Ego Mechanisms in Three Pulmonary Tuberculosis Patients A Contribution to the Study of the Psychosomatic Process ALFRED FLARSHEIM, M.D.

. D F F O R T S TO FIND specific psychic determinants for somatic illnesses have been quite frequent and usually quite disappointing. We have concepts that often enable us to understand how a particular experience led to a specific kind of emotional response in neurotic and psychotic reactions. When dealing with physical illnesses, however, we usually cannot specify the precise means by which an emotional experience contributed to a somatic reaction. The role that the physical illness plays in the patient's life can be observed and the precipitating and alleviating forces determined after they have been effective, but the mechanism of connection between the two sets of data (the emotional and the physical) is usually not known, even qualitatively. In discussing the relationship between adult personality and developmental factors, Freud8 pointed out that when one traces the development of an individual from the adult state back through childhood, one is able to establish a continuous developmental sequence. He noted, however, that it is impossible to start with the infantile and childhood history of a patient and predict what the outcome will be in the adult personality. He pointed out that "even supposing that we know thoroughly Received for publication August 25, 1958. VOL. xx, NO. 6, 1958

the etiological factors that decide a given result, still we know them only qualitatively, and not in their relative strengths. Some of them are so weak as to become suppressed by others, and therefore do not affect the final result. But we never know beforehand which of the determining factors will prove the weaker or the stronger— we can only say at the end that those that succeed must have been the stronger." Mirsky,14 Engel,4 and Greene9 note that loss of object relationships is followed by the precipitation of many major somatic changes, and they have investigated mechanisms whereby the separation may lead to the somatic change. This paper is an effort to increase our understanding of the psychological aspects of this mechanism by studying the ego operations that occur during the interval between the object loss and the onset of somatic illness. Data and Methods The data on which this paper is based were obtained from psychotherapeutic observation of 3 women seen in private psychiatric practice. Each of these patients had had pulmonary tuberculosis many years before begining psychotherapy. Similarities in character structure, for example points of libidinal fixation, conflicts, and patterns of ego defenses, were striking. The

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emotional reactions to significant events that were associated with the onset and the arrest of tuberculosis were also similar in the 3 women. Moreover, each of the patients experienced respiratory symptoms (coughing, wheezing, or hemoptysis) under comparable circumstances during psychotherapy. Finally, the emotional patterns of the early lives of all 3 patients were dramatically alike. The following methods were used in handling the data: 1. During the psychotherapy occurrence of respiratory symptoms was correlated with the observed psychological data. 2. The psychological data in the anamnesis were correlated with the history of activation and arrest of pulmonary tuberculosis. 3. Constellations of factors in the developmental histories of the 3 patients were correlated with common features in both their adult character structures and their somatic responses. Theory—The material presented in these 3 cases was examined in an attempt to determine the process connections between the psychic reactions and the somatic illness. The observations seem consistent with the view that both the pulmonary tuberculosis in the history of these women and the respiratory symptoms observed during psychotherapy occurred after the loss of a particular kind of object relationship. This loss initiated a chain of intrapsychic events that led to a state of exhaustion, at which time the somatic illness occurred. The somatic illness improved when the exhaustion was relieved. Two different processes that led to exhaustion will be described from the standpoint of ego operations. In this study the exhaustion state is considered a psychological entity. This view is consistent with comments in Freud's 1914 paper "On Narcissism."7 In it he states that "the ego becomes impoverished in consequence of its libidinal object cathexes and of the formation of the ego ideal, and enriches itself again [from the "narcissistic

