Some Psychodynamic Considerations of Psychosomatic Skin Disorders

Plethysmographic and Psychoanalytic Observations
FELIX DEUTSCH, M.D. .LOURING the analytic procedure we depend almost exclusively upon the verbalization of thoughts and feelings. Very often we become aware of preverbal behaviors, apparently related to the psychological situation of the moment. Sometimes the patient spontaneously expresses bodily sensations which he perceives and which can be interpreted as belonging to a psychosomatic unit. By and large, however, we tend to forget that analysis, which stirs up large quantities of psychic energies, is continually accompanied by correlated invisible physiological adaptations and responses. It should be kept in mind that whatever happens in one part of the organism is reflected in the whole and motivates the function of the whole. This is true for the smallest as well as for the more complex processes. In considering the nature of psychic or somatic fluctuations from within, in the response given by an organism, it must be accepted that neither the emotional or organic stimulus nor the organism remains constant, but at the threshold where only a few quanta of energy are involved it is the stimulus which is variable. The nature of its variability determines the variation encountered between stimulus and response. One may distinguish between visible and invisible stimuli. The visible ones are usually more readily understandable in relation to stimuli from the outside and from the inside. The invisible ones, like vasomotor reactions,
Read at the mid-winter meeting of the American Psychoanalytic Association, December 1950, in New York. Received for publication February 5, 1951. VOL. XIV, NO. 4, 1952

as a rule escape direct observation and develop their specific pattern of behavior inconspicuously. By and large their habitual response to external influences remains unrecognized. According to the law of the psychosomatic unit the invisible bodily behavior is integrated into the psychosomatic pattern just as is the visible one. These behavior patterns are formed as the result of experiences during the biological and psychological development of the individual and are a part of the personality profile, characteristic of psychosomatic skin disorders. An analytic observation may illustrate this: Case 1 A man in his late thirties came for treatment of a mild depression mainly because he considered himself, despite some business achievement, as inefficient and inadequate throughout his life. He saw in his father the ideal of a successful man with immaculate character, whose superior qualities made any attempt at competition with him futile. What made it worse was that the mother's blind admiration of the father turned him into a heroic figure. She tried in vain to arouse the ambition of her son to follow his father's example. As a result he became a secretive day dreamer, sensitive, a reticent romanticist. Life became only a pseudoreality. He depended on the support of mother and father. In spite of strong feminine identifications, he escaped overt homosexuality, but had passive anal inclinations. Apart from a rash in his earliest childhood he had never been sick. He was convinced that his penis was somewhat deformed and bent to the left. He considered the deformity to be a result of masturbatory activity in his late adolescence. He confided in no one.

