • • • • • • • • • • •

52

iii CHAPTER

PAGE Psychometric studies ......................

63

Two ulcer personality types

..............

68

S u m m a r y ..................................

70

Summary of studies with regard to parentchild relationships

..........

. . . . . .

72

Findings regarding asthma patients ........

72

........

74

. . . . .

78

Findings regarding ulcer patients Hypotheses . . . . . . . III.

MATERIALS

AND

PROCEDURE........................

M a t e r i a l s ................................. The Rorschach Test

82 83

........... • • • • •

85

The Thematic Apperception T e s t ............

86

The Psychosomatic Sentence Completion Test •

90

The Psychosomatic Biographical Data Form • •

93

The Otis Self-Administering Test of Mental Ab i l i t y .......................... Procedures

.........

• • • • •

94 95

S u m m a r y ...................................... 100 IV.

SUBJECTS

...........................

. . . . .

101

. . . . .

101

.........................

105

Selection of subjects

. ..........

General characteristics of the sample population

S u m m a r y ...................................... 109

iv CHAPTER V.

VI.

PAGE

THE CLASSIFICATION OF THE ULCER CASES INTO W O G R O U P S ............................

110

Criteria used for classification of cases . •

113

RESU L T S ..................................... Statistical treatment of the d a t a

125 *

126

Biographical data sheet ....................

135

Socio-economic status ....................

137

Childhood training

141

• • • . • • • • • • . .

Attitudes tOYrard p a r e n t s ................ Psychosomatic Sentence Completion Test

152

...

161

Relationship with the f a t h e r ............

163

Attitude toward male authority figures

167

Relationship with the mother

. .

• • • • • • •

169

Attitude toward females in general

• ••

•

176

Attitude toward childhood and home

. ;.

*

I83

Thematic Apperception Test

............

186

Relationship with the father and male authority figures ......................

188

Relationship v/ith the mother and females in g e n e r a l ............................ Rorschach T e s t ........................... Human figure responses to card III

• ••

Specifications to female figure in card VII

208 241

•

242 246

V

CHAPTER

PAGE Additional data on identification............ 249

VII.

INTERPRETATION OF RESU L T S........................ 256 Results related to hypotheses.................. 256 Hypothesis 1 ' .............

256

Hypothesis 2

................................ 260

Hypothesis 3

................................ 261

Hypothesis 4

...............

Hypothesis 5

................................ 266

264

Hypothesis 6

. . . . .

270

Hypothesis 7

................................ 272

Hypothesis 8

* ............................277

Hypothesis 9

.................

279

Hypothesis 1 0 ................................ 282 Additional findings .......................... Childhood training Dependency

...................... ♦

• • • • • • • • • • •

Goals and social v a l u e s VIII.

.......... . .

286 287 290 292

SUMMARY AND CONCLUSIONS.......................... 296 Statement of the-problem Subjects

.......

. . . . .............

Materials and procedure

296 293

................ 299

Conclusions ....................

. . . . . . .

301

Additional findings

............

304*

vi CHAPTER

PAGE

BIBLIOGRAPHY .......................................

306

APPENDIX A .........................................

316.

LIST OF TABLES TABLE I.

PAGE Age, I. Q., and Years of Education of the Two Psychosomatic Groups

II*

Educational Level of Ulcer and Asthma Patients

III.

............

• • • • • • • • . •

108

Number of Cases of Agreement of Each Griterion Item Criterion

IV.

106

with the combined ...........

122

Chance Probability of Significant Differ­ ences and Obtained Number of Differences Between Asthma and Ulcer Groups

V.

Sentence Completion Test:

. * . . * •

Attitudes to

F e m a l e s ............................. VI.

Sentence Completion Test: Females

VII.

Thematic Apperception Test:

179

Analysis of

Father-Son Relationships in Card 7BM . . . . VIII.

177

Attitudes to

. • • • • • • • • • • • • • • • • •

Thematic Apperception Test:

129

191

Analysis of

Relationships with Male Authority Figures in Card 1 2 M ......... • • • • • • • • • • • IX.

Thematic Apperception Test:

199

Analysis of

Relationships with Male Authority Figures in Card 8BM

. . . .

......................

20?

viii TABLE X.

PAGE ThematicApperception Test:

Analysis of

Mother-Son Relationships in Card 6BM • XI.

ThematicApperception Test:

• • • • 211

Analysis of

Parent-Child Relationships in Card I . . . . XII.

ThematicApperception Test:

ThematicApperception Test:

218

Analysis of

Parent-Child Relationships in Card II XIII.

.

. . . . 225

Analysis of

Relationships with Females in General .

in Card 4 M F ........................... XIV.

ThematicApperception Test:

231

Analysis of

Relationships with Females in General in Card 13M F ............... XV.

236

Numbers of Homosexual Signs given by the Asthma Group and the "A” and f,P,f Ulcer Groups to each of Five Rorschach Cards

. . . . 250

CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED During the last ten or fifteen years there has been a new viewpoint developed in medicine.

It has been called by

the various names of medical psychology, medical anthropology, social-psychological medicine and psychosomatic medicine. These terms have delineated a rather broad field in which the main consideration is that of viewing the sick individual as an organic unity in a social environment, rather than as composed of a dichotomy of factors of body and mind.

During

these years a great deal of literature has been written concerning this subject and some serious research has been accomplished.

Most of this work has been medical, psychiatric,

and clinical observation, but few studies have used psycho­ logical techniques* In some cases a full psychiatric history was obtained, or a brief psychoanalysis was done, but just as often the conclusions* have been incidental results of medical investi­ gations or treatment of cases, or casual observations by clinicians.

These approaches for evaluating the psychological

and emotional factors in psychosomatic disorders do not succeed sufficiently in objectifying and quantifying the data, as their methods lack adequate control and standardization. Studies using psychological test procedures have advantages in methodology over psychiatric studies in their comparatively

2. greater uniformity of administration and scoring, greater objectivity in the interpretation of the material, and more adequate quantified normative data* The present study is one part of a joint psychological research conducted at the Birmingham and Wadsworth General Hospitals of the Veterans Administration in the Los Angeles Area*

The over-all project involves a comparative investi­

gation of the psychological, emotional, and social factors in two psychosomatic disorders:

bronchial asthma and peptic

ulcer* I. THE PROBLEM Statement of the problem*

This paper is concerned

specifically with the comparison of the parent-child relation­ ships in bronchial asthma and peptic ulcer patients*

Current

theories regarding these psychosomatic illnesses stress the importance of the parent-child relationships as a factor in the determination of the specific type of psychosomatic breakdown.

If the peptic ulcer and bronchial asthma; attack

are conceived as the end product of a pathological process, it seems logical to assume that personality problems may have some etiological association with this process*

The j

development of personality problems must necessarily be considered in conjunction with the genetic childhood events, which contributed toward the character formation of the adult*

3 The relationship to parents is of primary importance in understanding these childhood events. The fundamental purpose, of the present study is to test the various specific hypotheses which have been advanced in the literature concerning parent-child relationships in the two psychosomatic disorders, bronchial asthma and peptic ulcers. A second main purpose of this study is to test the hypotheses which have been advanced in the literature concerning the parent-child relationships in the two types of peptic ulcer cases, that is, the aggressive type, or self-frustrating individual and the overtly passive type, or environmentally frustrated individual. Importance of the study.

The great prevalence of both

peptic ulcer and bronchial asthma indicate the need and importance of additional research and study concerning these disorders.

Cook(19) reports the incidence of bronchial

asthma to be approximately 1 per cent of the total population. This frequency makes asthma the fourth most common chronic disease.

The incidence of peptic ulcer for the total

population is unknown, although Cecil(l8) estimate that nearly 10 per cent of all individuals suffer at some time in their lives from peptic ulcers. statistics.

This estimate is based on autopsy

Both British and American authorities reported

4 that gastric disorders were the single most important medical problem of World War II. Despite the high incidence of these diseases and the great amount of study and discussion, there is still little that is definitely known concerning their etiology.

Gay(40)

has made the statement that: It may seem surprising that a common complaint such as asthma, known for ages, should in this day and generation still be shrouded in confusion and mystery. With regard to peptic ulcer, Alstead(7) has stated: Considering the frequent occurrence of peptic ulcer the question of its etiology constitutes one of the most vital problems in Medicine5 at the same time it is, unfortunately, still one of the most obscure ones, in spite of numerous investigations from different angles, both of a clinical and an experimental nature. II. DEFINITIONS OF TERMS USED Parent-child relationships. Warren*s Dictionary of Psychology(108) defines parent-child relations as ”social behavior between parent and child.M

This term is not used

in this study in the absolute sense of the behaviorial inter­ action which took place between the subjects of the study when they were children and their parents.

Since these were

adult subjects, many of whom at the time of this study lived in different parts of the country from their parents, or whose parents were already deceased, very little objective data concerning the behavioral interaction were available.

Thus, the term is used here to refer to the feelings or attitudes, that the subjects expressed on the projective techniques used, concerning their parent-child relationships* Bronchial asthma* Bronchial asthma is defined by Dorland*s Medical Dictionary(25) as:

”. * • a recurring

paroxysmal dyspnea, particularly evident in the expiratory phase, due to an allergic reaction in the bronchiles from the absorption of some substance to which the patient is hypersensitive*”

As Fine(33) points out:11. • • the above

is an hypothesis rather than a definition.

There is no

doubt of the allergic nature of most cases, but that all asthma is allergy is questioned by some authorities*”

As

is customary, the terms “bronchial asthma” and “asthma” will be used interchangeably in this study. Pentic ulcer*

Cecil(l8) defines peptic ulcer as:

”A sharply circumscribed loss of tissue resulting from the digestive action of acid gastric juice occurring on the stomach or duodenum.”

The terms “peptic ulcer” and “ulcer”

are used synonymously in this paper. Psychosomatic *

This term is used here primarily to

refer to a group of diseases which are considered to be either caused, predisposed, or aggravated, by psychological factors.

It is also used on occasion in a more general

sense to refer to a point of view concerning the relationship between mental and bodily processes* relative

A discussion of the

importance which psyche and soma have in such

disorders is not within the province of this paper*

CHAPTER IX REVIEW OF THE LITERATURE This chapter will present a review of the literature which is pertinent to this study.

It will include a discuss­

ion of general theoretical considerations in the field of psychosomatic medicine as well as a review of the findings of specific studies that have been made on groups of asthma cases and ulcer cases.

Since a comparison of these two

particular psychosomatic groups, using the same test instru­ ments to study each group, has not been made before, it will be necessary to present pertinent studies which have been concerned with either one or the other of the illnesses. These studies will be grouped, according to the methodology, into three types:

psychoanalytic, psychiatric, and psycho­

logical studies using projective techniques.

A summary and

evaluation statement will be made regarding the conclusions of the studies for each type of methodological approach. The chapter will be organized into five sections: 1.

General considerations of psychosomatic research, 2.

Studies on bronchial asthma, 3* 4.

Studies on peptic ulcer,

Summary of studies with regard to parent-child relation­

ships, I.

Hypotheses. GENERAL CONSIDERATIONS IN PSYCHOSOMATIC RESEARCH The term "psychosomatic*1 is being widely used to

apply to those types of r,bodily disorders whose nature can

8 be appreciated only when emotional disturbances (i.e., psycho­ logical happenings) are investigated in addition to physical disturbances (somatic happenings).11 Halliday(45), who in England has done the most comprehensive study of psychosomatic diseased to date, using a sociological as well as medical and psychological approach, has developed a general sevenpoint formula for the purpose of elaborating the concept of a psychosomatic affection.

He maintains that the great

variety of psychosomatic disorders, while apparently unrelated to each other, have the following seven characteristics in commons

1.

Emotion as a precipitating factor,

particular personality type, ratio, 5.

4.

3.

7«

A

A disproportionate sex

Associations with other psychosomatic affections,

A family history of the affection,

ation,

2.

6.

Phasic manifest­

The prevalence is related to change in the

communal environment considered psychologically and socially. Point number two, setting forth that a particular type of personality tends to be associated with each particular affection, is the most central point for consideration in connection with the present study, as well as being a most important controversial question in the whole psychosomatic field.

Subjects with psychosomatic disorders are being

studied with regard to the type of personality structure they have, the kinds of mechanisms of ego-defense they use, the kinds of external personality traits and behavior they exhibit,

9 the kinds of needs they express, and the kinds of emotional conflicts that are at the basis and core of their maladjust­ ment •

The personality types that Halliday describes appear

to be more in terms of external personality traits and symptoms, with patterns of behavior, rather than with the unconscious needs and conflicts in terms of which the theories of some of the psychoanalysts have been formulated.

He places

a very special emphasis on obsessional personality trends. It is to be noted, however, that he uses the term "obsessional trends" to cover such a broad category of personality traits and behaviors, that it is indeed not surprising to find that most individuals with psychosomatic affections also have obsessional trends. Dr.

Henry Brosin(13), in a critical review of

Halliday*s book expresses what probably has been until recently the predominant American opinions It is the nature of the underlying conflicts which are crucial in determining the form of the disorder . . . rather than the personality type, because the latter may not have a distinctive identity. . . . Persons with hysterical or obsessional characters may have widely different disorders . . . Hot all obsessionals have arthritis, even though Halliday finds that most arthritics are obsessional • • • The value of a personality profile as an independent criterion (No. 2 of Halliday1s seven-point formula) becomes severely diminished because it is too general. The idea of unconscious conflicts fits in better with the phasic nature of psychosomatic disorders; perhaps also

10 with the fact that an individual may have more than one disorder, such as peptic ulcer with hypertension. The most typical form of the basic explanation of how psychosomatic disorders develop derives from a rationalization of psychoanalytic theories regarding repressed conflicts with physiological research.

