In a new blog series, we will investigate how illnesses were once thought to result from stress, psychological disturbance, or deviant personality features. From the cancer-prone personality to the theory of ‘refrigerator mothers’, medicine appears to suffer from a recurrent tendency to attribute illness to psychosomatic causes. As a result, patients are often blamed for being sick. Doctors seem to keep making this mistake over and over again. By narrating this dark history of psychosomatic medicine, we hope to empower patients against harmful preconceptions.

L’histoire se répète: gaslighting of Long COVID

Chimére Smith, a 38-year-old middle-school teacher in Baltimore, is one of many who report long-term symptoms following infection by the new coronavirus. In an article on the Cut, she describes how doctors dismissed her physical complaints as psychosomatic:

“Since I got sick, I have been told over and over again that I have nothing, that I don’t have COVID, that I have anxiety, I have depression, that I probably need to visit a mental-health facility. I remember after one visit, I left the ER [Emergency Room], and I got in my car and cried. I was like, ‘Maybe you are crazy. Maybe you should check yourself into some mental-health facility, because clearly you’ve taken every test; every test has come back negative. Clearly, you must be the problem.’ I just felt so discouraged.”

Smith’s experience is not unique. Others have described how doctors interpret their physical symptoms following COVID-19 as a result of anxiety, stress, worry, or depression. “I’m so ill and some people are telling me this is a figment of my imagination”, Ailsa Court, a commercial makeup artist, said to NBC news. “It truly feels like a nightmare.”

In an article in the Atlantic, Angela Meriquez Vázquez, a children’s activist in Los Angeles, said: “In one of my first ER visits, I was referred for a psychiatric evaluation, even though my symptoms were of heart attack and stroke.” Another patient had a similar, frustrating ER visit. She said: “Of course I was anxious, but that was a consequence of the physical symptoms, not the cause!” 

In the ‘COVID-19 Prolonged Symptoms Survey’, somebody noted: “One provider suggested that my shortness of breath was due to anxiety. As a person who does high intensity exercising 3x a week to a person who now gets short of breath changing her bedsheets, I found that dismissive.” 

Doctor Nyarie Sithole, an infectious disease consultant and researcher from Cambridge University, said that “many patients who suspect they have long COVID say they feel dismissed by their GPs – some are even being told it’s psychosomatic,” says Sithole, “but from my experience, a good number of them really did have COVID.”

“I was one of those people who falsely believed that if you can’t see the illness it’s psychosomatic,” said Lauren Nichols, who contributes to ‘Body Politic’, a support group for long-covid patients. “Now I’m living it,” she said. “If I have one message for doctors, it’s: ‘Believe your patients.’”

Amy Watson, founder of the Facebook group ‘Long Haul Covid Fighters’, highlights that “people are waiting two months for an appointment, only to be told it’s their fault, that it’s psychosomatic anxiety. When people feel invalidated, it makes dealing with this much worse. A lot of new members come to the group in tears with the same stories.”

Mady Hornig, an epidemiologist, and psychiatrist at Columbia University, also experienced lingering symptoms such as an increased heart rate (tachycardia) following COVID-19. She wrote: “If one of my doctors could suggest to me that this post-Covid tachycardia likely reflects some deep-seated unconscious neurosis, then how will anyone without a medical background manage to be properly heard and guided through this?”

Unfortunately, it’s not just doctors. Glasgow-based journalist Vonny Leclerc talks about the difficulty of friends and family to understand that she experiences long-term physical symptoms after having COVID-19. “I’ve had messages saying this is all in your head, or it’s anxiety,” she said.

The popularity of psychosomatic causes

For some, it might come unexpected that so many doctors interpret physical symptoms of long COVID as psychosomatic. Unfortunately, it should come as no surprise. Even a brief look at the history of medicine reveals a recurring tendency to attribute illness to psychosomatic causes. This is especially true for illnesses that are characterized by vague symptoms such as pain and fatigue and where little is known about the cause and pathology. Patients with fibromyalgia, migraine, irritable bowel syndrome, or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) report similar experiences as the people with long COVID quoted above. When doctors cannot easily explain symptoms, they tend to say they are all in the mind.

