Etiology of psychosomatic symptoms: its relationship with traumatic recurrence and autistic withdrawal

Abstracts

A etiologia do sintoma psicossomático continua indefinida, apesar de inúmeros estudos de ciências afins. Apresento a hipótese de que este só se desenvolve em paciente portador de personalidade autista como predisposição, isto é, que tenha barreiras autistas - apego às "formas autistas" e aos "objetos autistas" - em resposta a um trauma no período fetal ou do nascimento, que promova sensação de descontinuidade física. Essas formas e objetos são elementos do próprio corpo, como a saliva, a língua, os dedos e as mãos em contato com suas próprias superfícies sensórias, mais a pele. A soma do registro dessas sensações pela memória implícita incipiente ou em desenvolvimento funciona como um ego biológico sem sujeito cognitivamente interpretante. O paciente portador de personalidade autista, diante de um novo trauma com a mesma sensação de morte, retira-se para o estado de homeostase autista, como se já soubesse o caminho, e aí fica hospedado. Dessa forma, seu corpo se converte em uma "mãe suficientemente boa", conforme conceituada por Winnicott. O sintoma psicossomático é uma representação das defesas biológicas e não um representante de conflitos que têm como base elementos sexuais ou destrutivos reprimidos. Inclui a angústia de morte, de deixar de existir. Os fenômenos psicossomáticos escondem, paradoxalmente, uma luta pela vida e, especialmente, pela sobrevivência psíquica do paciente, segundo MacDougall.

Sintoma psicossomático; personalidade autista; trauma; percepção sensória

THEORETICAL-CLINICAL COMMUNICATION

Etiology of psychosomatic symptoms: its relationship with traumatic recurrence and autistic withdrawal

Sebastião Abrão Salim

Associate professor R4, Faculdade de Medicina, Universidade Federal de Minas Gerais (FMUFMG), Belo Horizonte, MG, Brazil. Training psychoanalyst, Sociedade Psicanalítica do Rio de Janeiro (SPRJ) and Núcleo de Belo Horizonte

^{Correspondência}

ABSTRACT

Etiology of psychosomatic symptoms remains unclear, in spite of many studies by similar sciences. I present the hypothesis that the patient needs to have an autistic personality as predisposition, i.e., he needs to have autistic barriers - attachment to "autistic forms" and to "autistic objects" - in response to a fetal or postpartum trauma that produces a feeling of physical discontinuity. These forms and objects are elements of the body itself, such as saliva, fingers, tongue, and hands in contact with its own sensory surfaces, especially the skin. The sum of these registers by incipient or developing implicit memory works as a biological ego without a cognitively interpreting subject. The patient with an autistic personality withdraws to the autistic homeostatic state when there is a trauma with an instinctive notion of death, as if he already knew the way and remains in suspension there. Thus, the body becomes a "good enough mother," as quoted by Winnicott. Psychosomatic symptoms are a representation of biological defenses, and not a representative of conflicts based on repressed sexual or destructive elements. It includes death anxiety, of no longer existing. Psychosomatic symptoms paradoxically hide a fight to live and especially to the patient's psychic survival, according to MacDougall.

Keywords: Psychosomatic symptom, autistic personality, trauma, sensory perception.

Introduction

The etiology of psychosomatic symptoms (PS) has not been explained yet, despite several research studies from different areas of biological and psychological knowledge. The author of this work aims at presenting the hypothesis that PS etiology is related to traumatic recurrence and autistic withdrawal. They are both instinctive biological responses to harmonize and extend life.

To formulate it, the author uses his psychoanalytical knowledge and studies on trauma according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), autistic withdrawal, sensory perception, implicit memory and stress.

Review of the psychoanalytic theory of psychosomatic symptoms

Freud's discovery¹ of unconscious life and its relationship with neurosis psychopathology, dream formation and the phenomenon of transference present in the analyst-patient relationship were gratuitously extended to PS etiology, as if it were also a symbolic representative of repressed sexual content.

As an attempt to repair such extremism, Ferenczi² created the expression "organic neurosis" to differentiate psychosomatic entities from hysteric neurosis.

Later, Cannon³ demonstrated that emotional status linked to repressed feelings, such as anger, guilt, reproving, dependence, envy and others, had specific physiological concomitants, dependent upon each of these feelings

Shortly afterward, Alexander school⁴ became the landmark of this evolution. For him, PS "would be a physiological response to the status of chronic emotional tension, maintained by unconscious processes presided by the autonomous nervous system; they were not symbolic representatives of repressed sexual unconscious content."

