The dark psychosomatic history of peptic ulcer part II

Peptic ulcer was long seen as one of the prime examples of psychosomatic disease. From the 1930s to the 1980s, repressed emotions and stress were considered its main cause. “That psychic factors play a prominent role in the causation of ulcer is doubted by no one”, a 1952 JAMA review proclaimed.

The most popular theory was advanced by Franz Alexander, the father of psychosomatic medicine. He argued that ulcer patients had repressed desires to be loved and nurtured like a child but that they could not give in to these wishes because they wanted to appear strong and independent. The body, however, usually finds a way of expressing repressed emotions. In the worldview of a baby, the wish to be loved and cared for is closely associated with feeding. Therefore, Alexander advanced that unresolved dependency needs are expressed by the stomach. As peptic ulcer patients craved affection, their stomach was constantly preparing for food that would never come. This resulted in an overproduction of acid that over time resulted in the formation of an ulcer.

The common treatment of hospitalization, bed rest, and frequent feeding with milk and cream was seen as a confirmation of Alexander’s theory that peptic ulcer patients had a repressed desire to be nurtured. Multiple scientific articles proposed psychotherapy as “the only etiologic treatment in most cases of peptic ulcer.”

Then, in the 1980s a paradigm shift occurred. Two Australian doctors discovered that peptic ulcer was caused by a germ, earning them the 2005 Nobel Prize in medicine. Ulcers, it turned out, could easily be treated by a combination of antibiotics and acid inhibitors.

In this three-part series, we will explore the dark psychosomatic history of peptic ulcer. In part I we examined the reasons behind the popularity of psychosomatic explanations of peptic ulcer. In part II we will explore some of these psychosomatic theories in depth.

Franz Alexander’s theory on frustrated oral impulses

The most prominent theory was proposed in the 1930s by the father of psychosomatic medicine: Franz Alexander (1891-1964). Working at the University of Chicago, Alexander used the psychoanalytic approach of Freud and applied it to somatic conditions such as rheumatoid arthritis, hypertension, asthma, and many others. For peptic ulcer, Alexander started with the caricature patient that we discussed in part I of this series: the stressed and ambitious businesses man. Alexander thought that behind their outward appearance, these men had secret wishes to be nurtured, cared, and loved for. The ulcer patients, however, repressed these wishes because they wanted to be strong and independent. This meant that their dependency needs could not be expressed through thoughts or behavior. The body, however, usually finds a means to express these emotions. Here’s how Alexander described this:

“Those individuals who on account of the described conflict-situation have to repress and abnegate their over-strong receptive cravings express them in the tacit physiologic language of the stomach functions.”

In psychoanalytic theory, the hidden dependency needs of ulcer patients were seen as a regression to an earlier period of human development. Alexander, for example, wrote that in ulcer patients, there is “a strong regression to the infantile attitude of oral receptiveness and aggressiveness.” Therefore, one must take the perspective of a baby to try to understand this ‘infantile attitude’.

In the worldview of a baby, the wish to be loved and cared for is closely associated with feeding. Therefore, the unresolved wishes of peptic ulcer patients to be nurtured, express themselves in a stomach that is constantly preparing for food. As result, these patients produce too much stomach acid which over time could result in the formation of peptic ulcer. In the words of Alexander:

“The infantile wish to receive, to be taken care of, to be loved, to depend upon someone else, is most ideally gratified in the parasitic situation of the suckling infant. Thus, these emotional qualities of receptivity, the wish to be loved and taken care of, become closely associated in an early period of life with the physiologic functions of nutrition. Being fed thus becomes the primordial symbol (Ursymbol) of being loved. If the intense wish to receive, to be loved, to depend upon others, is rejected by the adult ego and consequently cannot find gratification in normal life relations, then only the regressive pathway remains open; the wish to be loved becomes converted into the wish to be fed. The repressed longing to receive love and help mobilizes the innervations of the stomach.”

This theory, absurd as it may seem, was the dominant view of peptic ulcer in psychosomatic medicine for several decades. It was based on only 9 cases: 6 patients with duodenal ulcer and 3 with “gastric neuroses”.

Alexander theory was inspired by the experiments of I.S. Silberman on sham feeding of dogs. Silberman used dogs with a hole in their esophagus, the tube that connects the throat with the stomach. By giving them food and retrieving it through the hole, Silberman reported that these dogs’ stomach was constantly working in preparation of food that would never come and that this resulted in ulcers. Alexander used this concept and applied it to peptic ulcer in humans. Other scientists, however, were unable to replicate these experiments. “it seemed to us that the ulcers observed by Silbermann were of the type which result from vomiting and malnutrition”, one group noted.

Alexander’s theory thus had shaky foundations but in the 1950s it received support from a study of more than 2000 soldiers. The soldiers who produced the most acid (or more precisely the most pepsinogen), showed the personality characteristics Alexander had described. Many took this as a validation of the psychosomatic approach to peptic ulcer. The study, however, has never been replicated and used questionable methods such as the Rorschach test.

