- Email: [email protected]
The Analysis of a Case of Merycism: Psychopathology - Psychodynamics
The Analysis of a Case of Merycism: Psychopathology - Psychodynamics GEORGE SPYROS PHILIPPOPOULOS,
Merycism has been defined as "rumination in human species".l It was first described by Fabricius (1687), quoted by S. Kinnier Wilson. The latter has given in his monumental Neurology (1944) 2, a brief but excellent clinical description of this peculiar condition: "... Food previously taken is brought up into the mouth again, resalivated, chewed and reswallowed. The process lies, as a rule, outside volition for no effort is required to bring the food back and nausea does not occur; food regurgitates embarrassingly in spite of attempts to retain it ..."
Unlike cardiospasm and many other psychosomatic disorders of the upper and lower gastro-intestinal tract, so called 'gastric neuroses', which are relatively common, merycism appears to be a rather rare clinical syndrome. S. K. Wilson considers merycism as a 'nervous tic' and classifies it amongst what he calls 'motor neuroses'. For him both, nervous tics and occupational cramps "might have beerlrelegated to the psychoneuroses, since their dependence on or connection with psychical factors in pathogenesis is apparent". At present we do not know very much about merycism. Its reference to the group of 'motor neuroses', as conceived by Wilson, implies "nothing as to their etiology but is governed by their symptomatic nature". From a clinical point of view the symptoms of merycism are outstandingly motor. They are caused by many cooperative factors whether hereditary, constitutional, physical (somatic), emotional or a combination of them all. In respect to this subject, the late Edward Weiss (I948)3, wrote that "each individual preserves unique dynamic aspects of his own and it is Paper read at the 9th European Conference on Psychosomatic Research (Vienna, 28 April, 1972). Dr. Philippopoulos is Former Acting Professor & Chairman (1968-1970), Department of Psychiatry; Athens University School of Medicine; Athens, Greece.
M.D.
always hard to decide if these are hereditary or acquired". Merycism, therefore, is a clinical syndrome worth being looked into from its psychosomatic aspect by the present-day psychiatrist. Some years ago, I happened to come across a typical case of merycism in a young Greek recruit referred to me by the medical department of a local General Military Hospital in Athens, for psychiatric evaluation. The patient eventually had upon my recommendation, a two-years exemption from the Army on medical grounds. Then he was with me in psychoanalytically inspired psychotherapy for nearly two years on a 3 to 4-timesa-week basis until he became free from his symptoms so that he finally rejoined the Army to complete his 24-months compulsory service with no complaints or symptoms at all. I shall quote below some extracts of interest from his reconstructed medical history: The patient was a tall, very handsome, a bit plump but witty and well-mannered youth of twenty. He was born to a rather well-off upper middle class family in Athens and was reared in its orthodox tradition. He was the first and only son among 3 siblings. Breast fed for nearly two years, he grew up normally and lived mostly in the company of his maternal grand-mother who "spoiled him in many ways". His father was a lawyer who died of a heart attack in his late forties when the patient was 6 years old. The mother, a high school (Gymnasium) teacher, had to give up her job to devote herself to the care of her three children, all of whom, to quote the patient, "were badly in need of being cared for". Two years after the father's death, the little boy was sent as a day boarder to a private boarding school of high reputation in Athens. He proved to be a very clever, industrious and hard working youngster who soon became the first in his class among 30 class-mates of the same age. He was very much liked by the other boys in the class. He graduated from this school turning next to studying law at the University of Athens. He himself wished to become a medical doctor but his mother insisted Vntl1m.. YTV
CASE OF MERYCISM-PHILIPPOPOULOS on his following his father's profession. However, he found himself unable to attend his c~urse ~nd discontinued his studies to ..!!lter engage hlDlself In other fields or activity. He became a very competent businessman, very successful in tourist affairs and set up a business with a partner "the best friend he had, since he was a child". His past medical history is free from any serious illness, particularly of the digestive system. His psychosexual development may be considered normal wit? reference to sexual initiation, masturbatory experiences, sexual phantasies and heterosexual orientation. He had his first heterosexual experience "however not without difficulties", with a very young and very attractive next-door widow who apparently seduced him at 17. In relating his memories relative to his sexual experience the patient says that he was almost going to lose erection and fail "because of the bloody thing" that happened the very moment he was ready to penetrate his partner. Nevertheless, he managed to overcome his anxiety and succeeded fully in copulation. This experience had obviously left its imprints on the patient's mind for he often happened in similar situations with other women to "almost fail", until he met his present fiancee with whom he has normal sexual intercourse at regular intervals with no problems or difficulties whatsoever. The personality structure of the patient, as shown in a battery of tests (T.A.T., Rorschach, Rosenzweig's Picture Frustrating Technique etc.)