As an example, duodenal ulcer was a consequence of the antithesis between tendencies to regression and the need of overcoming it. It was a consequence of physiological hyperactivity determined by that system. Parasympathetic pathways were related to dependence, and sympathetic pathways were related to tendencies of fight and competition. His studies led him to the conclusion that psychophysiological disorders were standard responses to given situations of conflict inside the individual. From that the "theory of conflict specificity" was developed.

Following the same line, Dunbar⁵ supported the hypothesis that "each disease would have its own psychological profile determined by traumatic child experiences." He described the "traumatophilic personality, i.e., the individual repeats in his life past traumatic situations without being conscious of this fact." As will be stressed below, such relationship with the trauma is associated with the theoretical draft presented by the author to propose his theory on PS etiology and the theory of organ frailty.

The studies by those three last authors related the etiology of this symptom to the autonomous nervous system. Unfortunately, analysts, since the mid-20th century, have been detaching psychoanalysis from biology (Kandel⁶) in exchange for valuing theories of object relations and intersubjectivity. Freud did the same when, at the beginning of his studies, abandoned his Project for a scientific psychology⁷ and later his work Beyond the Pleasure Principle⁸, both being attempts to find the biological foundations for mental processes. He abandoned them, but predicted, until the end of his work, that such foundations would be found in the future.

Except for Winnicott,⁹ perhaps due to his proximity with pediatrics, and Tustin,¹⁰ with her studies on sensory physical experience, psychoanalysts have understood PS as a "body language" to express repressed conflicts, i.e., an auxiliary for limited verbal expression in such patients. Therefore, they are not aware that the psychosomatic universe is a universe without words or symbols.

Among current psychoanalysts, McDougall,¹¹ although in agreement with this biological concept, seems to be undefined, sometimes interpreting PS as a "regression to an initial child eroticism." Marty & M'Uzan¹² can also be cited, with their concept of "operational thought." They describe PS as physiological concomitant, without abandoning the symbolic vortex. Such issue remains incident.

For the author, there is always anxiety of death or madness in such patient, a statement supported by McDougall,¹¹ who claims that "psychosomatic phenomena paradoxically hide a fight for life, and especially for the being's psychic survival."

Sensory perception and implicity memory

Sensory perception has a marked meaning since fetal life. Although Winnicott¹³ did not extend his studies to the fetal period of psychic development, he made its importance clear in his studies. He stated that "the base of psyche is soma and, in terms of evolution, soma was the first to come. Psyche starts as an imaginative elaboration of somatic function (...) Imaginative elaboration of the function should be considered present in all proximity levels of physical functioning itself ( ) it refers to almost-physical fantasy, the one that is less reachable by consciousness."

Tustin,¹⁰ with his studies on psychogenic autism and on what she called "autistic barriers in psychoneurotic patients," came close to such approach of fetal psyche. Although she did not explain or systematize it, Tustin made the importance of self-sensory generation by the fetus explicit, as reported in a recent article by the author this review.¹⁴

Later, Ogden¹⁵ developed the concept of an autistic-contiguous position, previous to the schizoparanoid position, leaving its continuity since fetal life implicit. According to him, the psychic matrix of this position generates psychotic psychopathology, which was illustrated with clinical cases.

For the author, such and other contributions of neurobiology validate the possibility of sensory perception being our first psychic representation with register by incipient fetal implicit memory. Sensory perception is not an inert presence. It responds by the fetus and newborn subjective notion of being alive, of who I am and where I am. Implicit memory is based on the amygdala. Its basic function is regulating the elements and procedures responsible for preserving survival. Hence it is also called procedure or long-term memory. It works independently of consciousness, like the Freudian unconscious.

Perhaps this memory is related to Freud's concept¹⁶ of "body ego," a concept that he did not elaborate. He only mentioned that "ego is, before all, corporal." In a footnote, added in 1927, he continues: "That is, ego ultimately derives from body sensations, especially those that originate from body surface (the skin - mine)." It could be said that ego, in this initial period, is a biological ego formed by the continuous registration of such sensory perceptions by implicit memory, whose rudiment is present since fecundation.

Maturation of the fetus central nervous system, dictated by embryology, in that period does not make it able for cognitive abilities. Their acquisition starts after the first 10 days of postnatal life, according to Harlow¹⁷ and Levine,¹⁸ with their experiments in newborn monkeys and rats. According to these authors, there is a difference in the behavior of these animals if they are separated from matrixes after birth or if they are separated 10 days after birth. In the first case, when both are put in contact with matrixes, 6 months after separation, they seem to be strange, seek for isolation and are devitalized. This state is irreversible and can be observed, some time later, in both types of animals. The same did not occur with the second group. They soon started socializing and recovered their vitality. Such experiments show the results of trauma and existence of two psychic matrixes, an important differentiation for psychopathology. It can be stated that there is an autistic matrix presided by the biological ego and another when the newborn acquires a psychic ego with ability to distinguish between self and non-self, between subject and object.

