The Core Problem of Psychosomatic Medicine
JURGEN RUESCH, M.D.
INFANTILE PERSONALITY MAY-JUNE, 1948
From the Division of Psychiatry, University of California Medical School, and the Langley Porter Clinic, San Francisco, California.
This is the third paper in a series entitled: Experiments in Psychotherapy.
IN A STUDY of the personality of patients suffering from post-traumatic syndromes (30, 31, 32), chronic disease in general (33), duo-denal ulcer (35), and thyroid conditions (34) it became more and more apparent that a common denominator existed in the majority of these psy-chosomatic conditions. Symptomatology (33), per-sonality structure (40), as well as social techniques (37) of these patients pointed to a rather primitive level of psychologic organization. Further evidence for immaturity was found in the need for modifica-tion of psychotherapeutic procedures commonly employed in the treatment of psychoneuroses for use in the rehabilitation of these patients (33). The common denominator then was identified as re-lated to faulty or arrested maturation, and somatic manifestations were recognized as constituting means of infantile self-expression. In the present paper an attempt is^made to discuss the immature personality as related to psychosomatic conditions, thus providing a better understanding of the psy-chotherapeutic needs of these patients.
When an individual goes through the various phases of psycho-physical development and then breaks down, terms such as fixation and regression have been introduced to denote that the individual returned to previous levels of adjustment and gratification (18, 20), and if an individual ex-presses certain repressed conflicts by means of symbolic physical symptoms, this process is called conversion (19). Most of these concepts have been derived from the study of highly organized and complex types of psychoneuroses (15). Then, some years ago, the attention of the psychiatrist shifted to the psychosomatic conditions. Though the con-cept of conversion was separated from the concept of vegetative neuroses (4), the attempts at corre-lating specific conflict situations with specific syn-dromes implied the use of the concepts of conver-sion and regression (2). At closer examination of these reports (12), however, one is struck by the importance which various authors (7, ri, 22, 27, 42, 44) attribute to features such as dependence, low frustration tolerance, vegetative or autonomic manifestations, specific and stereotype somatic re-actions 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 author's own conclusions (38, 40). Therefore, it seems justifiable to state how some of the theoretical concepts and therapeutic methods used in the treat-ment of complex and organized psychoneuroses have to be modified when applied to psychosomatic conditions. In the psychoneuroses we deal with a pathologic development, while in psychosomatic conditions one meets primarily arrested develop-ment. Some of these infantile patients, for example, have persisted since childhood in expressing them-selves in somatic terms, though visible pathology developed only after certain habits persisted for a number of years. In these cases it would be erron-eous to apply terms such as regression and conver-sion, when in reality a lack of progression has existed, to which attention is called when physical pathology is discovered. Rehabilitation in such cases is frequently a modified form of child psycho-therapy with chronologically adult patients.
Thus the most relevant clinical problem in psy-chosomatic conditions seems to center around the level of organization at which patients habitually operate. Since maturation is understood best in terms of social learning, reference will be made to the concepts of drive, cue, response, and reward (26). A drive impels a person to respond; a re-sponse as such is action, at first nonsystematized and later learned and organized. Cues determine when and where an individual will respond and which responses he will make. Whether a given response or action will be repeated depends on whether or not it is going to be rewarded. The process of emotional and intellectual maturation, then, consists of correct generalization of responses from the physical to the social sphere, acquisition of cues, discrimination, symbolic self-expression, de-velopment of social techniques and, finally, in-tegration. The state of maturity (6, 43, 45) as op-posed to the state of immaturity (21, 24, 25) is characterized by essentially three features: a) suc-cessful functioning as an independent unit with gratification of wishes in terms of the culture in which the individual lives (36); b) successful bio-logic and social interaction with other people (37); c) self-expression, self-extension, self-objectivation (6, 36). As space precludes further elaboration of the concepts set forth, the reader is referred to the original publications (36, 37). In applying the theory outlined, one arrives at the following illus-tration of the immature personality.
