Specificity of Peptic Ulcer
to Intense Oral Conflicts
HAL S. STREITFELD, Ph.D.
I N HIS now classical paper on the influence yet appeared in opposition to the theory. A
of psychological factors on gastrointestinal dis- few investigators, in the conduct of their re-
turbances, Alexander advanced the theory search, may implicitly or explicitly make ob-
that psychological factors causing a somatic jections to it. In his review of the many
disturbance are of a specific nature.2 research studies in pursuit of specific conflicts,
Two decades have elapsed since that theory Gildea can cite only Klein and Oberndorf as
was advanced. During this time innumerable having opposed the theory. From what has
studies, using a variety of methods, have been been published to date, it would appear that
carried out on psychosomatic patients with most psychosomatic specialists agree with
the express purpose of ascertaining specific Gildea that the theory has been validated.
psychological factors. Therefore, it would seem Yet a few psychosomatic specialists remain
pertinent to ask what the status of the "theory skeptical. Their feeling that the validity of
of specific emotional conflicts" is at the present the theory is still open to question rests on two
time in the field of psychosomatic research. major objections. The first of these deals with
When the psychosomatic literature of the the findings of the investigations into specific
past two decades is reviewed, one might very conflicts. While some of the conflicts un-
quickly get the impression that this theory is covered appear to be unique to a particular
no longer just a theory but has become an disorder, more frequently they are not. A con-
established fact. Research projects are being flict over hostile and/or dependent impulses,
continually reported in which the theory is for example, is reported with marked regu-
taken for granted and which have as their larity,i. s, 22,«. so j n ract> Ruesch/5 after
objective the unearthing of the specific con- studying the personalities of patients suffering
flict in a variety of diseases. At present, in the from posttraumatic syndromes, chronic dis-
opinion of the author, no systematic paper has ease, duodenal ulcer, and thyroid conditions,
From Topeka State Hospital, Topeka, Kansas. concluded that "the dependent male or female
This paper is based on a Ph.D. dissertation, An patient represents the personality disorder most
Attempt to Validate Specific Psychodynamic Formu-frequently encountered in clinical medicine."
lations in Individuals with Peptic Ulcer, submitted Ruesch's findings would appear to support
in partial fulfillment of the requirements for the a theory of a common basic conflict underlying
Degiee of Doctor of Philosophy, University of
Chicago, 1952. The writer gives his sincere thanks all psychosomatic disorders rather than a
to the many people who made this research possible, theory of specific conflicts. In contrast to these
particularly to Dr. Hedda Bolgar and Dr. Donald two opposing theories is still a third one. Re-
Fiske for their many valuable suggestions and to porting on the psychoanalyses of individual
Dr. Roy Grinker for his permission to use Michael psychosomatic patients, both Mittlemann33
Reese Hospital facilities.
and Oberndorf suggest that multiple causality
Presented at the tenth annual meeting of the
American Psychosomatic Society, April 19, 1953, is typical of all psychosomatic disorders and
Atlantic City, New Jersey. that deep investigation shows some psycho-
Received for publication April 14, 1953. logical influences such as anxiety, guilt, shame,
VOL. XVI, NO. 4, I954
316 ORAL CONFLICTS AND ULCERS
hostile or sexual impulses, and dependence Of all the psychosomatic disorders, probably
to be operative in all these individuals. The peptic ulcer has received the longest and most
results of the many psychosomatic studies in- intensive scrutiny. Until January, 1953, ap-
vestigating the role of psychological factors proximately 45 fairly systematic studies ap-
might easily support either of these latter peared in the literature. Of these, 19 pri-
theories rather than the theory of specific emo- marily used the interviewing method; 13, the
tional conflicts. projective test method; 7, the psychoanalytic
The second objection is a methodological method; and 6, the psychosomatic method
one. Gildea's review of these psychosomatic proper, that is, the coordinated use of psycho-
studies was not concerned with the adequacy logical and of physiological techniques. Be-
of their methodology. Recently, a methodo- cause of the large amount of work done on
logical review of those studies, making use this disease, it may be considered a good start-
of the Rorschach test, has been published. 6 ing point to test the theory of specific conflicts.
