The knowledge of the genesis of emotional and psychosomatic illnesses is of paramount importance in medicine. This paper is an attempt to obtain a perspective of the problem as it presents itself to the general practitioner. It consists of (a), a study of the incidence of emotional and psychosomatic illnesses in general practice, and (b) of a study of the causes of such illnesses. 950 cases were studied consecutively in the month of November, 1969 as they attended the office. A case would be classified as psychosomatic on 3 conditions: (1) The condition must belong to one of those listed as possibly psychosomatic. (2) The patient must admit to an emotional disturbance. (3) The emotional disturbance must precede the somatic condition. In this study an attempt was made to trace the relationship between life events and emotional illness. According to this study the catastrophic events are: ill-health in a household member, bereavement, son or daughter leaving home, demotion or loss of a job, menopause, alcoholic spouse, and separation from parents or next of kin.peer-reviewe

Fiorini, Godfrey T.

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66 is generally considered that radiotherapy should be offered to all cases of tumours not amenable to resection and to those that are not for technical difficulties ex-cised completely. To conclude: primary retro-peritoneal tumours, though uncommon, are not great rarities and should not be neglected. They merit more notice than is generally given them in the odd half page of the standard surgical text book. They pose a difficult and fascinating problem to the pathologist and to the physician. To the practising surgeon they are a challenge that may tax his resource. In dealing with them, though he can often only bring to his pa-tient temporary relief, he is occasionally rewarded with a gratifying outcome. EMOTIONAL AND PSYCHOSOMATIC DISORDERS IN GENERAL PRACTICE GODFREY T. FIORINI, M.D. Toronto, Ontario - Canada. Summary: The incidence of psychosomatic and emotional disorders in general practice was recorded and found to corroborate the findings of other authors. Psychotro-pic events were correlated to psychoso-matic illnesses. Any practising physician will neces-sarily be confronted with a certain propor-tion of patients who seek medical advice for emotional reasons having no apparent organic disease. Though it seems simple to classify illnesses into organic and emo-tional or psychosomatic, it soon becomes apparent that at certain times it is very difficult to draw a dividing line. It is obvious that organic illnesses generate emotional disturbances and emotional dis-turbances generate organic illnesses. The knowledge of the genesis of emotional and phychosomatic illnesses is of paramount importance in medicine. This paper is an attempt to obtain a perspective of the problem as it presents itself to the general practitioner. It consists of (a), a study of the incidence of emotional and phychoso-matic illnesses in general practice, and (b) of a study of the causes of such ill-nesses. 950 cases were studied consecutively in the month of November, 1969 as they attended the office. Each patient, on coming to the office, for whatever reason, would have his name taken down and listed on a special chart where he would be classified as to age, presenting symp-tom, diagnosis, race, education, civil sta-tus, religion and medication received whilst miscellaneous items relating to his medical and social history would be noted. These cases were gathered in sixteen working days. These consulta-tions would include some patients that would come weekly for an allergy injec-tion as well as those that woul'd come for a certificate for work. Some other pat:ents would be included twice, being cases of injuries sustained at work who would be seen once a week for follow up. So inevitably some visits would be very cursory. Many of these patients would have been known beforehand and their previous histories would have been re-corded, thus making a quicker appraisal possible. The main object of this first stage of the study was to sift those adults that were suffering from emotional disorders. Very few patients would present with a depression, anxiety state or just bad nerves. A larger percentage would pre-sent with a somatic complaint. Those patients that were suffering from an emo-tional disturbance as a result of an organic disability ,were excluded from the group. Amongst these would be included those patients who had suffered a coronary thrombosis or were suffering from cancer or from other prolonged illness. It is natural that such patients should suf-fer from emotional repercussions after such an event. What is not equally clear to many is the fact that such events gene-rate