Sippy diet

For most of the 20^th century, treatment of peptic ulcers consisted of hospitalization, bed rest, and hourly feeding with a mixture of milk and cream called the Sippy diet (named after Bertram Sippy the physician who introduced the regimen). Several physicians noted a resemblance between this treatment approach and Alexander’s theory. They suggested that effective treatment with bed rest and the Sippy diet proved that ulcer patients secretly yearned for milk and nurturing, just like a baby. One paper noted for example:

“The frequent ingestion of milk and cream does more than just buffer (neutralize) free acid; it has the meaning of actually receiving food, and unconsciously this stands for affection and security. The close resemblance of the Sippy regime to the feeding schedule of the young infant has been pointed out many times before, but its significance cannot be overemphasized. “

Similar thoughts were expressed as late as 1977 by Dr. Marvin H. Sleisenger from the University of California. In one of his paper Sleisinger, an expert in the field who edited journals and textbooks in gastroenterology, wrote:

“the effect of instituting frequent feedings of baby-type food with milk or milk and cream every hour or two hours seems to work magic in many patients. We have wondered: Is it really psychotherapy? The patient seems in this situation to be reduced to early childhood or even infancy, to be cared for by being offered something to eat frequently and to be ingesting only those foods most obviously identified with infancy. Perhaps “mothering” is better treatment than temporary acid neutralization!”

His words were picked up in New York Times article titled: “Worrying about ulcers”.

Szasz, Mahl and Draper

Other researchers made small adaptions to Alexander’s theory of peptic ulcers. Thomas Szasz, for example, emphasized hostility as an emotion that could also increase the production of stomach acid. In one of his papers, he recapitulated his theory as follows:

“We propose to explain the effect of anger on the secretory function of the stomach by a consideration of the close correlation which exists, in the oral-demanding infant, between anger (crying) and what anger usually accomplishes (feeding).”

Because of infantile hostility, the stomach of peptic ulcer patients was constantly preparing for food. Or as Szasz explained: “the upper part of the gastrointestinal tract of these patients “behaves” like that of the young infant who is fed every three hours.” Szasz would later become famous as a critic of psychiatry and for claiming that mental illness is a myth but in the years after the Second World War, he focused on psychosomatic interpretations of peptic ulcers.

Another researcher, named George Mahl, thought that anxiety was the main trigger of peptic ulcers. His theory was controversial because it went against the principle of specificity.

In psychosomatic medicine, researchers preferred to match a specific personality type or emotional state with a particular disease. They did not want these to overlap. Mahl went against this principle of specificity by arguing that any type of anxiety could lead to peptic ulcers and that it is not essential what the source of anxiety is. Alexander and Szasz quickly spoke out against these ideas.

Another interesting figure was George Draper, the former physician of president Franklin D. Roosevelt as he was suffering from polio. Draper was known for his “constitutional medicine”, which aimed to focus more on the characteristics of the patient rather than his disease. Draper’s writing, however, resembles racism more than precision medicine as we know it today.  Draper used ‘anthropometry’ and published pictures of the typical ulcer patient’s facial morphology. He spoke of the “peptic ulcer race” whose “qualities of soma and psyche which can be easily recognized”. He added that ulcer patients were “by far the most dramatic personalities on the medical and surgical wards.”

Much like Alexander, Draper emphasized that ulcer patients regressed to infantile behavior. He wrote:

“When you read the intimate histories of persons who have ulcers, however, the impression develops that these individuals, like frightened neglected children, are striving continually to recapture and maintain the mother principle which had ministered so meticulously to the demands of that delicate infant receptacle for milk”

He added that males with peptic ulcers often have a strong feminine component and that this explains some of their emotional complexes.  Draper’s views were published in prestigious such as Annals of Internal Medicine and The Journal of the American Medical Association (JAMA) but they didn’t seem to get as much following as Alexander’s. 

Weird theories

Some scientists advanced psychosomatic theories that were even more bizarre.

One group, for example, analyzed the language use of peptic ulcer patients and noted that they had an ‘up-down’ bias: when patients had more symptoms they used words with the theme ‘up’ and when they were symptom-free they used words related to the theme ‘down’.  According to the authors, the use of these words was an unconscious reflection of the illness. “It is as if the symptoms were exerting a steady pressure on the patient’s choice of words”, they explained, “and the same idea might be expressed one way when the symptom was present, and differently when it was absent.”

Another research group extended this theory by adding that temperature differences between the upper and lower part of the body show a similar pattern. Here’s an extensive quote that explains this, rather bizarre, theory:

“Thus, it has been shown that the greater the number of stomach symptoms male subjects experience, the more upwardly biased they are when judging the horizontal, the higher is their hand as compared to their leg temperature, and (at a border line level) the relatively less do they focus attention upon their upper body areas […] Generally, one can say that the more an individual has stomach difficulties, the more he is typified by a special bias in his up-down perception of space and also the more he displays a pattern of temperature difference between an upper and lower body site.”

Also interesting were the many projective tests used. The mean idea is to let the test subject respond to ambiguous stimuli so that a psychologist can then detect repressed emotions or hidden symbolism. The most famous is the Rorschach where test subjects are invited to say what they see in a series of symmetrical inkblot patterns. Psychosomatic studies of peptic ulcer used two more interesting projective tests.

