Behavior and Unconscious Fantasies of Patients with Rheumatoid

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					         Behavior and Unconscious Fantasies of
          Patients with Rheumatoid Arthritis

T.  H E PRESENT STUDY was designed as
a preliminary investigation into the personal-
                                                    low back pain was utilized. These patients
                                                    were as a group comparable to the rheuma-
ity patterns and unconscious fantasies of pa-       toid arthritic group in age (mean age 31.7
tients with rheumatoid arthritis. Johnson,          years), color, education (10.1 mean years),
Shapiro, and Alexander and French and               and duration of illness. T h e syndrome of low
Shapiro have reported on the personality            back pain was selected as a characteristic of
structure of a few isolated cases of arthritis.     the control group in order to use patients with
However, these cases were restricted to female      symptoms and degree of disability similar to
patients and the speculations advanced were         the arthritic group and yet diagnostically
based on data gathered during psychoanalytic        separate.
therapy sessions. There are also other studies
in the literature which have approached the
arthritic in terms of Rorschach test results.1'
2,3, 4 Yhg s tudy here reported was designed           Each patient was seen for an intensive indi-
to be a general exploratory one utilizing both      vidual interview and projective testing. A
clinical interview material and a variety of        standardized interview was first conducted
projective tests. It was felt that these combined   during which different areas of the personal
data would provide a sound basis for formu-         history were covered in detail. For example,
lating hypotheses regarding the unconscious         early development, relations with parents,
fantasies of arthritic patients.                    work record, sexual experiences, dreams, and
                                                    attitudes toward self were thoroughly ex-
                                                    plored. Next in order and usually at a second
                 Population                         meeting the Rorschach, T A T , and Draw-a-
   The experimental subjects studied consisted      Person tests were administered. T h e T A T
of 25 white, male veterans, in-patients of          was modified to the extent that three spe-
the Houston VA Hospital. All of the patients        cially designed pictures were included. On the
were positively diagnosed as having rheuma-         Draw-a-Person Test, each subject was asked
toid arthritis. They were on a medical ward         to tell a story about the figures drawn. Par-
being treated for the primary symptom of            ticipation in this project was entirely volun-
rheumatoid arthritis. The age range was 20—44       tary on the part of the patients and it was
years (mean age 31.8 years) and the length          made clear to them that personally they would
of hospitalization was restricted to six months     not benefit from this experience.
or less. Their mean educational level was
11.0 years. None of the patients had had any                           Results
drastic type of therapy such as A C T H or
surgery. A control group of 20 patients with        Projective Test Data
                                                      The projective test data was first ap-
  From the Veterans Administration Hospital,        proached in the traditional manner of analysis.
Houston, Texas.                                     Mean Rorschach scores of the two groups
  Received for publication March 30, 1953.          were computed and values for six scores were
VOL. XVI, NO. 4, 1954
328                                                     RHEUMATOID ARTHRITIS
obtained.* None of the following Rorschach          contain much of the pathology usually indica-
scores significantly differentiated between the     tive of a psychotic personality, such as con-
control and experimental groups: number of          taminatory and confabulatory responses, color
responses, movement responses, color or shad-       naming, and extensive poor form level. In
ing responses, and human and animal con-            the present group, 13 of the 25 arthritic pa-
tent responses. It may be here parenthetically      tients seemed this seriously disturbed. Ac-
noted that the low number of responses, low         cordingly, it is suggested that whatever the
M, and low color characterizing the arthritic       nature of arthritis may be as a defense, it is
Rorschachs confirms previous findings in this       frequently a desperate one in the sense of
area.1-2-3> 4 Booth's conclusion8 that arthritics   being a defense against further regression and
tend to give aggressive movement responses          personality disintegration.
was not confirmed.                                     In addition to the chaotic personality struc-
   Since these preliminary attempts to evaluate     ture suggested by the Rorschach records, the
the data in terms of quantified scoring cate-       projective test material also indicates that
gories did not prove fruitful, a descriptive and    certain specific kinds of unconscious fantasies

                               CERTAIN FANTASIES ON PROJECTIVE TESTS

                    Rorschach        Rorschach        Rorschach          TAT             woman
                     hard-soft       container        voyeuristic     voyeuristic       naked or
                     fantasies        fantasies        fantasies       fantasies        seductive
  arthritis           18               17               15               18              17
  (N = 25)

  Low back
  pain                 2                9                2                7               3
  (N = 20)

