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Perceptual Defense And Somatization: A Comparison Of The Perceptual Thresholds Of Obese And Peptic Ulcer Patients
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Perceptual Defense And Somatization: A Comparison Of The Perceptual Thresholds Of Obese And Peptic Ulcer Patients
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PERCEPTUAL DEFENSE AND SOMATIZATION:
A COMPARISON OF THE PERCEPTUAL THRESHOLDS
OF OBESE AND PEPTIC ULCER PATIENTS
bY
Channing H1 . Orbach
A D is s e rta tio n Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In P a r tia l F u lfillm e n t of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Psychology)
January 1960
UNIVERSITY O F SOUTHERN CALIFORNIA
GRADUATE SCHOOL.
UNIVERSITY PARK
LOS A N G ELE S 7, C ALIFOR NIA
This dissertation, written by
..................Chaming„H.._. Orbach....................
under the direction of h±&. Dissertation C om -
mittee, and approved by all its members, has
been presented to and accepted by the Graduate
School, in partial fulfillment of requirements
for the degree of
D O C T O R O F P H I L O S O P H Y
.................................
B ate...........J.anuar.y.,..-1 9 -6 .0 .
STATION COMMiTTE:
Chairman
ACKNOW LEDGEM ENTS
I would lik e to express my ap p re c ia tio n to the peo
ple who have helped m e in th is re se a rch . I am g r a te fu l to
a l l the members of my committee fo r th e ir advice and coop
e ra tio n . To Dr. Georgene Seward, I wish to express my
thanks for her help w ith the design of the experiment and
fo r her e d itin g a s s is ta n c e with th e manuscript. Dr. Alfred
Jacobs helped me to c l a r i f y m y th in k in g about methodology
and to sharpen up se v eral points in the m anuscript. Dr.
Mortimer Meyer, of the Veterans A d m in istratio n , and Dr.
Nicholas Rose, formerly of the V eterans A dm inistration,
were of invaluable a s sista n c e with the a d m in istra tiv e de
t a i l s involved in s e ttin g up the rese arch and obtaining
s u b je c ts . Dr. Harold G ied t, of th e Veterans Administra
tio n , and Mr. William D o ssett, of the Psychology Depart
ment, U n iv ersity of Southern C a lifo rn ia , made valuable sug
gestio n s for analyzing th e data. Thanks are due a ls o to
Miss E lizabeth Parr and Mrs. Jean n ette Speck, of the Veter
ans A dm inistration, for th e i r u n tirin g e f f o r t s in schedul
ing and rescheduling appointm ents. F in a lly , I wish to
thank the s ix ty - f iv e su b je c ts for t h e i r p a tien c e, coopera
ti o n and i n t e r e s t .
TABLE O F CONTENTS
Acknowledgements............................................................. . . . .
L ist of Tables ...................................................................................
Chapter
I. T h e o re tic a l Background ...................................................
The Theory of Psychosexual Development
F ix atio n and Regression
The Oral Character
P rim itive Ego Development and the Nature
of I n f a n tile P erceptions
Aggression
Oral Character T ra its
Obesity
Physiology
Psychology
P eptic Ulcer
Physiology
Psychology
Purpose of the Study
I I . P erceptual Defense and Ego Psychology . . . .
Statement of the Problem
Hypotheses
I I I . Method ........................................................................................
Subjects
Experimental Groups
P e p tic u lcer
Obese
Control Group
Apparatus and M aterials
Procedure
Baseline S eries
Blacky Test A dm inistration
Perceptual V igilance Series
Perceptual Defense Series
A dditional Measures
I n t e l l e c t u a l Level
O r a lity Q uestionnaire
Page
i i
v
1
41
46
i i i
iv
Chapter
IV. R esults
Page
60
The I n t e l l e c t u a l Level
The Perceptual Experiment
The Blacky Test
The O r a lity Q uestionnaire
Summary of R esults
V. D i s c u s s i o n ................................................................................ 85
L im itations of the Study
I n te r p r e ta t io n of Findings
Conclusions
VI. S u m m a ry .................................................................................... 100
Method
R esults
Conclusions
References
107
LIST OF TABLES
Table Page
1. I n t e l l e c t u a l Level: D ifferences among Control,
U lcer, and Obese Groups .............................................. 61
2. Baseline and Perceptual V igilance Mean Scores
and V a r i a n c e s ...................................................................... 63
3. Nonparametric A nalysis of Variance of Baseline
and Perceptual V igilance Scores ............................ 66
4. Wilcoxon Matched-Pairs Signed-Ranks Test for
S ignificance of D ifferences between Baseline
and Perceptual V igilance Scores ............................ 68
6. Perceptual Defense: D ifferences among Groups . . 72
6. Blacky Test—Oral Eroticism : Differences among
G r o u p s ............................................................ 76
7. O ra lity Q uestionnaire: Means and Variances of
Oral T ra it S c o r e s ............................................................. 78
8. O ra lity Q uestionnaire: D ifferences among
Groups on Single Measure of O ra lity ................... 82
v
CHAPTER I
T h eo re tica l Background
In re c e n t years th e re has been a g reat deal of
c r o s s - f e r t i l i z a t i o n between psychoanalysis and psychology.
P sychoanalytic t h e o r i s t s have paid in c re a sin g ly more heed
to rese a rc h methodology and experim ental design while
p sy ch o lo g ists have been attem p tin g to su b ject psychodynamic
concepts to la b o ra to ry methods.
Inasmuch as t h i s study w ill make ex ten siv e use of
psychoanalytic term inology, i t w ill be w ell to review those
asp ects of psychoanalytic p e rs o n a lity theory t h a t are most
re le v a n t to the present study.
The Theory of
Psychosexual Development
Cne of the fundamental te n e ts of psychoanalytic
theory is th a t the sexual l i f e of the in d iv id u a l begins a t
b ir th . The no tio n of i n f a n t i l e s e x u a lity has provoked
unfavorably re a c tio n s among c r i t i c s of psychoanalysis both
in p ro fe s s io n a l groups and with the lay p u b lic . Much of
the c r i t i c i s m may be tra c e d to a m isunderstanding of what
Freud (1938) meant by sexual. For Freud, sexual was equiv
a le n t to p le a s u ra b le . An i n s t i n c t is f e l t s u b je c tiv e ly as
a d istu rb in g stim ulus, a goad which brings about a s ta te
of te n sio n , rendering the in d iv id u a l uncom fortable. I t is
a s ta te of "u n p leasu re." I t is the re le a s e of te n sio n by
removal of the stim ulus which is f e l t as p leasu rab le.
Another term for pleasure is g r a t i f i c a t i o n . I t is the
experience of g r a t i f i c a t i o n in r e la tio n to ten sio n s ta te s
over and above those produced by su rv iv al needs which de
fin e s se x u a lity .
The e a r l i e s t m a n ife sta tio n of i n f a n t i l e se x u a lity
and the one th a t is c r u c ia l fo r th is study is the act of
sucking. Levy’ s research on o r a lity is fre q u en tly cited in
support of F reud’s view th a t th ere e x is ts a need to suck
beyond the minimum necessary fo r the a l l e v i a t i o n of hunger
(1928, 193b). Sears (1943) in h is review of the l i t e r a t u r e
on the genesis of erogeneity compiles a d d itio n a l evidence
supporting Levy’s fin d in g s. Blum (1953) points out, how
ever, th a t t h i s evidence n e ith e r supports nor re fu te s the
genesis of the oral drive. I t merely dem onstrates th a t i t
is independent of the hunger drive. Sears (1950, 1957), in
h is own research bearing on the issue of o r a l i t y , r e s ta te s
Freud's form ulation in learning theory language. Sears
points out th a t in infancy the sucking r e f le x is followed
by the primary reward of food. Thus i t becomes a learned
or secondary drive which in c re ase s in stre n g th with prac
t i c e . Again, t h i s does not deny the independence of the
sucking drive from the n u t r i t i o n a l d riv e, but i t does cast
3
doubt on i t s b io lo g ic a l or lib id in o u s b a s is.
Libido theory i s an energy theory. Every in d iv id
u a l, according to the th e o ry , is endowed a t b i r t h w ith a
fix ed q u an tity of i n s t i n c t u a l energy. The t o t a l amount of
energy remains constant throughout l i f e , but the d is t r ib u
tio n undergoes constant change.
Psychoanalytic theory th u s attem pts t o ex p lain
human development in term s of the changes in the d is tr ib u
ti o n of psychic energy or lib id o . According to the theory,
lib id o has a sp e c ia l a f f i n i t y for c e r ta in organs and ori
f ic e s of the body, p a r t i c u l a r l y th o se which are lin e d with
mucuous membranes and which are r i c h in nerve endings. I t
is th e se s e n s itiv e or erogenous zones which are the fo c i
fo r i n s t i n c t u a l behavior.
The psychosexual development of the in d iv id u a l con
s i s t s of se v e ra l overlapping sta g es whose names are those
of the various erogenous zones. Each stage is a sso cia ted
w ith a chronological age range. Moreover, th e age a t which
each zone a t t a i n s primacy can be equated w ith the neuro
muscular m aturation of the organ fo r which th e stage is
named. The i n s t i n c t s a s s o c ia te d w ith each of these stages
are r e f e r r e d to as p a r t i a l i n s t i n c t s , p a r t i a l in the sense
th a t in and of them selves they do not a t t a i n the ultim ate
goal of g e n ita l s e x u a lity . They a re necessary precursors t o
g e n ita l s e x u a lity in the sense t h a t they o f f e r fo re p lea su re
and excitem ent leading to the g e n i t a l sexual a c t i v i t y .
F ix atio n and Regression
No d iscu ssio n of i n f a n t i l e se x u a lity can proceed
without dealing with the r e l a t e d concepts of f ix a tio n and
re g re ssio n . W e have seen t h a t lib id o theory p o stu la te s a
fixed q u a n tity of energy. The necessary im p lica tio n of
t h is p o stu la te is th a t th e more lib id o th e re is in one area
the le s s there can be in o th er are a s. At b ir th a l l lib id o
is concentrated in the buccal c a v ity : the lip s , gums,
tongue, and the mucuous lin in g of the mouth. As th e in fan t
matures lib id o flows to th e anal o r i f i c e , leaving a c e rta in
residue in the buccal c a v ity . S im ilarly fu rth e r develop
ment sees a flow of lib id o to the g e n i t a l i a , leaving a cer
ta in p o rtio n remaining in th e anal mucosa.
F ix a tio n then r e s u l t s from excessive co n cen tratio n
of l i b i d o r e s id in g at any one of the erogenous way s ta tio n s
along th e path t o g e n ita l se x u a lity . Regression occurs
when th e weakened forces re p re s e n tin g the a tte n u a te d lib id o
su ffe r a defeat and are forced to r e t r e a t to one of the pre
g e n ita l stag es. In other words, the stronger the in f a n ti le
f ix a ti o n , the more lik e ly i t is t h a t reg re ssio n w ill occur
when an in d iv id u a l su ffe rs an emotional r e v e r s a l in la te r
l i f e .