·, was identical to the one described by Groen (1947)11, years ago, for his "ulcerative colitis" patients. Personally, I no more adhere to these 'personality profiles', than most of my colleagues in the field of psychosomatics do. Yet the picture emerging from the results of the tests applied, together with the opinion I formed of the patient during my long and close association with him in the course of his psychotherapy, revealed the following: The patient was of rather high intelligence, though not fully matured. for his age, on the emotional side. He also had a strong mother fixation reproduced in the doctorpatient relationship during the transference situation. He was ambitious, overactive, full of energy and yet reserved and fearful. He also was diligent, eager to please, prompt, cooperative, neat, sensitive, punctual and passive-dependent to an almost high degree of submission. Apparently, he was trying unconsciously to cover his deeply seated hostile-aggressive feelings through reaction formation. Right from his first interview the patient began to talk of his condition and the many serious implications it had brought upon his private life, his social • Many thanks are due to Mrs. Frieda Rassidakis Ph.D., for her invaluable help in assessing the patient'~ intelligence and personality. September-October. 1973
contacts and his professional activities. To him his symptoms were unquestionably related to an incident which occured at age 12 in the boarding school mentioned above. One day he was just about to finish his lunch in the school dining-room, when he was asked by a supervisor to immediately report to the principal's office. He felt rather confused by this unexpected invitation which, to his judgement, was "if not an order at least a demand". He interrupted his meal to go straight to the principal. The latter, a man in his late forties," a highly respected authority in the school", began to make overt sexual advances to the young student who, in his own words, "was utterly frustrated, filled with indignation and about to vomit". At this very moment he felt that a mouthful of food he had in the dining room immediately prior to going to the principal was brought up again into his mouth. He rushed out to go back to the dining room. There, he remained silent pretending that nothing had occured to worry about. To prove this, he carried on with his lunch but instead of taking in new food he belched and then began to regurgitate, remasticate and re-swallow the food already brought up into his mouth "only to avoid vomiting in front of my fellow-students". From then on, each time he had his meals whether at school, at home or in a restaurant, the patient was tormented by the impulse to repeat the process of rumination which gradually became for him a habit "as disgusting as pleasurable". Never had he confided in anyone, neither had he talked about the experience he had at the school since he considered the event "not only a sad and dirty affair but also a shameful topic to talk about even to my own self', he adds. In addition to this cardinal symptom the patient had also sporadic episodes of bulimia. During these episodes he would eat his meal voraciously, within a period of less than half an hour, having also a quart or two of beer. He then would stick his index-finger down to his throat and vomit. He never had any sign of anorexia. The patient had numerous physical examinations by medical doctors and G.I. specialists. He also had repeated X-Ray studies and barium meals together with laboratory procedures which all failed to prove any organic basis for his illness. It was first an Army doctor, an acute clinician who, by spending some of his precious time with the patient during the recruiting period, after a long interview with him, succeeded in coming closer to the origins of his illness.
In spite of a few lacunae existing in the patient's spectrum of psychosexual development, his actual sexual life may be considered normal since "normality is a way of functioning better than average and less than perfect" (Horton)",
PSYCHOSOMATICS
To form an idea of the patient's psychopathology, I shall quote here some of his associations, dreams and fantasies, from the rich material produced during his rather long and intensive psychotherapy: (*) First dream: " ... I was in myoId school which appeared to be like my home. A female teacher came in the classroom in a man's trousers. She had the face of our old principal; yet, she was like my mother and Mr. M., a neighbour whom I dislike as much as my mother does • • :'
In the process of the dream-work, the patient talks about this very neighbor who actually is the father of the young and beautiful widow the patient had sex with for the first time at 17. The patient does not like him at all. He hates him consciously on the ground that he still tries to force him to marry his daughter. ". . . I really hate him". he says, "and at times I would be glad to crush his neck and get rid of him .. :'.
In the dream cited above the repressed emotions of hostility, indignation and anger, which appear to be the most important constituents of his inner feelings, become apparent through the mechanism of condensation. The reason for this condensation of three different persons (principal-mother-neighbor) to only one lies, perhaps, in the fact that all these persons have had for the patient the same emotional meaning in that they all were persons disliked by him unconsciously, even his own mother who appears in the dream as sharing the patient's hatred towards the neighbor. Here is a fragment of another dream: ". . . I was passing by the school I went to when I was a small boy. The principal appeared at the
main entrance of the school and stretched his right arm to shake hands with me. I felt angry at him and moved away without even looking at him,"
Dreams of similar content were numerous throughout analysis whereas associations and fantasies were also brought to the fore filled with hostile-aggressive feelings, often projected on to the outer world and particularly towards people in authority. They were accompanied by and followed by an excessive amount of emotional charge, tinged as it were with anger, * I greatly appreciate the generosity of my patient who has granted me an unlimited freedom in using the material of his confessions.