This rationalization is stated,

in essence, as the official view of the U. S. Army and Veterans Administration, by Gen. William C. Menninger: The anxiety is relieved in such reactions by channel­ ing the originating impulses through the autonomic nervous system into visceral organ symptoms and complaints. These reactions represent the visceral expression of the anxiety which is thereby largely prevented from being conscious. The symptom is due to a chronic and exagger­ ated state of the normal physiology of the emotion, with the feeling or subjective part repressed. Long continued visceral dysfunction may eventuate in structural changes.(66) Cushing(21) established, by physiological evidence on man, the neurogenic basis of peptic ulcer of the duodenum. He showed that hypermotility, hypersecretion, and hypertonicity of the stomach, particularly the pyloric segment, (which are the effects commonly associated with peptic ulcer) can be experimentally produced in man by neural stimulation at the cerebellum. Alexanders psychoanalytic theory for gastric disorders, based on the work of a group of investigators at the Chicago Institute for Psychoanalysis,(l) is the only detailed attempt to link personality with physiological and pathological factors, and has provided considerable psychological insight into the

11 role or emotional factors.

It is based on the concept that

hunger for affection and hunger for food are phenomena that are linked in time and space, and that the former then gradually brings about the same kind of physiological response as the latter.

He developed the idea that permanent psychic

stimuli from unconscious mental sources may be capable of stimulating the subcortical centers similarly to the direct irritations observed by Cushing and others. None of the etiological theories in the medical field, except possibly that advanced by Ruesch(93)* seem to deny that a constitutional or systemic factor is probably funda­ mentally essential.

Thus, while many individuals in our society

suffer from the same type of core emotional conflict, some will have tissue changes resulting in an ulcer, for example, and others will not.

Thus the particular conflict is one of

a number of causes, and an organic constitutional predisposi­ tion is assumed to be another one.

This is in accordance

with the principle of "multiplicity of causes," Even Alexander, who has contributed most to developing the detail of the psychogenic psychoanalytic theory of ulcer, points out that he does not consider that the phenomena of a duodenal ulcer is a purely psychological one, but that an additional constitutional factor is essential.

He stated

that the ulcer itself, the tissue change, does not represent

12 or symbolize anything psychological whatever.

The changes in

gastric secretion and in the motor activity in the stomach may be considered to be the direct effect of, if not the symbolic representation of psychological factors.

The nicer

formation is an incidental bi-product. Alexander further distinguished the ‘‘vegetative neuroses11 from hysterical conversions.

Unlike the hysterical

conversion, the vegetative neurosis is not an attempt to express symbolically (through an organ or by motor or sensory behavior) a repressed unbearable emotion or idea, but is the physiological accompaniment of constant or periodically recurring emotional states - a kind of overflow - resulting in a sustained innervation in the autonomic nervous system. The peptic ulcer is neither one of these; it is a secondary physiological end-effect of a long standing dysfunction due to the vegetative neurosis*

When the gastric neurotic breaks

down under an excessive load of responsibility, it is claim­ ed, he recoils from his habitual reactivity and assumes the vegetative mood of the state that accompanies digestion, to which his alimentary tract reacts with a continuous hyper­ activity.

This recoiling from exaggerated outward activity

and strain Alexander calls “vegetative retreat.11 It is a “counter-coup11 phenomenon, a kind of exhaustion following sustained effort.

13 Ruesch questions the necessity of assuming a consti­ tutional factor on the basis of data gathered from various cultures*

His is the group or societal approach rather than

a focusing on the individual in the manner of Alexander and most other psychoanalysts* He contends that the theory of cultural influences determining the differences in the racial incidence of ulcer is just as plausible as the genetic hypothesis, and that it is premature to decide which is the more correct theory. DISAGREEMENTS WITH ALEXANDER'S THEORY OF UNCONSCIOUS NEED AND CONFLICT Grinker(42) proposes four fundamental propositions to represent the various theoretical conceptions that have been advanced to explain the psychogenesis of these disorders: 1* An inexpressible specific unconscious need or feeling is etiologically concerned in the development of a specific visceral syndrome, i. e., peptic ulcer or asthma* 2. The total personality expressed by external and conscious attitudes is specific for a visceral syndrome since it consists of characteristic reaction formations and compensations which are complex derivatives of the opposing psychological forces which prevent a specific need or feeling from becoming conscious* 3* The visceral dysfunction does not represent the central conflict but is the exaggeration in quantity and time of the normal visceral concomitant of the specific emotion not capable of expression through the highest levels of the neuraxis and hence is not exteriorized in thought, speech or behavior* 4.

The long-standing visceral dysfunction eventuates

14 in permanent irreversible morphological change in the implicated organ or system. He contends that theories developed from study of chronic psychosomatic syndromes in civilian life are not clearly confirmed when tested by experience with acute psycho­ somatic syndromes of military life. In the acute disorder, the symptoms do not appear to be caused by a single inexpressible feeling or need, or to represent a particular conflict, but rather appear as the secondary result of a breakdown in the normal channels of emotional expression.

Acute symptoms also do not appear to

be correlated with any specific quality in the external personality profile or the internal psychological preparation. He found mixed unconscious emotions of fear, rage, and dependent crying, rather than such repressed needs as hunger for dependent love or restitution, underlying symptoms of gastro-intestinal distress.

When these mixed emotions, which

were felt toward the Army authorities or toward the enemy were uncovered in brief therapy the symptoms usually disappear­ ed. All of Grinker's foregoing contentions and those of other psychiatric investigators are in apparent disagreement with the most widely influential theory of Alexander and other psychoanalysts, of the etiological significance of the specific need and conflict.

Further than this, Grinkerfs

15 contention of no correlation with specific external person­ ality traits or internal psychological preparatory attitudes would seem to mean a prediction of no significant differences between ulcer and asthma cases in the psychological tests used in the present study* Grinker reports that the symptoms appeared in most cases not to be expressive of a specific conflict but to be secondary regressive results of the increased stress of the situation and the severity of the external super-ego imposed by the Army.

The increased stress increases the emotions of

fear and rage and the rigid authoritative set-up minimizes the possibility of their expression in speech and behavior* Hence the regression and the symptoms* Both Grinker(42) and Harris(46) report that their military subjects were not purely cases of repressed emotional attitudes, but that most men had conscious anxiety, fear, rage, or need for love, which they felt, thought and openly verbal­ ized as well as expressed viscerally*

Grinker says "this

could have been due to a quantitative overflow * . . because of the severity of the stress*11 Harris in a psychiatric interview study, in a military hospital, of 50 soldiers with gastric complaints, found predominantly expressions of anger consciously and freely expressed (this was especially true of those cases who developed their symptoms only after being in

16 military service); also, the gastric symptoms of pain, nausea, and vomiting seemed to he saying, symbolically, in angers ,!I fm fed up.”

”You can't cram that down my throat.”

"I'm

fed up with the Army*” - - - "This reaction is reminiscent of the feeding problems observed in children who, by means of their stomachs, protest against pressure from their dominating mothers.” Saul(98) criticizes Harris's(46) conclusions as being superficial.

He says that the feeling of hostility may be

conscious, but its connection to its basic source in the personality is not conscious*

The patient is also not

conscious of its connection to his symptoms, or to his inter­ personal relations, and not aware of the intensity and depth of his hostility. Most of the evidence from recent physiological research sustains the opinion that it is difficult to trace a specific symptom, or the pathological physiology that is its forerunner, to a specific emotional reaction.

The

complicated physiological picture emerging is in line with Grinker's(42) assertions that a combination of various emotions underlies each symptom.

The studies of Wolf and

Wolff(109) on a patient with a gastric fistula showed that at least two emotions, anxiety and hostility, were involved in the production of hypermotility and hyperemia, the physio­

17 logical causes of peptic ulcer.

Szasz(104) further demonstra­

ted, physiologically, that the effect of fear was inhibiting to gastric secretion, and had the opposite effect of rage or hostility, which stimulated hypersecretion.

This suggests

a possible pathological dissociation of normal gastric function under the simultaneous effect of these two emotions. Ruesch(94) has made a well documented and definitive statement challenging the concept that the symptom expresses a specific unconscious need and conflict.

He describes tfthe

infantile personality” as being the core problem of psycho­ somatic medicine. leaves off.

Ruesch appears to take up where Grinker

While he, like Grinker, describes the symptoms

as being the result of the inability of the individual to express his emotions by thought, speech, and behavior in mature interpersonal relationships, he goes further and challenges that the process of regression is a necessary pre­ condition to psychosomatic illness.

Heretofore, the psycho­

somatic conditions have been explained psychoanalytically to be, like the symptoms of the typical psychoneurosis, the re­ sults of regression from a conflicting situation,

llexander(l)

had clearly stated: We found in our cases of peptic ulcer and gastric neurosis a strong regression to the infantile attitude of oral receptiveness and aggressiveness . . . Our studies have not yet been able to establish any constant background regarding the origin of the strong regression

18 . . . other than the usual conflicts in the field of genital sexuality, conflicts based on guilt feelings, in men centering around castration fear. The evidence for a regression was perhaps derived less from observation, even during a complete psychoanalysis, than from the preconceptions of theory. Rueseh(94) makes much of the distinction that the psychoneuroses are, structurally, primarily cases of patho­ logical development, and that the psychosomatic conditions are, structurally, primarily cases of arrested development: Some of these infantile patients, for example, have persisted since childhood in expressing themselves in somatic terms, though visible pathology developed only after certain habits persisted for a number of years. In these cases it would be erroneous to apply terms such as regression and conversion, when in reality a lack of progression has existed, to which attention is called when physical pathology is discovered. Though the concept of conversion was separated from the concept of vegetative neuroses, the attempts at correlating specific conflict situations with specific syndromes implied the use of the concepts of conversion and regression. At closer examination of these reports, however, one is struck by the importance which various authors attribute to features such as dependence, low frustration tolerance, vegetative or autonomic mani­ festations, specific and stereotype somatic reactions to various types of frustration, and poor or one-sided manipulative ability of these patients. All features mentioned are characteristic of immature personalities and tend to corroborate the author1s own conclusion. This emphasis on the factor of arrested development is an important contribution, but it does not deny that there is regression as well as "lack of progression” (immaturity) in psychosomatic cases.

It is not a question of one or the

19 other, but how much of each and how each affects the develop­ ment of the personality. The infantile pattern of dependent imitation of authority model- figures persists into the adult life of the psychosomatic individual.

He cannot proceed on his own as

he has no identity of his own, and can only live in close symbiosis with other persons.

The use of imitation is

probably part of the explanation for the superficial similarity that these individuals have with hysteric neurotics. Their excessive dependency requires control of their hostility and results in an underlying hostile form of identification with the parent figures of social authority. The relationship between the expressions of hostility and dependency beoomes a consideration of very central importance in psychosomatic conditions.

The methods of

handling his aggression and hostility by an individual have a direct relationship to how he manages his dependency conflict, because if he needs a continued flow of affection and support, he cannot afford to express his anger against his source of dependence. The present writer feels that a socially oriented formulation which considered the interrelationships of the factors of dependency, hostility, anxiety, and conformity is a most illuminating approach to the understanding of

psychosomatic disorders:

Dependency leads through the child­

hood socialization process to conformity with the cultural frame of behavior•

Conformity required the suppression of

aggression and hostility* relieving*

But conformity also is anxiety

In these two simultaneous effects of conformity

there is a basis for understanding how psychosomatic symptoms substitute for painful anxiety symptoms or for an anxiety neurosis.

It is in the willingness to barter the suppress­

ion of aggression and hostility felt toward authority figures, in exchange for the relief from painful felt anxiety which conformity brings* Social and Cultural considerations * A most recent development in the field of psychosomatic medicine, as well as in the field of medicine and psychiatry in general, has been the increased emphasis on the importance of cultural factors as a cause of psychosomatic illness.

Of course,

for a long time no?/ almost no one would argue that such social and economic factors as poverty, malnutrition, and various, social forms of living did not contribute to the cause of physical disease*

Such a social phenomenon as war,

causing a widespread disturbance in the living conditions of large populations, and intensifying the amount of environ­ mental stress confronting the combat soldiers, has clearly contributed to the development of a large number of psycho­

21 somatic symptoms*

The new focus of interest is not on the

effect of these pathological conditions of society, hut rather on the role that the conditions and standards of our culture which are considered to he normal and usual play in the determination of psychosomatic disease* Margaret Mead(65) has heen one of those largely responsible for translating this cultural and anthropological point of view to the medical and psychological field.

Her

unifying concept is that of a definite pattern of interaction between the psychosomatic functioning organism and the cultural systems A complete psychosomatic approach would call for an identifying of that which is common to every individual who is reared in our society, and an ability to see these special character types which are found in association with special disease pictures, as variants of this basic cultural type. She states that the psychosomatic point of view applies to every individual, not only to every patient, and that there is no basic human personality, but that each person must be seen against the cultural base line. It is in the inconsistencies in the goals and the attitudes which the particular society sets as a standard for its members, that are to be found the weak spots of the society, and the insight into how the society produces malad justed individuals•

22 This is essentially the position of the neo-Freudians* Horney(5l) who has been the outstanding exponent of this cultural emphasis within the psychoanalytic field in America, says: • . . in speaking of a neurotic personality of our time, I not only mean that there are neurotic persons having essential peculiarities in common, but also that these basic similarities are essentially produced by the difficulties existing in our time and culture* Fromm(37) contributes the concept of the ”pathology of normalcy” to the development of the cultural point of view* His thesis is that our society prevents the highest form of Expression of self” and of %ponteneity” of its members: If a person fails to attain freedom, spontaneity, a genuine experience of self, he may be considered to have a severe defect, provided we assume that freedom and spontaneity are the objective goals to be attained by every human being. If such a goal is not attained by the majority of members of any given society, we deal with the phenomenon of socially patterned defect. The individual shares it with many others; he is not aware of it as a defect and his security is not threatened by the experience of being different, of being an outcast, as it were. There is reason to believe that the tendency to conformity to an excessive degree (stereotypy), or to a degree that is more than average for the population, and the corresponding lack of spontaneity, is an important personality feature of some of our psychosomatic groups of patients.

In this sense these patients are more ill than

23 the average in the culture, because they have a relatively greater amount of the “defect1* that is common to the whole culture, Or another way of looking at it is that, if there are character defects that are flnormal“ for the culture, may there also not be psychosomatic symptoms, such as ulcer, that are “normal1* for a particular culture.

The “dependency-

independency” conflict that is considered as predisposing to ulcer may be well seen as the contradiction between two standards “normally11 adhered to simultaneously in our American culture.