What is re sp o n sib le for the p ilin g up of lib id o at
any one p re g e n ita l stage? The a n a ly sts m aintain th a t there
is an optimum degree of g r a t i f i c a t i o n of in s t in c t u a l demands
5
a t any one sta g e . A modicum of f r u s t r a t i o n is a necessary
p a r t of growing up. I f one is e x c e ss iv e ly g r a t i f i e d , one
has no in c en tiv e fo r s t r i v i n g and p ro g re ssin g . Thus one
rem ains ever n o s ta lg ic fo r the ease and comfort of the
e a r l i e r period p a r t i c u l a r l y in the face of the in e v ita b le
re v e rs e s th a t are a p a rt of everyday liv in g . S im ila rly ,
excessive f r u s t r a t i o n a t a given le v e l makes a person f e e l
cheated out of g r a t i f i c a t i o n so t h a t even though h is de
mands may be d riv en underground by th e process of re p re s
s io n , they remain in t h e i r p rim itiv e s ta te in the uncon
scious and continue to in flu en ce h is a t t i t u d e s and behavior
in l a t e r l i f e . F enichel (1945) s t a t e s th a t f ix a ti o n most
commonly occurs when the in d iv id u a l is affo rd e d the oppor
t u n i t y for i n s t i n c t u a l g r a t i f i c a t i o n a t th e same time th a t
he is experiencing some a n x ie ty . The an x ie ty might be
e n t i r e l y u n re la te d to th e i n s t i n c t in q u estio n . Thus the
p a r t i c u l a r i n s t i n c t u a l g r a t i f i c a t i o n becomes a means of
reducing an x ie ty no m atter what i t s o rig in might be.
The O ral C haracter
P rim itiv e Ego Development and the Nature of I n f a n t i l e
P ercep tio n s
The psychoanlaytic fo rm u latio n s r e l a t i n g to prim i
t i v e ego development are q u ite s p e c u la tiv e . Fenichel
(1945) admits th a t they are fo r the most p a rt in fe re n c e s
from data gathered in the course of psychoanalytic t r e a t
ment of reg resse d , adult psychotic p a tie n ts . The follow ing
is a summary of F e n ic h e l1s account of th i s e a rly stage.
The newborn in fa n t is a completely h e lp le ss crea
tu re who is completely dependent on others fo r nourishment
and g r a t i f i c a t i o n . His p r in c ip a l contact with the outside
world is through his mouth. He a lte r n a te s between s ta te s
of consciousness and unconsciousness, of u n re st and w ell
being, between s ta te s of te n sio n and re la x a tio n . In the
e a rly period preceding th e development of ob ject r e l a t i o n
ships th e re is no awareness of insidedness and outsided-
ness, of s e lf vs. other. He is only aware of p rim itive
fe e lin g s of discom fort and p leasu re. Supplies flow in
through his mouth producing r e la x a tio n and an "oceanic
f e e lin g of w ell-b e in g ," but he is not aware th a t the sup
p lie s o rig in ate outside him self. He makes an elem ental
judgment as to whether the su p p lies are good or bad by
swallowing them or s p it tin g them out. Thus t h i s incorpora-
tiv e mode of r e l a t i n g to objects is a p rim itiv e form of per
c e p tio n . The in fa n t is said to comprehend the outside
world by taking i t in. The p rim itiv e ego thus fe e ls omnip
o te n t because the world is in e f f e c t w ith in i t s e l f , having
been incorporated in the form of te n sio n reducing nourish
ment .
The p rim itiv e o b je c tle s s s ta te of w ell-being is
c a lle d one of "primary n a rcissism ." The term narcissism
denotes s e lf love and is d istin g u ish e d from object love in
l i b i d i n a l term s. That i s , lib id o is concentrated in the
s e lf r a th e r than being allowed to flow toward o b je cts. The
n a r c i s s i s t i c i n s t i n c t , which continues to crop up even
a f t e r the development of object r e la tio n s h ip s (secondary
narcissism ) has as i t s aim a re tu rn to the o r ig in a l object
le s s condition by the removal of the o b ject. One often
sees referen ce s in the psychoanalytic l i t e r a t u r e to a
p a t i e n t 1 s ".longing to re tu r n to the womb." The im plication
here is th a t in t h i s almost completely co n tro lle d and pro
te c tiv e environment the s ta te of primary n arcissism is
most clo se ly approximated because the in fa n t is automati
c a lly g r a t i f i e d before i n s t in c t u a l te n sio n s have had a
chance to b u ild up.
In the ea rly in f a n ti le s ta te wherein th e re is no
d i s t i n c t i o n between ego and non-ego, se lf-estee m is d ire c tly
p ro p o rtio n al to the fe e lin g of omnipotence. The closer one
fe e ls to the primary n a r c i s s i s t i c s t a t e , to the fe e lin g of
omnipotence wherein the oceanic f e e lin g is experienced,
the g re a te r is one's self-esteem .
Hunger in i t s e l f is of l i t t l e psychological s ig n if
icance because i t s aim permits no a l t e r a t i o n . I f the or
ganism is not nourished i t w ill d ie . But the theory s ta te s
t h a t food g r a t i f i e s not only the need to survive but i t
a lso g r a t i f i e s both n a r c i s s i s t i c and sexual needs before
those needs become d if f e r e n tia te d . Let us see how th is
follows from the preceding d iscu ssio n .
8
Food, which is supplied by an o b je c t or person, is
the o r ig in a l r e g u la to r of self-esteem . When the in fa n t
in c o rp o ra te s th e ob ject he d estro y s i t by swallowing i t .
By doing so he removes the o b ject and th u s re tu rn s to the
o r ig in a l s ta te of primary n arcissism where object r e l a t i o n
ships no longer e x i s t . This gives r is e to the o r ig in a l
oceanic fe e lin g wherein omnipotence is experienced because
the o b je ct becomes one with him. The world of o b je c ts is
experienced as being w ith in the in fa n t ego. However, sexu
a l needs develop in r e l a t i o n to o b je cts. Sexual needs de
pend on s tim u la tio n of erogenous zones which in the o ra l
stage of development happen to be the mouth. Thus th e oral
sexual aim is s a t i s f i e d by a u to e ro tic stim u la tio n of the
o ra l mucosa which may or may not be accompanied by inges
t i o n of food. The aforem entioned thumb sucking is an i l l u s
t r a t i o n of n o n - n u tritiv e a u to e ro tic stim u la tio n .
There seems to be a paradox involved in g r a tif y in g
these various s e ts of needs. The aim of the n a r c i s s i s t i c
need is in c o rp o ra tio n and th e re fo re d e s tru c tio n of an ob
j e c t . On the other hand, the sexual needs re q u ire o b jects
for t h e i r s a t i s f a c t i o n , even though the o b je ct be o n e's own
body, as in the case of au to e ro tic ism . In order to s a t i s f y
the one need, one must forego th e other, f o r in co rp o ra tio n
a b o lish e s the o b je ct. This is a paradox, however, only so
long as both sexual and n a r c i s s i s t i c needs lean on the
hunger need. However, the in f a n t is subsequently forced by
9
experiencing delay and f r u s t r a t i o n to renounce h is b e l i e f
in h is own omnipotence because he can no longer magically
c o n tro l the o b ject. This is a necessary co n d itio n for the
development of object r e la tio n s h i p s . Now he sees the sig
n if ic a n t ad u lts of h is world as the omnipotent ones. They
become for him the givers or w ithholders of su p p lies. With
the development of the i n f a n t 's perceptual and cognitive
f a c u l t i e s , n a r c i s s i s t i c supplies take on a symbolic charac
t e r in the form of dem onstrations of love and a ff e c tio n on
the part of these more powerful beings. These "tokens" be
come re g u la to rs of self-esteem . Love enhances i t while
disapproval degrades i t .
Sexual needs become d if f e r e n tia te d from n a r c i s s is
t i c needs when ad u lt a u th o rity is in te rn a liz e d in the form
of the superego. When t h i s occurs, se lf-este e m becomes
la rg e ly an in te r n a l a f f a i r between the ego and the super
ego. Behavior which conforms to one's values is "rig h t"
and enhances self-estee m . Behavior which is contrary to
o n e's values is "wrong," producing g u ilt fe e lin g s and low
ered self-esteem . On the other hand, sexual needs continue
to develop in r e l a t i o n to e x te rn a l objects.
Aggression
Mention was made of the f r u s t r a t i o n and delay which
is inherent in the development of object r e la tio n s h i p s .
The nursing mother has the power not only to give supplies
10
but a ls o to w ithhold. In the e a rly months the in fa n t is
completely at the mercy of the mothering person. This is
the stage of o ra l sucking or o ra l p a s s iv ity . Abraham
(1953a) makes a d i s t i n c t i o n between the pream bivalent stage
and a l a t e r ambivalent stage which coincides with the
eru p tio n of te e th . The in fan t now has i t w ithin h is power
to r e t a l i a t e by b itin g the b re ast th a t feeds him. This
stage has been dubbed by Abraham the o ral s a d is tic stage.
Here the in fa n t has h is f i r s t experience with p rim itiv e
aggression, the aim of the i n s t i n c t being to b ite the ob
j e c t . In so fa r as t h i s response e x is ts with the o rig in a l
oral e ro tic ism and as these opposing aims are experienced
in r e l a t i o n to the same o b ject, a s ta te of ambivalence is
said to e x is t toward the object.
As to the o rig in of the aggression, Fenichel and
most of the present day an a ly sts go along with F re u d 's and
Abraham’ s o rig in a l form ulations which describe aggression
as a r e a c tio n phenomenon to f r u s t r a t i o n , whereas Freud
(1939, 1942) in h is l a t e r w ritin g s on the death i n s t in c t
p o stu late d an independent need to destroy. The former
view has been given wide acclaim among psy ch o lo g ists in
the work of D ollard, Doob, M iller & Sears (1939).
Oral Character T ra its
Having discussed lib id o development a t the o ral
stag e, we are now ready to describe some of the ch a ra c te r
11
i s t i c s of in d iv id u als who are said to be fix a te d a t the
o ra l le v e l. Such in d iv id u a ls are thought to have strong
o ral e r o tic and o ra l s a d i s t i c and n a r c i s s i s t i c needs which
in adulthood continue to s tr iv e fo r expression (Abraham,
1953a; F en ich el, 1945; Glover, 1956).
