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The anniversary reaction: A meeting of Freud and Pavlov
BARNEY M. OLIN, M.D. H. KEITH FISCHER, M.D.
The anniversary reaction: A meeting of Freud and Pavlov Emotionally invested dates or times may trigger serious emotional, physical, or behavioral responses-anniversary reactions. Freud's concept of the repetition compulsion and Pavlov's conditioned response help to provide an understanding of such phenomena. The authors present illustrative case reports and make suggestions for treatment.
ABSTRACT:
Three of the first four U.S. presidents to die, died on a fourth of July; two of them who signed the Declaration of Independence died on its 50th anniversary. A Pennsylvania Supreme Court Justice widely known for his crusade to establish Columbus as the first true discoverer of America, died on Columbus Day. A young businessman suffered from recurring depressions, always just before Thanksgiving Day. His father had died around Thanksgiving when he was 9 years old, but he did not consciously link this loss with his subsequent depression. When he married and his wife became pregnant, he insisted on an
abortion. Nevertheless, the pregnancy and the child it could have produced continue to live in his mind. He counts the advancing age of his aborted child, who would now be 8 years old. Although the psychiatric glossary does not include a formal definition for "anniversary reaction," the anniversary phenomenon is often noted in historical anecdotes, on medical wards, in physicians' offices, and in psychiatric units. In general, the anniversary reaction is an emotional, physical and/or behavioral response related to an anniversary of a significant event. Usually, a specific time or event in the present triggers unresolved
Drs. D/in and Fischer are clinical professors of psychiatry at Temple University School of Medicine. Reprint requests to Dr. D/in, 230 West Aliens Lane, Philadelphia, PA 19/19. NOVEMBER 1979 ' VOL 20 • NO II
feelings related to a traumatic episode of the past. The reaction is nonspecific, and its form is unpredictable, but the anniversary often explains the time of onset-the "Why now" of a symptom, illness, or reaction. The reaction may manifest itself as a heart attack, a nightmare, a spell of depression, or even death. In many cases, the reaction is disguised. Since the early I950s, we have been investigating the problem of time-related reactions. I •4 What was initially described as an interesting clinical phenomenon is, it has become clear, of great clinical significance. It bridges all branches of medicine. The unusual isolated observations, some dramatic, some frightening, are gradually being honed into psychodynamic formulations. Yet, no one has been able to explain satisfactorily how anniversary reactions work. The existing literature does not offer much toward a unifying theory or a satisfactory explanation, even though papers have been written from autobiographical, anecdotal, psychiatric, 749
Anniversary reaction
somatic, cultural, religious, and mythological viewpoints.
Hypothesis We conclude that both Pavlov and Freud hold keys to unlocking the puzzle. The anniversary reaction phenomenon links Freud's repetition compulsions and Pavlov's conditioned reflex.6 We believe that Pavlovian conditioning7 will explain the physiology of the anniversary reaction, while Freud's explanation of the mind-particularly the repetition compulsion-will elucidate the psychodynamics of anniversary reactions. Of more immediate interest, therapists can successfully treat patients with anniversary reactions if both points of view are taken into consideration. Pavlov and Freud worked from opposite ends of the human spectrum. Freud began with the metapsychological, and he was convinced that biology would in time explain most human phenomena. Freud tried to understand the forces of the repetition compulsion. On the other hand, Pavlov started in the laboratory; and he felt certain that animal experimentation would help explain human behavior. Pavlov spent his life working on conditioning. Each man continued parallel pursuits of further understanding of his own observations. The parallels continue in Freudian psychoanalytic and psychodynamic therapy and in Pavlovian behavioral therapy. In the anniversary reaction, the two approaches meet and engage. The term "conditioning" designates a process in which, as a result of reinforcement, a response becomes more frequent or more predictable in a given environment. It is a form of learning in which either a given stimulus or signal becomes NOVEMBER 1979· VOL 20 • NO II
increasingly effective in evoking a response, or a response occurs with increasing regularity in a well-specified, stable environment. When two stimuli occur close together, one stimulus will come to induce a response resembling that induced by the other. The response can be described as one of stimulus substitution. This is called classical conditioning. In humans, there is always a consistent optimum interval between conditioned stimulus and unconditioned stimulus. When conditioned stimulus is appropriately followed by unconditioned stimulus, it leads to reinforcement.