It can be seen not only as a contradiction,

or inconsistency, but as Ruth Benedict(12) has pointed out as a sharp “discontinuity” in the cultural institutions available for child training and adult training: From a comparative point of view, our culture goes to great extremes in emphasizing contrasts between the child and the adult . , , The child must be protected from the ugly facts of life, the adult must meet them without psychic catastrophe; the child must obey, the adult must command this obedience • • • If our culture provides inadequate social institution­ al assistance to bridge the gap between a protected d ependent childhood and a socially enforced competitive, striving adulthood, the occurrence of disturbing dependency-independency conflicts is more frequent than it would otherwise be. Furthermore, given the fact of a conflict in the culture

pattern itself, the reason why some members develop symptoms and others do not must he the greater intensity of the application of the conflict in the lives of the former individ uals.

Otherwise the particular conflict cannot he said to

he specific to any certain group of individuals in the society The fact that children should he allowed to he depend­ ent and demanding in the early months of life, need not he considered as inconsistent with the view that sooner, or later, they must learn to he relatively independent.

The

patterning of the demands of the child varies from culture to culture, as does the socialization process, which in one important aspect is a process of transforming the dependent child into the dependable adult.

It is possible that we are

materially prepared in this society to give our children more support, affection, and gratification perhaps, than any society has ever given.

Theoretically it would he possible

for them, with this early dependency gratification, later to become mature independent individuals without necessarily developing a dependency-independency conflict. A formula then that is composed of one isolated factor such as a specific basic conflict (dependencyindependency) is not sufficient for etiology.

The conflict

must he found in the whole proper caaltural context, in a social cultural gestalt.

25 Any direct mechanical application of psychoanalytic principles, developed from the study of neuroses in middle class members of Western European culture, to other very different types of societies, is not adequate to the task. The personality and behavior of the members of a society can only be understood in terms of a broad cultural evaluation of the total society.

The methods of achieving adjustment

to the group may not require goals of individual aggression, competition and success at all.

The most important social

goals may just as likely prohibit becoming outstanding from the group, and require one just to be an equal part of the group.

Thus, as Eggan(30) points out, among the Hopi who

work selflessly and share their property, to gain personal status and distinction has a negative social value and such individuals that attempt it are outcast. Within the total complex American culture, there are a number of sub-cultures.

The importance of class differ­

ences in America has been increasingly recognized in recent years.

Membership in a particular social and economic class

is a powerful force in determining one1s personality and behavior.

Davis and Havighurst(23) studied the extent to

which the methods and timing, and the pace of early child training differed in the various social classes.

In their

controlled interview study of 200 Chicago mothers they found that middle class parents were more rigorous than lower class

26 parents in their training of children for feeding and clean­ liness habits. permissive.

They begin training earlier and are less

They subject their children to influences which

make them "orderly, conscientious, responsible and tame" individuals.

"Middle-class children probably suffer more

frustration of their impulses." Middle class parents started training their children earlier for achievement and responsibility.

The authors

explained this by the hypothesis that lower class people train their children to take responsibility only after the child is old enough to make the training pay substantial rewards in the work the child will do.

One might add that

probably the middle class parents must make a more conscious effort of teaching their children goals of achievement and to give up their dependency, because long-continued depend­ ency is a realistic possibility when the parents have money. In the working class it is more a matter of realistic necessity for the children to become independent.

It is a

matter of fact in their perceptual frame of reference, and the parents do not need to make such special efforts to inculcate it as a goal, in return for love.

The working

class child, perhaps, cannot as well blame his parents personally, for the denial of his dependency needs, and can blame society as a whole. It is reasonable to expect that such class culture

27 determined variations in child training procedures and in intra-family emotional relationships will have some bearing on the development of psychosomatic disorders, their incidence and type* Evidence of Cultural Influence in Psychosomatic Disorders*

If psychosomatic disorders are not yet considered

the normal expression of certain cultural patterns, but rather as deviations from the culture pattern, there is evidence to show that the forms and frequencies of deviation do depend on cultural circumstances* Earlier reference was made to the striking evidence on the sex shift in incidence of peptic ulcer(7?52)* females were affected, to each male, 150 years ago*

Six Today

the ratio is unquestionably reversed, it is estimated to be three to five males to each female*

Halliday(44) offers a

highly speculative thesis to the effect that the cultural changes in the sex roles in the past 50 years have been such as to fit the striking change in sex distribution of peptic ulcers: The alterations in the world of woman saw the emergence of the f,new woman*1 whose 11emancipation" although providing her with access to many new interests and satisfactions was not attended by the simultaneous withdrawal of the social sanctions which allowed her to retain her moods and modes of feminine behavior in virtue of which she still continued to be able to liberate her emotional tensions in many forms and expressions denied to the male*

28 A study of the statistics of the U. S. and British Armies(29) has shown that while cardiac complaints were the most typical and frequent complaint of soldiers during World War I, a distinct shift occurred to gastro-intestinal complaints, as the most frequent and important psychosomatic problem of World War II.

It does not appear reasonable to

try to explain such a shift on any constitutional basis.

It

appears more plausible to explain the differences found in the “racial” incidence of peptic ulcer on the basis of cultural influences.

The various races or nationalities,

which have been studied for the occurrence of ulcer, live under different conditions, have different family patterns, and wide variations of personalities and cultures. Rowntree(86) reported a striking difference of incidence of ulcer in selective service registrants in the U. S. Army, between Negroes and Whites.

Negroes had a rate of 1.4 in

war, and 0.6 per 1000 in peace, of 1000 examined.

Yet, the

Negro population in Ghieago appears to have as high a rate of ulcer incidence as the white population there, in spite of the much lower incidence in the country as a whole.

Since

the Negroes attain this high incidence rate after being exposed to the same conditions of urban stress and competition for a period of five years or more, Steigmann(lOl) made the point that such differences in incidence are due to psycho-

29 logical and environmental factors*

This differential between

Southern rural Negroes and Northern urban Negroes is perhaps the most crucial piece of evidence for environmental deter­ mination in that it rules out factors of "racial"- (i. e. biological or constitutional) difference more adequately than other studies* Donnison(24) made a valuable survey of the data available regarding the incidence of psychosomatic disorders in the populations of Asia and Africa*

He showed that peptic

ulcers, hypertension, exopthalmic goiter, and diabetes were either absent or quite rare in the so-called "more primitive" (i* e. less industrialized) areas of these continents.

But

these disorders began to appear in such communities as their social orders became disrupted by the introduction of Western industrialism*

Adequate statistical data do not exist,

perhaps, for these "more primitive" areas.

It has been widely

stated that peptic ulcer is a disease of modern industrial­ ized, capitalistic civilization.

Among primitive Himalayan

tribesmen and Indians ulcers are not found.

But Kouwenaar(59)

reports that for the same tropical area ulcers are somewhat more frequent among Chinese than they are among Javanese who show little emotional expression, have a "more stable autonomic nervous system, and are less sensitive to different stimuli." A constitutional difference is apparently suggested by this particular writer*

30 Halliday(44) reports that the statistics for England show a higher incidence of psychosomatic disorders for urban than for rural areas.

He explains this difference, in part,

to a rural milieu in infancy that does not instigate predis­ position to the extent that the urban milieu does: smaller number of artificially fed babies,

2.

1.

a

the young

growing life more directly exposed to the emotional influences of mother nature,

3*

in adulthood, the rural milieu allows

more individual self-expression,

4.

decline of religious

faith is relatively less, and intellectualism received little stimulation,

5*

work is more in accordance with diurnal

and seasonal rhythms, his fellows.

6.

a man is entitled to be unlike

In general, the older mores prevailed in rural

society to a greater extent than in the cities: The lower incidence of psychosomatic organic diseases in remote and rural areas may thus be collated with the alleged relative rarity of these diseases in 1primitive races1, that is in communities not influenced by indus­ trialized Western civilization.(44) While Hallidayfs foregoing analysis may appear to suggest a superiority for the older, more simple, mores, one should point again to the fact that more likely the maladjustments result from the inconsistencies to be found in the goals and standards set by industrial, urban, capitalistic society rather than the mere fact of greater complexity itself.

31 Ruesch(94) concurs in the comparison of rural life with urban life, and describes, for the American scene, how the city child is more insecure, dependent, and immature and therefore more prone to psychosomatic symptoms.

He

contends that this immaturity is the result of the over­ protection and the external security systems that are provided in urban society.

This is probably more pertinent

to the middle class, white urban child, than it is for the working class, urban child.

Furthermore, Ruesch’s findings

elsewhere(93), iu his study of ulcer cases, support this contention.

He found that the majority of ulcer cases

studied came from lower middle class homes rather than from working class homes. In this middle class urban culture, children are over­ protected and made dependent in a suppressed hostile way by the parents.

They develop a hostile form of identification

with their parental models.

The super-ego they develop does

not become an integrated and accepted part of the person but is felt as a burden or pressure.

They later conform to

society, but they do not develop well-integrated identifi­ cations with group movements, ideas, or with progressive values and forces in their society. Alexander(3) describes another well-defined cultural background^. in which his patients were second-generation

32 Americans, members of immigrant families, belonging to a racial minority group.

The father had difficulty adjusting

to the new country and the mother placed all her hopes on her eldest son.

Alexander states that while this was a

culturally determined family situation, observed in thousands of cases, there occurred a variety of outcomes in the sonfs adjustment, depending on the specific personality dynamics of the human characters involved in the typical situation. II STUDIES ON BRONCHIAL ASTHMA Psychoanalytic studies.

French and Alexander and

their colleagues at the Chicago Institute for Psychoanalysis(35) analyzed twenty-seven cases of bronchial asthma for periods of from two weeks to forty-three months.

In the group

studied, there were six men, ten women, six boys, and five girls.

Nineteen of the group were under treatment for six / months or more. Marked allergic hypersensitivity had been demonstrated in nearly all the cases. Although the personalities of their patients were very divergent they seemed to have one common feature. Beneath their more superficial behavior they all suffered from deepseated insecurity and a more or less intense need for parental love and protection.

The authors state:

The characteristic difficulty of the asthmatic

33 patient is that compensatory urge to seek vicarious satisfaction by giving to others what he himself needs comes into conflict with his own emotional insecurity and longing for the mother's love and protection* The natural urge to self-sufficienty seems to be absorbed in the task of mastering the fear of being left alone. One of the most pervasive features of the material of the asthma patients was the need to maintain a bond of mutual understanding with a parental figure by means of speech. A relationship was disclosed between asthma and erying or laughing.

It was suggested that the asthma attack

was equivalent to a repressed or inhibited cry of anxiety or rage. The situations precipitating attacks of asthma seemed to be traumatic in character.

The attacks occurred only

when the patient was overpowered by a mass of excitation which the ego is powerless to master. As a further procedure, the authors compared the dreams of twelve asthma patients with those of twenty-six control cases representing a varied collection of neurotic patients.

They found that the asthma patients had twice

as great a tendency towards having a type of intrauterine dream in which a strong dependent shelter-seeking attitude toward the mother came into expression. Regarding the relationship to the mother it was found in some cases she had been prohibitive and at the same time seductive toward these patients. On the basis of periodic discussions of the case

34 material by the entire research staff of the Institute, it was concluded that psychological and allergic factors probably were somewhat complementary in these cases.

In

some instances the attack might have been precipitated by emotional or allergic factors alone, while in others both factors may have been necessary to produce the asthma attacks• The authors caution against making generalizations from these psychoanalyses.

They state:

It is obvious that only patients who are suffering from some sort of emotional disturbance would be willing to undertake and continue through an analytic treatment. Therefore, it is well to state at the out­ set that it is impossible upon the basis of our studies to draw any reliable conclusions concerning the fre­ quency of emotional conflicts in bronchial asthma, since our procedure obviously selected just those patients who were suffering from both emotional difficulties and bronchial asthma(35)* Fenichel(32) does not state how many cases he has based the following fascinating observations on: It is in accordance with the pregenital character of the basic conversion that patients with asthma mainly present a compulsive character with all the features of an increased anal-sadistic orientation: ambivalence. bisexuality, personality deviations through reaction formations. sexualization of thought and speech . . . The anal orientation of the patients, as a rule has developed from an interest in smelling to an interest in breathing. The asthmatic cry is a cry for help to the mother, an attempt to introjeet the mother, by respiration, in order

35 to be permanently protected - - a reaction to fear of separation from the mother* Dunbar(28) gives a summary of the psychoanalytic literature to 1935*

Most of the authors quoted report only

observations without describing their subjects or mentioning the treatment used*

Several writers present evidence that

asthma symptoms were alleviated after psychotherapy, but neglect to give data concerning the patients. The study be French and Alexander and their colleagues(35) is the only comprehensive psychoanalytic study* As indicated by the authors themselves, it is impossible • • • to draw any reliable conclusions” from their study*

In add­

ition, the cases treated were of diverse ages and sex and contained only small numbers in each group*

As a final

criticsm it is to be noted that the subjects were treated by several analysts, who, undoubtedly employed different psychotherapeutic techniques* Psychiatric studies*

McDermott and Cobb(62) surveyed

fifty cases of bronchial asthma from a psychiatric point of view to determine the emotional factors in asthma* results may be summarized as follows:

Their

Thirty-seven of the

fifty cases studied seemed to have an emotional component in the asthmatic attacks*

The thirteen ”non-emotional"

cases were predominantly young males*

Twenty patients re-

ported that the first attack was emotionally precipitated. Thirty-one reported that later attacks were often emotionally precipitated.

Thirty patients showed neurotic traits other

than asthmatic, usually of a compulsive character.

Only

twenty per cent of the ”emotional group” were henefitted by somatic therapy, while fifty-four per cent of the ”nonemotional group” were benefitted.

Likewise in the ”neurotic

group” only about twenty per cent were helped by drugs and biological products, while fifty per cent of the ”nonneurotic group” were helped. Brown and Goitein(14) studied a group of forty asthma­ tic patients and forty otherwise allergic subjects by means of a psychiatric interview in an attempt to determine the personality type of the asthmatic. In their analysis of these cases they found a pattern of personality which they called ”the respiratory personality,” They concluded that the asthmatic might be characterized as having a cyclothymic disposition associated with paranoid features, repressed hostility, and self punishment motives. In another psychiatric study, Jensen and Stoeszer(53) worked with four cases of bronchial asthma to determine the influence of psychogenic and emotional factors.