Only the first part of this review has appeared Despite the variability in conceptual clarity,
in print, but it provides some indication of the sampling, techniques, and controls, there is an
adequacy of the respective experimental de- astonishing uniformity in the results of studies
signs. The authors mention the wide variabil- on peptic ulcer.* A conflict over intense oral-
ity in selection of cases and controls, and in dependent needs was invariably found. While
the statistical comparison between the two a conflict over oral-aggressive tendencies was
groups. They further note a common error, sometimes coupled with the dependency con-
the failure to ascertain whether the trends flict, it has come in for much less emphasis.
found in a group of cases were significantly In regard to the favored defenses of the ulcer
different from those to be found in individuals patient, uniform agreement no longer exists.
not suffering from the disease under study. Most of the initial work 14 ' "• 24 ' 34 pointed to
This criticism may have been based only on a pattern of self-sufficiency, independence, and
Rorschach studies, but it is also pertinent to over-responsibility—the classical "ulcer type."
those studies where therapy or interviewing Subsequent studies, however, disclosed ulcer
was the technique for eliciting information, patients who were just the opposite—lazy, de-
as even a cursory survey of the literature pendent, and irresponsible.7' 20> 4S The more
shows. Only a handful of psychosomatic recent and more extensive investigations find
studies have used a sufficiently large control these two opposing types, as well as others. 46 '
group of other psychosomatic diseases. In gen- 54, 62
eral, either no control group was used, or the
control group consisted of patients with a non-
psychosomatic, "purely" physical disease. The Method and Materials
latter type of control group may shed some Because the two oral tendencies have been
light on the problem of differences between given different emphasis in the literature, it
psychosomatic disorder and physical illness. It was decided to test them separately rather than
does not, however, provide an answer to the in a pattern. Because of the present lack of
question of the validity of the theory of spe- agreement about favored defenses, it did not
cific conflicts. For this it is necessary to com- prove feasible to set up an experimental design
pare systematically, and in a controlled fash- for the prediction of certain defenses. With
ion, two or more psychosomatic disorders. the criterion being prediction, the hypotheses
Believing that the theory of specific con- to be tested became as follows:
flicts has not as yet been adequately sub-
stantiated, both from the point of view of the * The term, peptic ulcer is intended in this paper
results obtained and of the methods employed, to include gastric, duodenal, and pyloric ulcers. In
the author's knowledge, no investigator has set forth
we have undertaken the present study for separate psychodynamic formulations for these differ-
the purpose of applying a more rigorous test ent types of ulcers. Consequently, the more general
to the theory. term peptic ulcer will be consistently employed.
1. Individuals with peptic ulcer differ from in- veyed by Blum and Hunt 1 0 who have con-
dividuals with non-gastrointestinal psychosomatic cluded that the results so far are encouraging
disorders in having a conflict over intense oral- and suggestive, although they do not definitely
dependent needs. The term oral-dependent here establish the test's validity.
refers to the passive wish to suck or to be fed. Certain minimal standards in the selection
2. Individuals with peptic ulcer differ from of cases were set: 8th grade education or
individuals with non-gastrointestinal psychoso- higher, ages within the range of 20 to 45, ab-
matic disorders in having a conflict over intense
sence of overt psychosis at the time of testing,
oral-aggressive wishes. The term oral-aggressive
here refers to the aggressive wish to bite or and absence of physical trauma causing symp-
devour. toms. An additional sampling criterion of
average or higher intelligence was determined
A crucial assumption underlying the pres- by means of the Wechsler-Bellevue Form I
ent investigation is that oral conflicts can be Vocabulary Test. Information about other
identified with reliability by means of projec- variables, such as class level, psychotherapy ex-
tive tests. Although there is no experimental periences, and psychological sophistication,
evidence to support this belief, clinical experi- which may have altered the character of the
ence would suggest that this is at least a one group more than the other, were obtained
tenable assumption. T h e Rorschach test and from each subject. This was done by means of
the Blacky Pictures were selected as the main a detailed, standardized set of questions on
instruments for testing the hypotheses. Al- personal history, family background, and
though the Rorschach test, as it is traditionally symptom history.
scored, does not give evidence of oral conflicts, The experimental group consisted of 20
a scoring system based on the affective con- cases of peptic ulcer, 12 male and 8 female.*
tent, developed by De Vos has been con- The diagnosis was confirmed in each instance
structed to obtain such data. This scoring by x-ray findings. On the basis of information
system divides Rorschach responses into pleas- in the clinic folder, as well as in the history
ant, unpleasant, and neutral content. Within obtained, 17 of the 20 cases could be char-
the unpleasant dimension are dependency and acterized as having a duodenal ulcer, of sev-
hostility categories, and within these larger eral years' duration, which was active at the
categories are subcategories of oral-dependency time of testing.
