Recent trends in the development of psychosomatic medicine and psychosomatic theory have marked a shift from earlier emphases on individual psychodynamics and on specific patterns of dynamic reactivity in relation to forms of psychosomatic disease to a more broadly conceived understanding of psychophysiologic reactivity to a variety of environmental stimuli. Along with this shift in perspective, there has been a refocusing of the understanding of psychosomatic processes, less in terms of linear causality and much more in terms of models of multiple causality and an understanding of many complex levels and varieties of influence that express themselves ultimately through psychophysiologic processes.1
Within this broadened theoretical perspective, social and ecological factors have come to play an important part. They have contributed considerably to the enrichment of the somewhat narrowed concepts of psychosomatic functioning that tended to focus on the interaction between psychic and dynamic factors, while disregarding or underemphasizing the influence of social and familial factors. The emergence of family theories, and their impact both on individual psychodynamics and on psychophysiologic interactions, have served to broaden and reinforce our faltering understanding of those factors rather than to undermine or diminish their importance.
In addition, there has been a shift in emphasis in current psychosomatic studies toward conscious emotional interactions and their correlative cognitive processes and their influences on physiologic concomitants. These conscious variables are more easily identified, quantified, and studied than the unconscious elements in psychological interaction, and thus have been studied more carefully and more scientifically. The evaluation of these conscious factors and their correlation with specific physiologic concomitants has now moved beyond concerns about mind-body relationships, with the latter now being considered only of abstract philosophic or theoretical interest.
This increasing emphasis on the conscious and quantitative, however, must not be interpreted as an abandonment of the more-difficult-to-elicit and unconscious dynamic factors that seem to operate pervasively in influencing psychosomatic outcomes. But the extreme difficulty of studying the influence of unconscious factors and their relationships to psychophysiologic correlates seems to be generally recognized; we apparently have run the string out, as it were, on the productive achievement of further understanding - at least for the time being. Research interests, consequently, have drifted away from this area and on to other aspects of the problem - with more comprehensible and more readily available results. It is not difficult to mitment to maintaining the status quo, resisting change and growth, and striving to maintain familiar modes of interaction. The sick child provides a conduit by which conflict can be avoided by being diverted into concern for the sick one.
Stress on the family system is particularly increased by the onset of adolescence, which challenges the family's adaptive capacity. The threshold of conflict tends to be low, but conflicts are not allowed to surface or be expressed, so the family system suffers from chronic subthreshold stress. The family overprotectiveness and rigidity allows for little or no expression or negotiation of differences. Religious or ethical codes often provide the rationale for suppressing or avoiding conflict. Patterns of avoidance vary. Some families may bicker constantly, but conflictual issues are never clarified, confronted, or resolved.
DISRUPTIONS IN THE FAMILY SYSTEM
When such relationships are disrupted they are likely to be experienced so intensely that they become the equivalent to the loss of one's self: the person feels incapable of surviving alone. The person's self-definition remains reactive and relational in the sense that preservation of his sense of autonomy and self-esteem is dependent on family relations in an excessive way.10 Such a pattern of emotional reactivity derives from the husband's and wife's need to act out their intrapsychic conflicts in the interpersonal sphere of interaction that constitutes the marriage relationship. When children are introduced into this matrix, this pathologic pattern comes to exercise enormous control over the personality development and functioning of the child, so that he fails to gain a sense of integration of sexual and aggressive impulses and does not come to experience himself as differentiated and independent from his involvement in this emotional interaction of the family. As the child grows to maturity, he fails to establish a stable and autonomous sense of himself and continues to be excessively involved in the family emotional system and to be influenced by its ongoing currents.11
Currents of emotional disruption within this family system may be generated from outside the family system and create disruptive effects within it or may be generated internally. Internal disruptions may come not only from a variety of crises that arise within the family (e.g., deaths, marriages, births, illnesses, and so on) but also from emotional conflicts generated within .the family system that prove to be stressful and disruptive on one or more family members. It is typical of such families that disruptive experiences can manifest themselves as either psychological or psychosomatic symptoms occurring somewhere within the family system.
