Abstract
The interrelationships among mind, body and environment in sickness and health are the central focus of psychosomatic medicine and the essence of George Engel's biopsychosocial model of disease [1]. Although Engel based this model on general systems theory, his understanding of mind – body – environment relationships and his clinical approach to somatically ill patients were also strongly informed by psychoanalysis. Engel had become increasingly aware of the psychological aspects of disease during the few years (1942–1946) he spent as an internist at the Cincinnati College of Medicine where he met regularly with a group of colleagues who shared a strong interest in psychiatry and psychosomatic medicine. After taking appointments in the Departments of Medicine and Psychiatry at the University of Rochester in 1946, Engel acquired a much deeper knowledge of the mind and how it might influence bodily health; he had a personal analysis with Sandor S. Feldman and for 5 years (1950–1955) commuted to Chicago for psychoanalytic training at the Institute founded by Franz Alexander. His thinking about psychosomatic processes was undoubtedly stimulated by Alexander, but Engel [2] also credited his supervisor Therese Benedek for her illuminating teaching of psychoanalytic concepts. After completing his psychoanalytic training, Engel remained working primarily on the wards of a medical service where he integrated psychoanalytic methods and concepts into his teaching, research, and clinical practice.
Although I did not study with Engel, I was taught his psychoanalytic approach to psychosomatic medicine by his colleague Franz Reichsman when I was a Fellow on his psychosomatic service at the State University of New York Downstate Medical Center in 1970–1971. Over the ensuing 30 years, Engel's contributions have influenced much of my own work at the interface of psychoanalysis and psychosomatic medicine [3]. My contribution to this memorial symposium focuses on some of the ways in which Engel applied psychoanalysis in medical settings and on some advances in psychosomatic theory and practice that resulted from his clinical research.
Engel's clinical approach to the patient
Whereas most physicians view the study of disease as a science and the care of the patient as an art, Engel [4–6] consistently asserted that patient care is as much a matter for science as is the study of disease and also that both are an art. He argued that human behaviour, feelings, transactions, and relationships can be investigated scientifically and that the instruments for data gathering are observation, introspection, and dialogue. Engel [7] had learned many of the methods of scientific research when he and his twin brother worked summers at a marine biological laboratory. When he got involved in a research project on delirium with John Romano in 1941, he became aware of the important psychological variables in medical illness and discovered the value of the medical interview and dialogue for gaining access to this information. It was during his years in Cincinnati, and especially his exposure to the scientific approach of Maurice Levine at weekly psychosomatic rounds, that Engel [8] began to appreciate the value of the psychoanalytic method for accessing personal and psychosocial data, and also for organizing and studying this data systematically.
Engel's subsequent training in psychoanalysis enhanced his skills for accessing psychological data. An openended style of interviewing, listening to the patient's verbal communications for hidden meanings, close observation of the patient's non-verbal communications, and looking inward to evaluate the feelings and fantasies evoked by the patient are basic to the psychoanalytic method [9]. In contrast to the interrogative ‘yes-no’ questioning that occurs in most medical interviews, Engel's [10] emphasis was on permitting patients to speak freely about themselves, their families and other relationships as well as about their symptoms. The physician's task was to observe the patient's gestures, posture, facial expression, and way of speaking, all of which were regarded as raw scientific data. Introspection and dialogue with the patient helped establish meaning to these verbal and non-verbal communications and to thereby clarify the nature of the patient's illness and its interrelationship with his or her personal life. Also required of the physician was critical scrutiny and analysis of his/her own behaviour and its impact on the patient [5].
Although not explicitly stated by Engel, the method of listening he advocated was comparable to Reik's [11] exhortation to psychoanalysts to listen with the ‘third ear’ and to Bion's [12, 13] injunction to suspend memory, desire, and preconceptions so that the mind is open to discovering the unexpected and new. Engel [5–7, 10] avoided the use of psychoanalytic jargon whenever he wrote about his method of medical interviewing. Indeed, through his style of teaching and writing, he translated basic psychoanalytic principles into forms that were meaningful and acceptable to most medical students and non-psychiatric physicians. By using the triad of observation, introspection, and dialogue, Engel acquired information that led to a more comprehensive understanding of ways by which mental processes and environmental events can influence bodily processes.