resentment, indignation and hostility. A typical recurring fantasy the patient had in his past which appeared also in some of his dreams, was the wish to become a surgeon "as eminent as Mr. G.", a very competent practicing surgeon in Athens. Once the patient had a dream in which he was acting as the chief surgeon in a Military Base Hospital in Athens. He was (in his dream) performing only amputations "but in a masterly way". During his analysis the patient was cooperative, eager and prompt in grasping the interpretations when timely offered by the therapist. The transference situation which appeared early in therapy in a latent yet conspicuous form, was kept steady throughout the course of psychotherapy, with its characteristic polarities and fluctuations. An important chapter of his analysis was the improvement of the patient's relations with his younger sisters. He often harbored negative feelings and had also 'dirty thoughts' for them, at times to the point where it was impossible for him to tolerate both. He could not help having a recurrence of the "bloody thing" each time he had to have meals with them at home or in public. After he had gradually understood the deeper meaning and the unconscious symbolism of his symptomatology, he succeeded, for the first time in years, in enjoying a dinner he had in a fashionable restaurant in Athens, in the company of his fiancee and his two sisters. This was indeed a turning point in the patient's therapy. From then on the task of the therapist became easy and in fact very simple, until the analysis gradually came to its final stage. DISCUSSION
It is common knowledge that aggressive behavior may be triggered off by repressed hostility, anger, rage and resentment which produce visceral response affecting gastrointestinal motility, the cardiovascular system, salivation, pilomotor erection and respiration. W. B. Cannonli , wrote as early as 1909, that "worry, anxiety, grief, anger and the 'major emotions', affect the normal way of functioning of the gastrointestinal system". Gastric neuroses on the other hand, as well as many other psychosomatic disorders, may be greater (or more inVolume XIV
CASE OF MERYCISM-PHILIPPOPOULOS
tense) when overt expression or acting out of aggressive impulses are dammed-up. It is also generally accepted that "release of energy through aggressive action is psychologically sounder than inhibition of aggression (Moll6, Halsked 7 ). The patient in the case just referred to, had strong but repressed violent feelings of rage along with considerable compensatory passivity. Aggression in him was reasonably mastered and well controlled while, at times of emotional turmoil, the patient was flooded with rage and hostility associated with guilt feelings and stressing anxiety, eventually converted to a physical symptom complex. The stomach and the upper part of the gastro-intestinal tract of this particular patient may be contemplated as the "chosen" organs to become the seat of symbolic expression of the actual emotional conflict, for the simple reason that the organs in question became more vulnerable since they were most active and under the highest tension (anxiety) at the moment the decisive repression occurred. This is in full accord with the views expressed by Felix Deutsch (1939)8, with reference to organ choice in psychosomatic disorders. The choice of the afflicted organs seems also to be determined by the ability of their function to express symbolically the unconscious meaning of the contlict. With regard to organ specificity (organ compliance, organ choice) in psychosomatic disorders in general and particularly in the case presented, I am inclined to accept the views supported by Lopez-Ibor in his Maudsley lecture (1972)9. It is indeed neither the Freudian libido cathexis nor Adler's concept of organ inferiority which determine the genesis of the specific symptom complex. "Symptom specificity is bound up with the relationship between anxiety and corporality", so that, to further quote Lopez-Ibor, "the psychosomatic symptom appears at the point at which the personality notes the possible dehiscence which produces anxiety. The symptom is located where the anxiety is located and the anxiety where the symptom is".