No single theory is adequate to explain and identify all of the factors that enter into the mosaic ofan anniversary reaction.
If unconditioned stimulus is omitted, no pattern develops. Freud's repetition compulsion describes a general human tendency to repeat painful experiences in an unconscious attempt to master them. In the course of living, people may experience a recurring series of unsettling and stressful episodes. Because they develop quite unexpectedly and are apparently unrelated to the individual's personality or general behavior, these episodes are attributed to bad luck or destiny. Persons with such recurrent life tragedies are sometimes said to be suffering from fate neuroses or repetition compUlsion. Examples include recurring nightmares after a traumatic event, and a child's repetition in his play ofa recently experienced trauma or loss.
Clinical observations When we first studied patients suffering from acute myocardial infarctions, we were impressed by the number of patients whose attacks occurred on a special anniversary date. This was the case too often to be coincidental. Indeed. the frequency of these occurrences convinces us of the presence of in ternal mechanisms that can set in motion a pathogenic process that can lead to illness or death. Of course, it must be emphasized that loss and trauma do not lead to an anniversary reaction in every instance. There are three distinct types of anniversary reactions: (I) time deadlines, (2) anniversary deadlines, and (3) classic anniversary reactions, as illustrated by the following cases. Case 1 A 23-year-old single woman reported a dream: "I tried to flush a newborn. fully developed baby down the toilet. but it just wouldn't be flushed. So I kept it. The baby and I agreed that we would never tell anybody what I had tried to do." The patient had aborted her pregnancy six months earlier, and the nightmare came on what would have been the expected delivery date. Prior to the dream, she had suffered from nausea, excessive hunger, and a loss of sexual desire. She told her therapist, "I don't think the gUilt will ever go away."
This case illustrates both time deadlines and anniversary deadlines. The time deadline refers to a specific time, unconsciously selected for the occurrence of a onetime event. After the abortion, this patient had eliminated all conscious thought of the pregnancy. However, her pregnancy continued unconsciously in her mind. She experienced her physical, emotional, 753
Anniversary reaction
and mental reactions at the time of the expected date of delivery. The anniversary deadline is a repetitive occurrence of a nonspecific stress reaction at specific times, usually selected for unconscious reasons. In this case, we can say that if the patient's feelings concerning the pregnancy, abortion, and delivery are not resolved, she may in the future have disturbing stress reactions at anyone of three time markers: conception date, abortion date, or delivery date. Repetition of the stress reaction at any of these specific times makes it an anniversary deadline. The conception, abortion, or delivery date can be seen as part of a repetition compulsion, with the patient unconsciously attempting to work through the pain of a traumatic event in a repetitive fashion. They may also be viewed as events and times for which the person has been conditioned. An event or date in the future may thus act as a reinforcement, a conditioned stimulus for a pathologic response. Case 2 A 30-year-old black belt karate instructor sought help for severe depression. He was married and the father of a 5-year-old child. He suffered height phobias, and was afraid of dying, obsessed with defending himself, and preoccupied with his own health and that of his chdd. It became clear that he had a fascination with death. He was obsessed with crashes and violent deaths, and drove extremely recklessly. When he was 5 years old, his 32-year-old father had died suddenly of a heart attack. The patient recalled that from the time he was a teenager, he felt that he, too, would be dead at age 32. He was totally unaware that his child served as his other "marker." The child was 5, the same age the patient had been
754
when his father died. Recognition of these markers and other dynamics imvolved in the depression cleared up his symptoms.
This case illustrates the classic anniversary reaction. Typical1y, its psychodynamic pattern develops after a child between the ages of 2 and 16 is sensitized by some emotional event, most severely by the death of the parent of the same sex. The child's specific age at the time of the trauma serves as the key time marker. Two additional related markers are the age of the parent at the time of the event and the exact
The therapist must be prepared to probe and elicit the complex chain ofevents related to the anniversary triggers.
date, day, month, or year the event took place. When, later, the sensitized individual's own child reaches the same age the patient was when he was originally traumatized, the stressful reactions occur. The patient is usually unaware of the source of the stress. There are three time lines to consider in the above patient's anniversary reaction: the father's time line, the patient's time line, and his child's time line. His father's death severely traumatized him. At the same time, he was conditioned. With the proper signals, frightening stress reactions of a pathologic nature would occur and he would be helpless to do anything about them. As far as he was consciously aware, his "fate" or "destiny" was determined.