A study of psychosomatic processes in early life
During his training at the Chicago Institute, Engel realized that new discoveries about the mother-infant relationship and the development of object relationships were important not only for psychoanalysis but also for understanding the psychosomatic process. In his Presidential address to the American Psychosomatic Society in 1954, however, he noted that at that time there was nothing known about the physiology of the motherinfant symbiotic unit and he made a plea for more systematic research in this area [14]. Engel and Reichsman [15, 16] were soon to make such a contribution as they had just begun a longitudinal study of an infant named Monica, which was to continue for 40 years.
Born with an oesophageal atresia, Monica was fed through a surgically produced gastric fistula during the first two years of her life. She showed poor bonding with her 19-year-old mother who was also unable to relate warmly to the child because she was depressed and conflicted over feeding her via a gastric tube. Monica failed to thrive and was admitted to hospital at 15 months of age in a depressed and marasmic state. During a 9-month period in hospital, Monica showed considerable improvement after she became attached to Reichsman and one of the nurses, both of whom in turn became quite attached to her. Engel and Reichsman [16] observed that Monica did not display the usual crying response to strangers but instead lapsed immediately into an unresponsive withdrawn state during which there was a loss of muscle tone, profound immobility, a sad facial expression, and gastric secretions ceased and became unresponsive to histamine stimulation. They named this state a depression–withdrawal reaction. When reunited with her familiar doctor or nurse, however, Monica showed a joyful response, muscle tone rapidly returned, and the rate of gastric secretion rose. These observations clearly demonstrated that an infant's (gastric) physiology, as well as its emotional state, can be regulated by an interpersonal relationship, provided there is an attachment bond and interaction with the other person. During the past two decades, developmental research using animal models has provided much more evidence that hidden within the interactions between infant and mother are a number of processes by which the mother serves as an external regulator not only of the infant's behaviour and autonomic physiology, but also of the neurochemistry of its maturing brain [17–19].
Engel and Reichsman [16] conceptualized the depressionwithdrawal reaction as a basic biologic anlage of depression and noted that Monica's appearance when she was in this state closely resembled the manifestations of anaclitic depression that Spitz [20] had observed in infants separated for prolonged periods from their mothers. Like Bibring [21], they questioned the application of the classical psychoanalytic formulation of melancholia to all cases of depression, and proposed that many clinical depressions reflect this primitive pattern of biologic withdrawal rather than morbid guilt and aggression turned on the self. In later years Blatt [22] further differentiated anaclitic depression from the classical introjective type of depression and defined the levels of object representation in each type.
Observing Monica periodically through her childhood and adolescence and also in her adult life, Engel et al. [23, 24] identified several enduring effects of her experiences during infancy. These included a persistence in the shallowness of her object relations; an impoverished fantasy life; a disinclination to introspection, submissiveness; a low level of manifest aggressivity; and a tendency to imitate rather than identify with others. When Monica became a mother herself, there was a close correspondence between the way she held her infants during bottle-feeding and the way she had been handled as an infant during fistula-feeding. This body behaviour felt ‘natural’ to Monica; it is a good example of how early experience can be encoded implicitly in the brain and be reactivated in later situations without any sense that something is being recalled [25].
Studies of ulcerative colitis
Toward the end of his psychoanalytic training, Engel [26–29] began writing a series of papers on ulcerative colitis in which he reviewed the literature on the nature of the somatic and psychologic processes, reported his own observations, and evaluated the adequacy of the various psychosomatic hypotheses. In contrast to many other psychoanalytically trained psychosomatic researchers, he made clear from the outset that he was concerned not with the problem of psychogenesis, but rather with identifying ‘conditions which may be contributory or even necessary yet may not be sufficient in themselves for the development of ulcerative colitis’ [28], p.231]. This conceptual approach was not inconsistent with the teaching of Alexander, who regarded specific intrapsychic conflicts as only one factor in the overall development of disease; a specific type of life event that activates the conflict and a biological vulnerability of a specific organ were also necessary factors in Alexander's model [30].
