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Personality structure and conflict situation in patients with myocardial infarction
Journal of Psychosomatic Research.
Vol. 11. pp. 41 to 46. Pergamon Press. 1967. Printed in Northern Ireland
PERSONALITY STRUCTURE AND CONFLICT SITUATION IN PATIENTS WITH MYOCARDIAL INFARCTION J. M. VAN DER VALK* and J. J. GROEN~ ALTHOUGH many researches have been done, knowledge about the real origin of acute myocardial infarction is still vague. One thing becomes certain : as in many instances in medicine-and certainly in psychosomatic medicine-it is not one circumscriptive cause that can be made responsible for the disease, but a combination of factors. Age and sex, arterio- and atherosclerosis, hypertension and diabetes, the diet and a high blood cholesterol level, lack of exercise and heavy smoking, all have their influence. Apart from this, there is the impression that emotional factors may play a role. However the scienti$c basis for this impression is weak. As in former investigations of the Amsterdam psychosomatic group we studied the possible influence of psychological factors in coronary disease by using the biographical anamnesis and extended out information with data from many other cases [l]. From this material we got the impression that the disease appears to occur during a constellation of three factors: First: Certain aspects of the personality structure which seem to predispose the individual to Second: A certain type of interhuman conflict situation, and Third: A certain behaviour by which this individual responds to this conflict. These three points will be discussed: Personality, Conflict situation, and Reaction pattern. PERSONALITY, OR GENERAL BEHAVIOUR The main common feature in these patients is an exaggeration of an otherwise rather normal behaviour pattern of western culture of today. There is a quantitative difference in behaviour between these patients and other individuals. One might say their aggression finds its main that they are more aggressive than others. Furthermore outlet in motor activity; there is a constant urge for being active and the activity is shown in the first place in the work situation. Coronary occlusion seems to occur with greater frequency in individuals who tend to work harder than others, the devotion to and responsibility for the work seems to be more intense, and they do their work more thoroughly. Work seems to be very deeply involved in the patient’s sense of duty. Whereas other individuals may regard it as one of the several functions of the human being, these patients very often regard work as the most important duty of man. For this reason they may sacrifice leisure, family life or contacts with friends to fulfil an almost compulsive urge of conscience which makes them work more and more and better and better. One might call them work-addicts. Work seems to be the main way along which they strive to climb on the social scale. Many of them have achieved higher social positions than their fathers. When * Physician, Psychosomatic Research Unit, Wilhelmina Hospital, Amsterdam. t Professor of Medicine, Hadasseh Hebrew University Hospital and Medical School, Jerusalem. 41
42
J. M. VAN DER VALK
and J. J. GROEN
no ascent on the social scale is possible, they strive for other forms of social recognition for their efforts. Another characteristic is a tendency to dominate and a difficulty in submitting to others; they strive towards, or fight for, power and leadership. A tendency to assume responsibility may also be seen as an expression of this tendency to dominate. They have to show that they are doing their work better than others. When having a leading position, or a business of their own, they are proud to work harder, start earlier and take a heavier task than their subordinates and they strive to defeat their competitors. Statistically the so-called ‘manager disease’ is not found mainly in managers, but the patients mostly like to be in jobs where they have a responsibility of their own and can take decisions. In the family situation, there is the same combination of a tendency to dominate and to assume responsibility. This is also one of the motivations behind their hard work, because through hard work they expect to improve their financial situation and to advance in social position, as a means to provide better for wife and children. Again, this is a widely spread ‘normal’ behaviour pattern in the average male member of modern western society but in these patients it is more pronounced than in others. As another expression of the tendency to dominate they expect wife and children to submit to them, to understand them, to respect them and to give them the love to which they feel they are entitled, also as a reward for their hard work and care. Actually, underlying the patriarchal domination there is a great need for love reception from the side of wife and children, but this is rarely admitted. Seemingly in contrast to these behaviour patterns is the finding that many of the patients had been markedly promiscuous. This can be an attempt to find a substitution when their own wife had not given them the submissive love they wanted; it can also be an aspect of their urge for manly achievements. On the other hand they will not accept any sign of a flirtation in their wives. Any behaviour of the wife that might draw the attention of other men may make them jealous and angry. In several instances they are strongly attached to their daughters, who may be more dependent, admiring and submissive than the wife, and they are jealous when a boyfriend becomes a steady partner. Their sons they expect to become someone to be proud of-according to their standards-to come into their business, etc. but on the other hand they keep on dominating them, giving them no responsibilities and showing It is an imminent danger that the son might them, ‘that they still have a lot to learn’. really show that he can outdo his father, or that he is preferred by the mother. For these patients it is a difficult point that in modern western society the status of the married unoccupied woman depends mainly on the place of her husband in this society. As the educational level is mostly the same in both sexes, this must result in a higher incidence of driving and exacting, passively demanding women; especially when-as in these patients-the husband pays little attention to his wife. On the other hand it may be that people with a personality as described are charmed and flattered and tend to marry girls who from the beginning show their dependence and their expectation ‘that he will take care of her’. In the community situation, these individuals are found more in certain professions where climbing in the social ladder is within reach by hard responsible work. The tendency to hard work and leadership brings some of them into prominent positions, although on the other hand, lack of promotion may provoke a severe fustration.