Discussion The various psychoanalytic theories of childhood trauma and repression are important but do not sufficiently explain why anniversary reactions occur and why they assume their various forms. No single theory is adequate to explain and identify all the factors that enter into the mosaic of an anniversary reaction. We suggest that such reactions go beyond the repressed (Freudian), as the trauma is locked or fixed in some psychobiological way. It is a somatic imprint, waiting to be touched off by specific Pavlovian triggers. If the triggers are left intact. the patient's anniversary reaction may be explosive and damaging. Effective therapy, however, can remove or desensitize dangerous internal forces to such a degree that when the anniversary occurs, all that will emerge are memories of the earlier, unresolved trauma. The potentially destructive time bomb is defused or converted into a harmless firecracker. Unfortunately, when they have discovered that a great deal of emotion is mobilized by the anniversary reaction, some therapists have been afraid to deal with it. Rather than recognizing it as an important pathogen, they ignore it, consider it part of a character disorder, and tell the patient that it is unimportant. The patient's retention of a pathologic pattern is thus supported by a physician-patient pact of denial. Such resistance to recognition and exploration of anniversary reactions is common. occurring even among skilled, knowledgeable, and even analyzed physicians. This denial may represent the therapist's attempt to protect himself from facing his own anniversaries. PSYCHOSOMATICS
Treatment
Some persons with anniversary reactions manage to work through their personal deadlines in a positive and undestructive way. Proper evaluation of therapy must take into account these spontaneous cures. The points that follow constitute suggested guidelines for treatment. • By recognizing his or her own anniversary responses, the therapist can overcome personal resistance and bias. • The therapist should routinely ask for emotionally significant time markers in the patient's life. These may include not only certain dates, but also seasons of the year or hours of the day. • The therapist must be prepared to probe and elicit the complex chain of events related to the anniversary triggers. Interestingly, the usual reaction of the patient to the probe is one of enthusiasm. As a rule, the patient readily cooperates in exploring time-related events, and often shows a fascination with the relationship between feelings or
NOVEMBER 1979 • VOL 20 • NO II
symptoms in the present and events in the past. • Specifically, the therapist helps the patient to lift the defense mechanisms by encouraging him to let more of his unconscious feelings become conscious. • Talking with other significant persons, such as the patient's spouse or friends, may aid in resolving the anniversary reaction.
The two forces of conditioning and repetition compulsion come together at the time of the anniversary. The result of this unusual reinforcement is the release of potent forces that can result in harm or even death to the patient. The therapist who understands the mechanisms has a solid foundation upon which to base treatment. 0
Summary
REFERENCES
An anniversary reaction occurs when the patient has suffered a significant traumatic experience in the past that later sets basic forces into motion. The key forces are: (I) the conditioning of the patient at the time of the event-a physiologic imprint that is subsequently reinforced by repeated exposures to specific signals in the form of time or events, as well as reinforcement from unconscious mental stimuli; and (2) the repetition compulsiona primary unconscious drive to repeat painful experiences in an attempt to master the original trauma.
1. Fischer HK, Olin 8M: Psychogenic determination of time of illness or death by anniversary reactions and emotional deadlines. Psychoso· matics 13: 170-173, 1972. 2. Fischer HK, Olin 8M: Man's determination of his time of illness or death. Anniversary reactions and emotional deadlines. Geriatrics 28:89-94, 1971. 3. Fischer HK, Olin 8M, Winters WL, et al: Emotional factors in coronary occlusion: II. Time patterns and factors related to onset. Psychosomatics 5:280-291, t 964. 4. Weiss E, Olin 8M, Rollin HR, et al: Emotional factors in coronary occlusion: I. Introduction and general summary. Arch Intern Med 99:628-641,1957. 5. Freud S: Beyond the Pleasure Principle, 1920. In The Standard Edition 01 the Complete Psychological Works 01 Sigmund Freud. London, The Hogarth Press, 1955, vol 18. 6. Pavlov IP: Lectures on Conditional Reflex, Gantt WH (trans-ed). New York, International Publishers, 1941, vol 1. 7. Gantt WH: Reflexology, schizokinesis and autokinesis. Conditional Reflex 1: JanuaryMarch 1966.
