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PSYCHOSOMATIC DISORDERS IN CHILDREN
785 FATAL TUBERCULOSIS IN A GENERAL HOSPITAL SIR,-Dr. Warren Browne’s letter of March 28 suggests that a much wider investigation for sources of tuberculosis is necessary than is sometimes appreciated. A recent experience in this hospital confirms this view. In
September, 1958,
a
boy
was
admitted with
miliary
tuberculosis. On X-ray examination his sister, aged 31 2J was found to have a primary tuberculous chest lesion, but no source of infection could be discovered in the immediate family or environment. It was only when the paternal grandparents were examined, as a result of our inquiries, that the grandfather found to have open tuberculosis, for which he has now received treatment. He was visiting his son’s family at the approximate time the children contracted their illnesses and no other source of infection has been found.
in
Holland,
was
"
I feel that this is an interesting case of long-range " contact tracing, which in these days of ease of travelling gains some significance in the epidemiology of disease. Bristol
Royal Hospital for Sick Children
C. W. JENKINS.
PSYCHOSOMATIC DISORDERS IN CHILDREN SIR,-I am grateful to Dr. Apley for his excellent paper on psychosomatic disorders (March 28) which brings me nearer to recognising the term psychosomatic as applying to a conception of illness rather than to particular disorders. He mentions that for non-specialists treatment involves taking a personal interest, not limiting ourselves to the superficial, listening patiently, explaining and reassuring, and offering sensible guidance ". In another place he rightly warns that reassurance which does not reassure is a waste of time. It seems to me that there is a need for a particular assurance for some patients which is only too often overlooked, with consequent prolonging or worsening of the patient’s illness. The patient suffering from a physical manifestation associated with a hidden emotional disturbance is often quite hopeless about the emotional situation. Perhaps this is why the emotional disturbance has to be hidden. Hopelessness of this sort has been clearly demonstrated to me several times recently. "
On one occasion the patient was a young man with abdominal discomfort, very like that due to a stomach ulcer. He had had similar symptoms some months before and there was a note to say that he was acutely upset over a girl friend. On the second occasion he assumed a cheerful aspect which seemed somehow rather brittle. When pressed he averred that he had " quite given up " worrying about girls. This point was taken up with him and the doctor said something like this:" Then it may be that your physical pain is a direct substitute for the emotional pain which you refuse." He did not appear to lose his poise but said after a little consideration, Then what hope is there ? "
"
This question brought home to me that one of the first things the patient needs, perhaps even before he is faced with his emotional problem, is some sort of assurance that many of us come to believe, rather wrongly, that emotional problems are insoluble. As a corollary, if the doctor adopts this attitude he must also be prepared to tolerate with the patient enough emotional distress to give the patient practical proof of his, the doctor’s, statement that emotional distress is tolerable. Another patient, a girl, after referral to an orthopaedic surgeon for pain in the knees, was sent back with the comment: "Consider this an emotional disturbance." When the girl
then returned to her doctor she, having hitherto been a cool, calm, and collected girl, was nearly in tears. " He thought I was just silly," she said. It needed a very brisk retort from her doctor, It’s not silly to be miserable ", to make her begin to see the impossible position which she had quite unnecessarily created for herself, over many years, with regard to her emotions. Similarly with a young married girl scared almost out of her wits over accepting sexual penetration: although it is well known that it is not enough to examine and to reassure about the fear that she is not like other girls ", much too small for intercourse ", it is sometimes not so clearly seen that there is an immense hopeless fear of being a little girl. What may be most needed, as a beginning, is the assurance that this situation is understood and accepted by the doctor with the confident knowledge that there is still plenty of time to grow up. Then an exploration of the lag in emotional development can be "
"
"
begun. University Health Service, Bristol.
AGNES WILKINSON.
SIR,-Dr. Apley stated that " allergic or infective less likely to produce asthma, or may completely fail to produce it, when the patient is emotionally stresses are
stable ". Miller
(allergist) and Baruch (psychotherapist) feel that symptoms express hostility, mask a feeling of guilt anxiety, and at the same time represent attempts to gain
" allergic or
sympathy ". Some years ago an asthmatic girl of 8 was referred to me for Her sister, aged 16, had suffered from asthma from the age of 4 and died. Four weeks later the younger one developed it. The father stated that although the two children were fond of each other they often had violent quarrels. Under hypnosis I questioned the child and got a confession that she felt guilty of her elder sister’s death. As she was a very intelligent child it was not a simple matter to convince her that she was completely innocent, and it was only when I felt she was reassured that I permitted her to awake from the
hypnotherapy.
trance.
She lost her symptoms, but I would hate to think what would have happened to her had she gone on year after year being treated for allergy. London, W.1
A. P. MAGONET.
THE RIGHT KIND OF CONTROL
SIR,-Your annotation
of March 21 refers to an experithe influence of physical side-effects in drug trials, and comments that " unfortunately since the urines were not tested for the drug we cannot be sure that all the treated patients took their capsules, or at least the right ones ". In the context of the Rome proceedings2 it may not have been made sufficiently clear that this point is irrelevant to our argument, but a fuller account of our findings has now been submitted for publication. We were not concerned to show simply that nurses often fail to recognise side-effects, or that patients often fail to take their medicine, both of which may be accepted We were interested in what happens when as true. side-effects are observed. Our main findings physical a that were, first, specific drug-induced sign (in this case, was flushing) reported in patients not receiving the drug at all, and secondly, that other symptoms (which cannot be ascribed to the drug) were reported much more frequently in patients who had already been observed to show this sign. We suggested, therefore, that the occurrence of physical side-effects of treatment may influence ment
1. 2.
of
ours on
Miller, H., Baruch, D W. The Practice of Psychosomatic Medicine as Illustrated in Allergy. New York, 1956. Mayer-Gross, W., Harris, A. D., Letemendia, F. Proceedings of the First International Congress of Neuro-psycho-pharmacology, Rome (in the press).