Personality structure and conflict situation in patients with myocardial infarction
43
They seem to take a more active part in the social life of thecommunity. Occupied with normal social activities, they again tend to exaggerate and some of them fill thereby executive or prominent community or honorary positions. Some of our patients were driven to these activities by the same sense of duty and responsibility which drive others into hard work for their family. They worked in leading positions in voluntary organizations for high human ideals. But at the same time it satisfied their need for power and leadership and their urge to outdo others. In their hobbies we find the same kind of hyperactivity. The hobbies are seldom relaxing. Fishing for instance is only acceptable to them as long as the catch is something to be proud of. They like to drive fast cars or motorbikes by which they are able to overtake everyone else, they drive more miles than others, they rather often smoke or drink heavily-and are proud of it, they don’t play a game for fun but for winning. They often do sports up to an older age, boasting that they still can teach younger people a lesson. As in their sexual life they have to prove themselves and others that they are still young and vigorous-and by doing this may ask too much from themselves. They tend to be individualists, people who do not like to appeal for help and who often believe that in modern society every man has to fight for his own position. Thus, although they may belong to many groups, and fulfil the duties connected with social activities, they derive relatively little benefit from the support which such groups can give to their members. Similarly they entertain less contact with their brothers and sisters than others so that in difficult times they receive less support than others, from relatives and friends. The tendency to provide for the family, together with the striving to ascend on the social scale and the wish to impress others, may drive them into financial ventures beyond their capacities. They tend to solve financial difficulties alone as long as possible and often keep their worries to themselves without even telling wives, relatives, friends or children [2]. Sometimes they confess that they would like to share their worries but have been rebuffed by their wives’ reproaches that ‘it is all their own fault’. They cannot stand to be dependent on others. When someone is being nice, kind and helpful to them it is nearly unacceptable. On the whole one finds that they strive for manly achievements; their ideal is to be big and strong, admired and invulnerable, whereas their fear is to be small and weak, old, dependent and feminine. Their passive wishes are unacceptable and dangerous to them and therefore repressed but are clearly present when they are given an opportunity to unburden. As some of them put it: ‘I am a big fellow, with a tiny heart’. INTERHUMAN
CONFLICT
SITUATION
In our patients the infarct seems to occur following an interhuman conflict situation which sometimes had been acute and severe, but in other cases was only a series of no more than at first sight trivial irritations, which, however, had a special meaning for them. The essence of this conflict situation is a frustration in their tendency to dominate in the work or in the family situation, or both, sometimes in the community situation; coupled with a frustration in the desire for love and recognition. Mostly they reacted to the frustration by working even harder or using all their energy even in a practically lost case. They sometimes expressed it as: fighting with their back to the wall. The frustration seems to be worst if the very person whom the individual
44
J. M. VAN DER VALK and J. J. GROEN
expected to submit to him, dominates him or puts him in a position in which he has to submit to them, for instance a nagging wife or a wife who dominates and always interrupts and ‘corrects’ her husband, a too independent or powerful son or daughter; a domineering business partner or boss; a colleague who rivals and wins. A special feature seems to be the repeated frustration by the ‘coldness’ of a wife, who does not show her love. This had sometimes followed the discovery by the wife of her husband’s relations with other women. Still in these cases they feel themselves unjustly treated by their wives. This is an example of the lack of insight they often have in their own role in the conflict situation. They are not aware how frustrating their described attitude can be for those around them. It will be clear that modern western society with its emancipation of women and children and its system of competition throughout life, will bring individuals with a personality structure as described more frequently into this type of conflict than others. We got the impression that the patients by their exaggerated strivings had involved themselves in more conflicts than others. In spite of their hard work and mostly good intentions they were in general more appreciated than beloved and they seemed, when they were in conflict, to be supported less by relatives and friends than others. BEHAVIOUR