  X2                  17.36             2.41            14.00             6.12           12.69
  PCdf = l )         >.001            >.12             >.001            >.O2            >.001

impressionistic approach was adopted. Two           characterize these patients. First of all, there
clinical psychologists jointly reviewed each        is in these tests an emphasis on the inconsist-
case, formulating in clinical terms the main        ent nature of things. Thus, on the Rorschach,
dynamic trends. When the formulations for           they give unusual responses referring to ob-
the individuals comprising the two groups had       jects with hard, bony, and shell-like exteriors
been reviewed, it was found that certain            but soft, jelly-like interiors. That is, things
consistent differences existed between the          are perceived as both hard and soft; things
arthritic and low back pain groups.                 have two opposing qualities simultaneously.
   The first important finding in the projec-       Such Rorschach responses as the following
tive test records is that as a group many of        serve as illustrations: "A sea-crab with a hard
the arthritic patients are sick people, psychi-     shell, split open, all soft inside," "A snail been
atrically speaking. This conclusion is drawn        run over and squashed, a rough hard skin,"
largely from the Rorschach records, which           and "A bug with a rubbery skin and jelly-like
                                                    on the inside."
                                                       In Table 1, the number of arthritic and low
  * Arthritic means: R:i5-7; M:i-5; Sum C:2.8;
                                                    back pain patients giving one or more of these
Sum Y:i-4; H%:n-5; A%:49-6. Low Back Pain
means: R:i4-4; M : I . I ; Sum C:2.2; Sum Y:l-4;    responses is reported. Eighteen of the 25
H%: 7 .6; A%: 4 8.5.                                arthritic patients give at least one such re-
                                                                        PSYCHOSOMATIC MEDICINE
CLEVELAND AND FISHER                                                                      329
sponse, while only 2 of the 20 low back pain     sponses referring to "figures with transparent
patients produce hard-soft Rorschach re-         dresses," "a man with something on under his
sponses. This difference exceeds chance          suit/1 and "someone looking through a
expectancy.                                      periscope."
   Parallel with this theme of inconsistency,       The arthritic's TAT stories focus on the
objects with soft interiors and hard exteriors,  clothing worn by the people; whether they are
there was also a tendency for arthritic patients clothed or naked; and how appropriately
to give more Rorschach responses referring to    dressed they appear. Such themes as the
hollow containers. Such objects as "vases,       following are prominent: A person acting on
pitchers, caves, tunnels, and oil well borings"  the stage; a woman undressing and being
are illustrative. Although an inspection of      spied upon by a peeping Tom; and a person
Table 1 reveals that the difference in "con-     looking at clothing in a store window.
tainer" responses between the arthritic and low     The figure drawings especially elicit these
back pain group does not attain statistical      voyeuristic and exhibitionistic fantasies, the
significance, the trend favors the arthritic     male figures are drawn clothed, the women
group. It should also be added that the 17       either unclothed or suggestively clothed. The
 arthritic patients in Table 1 gave a total of 55 female figure is characteristically either win-
 "container" responses, while the 9 low back      dow shopping or in a show window. The
 pain patients with such responses in their       physical attractiveness of thesefiguresassumes
 records gave a total of only 14 "container"     considerable importance and the arthritic
 themes. This finding further supports the        dwells on the beauty of each separate part of
 suggestion that arthritic patients do give       the body. In Table 1, the unusual divergence
 more Rorschach fantasies of a "hollow con-       of the two groups is apparent in regard to
 tainer" nature than do the low back pain         their drawings of the female figure. While
 patients. It is interesting to note that the     17 of 25 arthritic patients draw the woman
 "hollow chamber" type of fantasy was inci-       naked or seductively dressed, only 3 of the
 dentally observed by Booth1 in some of his       low back pain group do so.
 early analyses of arthritic Rorschach records.     In order to test further the objectivity and
 However, he assigned no particular signifi-      validity of this impressionistic approach which
 cance to his observation.                        was used to differentiate the arthritics from
   Another characteristic of the projective the low back pain patients, the following
tests is a prominence in the arthritic patients' procedure was next employed. The projective
fantasies of voyeuristic and exhibitionistic test records (Rorschach, TAT, and Draw-a-
wishes. A large value is placed on the act of Person) of 6 arthritis and also of 6 low back
looking and of being seen. In most cases the pain cases were selected at random from the
exhibitionistic impulse is inhibited and de- original population of subjects. Three clinical
nied. The arthritic makes much of the cloth- psychologists were instructed regarding the
ing and costumes covering the human figures various characteristics which on the basis of
perceived. The female figure is given a high the preceding analysis seemed to be unique to
place in his fantasies as an object of beauty, the arthritics. Each psychologist, working
an object to be seen with direct sexual impli- independently, was asked to select from the
cations, and at the same time a forbidden 12 cases submitted to him the 6 which were
sight. This unusual interest in looking, seeing, arthritic and the 6 which involved low back
and being seen is conveyed in many ways. In pain difficulty. Two of the raters made the
Table 1, an analysis is made of the number differentiation with complete accuracy. The
of patients in each group giving voyeuristic third rater made one error in his evaluations.
and exhibitionistic fantasies on the Rorschach Such results indicate that the projective re-
and TAT tests. In both cases, significantly sponses of the arthritic can be reliably distin-
more arthritic patients give such fantasies. On guished from those of the low back pain
 the Rorschach, this trend is evident in re- patient.
 VOL.   xvi,   NO.   4, 1954
330                                                          RHEUMATOID ARTHRITIS
Interview Data                                           I don't want to stand out, I just want to be
   From an analysis of the data elicited from            average."
the patients during their clinical interviews,              The arthritic reports that preceding his ar-
the following trends are clear: Overtly the              thritic incapacitation he had an intensive
arthritic patient appears to be a calm, com-             interest and participation in sports, athletics,
posed, and optimistic individual who rarely              and hunting and fishing. This participation
if ever expresses or even consciously feels              in sports went far beyond the interest of the
hostility. He boasts of never fighting or get-           average adolescent or young man. The ar-
ting angry. He spontaneously refers to his               thritic patient is likely to be a veteran of
handling of his anger in words such as: "I               varsity sports, Golden Gloves boxing, or semi-
never get upset or mad. You could walk over              professional baseball. His participation in
me from my toes to my head and I wouldn't                fishing or hunting is also unusually strong and
do anything," or "If I get mad I just swallow            he speaks of it in such terms as, "If I had all
it and keep thefireinside." When he does get             the time and money I would spend it playing
irritated, it is most likely to be with a category       golf or go sit by a river bank for six weeks and
of people that he variously describes as "smart          just fish." Table 2 illustrates the statistically