reservoir" of the organism] by the gratification of object love, and by fulfilling its ego ideal." The evidence for the existence of states of depletion or repletion accompanied by physical illness and a description of certain psychological mechanisms that contribute to such states are presented in this paper. The simultaneous occurrence of 2 events does not, of course, indicate that there is necessarily any causal relationship between them. The respiratory illnesses in these patients occurred during psychological states that I believe can be efficiently understood as manifestations of depletion of ego energy. Whereas we may be unable from this material to form any concept of dynamic specificity, we may speculate on the possibility of a psycho-economic concept. It is interesting to note that the ego impoverishment observed in these patients is consistent with the traditional medical opinion that chronic physical deprivation may predispose one to tuberculosis.3 The histories of these patients could be looked at from the standpoint of the effect on susceptibility to tuberculosis of lack of rest, poor nutrition, and of situations in which exposure to the disease was not unlikely. There are differences in the somatic responses of the 3 patients that cannot be accounted for by the methods used in this study. For example, the respiratory symptoms observed were chronic bronchitis in the first patient, intermittent cough with hemoptysis in the second patient, and intermittent bronchial wheezing with hemoptysis in the third patient. I was unable to detect any difference between the psychological constellation of events present during the precipitation and alleviation of these observed respiratory symptoms and the constellation that the history revealed to have been associated with the pulmonary tuberculosis of the past. This is obviously a very important differentiation and might be clarified by observation of patients earlier in the course of tuberculosis. Furthermore, the psychiatric histories of these patients do not seem PSYCHOSOMATIC MEDICINE

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tervening lung tissue throughout both lung fields. A year before beginning treatment she had become the mistress of a man with whom she had had her first sexual satisfaction. This arrangement was however such a flagrant violation of her moral standards that she felt she would prefer to be dead rather than to live in such a way. She suffered "terrible remorse," but for more than 2 years she felt compelled to continue the "intolerable" relationship. When it was suggested to her that there might be a connection between her respiratory and her emotional reactions, she considered this "permission to be well" and had remarkable relief from the bronchitis for a few weeks. Gradually, however, she came to feel more and more "degraded" by the relationship with her lover, and finally, one evening, felt that he treated her in the same condescending manner that he did a waiter in a restaurant. When she told of this the following day, she was coughing literally with every breath and was dyspneic and very cyanotic. She was agitated and wished for death. Immediately after this interview she decided to terminate the relationship and informed her lover of her decision. She haughtily rejected his offers of financial assistance in spite of her illness and need. Her depression and distraught state vanished, and when next seen a few days later she looked well and did not cough once during the entire hour. As an infant she had been breast fed but "nearly starved" until, after 2 months, she was reluctantly given supplementary feeding. During her childhood and adolescence she felt "exploited" by her mother but worked incessantly though unsuccessfully to please her. She beCase Reports came increasingly aware of and disturbed by Case 1 her mother's inconsistencies. If she succeeded The first patient, a 37-year-old widow, is in- in any way her mother felt left out, and if she tensely aware of symbols of prestige, esteem, failed her mother felt abused. Her mother also and respectability. When she came into ther- boastfully lied to others constantly about the apy she was distraught, depressed, and suicidal, patient's achievements and thus made her feel and suffered from severe nonspecific bronchitis that she was incapable of fulfilling her mother's superimposed on extensive pulmonary damage expectations and, by extension, of conforming fiom arrested tuberculosis. Because of the pul- to her own ego ideal. During adolescence her monary fibrosis, she became quite dyspneic and behavior toward her mother became harsh and cyanotic whenever she had a paroxysm of unfriendly, although she wished she could have treated her lovingly and felt "terrible remorse" coughing. X-rays revealed bilateral thickened pleura, because she did not. the heart and mediastinum displaced to the The climax of this conflict came at age 17, left with elevation of the left diaphragm, and when after having repulsed the sexual advances fibrocalcific foci with areas of retraction, of a man, as her mother had repeatedly warned bronchiectatic cavities, and emphysema of in- her she must always do, the patient was re-

to be different from those of many other patients who develop different psychiatric and somatic clinical syndromes. Since the data used in this paper were obtained from 3 female patients, they are of course not presented as derived from a representative sample of all tuberculosis patients. The study of a larger number of patients of both sexes, in different stages ot the disease, and at differing periods after the arrest of tuberculosis, would be valuable. Complete case histories are not presented, but only representative material deemed relevant to the correlation between personality structure and the course of the pulmonary tuberculosis in the histories, and the respiratory symptoms observed during psychotherapy. The events that are presented to illustrate this correlation are in each instance typical of repetitive patterns of reaction. For the purpose of the study, the onset oC tuberculosis is regarded as the time of the onset of the symptoms that called the patients' attention to the illness, without consideration of the question of what previous undetected pathological processes may have been occurring. Respiratory symptoms during psychotherapy, consisting of coughing, wheezing, or hemoptysis, were either observed by the psychiatrist, or reported by the patients.