In other words, the symptom is located "where the experiencing of the unity of the September-October, 1973
personality feels itself to be most threatened and this becomes functionally specific for the patient". Freud's concept and Adler's thesis with regard to organ choice in psychosomatic disorders are far more surpassed in their dynamic significance by Lopez-Ibor's views already referred to. The views of the latter are, in my opinion, closer to the clinical reality, that is closer to reason. Dambassis (1950)1° and many others prior to or after him, (Alexander, 1934), Wittkower (1938), Wolf and Wolff (1943), Groen (1947), Szasz (1948-1950) , Margolin et al. (1950-1951), Mirsky (1950-1952)11, supported the view that 'gastric neuroses' appear "to be associated with situations in which intense hostile tendencies were repressed or frustrated". In his brief paper, Dambassis writes that "the tendency to rumination seen frequently in children must, in the case of adults, be regarded as an expression of some conditioned reflex originated since childhood". "The numerous oral impulses (aggressive, receptive, sensual, rejective), undoubtedly play an important role in producing various forms of gastric neuroses, once the original drives are repressed or frustrated. The actual events of life are the precipitating factors and they occur in emotionally immature persons only". Grinker and Robbins (1954) 12, wrote that various emotional conflicts often incite a chain of neurovisceral responses which end in the specific organ supplied by the autonomous nervous system, thus producing the specific symptom or the symptom complex". In the case here reported, I failed to find any evidence whatsoever of more than one specific "noxious' dynamic factor involved in the genesis of the symptomatology of merycism, Le. aggression and anger. One is compelled, therefore, to attribute the clinical symptoms to this simple, single and very specific emotional conflict over hostile-aggressive impulses stemming up from experienced (or imagined) rejection and!or frustration. These aggressive drives were 'reasonably' repressed by a normally functioning superego, never expressed overtly. They were either concealed by a facade of dependency, 269
PSYCHOSOMATICS
conformity and exemplary behavior (reaction nearly two years. formation) or converted into the actual specific On the basis of the abundant material pra. symptom complex. duced (associations, dream, phantasies etc), It is well known that aggressive impulses the most interesting parts of which are quoted constitute a considerable proportion of human in the text, and the careful handling of the drives. They are the response to frustrations transference situation, it became possible for and have as their goal the overcoming of frus- the therapist to help the patient in gaining full tration itself. In part they appear closely re- insight into his condition by understanding the lated with certain sexual drives while "some ag· symbolism and perceiving the deeper (uncongressions seem to arise quite apart from sexual- scious) meaning of his symptomatology. Merycism, as interpreted to the patient, ity" (1. Dollard)l3. seemed to represent his inhibited unconscious In my opinion, in the case presented,'sexwish "to vomit at the face" of the person who uality is not at all to be blamed for the clinical actually instigated the conflict, in other words it symptoms in question, whereas aggression per was a hostile attack towards people in the pose seems to be an important if not the only imsition of authority. portant, causative dynamic factor. 92, Queen Sophias Ave., Athens, 611, Greece. The pleasure principle has been put out of action in this particular patient who had never BIBLIOGRAPHY I. Chamber's: Twentieth Cell/llry Dictionary of the really enjoyed a meal whether in public or at English Langllage. London 1929. home. Instead, he was unconsciously tormented 2. Wilson, S. A. Kinnier: Nellrology. Hafner Pubby tremendous feelings of guilt for his hostilelishing Co., New York, Ed. A. Ninian Bruce. aggressive impulses, directed outwards but 1970, vol. 2: 1633-1637. "eventually turned against his own Ego". 3. Weiss, Edward: Psychotherapy in everyday pracCONCLUSION
Merycism, as interpreted to the patient, has taken, through the mechanism of Ego regression, the clinical form of repetitive compulsive manifestation for him. His aggression primarily directed towards people in authority, had undergone a 'turning against his Ego', in accord with the Freudian axiom that "hostility towards frustrating objects, is often turned into hostility towards one's own Ego". This hypothesis has been confirmed and verified, as it were, by the positive results of the process of psychotherapy. SUMMARY
After a brief historical review of the subject, the history of a typical case of merycism (rumination in the human species) in a twenty-yearold young man is given, and the patient's psychopathology and psychodynamics are discussed. The patient was successfully treated by psychoanalytically orientated psychotherapy on a 3 to 4-times-a-week basis, within a period of
270
tice. lAMA 1948, 137:443. 4. Horton, P. C.: Digest of Psychiatry, 1972, 11 :47. 5. Cannon, W. B.: The influence of emotional states on the function of the alimentary canal. I. M. Sc. 1909, 137:225-287. 6. Moll, A.: Psychosomatic diseases due to battle stress. In Recent Developments in Psychosomatic Medicine. Ed. E. D. Wittkower and R. Gleghorn. J. B. Lippington. Philadelphia-Montreal, pp. 436454. 7. Halsked, J. and H. Weinberg: Peptic ulcer among soldiers in the Mediterranean Theatre of operations. New England Med. 1.1946,234:313. 8. Deutsch, Felix: The choice of organ in Organ Neuroses. Intern. I. Psa. 1939, 252262. 9. Lopez-Ibor, J. J.: Masked Dep:ession. 45th Maudsley Lecture. Brit. 101lrn. Psychiat. 1972, 556:245-258. 10. Dambassis, J. N.: The tendency to rumination. Amer. I. Digest. 1950, 17:159-160. 11. Quoted by Flanders Dunbar in: Emotions and Bodily Changes. Columbia University Press, New Yok, 1954, pp. 427-487. 12. Grinker, Roy and F. Robbins: Psychosomatic Case Book. The Blakiston Co. Inc., New York, 1954. 13. Dollard, J.: Quoted by Otto Fenichel in: Psychoanalytic Theory of Neurosis. W. W. Norton and Co., New York, 1945:58.