The control group consisted of 20 cases of
The Blacky Pictures is a new projective test accepted psychosomatic disorders with symp-
devised by Blum. 0 It consists of n pictures toms outside the gastrointestinal system, so
portraying a dog named Blacky in various chosen as to get a few cases to represent dif-
family situations. The subject is asked to tell ferent organ systems. Each diagnosis was un-
a story about the picture, after which a short equivocal and based on the generally accepted
inquiry in multiple choice form is conducted. medical findings and history for the particular
At the end of the test the subject is asked to disease. The composition of this group is
pick out those pictures he likes best and those shown in Table 1.
he likes least. Although only the first two pic- The "average" subject of these two groups
tures were relevant to the hypotheses, the en- may be characterized as a white, urban, native-
tire set was administered to each subject. The born, married individual without a college
first picture shows Mamma nursing Blacky,
and the second shows Blacky with Mamma's * This ratio does not correspond to the sex dis-
collar clenched between its teeth. For each tribution of duodenal ulcers. The investigator went
out of his way to obtain the rarer female ulcer bearers
picture an over-all dimensional score of ab- so as to be able to test for sex differences. There
sence, strong or very strong, is derived from was no statistically significant difference between
part scores on the story, the inquiry, prefer- ulcers in men and women nor between female and
ences, etc. The completed studies which have male controls. In view of this fact, male and female
cases were combined so as to give the larcer series
incorporated the Blacky test have been sur- of 20 for statistical tests.
VOL. xvi, NO. 4, 1954
318 ORAL C O N F L I C T S A N D ULCERS
education. Although no formal analysis was protocols for these conflicts. Agreement was
made, it would appear that almost all of the between 75 per cent and 90 per cent. The few
40 subjects, as measured by their occupational disagreements in scoring were discussed with
status, came from the lower middle class. As the judge and a final scoring mutually decided
regards cultural background, level of intelli- upon. In addition, the investigator scored the
gence, religion, disturbed home life, excessive stories to the remaining Blacky Pictures, as
use of alcohol, number of siblings, and many well as the nonoral dependency and hostility
other factors, there were no statistically sig- sub-categories on the Rorschach test, for con-
nificant differences between the two groups. flict. In order to establish the statistical sig-
With respect to other factors that might nificance of the findings, the Fisher-Yates Test
conceivably affect test findings, it was found of Significance in 2 X 2. contingency tables
was used. It will hereafter be referred to as
TABLE 1. COMPOSITION OF NON- the contingency analysis.
GASTROINTESTINAL CASES In considering the reliability of the scoring,
Cases testing rapport, and the handling of the data,
the biases of the investigator should be taken
Organ system and diagnosis Men Women
into account. While there may have been
Musculoskeletal some he was not aware of, there was one that
Rheumatoid arthritis 1 2
Respiratory was clearly conscious. Before undertaking this
Bronchial asthma 2 1 study, it was the investigator's belief that a
Metabolic-endocrine multiplicity of conflicts were present in each
Diahetes mellitus 2 2 psychosomatic group of diseases and that no
Circulatory one conflict would be found to be specific to
Essential hypertension 2 1
one disorder. Negative results, consequently,
Skin were expected.
Psoriasis 1 0
Urticaria 0 1
Neurodermatitis 1 1 Results
Eczema 0 1
Atopic dermatitis 0 1 The cell frequencies and significance levels
of the contingency analyses are shown in
10 10 Table 2. As can be seen, the findings bearing
on the oral-dependency hypothesis are not sig-
that the "average" subject was unsophisticated nificant. Neither the over-all dimensional score
about psychological matters and had not re- on the Blacky test nor the Related Comments
ceived any psychotherapy. The two groups score (a wish for Blacky to be fed appearing
were not statistically different in their degree on nonoral cards) reveal any significant dif-
of insight into the connection between emo- ferences between the two groups. In fact, the
tional problems and physical illness; in the Blacky story score, the Rorschach score, and
presence of such neurotic symptoms as pho- the combined Blacky and Rorschach score sug-
bias, compulsions, or obsessions; in attending a gest a very slight trend in favor of a greater
psychiatric or general clinic; or in test pro- oral-dependency conflict in the control group.