755
The anniversary reaction: A meeting of Freud and Pavlov Emotionally invested dates or times may trigger serious emotional, physical, or behavioral responses-anniversary reactions. Freud's concept of the repetition compulsion and Pavlov's conditioned response help to provide an understanding of such phenomena. The authors present illustrative case reports and make suggestions for treatment.
ABSTRACT:
Three of the first four U.S. presidents to die, died on a fourth of July; two of them who signed the Declaration of Independence died on its 50th anniversary. A Pennsylvania Supreme Court Justice widely known for his crusade to establish Columbus as the first true discoverer of America, died on Columbus Day. A young businessman suffered from recurring depressions, always just before Thanksgiving Day. His father had died around Thanksgiving when he was 9 years old, but he did not consciously link this loss with his subsequent depression. When he married and his wife became pregnant, he insisted on an
abortion. Nevertheless, the pregnancy and the child it could have produced continue to live in his mind. He counts the advancing age of his aborted child, who would now be 8 years old. Although the psychiatric glossary does not include a formal definition for "anniversary reaction," the anniversary phenomenon is often noted in historical anecdotes, on medical wards, in physicians' offices, and in psychiatric units. In general, the anniversary reaction is an emotional, physical and/or behavioral response related to an anniversary of a significant event. Usually, a specific time or event in the present triggers unresolved
Drs. D/in and Fischer are clinical professors of psychiatry at Temple University School of Medicine. Reprint requests to Dr. D/in, 230 West Aliens Lane, Philadelphia, PA 19/19. NOVEMBER 1979 ' VOL 20 • NO II
feelings related to a traumatic episode of the past. The reaction is nonspecific, and its form is unpredictable, but the anniversary often explains the time of onset-the "Why now" of a symptom, illness, or reaction. The reaction may manifest itself as a heart attack, a nightmare, a spell of depression, or even death. In many cases, the reaction is disguised. Since the early I950s, we have been investigating the problem of time-related reactions. I •4 What was initially described as an interesting clinical phenomenon is, it has become clear, of great clinical significance. It bridges all branches of medicine. The unusual isolated observations, some dramatic, some frightening, are gradually being honed into psychodynamic formulations. Yet, no one has been able to explain satisfactorily how anniversary reactions work. The existing literature does not offer much toward a unifying theory or a satisfactory explanation, even though papers have been written from autobiographical, anecdotal, psychiatric, 749
Anniversary reaction
somatic, cultural, religious, and mythological viewpoints.
Hypothesis We conclude that both Pavlov and Freud hold keys to unlocking the puzzle. The anniversary reaction phenomenon links Freud's repetition compulsions and Pavlov's conditioned reflex.6 We believe that Pavlovian conditioning7 will explain the physiology of the anniversary reaction, while Freud's explanation of the mind-particularly the repetition compulsion-will elucidate the psychodynamics of anniversary reactions. Of more immediate interest, therapists can successfully treat patients with anniversary reactions if both points of view are taken into consideration. Pavlov and Freud worked from opposite ends of the human spectrum. Freud began with the metapsychological, and he was convinced that biology would in time explain most human phenomena. Freud tried to understand the forces of the repetition compulsion. On the other hand, Pavlov started in the laboratory; and he felt certain that animal experimentation would help explain human behavior. Pavlov spent his life working on conditioning. Each man continued parallel pursuits of further understanding of his own observations. The parallels continue in Freudian psychoanalytic and psychodynamic therapy and in Pavlovian behavioral therapy. In the anniversary reaction, the two approaches meet and engage. The term "conditioning" designates a process in which, as a result of reinforcement, a response becomes more frequent or more predictable in a given environment. It is a form of learning in which either a given stimulus or signal becomes NOVEMBER 1979· VOL 20 • NO II
increasingly effective in evoking a response, or a response occurs with increasing regularity in a well-specified, stable environment. When two stimuli occur close together, one stimulus will come to induce a response resembling that induced by the other. The response can be described as one of stimulus substitution. This is called classical conditioning. In humans, there is always a consistent optimum interval between conditioned stimulus and unconditioned stimulus. When conditioned stimulus is appropriately followed by unconditioned stimulus, it leads to reinforcement.
