Claus Bahne Bahnson

ROLE OF THE EGO DEFENSES: DENIAL AND REPRESSION IN THE ETIOLOGY OF MALIGNANT NEOPLASM

Several previous workers in the area of psychophysiological aspects of neoplastic disease have pointed toward loss, separation, depression, and despair as important antecedents to the manifest development of cancer (Greene, 1954; Greene et al., 1956; Greene & Miller, 1958; LeShan, 1959, 1961, 1964; LeShan & Worthington, 1956; LeShan & Reznikoff, 1960; Meerloo, 1951, 1954; Kowal, 1955; Tarlau & Smalheiser, 1951; Schmale, 1958). Although we are very much in agreement that loss and depression may be significant antecedents to onset of clinical cancer, as shall be documented later in this paper, nonetheless, the main point is that these conditions and emotional states are found frequently in many people who do not develop cancer, and may be necessary, but not suficient antecedent conditions to prompt this particular psychobiological solution. More is needed than depression and despair to produce malignant neoplasm, as is so clearly demonstrated by the many cases of psychological depression and disorganization observable in mental hospitals, psychiatric and psychosomatic wards, and among friends and fellow citizens. The loss-depression hypothesis appears, then, to be more descriptive than dynamic, more correlational than functional. The concepts “drive,” “emotion” and “defense” in dynamic theory. Dependent upon one’s theoretical orientation concerning the organization of personality, emotion may be viewed, within a genetic dynamic framework, as a more or less peripheral phenomenon than need or drive. We tend to support the positions suggested by the late writings of Freud (1925, 1936) and by Rapaport (1950) that emotion may be a more central representation of drive than ideation, and we have formulated this position in a previous paper (Bahnson & Bahnson, 1961). However, while emotion may be understood as a central motivational variable (Shand, 1914), it still remains an index variable for drive and sometimes serves as a vehicle for communication with self or environment. Therefore, to consider emotion the main antecedent variable to neoplasm seems to us untenable, although it may indicate to the observer a particular fate of the drive discharge. Rather, the primary focus must be on the study of drive and modes of drive manifestations, including the inhibition and transformation of drive by means of a variety of defensive maneuvers. This brings our position close to that of ego-psychologists such as Anna Freud (1946), Ernst Kris (1944,1950, 1951), Hartmann (1946, 1950a, 1950b, 1952), and Hartmann, Kris, and Loewenstein (1946, 1949), and aims at expanding this late psychoanalytic and holistic formulation to include truly psychophysiological reactions (and not just conversion symptoms) in addition to ideational and phenomenologically affective aberrations, as also suggested by Deutsch (1949, 1959, 1962) and Alexander (1950). In order to do this, some years ago we developed a rather primitive theory of complementarity relating different forms of behavioral-ideational and somatic regressions to different typical modes of ego-coping mechanisms or ego defense. Although the final theoretical formulation is rather complicated, since it must take into account not only type of drive, developmental fate of drive discharge, conflictual foci, and a typical defensive pattern (whether varying and unstable or repetitive and rigid), the basic and

Behavioral variables and myocardial infarction in the southeastern Connecticut heart study

The potential etiologic role of sociological and psychological variables defined as stressful in the production of myocardial infarction (MI) was studied in 114 surviving hospitalized MI subjects, 114 subjects free of cardiovascular disease but hospitalized for a different serious illness, and 145 ‘normal’ subjects. All were white males aged 35–64 who were interviewed in their homes, the sick groups during convalescence. Hypotheses based on previous research relating to the following variables were not supported: situational stress, Symes cultural mobility, religious affiliation, commitment to social norms, feminine psychosexual identification, anxiety, alienation and psychopathological tendencies. However, MIs scored higher than both the other sick and normal subjects on an original scale designed to measure Rosenman and Friedmans Behavior Pattern A and on a scale of somatization, i.e. the tendency to translate conflict and affect into bodily symptoms. The principal conclusion is that what counts in the production of MI may not be the amount of situational or intrapsychic stress a person is subjected to but the way he copes with it—is defensive style.