Arrested or Faulty Social Learning
In terms of the theory of social learning, the in-fantile personality is characterized by the follow-ing criteria:
- Lack of generalization or over-generaliza-tion of modes of response associated with displace-ment of erogenic zones (13, 14).
- Paucity of instrumental actions, characterized by lack of diversification and lack of skill (34> 35> 37)-
- Deficiency in the discrimination of cues; paucity of cues; inability to understand the mul-tiple meaning of cues and roles; ignorance or re-pression of cues arising in self. These propriocep-tive cues which arise within the organism itself are made up of cues contained in instinctual drives (hunger, thirst, sex, etc.), of cues arising after outside interference (anger or anxiety), and of cues which are the result of super-ego or self-inter-ference (anger, anxiety, fear, shame, guilt, depres-sion) (36, 37).
- Substitute gratification prevails over subli-mation, and frustration is not used as a motivation for progression. The substitute gratification leaves vital needs ungratified, and ensuing frustration has to be appeased by more substitute gratification until a vicious circle is established. The rewards sought, therefore, are rather uniform and center around the securing of love and affection (10, 35).
- Social techniques are the result of fusion of instrumental actions with cues and rewards. Inas-much as the goals for which the techniques are de-signed are usually not achieved, true mastery is not accomplished; nonetheless, the techniques are ap-plied over and over again, partly because reapplica-tion elicits self-reward (good behavior), partly be-cause belated mastery is attempted. Manipulative ability for handling people, therefore, is much poorer than manipulation of objects or materials (9,11.36,37)
Genetic childhood events leading to faulty or ar-rested social learning are:
- Lack of continuity and consistency in per-sonal contact (marital discord, broken homes) (30, 32. 33> 34> 35)
- Uneven distribution of parental functions between the two parents; for example, one reward-ing with the other punitive, or, one the central fig-ure with the other peripheral (10, 16, 23, 34, 35).
- Change of parental attitudes towards child with arrival or departure of other siblings, or change of attitude between parents themselves are influences which can usually be mastered by a healthy child. However, these events can become traumatic if they occur at a period when the child is occupied with adaptation to other events, and needs a consistent attitude at home (16, 34, 35).
- Isolation from siblings in terms of years (35)-
- Lack of well-defined and consistent social structure among siblings, between patient and par-ents, and among the family as a whole (34, 35).
Genetic childhood processes leading to faulty or arrested social learning are:
- Absence of unconditional love and affection in first few years of life (13, 16).
- Goal rewards given sparingly while sub-stitute rewards predominate (35).
- Punishments administered by one parent containing hidden rewards; or, one parent punishes behavior which the other parent rewards (34).
- Parents not suitable as ideal models either because of their own inconsistency, their own in-fantilism, and their own anxiety, or because they cannot reward, being too punitive; all these factors may lead to incomplete and ambivalent identifica-tion (9, 16, 34, 35).
- Events become traumatic when the child is either biologically or socially unable to master the situation, and, instead of true mastery (technique) the child learns to hide the overwhelming frus-tration by means of defenses which lead to control rather than mastery (8, 9, 37).
Precipitating events leading to first occurrence or recurrence of physical symptoms in partially ma-ture people are:
- A change in external circumstances brought about by death, childbirth, marriage, separation, economic, or social factors. The social techniques and adjustment patterns of immature individuals are insufficient to master the new situations. Frus-tration brought about by the change is not utilized for development of new approaches, and excess tension is expressed in terms of organ language as an emergency measure, especially in children (8). In this case we deal with true regression but not with conversion (33).
- The individual may inadvertently have undergone a culture change through geographical mobility, change of social status, change from civil-ian to military life, or merely by having grown into a different age group. If dependent upon con-formance and outside approval, the individual can-not use his old techniques and systems of values. Inability to experiment with reality, combined with lack of models to be imitated, then produces a breakdown (35, 41).