September, 1958,
a
boy
was
admitted with
miliary
tuberculosis. On X-ray examination his sister, aged 31 2J was found to have a primary tuberculous chest lesion, but no source of infection could be discovered in the immediate family or environment. It was only when the paternal grandparents were examined, as a result of our inquiries, that the grandfather found to have open tuberculosis, for which he has now received treatment. He was visiting his son’s family at the approximate time the children contracted their illnesses and no other source of infection has been found.
in
Holland,
was
"
I feel that this is an interesting case of long-range " contact tracing, which in these days of ease of travelling gains some significance in the epidemiology of disease. Bristol
Royal Hospital for Sick Children
C. W. JENKINS.
PSYCHOSOMATIC DISORDERS IN CHILDREN SIR,-I am grateful to Dr. Apley for his excellent paper on psychosomatic disorders (March 28) which brings me nearer to recognising the term psychosomatic as applying to a conception of illness rather than to particular disorders. He mentions that for non-specialists treatment involves taking a personal interest, not limiting ourselves to the superficial, listening patiently, explaining and reassuring, and offering sensible guidance ". In another place he rightly warns that reassurance which does not reassure is a waste of time. It seems to me that there is a need for a particular assurance for some patients which is only too often overlooked, with consequent prolonging or worsening of the patient’s illness. The patient suffering from a physical manifestation associated with a hidden emotional disturbance is often quite hopeless about the emotional situation. Perhaps this is why the emotional disturbance has to be hidden. Hopelessness of this sort has been clearly demonstrated to me several times recently. "
On one occasion the patient was a young man with abdominal discomfort, very like that due to a stomach ulcer. He had had similar symptoms some months before and there was a note to say that he was acutely upset over a girl friend. On the second occasion he assumed a cheerful aspect which seemed somehow rather brittle. When pressed he averred that he had " quite given up " worrying about girls. This point was taken up with him and the doctor said something like this:" Then it may be that your physical pain is a direct substitute for the emotional pain which you refuse." He did not appear to lose his poise but said after a little consideration, Then what hope is there ? "
"
This question brought home to me that one of the first things the patient needs, perhaps even before he is faced with his emotional problem, is some sort of assurance that many of us come to believe, rather wrongly, that emotional problems are insoluble. As a corollary, if the doctor adopts this attitude he must also be prepared to tolerate with the patient enough emotional distress to give the patient practical proof of his, the doctor’s, statement that emotional distress is tolerable. Another patient, a girl, after referral to an orthopaedic surgeon for pain in the knees, was sent back with the comment: "Consider this an emotional disturbance." When the girl
then returned to her doctor she, having hitherto been a cool, calm, and collected girl, was nearly in tears. " He thought I was just silly," she said. It needed a very brisk retort from her doctor, It’s not silly to be miserable ", to make her begin to see the impossible position which she had quite unnecessarily created for herself, over many years, with regard to her emotions. Similarly with a young married girl scared almost out of her wits over accepting sexual penetration: although it is well known that it is not enough to examine and to reassure about the fear that she is not like other girls ", much too small for intercourse ", it is sometimes not so clearly seen that there is an immense hopeless fear of being a little girl. What may be most needed, as a beginning, is the assurance that this situation is understood and accepted by the doctor with the confident knowledge that there is still plenty of time to grow up. Then an exploration of the lag in emotional development can be "
"
"
begun. University Health Service, Bristol.
AGNES WILKINSON.
SIR,-Dr. Apley stated that " allergic or infective less likely to produce asthma, or may completely fail to produce it, when the patient is emotionally stresses are
stable ". Miller
(allergist) and Baruch (psychotherapist) feel that symptoms express hostility, mask a feeling of guilt anxiety, and at the same time represent attempts to gain
" allergic or
sympathy ". Some years ago an asthmatic girl of 8 was referred to me for Her sister, aged 16, had suffered from asthma from the age of 4 and died. Four weeks later the younger one developed it. The father stated that although the two children were fond of each other they often had violent quarrels. Under hypnosis I questioned the child and got a confession that she felt guilty of her elder sister’s death. As she was a very intelligent child it was not a simple matter to convince her that she was completely innocent, and it was only when I felt she was reassured that I permitted her to awake from the
hypnotherapy.
trance.
She lost her symptoms, but I would hate to think what would have happened to her had she gone on year after year being treated for allergy. London, W.1
A. P. MAGONET.
THE RIGHT KIND OF CONTROL
SIR,-Your annotation
of March 21 refers to an experithe influence of physical side-effects in drug trials, and comments that " unfortunately since the urines were not tested for the drug we cannot be sure that all the treated patients took their capsules, or at least the right ones ". In the context of the Rome proceedings2 it may not have been made sufficiently clear that this point is irrelevant to our argument, but a fuller account of our findings has now been submitted for publication. We were not concerned to show simply that nurses often fail to recognise side-effects, or that patients often fail to take their medicine, both of which may be accepted We were interested in what happens when as true. side-effects are observed. Our main findings physical a that were, first, specific drug-induced sign (in this case, was flushing) reported in patients not receiving the drug at all, and secondly, that other symptoms (which cannot be ascribed to the drug) were reported much more frequently in patients who had already been observed to show this sign. We suggested, therefore, that the occurrence of physical side-effects of treatment may influence ment
1. 2.
of
ours on
Miller, H., Baruch, D W. The Practice of Psychosomatic Medicine as Illustrated in Allergy. New York, 1956. Mayer-Gross, W., Harris, A. D., Letemendia, F. Proceedings of the First International Congress of Neuro-psycho-pharmacology, Rome (in the press).