Fenichel (1945) believes i t more c o rre c t to c a ll
the oral stage of l i b i d i n a l development the " i n t e s ti n a l"
stage. This is in keeping with the notion th a t th e f i r s t
experiences the in fa n t has with r e a l i t y are those revolving
around hunger and s a t i a t i o n . While the mouth is the focus
for e r o tic stim u la tio n , the i n t e s t i n a l t r a c t is concerned
with fe e lin g s of w ell-being or se lf-e stee m . I t follows
then th a t the o rally fix a te d in d iv id u a l is dependent on a
steady flow of n a r c i s s i s t i c su p p lies from the outside world
in order to maintain h is self-esteem . For these individu
a l s , sexual needs are not c le a rly d i f f e r e n tia te d from nar
c i s s i s t i c needs inasmuch as such d i f f e r e n t i a t i o n re q u ire s a
sta te of advancement beyond the o ra l stag e. When o ral
c h a racte rs su ffer r e v e r s a ls in t h e i r in te rp e rs o n a l r e la
tio n s which cause them to lose love, they become depressed,
which is another way of saying th a t they su ffe r a loss of
self-esteem . In s t r u c t u r a l term s, the ego su ffe rs a loss
of love from the in te r n a liz e d a u th o rity , the superego. In
order to reg ain the l o s t self-estee m , th ese in d iv id u als
fre q u en tly re s o rt to re g re ssiv e measures which involve both
stim u la tio n of the mouth and s a t i a t i o n of the i n t e s t i n a l
12
tr a c e . Thus e a tin g and drinking become s u b s titu te s fo r the
l o s t love tokens, inasmuch as these a c t i v i t i e s are the pro
to ty p es for such tokens, or symbols.
Oral optimism is said to be r e la te d to o v e rg ra ti
f i c a t i o n in infancy. Provided the environment remains suf
f i c i e n t l y p ro te c tiv e , such in d iv id u a ls have a pervasive
fe e lin g of w ell-being because they co n tin u a lly receive an
adequate flow of the needed n a r c i s s i s t i c su p p lie s. On the
other hand, the o ra l pessim ist is a person who has su ffe re d
severe d e p riv a tio n in infancy. This t r a i t is re la te d to
the l a t e r s a d is tic stage. Such in d iv id u als are aggressive
(freq u e n tly in a passive way) and demanding in th e ir r e l a
tio n s with o th e rs. They f e e l the world owes them a liv in g .
They are often querulous, b i t t e r and s a r c a s ti c . Such in d i
v id u a ls often a tta c h themselves to others lik e leeches,
demanding to be taken care of and given to w ithout thought
of re c ip ro c a tin g .
As is the case with most of th e p re g e n ita l charac
t e r t r a i t s , the mechanism of re a c tio n form ation makes for
bim odality. Thus a t one end of the continuum we might ex
pect t o fin d a c lu s te rin g of in d iv id u als who express t h e i r
passive longings openly, while a t the other end are those
who deny these longings and behave in a manner which would
b e lie them by being ex cessiv ely masculine and independent.
In lik e manner the o ra l s a d is tic in d iv id u al may e ith e r be
extrem ely stin g y because of h is need to take from o th ers
13
and give nothing in re tu rn , l i k e the h e lp le s s in f a n t. On
th e other hand, some in d iv id u a ls deny t h e i r in h e re n t
s tin g in e s s and become overgenerous in order to avoid the
su p ereg o 's d isap p ro v al for t h e i r bad s e l f i s h f e e lin g s .
From the foregoing d is c u s s io n of c h a ra c te r t r a i t s ,
i t can be seen th a t one set involves a c o n tin u a tio n of th e
o r ig in a l i n s t i n c t u a l demands in a form th a t is e i th e r in
i t s o r ig in a l form such as ex cessiv e e a tin g and d rin k in g ,
or only s l i g h t l y a l t e r e d as i s the case with th o se who
suck sym bolically from other people. The other se t of
t r a i t s involves r e a c tio n form ations or c o u n te r-c a th e x e s.
With the former se t of t r a i t s the o r a l i n s t i n c t s are ego
sy n to n ic, which im plies th a t th e ego can t o l e r a t e the ex
p re ssio n of these needs w ithout too much concern about of
fending the superego. With th e l a t t e r t r a i t s , however, the
passive longings are ego d y sto n ic . The ego must d ir e c t a
c o u n te r-fo rc e , expending a d d itio n a l energy in order to keep
th e se longings re p re sse d . This then becomes a c o n f lic t be
tween i n s t i n c t u a l needs which are s t r i v i n g fo r ex p ressio n
and ego needs which s tr iv e f o r approval from th e superego
by placing an ex c essiv ely h ig h value on t r a i t s which are
d i r e c t l y opposed to those which are based on i n s t i n c t u a l
n ee d s.
14
O besity
Physiology
Obesity is u su a lly defined by medical a u t h o r it ie s
as an excess of adipose t i s s u e . An obese condition re
s u lts from an imbalance in the body's economy. In d iv id u als
who become obese e a t in amounts th a t exceed t h e i r energy
requirem ents. This f a c t is common to the various th e o rie s
th a t have been advanced to explain the e tio lo g y of o b esity .
The e s s e n t i a l p o in t here is th a t the only source of f a t is
food. Rynearson & G astineau (1949) and Kaplan 8 , Kaplan
(1957) reviewed the psychological and p h y sio lo g ica l l i t e r a
tu re on ob esity . They c i t e numerous stu d ies th a t show th a t
in order to remain obese a person has to eat more than the
average person.
The c a lo r ic requirem ent is a fu n ctio n of body sur
face a re a . That i s , the la rg e r a person i s , the more
energy he r e q u ire s . Rynearson shows th a t i f an in d iv id u al
consumes more c a lo r ie s than h is body mass r e q u ir e s , he w ill
gain weight u n t i l the increased mass is commensurate with
h is higher le v e l of c a lo ric in tak e, a t which time h is weight
gain w ill le v e l o ff.
Inasmuch as the b asal m etabolic r a te in obese pa
t i e n t s is u su a lly found to be normal, the authors c ite d
conclude th a t o b esity cannot be the r e s u l t of disturbances
in metabolism. F u rth e r, they conclude th a t since obese
lb
people eat to o much, th e e x p lan atio n must l i e in those fac
to r s which le ad to in creased a p p e tit e .
The c e n t r a l nervous system has been e x te n s iv e ly
stu d ie d in connection w ith the e tio lo g y of o b e sity . Such
s tu d ie s have tended to im p lica te c e r ta in areas of the hypo
thalam us and of the c e re b ra l co rte x . Morgan and S t e l l a r
(I9b0) and Rynearson and G astineau (1949) review animal
experiments p o in tin g t o the e x isten c e of an a p p e tite mech
anism in the hypothalamus, d e s tru c tio n of which leads to
voracious e a tin g . In a d d itio n Rynearson and G astineau
(1949) discuss c l in ic a l- p a th o l o g ic a l s tu d ie s of obese hu
mans with tumors of the hypothalamus but conclude th a t such
cases are extrem ely r a r e . Stunkard and Wolff (1958) have
proposed a s a t i e t y mechanism in the hypothalamus. They
hypothesize t h a t the voracious e a tin g behavior noted in
c e r t a i n types of o b esity may be due not to a ravenous appe
t i t e but r a t h e r to a blocking of the n eu ral impulses s ig
n a llin g the in d iv id u a l to stop e a tin g .
Reviewing the evidence for c o r t i c a l le s io n s , Ry
nearson and G astineau (1949) f a i l to fin d e s ta b lis h e d cause
and e f f e c t r e l a t i o n s h i p s . Where the c e re b ra l co rtex does
play a p art, th e authors b e lie v e , is " in the form of
psychic c o n f l i c t s and nervous te n sio n " (p. 25).
Fundamentally, then, th e re g u la tio n of a p p e tite is
an autom atic process which is c a rrie d on by s u b c o rtic a l
mechanisms. Lower anim als, in the absence of a c tu a l damage
16
to th e se c e n te rs , normally ea t as much as t h e i r bodies re
quire and no more. As one goes up the phylogenetic sc a le ,
however, one notes an in creasin g en c ep h a liza tio n of the
fu n c tio n so th a t symbolic processes in the cortex can over
rid e the autom atic process. This then se ts the stage for
a d isc u ssio n of the ro le of psychic c o n f lic t in obesity.
Psychology
In the foregoing se c tio n we have seen th a t the
cause of ob esity is overeating and th a t the cause of over
e a tin g is abnormal a p p e tite . W e have fu rth e r seen th a t ,
w ith the exception of ra re cases of hypothalamic damage,
abnormal a p p e tite seems to be p rim arily a symbolic process
r a th e r than a m etabolic one.
Hilde Bruch (1957) has stu d ied the problem of
o b e sity over a period of approxim ately 25 years. In her
e a rly p e d ia tr ic work she attem pted to fin d an organic
e tio lo g y for o b esity . A fter having stu d ied 200 ch ild re n
and t h e i r fa m ilie s in a m etropolitan c l in ic she was able
to fin d no evidence e ith e r fo r endocrine disturbance or
i n t r a c r a n i a l tumor. What she did fin d to be a common theme
was th a t a l l these ch ild ren a te considerably in excess of
what they re q u ire d . Combined with t h i s was the finding
th a t these c h ild re n almost uniform ly avoided physical exer
tio n .
Her e s s e n ti a ll y negative p h y sio lo g ical findings led
17
her to in v e stig a te the psychological and so c ia l aspects of
obesity. Much of her e a rly work was concerned with the
m other-child r e la tio n s h ip . A ty p ic a l p a tte rn was the
mother who used her ch ild in an e f f o r t to make up for the
disappointm ents, f r u s t r a tio n , and emotional s ta rv a tio n she
was experiencing in her marriage. The feelin g toward the
ch ild was an ambivalent one. On the one hand she regarded
i t as a treasu re d possession. By allowing her child to
supplant her husband as the focus of her i n t e r e s t , she used
the child to punish her husband. At the same time she was
forced to do things for the ch ild th a t she regarded as bur
densome and odious. This in turn led her to fe e l uncon
sciously h o s tile and r e je c tin g toward the ch ild . She c ite s
as evidence the high incidence of self-in d u ced abortion and
the unsuccessful attem pts th a t had been made to abort the
children in the study. The r e s u lta n t p a tte rn was one of
overindulge nee and o ver-protection. Overindulgence con
s is te d of cramming the c h i l d ’s mouth f u l l of food as a
s u b s titu te for the re a l a f fe c tio n th a t she was unable to
fe e l.
In order to p ro tec t the youngsters from harm i t was
necessary for the mother to lim it t h e i r physical a c tiv i ty .
They were not allowed to play with other ch ild ren "who
might play rough." Furthermore, the mothers of th is group
prevented th e ir ch ild ren from s triv in g for and achieving
mastery of th e i r surroundings by w aiting on them, perform-
18
ing the elem entary functions of bathing and dressing fo r
them long a f t e r the average c h ild has learned to perform
these a c t i v i t i e s fo r him self. The passive p a tte rn was a lso
r e f l e c t e d in the p ersisten c e of b o ttle feeding up to age
fiv e in many of th e se c h ild ren .
Another fin d in g of Bruch's was th a t the onset of
the o b esity u su ally followed some emotional trauma: an
operation, an ac cid e n t or i l l n e s s , the b ir th of a s ib lin g ,
or death in the fam ily, Inasmuch as not a l l ch ild ren who
su ffe r em otional trauma become obese, Bruch reasons th a t
food must have an emotional sig n ific a n c e fo r these c h ild re n
in order to have acquired the power to reduce anxiety.