The "selected" patient. The factors operating within any family system that give rise to psychological or psychosomatic disruptions are little understood and require further study. But frequently the family system operates in such a way as to select one or other members of the family system to be the focus for the expression of family pathology. The identified patient or patients in such a family are relatively unable to be spontaneous and assertive and have difficulty in claiming their own individuality within the family system. They remain constantly reactive to emotional pressures deriving from other members of the family and the family system as a whole. Conversely, the selected patient is strongly motivated to perpetuate this mutually controlling and symbiotic involvement, since the alternative for him is fear of abandonment or, in the most severely disturbed cases (e.g., schizophrenia), annihilation. The patient then is caught up in an emotionally loaded, often tense and conflictual interaction within the family.
There is a relatively close connection between depressive tendencies and the genesis of psychosomatic and hypochondriacal symptoms. When depressive moods or the defenses against depressive affects dominate the family interaction, one can expect a high; incidence of psychosomatic disturbance. Family members in such cases of psychophysiologic disturbance frequently have special difficulties in dealing with aggressive conflicts and particularly in expressing relatively intense separation anxiety. Frequently, in families experiencing psychophysiologic disturbance, verbal communication is relatively blocked, as compared with families experiencing forms of psychopathology.
Blocked communication. The problems of blocking of verbal communication in these family systems, particularly in regard to the communication of conflictual affect, must be taken seriously, although it is difficult to know what their significance may be. Nemiah and Sifneos1215 have described a condition of "alexithymia" that they identify in many psychosomatic patients. Such persons have a difficult time putting their feelings into words. Much as in the French descriptions of pensee operatoire^6 a decade earlier, this inability to connect words and feelings is said to be related to a person's preoccupation with the minute details of external events and a striking lack of fantasies derived from inner drive states and/or affects. When these characteristics occur in conjunction with psychosomatic disease (this is not always the case), one might wonder whether the affected persons did not come from family systems in which the effective communication of affect was short-circuited and consequently channeled in psychophysiologic directions.
Frequently the selected patient in these circumstances seems to be functioning at a less than mature level, reflecting a relatively infantile personality structure. This immaturity of personality functioning may often be evidenced in forms of passivity and dependence, but it may also express itself in more defensive and compensatory forms of hyperadequate adaptation.
The patterns of hyperadequate and inadequate functioning may play themselves out in the family interaction quite regularly. A husband and wife frequently fall into such a pattern of reciprocal functioning where one partner may assume a position of dominance and/or strength and/or control in the family interaction while the other takes a reciprocal position of submission and/or dependency and/or passivity. Often the patterns will be reversed for certain circumstances, with one spouse dominating and the other dependent, only to be reversed once again in another context.
Such patterns are frequently observed in psychologically disturbed families.17,18 Psychosomatic disorders, along with tendencies to somatize, and deep-seated dependency problems tend to cluster in families where there is a low level of psychological differentiation.7
Conflict over dependency. The manner in which the selected patient comes to fulfill his function as such within the family varies greatly from family to family. It is usually reflected, however, either by his emotional closeness and dependent attachment or by the opposite reactive pattern of aggressive rebelliousness and hostility.
The underlying issue in either case seems to be a conflict over dependency. Such emotional involvement tends to be selective, in the sense that emotional investment from the parents, and involvement with them, tends to affect one child in the nuclear family rather than another. The ultimate reasons why one child is picked for his role as "selected patient" rather than another are complex, but among them are the pattern of parental needs within that particular family and the prevailing dynamic influences operating within it. The selection may even be influenced by physical factors, such as congenital deformities or disease in infancy. A child so affected may help fill the acute or chronic needs of the parents; the mother in particular may see such a child as uniquely vulnerable. Or other circumstances, such as a previous miscarriage, may set the stage for a particularly intense and distorted relationship between parent and child.
Events outside the nuclear family system - for example, the death of a grandparent or some other important figure in the extended family - may create a situation of exceptional vulnerability in the nuclear family into which a newborn infant is drawn; as this child grows, he continues to be a particular focus for parental anxieties and mourning.
But it is incorrect to view the child who becomes such a "selected patient" as a passive victim of inexorable forces operating within the family system. Far from it; he is an active participant and has as great an influence on the family system as the family system reciprocally has on him. In fact, his influence on the system may be even greater than the system's influence on him.
Within the emotional triad set up among the parents and the "selected child," feelings of helplessness play an important part and come to be acted out in the illness. The patient's illness then serves to stabilize the delicate emotional balance within the family, particularly within this parent-child triad. When the patient improves or becomes less ill, this tends to unsettle the fragile stability within the triad and leads to attempts on the part of other members to undermine the improvement.