                            Gels mad       Hunting, fishing              Sports             Cooking
                               at            interest and             interest and        interest and
                           "show-offs"          activity                activity            activity
 Rheumatoid arthritis
 (N = 25)
                             22                 21                       19                  15

 Low back pain
                              8                      9                    6                   6
 (N = 20)
 X2                          11.36                   7.49                 9.47                3.94
 PCdf = l )                  >.001              >.O1                     >.O1                >.O5

alecks," "eager beavers," "loud mouth brag-              significant degree of divergence of the two
gers," and "show-offs." In Table 2, a compari-           groups in respect to these activities.
son is made of the number of arthritic and low              Contrasting with this vigorous activity is
back pain patients reporting irritation at these         the arthritic patient's interest and participa-
kinds of people. T h e larger number of ar-              tion in household duties and activities, espe-
thritic patients expressing this kind of                 cially in cooking. While no occupational field
irritation exceeds chance expectancy.                    characterizes these patients, this interest in
   In respect to their own personality, these            household duties, especially in cooking, is
arthritic patients complain of their own social-         common. In Table 2, an analysis is made of
shyness and social inadequacies. They shun               the total number of patients in each group
the limelight and speak of desiring to be                reporting interest and participation in cook-
"just average, not stand out at all." They               ing. As a group, the arthritics report signifi-
complain of an inability to say the right                cantly greater interest than the low back pain
thing at the right time or to speak at all in            patients.
groups and social gatherings. They are con-                 Parents of the arthritic patient are described
stantly concerned about their looks, their               in common terms. Mother is seen as a hard-
clothes, and the impression they are making              working, efficient, "Christian" woman. T h e
on others. "People have to come to me, to meet           latter term implies self-sacrifice to the point
me. I can't go to them. I am shy, I'm always             of martyrdom: "Our home was open to any-
worried about what people will think of me.              one, even strangers; you were always welcome
                                                                              PSYCHOSOMATIC MEDICINE
CLEVELAND AND FISHER                                                                            331
there. Mother would give anyone anything             gestions made as to some of the personality
and go without herself. Anything I ever              needs being filled by these symptoms.
wanted I just asked for it and she gave it to           The image of himself and his body which
me. She treated me just like a baby." Mother         the arthritic unconsciously entertains seems
was an excellent housekeeper, compulsively           to be unique. He literally seems to have a
clean and efficient. Frequently she was an           concept of his body as being a hollow con-
active church worker and active also in social       taining chamber. This chamber he feels to
and community affairs. She was an excellent          be surrounded on the outside by a hard, dense
organizer and a hard worker in the home:             material. The inside of the chamber he per-
"She could do more work than all the kids."          ceives as filled with a soft material which
The arthritic patient characteristically says of     contrasts with the hardness of the outer layer.
mother, "She could get along with everyone;             What does it mean to think of one's body
if you couldn't get along with her there must        in this manner? Our materials suggest that
be something wrong with you." However,               this body image mirrors a mode of defense
mother was also the source of considerable           which the arthritic has adopted to defend
frustration since these patients also readily        himself against unacceptable impulses; more
admit that she was the disciplinarian in the         specifically, hostile impulses. The rheumatoid
home and a strict one at that: "Of course,           arthritic seems to be tremendously fearful of
mother disciplined us; she was the real or-          his own angers and resentments and hostili-
ganizer."                                            ties. He seems to fear that expressing his
   Father is perceived as being inconsistent in      inner anger will have disastrous consequences
his behavior, being strong and weak at the           for himself. Without exception, all of the ar-
same time. He is seen as a hard working, hon-        thritics interviewed indicated that as far back
est person, a friend to everyone, easy going,        as they could remember they had had great
and very good natured. His inconsistency is          difficulty in letting out their anger.
revealed, however, in patients' descriptions            Apparently, at one period in their life, ath-
following these introductory remarks: "He            letic participation and hunting and fishing
was quiet, but watch out! When he got angry          served as satisfactory sublimations for their
he would blow up, wow! He blew up peri-              anger. As they grew older and these outlets
odically." Inconsistency of behavior is also         became no longer available, overt expression
implied in such descriptions as: "Father was         of their anger became a problem. They learned
not strict but his word was law; if he said          to regard getting seriously angry as something
something he meant it." Frequently, father is        embarrassing and unnecessary. When asked
absent from the family, beginning early in           what kinds of people they most disliked, they
the patient's life, although this is not essential   referred particularly to "show-offs" and those
to the arthritic syndrome. Instead, father may       who express anger in an open, explosive way.