IN THE
CONFLICT
SITUATION
In the conflict situation the patient did not react with overt aggressive behaviour fighting or verbal outbursts of anger, with crying, swearing or patterns of complainor depression, but carried on as usual, keeping up an optimistic attitude or pretendindifference. As mentioned before, they might work still harder, trying to overcome difficulties even without any hope. Frustrated by the lack of approval they may turn the aggression towards themselves ‘Here I am with all my efforts and nobody sees it, I might as well drop dead!‘. In some patients the infarction happened clearly in a suicide situation. These men tend to inhibit emotional discharges more than others. This is in contrast to what they tell about their youth, when many of them were quick-tempered fighters or children who had frequent outbursts of rage. There is also marked absence of freely expressed anxiety, fear, or depression in their behaviour, and this even in situations which could almost naturally call for such outlet. They are people who, more than others, if asked how they are doing, will reply ‘fine’ even in difficult life situations. An admission of weakness or depression in such a situation is hardly ever heard from them; only after the heart attack has occurred this may happen and even then they This pattern of self-control is encoursometimes hide their anxiety under a humour. aged in our modern western society, but it is more traumatic for these individuals than for others, because: (a) they have more conflicts and (b) they are more in need of active discharge. So at the time of the illness there was mostly a combination of factors: 1. Lack of success, or a real failure or defeat. 2. Lack of tenderness and submission, or even a revolt, at home. 3. Lack of abreaction and real relaxation either in an emotional discharge or in sports and other activities. Mostly there were conflicts in two or three levels of activities: Work, family and community. Frustration only in one aspect does not seem to lead to an infarct. like ing ing the
Personality
structure and conflict situation in patients with myocardial infarction
45
Groen [3, 41 has described the double-level conflict in peptic ulcer patients. In coronary patients we find more or less the same (and possibly it can be found in other psychosomatic illnesses also). There are more analogies between coronary and ulcer patients as one may have understood from this description. Both suppress their wishes for love, tenderness and attention and feel that they only deserve sympathy when their achievements are worth while. A difference however lies in the competition with others. Whereas the ulcer patient likes to be accepted by his colleagues and only tries to be ‘father’s good-or best-son’, the coronary patient seems to be only satisfied when he can outdo his colleagues and dominate or defeat his father or fatherfigure [5]. In their youth they rather often had a heavy conflict with their father-sometimes leading to a row after which they left the house and/or father’s business-sometimes even leading to the opposite: a father thrown out of the house by his son. It is a pity to see that their own attitude later on may lead to a break with their own son, whereby this may become a family pattern : In some families coronary disease is seen in several generations! Most patients described their youth as having been hard and difficult, with hard work at an early age and little or no time for play and cosiness. Sometimes the poorness and dependency in their youth had given them an everlasting fear for lack of money and dependency. This may be one of the reasons for their later behaviour [6]. As to the actual pathogenesis of the heart attack we have the impression that the combination of strong but repressed emotions with unusual physical effort plays a role. Secondly the combination of, or rather In many cases we found this combination. a conflict between, two opposed emotions : aggression and a longing for passivity-a conflict between fight and flight, might result in opposed circulatory stimuli, or to put it in their own words : a discrepancy between ‘a big fellow and his tiny heart’. One dramatic example gives the components mentioned in a nutshell. A 48years old male visited the professor of cardiology with complaints of angina pectoris. He got the advice to avoid bodily exertion. Coming home he told his wife about it, when she asked him to lift the washing-tub to the table. She said: “So I’ll have to work me to death, while you sit and look!