Their sub­

jects were girls aged nine, ten, fifteen, and sixteen years. They found the following personality factors common to the

37 groups

nervousness, emotional tension and anxiety, and

repression*

The latter was suggested by their finding that

it was difficult for these girls to cry. Rubin and Moses(88) studied "bronchial asthma patients by means of the electroencephalograph"** and personality data. They obtained EEG records of fifty-four male cases of bronchial asthma under standardized conditions and gathered personality data in the course of an interview lasting from forty-five minutes to one hour. They found about three times as many asthmatics with dominant alpha records as in a normal group.

This pointed to

a passive receptive type of personality which other studies had indicated were also correlated with dominant alpha records. The interviews seemed to indicate that the group as a whole were fundamentally passive dependent people who were the children of an overprotecting dominating mother.

They had

not striven for independence in life and had continued to seek care and protection from the environment.

The authors

point out that their conclusions can only be considered as tentative. Of seven thousand patients surveyed by Maclnnes(63) he found only five who had allergic symptoms.

Three of

1 Electroencephalograph will hereafter be referred to as EEG.

38 these showed loss, or improvement of, allergic symptoms while suffering from mental illness and a return of symptoms with return of mental balance. Kerman(56) described two cases with chronic asthma attacks who developed an affective psychosis. repressive period the asthma disappeared.

During the

When electro­

shock treatment improved the mental illness, the asthma attacks came back.

The personality characteristics found in

these cases were mood swings, paranoid features, and selfpunishment drives. Miller and Baruch(69) studied 90 children with allergies and 53 children without allergies.

Their method

consisted of a diagnostic play session with each child and an interview with the mother.

They found that both groups

often felt rejected and became hostile to their parents, but the allergic children are afraid to openly express hostility and repress it until it breaks out in illness.

They feel

guilty over their hostility and punish themselves by getting sick.

These authors reported elsewhere(68) another part of

their study, which they did as a control on the incidence of maternal rejection inasthmatic children.

They found evidence

of maternal rejection in 62 of 63 allergic children studied, and in only nine of the 37 children in the rpn-allergic control group. ence.

This was a statistically significant differ­

They used the following definition of maternal reject-

39 ion as their criterion:

f,Qne whose behavior toward the

child is such that she consciously or unconsciously has a desire to be free from the child and considers it a burden," They required that the mother verbally express the attitude of behavior or rejection.

It is quite impressive that they

obtained this almost unanimous expression of rejection. They report as typical expressions of rejection, statements by the mothers that their child was an accident and had not been planned for.

In addition to the rejection, they found

that 36 of the 63 mothers had an apparent attitude of overprotection toward the child. While these psychiatric studies have resulted in interesting observations, only two studies used control groups(14,69)•

Two investigators found paranoid features

in their patiens, but in one study(56) this finding was based on only two patients.

The other studies mention

"compulsive character," "pre-genital conversion," "depressive tendencies," "anxiety," and "passive dependence." and dynamic factors mentioned are:

Genetic

rejection by the mother,

fear of being left alone, the equivalence of the asthma attack to an inhibited cry of anxiety or rage, the need to confess, the simultaneous prohibitive and seductive behavior of the mother, among others.

It is clear that many of these

results are contradictory and the methods of gathering data

40 are open to serious question* Psychometric studies*

Fine(33) recently conducted a

study to determine the relationship between personality variables and bronchial asthma.

He administered the

Horschach test, the MAPS test, TAT, Wolff Draw-a-Picture-ofYour-Family test, and a revised form of the Despart Fables to thirty asthmatic children between the ages of six and fourteen years*

As a control group he used thirty siblings of the

asthmatics.

In addition, both the mother snd children were

interviewed*

Comparisons were made between asthmatic boys

and sibling boys and between asthmatic girls and sibling girls as well as between all asthmatics and all siblings. The Rorschach data showed that asthmatics differed from the •hormal” control group in that they were more introvertive, had stronger oral drives, were more dependent, more explosive and uncontrolled, more conforming, and had* a more unpleasant father-image. The MAPS and TAT storeis were analyzed for the feelings and interpersonal relationships expressed.

In the asthmatics

there seemed to be more indications of sexual conflicts centered around the parents.

The asthmatics demonstrated

greater dependency, and more desire for a good family.

They

showed greater hostility to parent figures while they were more fearful of hostility directed toward themselves.

The

41 amount of hostility demonstrated seemed to he the same for both the asthmatics and the controls.

Indications of depress

ion and inhibition of crying were found in the asthmatic records*

They often used escape solutions to their problems

and indulged in more wishful thinking. Differences in responses to the Despart Fables reveal­ ed that asthmatics, as a group, had significantly more dependency, more hostility to the mother, and less hostility to the father than did their siblings. The only significant difference that was found in the child interview was that the asthmatics felt that their mother understood them best less often than their siblings. When the mothers were interviewed they described their asthmatic children as being more nervous than the siblings and as having more sickness, in addition to their asthma. The mothers reported that the asthmatic children cried more, fought less, and were friendlier and kinder than were the other children.

The asthmatics were also described as

having lower “frustration tolerance.11 An additional find­ ing was that the asthmatic children had voracious appetites. In an earlier study Schatia(lOO) attempted to discover whether the reaction of the asthmatic patient to an inner conflict was associated with any particular personality type.

He obtained Rorschach records from forty

42 bronchial asthma patients and compared them with each other and with two control groups of “normal” persons*

The ages

of the asthmatics ranges from 14 to 76, with an average age of 36*7 years.

Thirty-two of the subjects were female and

eight were male. Sehatia used Miale*s(67) signs as criteria for determining the incidence of neurosis.

The interpretation

of a composite Rorschach record for the asthmatic group showed them to have an obssessive type of neurosis.

They

tended to react in a theoretical and detached manner, were rigid, and covered their emotions with excessive intellectualizations.

They engaged in fantasy life as a refuge from

a hostile environment.

A depressive trend was also noted.

No specific phobias or compulsions were revealed. Steiner(102) studied a group of 27 asthmatic children and a control group of non-allergic children whose ages ranged from nine to fifteen years.

He wanted to determine

in what areas of maladjustment the two groups could be differentiated.

Using the Rogers Test of Personality, he

compared the groups in terms of family maladjustment,.social maladjustment, personal inferiority, daydreaming, and total maladjustment.

He found that for most of the areas measured

by the test there were no significant differences.

The

asthmatics seemed to have significantly less daydreaming.

43 More asthmatics came from broken homes and there seemed to be a consistent trend for the asthmatics to achieve lower maladjustment scores in the various areas tested. Steiner concluded that no paper and pencil test could adequately measure and describe the differences between the asthmatic and the non-allergic child. The three aforementioned studies are the only "psychometric” investigations of asthma that appear in the literature.

In the studies by Fine(33) and Steiner(102),

children were used as subjects, while Schatia*s(100) sample was composed largely of women. Summary*

No clear-cut picture of the personality of

the asthmatic has emerged from the numerous investigations which have been carried out.

In some of the studies the

lack of a definitive pattern may be attributed to ■uneven methodological procedures.

In other studies, where good

scientific methods were employed, the lack of agreement may be a function of the sampling technique.

It has been

claimed that the symptoms in some asthma cases are due more to "extrinsic** factors, and the symptoms in other cases are due more to "intrinsic" factors.

If this is true, it could

explain large differences in the nature of the sample selected for different studies.

The possibility remains, however,

that there is no single "basic" personality pattern in the asthmatic subject.

Ill Incidence.

STUDIES ON PEPTIC ULCER In a consecutive series of 15,000 patients

with gastric complaints at the Mayo Clinic, 15 per cent were found to have X-ray evidence interpreted to he the result of peptic ulcer.

Weiss and English(106) state that this is

ample evidence that peptic ulcer is the commonest organic lesion in the gastro-intestinal tract.

They also state that

it has been recognized by many sources, non-psyehological as well as psychological, that this disorder presents for discussion a clear-cut-'issue of psychosomatic medicine. Rowntree(86) reported that of 13,000,000 selective service registrants during World War II,

4.3 males per

1,000 showed evidence of peptic ulcer in wartime, as compared to 3.4 per 1,000 during the preceding peace time.

An

additional 3*4 per 1,000 gave a history of peptic ulcer. These figures would mean that close to 100,000 rejectees had ulcer or ulcer-like histories. Dunn(29) summarized the statistics of the British authorities by stating that there is agreement that gastro­ intestinal disorders were the most important medical problem of this war, and the single most prevalent type of disease among military patients.

Peptic ulceration apparently

occurred in over 50 per cent of the cases reported in the British services.

4? Gastro-intestinal disorders and ulcers became the most frequent psychosomatic syndromes in this war as contrasted with the frequent cardiac neuroses of World War I*

Halliday(44) explains the increased incidence during the

period between the two world wars as a response to ah increase of 11noxious psychological factors of the communal environment.11 Payne and Newman(75) claim that the peak age at which ulcer occurs is in the middle twenties.

Halliday(44) has

shown that there has been a retrogression of the peak of maximum age incidence toward the younger age groups, since 1900, when the greatest incidence was found in the older groups (50 to 60 years). Davies and Wilson(22) examined a series of two hundred unselected persons with peptic ulcer and found that in 84 per cent the ulcer had formed at a time when the individual was reacting emotionally to upsetting external events, whether financial, occupational, or domestic. Financial loss, personal frustration, sexual nsin,M or violent argument had preceded by one to ten days the onset of pain, hemorrhage, or perforation.

As a control they

examined a series of persons with inguinal hernia and found in this group that only 22 per cent of the hernias developed at a time of upsetting emotional reaction. difference is significant statistically.

The

46 Psychoanalytic studies*

The first detailed study of

the personality of ulcer patients was undertaken by Draper and associates(26).

They attempted to determine f,the

character of the psychology" of the ulcer type*

They studied

80 unselected cases of peptic ulcer using case history material and from two to five hours of interview directed toward a study of the "man within"

the patient.

They felt

that the most common feature of all the cases of ulcer was the fear emotion*

They present the following data showing the

percentage distribution of chief fear sources found in the studied group of ulcer patients; '84 per cent had an inner sense of insecurity based on actual or supposed physical inferiority, including gynic emphasis: 97 per cent showed a persistent hold on the mother principle and fear of loss of the mother surrogate's approval;

Jealousy-and aggression

appeared in 65 per cent of the cases;

guilt and fear related

to sex problems comprised 49 per cent of the total; and 56 per cent had compensatory strivings* They stressed that the unconscious awareness of the feminine components may be a stimulus to the over exploit­ ations of their virility which is so characteristic of ulcer bearers.

Thus, Draper and associates were the first to

introduce concepts such as dependence, insecurity, fear,

47 counteraction, reaction formation, guilt feelings into the study of ulcer.

They further elaimed that the ulcer patients

were of superior intellect, their emotional response heing swift and intense*

This is reminiscent of Alvarez1s(8)

early observations on the successful efficient business ex­ ecutive who is prone to develop an ulcer.

If this was true

25 years ago the illness has now probably spread to broader sections of the population* In 1934, Alexander developed his comprehensive theory concerning personality in ulcers.

He reported the Chicago

Institute for Psychoanalysis1 two year systematic study(l) of the psychic factors in a small group of gastro-intestinal cases.

The preliminary results presented are concerned

with ,fthe patient fs manifest emotional relations to the environment in an attempt to decide whether overt emotional attitudes and their immediate dynamic background could be established as typical for different types of organic cases.n

The cases included six duodenal patients and three

gastric neurosis patients as well as a few cases of colitis and constipation.

The data were obtained during the course

of psychoanalysis of the patients. The most conspicuous features of the ulcer and gastric neurosis cases were intense oral receptive wishes and the wish to be taken care of and loved, against which the patient fought internally because they were connected with extreme

48 conflict in the form of guilt and a sense of inferiority which usually led to their denial. or to receive;

”1 do not want to take

I am active and efficient and have no such

wishes,” formulates their conscious attitudes.

Their cons­

cious mental life is dominated by ideas of independence, activity and success. . The conflict situation consists of a rejection and repression of oral-receptive tendencies on account of their incompatibility with such active strivings and goals.

They reveal a characteristic regression to the

early stages of emotional life.

If the wish to be loved as

one formerly was by the mother is denied gratification, the associated tendency for being nourished is energized, and stomach symptoms are produced.

The ulcer is supposed to

develop because of continuous gastric secretion under the influence of chronic psychological stimuli consisting of oral fantasies and oral tendencies. Alexander(5) later reported on another analyzed case of peptic ulcer in 1947, and emphasized, that the dependency, passivity and fear of failure was due to the intense nature of the oedipal relationship and the resulting guilt derived from it, inhibiting aggressiveness.

Here again are the

genital and hysterical features, the potential ego-strength and the importance of the factor of regression. Halliday(45) reported in 1948 his impressions of

49 personality features of a large number of ulcer cases studied by means of psychiatric interview in England*

He found that

they all have a deep-seated sense of insecurity and depend­ ence, and that the majority attempt to overcome this by di ow­ ing on the surface an over-emphasized activity, efficiency and independence*

Many of them are hard self-drivers and

their breakdown usually tends to occur when their emotional security is threatened (often in the shape of threats of occupation or finance) or when they become inwardly anxious or depressed through the stresses of being in charge or in authority*

A minority, however, are obviously dependent

persons and many of these tend to show a readily provoked ill-humor or resentment, using their ulcer, if they have been told they have one, as a means of securing attention, of excusing their inadequacy, and even of revenging themselves against society, whether in the form of a particular person, or association of persons, or in the form of particular social arrangements. Van der Heide(49) psychoanalyzed two ulcer patients whose initial complaints were not concerned with their ulcers. He presented the case histories of the two eases and summarized what he felt were the common etiological dynamics* Both patients withdrew from infantile sexual activity and became passive, submissive children, attached to their fathers*

This resulted in growing affection for the fathers

50 with conflict regarding the highly different standards of the environment which required the opposite of being a "sissy.” This conflict resulted in regression toward oral dependency. Aggressive impulses were renounced but aggressive tendencies were maintained in the unconscious, and expressed in dreams in an oral aggressive fashion.

When the dependency wishes

were directed toy/ard men a homosexual coloring was the result, without overt expression.