Instead of focusing on specific conflicts, however, Engel investigated the interpersonal relationships of ulcerative colitis patients and observed a rather consistent pattern. Typically the patients had intensely dependent relationships with one or two key people (usually the mother or the spouse), yet they lacked the capacity to establish warm, mature friendships with other people. The onset or recurrence of colitis usually occurred when a key relationship had been threatened or disrupted and the patient had responded to the loss with feelings of helplessness, hopelessness, and despair. Engel [28] also observed ‘serious defects in ego function’ in colitis patients, which he did not fully explore but attributed to longstanding mutually dependent relationships with their mothers. He found that the patients either became very dependent on their doctor or established no relationship or at best a very superficial one. In his experience, those who developed a dependent relationship did better medically than those who did not. When there were disruptions in the doctor-patient relationship these dependent patients suffered a relapse of their colitis unless they formed a substitute relationship.
Based on these observations Engel [29] recommended supportive psychotherapy for most colitis patients and that the relationships with their psychotherapists or gastroenterologists never be completely terminated. Some support for his recommendation was provided a decade later by findings from a study at Columbia University where individuated patients with colitis were found to respond to interpretations of intrapsychic conflict, while highly dependent patients were best helped by support and suggestion [31].
The giving up – given up complex and a new model of disease
While Engel was studying colitis patients and the infant Monica, several of his colleagues at Rochester 452 MIND–BODY–ENVIRONMENT RELATIONSHIPS were investigating patients with leukaemia and lymphomas and other groups of hospitalized medical patients [32–34]. They found a similar association between feelings of helplessness and hopelessness in response to loss and the onset of disease. In later studies, Engel and his collaborators [35, 36] observed that sudden cardiac death in predisposed individuals tended to occur while they were experiencing the disruption of an important interpersonal relationship. They also found that object loss frequently contributed to the emotional disturbance during which an ischaemic stroke occurred [37]. Moreover, a study of patients admitted to an acute psychiatric service revealed a high frequency of object loss and an emotional reaction of defeat in the time period shortly preceding the onset of symptoms [38]. Deeply impressed by the strong association between object loss and the onset of disease, Engel and Schmale [39–41] postulated an intervening psychobiological state which they called the ‘giving up – given up’ complex. They conceptualized this complex as a transitional ego state during which suitable defences or devices for coping with object loss are unavailable or have not yet evolved. The attitudes of ‘giving up’ and ‘given up’ were associated with the specific depressive affects of helplessness and hopelessness [42]. The biological component of the complex was conservation–withdrawal, which had been observed initially in Monica as depression-withdrawal, but was renamed to eliminate any confusion resulting from mixing psychological and biological frames of reference.
Engel and Schmale [43] conceptualized conservationwithdrawal as a biological defence system that has survival value unless prolonged; it is associated with a predominance of parasympathetic activity and anabolic functions, in contrast to the ‘fight or flight’ response, which involves the sympathetic nervous system and catabolic functions and was part of all previous psychosomatic theories. Once the giving up – given up complex develops it was thought to initiate autonomic, endocrinologic and immunologic processes which lower the body's resistance and allow for the emergence of disease. Engel [43, 44] often made clear that he regarded the giving up – given up complex as neither a necessary nor a sufficient condition for disease development, but rather as a predisposing factor for some diseases, providing the other conditions necessary for the disease are also present. The model of disease that he and Schmale developed had several advantages over other psychosomatic models; as noted by Crown [45], it did not require separating unconscious from conscious mental processes, it could be easily operationalized thereby allowing for objective investigation and the possibility of disconfirmation, and it made no assumptions about the nature of disease. The model has been criticized on several grounds, however, especially for the retrospective nature of the bulk of evidence linking the complex to disease onset; nonetheless, support for the model was provided by several predictive and prospective studies which I have reviewed elsewhere [3, 46]. Moreover, the model has proven useful to psychotherapists and psychoanalysts for exploring episodes of medical illness that follow either significant life events or the mobilization of conflicts within the transference that stimulate fear of abandonment by the therapist [47, 48].