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proached by her mother who said that this man was important to her career and should have been encouraged. A few days alter this episode her first attack, of hemoptysis occurred, but she continued her strenuous work because her avaricious mother insisted. About 3 months later she collapsed. She was discovered to have active pulmonary tuberculosis, and her employer insisted that she have treatment. She was not put in a sanitorium because of the "social levelling" that that would have implied. After 10 years of bed rest and continuous pneumothorax, she met and married a man who had high prestige in the community. He encouraged her, gave her work to do, and relieved hei feeling of obligation to her parents by providing for their economic needs. Signs of aclivity of her tuberculosis disappeared when she married. She was grateful to her husband and considered their relationship necessary for her survival, but she did not love him. She found their sexual relationship "repulsive" but submitted to it "from duty and gratitude" and made him think she enjoyed it. She contributed to her husband's success through her ability to charm and influence people but reproached herself for being deceitful and manipulative. She was physically well during her marriage. Two years before she began psychotherapy her husband had died, after surgery to which she had consented She said she suffered great remorse because she felt responsible for his death but that she felt no grief since she had only pretended to love him. Shortly after his death she entered into the relationship that violated her standards of behavior and was accompanied by the respiratory symptoms and the agitated depressed state with which came to psychotherapy. Case 2 The second patient is a 45-year-old single professional woman. She came into therapy for mild depression after the psychiatrist to whom she had been going for 5 years left the city. The approval of persons whom she respected was of such importance to her that she felt she "would not survive" if she did not get it. She expected to be miraculously helped by the therapist to attain a state of blissful perfection. She had had active pulmonary tuberculosis for 5 years, 20 years earlier, and intermittent cough and hemoptysis since, without fever or x-ray progression or return of positive sputum.

X-rays revealed moderate fibrosis and bronchiectasis of both upper lobes and left lower lobe. She used her history of illness and fear of its return, memories of mistreatment in her childhood, and other manipulative, deceptive, and masochistic maneuvers to force the support and sympathy she so desperately desired. Whenever she felt that she was receiving this, her behavior was ascetic and conforming, and she neither reported nor was observed to have any respiratory symptoms. Whenever she felt that the therapist had disappointed her expectations her conforming behavior would break down, she would "go to pieces," act out in a self-destructive way, become distraught and angry and depressed, and develop bronchitis with cough and hemoptysis. When she felt that she was again receiving support and approval, the nonconforming behavior would cease, her depression would disappear, and she would experience relief from her respiratory symptoms. The patient had had a severe infantile trauma, having been born with a respiratory obstruction that she believes nearly caused her death. She was raised by her father and grandmother who, she felt, did not love or value her. During her early life she was "used and exploited in a deceitful, manipulative w.iy." She felt that her mother, who was not married to her father, and whom she rarely saw, expressed interest in her only in the hope of influencing her father and getting money from him. At about age 18 she ran away from home, expecting that someone would follow her and bring her back, as they had on previous occasions, and that she would then be better treated When this did not occur she felt angry and rejected and began a series of promiscuous relationships about which she felt guilty and anxious. It was in this setting, and with her behavior progressively less integrated, that her clinically active tuberculosis began. She was hospitalized in a city distant from her home and had a highly seductive' relationship with the doctor who cared for her. Her tuberculosis did not improve. After a time her family arranged for her to be transferred to a hospital near her home, where they visited her regularly. She then decided to "reform," and her tuberculosis was arrested. On a brief vacation during psychotherapy the patient went home to visit her father One night she stayed out rather late and her father PSYCHOSOMATIC MEDICINE