Guilt over the dependency

wishes led to strong overcompensation, resulting in traits of generosity and a sense of responsibility. Garma(3B) analyzed four peptic ulcer patients. were physicians, one a lawyer, and one an architect.

Two The

dominant common personality traits which he found are presented as follows:

strong family attachments and a

dominant role for the mother; infantile inactivity as a result of mother fixations persisting to adulthood; inactivity combined with compensatory overactivity satisfying the ambi­ valence about activity-passivity;

an unconscious desire to

be fed as in early infancy, which cannot be satisfied;

a

tendency to exteriorize an intense oral aggressivity, develop­ ed from infantile frustrations.

This aggressivity cannot be

satisfied as it is rejected by the environment. Guilt feel­ ings develop and there is a turning of the aggressiveness inward.

"The conscience is biting.11

51 While evidence of dependency-independency was found, it was more exactly described as a passivity-aetivity conflict*

The conflict began when the children, a few years

old, would normally have established the first social contacts outside the family, but were submissively bound to the dominant mother* Mood swings were also found in the patients when they ate a lot they were accepting their dependency, feeling good with themselves, experiencing the narcissistic omnipot­ ence of infancy*

When they did not eat it was because they

were feeling guilty and depressed, and were depriving them­ selves.

This appeared analagous, dynamically to the cycles

of infantile satiation and hunger tension states seen in mania and depression. Summary*

The psychoanalytic studies are in agreement

on several important characteristics of the personality structure in peptic ulcer patients.

All investigators

found these patients to be basically passive, submissive, dependent, and "oral.”

The specific prediposing condition

seems to be a frustration of the needs for ^maternal love.” As interpreted by Saul(98) maternal love means here the interest, esteem, and affection which everyone needs;

also

in a broad sense, recreation, emotional support, help from others, etc.

52 These studies may he criticized for their lack of objective procedures and criteria for evaluation of person­ ality variables, and the very small number of cases upon which conclusions were based,

Nevertheless, the amount of

agreement is indicative of a consistent "basic" personality in ulcer subjects. Psychiatric studies.

Kapp and Associates(54) studied

20 male cases with peptic ulcer, by psychiatric interview technique.

They found that all their cases had strong

dependent desires "which were secoid ary to either rejection or spoiling in childhood.11 This is one of the first studies to report findings of over-indulgence of needs in the early years and that this, instead of frustration of early needs, may be the predisposing condition. While they found none ofttheir patients to be "psycho­ logically mature,"

they found a wide range of external

personality and behavior pictures:

"Although the conflict

situation is similar in all . * . the resulting personality facade may vary from exaggerated independence to parasitic dependence."

This statement also suggests the possibility

of the two types of ulcer cases, one at each pole of the continuum;

those whose dependency needs are self-frustrated,

and those whose needs are frustrated by the environment. Mittelman and Wolff(70) compared thirty eases of

peptic ulcer with thirteen ^normal” subjects. histories and interviews to obtain data.

They used case

In all the histories

of the ulcer patients the authors found periods of prolonged emotional stress and conflict with reactions of intense anxiety, insecurity, resentment, guilt and frustration.

The

occurrence of pain and hemorrhage was correlated with these periods of special stress.

Compensating displays of

independence, self-sufficiency and perfectionism were also found to be common factors.

Experimentally created emotion­

al states demonstrated that destructive emotional reactions precipitated symptoms, (increased acidity and increased contractions in the stomach) in all of the ulcer group, and in many of the normal subjects.

Situations which engendered

feelings of security and assurance restored normal gastric function and eliminated symptoms. Wolf and Wolff(109) attempted to discover some stimulus ”which results in definite, sustained acceleration of acid production and which may be recurrent in the ordinary course of life in ulcer patients.”

Their studies were made on a

man with a large gastric fistula whose mucosa was readily accessible to view.

The patient was in excellent health

with only rare digestive complaints.

Frequent analyses of

gastric juices were made and vascular changes were estimated. The patient*s mood and the content of his thoughts

54 were carefully noted during the experiments and in separate daily interviews.

They attempted to classify his emotional

reaction patterns as contentment, Joy, gratitude, feelings of helplessness, dejection, doubt, fear, frustration, guilt, sadness, anxiety, tension, hostility and resentment. Observations were made that such emotions as fear and sadness, which involved feelings of withdrawal, were accomp­ anied by inhibition of gastric secretion*

Anxiety, hostility

and resentment were accompanied by increased gastric secretion, and, if these emotional states were prolonged, bleeding points appeared spontaneously*

The authors concluded that there was

a chain of events which began with anxiety and conflict and their associated overactivity of the stomach and ended with hemorrhage and perforation - - the peptic ulcer, Szasz and associates(104) intensively studied one case of peptic ulcer, a 23 year old white male, by means of psychiatric interviews and physiological tests.

They

experimentally demonstrated, with a Wangenstein apparatus that there was a physiological process of secretion of acid gastric Juice in response to the psychologic stimulus anger. The anger was psychologically induced by the psychiatrist prodding the patient, who was very defensive, with increas­ ingly personal questions.

The impressive features of this

study are that the gastric secretion was demonstrated to

55

follow an experimentally controlled anger stimulus in an intact human being, and that in a recheck of the experiment after the patient underwent bilateral section of the vagus nerves, the psychologic stimulus could no longer evoke the previously obtained physiologic response in the stomach. The patient reported that the only method he had used before the vagotomy for discharging suppressed hostility was to go off by himself and cry. The authors present a theoretical formulation to account for the role of anger and fear in gastric function: There exists in the infant a close emotional associa­ tion (equation) between anger (crying) and receiving food on the one hand, and fear and what is feared (not receiving food) on the other. . . In some ulcer patients, this association may persist and may then find its expression through the process of degressive innervation11 (the recapitulation of an infantile pattern of physio­ logic responses to certain emotional stimuli, mediated by nervous pathways)(104). The authors conclude that anger (hostility) may be an important psychological factor in the etiology of peptic ulcer.

They, in effect, add the factor of internalized ”oral

sadism,” or ”oral-demanding,11 to the formula which previously included repressed ”oral receptiveness.” An additional interesting speculation made by these authors relates to the fact that their subject had been a very fat breast-fed baby.

11His mother, apparently, knew

56 only one way of satisfying her childrens* needs, namely, that of feeding.*1 Perhaps, along with the frustration of dependency needs for love and support, there goes an overindulgence, or even a forcing, in terms of feeding, by the mother, in the early predisposing development of peptic ulcer cases. Zane(lll) reported on 85 patients (veterans of World Wars I and II), with X-ray and clinical evidence of gastric or duodenal ulcer, who were observed, studied and treated over a two year period at the Bronx Veterans Hospital.

He

found a common conflict in all the cases studied; and the tension accompanied efforts to resolve this conflict.

He

says the conflict is one in which the individual feels compelled to behave in a certain manner in order to achieve and succeed, despite his anticipation of failure.

The

conflict ”was found to have begun in early childhood.” ”The child seeks security by striving to meet rigid, exacting standards set up by the early authoritative figure, while at the same time'anticipating failure because of a strong feel­ ing of inadequacy.

To allay his fear of failing, of losing

his security, he struggles to perform precisely in the manner he feels is expected of him.”

Resentment accompanies

the need to deny and reject his own inclinations and impulses. Such a conflict, involving simultaneous opposing feelings

51 of fear and resentment, he also describes as a feeling of "having to, and fear of not being able to,fl or r,must and can* t.M The whole description here is that of an individual with severe super-ego, setting standards of perfection for himself and with a conflict in his relations to authority figures*

The emphasis is on a conflict over submission,

rather than over dependency* The underlying conflict in all the peptic ulcer patients studied was seen to be the same, but the outward personality and attitudes varied considerably.

No differences

were found between the gastric and duodenal ulcer types*

The

traits of being overconscientious, meticulous, careful, and hardworking were common to both* Fear and resentment are considered to have opposing effects on the stomach and duodenum.

When they are experien­

ced simultaneously by the patient, the reactions in the stomach are dissociated, often resulting in increased acid motility and vascularity, with decreased mucin.

Other

evidence of autonomic nervous system imbalance, such as excessive palmar sweating, tachycardia, urinary frequency, spastic colitis, and mucous colitis was frequently found in the ulcer cases*

Frequent recurrence of symptoms also

characterizes peptic ulcer.

In the Army the strain of

military life was found to induce recrudescence.

Chronic,

58 indolent peptic ulcers were found to heal as rapidly as acute ulcers when the conflict situation was removed♦ Cathcart(17), like Zane, emphasizes significant factors in the early childhood history of the patient.

On

the basis of his experience with ulcer patients in a Canadian Army Hospital, he concludes that: In all instances of ulcer an insecure looking child­ hood background plus some disturbing concern in relation to the immediate life situation was uncovered. The most frequent combination of emotional factors seen by the author were: mother given to worrying; a background of insecurity or resentment in the patient; some immediate cause for concern or frustration. Deep seated resent­ ment which generally remained unexpressed, was the most common single factor. It is the inability to express current resentments outwardly which produces ’inner tensions* and dysfunction of the gastro-intestinal tract. Beneath a placid, unemotional exterior there is often a seething struggle and the battleground is the ulcer bearing area. Pickard(76) in reporting conclusions of his study of a small group of ulcer patients, emphasizes anal fixations as well as oral fixations!

He maintains that the inward turning

of aggression has been found to be fixated at the anal and oral levels and is directed toward the gastro-intestinal tract. In addition he describes a typical overt personality pattern for the ulcer patient which is similar to that described by many other investigators:

overly conscientious, aggressively

alert but constantly worrisome, discontented, frustrated, resentful, insecure and defensive. In a recent psychiatric study on naval personnel,

59 Cox and Junnila(20) concluded that an underlying anxiety neurosis is a major factor in the etiology of duodenal ■ulcers. Anxiety symptoms occurred in combination with gastro-intestinal disturbances, or preceded the appearance of the ulcer. Harris(46) reviewed the histories of fifty men with upper gastro-intestinal complaints. in a military hospital.

All of them were studied

One-half of the group had pre-service

histories of similar symptoms, the other half had no previous history of the present complaint.

In psychiatric interviews

the author reports that he found the emotional attitude of the 25 patients developing gastro-intestinal disturbances only after entering military service, as contrasted with that of the other patients, was frequently one of conscious and freely expressed angry resentment.

In addition more of them

reported their mothers as the real "bosses" in their homes than did the controls. Behfuss(80) on the basis of clinical observation of cases makes the statement that he finds himself "constantly recognizing not only the ulcer syndrome but the ulcer type, many with the physical characteristics described by Draper(26), and usually dynamic, high strung and alert; in­ telligent and active.

The patient is ambitious, restless and

drives himself, working always under tension and at the maximum of effort, thus placing severe strain on his auto­ nomic nervous system.”

Another observation based on clinical impressions is that of Robinson(8l), who reports that ulcer patients display a relatively calm exterior and do their worrying alone and within.

They belong to the active driving group, rather

than the lethargic, slow-moving and slow-thinking group. They do not concentrate well, skim rather than probe, have bad memories and a tendency to view strange situations with suspicion.

They are not hypochondriacal, but look to the

future with hope and eheerfulness, and have a strong compassion for humanity in general. Unlike Catheart(17)> who reports that frank anxiety neuroses and peptic ulcer are frequently seen in the same patients, or Cox and Junnila(20) who state that an anxiety neurosis precedes or underlies development of the peptic ulcer, Robinson(8l) maintains that they neither have anxiety nor compulsions.

This difference of opinion may well result

from the fact that while Cathcart1s patients were in the army and Cox and Junnila*s patients were in the Navy, Robinsonfs patients were civilians.

In the relatively '’normal"

conditions of civilian life, where the anxiety is not so overwhelming as it is in combat areas, and where it is not considered as reasonable to express anxiety, it may be that not only dependent needs for love and hostile reactions must be suppressed under these conditions, but also the anxiety

61 which is related to these two, must he bound and channelled. The soldier, perhaps, feels more justified in expressing anxiety as well as hostility towards authority in speaking to the physician than does the civilian.

Or it may be in

civilian life, that if the hostility is suppressed the conforming behavior is rewarded by the anxiety being dissipated.

In combat areas, contrariwise, continuing to

conform to the demands of the authority figures may mean not being rewarded, but a greater likelihood of being returned to more combat and possibly being injured or killed. Rubin and Bowman( 87) studied one hundred peptic ulcer patients with the hypotheses that peptic ulcer cases were associated with a definite personality constellation and that EEG findings may be influenced by personality factors. Saul, Davis, and Davis(99) had found a high Alpha index was characteristically associated with a passive, dependent, receptive attitude toward other persons and that a low Alpha index was usually associated with a consistent, welldirected, freely indulged drive to activity.

These results,

together with the findings by Alexander and others that a passive dependent personality type was associated with peptic ulcer, led the authors to believe that an EEG study of peptic ulcer patients would be of distinct value in the critical evaluation of the validity of these studies.

62 They found that 71 per cent of their peptic ulcer cases had a dominant Alpha index as contrasted with a normal group in which only 20 per cent of the cases had a similar index.

Three and one-half times as many dominant Alpha

records were found in the peptic ulcer group as in the normal group.

Almost all of the patients who were not in

the dominant Alpha group (71 per cent) were in the ,frare Alpha” group (20 per cent).

Assuming the results of Saul

and Davis to he valid (high dominant Alpha record correlations with passive personality), the authors concluded that they had demonstrated a close relationship between peptic ulcer and a passive, receptive, fundamental personality structure. Moses(72) investigated further the psychodynamic and EEG aspects of the connection between the Alpha index and the personality of the ulcer patient.

He obtained

EEG records, under standardized conditions, from twentyfive cases of duodenal ulcer who were selected on the basis of X-ray evidence and serial hospital admission.

The group

consisted of naval inductees between the ages of tv/enty and forty years.

One-half of the group were stationed in the

United States and only a few others had been exposed to severe combat conditions.

Personality data were obtained in

a two hour interview and from observation of the individual during the one hour EEG recording.

