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Conferences

STRESS DISORDERSA CONFERENCE organised by the Society for PsychosomaticResearch was held in London on May 2-4.

Relation of Stress to Three Groups of DisordersESSENTIAL HYPERTENSION

Dr. JOHN HAMBLING (Canterbury) described thecorrelation observed in the labile hypertensive betweenfluctuations of diastolic blood-pressure and discussion ofemotionally charged topics. Suppressed rage and resent-ment were the most potent diastolic pressor factors. Toverbalise or act out these feelings could produce a dramaticfall in pressure. The potential hypertensive usually hadat least one parent who was dominating or driving, andhe tended to see his life situation in terms of dominance-submission, being ultrasensitive to any authoritarianelement.

ITCHING SKIN DISORDERS

Dr. BRIAN RUSSELL outlined the neurophysiology andbiochemistry of normal and pathological itching. It

might ultimately be found that emotionally activated

itching had a biochemical mechanism, but this was stillunknown. Itching sensations were conveyed by thenon-medullated C sensory nerve-fibres and were a formof weak protopathic pain. A stimulus of greater intensityeliminated the itching and replaced it by burning pain,often more tolerable. This itch-burning pain-itchsequence might explain the maintenance by scratching ofsome dermatoses. It was often difficult to establish the

temporal.. link between " stress " and itching skin dis-orders without prolonged observation. Dr. Russell drewattention to the psychological significance of the termsassociated with itching and irritating skin conditions. Inhis experience itching skin disorders were more oftenassociated with aggressive than with libidinous impulses.Pruritus might occur when a person feared to giveexpression to repressed or guilt-laden drives.

GASTROINTESTINAL DISORDERS

Dr. DESMOND O’NEILL prefaced his remarks with thereminder that disease should be considered in terms ofreaction patterns rather than of systems; a new taxonomywas needed, and what Dr. Michael Balint called " thepathology of the whole person " had still to be written.The gastrointestinal system reacted to stress in manydifferent ways. Overeating, leading to obesity, was thereaction of some patients to feelings of depression anddiscontent. Under-eating might alternate with this, or

might progress to anorexia nervosa because of guilt abouteating. Recurrent vomiting in children was another fam-iliar reaction. In his experience duodenal ulcer was astress disorder, gastric ulcer not always so. Another syn-drome he called " abdominal discontent ": the patientfelt " fed-up," and complained of heartburn, flatulence,and discomfort, and had sexual difficulties. Most recur-rent abdominal pain of which the cause was known couldbe related to stress. Diarrhoea, constipation, and ulcer-ative colitis were other disorders of the gut in which therelation to stress was well recognised.

Dr. PHILIP HOPKINS said that, in his general practice,of 259 patients with stress disorder 45 had gastrointestinalsymptoms. These had responded to simple psycho-therapy with improvement, maintained over five years’observation.

Dr. NicoLAS MALLESON said that of 500 universitystudents to whom he had given a questionary 150 hadreported some disorder of the gut. Stress disorderseemed to show itself more commonly in this systemthan in any other. He thought this might be because thehuman stomach, as was suitable to a ground ape, secretedgastric juices all day long. We were built for a casualomnivorous diet, but in modern life we ate like carnivores- alternately gorging and fasting.

Experimental StressSTRESS IN AVIATION

Group-Captain V. H. TOMPKINS (Portsmouth) saidthat the effect of stress on the airman had been the sub-ject of discussion since the earliest days of flying. AsDr. Denis Williams had pointed out, the stresses to whichthe nervous system of the airman had to become adaptedwere threefold: the way of life, the job, and the physicalconditions of the job (speed, radial acceleration, oxygen-ation, cold, &c.). It had been found in practice that inthese physical conditions there was no specific stress fac-tor comparable in its effects to the psychological factorof fear. Fear was considered responsible in 99-6% ofa series of 2200 flying crew who broke down with neuroses.Somatic reactive stress symptoms were usually mild ortransient in airmen, who were highly selected. He had theimpression that men with mild obsessional traits weremore apt to show such symptoms.

EXPERIMENTAL STRESS IN MAN

Dr. D. RussELL DAVIS (Cambridge) discussed the prob-lems encountered by the psychologist attempting to studythis subject. Pavlov’s dogs, posed an insoluble problem,would develop " experimental neurosis "; but the manhad a wider range of solutions, his interest was less easilyengaged, and he readily " withdrew ". Methods usingnon-specific stimuli such as electric shocks or loud noisesyielded little of importance. He had overcome thesedifficulties in some war-time studies, subjecting pilots totests of their newly acquired skills. He paid tribute tothe work of Kurt Lewin and Zeigarnik. Laboratorymethods, however, remained unsatisfactory for the studyof sustained stress: its effects were better observed innatural experiments and by clinical methods.

ANIMAL OBSERVATION

Dr. R. A. HINDE (Cambridge) spoke of some studiesof the behaviour of animals in nature under stress.

Short-term autonomic responses to stress-for example,when two conflicting tendencies were present-mightresult in a compromise form of behaviour or in a

" dis-

placement activity ". Many " displacement activities "were now thought to depend on autonomic response toone or other conflicting tendency. He also discussed thetheories about the population cycles of certain wild ani-mals, and why after a peak period the population may fallrapidly or

" crash ". Some workers had described a syn-drome marked by liver atrophy and hypoglycaemia inanimals that died during the crash period. Selye hadpointed out that this " shock disease " resembled a dis-ease of adaptation. This agreed with the finding of adirect relation between adrenal weight and populationdensity in mice in the laboratory.