In order fo r food to acquire such emotional s i g n i f
icance, she reasons f u r th e r , i t must be f a c i l i t a t e d by the
in d iv id u al b io lo g ic a l makeup of the ch ild . She has, in her
th inking about ob esity as a b io s o c ia l problem, expressed a
point of view th a t is quite sim ila r to E rik so n 's concept of
"mutual re g u la tio n " (1950J. That i s , she th in k s of the
m other-child r e la tio n s h ip as a re c ip ro c a l process. I t is
not s o le ly a question of the m other's emotional a t t i t u d e s
toward th e ch ild provoking c e rta in responses in the c h ild .
I t is j u s t as lo g ic a l to assume th a t the c h ild , responding
according to h is own b io lo g ic a l c o n s titu tio n , stim u la tes
c e rta in em otional responses in the mother. Thus i t is pos
s ib le fo r ch ild ren to be in n a te ly endowed with excessive
n u t r i t i o n a l needs. Such a c h i l d 's demands might evoke
19
anxiety and g u i l t in the mother because of her physical
i n a b i l i t y to g r a t i f y them. This could well lead to a
vicious cycle of n eu ro tic in te ra c tio n between mother and
ch ild .
Even though no s p e c ific biochemical c o n s titu tio n
has as yet been found in human o b e sity , Bruch believes th a t
t h is is a promising area fo r re se arc h . This in no way min
imizes the psychological problems of obesity. On the con
t r a r y her b io s o c ia l approach to o b esity is in keeping with
her th inking about p e rso n a lity development as a "dynamic
in te ra c tio n between b io lo g ic a l makeup and the moulding
in te rp e rs o n a l and c u ltu ra l in fluences" (p. 409). This is
c o n s is te n t, she b e lie v e s, with F re u d 's e a rly observation
on the subject of i n s t in c t s which he f e l t were u ltim a te ly
rooted in biology.
Whereas Bruch d escrib es a v a rie ty of in te rp e rs o n a l
p a tte rn s in o b e sity , other w rite rs emphasized s p e c ific
problems and c o n f lic t s itu a tio n s . Bychowski (1950) be
lie v e s th a t the overvaluation of food is an a d d ic tio n stem
ming from the e a rly a s s o c ia tio n of eatin g or sucking with
the a l l e v i a t i o n of anxiety and f r u s t r a t i o n . This connec
tio n had also been noted by Abraham (1953b) who compared
the craving fo r food of the compulsive e a te r to th a t of
n a rc o tic a d d ic ts and a lc o h o lic s .
Bychowski (1950) describes what he b eliev es are
the fa n ta s ie s of the compulsive o v erea ter. According to
20
him, the object, mother, has never been s u f fic ie n tly g r a t i
fying in infancy e ith e r because th e re was ac tu al depriva
tio n or because there was excessive demand on the part of
the infant. This evoked a desire to devour the object.
Devouring serves the twofold purpose of possessing the
object forever and expressing anger toward i t . When the
obese person feels g u ilty a fte r having gorged himself, he
is in r e a l i t y feeling g u ilty for having destroyed the love
o b je c t.
Rascovsky, Rascovsky, and Schlossberg (1950) stre s s
the quality of object rela tio n sh ip s in the mothers of obese
children. His po sitio n is similar to that of Bruch in th at
he says th a t the mother prolongs the dependency r e la tio n
ship with the child as a su b stitu te for the mature object
re la tio n s h ip of which she is incapable.
Richardson (1946) mentions impregnation fan tasies
in connection with the ingestion of food. Fenichel (1945)
has pointed to the a lte rn a tio n of periods of bulimia and
anorexia nervosa and re la te d i t to the manic-depressive
cycle. Repressed feminine and c a stra tio n wishes have also
been mentioned as contributing to excessive eating (Alexan
der, 1950).
U ntil recen tly there have been r e la tiv e ly few a t
tempts to v e rify experimentally some of the hypotheses
about the psychogenesis and psychodynamics of obesity.
Bruch (1957) c ite s studies by Danish investigators which
21
purport to show th a t a high proportion of obese children
show signs of emotional abnormality. She also discusses
some of her own work with a battery of t e s t s including the
Rorschach, and Draw-A-Person which show confusion about
id e n tity , d is to rtio n of body image, and marked preoccupa
tio n with and confusion about size. She also s ta te s , on
the basis of s c a tte r analysis of the Stanford-B inet, th a t
the majority of obese children who came to her c lin ic for
treatment showed signs of serious emotional problems.
Bruch's extensive work in the f i e l d of obesity, valuable as
i t is for h e u r is t ic purposes, does not provide evidence for
s p e c if ic ity or symptom choice because there is no informa
tio n provided on equated groups of non-obese children.
Stunkard (1958) compared a group of 15 obese women
with a like number of non-obese controls. A ttitudes toward
physical a c tiv i ty were assessed by means of a sentence
completion t e s t and compared with actual physical a c tiv ity
as measured by a pedometer. Obese women were found to be
s ig n ific a n tly less active than the non-obese controls. The
sentence completion items which rela ted to depression were
found to d if fe re n tia te the two groups. The obese women
gave responses which indicated a surrender to depressive
a f f e c ts such as crying or sulking. On the other hand, the
responses of the non-obese women on the same items in d i
cated an active struggle to overcome depressive feelings
by physical a c tiv i ty , such as engaging in housework. The
22
author concludes th at depression leads to decreased caloric
expenditure and thus may be one of the main e tio lo g ic fac
to rs in obesity. The study f a i l s to include any data,
however, th at would indicate th a t the obese women were more
depressed than the non-obese women a t the time of te s tin g .
Rather the data consist of the reco lle c tio n s of these women
of situ a tio n s wherein they were depressed.
Levy (1956) inv e stig a ted the perceptual defense
behavior of a group of adult obese men comparing them with
a group of alcoholics and a group of normal controls. He
exposed three categories of words ta c h is to s c o p ic a lly : (1)
aggressive or emotionally unpleasant words, (2) re a l words
derived from oral words, and (3) f i c t i t i o u s words derived
from oral words. He found th at (1) obese subjects had sig
n if ic a n tly higher thresholds to f i c t i t i o u s oral words than
e ith e r the control group or the alcoholic group; (2) obese
and alcoholic subjects had a higher proportion of oral pre
recognition responses than the controls; and (3) in a re
c a ll task the obese group was less successful than the con
t r o l s . The r e s u l t s were in terp reted to mean th a t obese and
alcoholic subjects are more oral in th e ir fantasy produc
tio n s than the general population and th a t they show more
perceptual defense than alcoholics because th e ir defenses
operate more successfully than do those of alcoholics. The
r e c a l l task r e s u lt s tended to support the hypothesis that
perceptual defense is re la te d to repression.
Peptic Ulcer
23
Physiology
According to Alexander and French (1948), peptic
ulcer is in i t s e l f neither a conversion symptom nor a vege
ta tiv e neurosis.
In some cases i t is the somatic end r e s u lt of a
long-standing neurotic stomach dysfunction, but in
i t s e l f has nothing whatever d ir e c tly to do with any
emotion. . . . I t is a secondary physiological end
e ffe c t of a long standing dysfunction. It is an or
ganic disturbance which in many cases is the end re s u lt
of a psychogenic functional disturbance, a vegetative
neurosis of the stomach. (Alexander & French, 1948,
p. 9)
What is the nature of th is dysfunction? B riefly
sta te d , peptic ulcer is the end r e s u l t of a chronic state
of hyperm otility and hypersecretion of the d igestive tr a c t.
The parasympathetic system, which prepares the
organism for rela x atio n and p assiv ity , controls such activ
i t i e s as eating, defecation and u rin atio n . In the "stom
ach neurotic" parasympathetic a c tiv i ty has the upper hand.
Under the innervation of the vagus nerve the stomach is
hyperactive and h y p ersecretiv e. M o tility and secretory
a c tiv i ty normally occur in the process of d ig estio n , but
the digestive t r a c t of the individual with a g a s tr i c dis
turbance is constantly and chronically active whether there
is food present or not. In the absence of food in the
digestive t r a c t , hydrochloric acid (digestive ju ic e ) erodes
the stomach wall u n til the ulcer c ra te r forms.
Psychology
Psychosomatic theories in general and ulcer theo
r ie s in p a rtic u la r f a l l into four categories: (l) character
typology th eo rie s, (2) conversion th e o rie s, (3) generalized
s tre s s th e o ries, and (4) s p e c if ic ity th e o rie s.
Typology th e o ries hold th a t c e rta in personality
types are prone to ce rtain psychosomatic disorders. For
example, A lvarez's (1943) ulcer type is the e f f i c i e n t , ac
t i v e , go-getter business man type. Draper, Dupertuis, and
Caughey (1944) describe the male ulcer type both in mor
phological and psychological terms. S tru ctu rally t h e i r
ulcer type tends to be of slender, asthenic physique, some
what feminine in character. Psychologically they found the
presence of masculine p ro te st, in se cu rity based on feelings
of physical in f e r io r ity , extreme conscientiousness, b etter
than average in te llig e n ce , high level of a sp ira tio n and
pronounced emotional responsiveness. Also prevalent was
marked dependence on mother fig u re s, rendering them i l l -
equipped for competitive striv in g . Draper (1944) believes
these personality t r a i t s to be part and parcel of the pa
t i e n t ' s co n stitu tio n .
Dunbar (1943) in her p ro file studies attempted to
co rrelate psychosomatic diseases with personality configu
ra tio n s . Dunbar's ulcer type, for example, is the ambiti
ous, hard-driving businessman sim ilar to the type th a t
Alvarez describes.
25
The term conversion was used by Freud to describe
a process whereby a sexual i n s t in c t , blocked from d irec t
discharge, overflows into some organ controlled by the
voluntary nervous system. The resu ltin g symptom is a type
of body language which symbolizes the c o n flic t. The symp
tom is a compromise solution allowing both for the in h ib i
tio n of the forbidden in s tin c t and for i t s p a r tia l dis
charge. Some analysts have attempted to apply the notion
of conversion to organs under the control of the involun
ta ry nervous system.
The viewpoint expressed by Melitta Sperling (1952)
is i l l u s t r a t i v e of th is attempt to apply libido theory
d ire c tly to the concept of organ neurosis. According to
th i s authority, the diseased organ is one which has become
ero tic iz e d by an excessive amount of libido. I n s tin c ts ,
blocked from d ire c t expression, overflow into the affected
organ.
The psychosomatic patient cannot consciously t o le r
ate his pregenital impulses because of his very strong
urge to s a tis fy them in r e a l i t y ; he therefore denies
them completely, and they are converted into somatic
symptoms, and in th is way g r a tif ie d . (Sperling, 1952,
pp. 287-88)
Garma (1950) also i l l u s t r a t e s conversion reasoning
applied to the involuntary musculature. Using concepts
developed by Melanie Klein he in te rp re ts the focal co n flic t
of the ulcer p atient in oral symbolic form. Thus the pa
t i e n t , feeling g u ilty over his oral aggressive wishes
26
against his mother, punishes himself by in te rn a lly b itin g
and digesting his own stomach.