emotional upheavals amongst close 'kinsmen. These emotional upheavals re-sult from grief, can occur in dependents experiencing financial difficulties and in persons closely related to the event, ex-periencing other sqcial repercussions. For example when the father of a family is hurt at work or elsewhere, this would cause emotional disturbances not to himself alone but also to his wife and chHdren with varying intensity, emotional effects being felt also by his friends and by other assqciates to a varying emotional extent. These emotional upheavals in the next of kin can generate a certain amount of organic illness. Many individuals would overcome the crisis without seek-ing medical advice, but others will present to the doctor as epigastric discomfort, or spastic colitis, or tachycardia etc. A case would be classified as psycho-somatic on 3 conditions: (1) The condition must belong to one of those listed as possibly psychosoma tic. (2) The patient must admit to an emotional disturbance. (3) The emotional disturbance must precede the somatic condition. The first 950 patients, including in-fants, seen in the ,first sixteen working days in November, 1969, were classified as already described, but no diagnosis of psychosomatic illness was attempted on children under 15 years of age. It is re-cognised that children of all ages, from 67 infancy onwards can suffer from symp-toms qf stress and emotional disturban-ces, but these would require a different perspective and woul be better dealt with as a separate series. This group of patients consisted al-most entirely of new Canadians, whose stay in Canada varied from a few months to twenty years. Many of these patients had some English language difficulty. The patients examined Children (under 15) consisted of: 230 325 395 Males (oyer 15) Females (over 15) ... Incidence of nervous and psycosoma-tic disorders: Males (over 15) 71 Females (over 15) ... 140 Males Females Total Total 211 Incidence 325 71 395 140 720 211 % 21.8'% 35.4% 29.3% M. 9.8% F.19.4% Events and psychosomatic illnesses In this survey an attempt was made to trace the relationship between life events and emotional illness. It is quite clear that we are continuously influenced by events. The fact that there is a war in South Vietnam is an event. The psycho-tropic effect that this war is causing or has caused on the Vietnamese people is ob-viously different from its effect on the American people and again different from its effect on the Canadian people. It is quite possible that some people around the world are not even aware that a war is going on. In such a case there would be no mental effect at all. So we may safely say in general terms that there are many events happening all around us, many of which we are not even aware of, some of which do not concern us at all, other.s still that strike home. It is with the latter that we are mostly concerned in this paper. There are some events which occur within the family group which are very momentous and generate emotional. con-flicts. These are events that may happen 68 Classification of certain conditions with reference to psyychosomatic status. Excluded Included Skin reactions: Musculoskeletal reactions Respiratory reactions Cardiovascular reactions Gastro-intestinal reactions Genitourinary reactions General physical conditions Mental reactions Urticaria Backache N euroderma titis Tension Headache Neurasthenia Tremors Palpitations Insomnia Irritability Loss of interest Confusing thoughts Apprehensive dreams Endocrine reactions Thyrotoxicosis Hypothyroidism Obesity to any family and there are many of them that must happen to all of us and yet though we are aware that such events should occur we find ourselves ill prepared to meet them when they do happen. An event is defined as a "happening or an occurrence". This implies a begin-ning. It also implies a duration, which is a variable. Some events last a very short time, others last longer and others still are chronic. The event may therefore have an ending or it may be such that its end-ing may not be in sight. The seriousness of an event is also a variable. What we are concerned with here is not merely a list of all the possible significant events that may influence an individual, but those occurrences which strike at a person's innermost constitution. These events we shall label as Psychotropic Events, and we shall divide them into acute or chronic. By definition psychotropic events can never be neutral in effect. They may either be traumatic, if noxious, or euphoric, if pleasant, or mixed. A pleasant life is usually built from day to day by a balan-cing of the traumatic with the euphoric events. It is when some unusual and un-expected traumatic event occurs, that the individual is thrown out