To detail and clinically illustrate the importance of sensory perception and implicit memory in PS etiology, the author uses symptoms of enuresis, sweating and intensive salivation.

Nocturnal enuresis is frequent in clinical practice and has been extensively studied in pediatrics, psychiatry and psychoanalysis. It is a psychosomatic manifestation of unknown etiology and unspecific treatment. It brings for the child and caregivers disturbances and embarrassments that, invariably, lead to difficulties in family and social relationships, often as physical and psychic traumas, with irreversible sequelae in adult life. Individuals who have this disorder are permanently marked by traumas. It is usually psychoanalytically interpreted as a symbolic representative of a repressed erotic excitement or repressed anger toward the mother or substitute, prevented from being verbalized.

Intensive sweating is also linked to a liquid element, in this case, sweat. It is commonly attributed to oedipal anxiety (castration anxiety). It occurs under varied situations, such as plane trips, job interviews or public exposure.

Salivation, although less frequent and bringing much discomfort, usually goes unnoticed, and can produce changes in dentition and mouth mucosa.

The author proposes the hypothesis that such symptoms are representative of the instinctive biological defense of self-generation of sensory perceptions. To do so, urine and sweat on the skin and salivation on mouth mucosa were used. They are similar to eczemas, which make individuals continuously scratch themselves. They are perceptions that grant the agent the notion of being alive, of physical and psychic cohesion, which can be tested by everyone, when we hold a pen in our hands or teeth.

The author's intuition is that, soon after fecundation, fetus sensory perceptions are those connected to vital processes of cell anabolism and catabolism, as well as to heart beats, bowel movements and respiratory functions of the mother, which have the same rhythm and intensity.

Later, as the fetus becomes biological mature, it is able to self-generate sensory perceptions with the aid of its own body elements, with sensory surfaces of its own body.

Tustin¹⁰ described the importance of these perceptions produced by the infant or newborn using soft and hard elements of its own body on its sensory surfaces, especially its skin. Among the former are saliva, urine, vomiting, liquid stool, airway mucus and then sweat and tear, which he called "autistic forms." Among the latter are stool, tongue, fingers, hands, feet and wrists, which she called "autistic objects." Fetal ultrasound clearly shows the fetus with its hands, fingers and tongue in its mouth, as well as movements of touching its genital organ, ear lobes and other body parts with its hands and fingers. If we are alert, we can note that these are movements performed in the same rhythm and intensity. They have the same regularity of vital autonomic movements of the fetus and mother. Such reflex actions of sensory perception self-generation persist in postnatal life until senility. They occur as biting or touching lips and mouth with the tongue, fingers and other hard and soft objects. Other examples are salivating, biting nails, squeezing hard objects using the hands, rhythmically moving the body and legs. Other representatives in adult life are repeated touches on rosary beads, long baths, twirling hair with the fingers and so many others. Wearing the masbarah is a universal habit of the Islamic people. It is a string of beads made of a hard material, arranged similarly to the rosary beads of the Catholics. Its users touch the beads with their finger tips to calm down for a long time during the day. Such arrangements follow the individual for his whole life and have been called "autistic barriers" by Tustin. They will compose the autistic personality if their presence is too evident.

These autistic objects and forms come before Winnicott's "transitional objects."¹⁹ According to him: "It s know that babies, as soon as they are born, tend to use their wrists, fingers and thumbs to stimulate the oral erogenous zone, to the satisfaction of this zone, and in peaceful union. It is equally known that, after a few months, babies of both genders start to enjoy playing with dolls and that most mothers allow their babies to use some special object, hoping that they become, so to speak, attached to such objects." Although this sexual component may be present, Winnicott did not relate such experience with sensory perception in a search for appeasing a death anxiety. He kept himself attached to Freudian's theory of libidinal drive.

Tustin¹⁰ could not move away from that classical theory of erotic zone satisfaction either, but she considered these actions as movements in search of cohesion and tranquility to their carrier.

Freud⁸ related this status to the "principle of conservation," and pointed to a psychopathology previous to sexual repression, linked to death, but he did not proceed with that study.

Autistic withdrawal

The term "autistic" has to do with the first biological stage of the emerging being. It is organized under the protection of homeostasis with optimized conditions to continue the processes of biological maturation and their maintenance. In that status, there is an oxygen absorption and uptake by cells in minimal amounts, enough to provide the required energy to vital processes, as shown in recent experiments by Eric et al.²⁰ They called it "animated suspension" due to the status close to vegetative inertia. Such experiments have shown that, through induced ischemia, the life of organs for transplantation can be prolonged using techniques that reduce oxygen uptake by the organ to be transplanted.