No single theory is adequate to explain and identify all of the factors that enter into the mosaic ofan anniversary reaction.
If unconditioned stimulus is omitted, no pattern develops. Freud's repetition compulsion describes a general human tendency to repeat painful experiences in an unconscious attempt to master them. In the course of living, people may experience a recurring series of unsettling and stressful episodes. Because they develop quite unexpectedly and are apparently unrelated to the individual's personality or general behavior, these episodes are attributed to bad luck or destiny. Persons with such recurrent life tragedies are sometimes said to be suffering from fate neuroses or repetition compUlsion. Examples include recurring nightmares after a traumatic event, and a child's repetition in his play ofa recently experienced trauma or loss.
Clinical observations When we first studied patients suffering from acute myocardial infarctions, we were impressed by the number of patients whose attacks occurred on a special anniversary date. This was the case too often to be coincidental. Indeed. the frequency of these occurrences convinces us of the presence of in ternal mechanisms that can set in motion a pathogenic process that can lead to illness or death. Of course, it must be emphasized that loss and trauma do not lead to an anniversary reaction in every instance. There are three distinct types of anniversary reactions: (I) time deadlines, (2) anniversary deadlines, and (3) classic anniversary reactions, as illustrated by the following cases. Case 1 A 23-year-old single woman reported a dream: "I tried to flush a newborn. fully developed baby down the toilet. but it just wouldn't be flushed. So I kept it. The baby and I agreed that we would never tell anybody what I had tried to do." The patient had aborted her pregnancy six months earlier, and the nightmare came on what would have been the expected delivery date. Prior to the dream, she had suffered from nausea, excessive hunger, and a loss of sexual desire. She told her therapist, "I don't think the gUilt will ever go away."
This case illustrates both time deadlines and anniversary deadlines. The time deadline refers to a specific time, unconsciously selected for the occurrence of a onetime event. After the abortion, this patient had eliminated all conscious thought of the pregnancy. However, her pregnancy continued unconsciously in her mind. She experienced her physical, emotional, 753
Anniversary reaction
and mental reactions at the time of the expected date of delivery. The anniversary deadline is a repetitive occurrence of a nonspecific stress reaction at specific times, usually selected for unconscious reasons. In this case, we can say that if the patient's feelings concerning the pregnancy, abortion, and delivery are not resolved, she may in the future have disturbing stress reactions at anyone of three time markers: conception date, abortion date, or delivery date. Repetition of the stress reaction at any of these specific times makes it an anniversary deadline. The conception, abortion, or delivery date can be seen as part of a repetition compulsion, with the patient unconsciously attempting to work through the pain of a traumatic event in a repetitive fashion. They may also be viewed as events and times for which the person has been conditioned. An event or date in the future may thus act as a reinforcement, a conditioned stimulus for a pathologic response. Case 2 A 30-year-old black belt karate instructor sought help for severe depression. He was married and the father of a 5-year-old child. He suffered height phobias, and was afraid of dying, obsessed with defending himself, and preoccupied with his own health and that of his chdd. It became clear that he had a fascination with death. He was obsessed with crashes and violent deaths, and drove extremely recklessly. When he was 5 years old, his 32-year-old father had died suddenly of a heart attack. The patient recalled that from the time he was a teenager, he felt that he, too, would be dead at age 32. He was totally unaware that his child served as his other "marker." The child was 5, the same age the patient had been
754
when his father died. Recognition of these markers and other dynamics imvolved in the depression cleared up his symptoms.
This case illustrates the classic anniversary reaction. Typical1y, its psychodynamic pattern develops after a child between the ages of 2 and 16 is sensitized by some emotional event, most severely by the death of the parent of the same sex. The child's specific age at the time of the trauma serves as the key time marker. Two additional related markers are the age of the parent at the time of the event and the exact
The therapist must be prepared to probe and elicit the complex chain ofevents related to the anniversary triggers.
date, day, month, or year the event took place. When, later, the sensitized individual's own child reaches the same age the patient was when he was originally traumatized, the stressful reactions occur. The patient is usually unaware of the source of the stress. There are three time lines to consider in the above patient's anniversary reaction: the father's time line, the patient's time line, and his child's time line. His father's death severely traumatized him. At the same time, he was conditioned. With the proper signals, frightening stress reactions of a pathologic nature would occur and he would be helpless to do anything about them. As far as he was consciously aware, his "fate" or "destiny" was determined.