Mahl (1949, 1950, 1952) repr esents the non-specif
i c i t y or generalized stres s point of view. Combining
learning theory p rinciples of Dollard and Miller (1950)
with re s u lts of animal experiments on hydrochloric acid
secretion, he has concluded th at chronic anxiety, irresp ec
tiv e of source, is cru cial to the development of peptic
ulcer. He believes th a t hyperacidity is the physiological
correlate of chronic anxiety. Thus hyperacidity can gener
a liz e to a v ariety of fear-arousing stim uli.
S p e cific ity theories attempt to link ce rtain phys
io lo g ical events with specific emotional p attern s. There
is a considerable body of l i t e r a t u r e which assigns a cer
ta in role in peptic ulcer genesis to the emotions of re
sentment and h o s t i l i t y . Mittelmann, Wolff and Scharf
(1942) took a group of ulcer p atie n ts and normal subjects
and discussed with them emotionally charged to p ic s. All
of the ulcer subjects and some of the normal subjects
showed increased g a s tric m o tility and a c id ity when the dis
cussions gave r is e to anxiety and anger, whereas the stom
achs of the subjects quieted down with feelings of con
tentment and well-being. Wolf and Wolff (1947) noted simi
la r changes in a subject with a g as tric f i s t u l a . Anger and
resentment were associated with hyperemia, hyperacidity and
hyperm otility. Sadness and fear reversed these e ffe c ts .
27
These findings would seem to contradict the findings of
those who emphasize the role of parasympathetic a c tiv i ty in
the etiology of peptic ulcer, for anger is clearly an emo
tio n which mobilizes the sympathetic branch of the autonom
ic nervous system. The contradiction can be resolved by
recourse to the concept of unconscious emotion. Whereas
the above experiments were working with conscious emotions,
Alexander (1950) and Alexander and French (1948), as w ill
be shown in the next section, emphasize the role of uncon
scious dependency yearnings in the etiology of peptic
u lcer. Thus the anxiety and anger arousing discussions
might also have served to arouse the s u b je c ts 1 basic de
pendency c o n f lic ts , the anxiety and anger being surface
manifestations of the more basic problem.
Szasz, Levin, Kirsner and Palmer (1947) assign a
cen tral role to h o s t i l i t y in the genesis of peptic ulcer.
Szasz makes the observation th a t in infancy there is an as
sociation between feeding and anger. When the hungry in
fant is fru s tra te d he responds with angry crying which con
tinues u n t i l he is fed. The angry crying becomes in effect
an instrumental act leading to feeding. In la te r l i f e ,
the prolonged suppression of anger can rea c tiv a te the con
nection between anger and g a s tric a c tiv ity through a proc
ess which Szasz terms "regressive in n e rv a tio n .1 1
While at the Chicago I n s t i t u t e for Psychoanalysis,
Franz Alexander and his associates were concerned with the
28
study of organic disease, using psychoanalytic methodology.
In contrast to analysts of the "conversion school," Alex
ander makes a sharp d is tin c tio n between conversion neurosis
and vegetative neurosis. According to him, peptic ulcer is
neither conversion nor vegetative neurosis. The vegetative
neurosis is the stomach dysfunction which caused the ulcer.
For Alexander, g a stric h y p eractiv ity and hyperm otility have
no in tr in s ic psychological meaning. They are not symbolic
of an emotion or of a c o n flict as is the case with conver
sion symptoms. Alexander believes th a t the term conversion
should be reserved for dysfunction of those bodily areas
which are under the control of the voluntary nervous system
and which normally produce voluntary behavior. On the
other hand, smooth muscles and organs of secretion, inner
vated as they are by the autonomic or involuntary system,
are those th a t are affected in a vegetative or organ
neurosis. A ctiv ity of the viscera, the blood vessels, the
ductless glands, e t c ., is the normal physiological expres
sion of emotional s ta te s . Rage is accompanied by pupillary
expansion, ca p illary d isten tio n leading to flushing, and
increased secretion of adrenalin. Hunger is accompanied by
g a s tric m o tility and g a s tric secretion. Chronic emotional
sta te s are accompanied by chronic physiological events.
The stomach and duodenum of the peptic ulcer p atien t is
chronically active because he is chronically hungry. This
comes about because of the early connection th a t is estab
29
lished between feeding and oral dependence. Thus Alexander
believes th a t the peptic ulcer person in an o rally fixated
individual who is unable to s a tis f y his oral cravings. The
chronic stomach a c tiv i ty thus is the physiological expres
sion of th i s emotion.
The in v estig a to rs at the Chicago I n s titu t e con
centrated on seven disease e n t i t i e s : duodenal u lc e r, ulcer
ative c o l i t i s , hypertension, a r t h r i t i s , neurodermatitis,
asthma, and thy ro to x ic o sis. The s p e c ific ity hypothesis
advanced by Alexander and French (1948) sta te s th a t for
each sp ecific disease there is a sp ecific c o n flic t pattern.
In the case of duodenal ulcer, the co n flict p a tte rn is as
follows:
I t was observed th at the wish to remain in the
dependent in fa n tile s itu a tio n —to be loved and cared
for—was in co n flic t with the adult ego's pride and
a s p ira tio n for independence, accomplishment and self-
sufficiency. (Alexander & French, 1948, p. 102)
This co n flic t p attern is somewhat independent of any given
personality type although i t may be more prevalent in one
type than another. The point th a t Alexander emphasizes,
though, is th a t i t is the c o n flic t th a t is s p e c ific , not
the personality type.
The primary ego defense of the ulcer individual is
reac tio n formation. He overcompensates for his unaccept
able, repressed oral longings by being overly ambitious and
aggressive. Scorning as he does any dependency g r a tif ic a
tio n he attempts to demonstrate his independence by carry
30
ing a heavy load of re s p o n s ib ility , allowing others to de
pend on him, but th is only exacerbates his own dependent
longings. The more burdensome the load of r e s p o n s ib ility
he c a rrie s, the more he longs for the safety and se cu rity
of the small child. I t is only when he becomes physically
i l l th a t his ego can allow him to be helped and nurtured.
Alexander points out th a t the mere f a c t of h o s p ita liz a tio n
often allows for spontaneous remission of symptoms aside
from the treatment regimen.
There is also another ulcer p attern noted by
Alexander (1947). Here the co n flict is not so much with
ego demands as i t is with an ungiving human environment.
These individuals are openly dependent, demanding, and
chronically d is s a tis f ie d . The cru cial fact for Alexander
is th a t of fru s tra te d dependency whether the f r u s t r a tio n
be in te rn a l or external.
When these desires cannot find g r a tif ic a ti o n in
human re la tio n s h ip s , a chronic emotional stimulus is
created which has a specific e ffe c t upon the func
tio n s of the stomach. (Alexander, 1947, p. 103)
Renneker (1956) states the current thinking of the
Chicago group on the concept of s p e c ific ity . The sp ecific
ity hypothesis now includes three elements: ( l ) the X
facto r, (2) the cru cia l co n flic t s itu a tio n , and (3) the
pre-onset li f e s itu a tio n , the p rec ip ita tin g event which
re a c tiv a te s the c o n flic t.
The X factor is nothing other than the aforemen-
31
tioned notion of somatic compliance or organic su scep tib il
ity which is e ith e r hered itary , or due to emphasis in in
fancy on a sp e cific area or to an illn e s s of the sp ecific
organ. According to Renneker, a l l three of these elements
must be present in order to produce the psycho-physiologi
cal decompensation that peptic ulcer represents. An indi
vidual, for example, who is somatically predisposed to
peptic ulcer and who is co n flicted over dependency needs
may never have an ulcer because he may have been able to
achieve some sort of equilibrium, however shaky. Thus, a
miJn may be an aggressive, ambitious individual who scorns
help, but he may in Renneker1s words have learned ce rtain
devices which enable him to "sneak in a c e rta in amount of
t h i s taking in," such as allowing a mothering wife to nurse
him when he has a headache. One might question whether the
headache might not be psychogenic, in which case i t would
appear th a t the individual in question is merely staving
off one symptom with another. Be th a t as i t may, i f the
p o te n tia l ulcer p a t ie n t 's wife were to die or leave him,
th a t event might be s u ffic ie n t to upset the equilibrium by
denying him t h i s outlet for his dependency needs.
S t i l l another approach to the problem of peptic
u lc er, which cuts across many of the theories thus fa r dis
cussed but emphasizes c u ltu ra l determinants is th at of
Ruesch, H arris, Christiansen, Loeb, Dewees and Jacobson
(1948). Ruesch was in te re ste d in the stre s se s imposed by
32
a c cu ltu ra tio n and upward social mobility and th e ir interac
tio n with the individual character stru ctu re. He was es
pec ially in te re ste d in the environmental events th a t pre
c ip ita te d the illn e s s .
In order to study these fa cto rs, he selected 42
Navy ulcer patients and compared them with a group of 20
c i v ilia n ulcer p a tien ts. He reasoned th at the tr a n s i tio n
from c iv ilia n l i f e to m ilitary lif e involved an accultura
tio n process. Since only a minority of Navy personnel
develop peptic u lcers, he hoped to find sp ecific character-
ological factors which may have predisposed these individu
als to break down.
One of the c h a ra c te ris tic features he noted was a
disturbance of the normal pattern of id e n tific a tio n s and
object re la tio n s h ip s . In the fam ilies of ulcer p a tie n ts,
one parent frequently was both id e n tif ic a tio n model and
source of dependency g r a tif ic a tio n . These problems were
fu rth e r complicated by iso la tio n age-wise and riv a lry with
sib lin g s. The close in fa n tile attachments engendered by
these d isto rte d developmental patterns p ersisted into adult
l i f e . The p atients were deprived of the opportunity to
learn active and r e a l i s t i c coping techniques. Rather,
t h e ir reactions to others outside the family circ le re
mained on a primitive level taking the form eith er of pas
sive submission or over-competitive striv in g . These two
rea c tio n p atterns seemed to correspond with Alexander’s
33
passive and re a c tiv e c a te g o rie s, one group remaining
overtly dependent while the other developed counteractive
d efen ses.
The t o t a l group, c i v i l i a n and m il ita r y , was pre
dominantly lower middle c la s s . Ruesch discovered a high
incidence of upward m obility s t r i v i n g . The "clim bers,"
those who managed to climb the so c ia l p re s tig e ladder, were
handicapped by t h e i r penchant fo r s o c ia l conformity. The
" s t r a i n e r s , " those who were unable to achieve r e a l i s t i c
upward m obility, attempted to compensate in fantasy by
form ulating u n r e a l i s t i c goals fo r themselves. Paradoxical
ly, e i t h e r success or f a i l u r e could lead to breakdown.