FLARSHEIM "accidentally" locked her out of his house. After this incident, for the first time in many years, the patient acted out promiscuously and masochistically. During her next interview she coughed continuously until she "confessed," when the coughing stopped for the rest of the hour. During this promiscuous relationship, which lasted for some months, the patient felt agitated and distraught and the bronchitis continued. When she finally terminated the relationship, the bronchitis disappeared and she was no longer distraught. She felt righteous, but sad and sorry for herself, and had little zest for anything. Cn.se 3 This patient started psychotherapy (with Dr. I. D. Berg) after 20 years of pulmonary tuberculosis, during which time she had had left pneumonectomy for far advanced parenchymal and bronchial tuberculosis. She was receiving chemotherapy for bronchial tuberculosis on the right, which was demonstrated by positive sputum, fan-shaped hilar density on x-ray, and bronchoscopically. She has been free of signs of activity of the tuberculosis for the succeeding 5 years, during which time chemotherapy has been continued along with the psychotherapy Bronchial wheezing and occasional blood-flecked sputum have persisted. The consistent nature of the emotional reactions that have accompanied the exacerbations and remissions of her respiratory illness are of interest despite the fact that such concurrence cannot demonstrate a causal relation between the emotional and the physical reactions. The patient considered the psychiatrist an omnipotent ally against both her illness and her demanding, "selfish" mother. Her health and enjoyment of life depend on a relationship with a consistent, reliable, authoritative person. When she has such a figure of authority on whom to rely, she conforms to his standaids, enjoys working hard, and is energetic and healthy. When there are inconsistencies in the standards or when she does not have what she feels is a strong and honest "authority" upon whom to depend, she feels "fallen apait and without purpose" and becomes distraught, desperate, and fatigued. Despite this she continues to work hard and develops respiratory symptoms. During therapy she developed reVOL. xx, NO. 6, 1958

479 spiratory symptoms under such circumstances on several occasions, notably when a social encounter made her feel that her psychiatrist was isolated from her, when she discussed her mother's death, which occurred during her therapy, and when she was acutely disappointed in her husband for having made an unwise business decision (although on another occasion, when she felt she had reason to think she might lose her husband to a woman who was also an "authority" figure for her, she was unhappy but resigned, and did not become ill or have any recurrence of respiratory symptoms). However, during the times of distress and fatigue, despite her feelings that she has no energy and nothing to give to others, she compels herself to work very hard and to fulfill all her duties, both professional and domestic. When a supportive relationship is restored, her respiratory symptoms vanish and her pleasure in life returns. The patient had been considered an extremely trying infant by her mother, apparently because she had cried a lot and was difficult to quiet. Her mother had resented the intrusion of the patient and her younger sister on her life with their father, and after the father's death when the patient was about 9 years old, her mother exploited her and her sister to indulge her own vanity and laziness. At the same time she taught the patient rigid rules of deportment, impressed her with the necessity of highly conforming social behavior, and made her feel that only "good girls" had the right to exist. The onset of active tuberculosis occurred when at the age of nineteen the patient was suddenly disillusioned with her mother's integrity by discovering that she had lied to her about an incident involving moral standards. This was followed by an even more disturbing example of her mother's inconsistencies. At her mother's instigation, the patient went to another city for the summer. She married there (secretly, because of fear of mother's disapproval). There was a sudden, last-minute wish that her mother would stop her but she felt compelled to proceed with the marriage, without enthusiasm. At this time she noticed her first wheezing. When she returned home she was reproached by her mother for immorality, simply on the basis of having been unchaperoncd, although she had gone under these circumstances at her mother's urging. Continued wheezing, fever, and weight loss led to x-ray examination, a left apical lesion was discovered, and she was hospitalised.