The EEG data showed a

63 high incidence of dominant Alpha activity; 76 per cent of the cases were in the dominant alpha group, and 20 per cent had a rare alpha rhythm* Moses characterized the personality constellation of the group as having "marked feelings of insecurity" associated with strong passive-dependent trends*

The group

showed a strong reaction against these trends with the development of "a facade of independence and aggressive­ ness*"

He concluded that the ulcer syndrome was probably a

result of the reaction of this personality constellation to the frustrating service environment. Psychometric studies* Euesch et al(93) investigated the "social and psychological factors in duodenal ulcer patients with special emphasis on situational difficulties and their relation to the character structure of the individual*"

The subjects were divided into two groups:

twenty civilians and forty-two Navy men*

These groups were

compared with a control group of seventy-two subjects with chronic diseases. Data were gathered by conducting five interviews with each patient, using open-end questions which were successive­ ly focused on the following aspects of the problem: "Material related to the patients* war and battle experiences and the circumstances surrounding the onset of symptoms;"

64 11attitudes regarding authority and superiors5” "attitude toward doctors, medical personnel, hospitals, and case history;11 "childhood history and his relationship to parents and siblings;"

"adult personality, his present difficulties,

sex adjustment, interests and sentiments.” The following psychological tests were used:

A short

form of the Ifechsler-Bellevue intelligence test consisting of the vocabulary, similarities, block design, and digit symbol tests;

an abbreviated form of the Minnesota

Multiphasic Personality Inventory and the Rorschach test. In addition each patient was asked to write an autobiography. General characteristics of the population studied were summarized as follows: istic of the ulcer group:

"Features which are character­ Age, around 30.

they tend to be middle aged. average.

Interests and hobbies above

High rate of arrests for minor misconduct.

in common with the delayed recovery group: between 20 and 30. 0-2.

If bachelors

High divorce rate.

Intelligence above average.

Age at marriage

Number of children

High percentage of

abstinence from drinking (in civilian group). common with the population at large: marriage.

Features in

Average duration of

Average distribution of occupations.

distribution of religious affiliations. sentences.

Features

Average

No jail or prison

A remarkably law-abiding group.

Avoidance of

65 injuries, accidents, fights, fractures, operations, and veneral disease.*1 Psychiatric interview indicated that 69 per cent of the Navy men and 85 per cent of the civilians suffered from anxiety attacks before the onset of the disease.

The Naval

personnel suffered primarily from acute or subacute ulcers, while the civilians had predominantly chronic ulcers. Physical and mental symptomatology was more severe in the civilian cases.

The situational factors at the onset or

recurrence of the symptoms seem to involve both adjustment to new ways of living, new cultures, and changes in social status, and also separation from beloved persons. Abbreviated Wechsler-Bellevue I.Q.*s were found to average 107 for the naval group and 111 for the civilians. These did not differ significantly from the fldelayed recovery” control group.

The range and variabilities of I.Q. in all

groups were equal to those in the general population. On the Minnesota Multiphasic the authors found that 90 per cent of the civilian ulcer patients had abnormal profiles, which was a higher percentage than for any other group studied.

Approximately 70 per cent of the Navy ulcer

patients had abnormal profiles.

This was lees than the

percentage for the ”delayed recovery” group.

The civilian

group scored highest on the Depression, Hypochondriasis,

66 Hysteria and Psychasthenia scales.

The naval group scored

highest on the Hypochondriasis, Hysteria, and Depression scales.

The authors feel that the most common abnormal

personality.trends indicated by this test are related to hysteria. The Rorschach showed the following deviations from normal expectancies:

an excess of whole response over

details, a predominance of movement over color and an animal over human movement, the free use of shading as texture and achromatic color, and the predominance of color-form responses over form-color.

Other deviant features characterizing

group trends are the small number of responses, the many popular and conventional responses, and the form-quality which is in the direction of vagueness.

Most records showed

both color and shading shock with the shading shock being more predominant.

The authors feel that all of the Rorschach

findings imply a primitive, simple kind of personality organization without mature ego development. In studying the personality sti*ucture of the patients all available clinical material was used.

In terms of need

variables their study revealed the patients a© dependent, conforming, overtly counteractive, and covertly passive. They lacked needs for acquisition, order and construction and do not avoid blame.

67 Analysis of the character conflicts reveals that dependence-non-dependence and aggression-nonaggression constitute the most ambivalent personality areas for these patients* The overt manifestations of aggression are related to the dependence conflict. Overtly depend­ ent persons showed a lack of aggressive tendencies, while the. covertly passive but overtly counteracting persons directed their aggressive tendencies into socially acceptable channels. Attachment to one parent and relative isolation from siblings made these persons perpetually hungry for love and affection. In continua­ tion of this childhood pattern their strivings as adults served either to insure moral support from one person or to attain recognition by achievement. Changes in en­ vironment which tended to separate these individuals from their source of reassurance, or situations which made counteraction and achievement impossible, preci­ pitated a breakdown(94)• The genetic childhood events of the ulcer patients were studied by reconstructing the family constellations illustrating the relation of the patients to their parents with the help of the patient's childhood memories.

These

were classified into three groups relating to the source of affection, authority, and the source constituting the ideal model.

"A large percentage of the naval ulcer bearers fall

into the pattern of a dominant mother and uninfluential father.

In contrast, the civilians seem to have had an

affectionate and idealized mother who protected the children against an extremely punitive father.”

The ulcer bearers

tended to be the younger or youngest children and were sepa­ rated from their next older or younger siblings by a space of several years which isolated them from the rest of the children.

68 The social class membership of the ulcer patients studied was primarily lower middle class.

There was a high

frequency of the group studied in the process of culture change.

These individuals are persons who wish to improve

their social position or persons who already have managed to increase their prestige, or persons who have had to adopt naval culture or change from other ethnic to American status.

Acculturation and social mobility were found to be

one of the most important sources of stress. Two ulcer personality types.

As a final consideration

in the review of the ulcer studies, special attention will now be paid to what has been said in the literature about the fact that there might be at least two different types of ulcer personalities:

Those who predominantly frustrate

themselves and those who accept their dependency but are frustrated by the environment.

This aspect of the total

problem is of special interest and more attention has been directed to it just recently in the literature.

A major

purpose of the present study is to compare the personalities of two separate groups of ulcer cases, as well as comparing all the ulcer cases with all the asthma cases. While reference is made to two distinctly different types of ulcer personalities, this is for convenience only and they are not actually conceived of in terms of a dichotomy.

69 Of course, their distribution in regard to any particular personality variable will be found to be on a continuum* What is meant here, is that instead of getting an approximate normal curve of distribution for the whole ulcer population, the distribution will rather-tend to be bi-modal, in regard to such an important variable as their acceptance of their intense dependency needs, and other important variables* There has been relatively little treatment of this aspect of the problem in the literature*

The present study

is the first psychometric study we are aware of that has set out to check the hypothesis that there is such a bi-modal distribution*

Although Ruesch(94) has given data to warrant

such a conclusion, he compared his Navy ulcer patients with civilians for the purpose of determining the importance of precipitating situational factors.

In this sense the present

study has had the purpose of a follow-up study to check Ruesch!s findings that there are essentially two types of personality structure ih ulcer patients. Alexander(1) at the time of his original formulation of his theory in 1934* already had pointed out that one could distinguish at least two personality types in his group of nine analyzed patients: This one example alone shows that • • • the specific external situation in which the patient lived created a conflict through external deprivation similar to the one which in a majority of cases is produced by internal deprivation as a result of an inner conflict.

70 Kapp(54), in his psychiatric interview study of 20 cases, found that the ’’personality facade may vary from exaggerated independence to parasitic dependence.” Grinker(42) arrived at a similar conclusion in his study of soldiers with gastro-intestinal complaints: Even actual contrasts to the expected personality profiles were encountered . . . Appropriate reaction formations and overcompensations were present in some patients but most of our young soldiers revealed direct evidences of the manifestations of aggressivity or passivity in their character formation . . . The aggressive overcompensation against passive dependency . . . was certainly not a characteristic finding. Ruesch(93) reported a similar distinction between the statistical average personality type of his Naval patients, and the average of the civilian patients: Overtly dependent persons (Naval) showed a lack of aggressive tendencies, while the covertly passive but overtly counteracting persons (civilian) directed their aggression into socially acceptable channels. The foregoing evidence from the literature was considered sufficient to hypothesize that in the present study the sample of ulcer patients will be found to consist of essentially two,^nersonalitv types:

1.

Those self-

frustrating of their dependency needs, who are covertly passive but overtly counteracting in their personality. 2.

Those whose dependency needs are externally frustrated,

who are overtly passive and dependent in their personality. Summary.

The results obtained in evaluating the

ulcer patient’s personality are quite clear.

There is

71 remarkable agreement from all sources, psychometric, psychoanalytic, and psychiatric, that these patients are passive, oral individuals who react aginst their strong needs for love and affection. Several of the studies emphasize that, in addition to the patients* anxiety, insecurity, guilt, frustration and compensatory strivings, the emotional reactions of hostility, resentment and aggressiveness are of special importance in understanding these cases.

The relationship

between the underlying dependency needs and the hostile emotional reactions, and the conflict resulting from these two contradictory forces, has not been carefully investigated with the notable exception of the study by Ruesch et al. The literature further suggests that there may be a bi-modal distribution in the personalities of ulcer cases. At one end of the distribution are personalities who overtly are overcompensating, aggressive and achieving, they are the ones who themselves frustrate their underlying dependency needs.

At the other end of the distribution are personal­

ities who are overtly more passive and dependent, but whose dependency needs are frustrated by the environment.

This

bi-modal tendency in ulcer personalities will be considered as a major hypothesis of this study and an attempt will be made to determine from the test data whether the hypothesis is supported or not supported.

72 IV SUMMARY OF STUDIES WITH REGARD TO PARENT-CHILD RELATIONSHIPS In the review of the literature, it has been seen that the majority of investigators have reported findings regarding parent-child relationships.

These findings will

now be summarized for they are pertinent to the hypotheses which will be presented in the last section of this chapter. Findings regarding asthma patients.

French and

Alexander(3?) report conclusions based on psychoanalytic therapy with asthmatics.

They found that all twenty-seven

cases showed deep seated insecurity and a more or less intense need for parental love.

They showed in many cases

that the acute asthma attack occurs in place of a repressed cry in reaction to temptation that threatens the patient with loss of the mother's love.

This might be a dependent call,

a hostile crying out, or a confession of a sexual temptation which is ".choked11 in patients throat.

A typical family

constellation in the early childhood of these patients is one in which the mother is over-protective to the little boy and binds him to her in a dependent relationship but immediately rejects the first signs of infantile genital interest in her, so that she appears at once seductive and prohibitive.

It would seem that the precipitating situation

is not the actual fact of separation ibom the mother but the

73 indecision and conflict between the urge to cling to the mother and the need to separate from her*

Fear of the father

does not seem to play so great a role as it does in the usual oedipal situation.

They found that it is rather the

loss of the father’s love that is feared.

The father seems

in fact to play the role of a mother substitute* Fenichel(32) writes that the asthmatic cry is a cry for help to the mother, an attempt to introject the mother by respiration, in order to be permanently protected - - a reaction to fear of separation from the mother. McDermott and Cobb(62) on the basis of psychiatric interview report that hirty of a group of fifty asthma patients had neurotic traits usually of a compulsive character, which might indicate a rigid up-bringing, with repressed hostility toward the parent figures. Brown and Goitein(14) compared asthmatic patients with patients suffering from other allergies by means of psychiatric interview.

They report asthmatics as having more paranoid

features, repressed hostility and self-punishment motives than the control group.

Rubin and Moses(88) studied asthma

patients by EEG recordings and interviews.

They report

asthmatics as being passive dependent individuals with mothers who had been over protecting and dominating.

Miller

and Baruch(68,69) compared asthmatic children with non-

74 asthmatic children by means of a diagnostic play session with each child and an interview with the mothers*

They found

that both groups often felt rejected and became hostile to their parents, but the asthma children are afraid to express hostility and repress it*

They appeared to develop asthma

attacks to punish themselves as a result of guilt over hostile feelings.

They found evidence of maternal rejection

in 98 per cent of the asthmatic children studied, with overprotection in 57 pel* cent of the cases.

The maternal reject­

ion evinced in the control group was 20 per cent. In a psychometric study of asthma children and nonasthmatip siblings, Fine(33) reports the followings

On the

Despart Fables, asthmatic children were more hostile towards the mother and less hostile toward the father than were their siblings, and as a group, showed significantly more dependency. On the MEPS and TAT the asthmatic children expressed more sexual conflicts centering around the parents.

They showed

greater dependency, and more desire for a good family, with greater underlying hostility to the parent figures.

In the

interview the asthmatic children expressed the feeling that their mothers misunderstood them significantly more often than their siblings expressed this feeling of being mis­ understood. Findings regarding ulcer patients.

Draper and

15 associates(26) by the case history and interview method found the most common feature of ulcer cases to be the fear emotion. Of eighty cases, 97 per cent showed a persistant hold on the mother with fear of loss of the mother’s approval.

Other

fears expressed concerned insecurity, aggression and sex, Alexander(l) studied ulcer patients by means of psycho­ analytic therapy.

He found intense oral receptive wishes and

the wish to be taken care of and loved against which the patient fights because of guilt and feelings of inferiority. If the wish to be loved as one formerly was by the mother is denied gratification, the associated tendency for being nourished is energized, and stomach symptoms are produced. Later Alexander emphasized that the dependency, passivity and fear of failure was due to the intense nature of the oedipal relationship and the resulting guilt derived from it, inhibiting aggressiveness, Halliday(45) reports on a large number of ulcer cases studied by means of psychiatric interviews.

He found that

all had a deep seated sense of insecurity and dependence. The majority attempt to overcome this by showing on the surface an over-emphasized activity and independence5 a minority, however, are dependent persons who used their illness to excuse their inadequacy and secure attention. Van der Heide(49) psychoanalyzed two ulcer patients.

He

reports that hoth had "been passive, submissive children, attached to their fathers.

There was a renouncement of

aggressive impulses which are oral in nature.

This oral

aggressiveness caused guilt and led to overcompensation. Garma(38) analyzed fopr ulcer patients.

He reports strong

family attachments and a dominant role for the mother; infantile inactivity as a result of mother fixations persist­ ing to adulthood; inactivity combined with compensatory overactivity satisfying the ambivalence about activitypassivity; guilt feelings result from strong oral aggressive wishes and this leads to aggression against themselves. Kapp and assoeiates(?4) studied twenty ulcer cases by psychiatric interview.