Volume XIV
Merycism has been defined as "rumination in human species".l It was first described by Fabricius (1687), quoted by S. Kinnier Wilson. The latter has given in his monumental Neurology (1944) 2, a brief but excellent clinical description of this peculiar condition: "... Food previously taken is brought up into the mouth again, resalivated, chewed and reswallowed. The process lies, as a rule, outside volition for no effort is required to bring the food back and nausea does not occur; food regurgitates embarrassingly in spite of attempts to retain it ..."
Unlike cardiospasm and many other psychosomatic disorders of the upper and lower gastro-intestinal tract, so called 'gastric neuroses', which are relatively common, merycism appears to be a rather rare clinical syndrome. S. K. Wilson considers merycism as a 'nervous tic' and classifies it amongst what he calls 'motor neuroses'. For him both, nervous tics and occupational cramps "might have beerlrelegated to the psychoneuroses, since their dependence on or connection with psychical factors in pathogenesis is apparent". At present we do not know very much about merycism. Its reference to the group of 'motor neuroses', as conceived by Wilson, implies "nothing as to their etiology but is governed by their symptomatic nature". From a clinical point of view the symptoms of merycism are outstandingly motor. They are caused by many cooperative factors whether hereditary, constitutional, physical (somatic), emotional or a combination of them all. In respect to this subject, the late Edward Weiss (I948)3, wrote that "each individual preserves unique dynamic aspects of his own and it is Paper read at the 9th European Conference on Psychosomatic Research (Vienna, 28 April, 1972). Dr. Philippopoulos is Former Acting Professor & Chairman (1968-1970), Department of Psychiatry; Athens University School of Medicine; Athens, Greece.
M.D.
always hard to decide if these are hereditary or acquired". Merycism, therefore, is a clinical syndrome worth being looked into from its psychosomatic aspect by the present-day psychiatrist. Some years ago, I happened to come across a typical case of merycism in a young Greek recruit referred to me by the medical department of a local General Military Hospital in Athens, for psychiatric evaluation. The patient eventually had upon my recommendation, a two-years exemption from the Army on medical grounds. Then he was with me in psychoanalytically inspired psychotherapy for nearly two years on a 3 to 4-timesa-week basis until he became free from his symptoms so that he finally rejoined the Army to complete his 24-months compulsory service with no complaints or symptoms at all. I shall quote below some extracts of interest from his reconstructed medical history: The patient was a tall, very handsome, a bit plump but witty and well-mannered youth of twenty. He was born to a rather well-off upper middle class family in Athens and was reared in its orthodox tradition. He was the first and only son among 3 siblings. Breast fed for nearly two years, he grew up normally and lived mostly in the company of his maternal grand-mother who "spoiled him in many ways". His father was a lawyer who died of a heart attack in his late forties when the patient was 6 years old. The mother, a high school (Gymnasium) teacher, had to give up her job to devote herself to the care of her three children, all of whom, to quote the patient, "were badly in need of being cared for". Two years after the father's death, the little boy was sent as a day boarder to a private boarding school of high reputation in Athens. He proved to be a very clever, industrious and hard working youngster who soon became the first in his class among 30 class-mates of the same age. He was very much liked by the other boys in the class. He graduated from this school turning next to studying law at the University of Athens. He himself wished to become a medical doctor but his mother insisted Vntl1m.. YTV
CASE OF MERYCISM-PHILIPPOPOULOS on his following his father's profession. However, he found himself unable to attend his c~urse ~nd discontinued his studies to ..!!lter engage hlDlself In other fields or activity. He became a very competent businessman, very successful in tourist affairs and set up a business with a partner "the best friend he had, since he was a child". His past medical history is free from any serious illness, particularly of the digestive system. His psychosexual development may be considered normal wit? reference to sexual initiation, masturbatory experiences, sexual phantasies and heterosexual orientation. He had his first heterosexual experience "however not without difficulties", with a very young and very attractive next-door widow who apparently seduced him at 17. In relating his memories relative to his sexual experience the patient says that he was almost going to lose erection and fail "because of the bloody thing" that happened the very moment he was ready to penetrate his partner. Nevertheless, he managed to overcome his anxiety and succeeded fully in copulation. This experience had obviously left its imprints on the patient's mind for he often happened in similar situations with other women to "almost fail", until he met his present fiancee with whom he has normal sexual intercourse at regular intervals with no problems or difficulties whatsoever. The personality structure of the patient, as shown in a battery of tests (T.A.T., Rorschach, Rosenzweig's Picture Frustrating Technique etc.)