Failure produced f r u s t r a t i o n of ambition, while success
produced f r u s t r a t i o n of dependency needs because dependency
g r a t i f i c a t i o n was now no longer a v a ila b le .
R.uesch concludes:
The essence of the psychological d i f f i c u l t i e s in
u lc e r p a tie n ts thus can be traced t o a poor prep aratio n
in terms of s o c ia l techniques. S o cial contact, th e re
fo re , was the source of p erpetual f r u s t r a t i o n which
became exaggerated when a change of environment oc
curred. G jlture change from c i v i l i a n to Navy, from
lower to middle c la s s , or from European to American
brought out t h i s defect in p a r t i c u l a r . A ccu ltu ratio n
re q u ired adaptive behavior in a f i e l d in which these
p a t ie n t s were poorly equipped. The coincidence of
s i t u a ti o n s re q u irin g a c c u ltu ra tio n in connection with
the s p e c if ic i n a b i l i t y of these p a tie n ts seemed to
p r e c i p ita t e the breakdown. (Ruesch e t a l . , 1948, p.
1 1 0 )
In co n trast to the work on obesity, there have been
a number of studies which have attempted to v e rify one or
34
more of the hypotheses about peptic ulcer etiology. A
series of studies at the University of Southern California
(Friedman, 1949; Goodwin, 1949; Prince, 1949; Stone, 1950)
compared the t o t a l p erso n ality makeup of peptic ulcer pa
tie n ts with th a t of bronchial asthma patien ts. The evi
dence from these studies tends to support the Alexander
formulation of a dependency-independency conflict in peptic
ulcer. However, the evidence is in s u ffic ie n t th at th i s
co n flic t is crucial for peptic ulcer (Friedman, 1949).
Negative evidence for s p e c ific ity comes from Prince's study
(1949). Prince found both asthma and ulcer p atien ts to be
predominantly oral in level of psychosexual development.
He also found both groups to be overly ambitious.
Studies which have used performance measures to
measure dependency and ambition have tended to support the
s p e c if ic ity hypothesis. Gordon (1953) found th a t both
neurotic p atien ts and ulcer patients depended excessively
on ex tern al cues on the Rod and Frame te s t . However, there
was a difference between the verbal reports of the two
groups regarding t h e ir dependency behavior. Whereas the
neurotic p atien ts acknowledged th e ir dependency on a behav
io ra l check l i s t , the ulcer p atien ts described themselves
as being independent. Both groups were described as de
pendent on the same check l i s t by th e i r physicians.
Keller (1955), using a level of asp ira tio n perform
ance measure, found th a t ulcer p a tien ts showed s ig n ific a n t
35
ly higher a s p ira tio n than eith e r a non-ulcer psychosomatic
group or a non-psychosomatic group. He interpreted t h i s
finding to mean th a t ulcer p atien ts were u n r e a l is ti c a l ly
ambitious. On the other hand, an a s p ira tio n inventory used
in the same study failed to d iffe re n tia te the three groups.
Hecht (1952), using the Purdue Pegboard as a level
of as p ira tio n t e s t , found th at ulcer p atients tended to
maintain a high level of a s p ira tio n in r e la tio n to achieve
ment in contrast to u lcerative c o l i t i s p atien ts who tended
to underestimate th e ir performance.
There is evidence which tends to v e rify Alexander's
c l in ic a l impressions and Ruesch's empirical findings of two
d iffe re n t types of ulcer cases. Stone (1950), Friedman
(1949), Blum and Kaufman (1952), and Marquis, Sinnet and
Winter (1952), using b a tte rie s of psychological t e s t s a l l
have found ulcer patients to d iffe r in th e ir manner of
handling the dependency c o n flic t, one group giving in to
th e ir dependency, the other using counteractive defenses.
An in te re stin g and promising line of investigation
is the work of Mirsky, Futterman and Kaplan (1952) and
Weiner, Thaler, Reiser and Mirsky (1957). These investiga
to rs are attempting to link up physiological variables with
psychological ones. S p ecifically they note re latio n sh ip s
between oral needs as measured by psychological te s ts and
concentration of serum pepsinogen. In the Weiner study,
relevant physiological and psychological data were c o lle c t
36
ed p rio r to the development of u lc e rs in the su b je c ts.
Blood samples were c o lle c te d from d ra fte e s a t an armed
fo rc es induction center. Men with extremely high and ex
trem ely low concentrations of pepsinogen were s e le c te d for
th e study. The subjects were given p s y c h ia tric and so c ia l
work in te rv ie w s , complete X-ray examinations of the G .I.
t r a c t , and a b a tte ry of psychological t e s t s and then sent
to 16 weeks of basic tr a in i n g . At the end of t h i s period,
they were again examined for evidence of peptic u lc er.
Nine su b je cts out of the t o t a l of 63 developed an u lcer.
A ll of the u lc e r cases had high pepsinogen counts, eight
being in the top 5 per cent. A b lin d an aly sis of the psy
chological t e s t s c o r r e c tly c l a s s i f i e d 85 per cent of the
cases according to the ph y sio lo g ical measure (high versus
low pepsinogen). P a tie n ts with p ep tic ulcer were found to
have major unresolved c o n f lic ts about dependency and oral
g r a t i f i c a t i o n . Mirsky e t a l. (1952) believe t h a t the in
nate se creto ry a c t i v i t y of the stomach, indicated by the
co n c en tratio n of pepsinogen in the blood, determines the
stre n g th of the i n f a n t ’s o ral drive. Such an in fa n t might
come to perceive of h is mother as r e je c tin g simply because
she is p h y sically unable to g r a t i f y his excessive oral
d riv e. This is a possible v a ria n t of the m other-child
r e la tio n s h i p which was posed by Bruch (1957) in connection
with obesity.
The findings c ite d above are co n sisten t with the
37
work of Stunkard and Wolff (1958) on obesity. These inves
t i g a t o r s a ls o see the p o s s i b i l i t y of discovering a physio
lo g ic a l r e f e r e n t for the psychoanalytic theory of in
s t i n c t s . They note th a t whereas Freud described in s t i n c t s
from the point of view of source, aim, and ob ject, most
in v e s tig a tio n s have d e a lt with the l a t t e r two while the
former has been neglected. They see in t h e i r h u n g e r-sa ti-
ety mechanism the p o s s i b i l i t y of c la s s ify in g drives accord
ing to source and thus providing a more rigorous d e f in it io n
of i n s t i n c t s .
Purpose of the Study
Much of the t h e o r e t i c a l d isc u ssio n and research in
these two psychosomatic d iso rd ers has been concerned with
the problem of s p e c i f i c i t y . Some stu d ies have been con
cerned with t o t a l p e rs o n a lity p a tte rn s , others with the
s p e c i f i c i t y of the fo cal c o n f lic t. Kaplan (1956) and Kaplai
and Kaplan (1957) in t h e i r reviews of the l i t e r a t u r e on
pep tic ulcer and obesity, fin d the evidence for s p e c i f i c i t y
to be wanting.
Methodological weaknesses such as f a i l u r e to in
clude equated non-ulcer or non-obese groups have c o n trib
uted to the ambiguity. The more c a re fu lly co n tro lled
s tu d ie s , on the other hand, have not unequivocally demon
s t r a t e d s p e c i f i c i t y .
Peptic ulcer and o besity were se le c ted for compari
38
son in th is inv e stig a tio n because they both a f f e c t the same
organ system, the digestive t r a c t , and because they seem to
have s im ila r it ie s in th e ir etiology. Within a psychoanal
y tic frame of reference, both of these conditions are
thought to have a strong element of oral fix atio n . In both
conditions there is an intimate re la tio n sh ip between Lhe
emotional statu s of the individual and his digestive t r a c t .
That i s , the early link between food on the one hand and
n a r c i s s i s t i c supplies, love, a ffe c tio n , being cared for,
dependency, oral eroticism , or whatever one chooses to c a ll
th i s emotional s ta te , p e rs is ts in the adult l i f e of the
individual. Thus stim uli th a t arouse th is co n stellatio n of
needs also stimulate parasympathetic g a s tric a c tiv ity .
Both groups are chronically f ru s tra te d in th e i r quest for
love and affe ctio n . However, they re ac t d iffe re n tly to the
f ru s tra tio n . The obese individual g r a t i f i e s to some ex
te n t his craving for love by re lie v in g a tension which for
him is f e l t subjectively as hunger. He does th i s by s tu ff
ing himself with food and putting an end at le a s t temporar
ily to the g a s tric a c tiv i ty . The peptic ulcer individual,
on the other hand, has no such o u tle t. He is in a constant
s ta te of tension because his digestive t r a c t is constantly
active and constantly behaving as if i t needed food. In
stead of feeding on external "supplies," he l i t e r a l l y di
gests a part of himself.
Both of these conditions have somewhat the charac
39
t e r of a vegetative or organ neurosis. That is, psycholog
ic a l stimuli provoke parasympathetic a c tiv ity which in and
of i t s e l f , has no psychological meaning. However, the
obese individual acts out. That is , he makes an attempt to
resolve his conflict by action not oriented to r e a l i t y but
ra th e r designed to relieve an unconscious tension. In th is
respect, he f i t s Alexander’s (1948) description of the
neurotic character, an individual whose e n tire lif e pattern
consists of tran sferrin g his in tern a l conflicts to the ex
te rn a l environment. These individuals, as was suggested
e a r l i e r , are closely a l lie d to addicts. Fenichel (1945,
pp. 375-376) describes addicts as having "the need to get
something th a t is not merely sexual sa tisfa c tio n but also
security and assurance or se lf-asse rtio n , and as such es
s e n tia l to the person's very existence." He states f a
th e r :
Addicts are persons who have a disposition to react
to the effec ts of alcohol, morphine, or other drugs in
'a specific way, namely, in such a way th at they tr y to
use these effects to sa tisfy the archaic oral longings
which is sexual longing, a need for security, and a
need for the maintenance of se lf esteem simultaneously.
Thus the origin and nature of the addiction are not de
termined by the chemical e ffec t of the drug but by the
psychological structure of the patient. (Fenichel,
1945, p. 376)
One has merely to substitute the "food" for "drug" to see
the application to the problem of obesity. In short, then,
the obese person is one who, unable to to le ra te internal
tension, impulsively runs to the re frig e ra to r to relieve
h is tension.
The peptic ulcer individual, on the other hand, can
best be described as a character neurotic rather than a
neurotic character. He is a man who liv e s constantly with
tension, who is able to achieve a shaky equilibrium by
character defense or re a c tio n formation. Decompensation
leads not to phobias, obsessions and anxiety as in the case
of the psychoneurotic , but r a th e r to physiological dysfunc
t io n and eventually s tr u c tu ra l damage.
The passive demanding ulcer individual has also to
live with ten sio n . For him, c o n flic t is ex tern alized as
in the case of the obese p a tie n t, but unlike the obese per
son, he does not discharge the tension by acting out. His
decompensation is instead like th a t of the re ac tiv e type.