Discussion The various psychoanalytic theories of childhood trauma and repression are important but do not sufficiently explain why anniversary reactions occur and why they assume their various forms. No single theory is adequate to explain and identify all the factors that enter into the mosaic of an anniversary reaction. We suggest that such reactions go beyond the repressed (Freudian), as the trauma is locked or fixed in some psychobiological way. It is a somatic imprint, waiting to be touched off by specific Pavlovian triggers. If the triggers are left intact. the patient's anniversary reaction may be explosive and damaging. Effective therapy, however, can remove or desensitize dangerous internal forces to such a degree that when the anniversary occurs, all that will emerge are memories of the earlier, unresolved trauma. The potentially destructive time bomb is defused or converted into a harmless firecracker. Unfortunately, when they have discovered that a great deal of emotion is mobilized by the anniversary reaction, some therapists have been afraid to deal with it. Rather than recognizing it as an important pathogen, they ignore it, consider it part of a character disorder, and tell the patient that it is unimportant. The patient's retention of a pathologic pattern is thus supported by a physician-patient pact of denial. Such resistance to recognition and exploration of anniversary reactions is common. occurring even among skilled, knowledgeable, and even analyzed physicians. This denial may represent the therapist's attempt to protect himself from facing his own anniversaries. PSYCHOSOMATICS
Treatment
Some persons with anniversary reactions manage to work through their personal deadlines in a positive and undestructive way. Proper evaluation of therapy must take into account these spontaneous cures. The points that follow constitute suggested guidelines for treatment. • By recognizing his or her own anniversary responses, the therapist can overcome personal resistance and bias. • The therapist should routinely ask for emotionally significant time markers in the patient's life. These may include not only certain dates, but also seasons of the year or hours of the day. • The therapist must be prepared to probe and elicit the complex chain of events related to the anniversary triggers. Interestingly, the usual reaction of the patient to the probe is one of enthusiasm. As a rule, the patient readily cooperates in exploring time-related events, and often shows a fascination with the relationship between feelings or
NOVEMBER 1979 • VOL 20 • NO II
symptoms in the present and events in the past. • Specifically, the therapist helps the patient to lift the defense mechanisms by encouraging him to let more of his unconscious feelings become conscious. • Talking with other significant persons, such as the patient's spouse or friends, may aid in resolving the anniversary reaction.
The two forces of conditioning and repetition compulsion come together at the time of the anniversary. The result of this unusual reinforcement is the release of potent forces that can result in harm or even death to the patient. The therapist who understands the mechanisms has a solid foundation upon which to base treatment. 0
Summary
REFERENCES
An anniversary reaction occurs when the patient has suffered a significant traumatic experience in the past that later sets basic forces into motion. The key forces are: (I) the conditioning of the patient at the time of the event-a physiologic imprint that is subsequently reinforced by repeated exposures to specific signals in the form of time or events, as well as reinforcement from unconscious mental stimuli; and (2) the repetition compulsiona primary unconscious drive to repeat painful experiences in an attempt to master the original trauma.
1. Fischer HK, Olin 8M: Psychogenic determination of time of illness or death by anniversary reactions and emotional deadlines. Psychoso· matics 13: 170-173, 1972. 2. Fischer HK, Olin 8M: Man's determination of his time of illness or death. Anniversary reactions and emotional deadlines. Geriatrics 28:89-94, 1971. 3. Fischer HK, Olin 8M, Winters WL, et al: Emotional factors in coronary occlusion: II. Time patterns and factors related to onset. Psychosomatics 5:280-291, t 964. 4. Weiss E, Olin 8M, Rollin HR, et al: Emotional factors in coronary occlusion: I. Introduction and general summary. Arch Intern Med 99:628-641,1957. 5. Freud S: Beyond the Pleasure Principle, 1920. In The Standard Edition 01 the Complete Psychological Works 01 Sigmund Freud. London, The Hogarth Press, 1955, vol 18. 6. Pavlov IP: Lectures on Conditional Reflex, Gantt WH (trans-ed). New York, International Publishers, 1941, vol 1. 7. Gantt WH: Reflexology, schizokinesis and autokinesis. Conditional Reflex 1: JanuaryMarch 1966.
755