·, was identical to the one described by Groen (1947)11, years ago, for his "ulcerative colitis" patients. Personally, I no more adhere to these 'personality profiles', than most of my colleagues in the field of psychosomatics do. Yet the picture emerging from the results of the tests applied, together with the opinion I formed of the patient during my long and close association with him in the course of his psychotherapy, revealed the following: The patient was of rather high intelligence, though not fully matured. for his age, on the emotional side. He also had a strong mother fixation reproduced in the doctorpatient relationship during the transference situation. He was ambitious, overactive, full of energy and yet reserved and fearful. He also was diligent, eager to please, prompt, cooperative, neat, sensitive, punctual and passive-dependent to an almost high degree of submission. Apparently, he was trying unconsciously to cover his deeply seated hostile-aggressive feelings through reaction formation. Right from his first interview the patient began to talk of his condition and the many serious implications it had brought upon his private life, his social • Many thanks are due to Mrs. Frieda Rassidakis Ph.D., for her invaluable help in assessing the patient'~ intelligence and personality. September-October. 1973
contacts and his professional activities. To him his symptoms were unquestionably related to an incident which occured at age 12 in the boarding school mentioned above. One day he was just about to finish his lunch in the school dining-room, when he was asked by a supervisor to immediately report to the principal's office. He felt rather confused by this unexpected invitation which, to his judgement, was "if not an order at least a demand". He interrupted his meal to go straight to the principal. The latter, a man in his late forties," a highly respected authority in the school", began to make overt sexual advances to the young student who, in his own words, "was utterly frustrated, filled with indignation and about to vomit". At this very moment he felt that a mouthful of food he had in the dining room immediately prior to going to the principal was brought up again into his mouth. He rushed out to go back to the dining room. There, he remained silent pretending that nothing had occured to worry about. To prove this, he carried on with his lunch but instead of taking in new food he belched and then began to regurgitate, remasticate and re-swallow the food already brought up into his mouth "only to avoid vomiting in front of my fellow-students". From then on, each time he had his meals whether at school, at home or in a restaurant, the patient was tormented by the impulse to repeat the process of rumination which gradually became for him a habit "as disgusting as pleasurable". Never had he confided in anyone, neither had he talked about the experience he had at the school since he considered the event "not only a sad and dirty affair but also a shameful topic to talk about even to my own self', he adds. In addition to this cardinal symptom the patient had also sporadic episodes of bulimia. During these episodes he would eat his meal voraciously, within a period of less than half an hour, having also a quart or two of beer. He then would stick his index-finger down to his throat and vomit. He never had any sign of anorexia. The patient had numerous physical examinations by medical doctors and G.I. specialists. He also had repeated X-Ray studies and barium meals together with laboratory procedures which all failed to prove any organic basis for his illness. It was first an Army doctor, an acute clinician who, by spending some of his precious time with the patient during the recruiting period, after a long interview with him, succeeded in coming closer to the origins of his illness.
In spite of a few lacunae existing in the patient's spectrum of psychosexual development, his actual sexual life may be considered normal since "normality is a way of functioning better than average and less than perfect" (Horton)",
PSYCHOSOMATICS
To form an idea of the patient's psychopathology, I shall quote here some of his associations, dreams and fantasies, from the rich material produced during his rather long and intensive psychotherapy: (*) First dream: " ... I was in myoId school which appeared to be like my home. A female teacher came in the classroom in a man's trousers. She had the face of our old principal; yet, she was like my mother and Mr. M., a neighbour whom I dislike as much as my mother does • • :'
In the process of the dream-work, the patient talks about this very neighbor who actually is the father of the young and beautiful widow the patient had sex with for the first time at 17. The patient does not like him at all. He hates him consciously on the ground that he still tries to force him to marry his daughter. ". . . I really hate him". he says, "and at times I would be glad to crush his neck and get rid of him .. :'.
In the dream cited above the repressed emotions of hostility, indignation and anger, which appear to be the most important constituents of his inner feelings, become apparent through the mechanism of condensation. The reason for this condensation of three different persons (principal-mother-neighbor) to only one lies, perhaps, in the fact that all these persons have had for the patient the same emotional meaning in that they all were persons disliked by him unconsciously, even his own mother who appears in the dream as sharing the patient's hatred towards the neighbor. Here is a fragment of another dream: ". . . I was passing by the school I went to when I was a small boy. The principal appeared at the
main entrance of the school and stretched his right arm to shake hands with me. I felt angry at him and moved away without even looking at him,"
Dreams of similar content were numerous throughout analysis whereas associations and fantasies were also brought to the fore filled with hostile-aggressive feelings, often projected on to the outer world and particularly towards people in authority. They were accompanied by and followed by an excessive amount of emotional charge, tinged as it were with anger, * I greatly appreciate the generosity of my patient who has granted me an unlimited freedom in using the material of his confessions.
