Many illnesses are caused by organic factors, such as pneumonia.
These organic diseases are those studied most easily by laboratory techniques. Some other illnesses, such as psychoneurosis, seem to be almost entirely functional, with psychological conflict their predomi-nant etiologic factor. Neither group is exclusive. There are always psychological reactions to organic illness, and the functioning of the body is clearly affected by the emotional state of the patient's mind.
Cultural stereotypes, such as aging, may contribute to psychosomatic problems (Sachs, 1982). Stress is conceptualized as the mediating link between environmental, social, and psychological factors and the onset of psychosomatic illnesses (Sachs( 1983).
There has been increasing recognition, particularly since the 1940s, that some diseases seem to fall between the primarily organic and the primarily psychological illnesses. Conditions that fall into this category come readily to mind—peptic ulcer, ulcerative colitis, bronchial asthma, some skin disorders, and some cases of arthritis. Such dis-orders are generally referred to as ''psychosomatic," although the term
"psychophysiological" has been more in vogue during recent years.
No clear dividing line exists between psychosomatic disorders and the adjacent categories of physical and emotional illnesses. Franz Alexander introduced a distinction between illnesses manifesting pri-marily through the voluntary nervous system and those principally affecting the involuntary autonomic system. T h e latter are termed
"psychosomatic," while those expressed through the voluntary
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culature are considered more conversion " r e a c t i o n s " and are thought to have a more symbolic meaning,
For example, a man who felt dominated by his aggressive wife, yet felt that to speak to her of his anger would not be gentlemanly,
developed a symptom of hoarseness. This change in his voice ex-pressed simultaneously both the desire to speak and the inhibition of speech. The symptom thus had a symbolic meaning as well as being expressed through a voluntary system. It would be considered a con-version reaction. In contrast, a man with strongly repressed anger if he had inherited a high level of pepsinogen might tend to develop peptic ulcer. The ulcer would have little if any symbolic meaning, would be expressed through the nonvoluntary automatic nervous system, which controls gastrointestinal motility and secretion and would be consid-ered a psychosomatic or psychophysiological disease.
In the early years of interest in psychosomatic illnesses Helen Flanders Dunbar (1939) defined a number of personality profiles, based on depth interviews, that she felt were associated with specific types of psychosomatic disorder, Today there is more emphasis on defining a
nuclear conflict and relating the emotional effect on the body to the development of structural changes in organ systems. It may be that for an extended time, perhaps years, the physical effects of emotional states may be reversible but may lead over a prolonged period of time to structural changes which are not reversible even if the emotional conflict is alleviated.
Hypnosis has long been used in attempting to influence the nonvo-luntary aspect of neural functioning (Erickson, 1943; Wolberg, 1947).
Raginsky (I960) was a widely recognized writer in the field of hypnosis and psychosomatic medicine. His section "Hypnosis in interna! medi-cine and general practice" in Hypnosis in Modern Medimedi-cine (1953), edited by Jerome Schneck, is a classic introduction to this entire subject.
With psychosomatic problems it is vitally important to use hyp-nosis with due regard to the organic factors that may be involved. The organic factors may include drug addition (Kolouch, 1970). The psychodynamic meaning of any conflict underlying the symptom must be explored—in psychotherapy, in psychoanalysis, or in hypnoan-alysis. Pure symptom removal, without concurrent work on the emo-tional conflict, could possibly lead to an unexpected substitute symp-tom.
In some cases of psychosomatic illness, when the patient is not motivated or willing for such exploration, we have limited hypnotic suggestion to inducing a sense of profound relaxation with no attempt
to suppress directly the presenting symptom. This was effective in producing symptomatic relief in an 80-year-old man with a history of diverticulitis. In this case it was interesting that the patient, a very intelligent and professional man, spontaneously worked on a dream he had remembered from 20 years previously. T h e interpretation of the dream linked the illness with a traumatic childhood situation involving his mother. In this case it seemed that relief of his general sense of anxiety and tenseness allowed repressed traumatic material to reach consciousness. This is the reverse of the classic analytic approach, in which meaning is first explored and symptomatic relief expected to follow. Such a case is unusual, the ordinary approach being a mixture of hypnosis and psychotherapeutic exploration. It illustrates, however, the push toward health that is active in the
unconscious-Hypnosis has been used experimentally to induce psychosomatic changes. If the hypnotized subject is told to hallucinate a frightening situation, his or her heart rate will rise, as in a fear reaction. In a control study published in the International Journal of Clinical a n d Experi-mental Hypnosis in 1959, we reported that hypnosis itself, without specific suggestions for change, did not alter the pulse or respiration rate. Blood pressure was also unaffected. We introduced the term
"neutral hypnosis" to describe the trance state without specific sug-gestions having been given (Crasilneck and Hall, 1959).
Chapman, Goodell, and Wolff (1959) published laboratory dem-onstrations of the effectiveness of hypnosis on nonvoluntary bodily reactions. In this study one arm of the subject served as a control, The
hypnotized subject was told, for example, that the right arm was resistant to injury while the left arm was very vulnerable. Equivalent areas of both arms were then subjected to a measured thermal stimulus.
The resistant arm showed very little response, measured by the pres-ence and size of a wheal and flare reaction. In contrast, the "vulner-a b l e " "vulner-arm showed m"vulner-arked response.
If one imagines similar "vulnerability" being induced by un-conscious conflict in other involuntary and supposedly automatic proc-esses in the body, it is easy to conceive that psychosomatic stress might
lead to structural organic change. Some clinical observations strongly support the possibility that hypnosis might directly affect processes that are otherwise outside of conscious influence. Among these ob-servations are those of removal of warts, discussed in the chapter on dermatology. Warts have been shown to be a viral-induced tumor of the skin. Although it is clearly established that in many cases they may be influenced by hypnotic suggestions, there is as yet no clear
conceptual-ization of what intermediary mechanisms may be involved in actually producing their regression.
Among others, Bernstein (1965), Lassner (1969), Morton (1960), Takaishi (1971), and Wright (1966) have written about the use of hypnosis in psychosomatic medicine. In 1969, an international con-gress for hypnosis and psychomatic medicine was held in Paris. Spiegel and Spiegel (1978) caution about the necessary differential diagnosis of conversion symptoms and neurological diseases. They also discuss
how inadvertent remarks by physicians about a patient's physical condition can, in suggestible persons, predispose the patient to the development of psychosomatic symptoms.