PHYSIOLOGY OF STRESS RESPONSES

Dr. W. J. H. BUTTERFIELD presented the results of hisstudies of volunteers receiving oral hydrocortisone and of25 burned patients. Most of the metabolic changes

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caused by burns could be mimicked by hydrocortisone.The size of the metabolic response was roughly propor-tional to the stress, measured by the percentage of thebody burned. The liver’s failure to metabolise adrenalsteroids might play an important role in metabolic changesafter burning. A further effect of this was the develop-ment in some burned patients of diabetes of Cushing-disease type; this might later become insulin-dependent.

Stress and OccupationSTRESS DISORDER IN SOCIETY

Dr. F. M. MARTIN (Edinburgh) said that epidemiologyhad so far contributed little to the study of stress dis-order. This was because the two prerequisites of accur-ate counting and significant analysis of data were so rarelyfulfilled. There was need for the sociological as well asthe clinical approach in gathering and evaluating data.When rapid changes were in progress in a community thesociologist would focus attention on the stresses this

might cause. In more stable societies he would look for

dysfunctions in the organisation of society and the effecton the individual of his quest for culturally sanctionedgoals. There was a danger of circular reasoning. He didnot think the concept of " the stress and strain of West-ern civilisation " very helpful. Hypertension fitted inwith this; but duodenal ulcer was common not only inthe American Negro but in natives of Nigeria and ofSouth India. He thought that the factor of social cohesionmerited attention; this had been shown to be significantin the epidemiology of suicide and schizophrenia. In thisway the social scientist could hope to throw light onstress disorder.

STRESS IN INDUSTRY

Dr. J. J. O’DwYER felt that industry and work condi-tions were often blamed for stress caused by family orsocial maladjustments. The social contacts in industrywere important, and promotion often caused stress

because it made even a charge-hand feel somewhat iso-lated. In managerial staff it might involve the individualand his family being uprooted to move to where thehigher job was. The industrial medical officer and the

general practitioner each knew too little of the other’sview of the worker-patient.

THE UNIVERSITY STUDENT

Dr. MALLESON said that about 70% of the students ofUniversity College, London, consulted the physicians ofthe student health service during their three-year courseof studies. They usually came with some physical symp-tom, mostly as a face-saving excuse for seeing the doctorfor troubles which they themselves attributed to " nerves".The stress affecting the average student fell into two maincategories: adolescence (sex problems, leaving home, self-management,

"

growing-up ", &c.), and studying for adegree. Figures for 1950 and 1951 showed that the moreseverely neurotic student failed his examinations abouttwice as commonly as the average, but the slightly neur-otic had a lower-than-average rate of failure. For the

student, as for civilised man, it might be a choice betweenstress and stagnation.

The Person in his Family SettingTHE FAMILY DOCTOR

Dr. H. N. LEVITT said that, as a general practitioner,he would agree with Dr. Stephen Taylor’s estimate thatat least a third of general-practice cases were psychiatric.The bulk of dyspepsia he himself saw was non-organic.

The family doctor could often see the effects of the pres-sure of family, home, neighbours, work, and community,like concentric rings in a magnetic field, surrounding andinfluencing the patient. Sometimes, to break the circuit,removal of the patient to hospital or nursing-home wasessential.

PERSONALITY DEVELOPMENT

Dr. JOSEPH SANDLER described the case of a marriedwoman, aged 35, treated by psychoanalysis for vaginismusand phobic symptoms. It had become clear in the

analysis that the patient had unconsciously sought a

stressful condition as a means of gratifying masochisticneeds and of averting worse evils.

STRESS IN CHILDHOOD

Dr. JAMES ANTHONY said that in considering stress

disorders in children it was difficult to distinguish cor-relation from causality. In one series of 100 childrenwith bowel-training difficulties there was found to be

strong correlation between the type of training and laterbehaviour. Strictness and insistence on early sphinctercontrol by the mother was found to result in the child’sencopresis or strong aversion to fseces, and undue laxity intraining to be connected with soiling. Sleep disorders werealso associated with stress. The child with eidetic imagerywas more likely to have nightmares, while the child ofhaptic, kinaesthetic make-up reacted by sleep-walking.

Special Articles

THE NEW LIVERPOOL MEDICAL SCHOOL

THE growth of all departments and the creation ofnew ones has meant that the medical school at Liverpool(like many others) has been spread around the precinctsof university and hospital-in a converted house, a

former nurses’ home, and part of the city laboratories.At last many departments--of pathology, bacteriology,medicine, pharmacology, and obstetrics and gynaeco-logy, with the subdepartment of radiodiagnosis-havebeen gathered into a new building in Ashton Street.The department of medicine has well-equipped laboratories

(provided through the generosity of the family of the lateSir Montague Burton) where electroencephalography and

hereditary factors in disease are among the subjects investi-gated. In the department of pharmacology and general thera-peutics the studies include the action of drugs on the nervoussystem, myasthenia gravis, and the thymus. In the departmentof pathology, formerly housed in the Thompson-YatesLaboratories opened by Lord Lister sixty years ago, work is inprogress on endocrine aspects of cancer, and in the depart-ment of obstetrics and gynaecology cancer in women, toxaemia,and sterility are being studied. The work in the departmentof bacteriology includes investigations on the viruses of small-pox and poliomyelitis and on tissue cultures. Each depart-ment is housed on one floor, except that the department ofpathology occupies most of two floors.

Besides these departments the new building containsthree lecture theatres and class laboratories for the 506undergraduate and 177 postgraduate students, as wellas the dean’s offices, a staff common-room, and a com-mittee-room.

Designed by Mr. A. G. Bullen, F.R.I.B.A., the buildinghas a flexible plan, for the floor-space on each storey is un-broken ; rooms of any size can be made by internal partitionsbased on mullions at five-foot intervals along the perimeter.The frame is of reinforced concrete, with prestressed concrete