he felt as if these people were afraid of him and rejected him. Thus when he had achieved something." He remembered an acquaintance. together with sneezing spells. who obviously attempted to deny her femininity. the patient put on a stolid. he had returned to his former passive dependency on his mother and developed an atopic dermatitis. Thus he had been depreciating his own worth in order to spare the feelings of others. as if she wanted to express in this way her objections to her femininity. imperturbable facade. In disgust he said. His ideas that his penis was deformed and bent to the left were again expressed. mixed with modesty and bashfulness. mother's boy. With the increasing struggle between the passive and aggressive tendencies the arm was freed from its adherence to the pillow base. Formerly he had felt that he ought to believe in the goods he exhibited and sold. He remembered that his younger brother. After a few days a rash appeared on his right arm. In his daily contact with his father he began to notice a repulsive. He saw in his brother a weakling who often had pain and aches and who had various allergies. pricking and crawling sensations. where he had been accepted as a man. He tried to camouflage his feelings. he always had to destroy it or at least reduce its valu6. Whenever he should make a stand against somebody and express his anger. He thought that his rash was therefore a protest against his masculinity. These devaluating thoughts were abundantly expressed in this phase of the analysis. she developed a rash in her face which disfigured her. where his new self-assertive tendency conflicted with his former submissive attitude. liar. What he wanted now was to be wonderful as a man as well as a woman. It appears to him as if changing meant not being afraid any more of being disfigured in a "womanly" way. he begins to itch or has a sneezing spell. while he began to have the itch in the ear and in the nose. who was always a sickly. sweet odor which nauseated him. He recalled that when his brother was discharged from the Army. as he was sensitive to any criticism. When his need for assertion of his masculinity became more firmly rooted and his feminine identification with the mother became undermined. of being doomed to failure. It alternated with tingling. "Only women have those rashes. attractive woman. the itch disappears. She lost this trouble after the marriage. in which he felt himself either becoming small as a whole or in which he felt like PSYCHOSOMATIC MEDICINE In the phase of analysis in which his rebellion against the father was revived. placid. which she soothed by scratching it with a hair pin.and macro-kinesthetic sensations. Behind his facade he concealed his derisive thoughts of himself as a coward. During the period of this increasing insight he developed in the analytic hour micro. He saw himself through the eyes of others and watched over the effect of everything he did or said. was allowed to stay in bed with his mother. The rash spread up to the chest as his aggressive tendencies became stronger. Simultaneously devaluating thoughts and death wishes against the domineering father occurred. paresthetic sensations appeared first as a feeling of swelling and enlargement of the head and jaws. which he had noticed as a little boy when he went into his father's bed. This arm usually rested quietly on the pillow on the couch. In contrast to his brother. and when the attempt at self-assertion against the powerful father should have been settled on an adult level. It reminded him of the familiar odor in the father's bedroom. an unbearable itch on his right arm appeared. because everything was foredoomed to failure. this made him cringe when he saw it. When he expresses the anger verbally. At first he tried to hide it. against his wish to be a man and that he thus disfigured himself when this wish collided with his feelings of hatred and with his death wishes against his father. It also appeared in connection with his work as a salesman. He now begins to feel as if a change were taking place in him. "Only weaklings have such a rash. when she became pregnant and had a child.288 PSYCHOSOMATIC SKIN DISORDERS tions of the patient to his rash were that his wife before their marriage had an unbearable itch in her right ear. a very aggressive. crook. This sensation disappeared and was then increasingly felt in the right arm as numbness. He found it easier to sell something to people whom he consciously disliked. of doubt in his efficiency. However. but he could win friends only through bashfulness and agreeableness. Further associa- ." he thought. diagnosed as lichen planus. which he usually squeezed playfully. but he also felt that exhibiting and selling to other people lowered them. What had happened to him up to now was that the woman in him had torn down the man while the man had exalted the woman. These disturbing feelings were associated with thoughts of worthlessness. the patient had a great contempt for this. of lack of confidence.

. That is illustrated in Fig. The meaning of this behavior became quite clear to him as birth fantasies." There occurred other kinesthetic feelings. The trend of the curve corresponds to finger volume changes. and a decrease in pulse volume height is accompanied by a decrease in finger volume. exhibitionistic personality traits of this patient with his hiding tendencies are apparent. in order to ward off and to deny the gratification of the antagonizing forces. He developed sneezing attacks and interpreted them as attempts to get the fetus out of him and to give up his passive feminine wishes. As the involvement of these trends in the struggle between the passive feminine and aggressive masculine drives came to a climax. These have variously been termed psychogenic or spontaneous waves and are. 1952. There are others who have very unsteady curves. One can observe the rate and the rhythm of the pulse as well as changes in pulse volume height. The degree of mimetic reaction is independent of the reaction on the stimulated side. The plethysmographic tracing of most patients also shows waves which have no relationship to respiration and do not occur in a definite rhythm. As an exemplification of these reactive responses to different stimuli. 289 a symmetromimetic reaction in the rest of the body surface. observations of the capillary behavior of the skin obtained with photoelectric and mechanical plethysmography may he briefly cited ( i ) . Any stimulus—external or internal—represents merely an additional one to other stimuli continually in force. Very often the xiv. The curve can be steady or undulating. due to unconscious emotional stimuli. vascular changes of the skin can be detected. so to speak. or segregates one function from the whole. which has not been stimulated.e. applied to the back of one hand until the sensation of cold is perceived. purely local in character. It seems as if any impulse in this system can set the whole system going. depending on the finger volume. at a place and in a form which corresponds to the psychosomatic pattern. The photoelectric plethysmographic tracing can be used for the study of a number of phenomena. provokes a "mimetic" response on the other side. Ordinarily an increase in pulse volume height accompanies an increase in finger volume. Simultaneous photoelectric and mechanical plethysmographic recordings on the finger tips of both hands can show that a physical as well as an emotional stimulus applied on either side of the surface of the body evokes VOL. When this struggle goes beyond a harmonious cooperation of bodily processes. in which spontaneous waves are very rare and in which the curve remains on the same level throughout. the irradiation of the autonomic nervous system spreads to the rest of the system. like a skin disorder. 1. By and large. with many and deep psychogenic waves. Likewise a cold stimulus (ethyl chloride). Every change in the blood volume in one fingerpad is simultaneously reproduced in the corresponding finger on the other side and becomes manifest as "mimetic synchronous waves. or as "fetal behavior. There are patients who always show a steady curve. The whole strugglefinallyended with the disappearance of the lichen planus after a few weeks. The narcissistic. very probably. 4. Any specific stimulus passes through long prepared pathways and becomes metamorphosed before integration and conscious perception. like being in an open space and floating in it.. The mediator for this discharge is the autonomic nervous system. as simultaneous movements of the blood volume on both sides. it can lead to a structural damage. but as a rule it is constrictory on both sides. NO. and there was no recurrence.DEUTSCH a "swell head. Waves may also be observed which are synchronous with respiration and are due to rhythmic variation of the heart action through the respiratory cycle." as he called it. the bodily representations and symbolizations of these drives with their cathexed sense perceptions were set in motion. Since the absorption of light by transilluminated tissue varies with its blood content. while still others react particularly to the respiratory movements with respiratory waves." i.