- Absence of any precipitating events. Here, organ expression always existed and finally led to manifest pathology. The precipitating event did not really precipitate but merely called attention to an already existing process (33).
Poor symbolic self-expression is the result of ar-rested development. The average person learns self-expression in three well-defined steps:
First step: the child generalizes modes of action to the social sphere and learns to expend excess tension in interpersonal relations. If this step is only partially or incompletely mastered because of unsatisfactory early interpersonal relations, self-ex-pression remains on the level of organ responses, either muscular, visceral, or vascular (8, 36, 37). For example, intake, retentive, and output func-tions can be carried out not only by the intestinal tract, but the individual as a whole can apply these modalities in social action. If for some reason this step cannot be undertaken one deals with a partial response of the organism (psychosomatic condi-tion), and not with the distorted total response which is symbolized in one organ system (con-version hysteria).
Second step: if die child is able to generalize, then the processes of discrimination and learning of certain social cues result in organization of more complex actions. Feelings, emotions, and conflicts are expressed at diis level in terms of doing some-thing that will convey to others the desired mean-ing, or which will elicit emotions in the other per-son. Children and adults remain on this level of acting out (1) all internal events or of partici-pating in actions of others by means of projection or identification if the third step, namely, symbolic expression cannot be mastered.
Third step: successful maturation is dependent upon the individual's ability to learn to express or-gan responses, as well as whole actions, symboli-cally (28). Verbal, gestural, artistic, or other ex-pression results in almost as much satisfaction as if organ or action responses had been carried out in full. Symbolic expression (6) widens the sphere of influence and permits more action per unit of time. Mature people operate on a level at which symbolic expression predominates, expression through action has a lesser share, and organ expres-sion is negligible.
Self-Expression and Somatic Manifestations
In sham maturity, or nominal acceptance of symbols, we do not deal with self-expression but with an infantile manipulation of symbols with-out corresponding participation of the individual. The exteroceptive cues are known to the individual but the corresponding proprioceptive cues do not arise within that person. Self-expression then oc-curs on either the level of action or organ expres-sion, especially with regard to tension. Mature persons can discharge tension through initiation of action to remove the cause of the frustration or in-terference, and expend any excess tension through verbal, gestural, or creative symbolisms in inter-personal relations. Immature persons can do neither. They simply get stuck with their tension. This, in turn, means that heart rate, blood-pres-sure, muscular tension, and other mechanisms used for preparation for action are abused (3). In the mature person, action in itself returns the or-ganism to a resting condition, while lack of action in the immature person does not terminate the organism's readiness for action. It seems as if this prolonged state of readiness for action without re-demption can lead to vascular and intestinal pathol-ogy (38, 43). This hypothesis is supported by the observation that when a patient can learn to initiate action or to express frustration through verbal com-munication, physical symptoms tend to disappear. The reverse is true of people who act out (8), in-asmuch as immobilization of such persons usually promotes reappearance of symptoms. This concept would lead to the following classification of psycho-somatic conditions:
- If both symbolic self-expression and action are impossible, excess tension cannot be resolved in interpersonal relations. This tension is then ex-pressed in the striated and smooth muscles of the vascular, intestinal, respiratory, skeletal, and other systems. The choice of the organ is based upon both hereditary and experiential factors.
- If in interpersonal relations an individual chooses action as the prevailing vehicle of expres-sion, resolution of excess tension depends upon the possibilities of carrying out such action. While symbolic expression for the sake of communica-tion needs little or no social space, action-expres-sion needs a suitable setting; otherwise it results in conflict with the environment. Expression through action is, on the whole, gratifying only when there are other individuals who understand this type of communication; otherwise there is either regression or action is used to provide for substitute gratification, compensation, and al-leviation of frustration without getting at the root of the interference. Over-eating, fractures, promis-cuity and venereal disease, alcoholism, drug addic-tion, and multiple operations are examples of pa-thology which may be the result of anxiety-al-leviating activities.