PARALLELISM BETWEEN PHYSICAL AND EMOTIONAL SYSTEMS
The onset of disease symptoms in a "selected patient" can often be related to periods of emotional disruptions within the family following the loss of some significant person somewhere within the family system. Such a loss may be followed by a period of inadequate and morbid grief, which is then replaced by the disease state. Such patterns have been traced in cases of ulcerative colitis, rheumatoid arthritis, leukemia, and a variety of other forms of organic decompensation. One may even find forms of anniversary reaction expressed itself in a psychophysiologic form.
Emotional disruptions disturbing the emotional balance in the family system are not specifically tied to the loss of a significant person or object, however, but may be occasioned by a variety of factors. In addition to death, serious illnesses, births, divorces, psychotic breakdowns, marriages, and even graduations may serve as disruptive influences. (Some events, such as marriages and births, may not characteristically be disruptive, but they result in shifts in the family configuration that may have a secondary or disorganizing effect.)
The selected involvement of affected family members in the family affective system becomes particularly important as an aspect of family functioning, since it is precisely the members whose emotional involvement is particularly intense who manifest physical symptoms in conjunction with emotional crises. Emotional disorganization within the family does not affect all members of the family in the same way but, rather, differentially according to this principle of selectivity, in proportion to the degree of involvement. The presence or absence of such involvement and its degree of intensity then become crucial issues in understanding the emotional factors that play a part in precipitating disease symptoms and thus contribute to the total etiology of the disease process.
One of the interesting facets of family pathology is the similarity of patterns of both psychological and organic disruption. Not only do these causative influences follow similar patterns, but they are at times conjoined - that is, in a given situation of crisis one family member may respond with psychological disability while another responds in organic terms. These parallel patterns suggest that similar factors may be operating within the family system in both cases.
The question remains as to the differential responsiveness - why the response to emotional disruption within the family should produce psychological symptoms in some members and physical symptoms in others. The discriminating factors remain unclear, and we are left with a considerable amount of guesswork, but the identification of minor somatic dysfunctions in relation to lesser emotional crises may allow us to predict which members of the family might develop more severe symptomatology in more disruptive emotional crises.
The problem is made even more complex by the phenomenon of alternation between psychological and physical symptoms. Cases have occurred in which such alternation is striking. Grinker and Robbins19 describe one patient whose psychogenic pain was relieved when he was able to express his aggressive impulses; when the pain disappeared, however, he became clinically paranoid. Kellner20 has suggested that family illnesses tend to occur in clusters, the psychosomatic illness promoting further instability in the family system, thus precipitating secondary somatic disruptions. It is not clear, however, how general this phenomenon may be and whether it occurs only in certain kinds of illness or certain types of family systems, or whether it tends to affect only certain members within the system. The alternation of symptoms between psychosomatic disorder and psychosis, for example, may not prove to be a very common individual phenomenon, but such patterns of alternation can be identified relatively easily among members of a family system. Both parallel pathology and reciprocal pathology - that is, improvement of one family member associated with deterioration of another family member - have been described as characteristic of somatic processes. However, the data are primarily anecdotal and require more systematic and controlled observation.
In many disturbed families the parallelism between physical and psychological disturbance is striking. Both the onset of illness and the recovery of the patient can precipitate changes in other family members. Psychosomatic reactions may be involved in such patterns of precipitation, particularly in connection with emotional disruptions in the family system. There is some evidence to suggest that both psychological and physical disturbances tend to cluster among family members rather than to affect individual members. Such patterns of interaction can be identified in married couples. Spouses of psychiatric-clinic patients tend to present physical symptoms more frequently than controls. Wives are more likely to reflect the illness of the husband than the other way round. Kellner20 found that the wife's illness tended to follow upon the husband's twice as often as the reverse. In some of these cases, he commented, one spouse seemed to labor to remain healthy so that the other might remain ill.
FACTORS PRECIPITATING PSYCHOSOMATIC ILLNESS
Studies of recurrent psychosomatic illness suggest that exacerbations tend to coincide with periods of increased marital tension. There is usually a much greater degree of marital disharmony and sexual maladjustment in the history of patients whose hypochondriacal symptoms mask an underlying depression (as well as the higher incidence of psychosomatic disorders) than in depressive patients who are nonhypochondriacal. When hypochondriacal symptoms do mask depression, the somatic symptoms may serve as a form of neurotic control mechanism, which has the function of stabilizing a relatively brittle and conflictual marital relationship.