The first one is called ‘Blacky Pictures’. It consists of a series of pictures with a dog called Blacky in various family situations. The test subjects have to tell a story that fits with each picture. According to one study, ulcer patients were more likely to tell a story where Blacky bites:  “the oral aggression conflict appeared more prominently in the ulcer group in the tendency of these patients to have Blacky bite when frustrated in a variety of situations.”

The other projective test is human figure drawing. Here patients were asked to freely draw a human person with pencil and paper. The researchers could then use every detail of these drawings to unravel repressed emotions and personality complexities. The following quote, an analysis of a drawing by a peptic ulcer patient, gives an indication of how far these interpretations went:

“The large size of his drawing of the human figure is indicative of a considerable attempt at self-inflation. Clothing is seen to cover the entire figure, which may serve to hide any body weakness. The mouth is emphasized and reinforced indicating perhaps guilt concerning some type of oral sexual experience. The eye is empty perhaps so that he cannot see his problems. The broken back line suggests vulnerability to the environment. This would presuppose the need for wariness which he symbolizes with the large ear in the drawing that ‘listens too much.’”

Lastly, in a time when psychoanalysis was mainstream, there were multiple psychosomatic theories that focused on warped sexual impulses to explain illness and disease. Angel Garma, a pioneer of psychoanalysis in Argentina and Spain, argued that peptic ulcer is caused by“lack of genital instinctive gratification which is experienced regressively as hunger due to the lack of food and which injures the digestive tract.”

Another psychoanalysist, Robert Savitt reported a case where the peptic ulcer patient secretly wished to have anal sex with him (caution: this quote includes explicit language):

“In the third session of his analysis, he reported a dream in which he desired homosexual union with the analyst by having the analyst penetrate him anally with his phallus. He reluctantly came to realize the unconscious meaning of this key dream only after a lengthy period of analysis. In the transference he responded to the analyst as if the analyst were a bisexual parent, representing both mother and father. The analyst was to ‘feed’ him in a maternal fashion by inserting his phallus= breast into the patient’s anus, unconsciously conceived as a mouth.”

Psychotherapy

With so many psychosomatic theories, it may come as no surprise that many physicians recommended psychotherapy to treat peptic ulcers. One author proposed that the ulcer patient “must be encouraged to seek out the impulses he is unaware of behind his symptoms that exploit the soma as a substitute for proper affective expression.” He continued:“with a more mature, independent type of behavior, the ‘regressive visceral language’ of the ulcer will no longer be necessary, and somatic improvement will occur.”

Others, writing in the prestigious journal The Lancet, stressed that the most important point of treating peptic ulcer was to “to facilitate the conviction of the patient that his mind is capable of bringing distress to his stomach” […] once, however, the patient accepts this relation, he can, we think, do much to put his house in order.” Another group even suggested that we may “prevent many ulcers, by relieving the chronic emotional irritation before ulcers form.”

There were some psychosomatic researchers who argued that psychotherapy could not be the first line of treatment but they didn’t mean to suggest it was inappropriate. Instead, they argued that it would be practically unfeasible (as there were too many patients with mild symptoms) or because ulcer patients frequently rejected psychotherapy. As one paper on ‘the psychological management and treatment of patients with peptic ulcer’ explained:

“A formidable barrier to treatment from the very beginning is the strong tendency of such patients to use their somatic symptoms as a resistance to an investigation of their psychological problems as well as to the comments and interpretations offered by the therapist concerning them”

Some researchers were clearly frustrated that peptic ulcer patients frequently rejected the suggestion of psychotherapy. “We all ought to be mature enough to accept that we have dependent”, Ernest Wolf said in a 1956 discussion on the subject. “What is there so bad about wanting to be a baby occasionally?”

Another recurrent theme in the psychosomatic literature is the idea that curing peptic ulcer without addressing the patient’s underlying psychological problems, is erroneous because it would only be a matter of time before it results in new physical symptoms. Several researchers criticized surgical treatment such as vagatomy, based on this reasoning. One group for example wrote that “if an outlet cannot be found for emotional tension, then the body will find a means of expressing this tension through a kind of organ language. Hence in patients with vagotomy, we can look for an increase in the incidence of circulatory disease.”

Thomas Szasz was one of the researchers who promoted this idea. In a 1949 paper he explained:

“… upon removal by vagotomy of the peptic ulcer, the energy bound by the illness may be released in a rather diffuse manner—comparable to free-floating anxiety on an ‘organ-level’—and may then result in a number of poorly organized and changing symptoms.”

Szasz argued that treating peptic ulcers with vagotomy was “potentially harmful” if there was no “symbolic oral gratification” for the patient. In his opinion, psychoanalysis was “the only etiologic treatment in most cases of peptic ulcer.”

In the third and last episode of this series, we will look at some critical voices in a time when psychosomatic theories of peptic ulcer ruled. We will explore the impact of the discovery of Helicobacter Pylori and the current state of the research linking stress with peptic ulcer. 

Click here for an overview of all our articles on the dark history of psychosomatic medicine.