ductivity. In contrast to these negative findings, the
After the battery had been administered, results bearing upon the oral-aggression hy-
the Rorschach test and the first two pictures pothesis reveal differences significant at a mod-
of the Blacky test were scored for responses erate level of confidence. The results of the
indicative of conflicts over oral-dependency or Blacky test taken together with the Rorschach
oral-aggression according to the scoring sys- test reveal differences significant at the 2 per
tems of De Vos and Blum. The reliability of cent level. The over-all dimensional score on
the investigator's scoring was checked by hav- the Blacky, however, is not significant. Two
ing an independent judge score the entire 40 of the component scores, however, are sig-
nificant. Related Comments (Blacky biting about half of the control group evidenced a
when frustrated on nonoral pictures) is sig- strong oral-aggression conflict.
nificant at the 6 per cent level and Spon- Table 3 lists all categories tested for sig-
taneous Stories is significant at the 9 per cent nificant differences. Contingency analyses on
level. It should be noted that on every measure the additional data obtained from the Ror-
T A B L E 2. C E L L FREQUENCIES AND SIGNIFICANCE LEVELS OF CONTINGENCY ANALYSES ON ORAL-
DEPENDENCY AND ORAL-ACCRESSION DATA
T* A T
6 14 20 9 11 20
Over-all dimensional score
of Very Strong control 6 14 20 5 15 20 n.s. (0.16)
total 12 28 40 14 26 40
13 7 20 16 4 20
Spontaneous stories control 17 3 20 11 9 20 0.09
total 30 10 40 27 13 40
11 9 20 12 8 20
Inquiry control 13 7 20 10 10 20
total 24 16 22 18 40
3 17 20 12 8 20
Additional comments control 2 18 20 6 14 20 0.06
5 35 40 18 22 40
7 13 20 15 5 20
control 11 9 20 9 11 20 0.05
total 18 22 40 24 16 40
RORSCHACH AND BLACKY COMBINED 11
11 9 20 17 3 20
control 13 7 20 10 10 20 0.02
24 16 40 27 13 40
The number within each cell represents individuals who had the conflict present ( P ) or absent ( A ) . T
stands for total. Presence on the Rorschach was established on the basis of single response indicative of the
conflict. T h e alternative use of percentage of total responses was also tried and this gave identical results.
By this is meant the total number in each group who gave either a response on the Rorschach indica-
tive of an oral conflict or obtained a Very Strong Over-all Dimensional Score on the Blacky.
VOL. XVI, NO. 4, 1954
320 ORAL CONFLICTS AND ULCERS
TABLE 3. SIGNIFICANCE LEVELS OF and 8 on hostility categories, other than oral,
CONTINGENCY ANALYSES ON ALL DATA were not significant, taken separately or as a
total. The contingency analyses on stories to
Oral-dependency" n.s. the 8 remaining Blacky Pictures did not pro-
Oral-aggression n.s. C.I 6—u)& duce significant differences. A trend did ap-
Anal-retentiveness n.s. pear towards a strong anal-aggression conflict
Anal-aggression 0.10 C O in the control group (io per cent level).
Oedipal intensity" n.s.
Masturbation guilt n.s.
A quantitative analysis alone cannot give a
Castration anxiety n.s. full picture of these data. It particularly does
Identification process n.s. not do justice to the strength of the oral-
Sibling rivalry n.s. C.257—u) aggression conflict in the ulcer cases. On the
Guilt feelings n.s. Rorschach test this was revealed by many such
Ego ideal n.s.
Narcissistic love object n.s. vivid responses as:
Anaclitic love object n.s.
1. A panther showing his teeth, snarling.
RonscHACH 2. Two vultures waiting for an animal to die so
Dependency that they can come down and strip the carcass.
Oral-dependency n.s. 3. Two cannibals standing over a boiling pot
Fetal responses n.s. where they're cooking something—maybe
Clinging responses n.s. their brother-in-law.
Childishly toned responses n.s. C 2 5 7 - O 4. Two people pulling something—both grab-
Security responses n.s. bing for the same thing.
Longing responses n.s. 5. Two bats biting on a leg of furniture.
Authority responses n.s.
Passive responses n.s.
Total dependency responses ex-
In contrast to this, only 2 control cases, both
clusive of oral* n.s. male bronchial asthmatics, give such vivid
Oral-aggression 0.05 Cu) There was not as marked a difference in
Depreciation of human figures n.s. C-16-0 the responses of the two groups, to the picture
Direct hostility expressed n.s. of Blacky with Mamma's collar clenched in
Indirect hostility n.s.