But it’s not only poorly understood illnesses that are viewed this way. If we look further back into the history of medicine, we find that psychosomatic explanations were once popular for various diseases, from epilepsy, asthma, and colitis to diabetes and rheumatoid arthritis. Some of these explanations became part of our culture and way of thinking. Stress is believed to lead to ulcers while repressed anger is thought to lead to hypertension. A heart attack is sometimes blamed on a workaholic personality while cancer was associated with emotional suppression.

Organ language

Psychosomatic explanations reached their peak in the 1930s and 1940s when several researchers started to apply Freud’s psychoanalytic principles to physical illnesses. Franz Alexander, a Hungarian-born psychiatrist at the University of Chicago and one of the most important members of the psychosomatic movement, summarized its credo as follows: “when emotion cannot be expressed and relieved through normal channels by voluntary activity it may become the source of chronic psychic and physical disorders.”

In a 1940 article in the New York Times titled ‘Emotions blamed for physical ills’ another founder of the psychosomatic movement, Edward Weiss, said that he explained to his patients:

“that If they cannot find an outlet for tension of emotional origin by word or action, the body will find a means of expressing this tension through a kind of ‘organ language.’ For example, if a patient cannot swallow satisfactorily and no organic cause can be found, it may mean there is something in the life situation of the patient that he ‘cannot swallow.’ Nausea in the absence of organic disease sometimes means the patient ‘cannot stomach’ this or that environmental factor. The patient who has lost his appetite and as a consequence has become severely undernourished is very often emotionally starved just as he is physically starved.

A personality type for each disease

A third important figure in psychosomatic thinking is Helen Flanders Dunbar. She was the first president of the American Psychosomatic Society and the first editor of its journal Psychosomatic Medicine. Dunbar’s main idea was to associate each disease with a personality type that predisposed people to develop the disease. While writing about coronary heart disease Dunbar stated that “The personality factors and their history are often of more importance than the presence or absence of actual organic damage.”

Dunbar said that it is a characteristic feature of people who suffer from heart disease that they are hard workers, “driving themselves without mercy and apparently enjoying it. It is typical of them to say: ‘I have to keep doing something useful.’” The typical victim of hypertension was believed to be nervous with an inability to relax. Patients with colitis or hemorrhoids were viewed as infantile, lonely, and not emotionally mature. Asthma and hay fever were understood as the result of ‘smother love’ and conflicts about longing for attention of the mother. An asthmatic attack was therefore interpreted as a cry for the mother. Dunbar warned that “asthma may also serve as a means of getting attention which would otherwise be diverted to others, and will finally become an unconscious reaction if the individual is deprived of what he thinks is his due.”

There was also a diabetes personality, a rheumatoid arthritis personality, and even an accident-prone personality. Dunbar called this half-jokingly ‘accidentitis’. She stated that “at least 80 per cent of the millions of major accidents which happen every year are due to this ailment.” Persons with ‘accidentitis’ were said to be extremely impulsive and have a strong need for independence and a resentment of authority. These persons had repeated accidents because of their personality type, Dunbar said: “They think they are the victims of bad luck of divine punishment. In reality they have been struck down by their own emotional conflicts.”

Type A and the cancer-prone personality

One of the most popular illness-prone personalities was called ‘type A’.  It was used for people who were highly competitive, ambitious, work-driven, impatient, and aggressive. The concept was developed in the late 1950s by two cardiologists: Meyer Friedman and Ray Rosenman. The story goes that they noticed the chairs in their waiting room were worn out quickly because their patients with heart disease were impatiently leaning forward. Friedman and Rosenman argued that people with type A personality behavior patterns (TABP) were more likely to develop coronary heart disease. Initial studies seemed to confirm this hypothesis and the type A personality entered the popular press to become a household phrase. Most studies have however failed to confirm a link between type A behavior and coronary heart disease.

Mark Petticrew and colleagues analyzed tobacco industry documents showing that the industry was a major funder of research into type A personality and coronary heart disease. The authors argue that “the industry’s strategy regarding TAPB from the late 1950s to the early 1980s was to suggest that the risks of smoking were caused by the psychological characteristics of individual smokers rather than tobacco products.”