They found that all their cases had

strong dependent desires which were secondary to either re­ jection or spoiling in childhood.

Zane(lihl) reported on

eighty-five cases studied and treated over two years.

He

found the common conflict in all cases studied was one in which the individual feels compelled to behave in a certain manner in order to achieve and succeed, despite his anti­ cipation of failure.

The conflict was found to have begun

in early childhood, where the child seeks security by striving to meet rigid, exacting standards set up by the early authoritative figure.

The emphasis here is more on a

conflict over submission, rather than over dependency. Cathcart(17) like Zane, emphasizes significant factors in

early childhood history*

He reports that the most frequent

combination of emotional factors seen were:

mother given to

worrying; a background of insecurity or resentment in the patient; some present-day cause for concern or frustration. Harris(46) reviewed the histories of fifty men with upper gastro-intestinal complaints.

One-half of the group has pre­

service histories of similar symptoms, the other half had no previous history.

More of the latter group reported their

mothers as the real "bosses11 in their homes.

Bubin and

Bowman(8?) * Saul and Davis(98) and Moses(72) have studied ulcer cases by means of EEG records.

All report a large

percentage of these patients demonstrate a high Alpha index which is characteristically associated with a passive, dependent, receptive attitude toward other persons. Ruesch et al(93) investigated the social and psycho­ logical factors in duodenal ulcer patients by means of psychiatric interview and psychological testing.

They

report two sub-groupings regarding personality characteristics of the ulcer patients.

One sub-group had reacted against

their dependency needs - - - a self-imposed frustration whereas the second sub-group had developed ulcer symptoms because of frustrations of dependency needs imposed upon them by the environment.

The core conflict of both sub­

groups centered in the areas of aggression and dependency.

78 Overtly dependent patients showed lack of aggressive ten­ dencies while the covertly passive patients who reacted again­ st this passivity directed their aggressive tendencies into socially acceptable channels.

In regard to the parent-child

relationships it was found that a large percentage of the self-frustrating sub-group seem to have an affectionate and idealized mother who protected the children against an extremely punitive father.

In contrast the environmentally

frustrated sub-group had a family constellation of a dominant mother and uninfluential father. V. HYPOTHESES The following hypotheses regarding the parent-child relationships of peptic ulcer and bronchial asthma patients will be studied. the literature.

These hypotheses have been inferred from The particular studies from which each

hypothesis was derived are indicated by bibliographical reference numbers.

The study will use the following

rationale in testing the hypotheses:

where the literature

states an hypothesis that a particular relationship exists between the parents and children in one of the psychosomatic groups, and where no similar relationship is stated in the literature concerning the other group, this relationship must be found in test data significantly more often in the

79

former group in order for the hypothesis to be considered supported. 1*

The ulcer group will react to mother-figures as

being dominant, overprotective and holding a high level of aspiration for the child.(1)(46)(54)(93)• 2.

The aggressive ulcer patients will tend to idea­

lize the mother-figure more than the passive ulcer patients.(93) 3*

Ihe asthmatic group will react to mother-figures

as being dominant, overprotective with the dual role of being seductive but at the same time prohibitive and reject­ ing. (35*68,69,88,74) 4.

There will be more overt affection expressed

toward the mother-figure by the ulcer group than the asthma group.(93) 5*

The asthmatic cases will evince more suppressed

hostility toward the mother-figure than will the ulcer cases.(74,14,69,32) 6.

The asthma eases will express more concern over

the conflict between the urge to cling to the mother and the need to separate from her than will the ulcer cases.(35 *32) 7*

There is no consistent pattern in the reaction of

ulcer cases to father-figures.

80 a)

the passive ulcer cases more often will un­

consciously react to father-figures as if they are weak ineffectual individuals who are dominated by the mother-figures, however, consciously they do not accept this failure in the father role.(93) b)

The aggressive ulcer cases will more often

unconsciously react to father-figures as if they are dominant, assertive individuals, however consciously they consider the father-figures to have failed in his responsibility for support of the family.(1,93 *104) 8.

The asthma cases will react to father-figures as

if they are submissive and passive individuals in their relationship to the mothers, but who are giving individuals and frequently play the role of mother substitute.(35) 9*

The asthmatic eases will express more of a tender

attachment to an understanding father-figure, whereas the ulcer cases will more often see the father-figure as an aggressive challenging individual.(35*93) 10.

There is one additional hypothesis which is not

presented in the literature, but which is believed by the writer to be indicated: a)

The asthmatic cases and the passive ulcer

81

cases will have more identification with the motherfigure than the aggressive ulcer cases. h)

The aggressive ulcer cases will have more

identification with their father-figures than the asthmatic cases and passive ulcer cases.

CHAPTER III MATERIAL AND PROCEDURE General design*

In the psychological studies that

have been made of groups of patients suffering from specific psychosomatic disorders, nearly all have used cases without psychosomatic symptoms for a control group.

This method has

the advantage in that it approximates a "normal control" group of some sort and enables the investigator to proceed to determine how the psychosomatic person differs from the non-psychosomatic, or so called "normal" individual.

But

the present method of comparing two differing psychosomatic groups, each with a distinct disease entity, also has certain advantages. In the former method, in which a psychosomatic group is compared to a non-psychosomatic control, one does not know whether the personality characteristics in which the psychosomatic group differs from a "normal control" group, are due to the general fact of psychosomatic illness or due to some factors specific to the particular psychosomatic syndrome (i.e., ulcer or asthma).

It is contended by some

that there is a general psychosomatic factor that disting­ uishes all psychosomatic individuals by the immaturity of their personality structure from mature, "normal" individuals. If we accepted this as our hypothesis, we might expect to find relatively little difference between the personality

structure of two distinct psychosomatic groups in such a comparative study as the present one*

On the other hand

there have been advanced psychoanalytic theories to the effect that there is an underlying conflict and/or a particular personality structure which is specific to each of the psychosomatic disorders*

It is also believed by many that

there are traits of personality and behavior characteristics of the individuals who have a specific psychosomatic disorder* It is these latter two hypotheses that a comparative study such as this one has the possibility of testing* I

MATERIALS

This study will present one portion of a group research which has been undertaken by four Ph.D. candidates in Psychology at the University of Southern California. The instruments used for the entire project included:

the

Rorschach Test, the Thematic Apperception Test, the Psycho­ somatic Sentence Completion Test, the Psychosomatic Bio­ graphical Data Blank, the Otis Self-Administering Test of Mental Ability, Higher Examination Form C, and the Rosenzweig Pieture-Frustration Study. (A copy of each test not elsewhere published appears in Appendix A.)

The results to

be presented in this paper are based on data obtained from the first five of these six sources.

These will be discussed

84 and the procedures followed in their administration will be presented.

The degree to which each instrument has been

utilized in the preparation of this paper has varied accord­ ing to the appropriateness of each in yielding data regarding conscious and unconscious attitudes toward parent-child relationships• Tottest the hypotheses regarding personality differ­ ences in the two psychosomatic groups, projective techniques appeared to be more appropriate than objective tests of personality which are available.

In recent years, many

attempts have been made to quantify data obtained from projective materials and thus make them more amenable to experimental methods.

This trend has been particLilarly

evident for the Rorschach and the Thematic Apperception Test.

Bell(ll) summarized the advantages of projective

techniques in clinical psychology and difficulties involved in their use: • • .(an) aspect of method common to projective techniques is that they sample individual behavior in a structured event of sufficient brevity to be clinically practicable and of sufficient stimulation to call forth a wide range of individual responses. In interpretation of the responses, the emphasis is upon the personal element shown in the diversity of behavior. Projective techniques emphasize primarily the uniqueness of, the responses - - those qualities that discriminate between individuals. Thus the best technique is that which will command the great­ est range of responses in the shortest possible time. While one goal in the interpretation of these methods

85 is to develop normative standards for the responses, the value of such norms is considered to he not so much how they group persons together by means of similarities as hoy/ they show departures from the norms, or dissimilarities* This means that the re­ sponses on a projective test are less easy to abstract quantitatively under a simple formula than are the choices recorded by personality inventories* It means, further, that the responses to projective tests are usually less easy to treat statistically than are the limited types of responses secured by the paper-andpencil personality tests, thus making measurement of the reliability and validity of the techniques a diff­ icult but essential procedure* It does not mean, however, that quantitative methods are undesired in the interpretation of projective responses. Quite the reverse is true, even though reaching such a quantification is frequently a complicated task . * . in many respects . . . qualitative measures have been the forerunners of quantitative analyses. It is to this point, the qualitative in projective techniques, that the strongest criticism has been directed - but, that there is a qualitative element in scoring and interpretation is not usually the result of a preference for intuitive methods but of the complexity of the data to be dealt with, and hence of the difficulty in applying mathematical methods.(11) The Rorschach Test.

At the present time, the Rorschach

is one of the most widely used methods of evaluating personality in clinical practice.

Studies on reliability

and validity of the Rorschach indicate that it is an instrument which is acceptable in experimental research.

It

was selected for use in this group investigation primarily because of the information it yields regarding the personal­ ity structure.

The reader is referred to two other

dissertations based on data collected in this group project by A. S. Friedman(36) and S. D. Prince(78) for a complete

86

analysis.

In this paper a very limited use of the Rorschach

is made concerning the area of identification.

This will be

discussed in detail in section V of Chapter VI. The Thematic Apperception Test. widely used projective technique.

The TAT is also a

Results of studies of

validity on the TAT. have varied to some degree, depending on the method used.

Generally, these studies indicate its

value as a method of obtaining data regarding the subjects attitudes, conflicts, value systems, modes of adjustment, and parent-child and interpersonal relationships. Balken(9) indicates some problems involved in the establishment of reliability and validity in this test. Regarding reliability, the split-half method is difficult to apply because of the wide range of content and amount elicit­ ed from the various cards.

The test-retest method is not

appropriate for it can not be assumed that experiences between testings do not affect the productions.

Regarding

validity, the difficulty lies in the complexity of the material obtained on the TAT.

It is possible to handle a

few variables in such a validation study but not possible to handle statistically all the possible variables in their relationships to one another.

However, attempts have been

made and results indicate the acceptability of this instru­ ment for experimental studies.

87 Several methods have been employed in validation studies.

Murray(74) compared TAT stories with data obtained

from interviews, test, autobiographies, and other projective tests.

Sarason(96) found good agreement between dreams and

TAT protocols.

Balken and Masserman(lO) and Rapaport, Gill,

and Shafer(79) have found statistically significant differ­ ences among various diagnostic groups on their TAT productions. The most commonly used method for studying validity has been the matching method. of the method is cited.

For this reason, an example

Harrison(47) gave the TAT to forty

patients in the clinical setting.

He had no previous in­

formation or contact with these patients.

He wrote reports

on these individuals which were then checked with case histories by an associate.

The amount of agreement was

expressed as a percentage of total agreements plus disagree­ ments.

To determine how much above chance these percentages

were, two control groups were contrasted.

In one control

group of fifteen cases, TAT stories were matched with actual case histories.

He found 75 per cent correct match­

ing for the experimental group which was significantly higher than the chance level of agreement of either control group.

He expresses his results in terms of the "mean

validity index11 which was 82.5 per cent for the experimental group.

88

Of the twenty pictures in the standard set which are used with male subjects, ten were selected for use in the total group research.

The choice of these cards was based

on the consideration of the probability of obtaining data relative to specific hypotheses in certain areas, such as dependency, hostility and parent-child relationships. A brief description of each of the ten cards is quoted from Murray(74), in the order in which they were administered s 1.

A young boy is contemplating a violin which rests

on a table in front of him. 2.

Country scene:

in the foreground is a young

woman with books in her hand;

in the background a man

is working in the fields and an older woman is looking on. 4.

A woman is clutching the shoulders of a man whose

face and boy are averted as if he were trying to pull away from her. 6BM.

A short elderly woman stands with her back turn­

ed to a tall young man.

The latter is looking downward

with a perplexed expression. 7BM.

A gray-haired man'is *looking at a young man who

is sullenly staring into space. 8BM.

An adolescent boy looks straight out of the

89 picture.

The barrel of a rifle is visible at one side,

and in the background is the dim scene of a surgical operation, like a reverie-image. 12M. closed.

A young man is lying on a couch with his eyes Leaning over him is the gaunt form of an elder­

ly man, his hand stretched out above the faee of the reclining figure. 13MF.

A young man is standing with downcast head

buried in his arm.

Behind him is the figure of a

woman lying in bed. 18BM.

A man is clutched from behind by three hands.

The figures of his antagonists are invisible. 18GF.

A woman has her hands squeezed around the

throat of another woman whom she appears to be pushing backwards across the banister of a stairway. This paper is concerned with the analysis of the stories on the first eight of these ten cards. of scoring the TAT is not yet completely solved.

The problem There are

a great many different methods of analysis and scoring of the stories that are possible, and that have been made.

In this

present study, which concerns, itself directly with parentchild relations and indirectly with interpersonal relations in general, the analysis was oriented to point up the inter­ action and relationships of the characters involved in the

90 stories*

For each particular card, categories were establish­

ed in the form of questions derived from the hypothesis.

The

manifest content of the stories was then rated as to the presence or absence of the various categories.

A more

detailed discussion of the system, as well as the establish­ ment of the reliability of the rating will be given in Chapter VI. The Psychosomatic Sentence Completion Test.

This is

test which presents the subject with short phrases which can readily be completed to form whole sentence.

The subject

is instructed to write down the first association that comes to his mind for completing the sentence.

In clinical pract­

ice this test has been found to be a successful controlled projective device for yielding data regarding areas of the personality and revealing significant personal attitudes and themes of the subjects life.

It lends itself readily

to providing data concerning specific hypothesis in that, sentences can be structured in such a way as to force responses to specific situations,; No existing sentence completion tests could be found which were appropriate to the hypothesis of this study, so, a new test was developed by the investigators.

It was

decided that the test would encompass four main areas: hostility, dependence-independence, dominance-submission

91 and parent-child relationships, with an additional miscell­ aneous category.

Some of the items were chosen from sentence

completion tests that are now in use, others were newly devised.