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The similarities in the lives and characters of these 3 patients are apparent. Each suffered severe trauma in early infancy and felt exploited rather than given to by her mother. Each felt threatened and vulnerable and had a tremendous need to conform. By conformity they hoped to get the approval that seemed to them essential for survival. Such approval was so important to them that they resorted to deceptive, manipulative tricks that they had learned from their mothers' behavior. We can say immediately that these patients had unusually great need for external support to help sustain their psychological adaptive processes. During psychotherapy, respiratory symptoms were precipitated and alleviated in circumstances quite comparable to those described by French and Alexander1 in cases of bronchial asthma. The aspect of these cases on which I am foscussing is not that of the content of instinctual conflict but rather the way the energy balance was affected by certain ego operations in the interval between loss of certain external support and the onset of somatic illness. The occurrence of physical symptoms after the- loss of an important relationship, with some depressive and agitated feelings, could lead one to consider the somatic reaction a "depressive equivalent." The data presented in these cases seem consistent with this concept. However, I am attempting to go a step further and develop an hypothesis regarding the mechanism of connection between the subjective and behavioral response to the precipitating experience, and the somatic response. The psychological findings in these 3 women are consistent with those reported by Holmes,11 who studied 100 consecutive admissions to a tuberculosis sanitarium and concluded that most of the patients found it unusually difficult to attain their ego ideals. All 3 women enjoyed relative emotional and physical health when the relationships on which they depended for their self-

esteem were intact. When the security of these crucial relationships was lost, a distraught state with loss of hope, confidence, and self-esteem occurred. In the first 2 women the loss of a significant relationship that had enabled the patient to sustain conformity of behavior and self-esteem was followed by anxiety and a breakdown of conforming behavioral patterns. This led to guilt and increase of the initial distraught state, with feeling of hopelessness and worthlessness. Both patients continued their unacceptable behavior with a feeling of continued guilt and increasing hopelessness. In the history, onset of symptoms of pulmonary tuberculosis had occurred under such circumstances for both patients, and during psychotherapy respiratory symptoms were observed under similar circumstances. When the defensive equilibrium was restored, either by a reunion with a supportive person or by sacrificing a relationship that violated the patients' standards of propriety, self-esteem was restored and the respiratory symptoms improved. Arrest of the original pulmonary tuberculosis had occurred under these circumstances in both patients, and during psychotherapy dramatic remission of respiratory symptoms was observed under the same circumstances. Somewhat different psychological reactions were observed in the third patient. This woman also seemed to depend on a secure relationship with some guiding person for her narcissistic supplies. When she had such a relationship she worked effectively and was quite giving to others, with energy, confidence, and enjoyment. When, however, she lost this supportive relationship, she felt compelled to continue to work very hard and to give to others, but now with fatigue and a feeling that she had nothing to give. At such times she became desperate, distraught, and mildly depressed. In her past history active pulmonary tuberculosis had begun under such circumstances, and during psychotherapy respiratory symptoms were observed under the same circumstances. When she was reTSVCHOSOMATIC MEDICINE

FLARSHEIM united with a supportive person and felt that she was behaving in a way valued by that person, the distraught state was replaced by a feeling of zest and enjoyment and both her pulmonary tuberculosis and the respiratory symptoms observed during psychotherapy became inactive. It is interesting to note that the loss of a love object per se was not necessarily associated with the onset of respiratory symptoms. It was rather the loss of the selfesteem that had been provided by the particular kind of relationship that precipitated these symptoms. In the first 2 instances, self-esteem was restored and respiratory symptoms improved when the patient lost the relationship with a loved person who caused her to feel degraded. The loss in such instances had the meaning of a reunion with an idealized supportive image or person and enhanced the patient's selfesteem. In the third instance a distraught state with respiratory symptoms occurred when the patient's need to see her husband as perfect was frustrated because he made an unwise business decision. But when during psychotherapy she felt herself in danger of losing him to a woman who was both maternal and an authority figure, she felt unhappy, angry, and righteous, but she had no somatic symptoms. The respiratory illnesses in these patients occurred during states of exhaustion that followed failure of defensive operation. In the first 2 patients this state of psychic exhaustion or depletion occurred when a supportive relationship was lost, after which the patients' behavioral controls became less effective. Behavior followed that was at variance with the patients' ego ideal, and led to self-hatred and depression, and added to the depletion. This intrapsychic conflict, leading to an increase in the depletion and resultant ego disintegration, acted as a circular feedback system and was associated with the somatic changes. Somatization can be considered a manifestation of primary process functioning associated with failure of the higher ego-integrative funcVOL.

