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Dunbar, F. (1939). Character and Symptom Formation—Some Preliminary Notes with Special Reference to Patients with Hypertensive, Rheumatic and Coronary Disease. Psychoanal Q., 8:18-47.

(1939). Psychoanalytic Quarterly, 8:18-47

Character and Symptom Formation—Some Preliminary Notes with Special Reference to Patients with Hypertensive, Rheumatic and Coronary Disease

Flanders Dunbar


I. On the basis of a study of some 1300 cases (covering five different types of somatic disorder) material has been obtained indicative of differences in the constellation—constitution, focalconflict, character resistances—for each of the groups studied and for subdivisions of the cardiovascular group. This has been illustrated in the present paper with special reference to cardiovascular syndromes.

II. Emphasis has been laid on the third element in this constellation (character defenses) because of its rather general neglect, and the significance of its diverse physiological manifestations.

III. There has been no intention to do more than give a superficial picture with suggestions. All of these however have been checked by psychoanalysis of individuals in each group. We may note that valuable as it is for us to coöperate with our colleagues in other branches of medicine, it is even more valuable to increase our understanding of disease. An important step in this direction is careful observation by psychoanalysts of somatic occurrences in patients that come under observation.

IV. Some suggestive points may be summarized as follows. Most fracture patients, like hypertensive patients, have a focal conflict over submission to authority and marked hostility. One expresses this in action, another in an attempt to inhibit action. The one has a jerky spastic type of tension, the other generalized tension involving both skeletal and smooth musculature. Both the disturbance in muscle tension and the tendency to impulsive action or inhibition of action are relieved by the working through of this conflict, even without complete correction of the personality disorder. It is possible in many cases to interrupt the accident habit or to bring about a return of blood pressume to normal in this way. Patients with

marked syndromes of dyspnoea and palpitation and patients with arthritis show similarities in focal conflict against which they have developed different defenses. They differ in both these respects from hypertensive and fracture patients. Their defenses seem to bear a relationship to their symptomatology. In the two case histories of patients with anginal syndromes, one with and one without organic damage, we see a striking similarity in history and focal conflict, but a difference in constitution and in expression of the conflict. These comments are of course, all tentative and merely suggestive.

V. It must be stated emphatically, as I have done before, that in any general statements made, the intention is not to relate the characteristics set down exclusively to the somatic syndromes in question, that is accidents resulting in fracture, asthma, and various types of cardiovascular disease, but merely to note that they have been found in these patients, as of course also in many others, but in varying degrees of prominence as one of these groups is compared with the other.

A difficulty with general hospital material lies in the fact that many patients go to the general hospital only in time to die. It is obvious that little or no evidence can be obtained from such patients concerning the psychic component in the illness although findings in patients with the same illnesses, hospitalized at an earlier stage, suggest the importance of psychic factors in the others also. Our evidence is to the effect that fewer patients would reach advanced stages of these diseases had we more knowledge of the type just indicated. Such knowledge would greatly increase our efficiency and decrease the time expended in therapy and prevention.

VI. The material given demonstrates once more the fact that treatment should be instituted in the minor illness phase, and that the treatment should be as nearly as possible etiological in both its somatic and its psychic phases, not merely symptomatic or palliative; not merely a matter of either forgetting the patient or keeping him 'under observation' until organic

damage has taken place. It is only in this way that we may hope to cut down the ever increasing bulk of chronic illness and to deal adequately with the illnesses which are now our major causes of morbidity and mortality.

In brief then, although methodology is still undeveloped, it is our impression that much can be learned from the recording of sequences observed through the lens of the best methodology of physiology and clinical medicine on the one hand, and psychoanalysis on the other. On the basis of such material coincidences can be observed which may be either accidental or relevant to our problem. As the number of cases studied increases, and the period of follow-up lengthens, it will be increasingly possible to ascertain which alternative is the case and why.

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