“, “That I cannot take!” said the man, lifted the heavy tub on the table-and dropped dead! In this paper some rather subjective impressions were given, derivedfrominterviews with patients and their relatives. We are aware that what has been put forward can only be called a preliminary hypothesis that needs urgently confirmation by other independent methods [6]. One of these methods is used by our psychologist, who will give some of his results in one of the following papers. SUMMARY
From the life-histories tional information from common features in these behaviour in the conflict common male behaviour
of 24 male patients with a myocardial infarction, and addimany other cases, a hypothesis was formed as to certain patients in their personality structure, conflict situations and situation, which can be summarized as an exaggeration of a in today’s western culture. REFERENCES
1. GROEN J. J., VAN DER VALKJ. M., TREURNIETN., KITS VAN HEYNINGENH., PELSERH. E. and WILDEG. J. S. Acute Myocardiallnfavction, APsychosomaticStudy. (In Dutch-English summary) De Erven F. Bohn N. V., Haarlcm (1965).
46
J. M. VAN DER VALK and J. J. GROEN
2. BENDIENJ. and GROEN J. J. Neuroticism and extraversion among patients with coronary heart disease. J. Psychosom. Res. 7, 11 (1963). 3. GROENJ. J. Emotional factors in the etiology of internal diseases. J. Mr. Sinai Hosp. 18,71 (1951). 4. GROENJ. J. Psychosomatic Research, a Collection of Papers, Pergamon Press, Oxford (1964). 5. KUSVANHEYNINGENH. Some notes on the psychiatric aspects ofpatients withcoronary occlusions. Advanc. Psychosom. Med. 1 (1960). 6. VAN DER VALK J. M. Comparison of the social setting and behaviour of patients with bronchial asthma, coronary occlusions and healthy subjects. Aduanc. Psychosom. Med. 1 (1960).
Vol. 11. pp. 41 to 46. Pergamon Press. 1967. Printed in Northern Ireland
PERSONALITY STRUCTURE AND CONFLICT SITUATION IN PATIENTS WITH MYOCARDIAL INFARCTION J. M. VAN DER VALK* and J. J. GROEN~ ALTHOUGH many researches have been done, knowledge about the real origin of acute myocardial infarction is still vague. One thing becomes certain : as in many instances in medicine-and certainly in psychosomatic medicine-it is not one circumscriptive cause that can be made responsible for the disease, but a combination of factors. Age and sex, arterio- and atherosclerosis, hypertension and diabetes, the diet and a high blood cholesterol level, lack of exercise and heavy smoking, all have their influence. Apart from this, there is the impression that emotional factors may play a role. However the scienti$c basis for this impression is weak. As in former investigations of the Amsterdam psychosomatic group we studied the possible influence of psychological factors in coronary disease by using the biographical anamnesis and extended out information with data from many other cases [l]. From this material we got the impression that the disease appears to occur during a constellation of three factors: First: Certain aspects of the personality structure which seem to predispose the individual to Second: A certain type of interhuman conflict situation, and Third: A certain behaviour by which this individual responds to this conflict. These three points will be discussed: Personality, Conflict situation, and Reaction pattern. PERSONALITY, OR GENERAL BEHAVIOUR The main common feature in these patients is an exaggeration of an otherwise rather normal behaviour pattern of western culture of today. There is a quantitative difference in behaviour between these patients and other individuals. One might say their aggression finds its main that they are more aggressive than others. Furthermore outlet in motor activity; there is a constant urge for being active and the activity is shown in the first place in the work situation. Coronary occlusion seems to occur with greater frequency in individuals who tend to work harder than others, the devotion to and responsibility for the work seems to be more intense, and they do their work more