resentment, indignation and hostility. A typical recurring fantasy the patient had in his past which appeared also in some of his dreams, was the wish to become a surgeon "as eminent as Mr. G.", a very competent practicing surgeon in Athens. Once the patient had a dream in which he was acting as the chief surgeon in a Military Base Hospital in Athens. He was (in his dream) performing only amputations "but in a masterly way". During his analysis the patient was cooperative, eager and prompt in grasping the interpretations when timely offered by the therapist. The transference situation which appeared early in therapy in a latent yet conspicuous form, was kept steady throughout the course of psychotherapy, with its characteristic polarities and fluctuations. An important chapter of his analysis was the improvement of the patient's relations with his younger sisters. He often harbored negative feelings and had also 'dirty thoughts' for them, at times to the point where it was impossible for him to tolerate both. He could not help having a recurrence of the "bloody thing" each time he had to have meals with them at home or in public. After he had gradually understood the deeper meaning and the unconscious symbolism of his symptomatology, he succeeded, for the first time in years, in enjoying a dinner he had in a fashionable restaurant in Athens, in the company of his fiancee and his two sisters. This was indeed a turning point in the patient's therapy. From then on the task of the therapist became easy and in fact very simple, until the analysis gradually came to its final stage. DISCUSSION
It is common knowledge that aggressive behavior may be triggered off by repressed hostility, anger, rage and resentment which produce visceral response affecting gastrointestinal motility, the cardiovascular system, salivation, pilomotor erection and respiration. W. B. Cannonli , wrote as early as 1909, that "worry, anxiety, grief, anger and the 'major emotions', affect the normal way of functioning of the gastrointestinal system". Gastric neuroses on the other hand, as well as many other psychosomatic disorders, may be greater (or more inVolume XIV
CASE OF MERYCISM-PHILIPPOPOULOS
tense) when overt expression or acting out of aggressive impulses are dammed-up. It is also generally accepted that "release of energy through aggressive action is psychologically sounder than inhibition of aggression (Moll6, Halsked 7 ). The patient in the case just referred to, had strong but repressed violent feelings of rage along with considerable compensatory passivity. Aggression in him was reasonably mastered and well controlled while, at times of emotional turmoil, the patient was flooded with rage and hostility associated with guilt feelings and stressing anxiety, eventually converted to a physical symptom complex. The stomach and the upper part of the gastro-intestinal tract of this particular patient may be contemplated as the "chosen" organs to become the seat of symbolic expression of the actual emotional conflict, for the simple reason that the organs in question became more vulnerable since they were most active and under the highest tension (anxiety) at the moment the decisive repression occurred. This is in full accord with the views expressed by Felix Deutsch (1939)8, with reference to organ choice in psychosomatic disorders. The choice of the afflicted organs seems also to be determined by the ability of their function to express symbolically the unconscious meaning of the contlict. With regard to organ specificity (organ compliance, organ choice) in psychosomatic disorders in general and particularly in the case presented, I am inclined to accept the views supported by Lopez-Ibor in his Maudsley lecture (1972)9. It is indeed neither the Freudian libido cathexis nor Adler's concept of organ inferiority which determine the genesis of the specific symptom complex. "Symptom specificity is bound up with the relationship between anxiety and corporality", so that, to further quote Lopez-Ibor, "the psychosomatic symptom appears at the point at which the personality notes the possible dehiscence which produces anxiety. The symptom is located where the anxiety is located and the anxiety where the symptom is".