be physically present but psychologically ab-        And in the projective responses of the ar-
sent, weakened by chronic illness and disease,       thritics, there is almost a complete repression
                                                     of hostile feeling, even of symbols which in-
or absent from the home periodically because
                                                     directly refer to hostility. One may postulate,
of occupation.                                       then, that the hard, outer shell represents a
                                                     means of preventing the escape of bottled-up
                                                     anger. The soft material within the chamber,
                     Discussion                      which is so often referred to in the Rorschach
   In the following discussion, an attempt will      data, is the fluid, angry impulses seeking out-
be made to tie together the historical material      let. What this means is that the arthritic
reported by the patients with their uncon-           dramatizes in his body schema a conflict that
scious fantasies elicited by projective tests.       he has about expressing anger. For him, the
The relationship of these fantasies to the           outer rigidity of his body represents a way
arthritic symptoms will be described and sug-        of inhibiting something bad within himself.
VOL.   xvi,   NO.   4, 1954
332                                                      RHEUMATOID ARTHRITIS
To conceive of one's body as consisting of two        overt expression of this aspect of their identi-
contrasting layers, so to speak, of hardness and      fication.
softness, or of that which is inhibited and              A second important characteristic of the
that which is fluid, must have some basis in          arthritic's body image, and one partially im-
the past learning experience of the individual.       plicit in that just described, is the tremendous
   In the case of the arthritic, this basis is felt   value placed upon the body as something to
to exist in the very inconsistent relationships       show to people. In his unconscious thinking
he had had with the primary parental figures.         the arthritic seems to reason, "My body is a
Thus, the arthritic seems to be identified            unique and supremely important thing, so
with an inconsistent and shifting father. In          special that people ought to come and look
both the interview and projective data, father        at it and admire it." This feeling pervades all
is pictured as very inconsistent about the            aspects of the data. Thus, in the interview
expression of hostile impulses. Almost without        material, the arthritic dwells almost lovingly
exception, the tendency of father to restrain         upon how healthy his body used to be, how
his anger, but then to let it forth periodically      much time he gave to building up his body,
in an explosive, unpredictable fashion, is pic-       how strong and agile he once was. There is
 tured. The arthritic tried unconsciously to          great value placed upon body activity and
encompass father's example by a division of           movement. Furthermore, in the TAT there
himself into two layers, as it were. In his outer     is a perseverative interest in themes of looking
rigidity, he is attempting the control and            and being looked at. There is an obsessive
 denial of anger which father showed. His             concern with the clothing of the story char-
 inner softness represents the anger which            acters, the amount of clothing, and the parts
 periodically bursts forth from father.               of the body it covers or does not cover. The
    The mother figure also is typically depicted      looking and being looked at theme is perhaps
as a very inconsistent person. On the outside,        revealed most clearly in the figure drawings
she played the role of a completely self-             of the arthritic. Repeatedly one finds draw-
sacrificing person who gave herself entirely          ings in which the male figure is heavily
for her children, a Christian woman, religious        clothed and the female figure is nude. And
and moralistic. But yet there are frequent            the story related about these figures usually
references in the projective material, especially     focuses on some aspect of the woman's nudity.
in the figure drawings, to the fact that covertly     The exhibitionistic impulses are highly un-
mother was very demanding and selfish and             acceptable to the arthritic and he fights to
seductive. Mother was also an agent of frus-           hide them. His desire to exhibit his body is
tration; she was the disciplinarian and organ-         probably another one of the bad impulses
izer of the family. She was simultaneously a           which he seeks to inhibit by means of his
total provider and, at times, an object of hos-        hard outer shell. But actually the arthritic
 tility, and yet no hostility could ever be ex-        symptom, with all of the attention that it
pressed toward her by the child because of her         brings to the body, indirectly supplies much
perfect and self-sacrificing behavior. On the          hidden gratification of the exhibitionistic de-
 inside, she was almost the opposite of what she       sires. One may also speculate that it is the
 appeared to be on the outside. It is easy to see      unique valuation placed upon his body by
 how this type of inconsistency would combine          the arthritic which predisposes him to use
 with and reinforce the father's inconsistency         body symptoms as a way of expressing psychic
 and so lay the basis for the unique body-image        conflict.
 split which has been described.
     Although arthritic patients spend most of        Summary and Conclusions
 their time denying their exhibitionistic identi-
 fication with mother, in some of their behavior   A group of 25 male patients with rheuma-
 one sees such an influence. For example, their toid arthritis and a comparable group of 20
 unusual interest in cooking may represent an patients with low back pain were investigated.
                                                                          PSYCHOSOMATIC MEDICINB
CLEVELAND AND FISHER                                                                             333