That study proposes that any trauma with notion of discontinuity of being instinctively promotes, even in the fetal period, a return to the previous homeostatic status to prolong the life of its carrier. The author calls such return autistic withdrawal and considers it as a key element in PS etiology.

The theory of trauma according to DSM-IV

Trauma is defined by DSM-IV²¹ as "an event that determines in its victim or witness a concrete notion of death." It has major organic and psychic developments, which go from immobility to physical and psychic hyperactivity, previously described by the author.²²

Fetal trauma can result from a labor trauma, toxic and infectious states during pregnancy, congenital malformation and any factor that puts the survival of the fetus or newborn at risk.

As previously mentioned, there is an autistic withdrawal with presence of immobility, without pathological consequences, if transient, as it occurs in normal labor or in a temporary existential situation. It is ruled by the parasympathetic nervous system.

There can be another response characterized by hyperactivity, and its vital functions are ordered by the sympathetic nervous system. If prolonged, it triggers a deterioration process, which Selye²³ called stress. It triggers the so-called "general adaptation syndrome," which involves hypophysis, hypothalamus, sympathetic and parasympathetic nervous system and suprarenal glands. It ends as an irreversible morphological change of the organ and a state of organic and psychic failure, as can be seen in the psychosomatic patient. It is usually insufficient for family, social, sexual and professional life.

Both hypo- and hyperactivity are dependent on an intuitive assessment by our reptilian brain of the severity, intensity, imminence of danger and previous traumatic experiences to choose for movements of immobility, fight or escape. The body arrives before cognition.

Scaer²⁴ made an important statement that the pathological effect of trauma on its victim depends on the predisposition of the latter. He observed that severe motor vehicle accidents did not always produce effects of posttraumatic stress disorder, whereas other insignificant events did. The author proposes that such predisposition is conditioned by the autistic personality, resulting from the victim's fixation in the autistic state, to which he returns as if the path was already known.

Clinical case

L. was 34 years old when she started psychoanalytic psychotherapy with the author in two weekly sessions. She complained of bruxism, severe eczema, marked constipation, disability for work and lack of interest for life. Since adolescence she occasionally presented those symptoms, which worsened at the age of 27, after the uncle with whom she worked died.

She reported that her father died when she was young, and her mother had to work. She started taking care of her younger brothers. In youth, she had relationship difficulties in school due to her temper of being alone and quiet. She had prolonged amenorrhea. At the age of 18, she started work in her uncle's company, who showed her affection and trust. She dedicated herself to her work and was gradually taking control of management. She managed to gather some assets.

She got married at 22, but divorced 1 year later, because she could not stand her husband's outgoing behavior, which collided with some moderate eating and entertainment rituals and with her attachment to family and work. At 27, her uncle died, and his family stopped her from continuing in the company.

Bruxism made her submit to a long-term dental treatment, otherwise she could have lost her teeth. She underwent several medical treatments since then, throughout all following years, with no improvement.

At the age of 32, she was invited by the relatives who dismissed her from the company to resume her management. She felt physically and psychically insufficient. She chose to do embroidery, which she did skillfully and provided her with some income. At that time, she sought treatment with the author.

After 2 years, she presented considerable improvement. She understood about the importance of recurrent traumatic experiences of losing her father and uncle on the worsening of her symptoms and that these resulted from her need of producing sensory perceptions to feel alive. She was starting a new life with the support of a regular maintenance of the setting, through regular schedules, by the author's constant affective treatment, by looks, speech and empathetic understanding.

The interpretative work of her relationship with insufficiency to live was also being useful. She underestimated herself and was underestimated by others, which kept her under constant low self-esteem. She is still undergoing treatment.

Conclusion

According to what has been stated, PS etiology is related to traumatic recurrence in patients with autistic personality. Due to the presence of homeostasis, the body converts into the "sufficiently good mother," a concept developed by Winnicott.⁹

A proper therapeutic setting, especially provided by a constant trust in the psychotherapist, maintains similarities with homeostasis, and the patient can resume his maturation processes. The healing mechanism is slow and goes through affection, according to Almeida.²⁵ The interpretative work is destined to the elements of transference/countertransference and patient's relationship with his disease, which are related to the schizoparanoid, depressive and Oedipal psychic matrix.

One can argue that the issue of "organ fragility" could go back to the moment of trauma with the embryology of a given organ. Such trauma would be registered by procedure memory and evoked later on in case of a new trauma, with the biological weight falling on the previously affected organ.

Further studies are needed in a joint effort between psychoanalysts, psychiatrists and neuroscientists.

References

Received April 1, 2007

Accepted July 16, 2007

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Publication Dates

• Publication in this collection
  19 Dec 2007
• Date of issue
  Aug 2007

History

• Received
  01 Apr 2007
• Accepted
  16 July 2007