In other words, the symptom is located "where the experiencing of the unity of the September-October, 1973
personality feels itself to be most threatened and this becomes functionally specific for the patient". Freud's concept and Adler's thesis with regard to organ choice in psychosomatic disorders are far more surpassed in their dynamic significance by Lopez-Ibor's views already referred to. The views of the latter are, in my opinion, closer to the clinical reality, that is closer to reason. Dambassis (1950)1° and many others prior to or after him, (Alexander, 1934), Wittkower (1938), Wolf and Wolff (1943), Groen (1947), Szasz (1948-1950) , Margolin et al. (1950-1951), Mirsky (1950-1952)11, supported the view that 'gastric neuroses' appear "to be associated with situations in which intense hostile tendencies were repressed or frustrated". In his brief paper, Dambassis writes that "the tendency to rumination seen frequently in children must, in the case of adults, be regarded as an expression of some conditioned reflex originated since childhood". "The numerous oral impulses (aggressive, receptive, sensual, rejective), undoubtedly play an important role in producing various forms of gastric neuroses, once the original drives are repressed or frustrated. The actual events of life are the precipitating factors and they occur in emotionally immature persons only". Grinker and Robbins (1954) 12, wrote that various emotional conflicts often incite a chain of neurovisceral responses which end in the specific organ supplied by the autonomous nervous system, thus producing the specific symptom or the symptom complex". In the case here reported, I failed to find any evidence whatsoever of more than one specific "noxious' dynamic factor involved in the genesis of the symptomatology of merycism, Le. aggression and anger. One is compelled, therefore, to attribute the clinical symptoms to this simple, single and very specific emotional conflict over hostile-aggressive impulses stemming up from experienced (or imagined) rejection and!or frustration. These aggressive drives were 'reasonably' repressed by a normally functioning superego, never expressed overtly. They were either concealed by a facade of dependency, 269
PSYCHOSOMATICS
conformity and exemplary behavior (reaction nearly two years. formation) or converted into the actual specific On the basis of the abundant material pra. symptom complex. duced (associations, dream, phantasies etc), It is well known that aggressive impulses the most interesting parts of which are quoted constitute a considerable proportion of human in the text, and the careful handling of the drives. They are the response to frustrations transference situation, it became possible for and have as their goal the overcoming of frus- the therapist to help the patient in gaining full tration itself. In part they appear closely re- insight into his condition by understanding the lated with certain sexual drives while "some ag· symbolism and perceiving the deeper (uncongressions seem to arise quite apart from sexual- scious) meaning of his symptomatology. Merycism, as interpreted to the patient, ity" (1. Dollard)l3. seemed to represent his inhibited unconscious In my opinion, in the case presented,'sexwish "to vomit at the face" of the person who uality is not at all to be blamed for the clinical actually instigated the conflict, in other words it symptoms in question, whereas aggression per was a hostile attack towards people in the pose seems to be an important if not the only imsition of authority. portant, causative dynamic factor. 92, Queen Sophias Ave., Athens, 611, Greece. The pleasure principle has been put out of action in this particular patient who had never BIBLIOGRAPHY I. Chamber's: Twentieth Cell/llry Dictionary of the really enjoyed a meal whether in public or at English Langllage. London 1929. home. Instead, he was unconsciously tormented 2. Wilson, S. A. Kinnier: Nellrology. Hafner Pubby tremendous feelings of guilt for his hostilelishing Co., New York, Ed. A. Ninian Bruce. aggressive impulses, directed outwards but 1970, vol. 2: 1633-1637. "eventually turned against his own Ego". 3. Weiss, Edward: Psychotherapy in everyday pracCONCLUSION
Merycism, as interpreted to the patient, has taken, through the mechanism of Ego regression, the clinical form of repetitive compulsive manifestation for him. His aggression primarily directed towards people in authority, had undergone a 'turning against his Ego', in accord with the Freudian axiom that "hostility towards frustrating objects, is often turned into hostility towards one's own Ego". This hypothesis has been confirmed and verified, as it were, by the positive results of the process of psychotherapy. SUMMARY
After a brief historical review of the subject, the history of a typical case of merycism (rumination in the human species) in a twenty-yearold young man is given, and the patient's psychopathology and psychodynamics are discussed. The patient was successfully treated by psychoanalytically orientated psychotherapy on a 3 to 4-times-a-week basis, within a period of
270
tice. lAMA 1948, 137:443. 4. Horton, P. C.: Digest of Psychiatry, 1972, 11 :47. 5. Cannon, W. B.: The influence of emotional states on the function of the alimentary canal. I. M. Sc. 1909, 137:225-287. 6. Moll, A.: Psychosomatic diseases due to battle stress. In Recent Developments in Psychosomatic Medicine. Ed. E. D. Wittkower and R. Gleghorn. J. B. Lippington. Philadelphia-Montreal, pp. 436454. 7. Halsked, J. and H. Weinberg: Peptic ulcer among soldiers in the Mediterranean Theatre of operations. New England Med. 1.1946,234:313. 8. Deutsch, Felix: The choice of organ in Organ Neuroses. Intern. I. Psa. 1939, 252262. 9. Lopez-Ibor, J. J.: Masked Dep:ession. 45th Maudsley Lecture. Brit. 101lrn. Psychiat. 1972, 556:245-258. 10. Dambassis, J. N.: The tendency to rumination. Amer. I. Digest. 1950, 17:159-160. 11. Quoted by Flanders Dunbar in: Emotions and Bodily Changes. Columbia University Press, New Yok, 1954, pp. 427-487. 12. Grinker, Roy and F. Robbins: Psychosomatic Case Book. The Blakiston Co. Inc., New York, 1954. 13. Dollard, J.: Quoted by Otto Fenichel in: Psychoanalytic Theory of Neurosis. W. W. Norton and Co., New York, 1945:58.
Volume XIV