Haley21 has suggested that the symptoms in such a delicately balanced emotional system often function to protect the spouse by denying a marital problem and avoiding its resolution. In such contexts, double messages and double binds abound. He cites as an example the impotence of a husband in relation to his wife's demand that he be more assertive sexually, while at the same time she would be unable to tolerate the surrender to him that such assertiveness would require on her part. In like manner, one spouse will undermine the other's attempt to interrupt distressing systems in order to avoid the consequences of exposing his own pathology. Thus, the husband whose wife ceases to be frigid may suddenly become impotent, or the woman whose husband's headaches no longer prevent them from going out of the house may become agoraphobic. A similar interlocking pattern has been described in couples in which the wife had rheumatoid arthritis and the husband peptic ulcer. Equilibrium was maintained by the wife's controlling and dominating behavior, interlocking with the husband's need to be controlled and dominated.22
THE FAMILY AFFECTIVE SYSTEM: HYPOTHESIS
Evidences of the sort described above point in a consistent direction. They allow us to formulate the notion of the family affective system as a mediating construct to pull together these different strands of evidence.
The hypothesis of the family affective system can be summed up in these five points:
1. The patient is less than mature; his immaturity is directly proportional to the degree of emotional involvement he has in the family affective interaction.
2. The patient is caught up through his emotional involvement in the affective system of the family, which is constituted by the emotional involvements of all the members of the immediate family. His involvement in the family may be reflected in patterns of either passive dependence and attachment or of rebelliousness and hostility; the emotional involvement itself, however, and its effects on the patient, usually remain unconscious and implicit.
3. How well the involved person functions depends on the balance of emotional forces within the family system. The person's own basic insecurity and instability is compensated for, and more or less stabilized, through his emotional interactions with other members of the family system.
4. Certain events that are emotionally significant can disturb the emotional interrelationships within the family system and create disorganizing influences within it. This affects the patient deeply on an emotional level - either consciously or unconsciously, or both, since the stabilization of the patient's own emotional lability is achieved through and is dependent on the balance within the family system.
5. Disorganization or emotional disruption within the family system can precipitate an emotional crisis in such a deeply involved member. With his emotional supports withdrawn, such a person lacks sufficient inherent ego resources to maintain adequate functioning on all levels. He consequently responds to this stress with a form of decompensation. In psychosomatic illnesses, the decompensation is specifically somatic - that is, it is expressed in the form of some somatic dysfunction.
Discussion. While the notion of the family affective system helps to unify the available observations, it tends to raise more questions than it resolves. Psychosomatic processes tend to be extremely complex phenomena that reflect the operation of many causes and influences. The family processes enter the picture only as one set of operating factors, functioning in combination with complex and multiple etiologic variables. Consequently, the degree of involvement and of impact of the family affective system in the precipitation of illness may prove to be quite variable.
The formulation presented here also tends to focus on the impingement of the family affective system on the involved and affected member - that is, the selected patient - but it also brings into focus the patterns of emotional interaction and involvement within the family itself. This shift of orientation emphasizes that the unit of analysis and the unit to which the psychosomatic process can be meaningfully related is the family system itself. It should be remembered that the family system is not coextensive with the family group, either as nuclear family or as extended family; it is, rather, a structured emotional system within which the balance of emotional vectors is intimately related to the functioning of its involved members.
We can appropriately add a few words about the use of family therapy in approaching psychosomatic disease. The family-therapy approach undoubtedly adds a new dimension and a quite different emphasis in the treatment of psychosomatic problems. Dramatic results often can be obtained in a psychophysiologically affected person when the patterns of family interaction that have been operative in his selection as "patient" and in the prolonging of the sick role and its symptoms can be explored effectively and opened for discussion. The family therapists or cotherapists, however, must be prepared to meet with powerful resistances from the various family members, for they are proposing a disruption of forces that have served to maintain and reinforce the patient's position as patient and his psychosomatic symptoms.
As the patient improves and his symptoms wane, one must anticipate a radical disequilibrium within the family system. The patient's recovery will be disruptive throughout the family system and bring about an increase of stress. If the patient's improved condition can be maintained in the face of such powerful family resistance, the therapist must expect disruption and disorganization to become manifest in some other part of the family group. And this disorganization and disequilibrium can be expected to create patterns of decompensation that may well express themselves in other forms of physical disease in other family members (depending on the degree of involvement and the psychophysiologic vulnerability of each). Such disruption may take the form of frank psychiatric symptom formation and psychopathology.