of balance and in some cases falls ill. A group of 134 patients were chosen and asked to answer a series of 60 ques-tions. The patients were divided into two groups. The first group consisting of 77 patients who were suffering from what was diagnosed as psychosomatic illnesses; the second group of 57 persons were pa-tients who 'did not seem to have any emo-tional disturbances and had come to the office for some other reason, such as pre-gnancy, a minor injury, a minor cold etc. In this survey all the patients were ques-tioned as to the incidence of recent or chronic events, as well as to their hob-bies or tension relief events. The score was recorded per patient. The following is a list of the events, divided into 3 groups, on which the pa-tients were questioned: (A) - Acute Psychotropic Events (Events that occurred w£thin 2 years) 1. Change of residence. 2. Change of health in a member of the household. 3. Personal injury or illness. 4. Immigration to Canada. 5. Separation from parents and siblings. 6. Death of a close friend. 7. Death of a parent or close relative. 8. Taking on a major debt, such as a motgage or loan. 9. Promotion at work. 10. Change to a 'different kind of work. 11. Son or daughter leaving home. 12. Demotion at work or loss of a job. 13. Retirement. 14. Separation or divorce. 15. Arrest and/or court conviction. 16. Business and financial setbacks. 17. Family and in-law squabbles. 18. Pregnancy. Psychosomatic No. of Acute Cases Events 77 362 204 Average 4.70 2.6 Control Group 57 187 127 Average 3.28 2.23 69 19. Marriage. 20. Birth. 21. Began or ended school. 22. Menopause. 23. Inter-racial marriage. (B) - Chronic Psychotropic Events 1. Chronic illness of a member of the family. 2. Chronic illness or disability of person concerned. 3. Tight finances. 4. Homosexual spouse. 5. 'Involuntary lack 0,£ children to mar-ried couples. 6. Teenagers in the home. 7. Alcoholic spouse. 8. Separation from parents or next of 'kin: 9. Parents died over five years ago. 10. Parents do not get along. 11. Husband' and wife do not get along. 12. Bachelorship or spinstership. (C) - Hobbies or Tension Relief Events 1. Fishing. Summer or Winter. 2. Sports. Games. Outdoor or Indoor. 3. Vis,iting friends or relatives. 4. Cinema. 5. Theatre. 6. Watching television at home. 7. Reading. 8. Craftwork at home. 9. Daily alcoholic drink with meals or in the evening. 10. Playing a musical instrument. 11. Card games. 12. Music - records or radio. 13. Dancing. 14. Membership in a club. 15. Other hobbies. 16. Social gatherings - weddings, par-ties. The following is the score obtained by the psychosomatic cases and the con-trol group: Chronic No. of Tension Relief Events 158 303 2.05 3.9 60 256 1.05 4.5 70 Analysis of the incidence per event. (A) Acute Psychotrapic 1. Change of residence Per cent - -----:-:~--t-------l---11 Psy. Grp. Per cent Control Grp. 36 18 23 17.5 3 2. Change of health in a household I 17 8 5 4 I . member 3. Personal injury or illness I 4. Immigration to Canada I 5. Separation from parents and sib- I lings 6. Death of close friend I I I I 7. Death of a parent or close relative i 8. Taking on a major debt, mortgage i or loan I 9. Promotion at work 10. Change to a different kind of work 11. Son or daughter leaving home 12. Demotion at work or loss of a job 13. Retirement 14. Separation or divorce 15. Arrest or court conviction 16. Business or financiaJ setbacks 17. Family and in-law squabbles 18. Pregnancy 19. Marriage 20. Birth 21. Began or ended school 22. Menopause 23. Inter-ra.cial marriage In analysing the figures the first im-pression seems ta be that there are more events happening to psychosomatic pa-tients than to the control group. In ana-lysing the figures further we find that the average for the psychosomatic and the 7 18 20 10 10 20 1 6 7 10 10 1 o 2 9 8 12 o 7 2 3.5 9 10 5 5 10 0.5 3 3.5 5 0.5 5 0.5 o 4.5 4 6 o 3.5 1 14 12 11 12 7 o o 8 3 o o 3 7 4 4 o o 13 9 9.5 0.8 0.8 9.5 0.8 5.6 0.8 o o 6.4 2.61 o o 2.3 5.6 3 3 o o control group as far as the acute events are concerned is about the same, while the average chronic events is higher in the psychosomatic group than in the control group. The reason that the acute events are about equal in the two groups is ob-(8) Chronic Psychotrapic Events I l. Chronic illness of a member ofl family I 2. Chronic illness or disability of person concerned 3. Tight finances I 4. Homosexual spouse 5. Involuntary lack of children to married couples 6. Teenagers in the home 7. Alcoholic spouse 8. Separation from parents or next of kin 9. Parents died over 2 years ago 10. Parents do not get along 1l. Husband and wife do not get along 12. Bachelor or spinster viously because the control group came to the office for a medical event such as a pregnancy, an injury