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481 tions, as Schur19 and Grinker10 have pointed out. In the third patient loss of a supportive relationship was followed by continued expenditure of energy in an unsuccessful attempt to restore energy available for integrated functioning. But since the effort was no longer directed toward an appropriate object, it led to further depletion rather than to repletion. The somatic illness was observed to occur in the setting of the failure of ego-adaptive patterns, with exhaustion. One could speculate that the somatic illness resulted from some adaptive response, part of an unsuccessful effort at restoration of equilibrium. The clinical data, however, consist of time correlations between respiratory illness and particular kinds of psychological adaptation. From this data I do not see that the illness can be considered a "problem-solving" or defensive manifestation in itself. The state of being ill may have secondary defensive effect. The attendant regression and the kind of nursing care the patient receives is traditionally expected to reduce the demands on the homeostatic mechanisms and therefore contribute to the restoration of the defensive equilibrium. In these patients the restoration of the depleted self-esteem, either by a change in behavior or by reunion with a supportive person, was followed by improvement. The rapidity of this improvement seems consistent with the thesis that energies of the total organism were not exhausted but insufficiently available for homeostatic adaptation under certain circumstances. It is noteworthy that the patients in this study accepted the supportive relationships rather easily, despite their deceptiveness and distrust. In this respect they differ from the patient reported by Alston,2 who was more disturbed emotionally and whose tuberculosis progressed during psychotherapy, although less rapidly than it had previously. There are many differences between Alston's case and these, but one difference that seems relevant here is that his patient had paranoid persecutory delusions about

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her physicians, whereas these patients improved when they felt magically protected. The relief that was observed to occur following certain behavioral changes or reunion with a supportive person seems similar to the "anaclitic treatment" reported by Margolin,13 in which a highly structured adjustment is imposed on a patient who is handled in an authoritative, omnipotent fashion. Certain predesignated pregenital impulses are indulged, while the indulgence of other regressive impulses is presumably implicitly or explicitly forbidden. In this highly structured authoritarian situation, the patient's insufficient energy to sustain ego (homeostatic) integration is apparently restored by his conformity to the demands and prohibitions of the therapist, who functions as an "external auxiliary ego," reducing demands on the patient's adaptive capacity. As postulated above, in so far as the therapist comes to represent the idealized protective and supportive person, the patient's conformity to the therapeutic demands may lead to an increase of energy for adaptive functions. It seems a reasonable assumption that in Margolin's anaclitic therapy there is formed a situation similar to that in which the respiratory symptoms of these patients were observed to improve. In such a situation regression is apparent in terms of the patient's passive dependent behavior (temporal regression), but there is increased psychophysiological integration (topographical progression) .6 In the present study I have concluded that a psychologically induced state of exhaustion occurs. In this state there is an insufficient quantity of (instinctual) energy available for the maintenance of psychological and physiological homeostasis, and in this regressed state, a somatic illness develops. A speculative additional determinant of illness could be that in addition to an insufficient quantity of available energy, a qualitative change in the instinctual energies takes place. Freud in 19235 and Jacobson more recently12 have stated that in regressed states destructive (and self-destructive) drives predominate quantitatively