Somatoform disorders
In addition to his psychoanalytic approach to patients with somatic diseases, Engel [49–51] employed psychoanalytic concepts to help understand patients with physical symptoms that are not fully explained by a general medical condition. Like most psychoanalysts, he attributed many such symptoms to the psychic mechanism of conversion, whereby an idea, fantasy, or wish is symbolically expressed through the body. Although the most common conversion symptoms are those of conversion disorder and affect voluntary motor or sensory functioning, Engel [8] suggested that in some instances the conversion process may involve a reactivation of autonomically innervated parts of the body that have achieved mental representation and become associated with other mental content; the resulting physiological disturbances may lead to bodily lesions. Such lesions, he noted, neither have primary psychological meaning as wish or fantasy nor serve a defensive function; conversion is responsible for the location and time of onset of these lesions, but not for their pathological nature. Engel [49, 50] emphasized, however, that some bodily symptoms (such as palpitations, sweating, and fatigue) merely reflect the physiological changes that accompany affects. He also differentiated between conversion symptoms and hypochondriacal symptoms, the latter involving an unusual awareness of even the most trivial bodily sensations to which patients ascribe grave consequences. Engel [51] observed that hypochondriacal symptoms have an insistent, demanding, and even persecutory quality, and at times assume the quality of somatic delusions. He was careful not to classify irritable bowel syndrome as a ‘psychogenic’ or ‘psychophysiological’ disorder, which he considered an oversimplification. His view that there may be as yet unidentified organic factors influencing the bowel response to psychological stress is supported by recent research [52, 53].
Engel's major contribution to the field of somatoform disorders was his conceptualization of the mechanisms of pain and the psychodynamics of unexplained chronic pain in patients whom he had seen on medical wards or treated in psychoanalysis. In a classic paper published in 1959, Engel [54] challenged the then dominant theory of pain, which regarded pain as a peripheral sensation mediated by pain receptors and transmitted to higher pain centres by pain fibres and pain tracts. This theory allowed for no way of conceptualizing pain other than as arising from a peripheral site. Engel's approach was to regard pain as a subjective experience much like an affect which, once it is represented psychically, no longer requires peripheral stimulation to be provoked. When the pain is projected outside the mind it is experienced as being in some part of the body and is then indistinguishable to the patient from pain arising in the periphery. This viewpoint made it possible to understand how pain may occur without any accompanying tissue injury or pathology.
Although Engel has been strongly criticised for popularizing the concept of ‘psychogenic pain’ (a diagnostic term that was fashionable at the time and was subsequently used in the DSM-III, but discarded in the DSMIII-R) [55], his revision to the theory of pain is consistent with the gate-control theory of pain that was advanced a few years later by Melzack and Wall [56] and thereafter adopted by Engel [57]. This theory postulates that the experience of pain is influenced not only by input from peripheral stimulation, but also by inhibitory and facilitatory messages descending from the brain. The brain therefore plays an important role in generating the subjective experience of pain both in response to and independent of sensory input.
As with other affects, Engel [54] noted that pain and its relief enter into the formation of interpersonal relationships and into the concepts of good and bad, reward and punishment, success and failure. Pain then becomes a way of assuaging guilt and thereby influencing relationships. Among the psychodynamic factors that may be involved in the pathogenesis of pain, Engel included an unconscious need to suffer, a response to a real, threatened or fantasied loss, and guilt over intense aggressive or forbidden sexual impulses. He described also how the choice of location of pain may be determined by a previous experience of pain in the same location, identification with pain experienced by someone else, or a conscious or unconscious wish that some other person suffer pain in that location.
Engel observed that many patients seem predisposed to ‘psychogenic pain’ because of early family relationships in which aggression, suffering, and pain played an important role. Empirical support for this observation was provided 30 years later by Adler et al. [58] who compared the childhood experiences of groups of patients with psychogenic pain, organic pain, psychogenic bodily symptoms, and organic disease. It is unfortunate, however, that these investigators perpetuated the distinction between ‘psychogenic’ and ‘organic’ pain which has been severely criticized in recent years as a remnant of specificity theory and Cartesian dualism. As Gagliese and Katz explain, there is no basis for distinguishing discrete ‘organic’ and ‘psychogenic’ aetiologies of pain; rather, all pain (including when there is no apparent tissue damage or pathology) is ‘a multidimensional experience made up of a complex interaction of sensory, affective, and cognitive components within the central nervous system’ [55], p. 252–3]. Notwithstanding these considerations, Engel's contribution still offers clinicians useful ways of thinking about psychodynamic factors that may play a role in the pathogenesis of medically unexplained pain or in the dramatic presentation of pain that is associated with tissue pathology.