This brings us to the cancer-prone personality. Research into this hypothesis came from a cohort study in former Yugoslavia by sociologist Ronald Grossarth-Maticek. He reported an association between the repression of emotions, such as anger and anxiety, and the development of lung and other cancers. Grossarth-Maticek’s findings were incredible with certain personality types having a 40 to 70-fold increased risk of dying from cancer. The studies were given respectability, however, by one of the most influential psychologists of the 20^th century: Hans Eysenck.

Eysenck appeared as a co-author with Grossarth-Maticek and defended his controversial results in public. He proposed behavior therapy to express emotions more freely as a way to prevent cancer.  At the same time, Eysenck was casting doubt on the association between smoking and lung cancer. He wrote, for example: “it is clear that simplistic formulations like ‘Smoking causes cancer’ have no part to play in the scientific study  of this disease.” Instead, Eysenck proposed research to focus on psychosocial factors such as stress and personality features. As you might have guessed, Eysenck received funding from the tobacco industry to promote his congenial views. Many of the papers he published with Grossarth-Maticek have recently been withdrawn from the scientific literature.  An inquiry by Eysenck’s former university King’s College London, flagged the papers he co-authored with Grossarth-Maticek as ‘unsafe’. Researchers have also reported errors and inconsistencies hinting at possible data manipulation in Eysenck’s work with Grossarth-Maticek.

Refrigerator mother

Theories about personality often had a negative influence on patients and how others viewed their illness. When American writer Susan Sontag got breast cancer she wrote a book criticizing how “cancer is regarded as a disease to which the psychically defeated, the inexpressive, the repressed – especially  those who have repressed anger or sexual feelings – are particularly prone.” She argued that such psychosomatic metaphors cause stigma and blame and should therefore be avoided when talking about illness. She notes that tuberculosis suffered from similar narratives – “a disease apt to strike the hypersensitive, the talented, the passionate” – and that these connotations disappeared as soon as a bacterial cause was discovered and treated effectively.

The most striking example of a psychosomatic myth that harms the people it is supposed to help, is the refrigerator mother theory. This theory attributed severe autism to cold mothers who were disinterested in their children and unable to bond with them. The foremost proponent of this view was the Austrian-born psychologist Bruno Bettelheim. We now know that Bettelheim was a charlatan who faked academic credentials but up until the 1970s he was held in high esteem and appeared in the media as an expert on mentally disturbed children. In one tv-appearance on the Dick Cavett show, Bettelheim argued that children with severe autism regressed because their parents thought it would be better if they never existed. He even compared the life of autistic children to growing up in a concentration camp (he himself had been in Dachau and Buchenwald concentration camps during WOII).

The documentary Refrigerator Mothers, recorded how harmful such views can be. It interviewed several mothers who sought help for their autistic children but were instead accused by psychiatrists of making their children ill. As one mother explained: “What have we done that is so awful that would drive a child into such a regression? I was told I had not connected or bonded with the child because of inability to properly relate to the child. And this caused autism. I couldn’t quite see how that would happen. But here’s someone of authority saying it had happened.”

Many parents were desperate and willing to do anything to make their children better. One mother explained how she went along with psychoanalytic explanations: “Well, I wanted to have it to be true so I could change and she get well, don’t you see? I don’t care what you put on me. If it was true, and I changed, she’ll get well. That’s what I wanted to believe.”

A new blog series

The testimonies of women accused of being refrigerator mothers and the stories of long COVID being dismissed as stress or anxiety, are just two examples of the dark history of psychosomatic medicine. In upcoming blog posts, we hope to delve further into this subject and unveil some of the errors of the past. In each new article, we will try to tell the psychosomatic history of a disease, starting with multiple sclerosis, asthma, epilepsy, diabetes, rheumatoid arthritis, autism, and hopefully many more. We will not only try to summarize the psychosomatic literature but also estimate how it might have influenced doctors, patients and the public at large.

Overview of the subjects of this series:

Multiple Sclerosis

Asthma

Epilepsy

Diabetes

Autism

Schizophrenia

Cancer part I / Cancer part II / Cancer part III

The remarkable testimony of Richard Renneker

Heart disease part I / Heart disease part II

Rheumatoid arthritis

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