The transcripts of recorded clinical psychiatric interviews with 20 patients (8 women and 12 men) suffering from psychosomatic illness were studied to ascertain the nature of their mental content and their capacity to experience affect. In 16 of the 20 patients there was evidence of a form of mentation that appears to have escaped the explicit attention of all but a few investigators: 1) These patients manifested either a total unawareness of feelings or an almost complete incapacity to put into words what they were experiencing. 2) The associations of the majority of the patients were characterized by a) a nearly total absence of fantasy or other material related to their inner, private mental life of thoughts, attitudes and feelings, and b) a recounting, often in almost infinite detail, of circumstances and events in their environment, including their own actions. Their thoughts, that is, were stimulus-bound rather than drive-directed.

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Certain clinical observations cast doubt on the validity of the traditional psychological explanation of psychosomatic disorders, which invokes the concept of a psychodynamic conflict derived from psychoanalytic theory. Psychosomatic patients appear to be unable to describe feelings in words, show a marked paucity of fantasy, and do not make significant internal psychological changes in these areas in the course of psycho-dynamically oriented psychotherapy. It is suggested that neurophysiological hypotheses may be more useful for understanding psychosomatic processes and specifically that disturbances in the function of the palleostriatral dopamine tract are related to psychosomatic disorders. Testable inferences from this hypothesis are proposed, including the suggestion that clinically and neurophysiologically, schizophrenia and psychosomatic disorders are the obverse of one another.

We have investigated prospectively the efficacy of two nonpharmacologic relaxation techniques in the therapy of anxiety. A simple, meditational relaxation technique (MT) that elicits the changes of decreased sympathetic nervous system activity was compared to a self-hypnosis technique (HT) in which relaxation, with or without altered perceptions, was suggested. 32 patients with anxiety neurosis were divided into 2 groups on the basis of their responsivity to hypnosis: moderate-high and low responsivity. The MT or HT was then randomly assigned separately to each member of the two responsivity groups. Thus, 4 treatment groups were studied: moderate-high responsivity MT; low responsivity MT; moderate-high responsivity HT; and low responsivity HT. The low responsivity HT group, by definition largely incapable of achieving the altered perceptions essential to hypnosis, was designed as the control group. Patients were instructed to practice the assigned technique daily for 8 weeks. Change in anxiety was determined by three types of evaluation: psychiatric assessment; physiologic testing; and self-assessment. There was essentially no difference between the two techniques in therapeutic efficacy according to these evaluations. Psychiatric assessment revealed overall improvement in 34% of the patients and the self-rating assessment indicated improvement in 63% of the population. Patients who had moderate-high hypnotic responsivity, independent of the technique used, significantly improved on psychiatric assessment (p = 0.05) and decreased average systolic blood pressure from 126.1 to 122.5 mm Hg over the 8-week period (p = 0.048). The responsivity scores at the higher end of the hypnotic responsivity spectrum were proportionately correlated to greater decreases in systolic blood pressure (p = 0.075) and to improvement by psychiatric assessment (p = 0.003). There was, however, no consistent relation between hypnotic responsivity and the other assessments made, such as diastolic blood pressure, oxygen consumption, heart rate and the self-rating questionnaires. The meditaiional and self-hypnosis techniques employed in this investigation are simple to use and effective in the therapy of anxiety.

Psychodynamic observations and theory have important implications for psychosomatic research and treatment.