The present in v e s tig a tio n is concerned with a d if
fe re n t type of s p e c if ic i ty than has so fa r been considered.
I t does not ask the question, "Is the obese p a tie n t or ul
cer p atien t more oral than the asthmatic or the hyperten
sive?" I t does ask the question, "Do these two disorders
of the d ig estiv e t r a c t represent oral fixation? I f they
do, is there a difference in the way obese p a tie n ts and the
two types of ulcer p a tie n ts cope with t h e i r o rality ?" In
other words, i t is the choice of d ig estiv e tr a c t symptom in
p a tie n ts wherein f r u s t r a te d o ral longings are thought to
play a major role th a t is the concern of t h i s study.
CHAPTER I I
Perceptual Defense and Ego Psychology
Modern p ro jectiv e t e s t theory is based on the as
sumption th a t individuals d is t o r t t h e ir responses to stimu
l i in accordance with t h e i r own needs, wishes, and fears.
These d is to rtio n s occur d aily in the business of living
with and in te ra c tin g with other people. Generally speaking,
the more ambiguous the stimulus, the g reater the chance for
d is to rtio n .
The perceptual defense method is a variant of the
p ro je c tiv e t e s t . In th is type of research the stim u li,
consisting usually of words, are rendered ambiguous by
ta c h isto sc o p ic p resen tatio n . In the ty p ic a l experiment, a
word is flashed on a screen at a fra c tio n of a second, and
the subject is asked to id e n tify the word. The ambiguity
of the stimulus can be co n tro lled by the speed of exposure
and/or by the in te n s ity of lig h t.
The term perceptual defense was coined by Postman,
Bruner, and McGinnies (1948) when they found differences in
reco g n itio n thresholds for ta c h is to s c o p ic a lly exposed words
representing d if fe re n t value areas on the Allport-Vernon
Study of Values. The higher the value, the lower was the
re co g n itio n th resh o ld . Thus perceptual defense came to
41
42
have the meaning of the converse, t h a t is, a r e la tiv e l y
high recognition threshold to c e rta in words which had low
value to the subject.
The next step in the development of th is technique
was an attempt to take account of the role of anxiety and
to r e la te perceptual defense to the concept of ego defense.
MiGinnies (1949) developed the so-called " d irty word tech
nique," on the theory th a t socially-taboo words would arouse
anxiety in the subjects. Thus high perceptual thresholds to
these words should indicate the presence of anxiety and
defense against anxiety by means of denial.
The experiment was c r iti c iz e d on two major grounds.
Howes and Solomon (1950) pointed out that McGinnies* "dirty
words" occur less frequently in the English language than
do the neutral words which were used. Therefore, the re
su lts could be explained as a function of word fa m ilia rity .
An a lte rn a te explanation is that the high recognition
threshold to these words is not a function of defensive
denial or misperception but rather th a t of the s u b je c t's
conscious hesitancy to su ffer the embarrassment of respond
ing erroneously with a taboo word where i t might in actu
a l i t y be a neutral one (Eriksen, 1954; Postman, 1953).
Postman, Bronson and Gropper (1953) question the
necessity of considering motivational factors to explain
the r e s u lts of perceptual defense experiments and in so
doing question the concept of perceptual defense i t s e l f .
43
Postman b e liev e s t h a t the fa c ts can be more parsimoniously
subsumed under the aegis of perceptual theory by recourse
to such concepts as f a m i l i a r i t y and set as well as se lec
tiv e v e rb a l re p o rt. Thus, what is labeled perceptual de
fense may be merely the r e s u l t of competing a l te r n a ti v e
responses or hypotheses. Much of the current discussion
and experim entation in the l i t e r a t u r e is concerned with
these is s u e s r a is e d by Postman (Blum, 1955; Cowen and
O b rist, 1958; Dulany, 1957; Freeman, 1955; Lazarus, 1954;
Weiner, 1955). The r e s u l t s of these experiments have
tended t o vary with the methodology employed.
Other tren d s in perceptual defense rese arch might
be b r i e f l y mentioned. Instead of assuming th a t a s o c ia lly -
taboo word is anxiety laden for a l l su b jects, the ex p eri
menter renders c e r t a in innocuous words traum atic by p airing
them with an unpleasant stimulus such as an e l e c t r i c shock
(Dulany, 1957), or by inducing f a i l u r e on an ego-involving
ta sk (Spence, 1957). Other experiments have employed pro
je c tiv e techniques to f e r r e t out em otionally-laden words
(Carpenter, Weiner, and Carpenter, 1956). S t i l l other ex
periments have sought to r e l a t e perceptual defense behavior
to s p e c if ic defense mechanisms (Blum, 1955; Kleinman, 1957;
Lazarus e t a l . , 1951).
A ctually the perceptual defense experiments seek to
get at not one, but two, processes. In order for a subject
to show defensive behavior, he must have perceived some
44
thing against which to defend himself. This phenomenon has
been labeled variously subception (Lazarus and McCleary,
1951), se lec tiv e vigilance (Bruner and Postman, 1947), and
se le c tiv e s e n s itiz a tio n (Lazarus et al., 1951). This is
consonant with the psychoanalytic theory of i n s t i n c t s .
According to t h i s theory, repressed sexual and aggressive
drives are constantly s triv in g for expression. The ego,
sensing the danger involved in allowing such impulses to
r i s e to consciousness autom atically e re c ts a defense
against the pleasurable but at the same time objectionable
impulse.
Statement of the Problem
Psychoanalytic th e o r i s t s in general believe th a t
both peptic ulcer and obesity rep resen t fix a tio n s at an
oral le v el. This implies th a t oral impulses are constantly
s triv in g for expression. The obese individual surrenders
to h is o r a lity by overeating. On the other hand, the ulcer
p a tie n t is in c o n flic t over his oral impulses. This con
f l i c t takes two d iffe re n t forms. The passive type is
o vertly dependent. C onflict for him occurs when the en
vironment ceases to g ra tify his oral needs. In co n tra st,
the reactiv e type suffers from an in te rn a l c o n f lic t. He
f r u s t r a t e s himself by being overly independent, aggressive,
and ambitious. On the basis of t h i s logic, we might pre
d ic t c e rta in s i m i l a r i t i e s and differences between these
groups.
Hypotheses
1. Both peptic ulcer and obese individuals should
show vigilance when confronted with a stimulus th a t suggests
o ra lity .
2. Inasmuch as obese individuals derive su b stitu te
g r a t i f i c a t i o n for t h e i r oral impulses, they should show a
minimum of perceptual defense.
3. Inasmuch as peptic ulcer individuals make use
of defensive denial and counteraction, they should show
strong perceptual defensive behavior.
4. Since passive ulcer patients are overtly de
pendent and reactive patients deny th e ir dependency, pas
sive ulcer p atien ts should be less defensive than reactive
ulcer p atien ts and sim ilar to obese patients in t h e ir per
ceptual defensive behavior.
CHAPTER I I I
Method
Seward, Morrison and Fest (1951) in th e ir s p a s tic
c o l i t i s study r a i s e the following question in the d iscu s
sion of t h e i r r e s u l t s : "What the findings of the present
study mean in terms of p re g e n ita l f ix a ti o n cannot be d eter
mined without more v alid and extensive ex p lo ratio n of early
development" (p. 22). This conclusion, based on the re
s u lts of p ro je c tiv e t e s t and interview d ata, could well be
applied to a major part of the research in psychosomatic
medicine. I t is t h i s a u th o r's b e l ie f , however, t h a t the
p o s s i b i l i t i e s for exploring the p e rso n a lity fa c to rs in
psychosomatic disease through perception have not been
fu lly ex p lo ite d . P ro jectiv e t e s t s , i t is tr u e , r e l y on the
perceptual process, but the perceptions must be f i l t e r e d
through the verbal rep o rts of the su b je c ts . This i n t r o
duces intervening perceptions on the part of the in v e stig a
t o r . The perceptual vigilance-defense method, on the other
hand, might a ffo rd a more d ir e c t measure of p re g e n ita l
f i x a t i o n than the p ro jectiv e t e s t response because i t mini
mizes the verbal re p o rt.
Even p ercep tu al-v iy ilan ce-d efen se research is sub
j e c t to c e rta in lim ita tio n s as evidenced by the controversy
46
47
in the l i t e r a t u r e about word f a m i l i a r i t y and conscious
withholding of responses by su b je c ts. This was the prime
co n sid eratio n in using p ic tu re s instead of words as stimu
l i .
The p erce p tu al-v ig ilan c e-d efen se phase of the study
is based on a forced choice technique developed by Blum
and h is a s s o c ia te s (1954). These in v e s tig a to rs conceived
the idea of using the Blacky P ic tu res (Blum, 1950) in
ta c h is to s c o p ic p re se n ta tio n . The task i s r e l a t i v e l y non
th re a te n in g and allows for objective scoring by merely
t a l l y i n g the frequency of choices for a s p e c if ic p ic tu re .
Moreover the Blacky P ic tu re s were designed s p e c if ic a lly t o
ta p p re g e n ita l drives.
Before describing the experimental procedure, some
d iscussion is in order of the Blacky t e s t as a method fo r
assessin g c e r t a in p e rso n a lity v a ria b le s. The Blacky t e s t
is a r e l a t i v e l y stru c tu re d p ro je c tiv e t e s t which u t i l i z e s
cartoons of dogs in various family s it u a t i o n s . There are
four ch aracters in the s e rie s of eleven cartoons: a mama
dog, a papa dog, a - s ib lin g of indeterm inate sex called
Tippy, and f i n a l l y the son, Blacky, who i s the main charac
t e r . Each cartoon is designed to measure a stage in psy-
chosexual development or a s ig n i f ic a n t object r e la tio n s h i p .
Blum’ s method of checking on the v a l id ity of his instrument
involved a p o std ic tiv e ra th e r than a p re d ic tiv e technique.
That is , in stea d of making deductions from the theory and
48
checking on the t e s t behavior, he took the t e s t r e s u lt s and
went back to the theory. He was in terested in two kinds of
r e s u lt s : (1) in te rre la tio n s h ip s between psychoanalytic di
mensions, e.g. between anal expulsiveness and ca stra tio n
anxiety, and (2) sex differences on each dimension. Taking
the sig n ific a n t r e s u lt s , te tra c h o ric correlations between
dimensions and chi square for sex difference, he went back
to the th e o re tic a l w ritings of Freud and Fenichel to see if
the theory would predict such re la tio n s h ip s . For using
only the s t a t i s t i c a l l y s ig n ific a n t re la tio n sh ip s, he has
been c r iti c iz e d by Seward (1950).
Blacky entered the perceptual defense controversy
with a finding by Blum (1954) th a t i t was possible to tap
two levels of unconscious awareness of psychosexual motiva
tio n by presenting c e rta in of the Blacky pictures ta c h is to -
scopically at two d iffe re n t speeds. The f i r s t speed, well
below the recognition threshold, was thought to get at a
ra th e r deep level of awareness (vigilance), while the sec
ond speed, approaching a threshold value, was thought to
tap a level approaching conscious awareness, a level at
which perceptual defense might be expected to be operative.