thoroughly. Work seems to be very deeply involved in the patient’s sense of duty. Whereas other individuals may regard it as one of the several functions of the human being, these patients very often regard work as the most important duty of man. For this reason they may sacrifice leisure, family life or contacts with friends to fulfil an almost compulsive urge of conscience which makes them work more and more and better and better. One might call them work-addicts. Work seems to be the main way along which they strive to climb on the social scale. Many of them have achieved higher social positions than their fathers. When * Physician, Psychosomatic Research Unit, Wilhelmina Hospital, Amsterdam. t Professor of Medicine, Hadasseh Hebrew University Hospital and Medical School, Jerusalem. 41
42
J. M. VAN DER VALK
and J. J. GROEN
no ascent on the social scale is possible, they strive for other forms of social recognition for their efforts. Another characteristic is a tendency to dominate and a difficulty in submitting to others; they strive towards, or fight for, power and leadership. A tendency to assume responsibility may also be seen as an expression of this tendency to dominate. They have to show that they are doing their work better than others. When having a leading position, or a business of their own, they are proud to work harder, start earlier and take a heavier task than their subordinates and they strive to defeat their competitors. Statistically the so-called ‘manager disease’ is not found mainly in managers, but the patients mostly like to be in jobs where they have a responsibility of their own and can take decisions. In the family situation, there is the same combination of a tendency to dominate and to assume responsibility. This is also one of the motivations behind their hard work, because through hard work they expect to improve their financial situation and to advance in social position, as a means to provide better for wife and children. Again, this is a widely spread ‘normal’ behaviour pattern in the average male member of modern western society but in these patients it is more pronounced than in others. As another expression of the tendency to dominate they expect wife and children to submit to them, to understand them, to respect them and to give them the love to which they feel they are entitled, also as a reward for their hard work and care. Actually, underlying the patriarchal domination there is a great need for love reception from the side of wife and children, but this is rarely admitted. Seemingly in contrast to these behaviour patterns is the finding that many of the patients had been markedly promiscuous. This can be an attempt to find a substitution when their own wife had not given them the submissive love they wanted; it can also be an aspect of their urge for manly achievements. On the other hand they will not accept any sign of a flirtation in their wives. Any behaviour of the wife that might draw the attention of other men may make them jealous and angry. In several instances they are strongly attached to their daughters, who may be more dependent, admiring and submissive than the wife, and they are jealous when a boyfriend becomes a steady partner. Their sons they expect to become someone to be proud of-according to their standards-to come into their business, etc. but on the other hand they keep on dominating them, giving them no responsibilities and showing It is an imminent danger that the son might them, ‘that they still have a lot to learn’. really show that he can outdo his father, or that he is preferred by the mother. For these patients it is a difficult point that in modern western society the status of the married unoccupied woman depends mainly on the place of her husband in this society. As the educational level is mostly the same in both sexes, this must result in a higher incidence of driving and exacting, passively demanding women; especially when-as in these patients-the husband pays little attention to his wife. On the other hand it may be that people with a personality as described are charmed and flattered and tend to marry girls who from the beginning show their dependence and their expectation ‘that he will take care of her’. In the community situation, these individuals are found more in certain professions where climbing in the social ladder is within reach by hard responsible work. The tendency to hard work and leadership brings some of them into prominent positions, although on the other hand, lack of promotion may provoke a severe fustration.