expressing the defense against a repressed unconscious wish related to the touching of the mother's genitals. It is of significance that his mother. while she wanted him to pray for her death. being afraid that he might hit somebody. where he then developed the symptoms of lichen planus. It was the hand of the same arm which he used for sexual practices on his own genitals. or kill himself. Her death was a hard blow for him. to whom he was deeply devoted and with whom he identified himself in many respects. G. married man. the skin condition of his left arm was of particular concern to him. was left-handed. as the decrease in finger volume on one side was accompanied by an increase inPSYCHOSOMATIC MEDICINE .PSYCHOSOMATIC SKIN vasoconstriction expressed in the decrease of finger volume and pulse volume precedes the sense perception of cold. When he first recognized the rash. was a 40-year-old. as he had ardently prayed to save her life. He also had the idea that there was a poison in his body and that he had to keep himself thoroughly FIGURE I These mirrorlike vasomotor behaviors seem to be unspecific since they are not provoked by the particular stimulus itself on the rest of the body. because the speed of the reaction is too rapid for the intervention of any hormonal or chemical factors. 2. to his embarrassment. When sense perception of cold and pain had disappeared subjectively and objectively. have a collision. whose first symptoms of lichen planus appeared twenty-three years ago. which were symmetromimetic but dissociated. and on which he experienced twitching and beating clean. On these occasions he very often. This after-effect of the cold pain-stimulus was further expressed in waves of decrease in finger and pulse volume. a cold reaction as such. the reaction on the left was stronger and more protracted than on the stimulated side. He developed a phobia about driving a car. 3). or that some other catastrophy might happen. This led to a compulsive washing ritual. white. when he attended the funeral of his mother. Later associations of the patient to the sensation on the hand revealed that it was the reaction to a kind of after-image. However. To a cold stimulus applied to either hand the reaction consisted of a decrease in finger volume (Figs. T h e responses in other parts of the body may therefore be ideationally motivated. a spontaneous after-effect occurred which resembled the reaction to the original cold stimulus. even when only the right hand was stimulated. It is likely that the response to cold has a neurogenic reflex basis similar to the psychogenie waves and is ideationally provoked. He suddenly felt itching on his left arm. or at least not fully. he thought of infection or syphilis. Case 2 F. This fact suggests that the vasoconstriction is not. He recovered the memory that it was the left arm on which he had carried his sick mother out of and into her bed. but rather an unspecific response to a stimulus. felt her naked body. She had suffered for years from tuberculosis. DISORDERS movements as a child. Some proof of this assumption can be given in the following observation. The plethysmogram of the patient at rest showed a rather steady curve with few respiratory waves. Once he broke this arm. This reaction was considerably stronger on the left side.

This peculiar behavior varied in intensity on the different days on which the experiment was repeated. too. Here. In the itching experiment. an identical decrease in finger and pulse volume appeared. XIV. it appears as if tissue which is pre- 291 phoretically with histamine on the dorsum of the foot. Furthermore. 4. like the former response . i. produced electroVOL. the disquietude of the curve on the left side lasted longer than that on the right side.. NO. although the vasoconstriction was substantially stronger on the left FIGURE 2 FIGURE 3 disposed to irritation takes a longer time to subside after responding to a stimulus. there was the same reaction to the cold stimulus. after the itching reaction had vanished and the curve had become steady again.e.4). I952 side (Kg.DEUTSCH stead of a decrease on the other side and vice versa. the reaction appeared homogeneously on both sides of the hand.