- Whenever symbolic self-expression prevails in interpersonal relations we deal with relatively ma-ture individuals. Psychopathology can, however, arise when the actions designed to remove the frustration are unsuccessful, or when self-expres-sion does not lead to a response in other people (foreign language, prisoner of war, culture change). However, psychopathology in such per-sons is likely to be organized and complex. If somatic symptoms arise they represent true con-version symptoms; impotence, pseudocyesis, hys-terical contractures, or blindness fall into this cate-gory. Regression is here combined with conversion and therapy is frequently of short duration be-cause the patient has merely to be brought back to his habitual level of functioning.
- An incidentally contracted disease can be as-sociated with a totally unrelated psychologic prob-lem because of simultaneous occurrence in time and conditioning (33). Upon closer study such persons turn out to be infantile or hysterical per-sonalities, who, as an emergency measure, regress and then discharge excess tension through their symptoms; thereafter this mechanism is utilized persistently for the management of situational dif-ficulties.
Perception, Thinking, and Ideation
The infant's experiences have different dimen-sions than those of the adult. This is the result of extrauterine maturation which at various stages (13, 14) emphasizes different functions and mo-dalities of action. The adult, in turn, is not compelled to use certain modalities more than others. If he does, it is the result of cultural influences or of traumatic events in early childhood. Distortion of the problems of prestige, intimacy, and identity can occur (37) when mastery is not achieved and control is substituted for it. In such cases the child's thinking has become distorted and gratification has been projected into the future. For ex-ample, a child might consciously expect that by next year he will be taller and bigger and stronger, that he will have more rights, more abilities, more skills, and that he can satisfy more demands. This experience of growth leads to a faulty generaliza-tion which teaches the child to set ideals and goals well ahead of real ability. As the child gets older the period of rapid growth ends. Goals and ideals have to be reset, and instead of hoping for new experiences and magnification of existent experi-ences a readiness for acceptance of the status quo has to be developed. Physical as well as psycho-logic growth follows a curve which is steep in the first few years of life, and which gradually flat-tens out when maturity is reached and subsequently changes into a decline (29). Mature people are aware of these changes and know that linear gen-eralizations from the past into the future cannot be made. The infantile but chronologically adult personality, however, tends to continue with such expectations, which constitutes the basis of magic and omnipotent thinking. Such an attitude fre-quently impresses the observer as being a sign of youthfulness and optimism, while in effect it con-stitutes inability to discriminate, which then leads to a distortion of reality. In these cases fantasy does not fulfill the function of sublimation or an-ticipation (8) but substitutes for action and there-fore constitutes a defense mechanism.
In the infant mastery of reality is achieved either through experimentation, that is, learning through trial and error, or through imitation of parents or other adult persons with whom a significant inter-personal relationship has been established. This latter form of learning compensates for the insuf-ficent strength and experience of the child and en-ables rapid growth, a process which consists of transferring relevant cues and of rewarding the act of imitation (37). If the child had to find out by himself all the aspects of a modern, technical civilization he would have to live thousands of years. While in childhood dependence is instru-mental for reaching maturity, in adulthood the ef-fect of learning through imitation prevents ma-turation and obliterates utilization' of experience gained through learning by trial and error. Per-sistence of this infantile pattern of imitation in adult persons is usually caused by inability to form consistent and clear-cut proprioceptive cues which would enable the individual to proceed on his own. Thus he does not react to signals of an-xiety, anger, or fear; he does not react appropriately to his urge for sex, hunger, or shelter, and he does not know about his needs for membership in a group. Instead, he relies upon cues received from others, which necessitates permanent guidance and support by others. These infantile personalities can live only in close symbiosis with other persons, since they do not possess an identity of their own.