Drive theory versus relational concepts in psychoanalysis
In studying medical illness within a relational context, Engel anticipated the shift that subsequently occurred within the field of psychoanalysis from an emphasis on drives and their transformations to a concern with object relations and the concept of the self [3, 59, 60]. And whereas previous psychosomatic models of disease focused primarily on unconscious conflicts, Engel gave the ego's capacity to manage affects evoked by real or threatened object loss a central role in influencing an individual's susceptibility to medical and psychiatric illness. As is evident in his formulation of conversion and pain disorders, however, Engel did not discard the role of unconscious drive-related conflicts. And even for gastrointestinal diseases, he assumed that conflicts over oral-dependent and oral-aggressive impulses, as well as unresolved conflicts around bodily control in childhood, could produce changes in gastrointestinal function or at least contribute to the dependent or obsessive–compulsive character traits seen among individuals who are prone to duodenal ulceration or ulcerative colitis [51]. As mentioned earlier, however, Engel's primary goal in the psychotherapy of most colitis (and other medically ill) patients was to establish a relationship and gratify dependent needs rather than to interpret unconscious conflicts. Insight-orientated therapy was recommended only for patients who manifest ego strength and are relatively independent. Although Engel [51] believed that psychotherapy can render an individual less vulnerable to the psychobiological consequences of object loss and other stressful environmental events, he emphasized that psychotherapy, no matter how intensive, cannot eliminate the biological defects that predispose to various diseases.
In conceptualizing individual differences in the way people respond to object loss, Engel recognized that it is the loss of the functions provided by the object rather than the loss of the object itself that triggers a giving up – given up complex. Well-individuated people with a cohesive self usually respond to object loss with appropriate grief and sorrow which is gradually dispelled by the process of mourning [61]; in contrast, those who depend excessively on the object for important psychological regulatory functions are unable to mourn and experience the loss as a withdrawal of narcissistic supplies or as a loss of part of the self [62]. Despite his awareness of these complexities, however, Engel made little attempt to integrate his observations with those of Kohut [63] and Bowlby [64] who during the 1970s proposed new theoretical models for conceptualizing interpersonal relationships and individual differences in vulnerability to object loss. Nor did he make use of the object relations theories of Klein and Fairbairn [65] to conceptualize the relationship of an individual to his or her internal objects.
Like many psychoanalysts of his time, Engel [66] was critical of Bowlby for misrepresenting psychoanalytic drive theory and for confusing the psychological and behavioural frames of reference. Perhaps because of his close observations of Monica, Engel believed also that Bowlby was mistaken in insisting that the development of attachment is relatively independent of oral instinctual behaviour. Consequently, his use of attachment theory was limited to viewing the characteristic gesture of helplessness (raising the arms, rotating the palms outward, then letting them fall limply on the thighs) as a derivative of an inhibition in action of one of the typical components of attachment behaviour (upraised arms inviting a parent to pick the child up).
If Engel had been more receptive to Bowlby's work and other developments in psychoanalysis, he might have foreseen some of the ways whereby attachment theory is now being integrated with traditional theories [67]; and he might have devised a psychotherapeutic approach that enables medical patients who are highly dependent and insecurely attached to become more autonomous and less vulnerable to the impact of object loss. Whereas Engel's [28] approach was basically to replace the object, often with the physician or psychotherapist becoming a necessary and supporting psychic object for the patient, many contemporary psychoanalysts not only establish a ‘holding environment’ but also attempt to modify the patient's internal object world, thereby strengthening psychic structure and enhancing the patient's capacity to organize and selfregulate drives, affects, and other aspects of self experience [68–71]. Nonetheless, because such therapy is a lengthy and difficult process, Engel's supportive psychotherapy offered physicians a practical approach for restoring and maintaining the psychological equilibrium of many medical patients and thereby reducing recurrences of illness.