Indirect hostility-anxiety n.s. C.I 36—u) his teeth. However, there was 1 ulcer patient
Distorted figures n.s. who hoped that Blacky had not eaten Mamma
Inner tension n.s. and 3 ulcer patients who went out of their
Sado-masochistic responses n.s. 0226—u) way to say that Blacky was not angry. This
Total hostility exclusive of orald n.s.
kind of response did not occur in the control
° In terms of over-all dimensional score of Very group. The oral aggression conflict appeared
Strong. more prominently in the ulcer group in the
The abbreviation n.s. stands for not significant tendency of these patients to have Blacky bite
above the 25 per cent level. The letter after the
significance level refers to the group—ulcer Qa) or when frustrated in a variety of situations.
control CO—which scores the stronger in the cate- Extremely few of the oral-dependent re-
gory. Significance levels between 10 and 25 per cent sponses given by the ulcer group were as vivid
levels are placed in parentheses. These levels are as the oral-aggressive responses which they
furnished merely to indicate the direction of the
gave. Only three ulcer cases gave such re-
The remaining nine Blacky dimensions were sponses as:
scored by the investigator alone.
I n terms of percentage of total responses with a 1. A baby drooling.
cutting point at the mean for the establishment of 2. A bear as when you throw peanuts to him.
highs and lows. 3. Two bears looking at an ice cream cone.
schach test resulted in no statistically sig- Just as many of the control group gave this
nificant differences. The 9 contingency analy- frank kind of response. The surprising fact
ses on dependency categories, other than oral, was that twice as many of the control group
(8 cases) as of the ulcer group gave unpleas- strating that a strong oral-dependent conflict
ant food responses. Responses which might does not differentiate peptic ulcer from other
symbolize dependent needs more indirectly— psychosomatic disorders. Two opposing types
caves, shelters, harbors, inlets, and churches- of tests as well as various aspects within each
were seen just as often by one group as by the test concur with a negative finding.
other. The same held true for responses de- This finding suggests that the importance
noting clinging, a need for security, or a long- of frustrated oral-dependent needs in the eti-
ing for assistance. ology of ulcer formation has been overrated.
The majority of the cases from both groups This is not to say that such wishes do not play
were unwilling or reluctant to describe a part in the general configuration of psychic
Blacky's feelings about being nursed in their conflicts in ulcer individuals. Too many inde-
stories to the picture of Blacky sucking. A fre- pendent studies have corroborated its presence.
quently recurring slip of the tongue in both What has been generally overlooked is that
groups was "Blacky is nursing Mamma." Ref- this very same conflict has turned up in re-
erences to Blacky having an excessive need search on essential hypertension,8 bronchial
for oral gratification were made by a few asthma,38 diabetes,1 etc. Far from being spe-
cases in each group. This was expressed in cific, this conflict, in terms of the frequency
such remarks as, "seems awfully hungry," with which it is mentioned, not only in refer-
"drinks and drinks and drinks," "Blacky would ence to psychosomatic diseases but to many
always be first," and "he gets all his mother's other illnesses, could be considered to be the
milk while Tippy is actually starving to most typical one to be found in our culture.
death." However, only the ulcer group (4 The proponent of the anxiety hypothesis31 for
cases) went out of their way to deny the nurs- the etiology of peptic ulcer has been attacked
ing by saying Mamma was sleeping or merely on the grounds that anxiety is ubiquitous in
resting. emotional disturbance, and, therefore, it can-
No frequency count of the kinds of surface not be a specific agent. In view of our negative
personalities or characteristic defenses of the finding, we would have to face the proponents
total 40 patients was attempted. A brief quali- of the oral-dependency hypothesis with the
tative inspection of the entire data on each of same objections. A conflict over oral-dependent
the cases revealed extreme variability in the needs is much too common to be considered a
character fagades these people presented to specific agent. It may play a minor contribu-
the world. There were, it is true, several tory role in ulcer formation but hardly a
"classical" ulcer personalities—tense, striving, major one.
hard-working, etc. This personality picture by Can a conflict over oral-aggressive wishes,
no means dominated the ulcer group. In fact, then, be considered a specific etiological agent?
no one kind of overt personality stood out. The present study found this conflict to be
There were some who were openly dependent, significantly stronger in ulcer patients than in
some chronically depressed, some hypomanic, other psycbosomatic patients. This difference,
some delinquent, and some emotionally con- however, was not found consistently on all
stricted. However, the paranoid defense was tests, nor was it significant at a very high level
conspicuously absent. There were 3 of the of confidence. Moreover, half of the control
control group who did reveal this defense, in group showed evidence of it. Further, this con-
contrast to none in the ulcer group. flict has been reported as basic in many dis-
ease entities. Such findings prevent us from
attributing too great an importance to it as a
Discussion specific agent. Yet, they suggest that it is more
This study sought to discover whether important and more differentiating than the
strong oral conflicts are specific to peptic ulcer oral-dependency conflict.