Conscience and Ideals
When the infantile personality reaches a cer-tain level of organization, the suger-ego is char-acterized either by an overbearing conscience and high-pitched ideals, or by weakness or absence of these functions. If the conscience is powerful it dictates in a stereotype manner in terms of good and bad, making operational assessment of reality impossible. Since judgment and experience are not utilized the individual relies upon values and rules which derive either directly from others (overt de-pendence), or which have been internalized (de-pendent upon suger-ego). The naive observer is frequently impressed by the pseudo-maturity dis-played by people with a rigid super-ego. On closer scrutiny it is easy to recognize that ideals are high-pitched and out of proportion to the individual's potentialities, while a restrictive conscience im-pedes free choice of responses and gratification of vital needs. High-pitched ideals result in depres-sion and disappointment, and a strict conscience leads to self-condemnation and appeasement of guilt in terms of self-punishment. Such patients become so dependent upon these impulses arising in the super-ego that they appear to be controlled, driven, and forced to act in a stereotype way. In-stead of using impulses arising in the super-ego as mere warning signals, the moral forces in these in-fantile individuals seem to lead to the establish-ment of an intrapsychic dictatorship which is not felt as an integral part of a person but somehow remains a foreign body and is felt as a burden or pressure. Therefore, identification with groups, movements, ideas, and values becomes difficult; in-stead, destructive and secondary ego-identification with other persons prevails. While ego-identifica-tion is the result of fear or anticipated threat lead-ing to a siding with the more powerful enemy (17) and ultimately leading to its destruction, super-ego identification (15, 29) is the mechanism which enables permanent and solid group identi-fication. Ego identification is instrumental and ancillary in character, while super-ego identifica-tion emphasizes values and goals. In a mature in-dividual, however, all these part functions are in-tegrated and therefore cannot be isolated.
Integration and Compensation
The lack of integration of the infantile per-sonality is not expressed only in fluctuations of super-ego pressure. There is a remarkable absence of hierarchical organization of perception, involv-ing stimuli arising outside (exteroceptive cues) as well as inside the individual (proprioceptive cues involving drives, gratification, and interfer-ence). Experience enables a mature individual to establish a rank order and hierarchy in perception and thinking, as well as in action. This hierarchy is unknown to the infantile personality, and in adapting to the surroundings the hierarchy is de-rived from other people. This impresses the ob-server as flexibility and adaptability while in reality it is based upon inability to assess what is appropriate for a given situation. The result is an excessive degree of conformance to standards either prescribed by the culture, by the family, or by cer-tain persons. It was found to be particularly true of the middle class (33, 34, 35) where parents through hostile overprotection tend to prevent the children from learning by means of trial and error. The children, in turn, are unable to acquire proprioceptive cues, as well as a hierarchy of ef-ferent and afferent functions and independence. In adulthood infantile personalties tend to emphasize in their basic orientation similarity with others, which is expressed in conformance and in hostile identification with other persons necessitating re-pression and lack of self-expression. This tendency prevents the establishment of a mature optimum between independence, originality, and difference, on the one hand, and conformance, group partici-pation, and similarity, on the other.
In our progressively technical, and urban civili-zation there is a tendency to overprotect children and to raise dependent and immature individuals, since at an early age there are already dangers to be avoided and gadgets to be mastered—necessita-ting transfer of relevant cues to the children by means of models. In contrast, in a suburban or rural section there is the tendency for the child to experiment and gain self-confidence. Lacking this internal security, which lack is expressed through inappropriate self-expression and unawareness of proprioceptive cues as well as defective integra-tion, infantile personalities tend to establish an ex-ternal and compensatory security system. Since they tend to overevaluate exteroceptive cues and do not trust proprioceptive cues, they surround themselves with indicators of their own value, their own pres-tige, their own success or failure, and their own position in the group. The opinion of others as-sumes unusual proportions, and the impression made upon others becomes a vital factor. Break-down of immature personalities cccurs when re-liance upon the external security system is impos-sible, when there is no model to be copied, when personalized rewards in terms of affection are un-obtainable, or when independent action is neces-sary (35). To express it in other words, one might say that breakdown is precipitated in dependent personalities through separation from the source of dependency, or when compensation is made impossible.www.psychspace.com