PSYCHOPHYSIOLOGICAL COMPLEMENTARITY IN MALIGNANCIES: PAST WORK AND FUTURE VISTAS

The present monograph on psychophysiological aspects of cancer follows three years after the previous, and first, monograph on this topic, and in many ways serves as its continuation. The first conference succeeded in bringing together evidence from many quarters demonstrating unequivocally that malignant processes are related to certain psychosocial conditions and psychodynamic states. However, the physiological processes mediating among experiential, affective, and coping processes on the one hand, and the physiological, biochemical, and immunological processes related to the malignant development, on the other, were not clearly elucidated. In brief, the first work demonstrated that an empirical relationship does exist between psychological states and malignancies, but did not investigate how these relationships are mediated. That is the task of the present conference. Here, we wish to initiate a careful mapping of the physiological, biochemical, hormonal, immunological, and other processes that may mediate the psychological states that have been observed to antecede onset of clinical cancer. The search for cross-relationships between different levels of investigation inevitably raises basic theoretical questions. One of these questions is whether it is possible to conceptualize somatic and psychological phenomena within one model, relating them to each other in a meaningful way. Although the mind-body problem is as old as science itself, and would require several conferences just to be properly presented, it was obvious at the end of our first conference that the participants were able to work with somatic and psychological concepts within a single theoretical construct without feeling too uncomfortable. There was a reasonable amount of agreement that the old-fashioned dualistic, or multifactorial, interactive concepts were too narrow and rigid for our purpose, and that in general, a monistic approach such as Grinker’s field theory would be required as an effective working model. Grinker himself expressed it thusly: “We have, I hope, abandoned the convenient but restricted and artificial twofoci correlations linking single factors in causality of disease processes. Hence, we need no longer argue whether a disease is caused by heredity, constitution, disordered chemistry or physiology, infection, trauma or repressed pathogenic emotions. We are no longer concerned with such either-or single-factor polarities but currently attempt to map out the widest possible ranges of conditions, all of which in some way and at some time, seem to be implicated in a dynamic chain of causes and effects.” (1966a, p. 876) Other participants in the first conference (1966), such as Reiser, Margolin, Rakoff, and I, also addressed ourselves to basic psychosomatic issues, and introduced encompassing working models that will allow for heuristic psychosomatic formulations. Now I shall

EGO DEFENSES IN CANCER PATIENTS

A theory of complementarity between physiological and psychological regression has been proposed previously by us (Bahnson & Bahnson, 1964a & 1966). From this general psychosomatic theory, we have predicted that cancer patients make extensive use of repressive and denying ego defenses in order to cope with a number of psychological conflicts related to loss and depression, aggression, hostility and dominance, and libidinal as well as narcissistic creative urges. Within the framework of this theory of complementarity between different ego defensive modalities and psychosomatic manifestations of repression, the ego defenses repression and projection are conceptualized as extreme, opposing, and mutually exclusive coping mechanisms. Ego adaptive rather than ego defensive coping patterns are represented somewhere near a midpoint between the operation of repression and projection. The type of repression specified herein is secondary repression in contrast to primary repression, which, according to psychoanalytic theory, antecedes the projecting and displacing defenses that are engaged when the primarily repressed impulse returns and is discharged in action or ideation. Secondary repression refers to a continual defense process that successfully prevents the conflictual impulse from ever discharging in ideational or behavioral form. Thus, according to our conceptual framework, a person who utilizes repression blocks any behavioral or cognitive outlet of the disturbing impulse; rather, he must cope with the drive, not psychologically, but somatically, through internal discharge mechanisms. In this more specific definition of repression, the most extreme examples of both defenses, secondary repression and projection, are thought to operate substitutively, or temporally exclusive of each other. Most persons utilize both defenses to varying degrees, but each person at particular points in time probably could be described by his tendency to utilize one defense more readily than the other. If, for the moment, one disregards ego adaptive mechanisms and considers only ego defensive solutions, one may conclude that absence of projection indicates the operation of repression, whereas absence of repression indicates the operation of projection. This conceptualization is central to our theory of complementarity and provides a necessary foundation for the hypothesis evaluated herein: i.e., that cancer patients make use of projective defenses to a lesser extent than do normal subjects. As has been demonstrated so aptly by the Midtown Manhattan Study (Srole et al., 1961 : Langner & Michael, 1963), most “normal” subjects definitely make

SOCIAL AND PSYCHOLOGICAL FACTORS IN CORONARY HEART DISEASE.

Sociological and personality factors in the etiology of coronary heart disease were investigated by comparing all the surviving cases of myocardial infarction occurring in one year in white males aged 35-64 with an equal-sized age-matched series of seriously ill persons residing in the same county. Urban middle-class Protestants of Northwestern European stock were found to be the most vulnerable to the disease. Several personality and social characteristics were also found to be closely associated with coronary heart disease.

Socio-environmental antecedents to coronary heart disease in 87 white males.

Abstract Men of middle-class Protestant background have the highest ratios of “observed” to “expected” cases of coronary heart disease even when other sociological and selected “physiological” variables (hypertension, obesity, smoking, and diet) are controlled for. “Preference for planning vacations hour by hour” and “inability to relax after a hard day” in the coronary patients are interpreted as supporting evidence that personality characteristics associated with Protestant and middle-class values may be important in the etiology of this puzzling disease.

Epistemological perspectives of physical disease from the psychodynamic point of view.

relationships clearly do exist. Andhowcoulditbeotherwise? Everyone knows frompersonal experience thatupsetting life events often result insomekindofsomatic disturbance, forexample, in changed gastrointestinal mobility orintachycardia, to mention onlytwoexamples. Galen, Hippocrates, andother classic founders ofmedicine, aswellasthephilosophers Spinoza, Descartes, Leibniz, andtheir contemporary offshoots, havepointed totheintricate interaction between psychological andsomatic phenomena intheir statements. Themind-body problem isnotnewbuthasbeenwithus foralong, longtime. Onlyitseemsthat eachgeneration has toreexplore therelationship andreformulate itintermsof its ownframework andvocabulary.