within the psychosomatic disease group. The We are in agreement with Kezur and
results are clear and consistent in demon- Kapp27 when they state that not enough em-
VOL. xvi, NO. 4, 1954
322 ORAL CONFLICTS AND ULCERS
phasis has been put on oral-aggression in ulcer with the intensity or frequency that ulcer pa-
cases. Reports on the psychoanalyses of ulcer tients do.
patients21' so'53> 57 also suggest a heavy pre-
ponderance of biting and cannibalism in their Summary
fantasy lives. It is possible that this particular
type of hostile, aggressive wish—to bite rather Alexander's theory of emotional specificity
than to scratch, to kick, to eliminate, etc.—as a served as the theoretical background for the
reaction to the internal or external frustration present study. With the belief that this theory
of dependent needs, plays a key role among has not yet been fully validated, a rigorous
the psychological factors. Only further re- investigation into the specificity of the con-
search can tell. flicts attributed to peptic ulcer was under-
Can a particular defense be important in taken. It was hypothesized that individuals
ulcer formation? Though the main defenses with peptic ulcer could be differentiated from
of our patients were not systematically classi- individuals with non-gastrointestinal psycho-
fied, a qualitative inspection of the data sug- somatic disorders in that the former would
gested wide variability. This lack of uniformity have an intense conflict over oral-dependent
is very likely due to the variety of sources from needs (a passive wish to suck or be fed) or
which the population was obtained. The pa- oral-aggressive wishes (an aggressive desire to
tients used in previous studies of ulcer per- bite or devour).
sonality usually came from the same clinic or To test these hypotheses, an experimental
office. Such populations were not truly repre- group of 20 cases of peptic ulcer and a control
sentative. Our population is not truly repre- group of 20 mixed non-gastrointestinal psycho-
sentative either, for none of our cases was an somatic cases were administered the Rorschach
upper middle class executive. Nevertheless, test and the Blacky Pictures. The Rorschach
we obtained much greater variety than usual test was not scored in the traditional way, but
when we procured patients from a free clinic, according to the Affect Index of De Vos, a
a fee-based-on-income clinic, a psychiatric scoring system based on the content in the
clinic, a private gastroenterologist, and a vet- Rorschach test and containing categories of
erans' hospital. Thus it is not surprising that oral-dependency and oral-aggression.
no one kind of defense system stood out. We A conflict over oral-dependent needs, as
would be inclined, therefore, to agree with measured by the Rorschach and Blacky tests,
Alexander3 that almost any kind of defense did not significantly differentiate the two
may be utilized as a means of coping—success- groups. On the measures for a conflict over
fully or unsuccessfully—with the underlying oral-aggressive wishes, the ulcer group was sig-
conflicts. In view of the evidence accumulating nificantly different from the control group.
from work based on even larger samples,48' 54 This difference was significant at a moderate
the search for specific defenses would appear level of confidence, but approximately half
to be fruitless. the control group scored strong on this con-
In conclusion, we suggest as a reformulation flict. Comparison of the two groups on other
of the psychodynamics of peptic ulcer the hostility or dependency measures in the Ror-
following: peptic ulcer patients do not differ schach test, as well as other types of conflicts
from other psychosomatic cases in being frus- on the Blacky test, did not produce significant
trated in the gratification of their oral-depend- differences.
ent needs. Nor do they differ in the kind of These results suggest the following con-
overt personality they present to the world. clusions:
Where they do differ is in their tendency i. A conflict over strong oral-dependent needs
to react with strong oral-aggressive wishes to is not specific to peptic ulcer in the psychoso-
the frustration of their oral-dependent needs. matic group of diseases.
Other psychosomatic cases may indulge in i. A conflict over oral-aggressive wishes tends
such wishes, but they usually do not do so to be more common, intense, and chronic in pep-
tic ulcer patients than in non-gastrointestinal 9. BLUM, G. A study of the psychoanalytic
psychosomatic patients. theory of psychosexual development. Genet.
Psychol. Monogr. 13:3, 1949.
3. Some psychosomatic cases other than peptic 10. BLUM, G., and HUNT, H. The validity of the
ulcer have conflicts over oral-aggressive wishes Blacky pictures. Psychol. Bull. In press.
that are just as common, intense, and chronic as 11. BLUM, G., and KAUFMAN, JEWEL B. TWO
in ulcer cases. patterns of personality dynamic in male ulcer
patients. Am. J. Orthopsychiat. In press.