etc. If the control group were picked up from the general population the score of the control group would obviously be lower. The tension relief events hit about the same ,average in both groups. Again this is to be expected considering that both groups come essentially from the same ethnic background, having the same cul-tural and social status. There is how-ever, a slightly higher occurrence of ten-sion relief events in the control group. Discussion: An attempt was made to find the in-cidence of emotional illness in general practice. This was found to be in the region of 22% for men and 35.4% for wo-men. On comparing the results of other authors (Coats, a 1969; Coats, b 1969; 71 Psy. Grp. Per cent Control Grp. Per cent 12 7.5 4 6.7 3 2 8 13 55 35 25 41.5 1 0.63 0 0 0 0 2 32 2 1.26 3 48 7 4.41 1 1.6 El 6.3 0 0 1 1.63 0 0 30 18.9 7 11.2 14 8.82 4 6.4 9 5.67 3 4.8 Kessel and Shepperd, 1962; Kessel, 1965; Mazer, 1967; Roessler, 1961; Rowen, 1960; Silverman, 1968; Watts and Cawte, 1964), observations were found to be essentially similar except for the fact that these ill-nesses were labelled as neuroses by these authors. The term neurosis has been avoided in describing these patients as the term seems to have a morbid personality connotation which seems to imply a cer-tain degree of frustration on the part of the doctor in handling these patients. It is felt that these patients are ordinary citizens in the grip of the currents of human civilization and facing the hard facts of life. Their symptoms are only an expression of the uncontrollable reac-tive processes that automatically occur within the body as a result of psychotro-pic events. What the physician sees in his office from behind his desk is only a snapshot of a phsiological reaction in a process of resolution. Hence 72 the frustration of the physician when prescribing the usual antacid and anti-spasmodic for the symptomatic relief of gastric symptom caused py the fact that the worker has been laid off from his work. These emotional problems should not be considered as merely func-tional and therefore not requiring treat-ment, as they would otherwise lead into actual organic illness, which would natu-rally satisfy the organic oriented doctors. It is true that many events correct them-selves in time. The worker who loses his job may find a better one. It is therefore important to enumerate the events in his history when assessing the medical status of a patient. Medication and advice should be given accordingly. The human biolo-gical reaction may be presented in this manner. Event > Emotional disturbance > Somatic disturbance > Actual organ pa-thology. A list of psychosomatic illnesses has been given. Many conditions that are ques-tionably psychosomatic such as bronchial asthma, thyrotoxicosis etc., have been deliberately omitted; other conditions that are still possibly psychosomatic have not been even mentioned, such as repeated respiratory infections. The score on events among the two groups was fourtd to be moderately higher in the psychosomatic group. It is obvious that man is capable and prepared to cope with a certain number of unpleasant events, but there are a few events which, when they occur, cause a break in the adaptive processes of man. According to th:s survey the catastrophic events are: Ill-health in a household member Bereavement Son or daughter leaving home Demotion or loss of a job Menopause Alcoholic spouse Separation from parents or next of kin. These are events that actually happen to most people at some time or other. Yet we seem to be so unprepared for them when they do happen. It would appear that mental provisions should be laid out in preparation for such events. The ten-sion relief events, one notes the lace of ly poor in both groups. Considering ten-sion relief events one notes the lack of physical exercise especially in the female population. The mental stimulation and the physical well being engendered by physical exercise or sporting activities seem to have been missed by this group of persons. References COATES. D. (1969) Yorklea s.tudy. June. Primary relationships in the city: some preliminary ob-servat:ons. COATES. D. b. (I969) Yorklea study. Dec. Symp-toms. problems and life events. KESSEL. N. (I965) Pract .• I94. 636. KESSEL. N. and SHEPPERD. M. (1962) J. Ment. SC!. MAZER, M. (I967). Am. J. Psychiat. ROESSLER. R. (I96I) Psychosom. Med .• 23. 4I3· ROWEN. M.J. (I960). J. Med. Soc. N. Jersey. SILVERMAN. C. (I968) Am. J. Psychiat. WATTS. C.A.H. and CAWTE. E.C. (1964) Brit. Med. J .. 2. I35I. 

Emotional and psychosomatic disorders in general practice

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Emotional and psychosomatic disorders in general practice

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