IN MEMORY OF DR. DAVID M. KISSEN: HIS WORK AND HIS THINKING

We shall all miss David M. Kissen, who so suddenly and prematurely passed away only several weeks prior to the conference on which this monograph is based. Dr. Kissen had looked forward to participating in it with particular expectations because he had been so very much disappointed at not being able to attend the first conference because of the sudden illness that presaged his recent death, although it was his vision to originate and initiate the arrangement for that first conference. Fortunately, the two studies Dr. Kissen worked on with his group in Glasgow were sufficiently well developed before his death to make it possible for his co-workers to complete the analyses and present the results in two papers at this conference. In order to bring added perspective to this new work, which Dr. Kissen’s co-workers will present, a review of some of the main trends in his research and in that of the Psychosomatic Research Unit, which he founded and directed in Glasgow, may be helpful. David M. Kissen began his earliest studies in the psychosomatic field as a chest physician, and was particularly attracted to the study of emotional factors in pulmonary tuberculosis. The paper “The Patient’s Personality” ( 1958) reflects the sensitivity and sophistication with which he approached complex psychosomatic problems from the very beginning of his work in this field. However, David Kissen soon turned his main interests to the study of personality in lung cancer, and he initiated this research, which he was to continue for a decade, in the best possible and most thorough fashion: he carried out intensive psychological interviews in several chest departments with a variety of chest patients whose diagnoses were unknown to him and to themselves at the time of the interview. About half of these 900 patients subsequently were found to suffer from lung cancer, and could be compared with the remainder of the patients serving as controls. On the basis of this essentially clinical procedure, he first characterized lung cancer patients, as opposed to noncancer pulmonary patients, as having “poor outlets for emotional discharge.” By this, he meant that they have a facility for absorbing and containing emotional conflict, at an unconscious level, which results in an absence of apparent response. The basic clinical observation of “poor outlets for emotional discharge” in lung cancer patients was made quite independently of similar observations by other workers at approximately the same time, although phrased in a different terminology. This theoretical formulation of his observations was to become one of the main conceptual strains in his research, to be cross-validated on other subject groups and with different techniques of evaluation in several of the studies that followed. David Kissen, however, was not satisfied with just carrying out empirical research without coming to grips with basic conceptual and methodological problems raised by the scientific approach to psychosomatic research. His paper “A Scientific Approach to Clinical Research in Psychosomatic Medicine” (1 960a) reflects his critical and analytical interest in research methodology. Evaluating the methodology of psychoanalytic studies in psychosomatic con-

PANEL DISCUSSION 3: THE PSYCHOLOGICAL APPROACH

DR. BAHNSON: The second panel, particularly, but also the first, brought up several subtle points to which I should like to address myself before we go into the panel itself. There seems to be some epistemological confusion about cause and effect. An either/or problem, whether psychological problems may or may not be related to endocrine processes, whether biochemical aspects are related to immunological aspects, and so on, has been raised. It seems to me that although there has been a general trend toward openness, many of the participants now have gotten “cold feet.” I think the common “super ego” is beginning to work, with the result that more caution has been expressed in the last few hours than during the last three days. I do not welcome this development at all, but I want to emphasize the underlying point: that it is a nai’ve and mistaken assumption that one can talk about cause and effect at all. All we can do is organize observations over time, within different theoretical conceptual systems. We usually assign a causal antecedent effect to those events that come early in time and dependent effects to those that come later in time. Now, in our case, as Dr. Weiss so brilliantly pointed out, we have many different systems operating at the same time, with the emphasis that systems do not really exist, but are different levels of organization of processes based on our selection of methodology and theory in approaching the subject matter. We have tried to communicate with immunologists and with endocrinologists, and have tried to listen to their language. Some of my panelists may not agree with me on this point, but I feel that they have not listened enough to our language. Dr. Bennette was correct when he said that it is perfectly legitimate to observe carefully and, in some cases, even measure experience, which is one of our most permanent companions. One should not be a reductionist to the ridiculous degree that only certain laboratory or bench observations are legitimate, and that experiences that have been obtained in a clinical setting or in a subjective or phenomenological setting become less respectable. Of course, this is part of the pragmatic attitude in the Western world today, with its great emphasis on gadgets and meters, but we should not forget that there are other ways of assessing psychobiological phenomena. I emphasize this point, because it seems to me that there has been a tendency to play down the respectability and the worthwhileness of studying man in terms of his experience and his psychological reactions. We have been bearing with this because we have tried to be good hosts, but there are limits, and I think that we want to stand up for the relevance of studying psychological experience. DR. LAWRENCE LESHAN: There are many things we have learned from this conference. Perhaps one of the most important is that an individual does not just “get” the malignancy, which starts on the cellular or immunological or endocrinological or psychological level. The entire organism eventuates toward cancer. His