(It is like the response to an after-image. those patients with mines. as if the stimulation had been repeated. that any skin with an increase in finger volume and an insensation. The simultaneous plethysmographic study on both fingertips of this patient with lichen planus reveals that the cathexis of a part of the body can lead to a dissociated vasomotor behavior. In contrast to them. who have not developed sufficient from hypnotic experiments. moreover. when re. What is true for who cover up and control their anxieties the concept "cold" is also valid for any other through their compulsive defenses.are often more pronounced than the vasomotor called. whatever happens in one part of the body has T. therefore.crease of psychogenic waves. That became clear in the plethysmographic recordings of this patient. This suggests. L. engraves a memory which. as a rule PSYCHOSOMATIC MEDICINE .292 PSYCHOSOMATIC SKIN DISORDERS sense perception. A real cold stimulus on a circumscribed spot leads to a conceptual cold reaction on the remaining surface without a cold sensation on this part of the body. Such autosuggestive reaction patterns are well known anxiety.P 8 15 sees. is sufficient to reactivate the experience responses to emotional stimuli. "cold. It is the -meaning defenses against their anxiety-provoking conof "cold" to a certain individual which deter. as if the stimulus had been reapplied. Accordingly the itching stimulus. body. When the reaction to the cold and itching stimulus respectively had already subsided. P Itching B. These reactions enced.Q. which was brought to the fore by stimulation of the skin with different stimuli. and is expressed in the particularly strong in patients with neurotic vasomotor system as if it were real. an identical vasomotor response reappeared." once experi. 5 FIGURE 4 repercussions and spreads to the rest of the formly the most intensive vasomotor response. Generally speaking. to what degree he will react an obsessional compulsive personality pattern. In all cases of psychosomatic skin disorders the subjective sensation of itching is the leading symptom. to this particular sensation. experimentally applied. provoked uni- to the itching stimulus.) This patient gave the information that he felt as if the cold or the itching had occurred again. which are in the whole body.flicts. for instance.

4. The fusion of these two processes. 10.DEUTSCH 293 manifest these character traits in a steady plethysmographic curve. NO. 8. The degree of the ego weakness and the ego's inability of solving the conflicts otherwise. The degree of the resulting ego defect and organic defect. The symbolization and personification of these or similar figures in early life in the parts of the body involved. 9. The frequency of the simultaneous repetition of this dysfunction and of the specific conflict. rrrJ3_8. 6. 2. \ . Factors and figures in the environment which stimulate the specific conflict. Figure 5 might illustrate how the fusion between certain sense perceptions and their meaning in the unconscious leads to their interrelation with significant personality traits in skin disorders (2). invisible bodily behavior is integrated into the psychosomatic pattern just as is the visible. 11. of good and bad smell or taste leads inevitably to personality traits significant for persons with skin disorders. 3. 1952 . 4. 7. and on the extent of involvement. '5 K_-§ I i 2—1 •5 ~ •a O c «3 ao/ S »'B g • | —%r- « — J /3 60/ •" 6 0 / . Hence the choice of the skin for solution of the pathologic conflict depends on: 1. The coincidence of this dysfunction with instinctual conflicts on the specific level of psychic development. 8 w N j [3 xiv.or hypo-) in the neonatal or early infancy period. According to the law of the psychosomatic unit. smooth and moist (touch). The repression of the original conflict. 5. The number of sense perceptions which become involved in the psychosomatic process. of rough. The consistency of using the organic dysfunction as the preverbal expression of the conflict when it is remembered. The occurrence of an organic dysfunction (hyper. The symbolic meaning of dark and white (vision). This integration of sense perceptions into the psychodynamic process is a cardinal postulate for the development of a psychosomatic skin disorder.5 / 62 ™ (J 58 Q > VOL.

References 1. Child 5 C4): 1946. The type of neurosis of the parental and family figures. Charles Rupp PSYCHOSOMATIC MEDICINI . New Jersey. Thomas K. Houston Merritt Assistant Secretary—Dr.294 PSYCHOSOMATIC SKIN DISORDERS 12. Mackay First Vice-President—Dr. orient. James C. 1952. the following officers were elected for the year 1952. p (8-9): 1950. Nerv. Roland P. DEUTSCH. 13. Acta med.-1953: President—Dr. Mass. The type of behavior disorder or neurosis which has finally developed. 82. Psychosomatic aspects of dermatology with special consideration of allergic phenomena. White Secretary-Treasurer—Dr. Boston 16.. Davis Second Vice-President—Dr. American Neurological Association At the Seventy-seventh Annual Meeting of the American Neurological Association held in Atlantic City. May 8-1 o. R. H. 2. F. 14. Reese President-Elect—Dr. Thus speaks the body: A psychosomatic study of vasomotor behavior. DEUTSCH. Other incidental and accidental life experiences. and NADELL. Hans H. Marlborough St.. F.

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