PSYCHOSOMATICS IN THE HOLISTIC UNDERSTANDING OF DYNAMIC PSYCHIATRY

By now the term >>psychosomatics<< representing the interplay of body and soul, psyche and soma, has become established in modern medicine. Ammon quotes the WHO definition of health as >>physical, psychic and s ocial well-being<<, but furthermore understands it as the integration of physical, mental and psychic functions. Illness is seen as a failed attempt of liberation from unconscious or unbearable restrictions of the multidimensionality of man, as desintegration of body, mind and so ul<< (Ammon 1988). The author discusses some concepts of psychosomatic s (e.g. Freud 1894, Alexander 1950, Mitscherlich 1954, Sifneos 1975, S elye 1950, Uexkull 1992). Dynamic psychiatry describes man as a holist ic and multidimensional being with a need for a life-long development of his identity. Illness represents only a single dimension. The motor of the identity process is the social energy, a hypothetic construct postulated by Ammon. Social energy represents the energy an individual is given by his human environment and which is mediated in interperso nal contact, demands, requests, arguments and care. In Ammon's human-s tructurology the personality structure of a person is manifested socia l energy. The personality or human-structure is formed by a network of primary biological-organic, central and mostly psychic-unconscious, a nd secondary or behavioral human-functions. As a consequence of the la ck of constructive social-energetic processes during childhood a human -structural deficit develops which will be filled by the illness and i ts symptoms. As it were, the symptoms are filling the >>hole in the Eg o<< (Ammon 1972). The author describes the specific human-structure of the psychosomatically ill, who asks about his symptoms (>>What have I got?<<) instead of asking about his own identity (>>Who am I?<<). Als o the special features of the primary group dynamics are depicted in a case vignette. The emotional emptiness and desolation in the early fa mily group makes the child search for love and attention by the signal of a physical psychosomatic disease. The constant fear of desolation leads to psychosomatic patients' reaction with physical, sometimes eve n critical, symptoms, when they are in a situation of separation. Ther efore, Ammon calls psychosomatic disease a >>separation illnes<<, too. The dynamics of dependence and submission to other people are demonst rated particularly in the clinical picture of colitis ulcerosa. A case study (Monnich 1982) illustrates this infantile dependence and isolat ion from the >>real world<< of adults to the extent that the patient d oes not even question his parents' wishes. Therefore, Ammon uses the t erm >>submission illness<<. Concerning the psychogenesis of psychosoma tics he refers to the concept of >>given up - giving up<< described by Engel and Schmale (1967), in which the patient repeats the helplessne ss and hopelessness he has experienced in childhood. Structural common features are to be found in psychosomatics, depression and schizophre nia, and the often reported shifting of symptoms may occur in the cour se of these diseases. particularly, if a physical symptom is taken awa y by medical intervention, the patient may react psychotically. A pati ent of Ammon's suffered from anorexia nervosa and eczema during his ch ildhood and from a rhinophyma during his adolescence. Later he develop ed an asthma bronchiale, which disappeared by therapeutic measures and turned into a severe depression. During his psychoanalysis the patien t suffered from most severe panic attacks, which he himself described as >>asthma without asthma<<. The lack of physical contact and >>bodin ess<< (touching, feeling, moving, being touched and being seen) during childhood is important for the psycho-dynamics and phenomenology of p sychosomatics and especially skin diseases. This is also reported by p atients in a questionnaire study (Ammon et al. 1985). A frequent shift ing of symptoms indicates the patient's closeness to psychosis. The ch ild experiences loving attention and care only if he/she is sick. A mo ther even threw her new-born baby on the other side of the bed, becaus e it was a girl and not the desired son. This girl developed already i n her first year a severe neurodermatitis and later an additional asth ma bronchiale. As a young woman she could not feel any interest for ot her people or have contact with them. She treated her own child very s imilarly to her own treatment by her mother. Only psychoanalytic thera py could stop that vicious circle. Along with the holistic view of psy chosomatics also psychotherapy must be directed toward an integration of body and soul and the development of identity. In human-structural therapy the matter of priority is to liberate the patient from his dee p anxiety of being destroyed and deserted and to develop his personali ty, and not the elimination of symptoms. The patient is disturbed in h is holeness, alienated from contact with his own unconscious and other people and restricted to few dimensions. If psychotherapy aims to ach ieve not only a mere temporary recovery, but structural changes and th e building-up of identity, it has to start from the unconscious core o f human-structure. In this case, following the author's experience, th e symptoms often disappear without working directly on them. The treat ment covers a spectrum of different methods: the psychoanalytic standa rd setting, psychoanalytic-humanstructural individual and group therap y and their combination as well as in-patient treatment in the Dynamic -Psychiatric Hospital Menterschwaige. Because of the great differences in genesis, structure, function and symptomatology both within singul ar disease (e.g. asthma bronchiale) and between them and, in addition, their complex interwovenness, a careful diagnosis of the biological, psychological and social functions is required. Ammon enumerates the M MPI, intelligence and concentration tests, the Ego-Structure-Test by A mmon (ISTA), projective tests etc. as the methods applied to obtain a differential personality profile. Thus an individual therapeutic conce pt can be established which is adapted both to the psychosomatic struc ture of the patient and the therapeutic process. Parallelly the somati c symptoms are treated medically. Leading the patient away from his ri gid concretism in thinking, perception and feeling to a meta-view and to conceptual thinking, is of great importance. An admission to an in- patient psychosomatic clinic may become necessary for medica