When the underlying causative mechanisms can be explored and modified, however, the processes that serve to maintain and reinforce psychosomatic symptoms can gradually be eroded and the capacities within the family to deal with the underlying tensions and conflicts can be increasingly utilized. The therapeutic effects of such intervention are most dramatic when the "selected patient" is a child.9 Often in such cases, as the family interactions are explored and the underlying conflicts brought to the surface and worked on, the need is diminished for the child to fill the role of "selected patient" and express the family conflicts with his pathology.
In adult patients, however, the results are usually not so dramatic. While benign results are frequently seen and always can be hoped for, the powerful drives and needs that sustain the family affective system and contribute to the psychosomatic expression are not easily undermined or done away with. Therapeutic optimism thus must be tempered by therapeutic realism. In any event, the perspective added by the family-therapy approach contributes an added dimension to the understanding of psychosomatic problems and provides the therapist with another avenue of approach, another tool in his armamentarium, with which to engage and, we may hope, to defeat the forces of pathology.
1. Lipowski, Z. J. Psychosomatic medicine in the seventies: an overview. Am. J. Psychiatry 134 (1977), 233-244.
2. Holmes, T. H., and Masuda, M. Life change and illness susceptibility. In Dohrenwend. B. S., and Dohrenwend, B. P. (eds.). Stressful Life Events: Their Nature and Effects. New York: John Wiley & Sons, 1974, pp. 45-72.
3. Rahe, R. H. Epidemiological studies of life change and illness. Int. J. Psychiatry Med. 36 (1975), 133-146.
4. Rahe, R. H., and Arthur, R. J. Life change and illness studies: past history and future directions. /. Hum. Stress 4:1 (1978), 3-15.
5. Rahe, R. H., McKean, J., and Arthur, R.J. A longitudinal study of life change and illness patterns. J. Psychosom. Res. 7 0(1 967), 355-366.
6. Wyler, A. R., Masuda, M., and Holmes, T. H. Magnitude of life events and illness. Int. J. Psychiatry Med. 33(1971), 115-122.
7. Meissner, S. J., W.W. Family process in psychosomatic disease. Int. J. Psychiatry Med. 34 (1974), 41 1-430.
8. Bowen, M. A family concept of schizophrenia. In Jackson, D. D. (ed.). The Etiology of Schizophrenia. New York: Basic Books, 1960, pp. 346-388.
9. Minuchin, S., et al. A conceptual model of psychosomatic illness in children. Arch. Gen. Psychiatry 32 (1975), 1031-1038.
10. Slipp, S. The symbiotic survival pattern: a relational theory of schizophrenia. F am. Process 12 (1973), 377-398.
11. Meissner, S. J., W. W. The conceptualization of marriage and family dynamics from a psychoanalytic perspective. In Paolino, T. J., and McCrady, B. S. (eds.). Marriage and Marital TherapyPsychoanalytic, Behavioral and Systems Theory Perspectives. New York; Brunner/Mazel, 1978, pp. 25-88.
12. Nemiah,J. C, and Sifneos, P. Affect and fantasy in patients with psychosomatic disorders. In Hill, O. (ed.). Modern 7 rends in Psychosomatic Medicine - 2. London: Butterworth Sc Co., 1970.
13. Nemiah, J, C. Alexithymia: Theorectical considerations. Psychother. Psychosom. 28 (1977), 199-206.
14. Nemiah, J. C. Alexithymia and psychosomatic illness. /. Contin. Educ. Psychiatry 19(10, (1978), 25-37.
15. Sifneos, P. The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psycother. Psychosom. 22 (1973), 255-262.
16. Marty, P., and de M'Uzan, M. La pensee operatoire. Rev. Fr. Psychanalyse 27: Suppl. (1963).
17. Meissner, S. J., W. W. Thinking about the family - psychiatric aspects. Fam. Process 3 (1964), 1-40.
18. Lidz, T., Fleck, S., and Cornelison, A. R. Schizophrenia and the Family, New York: International Universities Press, 1965.
19. Grinker, R.. and Robbins. F. Psychosomatic Case Book. New York: Blakiston, 1954.
20. Kellner, R. Family III Health: An Investigation in General Practice. Springfield, 111: Charles C. Thomas, Publisher. 1963.
21. Haley, J. Marriage therapy. Arch. Gen. Psychiatry 8 (1963) 213-234.
22. Cobb, S., et al. The intrafamilial transmission of rheumatoid arthritis. J. Chronic Dis. 22 (1969), 193-296.