Personality structure and conflict situation in patients with myocardial infarction
43
They seem to take a more active part in the social life of thecommunity. Occupied with normal social activities, they again tend to exaggerate and some of them fill thereby executive or prominent community or honorary positions. Some of our patients were driven to these activities by the same sense of duty and responsibility which drive others into hard work for their family. They worked in leading positions in voluntary organizations for high human ideals. But at the same time it satisfied their need for power and leadership and their urge to outdo others. In their hobbies we find the same kind of hyperactivity. The hobbies are seldom relaxing. Fishing for instance is only acceptable to them as long as the catch is something to be proud of. They like to drive fast cars or motorbikes by which they are able to overtake everyone else, they drive more miles than others, they rather often smoke or drink heavily-and are proud of it, they don’t play a game for fun but for winning. They often do sports up to an older age, boasting that they still can teach younger people a lesson. As in their sexual life they have to prove themselves and others that they are still young and vigorous-and by doing this may ask too much from themselves. They tend to be individualists, people who do not like to appeal for help and who often believe that in modern society every man has to fight for his own position. Thus, although they may belong to many groups, and fulfil the duties connected with social activities, they derive relatively little benefit from the support which such groups can give to their members. Similarly they entertain less contact with their brothers and sisters than others so that in difficult times they receive less support than others, from relatives and friends. The tendency to provide for the family, together with the striving to ascend on the social scale and the wish to impress others, may drive them into financial ventures beyond their capacities. They tend to solve financial difficulties alone as long as possible and often keep their worries to themselves without even telling wives, relatives, friends or children [2]. Sometimes they confess that they would like to share their worries but have been rebuffed by their wives’ reproaches that ‘it is all their own fault’. They cannot stand to be dependent on others. When someone is being nice, kind and helpful to them it is nearly unacceptable. On the whole one finds that they strive for manly achievements; their ideal is to be big and strong, admired and invulnerable, whereas their fear is to be small and weak, old, dependent and feminine. Their passive wishes are unacceptable and dangerous to them and therefore repressed but are clearly present when they are given an opportunity to unburden. As some of them put it: ‘I am a big fellow, with a tiny heart’. INTERHUMAN
CONFLICT
SITUATION
In our patients the infarct seems to occur following an interhuman conflict situation which sometimes had been acute and severe, but in other cases was only a series of no more than at first sight trivial irritations, which, however, had a special meaning for them. The essence of this conflict situation is a frustration in their tendency to dominate in the work or in the family situation, or both, sometimes in the community situation; coupled with a frustration in the desire for love and recognition. Mostly they reacted to the frustration by working even harder or using all their energy even in a practically lost case. They sometimes expressed it as: fighting with their back to the wall. The frustration seems to be worst if the very person whom the individual
44
J. M. VAN DER VALK and J. J. GROEN
expected to submit to him, dominates him or puts him in a position in which he has to submit to them, for instance a nagging wife or a wife who dominates and always interrupts and ‘corrects’ her husband, a too independent or powerful son or daughter; a domineering business partner or boss; a colleague who rivals and wins. A special feature seems to be the repeated frustration by the ‘coldness’ of a wife, who does not show her love. This had sometimes followed the discovery by the wife of her husband’s relations with other women. Still in these cases they feel themselves unjustly treated by their wives. This is an example of the lack of insight they often have in their own role in the conflict situation. They are not aware how frustrating their described attitude can be for those around them. It will be clear that modern western society with its emancipation of women and children and its system of competition throughout life, will bring individuals with a personality structure as described more frequently into this type of conflict than others. We got the impression that the patients by their exaggerated strivings had involved themselves in more conflicts than others. In spite of their hard work and mostly good intentions they were in general more appreciated than beloved and they seemed, when they were in conflict, to be supported less by relatives and friends than others. BEHAVIOUR
IN THE
CONFLICT
SITUATION