Gut of several hundred items considered, sixty

were chosen by joint agreement of the four investigators. In the final form the test was divided into* two sections (Appendix A ) •

Part I consists of thirty items presented in

an impersonal manner, being stated in the third person (referring mostly to ’’he” and "him”).

Part II consists of

thirty items directly calling for the subjects reaction, being stated in the first person (referring to "I", "my", "me"). -This division was based on the rationale that the subject who is ego-defensive will perhaps feel more free to project his own attitudes when he is given the semantic protective device of non-personal items of Part I, than when he is given the directly personal items of Part II. Each item was designed as a stimulus which it was hoped would be likely to elicit a response relating to one of the four above mentioned variables.

The inclusion of

items which the investigators hoped would elicit material regarding these particular variables, obviously did not insure the items* success in practice.

Many items, of .

course, may either get responses that are evasive or neutral and therefore unscorable for the specific variable, or re­

92 sponses that could be scored for some other variable than the one they were intended for. This paper is concerned with the analysis of twentythree items in the test which are either directly or indirect­ ly related to parent-child relations.

These may be divided

into three main groups, with a varied number of items in each group.

They are:

(a) Relation to mother,

to father and (c) Attitudes concerning childhood.

(b) Relation The

analysis of the data and the establishment of the reliability of the analysis will be presented in Chapter VI. Three studies which have been reported on Sentence Completion Tests are reviewed here in order to evaluate the usefulness in research of this projective technique, the kind of validity it may have, and the degree of reliability that may be expected from it: With a sentence completion test of forty items, Rotter and Wellerman(85), using the split-half method of reliability, obtained an r of .8? (corrected by Spearman-Brown formula). By the method of interscorer reliability, they obtained an average coefficient of .89, using seven raters.

They

compared test results with a psychologists judgment on the severity of the subjects disturbances as determined by an initial interview.

The coefficient was .61.

Symonds(103) has carefully compared data obtained on

93 a one hundred item sentence completion test from ten subjects with data from a biographical information blank which included attitudes, goals, drives, and inner states* The data were not treated statistically.

Symonds concltided

that there were more agreements than disagreements between the sets of data*

Sentence completion items given in the

third person tended to give unconscious projections regard­ ing wishes, hostilities, loves, fears, and motives in general. Items given in the first person tended to give information about these areas when information was available to conscious­ ness. Sacks(95) reports a study directly concerned with the validity of a sixty item sentence completion test.

Psycho­

logists rated the degrees of disturbance of one-hundred mental hygiene outpatients on the basis of responses to the test.

Their bases for such ratings were data drawn from

responses concerning attitudes toward parents, family, heterosexual relationships, authority figures, colleagues, the future, and goals.

Psychiatrists rated the subjects on

the basis of clinical impressions obtained during therapy. The degree of agreement was beyond the .001 level of chance occurrence. The Psychosomatic Biographical Data Form.

Certain

information was desired regarding the patient*s life history,

94 such as:

The social and economic status of his family, the

type of community he grew up in, early developmental facts, childhood experience, his relationships to his parents, his conscious attitudes toward his parents, his educational and occupational history, his sex and marital history, his present status, goals and attitudes.

It was desired to obtain

this information in readily quantifiable form, although it was obvious that some important information would be lost by a questionnaire rather than a personal interview. No available existing biographical data blank appeared to include all the specific items on which information was desired.

Therefore, the investigators developed a form

which could be quickly and easily filled out and did not require the subject to write at length.

Most of the items

were set up so that he could rate his experience or his attitude in a particular area by placing a check mark.

The

subject was encouraged to write in a detailed explanation for any item which he was unable to answer by checking (Appendix A)♦ The Otis Self-Administering Test of Mental Ability (Higher Examination, Form C).

A measure of general intelli­

gence was required for the purpose od determining whether there were any differences in intellkgence between the t"wo groups.

Two qualifications for such a test were deemed

95

necessary:

First, acceptable reliability and validity, and

second, brief administration time*

The second qualification

was based on practical considerations since the test battery required a number of horn’s to administer, and the projective techniques were considered more important to the study than an intelligence test.

It was not expected that there would

be large differences betv/een the two groups in mental ability, and that such a test might serve to equate the two groups for intelligence by yielding similar means and standard deviations of the distribution of their intelligence scores.

The Otis Test of Mental Ability was considered

appropriate for this quick, overall estimate of intelligence. II

PBOCEDUBES

A procedure manual was developed to insure as far as possible standard testing conditions.

At first contact, a

suitable subject was asked to participate in a research of interest to both psychologists and physicians.

It was

explained that he would be given several tests which many people found interesting and it wa,s made explicit that most of the tests were not tests in the usual sense of having right or wrong answers.

He was also told that there was

one test of ability and a group of questions regarding himself.

Nothing more was stated regarding the nature of

the study unless the prospective subject asked for specific details.

In some instances the individuals did not want to

consent to take the battery until they knew more specifically what the tasks involved.

In such cases, the tests were

briefly described in general terms.

Many of the potential

subjects were referred to the investigators by physicians. In such instances, the individuals had been encouraged by the doctors to participate and little or no explanation of the research was necessary.

The subjects participating in

the study were all volunteers in the sense that they were given the choice of either taking the test battery or not. There were several instances in which a subject began testing and then decided not to continue. The Rorschach Test.

All investigators had been

taught Rorschach administration according to Klopfer(?8) and were considered competent by their supervisors.

The

essential points in introducing the Rorschach included statements covering four points 5 the actual wording was left to the particular examiner.

First, the subject was

assured that there were no right or wrong answers to the ink blots.

Second, the subject was asked to simply tell

what the stimulus looked like to him; of what it reminded him.

Third, the subject was told that different individuals

see different things.

Fourth, the subject was free to give

as few or as many responses as he chose* In Rorschach administration, "testing the limits" is probably the procedure -which differs most widely among examiners*

For this study, a blank was developed which

made uniform the administration of this phase of the Rorschach (Appendix A ) . The Thematic Apperception Test*

No well-defined

mode of administration exists for the Thematic Apperception Test*

Consequently, a statement of introduction to the test

was prepared and used by each investigator: I .am going to show you some pictures, one at a time, and your task will be to make up as dramatic a story as you can for each. Tell what has led up to the event shown in the picture, describe what is happening at the moment, what the characters are feeling and thinking, and then give the outcome. Speak your thoughts as they come to your mind. Do you understand? Since you have fifty minutes for ten pictures, you can devote about five minutes to each picture. The protocol was recorded verbatim by the tester. When the subject had finished the first card, the examiner reminded him of the instructions, unless he had faithfully obeyed them.

For the remainder of the test, the examiner

made statements regarding only the following points:

first,

informed the subject as to whether he was ahead or behind schedule|

second, encouraged him with a little praise from

time to time;

third, prompted him with some brief remark if

98 he omitted some crucial detail. in the following orders

The cards were presented

1, 2, 4, 12M, 18GF, 8BM, 6 BM, 131F,

7BM, 18BM. Information wqs desired regarding specific cards.

To

obtain this data, an inquiry was included in the test pro­ cedure.

After cards 6BM, 12M, and 18GF respectively, the

examiner asked the subject to tell him the ages of the people in these cards.

After card 18GF, the examiner asked,

,!Could he (or she) be being choked?" to thfs question was recorded.

The complete response

After all ten cards had been

completed, the investigator asked, "Would you please go through all the cards briefly and tell me which characters you found most pleasant or liked best?

Which characters did

you find least pleasant or liked least?"

Responses to these

questions were completely recorded. It should be noted that the fifty minute time limit was not adhered to in any case.

This rather arbitrary time

interval was established to give the subject the set of five minutes per card rather than a shorter period of time. This was done for the reason that the investigators* past experience with this instrument indicated that most subjects spend less than five minutes on each card.

Consequently,

the usual effect of this time limit was probably to set a more leisurely pace than would have occurred if nottime limit had been stated.

99 The Bosenzweig Picture-Frustration Test. The test blank was presented to the subject with the following in­ structions: Each of the following pictures contains two or more people. One person is always shown saying certain words to another. You are asked to write in the empty space the very first reply to these words that comes into your mind, .Avoid being humorous. Work as rapidly as you can. Most people finish the test in about twentyfive minutes. The Psychosomatic Sentence Completion Test.

The

subject was given this test with the following instructions: Here are a series of incomplete sentences which I should like you to complete as rapidly as possible with the first thing that comes to your mind. Most people are able to complete the sentences in about twenty minutes. Work as quickly as you can. If you can*t complete a sentence at once, make a pencil check before the number and come back to it later. Go ahead. The Psychosomatic Biographical Data Blank.

The

subject was given this blank and asked to fill it out com­ pletely.

It was explained that most items could be answer­

ed merely by checking the appropriate answer.

He was en­

couraged to write further details regarding any item which he felt needed a more detailed answer than was supplied on the blank. The Otis Self-Administering Tests of Mental Ability The standard instructions were followed for this test, as

100

given on the first page of the test folder.

In introducing

this test, it was explained that the test was an intelligence test and it was not expected that anyone would obtain a "perfect score".

The thirty minute time limit was used. Ill

SUMMARY

This chapter has presented the materials used in the group research from which the data presented in this paper were collected.

A review of some pertinent literature

regarding the reliability and validity of these tests was also presented.

Also discussed in this chapter were the

procedures followed in the administration of the test battery.

CHAPTER

IV

SUBJECTS There were fifty-five subjects used in this study. The total number represents a group of thirty patients with peptic ulcer, and a group of twenty-five patients with bronchial asthma.

Both groups were selected for study and

tested in the course of a year*s time at two Veterans Administration General Medical and Surgical Hospitals.

All

subjects were white, American born males between the ages of twenty and forty-five years. War II.

All were veterans of World

This chapter will present both the criteria used

for selection and a description of the general characteristics of the two samples studied. I

SELECTION OF SUBJECTS

To ma&e the comparison of the two groups effective it was necessary to establish strict criteria for inclusion of the subjects in the study.

The reason for these criteria

was to control as many extraneous factors as possible which might have resulted in obtaining differences unrelated to either psychosomatic condition.

For example, if the patients

had not been selected for a certain age range, and a number of older individuals appeared, by random selection in one group and not in the other, it would then not be possible to tell whether certain obtained differences in personality

102

features and attitudes were related to the psychosomatic disorder or related to the fact of the age difference* Similar arguments would apply, if one experimental group included individuals with widely different ethnic cultural background, or racial origin, from the other group; or if one group had a number of foreign-born individuals and the other did not. There are essentially two methods of selection that can be used to achieve holding constant all recognizable factors other than the experimental variable. have matched pairs of cases.

One is to

As for example in this study to

match an ulcer case with an asthma case for all important factors such as age, education, intelligence, marital status, etc.

The other method is to achieve equivalent means and

standard deviations of the distributions of the scores of each factor for the two groups.

In this study the latter

method was used, but with regard to some factors the require­ ments were not completely achieved.

However, it will be

seen that the two groups are sufficiently alike in terms of these extraneous factors, so as to safely ascribe signi­ ficant differences in their personalities, revealed by the tests, to the major experimental variable. In order for a subject to be included in either group, each of the following requirements had to be met:

103 Diagnosis of the disease process*

Every subject was a

patient receiving treatment at a Veterans Administration General Hospital at the time of being tested.

It was necess­

ary for each subject in 'the asthma group to have been unequivocably diagnosed as suffering from bronchial asthma, and for every subject in the ulcer group to be unequivoeahly diagnosed as suffering from peptic ulcer.

In the majority of cases the

diagnosis was made by more than one physician, or in staff conference. being tested.

All patients were ambulatory at the time of Care was taken that they were not suffering

severe pain that would affect their performance, or that they were not under the influence of drugs used in their treatment which would have adverse mental effects. Length of illness.

No individual was eligible for

this study who had a history of suffering from either bronchial asthma or peptic ulcer before his entry into military service for World War II.

This control had the positive

result of ruling out the effects of an illness of long duration on the personality of the individual.

It may have been more

desirable to include only subjects-who had just been diagnosed for the first time.

This, however, was not practical since

most of the subjects had a service connected disability and had received the original diagnosis during the War.

The

great majority of the cases could then be considered as

104 chronic, since their illness had a history of at least three or four years, and their current hospitalization represented the second or third exacerbation* Physical complications.

In order to be admitted to

the study no individual could have symptoms of any consequence of any other disease process, no matter how definitely the diagnosis of peptic ulcer or bronchial asthma was indicated. In this sense only "pure11 cases were accepted without secondary or complicating diagnosis.

Moreover, cases with

disfigurements such as facial scars, amputations, or lame­ ness were excluded. Psychiatric complications. No individual was admitted to this study who was ill with a psychiatric condition at the time of being tested, or who gave a history of a diagnosis of any psychotic process, or severe neurotic condition.

It was practically unavoidable, however, that

some of the subjects would have a previous history of some neurotic symptoms.

The incidence of any one of the follow­

ing symptoms in the history of the patients, as recorded by them on the Biographical Data Form, did not exceed five cases in either group:

nailbiting, thumbsueking, stammering,

night terrors, tantrums, sleepwalking, enuresis, frequent constipation and indigestion.

10?

II

GENERAL CHARACTERISTICS OF THE SAMPLE POPULATION On the basis of the criteria which have been discuss­

ed above, two clear-cut groups of subjects were selected* These were a group of 25 subjects with bronchial asthma and a group of 30 subjects with peptic ulcer*

The method of

selection resulted in obtaining subjects in both groups with the following characteristics:

Caucasian, American born,

male, age between 20 and 45 years, veteran of World War II, unequivocal diagnosis of either asthma or ulcer, and no diagnosis of other physical or psychiatric complications* Further descriptive data were obtained from case records and tests* Age.

Some of these are summarized in Table I, page 106* For the asthma group the age range was from

twenty-three years to forty-one years*

As indicated in

Table I, page 106, the mean age was 29*5 years, standard deviation 4.8*

In the ulcer group the age range was twenty-

two years to forty-one years. standard deviation 5*8*

The mean age was 32*1 years,

Thus the groups are very similar

in age. Intelligence. As seen in Table I, page 106, the mean intelligence quotient for the asthma group (as measured on the Otis Self-Administering Test of Mental Ability) is 105^9 * standard deviation 12.8.

The mean intelligence quotient for

106

TABLE I AGE, I.