This study does not disprove the theory of 12. BROWN, M., et al. Personality factors in men
emotional specificity. The examination of one with peptic ulcer. Psychosom. Med. 12:1,
concrete illustration of a theory is not suffi- 1950.
cient. T h e objection can be made that this 13. CRIDER, R. M., and WALKER, S. M. Physi-
particular conflict in peptic ulcer may be ologic studies on the stomach of a woman with
a gastric fistula. Arch. Surg. 57:1, 1948.
erroneous, while the specific conflicts found 14. DAVIES, D. T., and WILSON, M. Observations
in the other psychosomatic disorders are still on the life history of chronic peptic ulcer.
valid. Therefore, further controlled research Lancet 2:1353, 1937-
into these other specific conflicts is necessary 15. DE VOS, G. A quantitative approach to affec-
before the validity of the theory can be estab- tive symbolism in Rorschach responses. ]. Pro].
Tech. 16:133, 1952.
lished or denied. Replication of the present 16. DRAPER, G. Emotional component of ulcer
study would also be in order. The findings of susceptible constitution. Ann. Int. Med. 16:
this investigation, while they cannot strictly 633, 1942.
prove or disprove the theory of emotional spec- 17. DRAPER, G., and TOURAINE, GRACE. The
ificity, do strongly suggest that the theory man-environment unit and peptic ulcer. Arch.
Int. Med. 49:615, 1932.
should not yet be taken for granted. 18. FINNEY, D. J. The Fisher-Yates test of signifi-
cance in 2 x 2 contingency tables. Biometrika
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California Press, 1948, p. 118. Alexander, who was quoted by Dr. Streitfeld as
the instigator of considerable research on speci- these to quanta in order to run contingency
ficity, had this to say in 1952: analyses, impresses one as highly commendable
from the standpoint of the experimentalist, but
The recognition of these psychological com- of dubious worth from the point of view of the
ponents of illness does not constitute a full dynamically oriented clinician. One misses in
etiological theory of gastrointestinal disturb- such fragmentations the complexity of ego-de-
ances. Similar emotional conflicts involving fenses, the reaction formations, displacements,
receptive urges are found in individuals who substitutions, and other complex manifestations
do not suffer from any disorder of gastroin- of psychic activity. It is as if the dynamically
testinal functions. Still unknown coexisting significant material of the projective techniques
local physiological or anatomical factors must were being treated as answers to a questionnaire.
be assumed to explain pathological develop-
The danger of oversimplified single-variable
ments as a result of this type of emotional con-
analysis cannot be underestimated. In my own
flict situation. In addition, quantitative factors
unpublished study of patients with peptic ulcer
may also play a role in determining the precise
and ulcerative colitis, I found a similar person-
results of such conflict situations.
ality structuring in the two groups when the
The studies cited by Dr. Streitfeld, however, material was considered quantitatively. But the
demonstrate that he has attacked a very real prob- problem of psychosomatic differentiation involves
lem in his thought-provoking paper. I doubt more than statistical balancing and measuring
whether Alexander's principle of specificity, through strict abstraction. One must deal with
which seems to have undergone some qualifica- problems of quantity, which takes us into the
tions, is entirely responsible for the community qualitative field in such a way that greater or
of agreement referred to by Dr. Streitfeld. I lesser amount of a variable is directly related for
would rather choose to believe that ulcer pa- its eventual weighting to other elements in the
tients tend to give certain patterns on psycho- constellation. This is quite evident to any worker
logical tests which recur with more than chance with projective techniques who does more than
frequency. That oral sado-masochistic conflicts count responses. Problems of emphasis must be
occur in disorders other than gastrointestinal considered, strategics come into play, and coping
comes as a surprise to no one who has worked mechanisms must be considered. The patterns
closely with patients on the psychosomatic ward, may be as alike as an original Rembrandt and a
especially when we take into consideration the good copy by a bright art student, but the subtle
quality and dynamics of regression in such pa- and unquantifiable nuances establish the differ-
tients and the complex shifts in psychic homeo- ence between the two.