Developmental data and social histories were       calm, easy-going person, but one who burst
obtained through clinical interviews. Uncon-       forth irrationally at times. Mother is remem-
scious fantasies and personality dynamics were     bered as an overtly moralistic and self-sacrific-
estimated by use of the Rorschach Test, TAT,       ing person, but on the projective tests she is
and Draw-a-Person Test. Two clinical psy-          also revealed as having been a prohibiting
chologists reviewed the interview and projec-      and seductive figure. The arthritic patient
tive test data and the principal characteristics   attaches unusual significance to his body and
of the two groups were identified. The un-         is unconsciously desirous of exhibiting his
conscious fantasies of the arthritic group were    physique. Overtly he denies his exhibitionistic
so unique that three psychologists were able       desires and in fact complains of his shyness
to differentiate with only one error the projec-   and inadequacy.
tive test records of 6 arthritic patients from
those of 6 patients with low back pain.
   In summary, the following personality de-
scription was found to be unique among the         1. BOOTH, G. C. Material for comparative case
arthritic group: He is likely to be an overtly        study of a chronic arthritic personality: I.
                                                      Psychiatric report. ROTS. Res. Exch. 1:49, 1936.
calm individual who rarely expresses or con-       2. BOOTH, G. C. Personality and chronic arthritis.
sciously feels anger. However, covertly he            ]. New. & Menu Dis. 85:637, 1937.
seems to be containing a large amount of           3. BOOTH, G. C. Organ function and form per-
hostile feelings. Aiding him in his defense           ception: Use of the Rorschach method with cases
against hostile expression is his unique body         of chronic arthritis, Parkinsonism, and arterial
image. As expressed through his Rorschach             hypertension. Psychosom. Med. 8:367, 1946.
                                                   4.   BOOTH, G. C., and KLOPFER, B.      Personality
fantasies, the arthritic thinks of his body as          studies in chronic arthritis. Rors. Res. Exch.
a kind of hollow container filled with uncon-           1:40, 1936.
trolled, fluid material and surrounded by a        5. FRENCH, T. M., and SHAPIRO, L. B.       The use
hard, impenetrable surface. Inconsistent par-           of dream analysis in psychosomatic research.
ents seem to have supplied the original model           Psychosom. Med. 11:110, 1949.
for this body image. Father is described by        6. JOHNSON, A., SHAPIRO, L. B., and ALEXANDER,
these patients as having been inconsistent in           F. Preliminary report on a psychosomatic study
                                                        of rheumatoid arthritis. Psychosom. Med. 9:
his expression of anger, being ordinarily a             295, '947-

VOL. XVI, NO. 4, 1954

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