In the conflict situation the patient did not react with overt aggressive behaviour fighting or verbal outbursts of anger, with crying, swearing or patterns of complainor depression, but carried on as usual, keeping up an optimistic attitude or pretendindifference. As mentioned before, they might work still harder, trying to overcome difficulties even without any hope. Frustrated by the lack of approval they may turn the aggression towards themselves ‘Here I am with all my efforts and nobody sees it, I might as well drop dead!‘. In some patients the infarction happened clearly in a suicide situation. These men tend to inhibit emotional discharges more than others. This is in contrast to what they tell about their youth, when many of them were quick-tempered fighters or children who had frequent outbursts of rage. There is also marked absence of freely expressed anxiety, fear, or depression in their behaviour, and this even in situations which could almost naturally call for such outlet. They are people who, more than others, if asked how they are doing, will reply ‘fine’ even in difficult life situations. An admission of weakness or depression in such a situation is hardly ever heard from them; only after the heart attack has occurred this may happen and even then they This pattern of self-control is encoursometimes hide their anxiety under a humour. aged in our modern western society, but it is more traumatic for these individuals than for others, because: (a) they have more conflicts and (b) they are more in need of active discharge. So at the time of the illness there was mostly a combination of factors: 1. Lack of success, or a real failure or defeat. 2. Lack of tenderness and submission, or even a revolt, at home. 3. Lack of abreaction and real relaxation either in an emotional discharge or in sports and other activities. Mostly there were conflicts in two or three levels of activities: Work, family and community. Frustration only in one aspect does not seem to lead to an infarct. like ing ing the
Personality
structure and conflict situation in patients with myocardial infarction
45
Groen [3, 41 has described the double-level conflict in peptic ulcer patients. In coronary patients we find more or less the same (and possibly it can be found in other psychosomatic illnesses also). There are more analogies between coronary and ulcer patients as one may have understood from this description. Both suppress their wishes for love, tenderness and attention and feel that they only deserve sympathy when their achievements are worth while. A difference however lies in the competition with others. Whereas the ulcer patient likes to be accepted by his colleagues and only tries to be ‘father’s good-or best-son’, the coronary patient seems to be only satisfied when he can outdo his colleagues and dominate or defeat his father or fatherfigure [5]. In their youth they rather often had a heavy conflict with their father-sometimes leading to a row after which they left the house and/or father’s business-sometimes even leading to the opposite: a father thrown out of the house by his son. It is a pity to see that their own attitude later on may lead to a break with their own son, whereby this may become a family pattern : In some families coronary disease is seen in several generations! Most patients described their youth as having been hard and difficult, with hard work at an early age and little or no time for play and cosiness. Sometimes the poorness and dependency in their youth had given them an everlasting fear for lack of money and dependency. This may be one of the reasons for their later behaviour [6]. As to the actual pathogenesis of the heart attack we have the impression that the combination of strong but repressed emotions with unusual physical effort plays a role. Secondly the combination of, or rather In many cases we found this combination. a conflict between, two opposed emotions : aggression and a longing for passivity-a conflict between fight and flight, might result in opposed circulatory stimuli, or to put it in their own words : a discrepancy between ‘a big fellow and his tiny heart’. One dramatic example gives the components mentioned in a nutshell. A 48years old male visited the professor of cardiology with complaints of angina pectoris. He got the advice to avoid bodily exertion. Coming home he told his wife about it, when she asked him to lift the washing-tub to the table. She said: “So I’ll have to work me to death, while you sit and look!“, “That I cannot take!” said the man, lifted the heavy tub on the table-and dropped dead! In this paper some rather subjective impressions were given, derivedfrominterviews with patients and their relatives. We are aware that what has been put forward can only be called a preliminary hypothesis that needs urgently confirmation by other independent methods [6]. One of these methods is used by our psychologist, who will give some of his results in one of the following papers. SUMMARY
From the life-histories tional information from common features in these behaviour in the conflict common male behaviour
of 24 male patients with a myocardial infarction, and addimany other cases, a hypothesis was formed as to certain patients in their personality structure, conflict situations and situation, which can be summarized as an exaggeration of a in today’s western culture. REFERENCES
1. GROEN J. J., VAN DER VALKJ. M., TREURNIETN., KITS VAN HEYNINGENH., PELSERH. E. and WILDEG. J. S. Acute Myocardiallnfavction, APsychosomaticStudy. (In Dutch-English summary) De Erven F. Bohn N. V., Haarlcm (1965).
46
J. M. VAN DER VALK and J. J. GROEN
2. BENDIENJ. and GROEN J. J. Neuroticism and extraversion among patients with coronary heart disease. J. Psychosom. Res. 7, 11 (1963). 3. GROENJ. J. Emotional factors in the etiology of internal diseases. J. Mr. Sinai Hosp. 18,71 (1951). 4. GROENJ. J. Psychosomatic Research, a Collection of Papers, Pergamon Press, Oxford (1964). 5. KUSVANHEYNINGENH. Some notes on the psychiatric aspects ofpatients withcoronary occlusions. Advanc. Psychosom. Med. 1 (1960). 6. VAN DER VALK J. M. Comparison of the social setting and behaviour of patients with bronchial asthma, coronary occlusions and healthy subjects. Aduanc. Psychosom. Med. 1 (1960).