Anniversary phenomena
One striking contribution in which Engel [72] explored the interplay of object loss, unconscious conflicts, and self and object representations was an extensive report of his self-analytic observations over a period of 10 years, during which changes in his own health coincided with anniversary reactions to the deaths of his father and his twin brother. It has long been recognized that heart attacks sometimes occur on the anniversary of important losses or other previously traumatic events, even when these events appear to have been fully accepted. Such reactions are thought to involve a reactivation of unresolved conflicts that had remained unconscious and effectively defended against.
Engel's father died from complications of a heart attack two days after George and his twin brother Frank had celebrated their 15th birthday, and two days before his own 59th birthday. This loss left Engel with the conviction that he would not live longer than his father, specifically not beyond two days before his 59th birthday on December 10, 1972. In July 1963, however, Engel's twin brother (who was an endocrinologist) died from a sudden heart attack at age 49. Soon after the funeral, Engel was medically examined and found also to have coronary heart disease. He gave himself a year to live, but survived the anticipated myocardial infarction which occurred 11 months later. Over the succeeding years Engel became less preoccupied with significant anniversaries, but various incidents and dreams reminded him that he had been repressing the painful loss of his brother as well as rivalrous feelings and guilt over his own survival. Moreover, there was evidence of a persistent unconscious confusion of himself and his brother which he attributed to a vagueness of boundaries between his self and object representations, a not uncommon finding in twins. To no longer be a twin was a narcissistic loss, but to be joined was to die. When his nemesis year dawned, Engel curiously held the notion that his father had died two days before his 60th, rather than his 59th, birthday. A dream and the realization that he had unconsciously linked his father with his twin lifted this repression as well as a defensive denial that he had become anaemic due to bleeding from haemorrhoids. Following treatment, Engel celebrated his 59th birthday and two days later passed the anniversary of his father's death without further incident. He concluded his report in 1973 after passing the 10th anniversary of Frank's death. Although Engel's [73] older brother followed the family pattern and died from a heart attack at age 69, Engel lived until a few weeks short of his 86th birthday.
One wonders whether Engel's training analysis followed by many years of self-analysis contributed to his longevity. At a university dinner honouring his twin brother in 1957, someone noted that Frank was declining high cholesterol foods; this led to a discussion of how anyone could ever evaluate the outcome. Frank declared that he had a control in his twin brother; ‘We'll see who gets the coronary first.’ George responded, ‘Yes, indeed, but you forget that I have been analysed, you have not!’ Engel's confidence in analysis as a protective factor is now supported by recent evidence that male psychoanalysts have a mortality rate 48% lower than that of the white male population at large, and significantly lower than the mortality rate for comparison groups of male physicians and male psychiatrists and neurologists [74].
Epilogue
Engel [14, 75] was a strong advocate for crossfertilization between psychoanalysis and other disciplines. While he successfully integrated many psychoanalytic methods and concepts into his work in internal medicine and psychiatry, he also often reminded psychoanalysis that affects and other mental phenomena evolve from the body and that the discipline can be enriched by findings from biological and infant observational research [66, 76, 77]. Engel viewed the human organism as a psychobiological entity that is constantly open to influencing and being influenced by its environment and the people in it. He rejected the term ‘psychosomatic disease’ since it implies a special class of diseases of psychogenic aetiology, and asserted that the basic task of psychosomatic research is to identify psychosocial factors that alter individual susceptibility to any disease [78, 79]. His psychoanalytically informed studies of Monica and of the setting of disease onset, and his formulation of the giving up – given up complex, collectively advanced the field of psychosomatic medicine by opening a new approach to research on how psychosocial variables might dysregulate biological processes and thereby alter susceptibility to disease. Although psychoanalysis no longer occupies a central place within the field of psychosomatic medicine, Engel's research paved the way for studies in developmental biology, which have provided further evidence that attachment relationships function as external biological regulators during early development [17–19, 80]. It remains for other psychoanalytically orientated psychosomatic researchers to evaluate whether the mental representations of relationships might also come to serve as biologic regulators throughout life [80, 81], and whether variations in the quality of these representations contribute to individual differences in the ability to modulate the impact of losses and other stressful environmental events on bodily processes.