over libidinal drives. This may be a psychological correlate of the concept of "regressive innervation" and is not dependent on embryological considerations as to the relative sequence of functional dominance of various parts of the nervous system. Summary The thesis of this paper is that certain changes in ego operations constitute a part of the chain of events whereby the loss of an object relationship is followed by a somatic illness. This is based on the observation of time correlations between integrating and disintegrating emotional forces, and remission and exacerbation of respiratory illness. An hypothesis is advanced regarding the mechanism of connection between the state of ego integration and the physical illness. It is postulated that: A. Susceptibility to respiratory illness in these patients is increased when there is what we consider psychologically to be ego depletion. Resistance to the physical illness is correlated with replenishment of ego energy from the narcissistic reservoir. B. Two mechanisms whereby psychological integrative mechanisms may contribute to this energy depletion and restoration are advanced. These are: 1. In the first two patients the loss of a supportive relationship led to lowered selfesteem, hopelessness, and a distraught state, considered to be evidences of ego depletion, and also to breakdown of behavioral controls. The latter added to the ego depletion, and the process then became circular. 2. In the third patient the loss of a supportive relationship led to lowered selfesteem, hopelessness, feeling of lack of motivation or purpose for working, and lack of energy to work, considered to be evidences of ego depletion. Despite this depleted state, the patient continued the expenditure of great effort and became ill. 25 East Washington St. Chicago 2, III. PSYCHOSOMATIC MEDICIN1".

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7. 8.

9. 10.

References ALEXANDER, F Psychosomatic Medicine. New York, Norton, 1950. ALSTON, E. F. Psychoanalytic psychotherapy conducted by correspondence. Intemat. J. Psycho-Analysis 38: January, 1957. BOYD, M. F. Preventive Medicine. Philadelphia, Saunders, 1942, pp. 357, 11, 107. £NCLE, C. C. Selection of clinical material in psychosomatic medicine. Psychosom. Med. 16: 3G8, 1954. FREUD, S. The Ego and the Id, (1923). London, Hogarth Press, 1957, p. 57. FREUD, S "The Interpretation of Dreams." In The Complete Psychological Works of Sigmund Freud, Vol. V. London, Hogarth Press, 1953, p. 548. FREUD, S. "On Narcissism" (1914). In Collected Papers, Vol. IV. London, Hogarth Press, p 57. FREUD, S "The Psychogenesis of a Case of Homosexuality in a Woman" (1920) . In Collected Papers, Vol. II. London, Hogarth Press, 1928, p. 226. GREEN, W. A., JR. Process in psychosomatic disorders. Psychosom Med 18:150, 1956. CRINKER, R. R. "Some Current Trends and Hypotheses of Psychosomatic Research." In

11. 12. 13. 14.

15.

The Psychosomatic Concept in Psychoanalysis, Felix Deutsch, ed. International Universities Piess, 1953. HOLMES, T. H., et al. Psychosocial and psychophysical studies of tuberculosis. Psychosom. Med. i9.134, 1957. JACOBSON, E. R. "The Self and the Object World." In Psychoanalytic Study of the Child, Vol IX, 1954 MARGOLIN, S. In The Psychosomatic Concept in Psychoanalysis, Felix Deutsch, ed. International Universities Press, 1953 MIRSKY, I A. "Psychoanalysis and the Biological Sciences." In Twenty Years of Psychoanalysis, Franz Alexander and Helen Ross, eds. New York, Norton, 1953. SCHUR, M. "Comments on the Metapsychology of Somatization." In Psychoanalytic Study of the Child, Vol. X International Universities Press, 1955, pp. 119-164.

Other References A. BERG, I. D. Unpublished paper on the role of emotional reaction in pulmonary tuberculosis. B.

FRENCH, T. M,

and WHEELER, D. R.

Hypertensive Disease Research The Department of Preventive Medicine of the University of Illinois College of Medicine announces a training program in research related to the broad area of hypertensive disease. Stipends for an associate are available from $4,400.00 to $5,400.00. Inquiries may be addressed to Dr. Adrian M. Ostfeld, Department of Preventive Medicine, University of Illinois College of Medicine, Chicago, Illinois.

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"The

Role of Hopes in Psychoanalytic Therapy"— unpublished.