stasis. Dr. Streitfeld states that "not enough emphasis
To approach the problem from the standpoint has been placed upon oral-aggression in ulcer
of statistical analysis, to select categories of test cases . . . their tendency to react with strong
responses, and then test for significant differ- oral-aggressive wishes to the frustration of their
ences, strikes me as possibly the least promising oral-dependent component." In our own study
of available approaches to problems of psycho- we found that these patients are not passive (ac-
dynamic interaction. Statistical evaluations of the tive M), that their dependency has a strong
Rorschach test, for example, have yielded discon- aggressive quality, and that they are demanding
certingly negative results, while the degree of without being able to give in return. But the type
agreement between dynamically sophisticated in- of aggression and hostility is not basic to the
terpretations of material obtained from projective personality. The personality structure is weak and
techniques and clinical analysis of the patient's dependent, with a passive identification strug-
personality has been sufficiently promising to gling against the active life role they stress. They
encourage continued use of these methods. are, it would seem, oral-aggressive, but not al-
Statistical evaluation overlooks such important ways in the form of "taking" and "demanding."
factors as the pattern of symbolism, allegorical Instead, they can have a strong depression and
projections, and the interaction of unconscious inability to relate in which oral-receptive needs
content material in terms of the stimulus signifi- predominate. Furthermore, they are not destruc-
cance of the Rorschach plates themselves. To tive, acquisitive, and hating types, and even
abstract, even by the De Vos system, certain cate- when such manifestations seem to be present,
gories from the Rorschach test and to reduce they are not integrated into the personality. Ag-
VOL. xvi, NO. 4, 1954
326 ORAL CONFLICTS AND ULCERS
gressive needs are ego-alien and repressed from taking needs, which stamps these patients as un-
consciousness. They are not genuinely hostile, pleasant characters. They do not seem to have the
fear their hostility, and are very sensitive to compensatory drive and ambition of the ulcer
criticism. They are more likely to react with de- patient, and there is not enough social guilt to
pression than with rage and with discomfort and enable them to maintain a mask of social altruism
tenseness than hostility. Their aggression is not and efficiency.
a hostile attitude toward the world, but primarily
an infantile reaction to disappointment. Hence, Finally, while there is still much that we do
the oral-aggressive needs in our study cannot be not know about peptic ulcer and other psycho-
understood except in the context of the underly- somatic diseases, and while we must begin to
ing passive needs, and the oral passivity com- consider specificity as something more intricate
than a static symptom-to-dynamics relationship,
ponent and its vicissitudes cannot be understood
which demands an appreciation of the broad
except as a contextual emergent. We would there-
range of individual differences within any single
fore disagree with Dr. Streitfeld when he states
subgroup, we cannot agree with Dr. Streitfeld
that "a conflict over oral-aggressive wishes tends when he states that "the importance of frustrated
to be more common, intense, and chronic in oral-dependent needs in the etiology of ulcer
peptic ulcer patients than in non-gastrointestinal formation has been . . . over-rated." We should
psychosomatic patients." Here again abstracted like to re-emphasize that it is not the presence or
elements placed in a statistical matrix can prove absence of test-derived categories which is crucial
misleading if one does not make fine qualitative in these cases, but the manner in which they
psychodynamic analyses. form themselves into constellations in the total
With respect to the last conclusion, that cases test battery. The static facts of mental illness
other than peptic ulcer have conflicts over oral- were observed here and there long before Freud,
aggressive wishes, we can only point to another but it required the patient psychodynamically
unpublished study of 16 patients with ulcera- attuned evaluations of data to discover and utilize
tive colitis who show the following characteristics strategic facts. It is my impression that the statis-
based upon a test battery analysis: tical approach in psychosomatic medicine, if used
alone, deals primarily with static facts.
1. Greater general pathology than patients
with peptic ulcer. I would not wish this to be construed as a
2. Great aggression, and hostility which is not carping criticism of Dr. Streitfeld's contribution.
ego-alien and not the result of frustration. We need men of his training and scientific in-
3. Strong anal interests of an anal-erotic type, tegrity and objectivity as members of the psy-
with interest in the evacuation of solid, phallus- chologist-psychiatrist-internist team. Dr. Streitfeld
like feces. Anality is used as a weapon of aggres- can teach us much about experimental design,
sion and represents anal-sadistic reactions to frus- population sampling, and evaluation of data. The
tration at the oral level. Simultaneously, this is physician can share with him his psychodynamic
also a defense against regression to the oral plane. frame of reference and observations which tran-
4. In sharp contrast to the peptic ulcer cases, scends rigorous quantifications. A liaison of the
the oral dependency needs in these patients seem two approaches can bring forth viable concepts
to have been converted into oral grasping and and principles.