Blum arranged four Blacky pictures on a single card
so th a t one was at the top, one at the bottom, one at the
l e f t , and one a t the rig h t. He used six such cards with
the same four Blacky pictures on each card. However, the
r e la tiv e positions of the pictures were changed from card
49
to card. One of the four pictures was structured as the
traumatic picture, another as the neutral p ic tu re , and the
other two were d is tra c to rs . Blum used seven men and seven
women college students in the experiments. For the men,
Masturbation Guilt (V) was structured as the traumatic pic
tu re and Oral Sadism ( I I ) as the neutral picture. For the
women, the situ atio n was reversed. Oral Sadism was struc
tured as the traumatic stimulus and Masturbation G uilt as
the neutral stimulus. The structuring was accomplished by
( l ) a lte rin g the set of the subjects, and (2) making
physical changes in one of the pictures. For the males,
for example, Masturbation Guilt was maximized by showing
them Cartoon V, t e llin g them th a t Blacky was "licking his
sexual parts" and asking them to r e c a ll when they had f e l t
the same way. At the same time Oral Sadism was neutralized
by removing the word "Mama" from the co llar and changing
the fierce expression on Blacky's face. For the female
subjects, Cartoon II (Oral Sadism) was maximized by pre
senting i t without the a lte ra tio n s and implanting the sug
gestion th a t Blacky was " b itte r ly angry at her mother," and
a neutral situ a tio n was suggested for Cartoon V (Masturba
tio n G u i l t ).
The f i r s t se ries of t r i a l s served merely as a base
lin e for evaluating subsequent changes in response. Each
card was flashed on the tachistoscope well below the rec
ognition threshold and the subject was in stru cted to indi
50
cate which p ic tu re "stands out the most" by responding
" l e f t , " " r ig h t," "top," or "bottom." This s e rie s of t r i a l s
occurred p rio r to any f a m i l i a r i t y with the p ic tu re s . I t
was followed by the s e n siz a tio n process described above.
Then the ta c h is to s c o p ic p re se n ta tio n was repeated. The
number of su b je cts who chose the traum atic pictu re r e l a t i v e
ly more often, a f t e r the manipulation of t h e i r set than
before, was found to be s i g n i f i c a n t . This was regarded as
a demonstration of perceptual v ig ila n c e .
The p ercep tu al defense phase of the experiment
involved both a change in the in s tr u c tio n s and a longer
exposure time for each fla sh . The su b je cts were asked now
to find the traum atic p ictu re and then to find the n e u tra l
p ic tu re . Inasmuch as the su b je c ts had more success on the
n e u tra l p ic tu re than on the trau m atic p ic tu re the hypothesis
of perceptual defense was accepted. The ra tio n a le for the
change in in s t r u c tio n s was t h a t by giving the su b jects a
ta s k o rie n ta tio n , finding a p a r t i c u l a r p ic tu re , the ego was
brought in to play more than by the previous in s tru c tio n
which merely c a lle d for an impression of which p ic tu re stood
out the most. The longer exposure time also allowed for
conscious re c o g n itio n of one or two of the p ic tu re s a t each
f la s h , a s i t u a t i o n which was optimal for demonstrating de
fensive behavior.
Blum's experiment used normal college stu d e n ts, but
he manipulated the se t by what he r e f e r s to as a shot of
51
"psychosexual serum. 1 1 The present in v e stig a tio n makes use
of c l in ic a l groups, the ra tio n a le being th a t "psychosexual
serum" is unnecessary because i f these groups are tr u ly
o ral characters they w ill have a b u i l t - i n s e n s i t i v i t y for
oral stim uli.
Subjects
The subjects in the study were 65 white male v eter
ans. The peptic ulcer and obese subjects were drawn from
both the Veterans Adm inistration o u tp atien t f a c i l i t y and
from Wadsworth General Hospital. The Control group was
drawn e n tire ly from Wadsworth General H ospital. Due to
the fa c t th a t the p a tie n t populations were so small, i t was
not possible to use any sampling techniques. A ll p a tie n ts
who met the c r i t e r i a and were w illing to cooperate were
used in the study. Racial o rig in and age were the most
frequent reasons for re je c tio n of subjects.
Experimental groups
Teptic u l c e r . This group was composed of 25 pa
t i e n t s who were under treatment for a d e f in it e ly diagnosed
duodenal u lcer. Nine were taken from the f i l e s of the out
p a tie n t f a c i l i t y and 16 from Wadsworth. The names of the
ulcer ou tp atien ts were obtained from the records of a pre-
vious study. These individuals were contacted by mail and
asked to come in to the c lin ic in order to provide fu rth er
52
information r e la tiv e to the research th a t the Functional
C linic was engaged in.
The h o sp ita liz e d ulcer group was selected a f t e r a
perusal of the c l i n i c a l records on the wards to insure th a t
they met the c r i t e r i a .
The Ulcer group ranged in age from 24 to 42 with a
mean age of 33.8. A ll subjects were within normal height
and weight lim its according to the ta b le s published by the
M etropolitan Life Insurance Company (1950).
Obese. This group comprised 15 subjects ranging in
age from 25 to 42 with a mean age of 35.3. All subjects
were at le a s t 25 per cent overweight according to the
M etropolitan (1950) c r i t e r i a for the large-frame individual.
The 12 outpatient obese subjects were drawn from the f i l e s
of the d ie tic ia n at the f a c i l i t y . They too were contacted
by l e t t e r which sta te d th a t th ere was a research project
under way to study people on reducing d ie ts and th a t th e ir
p a r tic ip a tio n was requested. The three h o sp ita lize d obese
p a tie n ts were obtained by canvassing the wards in search of
individuals who met the overweight c r i t e r i a . All these
p atien ts were under treatm ent for conditions other than
obesity. Special d ie ts had been recommended to improve
t h e i r general health. These subjects were ca re fu lly
screened to rule out any previous ulcer h isto ry .
53
Control Group
These subjects were taken e n tire ly from Wadsworth.
The g reat majority of these subjects were on the surgical
wards. Most of them had been admitted for surgical t r e a t
ment of some acute disorder such as inguinal hernia, ap
p e n d ic itis , or pilo n id al cyst. Their ages ranged from 21
to 40, with a mean of 30.4. This group f e l l within normal
height and weight lim its and again any previous ulcer h is
tory was ruled out.
All subjects in the study were ad d itio n ally
screened for any evidence of psychosis or psychoneurosis in
th e ir h is t o r ie s . Most of the hospitalized subjects in a l l
these groups were tested within two weeks of th e ir admis
sion.
Apparatus and Materials
A tachistoscope was constructed by placing a
Wollensak shutter over the lens of a Keystone 500 watt
3 x 4 slid e projector. The stim uli were flashed on a
radiant screen. The Blacky pictures, miniature positive
film p r in ts of the original cards, were mounted in patterns
of four on the slid e s. In addition to Cartoon I, Oral
Eroticism, the hypothesized traumatic p ictu re, there were
three other cartoons selected: Cartoon VI, Castration anx
iety; Cartoon V III, Sibling Rivalry; and Cartoon IX, Guilt
Feelings. The three neutral pictures were selected accord-
54
ing to th e i r physical properties on the basis of p re te sts
with pictures which seemed to have about the same propor
tio n of black and white as did Oral Eroticism.
The stim uli consisted of eight s lid e s , each con
taining a p attern of the same four p ic tu re s, each p attern
having a d iffe re n t arrangement of p ic tu re s. The patterns
were so constructed th a t each picture appeared in a given
position twice in the series of eight p attern s.
Procedure
Before the perceptual experiment began, the sub
je c ts were screened for visual acuity with a Snellen chart.
A minimum of 20/40 corrected was considered acceptable.
Following t h is , the subjects were led into the room where
the experiment was to take place. The subjects were te s te d
in groups of one to four, depending on how many appeared
for a given te s tin g session. The subjects were seated 10
feet from the screen and were provided with a response
sheet with p atterns numbered from 1 to 48.
Baseline Series
The purpose of th is se rie s of t r i a l s was to estab
lish for each subject a score based so le ly on the physical
properties of the stim uli. Since the subjects were not
fam iliar with the pictures and since the speed of exposure
was such th a t i t would not permit recognition, i t was pre
55
sumed th a t motivational fac to rs would be at a minimum. The
subjects were in stru cted merely to designate "which picture
stands out the most"— l e f t , rig h t, top, or bottom—by plac
ing an "X" in the appropriate box on the response sheet.
A f la s h lig h t focused in the center of the pattern provided
a fix a tio n point prior to each flash .
Following the in stru c tio n s, the examiner flashed
three sequences of the eight patterns at a shutter speed
of .03 seconds u n til he reached p attern number 24. After a
short break, the procedure was resumed u n til a l l 48 pat
terns had been flashed.
Blacky Test Administration
After the response sheets had been co llected , the
subjects were to ld th a t the pictures th a t had been flashed
were cartoons sim ilar to those found in comic s tr ip s . The
experimenter then read the standard in stru c tio n s for the
adm inistration of the Group Blacky (Blum, 1951). Spontane
ous s to r ie s and inquiry were obtained on the four pictures
which had been u tiliz e d in the tachistoscopic presentation.
In addition, story and inquiry were obtained on Cartoon II,
Oral Sadism.
Card preferences were e l i c i t e d at the completion
of the adm inistration of the t e s t as prescribed in the
standard in stru c tio n s.
The purpose of the Blacky Test adm inistration was
56
two-fold. The primary purpose was to provide an equal ex
posure to and fa m ilia rity with each of the four pictures
so th a t any subsequent changes in card choice could l e g i t
imately be a ttr i b u te d to personality variables. This pro
cedure corresponded to that of Blum’s wherein he allowed
his subjects to view the traumatic and neutral p ictu re.
However, in the present experiment there was no attempt to
manipulate the set of the subjects. Secondly, the Blacky
t e s t m aterial was to provide an ad d itio n a l set of data con
cerning o r a lit y which could be compared with the perceptual
data. The addition of Oral Sadism was to provide informa
tio n about a dimension of o r a lity which was not tapped in
the perceptual experiment, a dimension which has been em
phasized by some in vestigators in connection with the
genesis of peptic ulcer (Mittlemann et a l . , 1942; Szasz et
a l . , 1947; S t r e i t f e l d , 1954). Also the inclusion of an
extra cartoon would serve to eliminate a cue as to how many
d iffe re n t pictures were involved in the perceptual part of
the procedure.
Perceptual Vigilance Series
The in stru c tio n s and procedure were the same as for
the Baseline s e rie s. The purpose was to compare the two
sets of scores for each subject, the assumption being th a t
changes would be a function of the intervening experience
with the Blacky t e s t and thus an indication of m otivational
57
v a ria b le s .
Perceptual Defense Series
In th is phase of the experiment, the sh u tter speed
was reduced to .3 seconds, a speed th a t Blum (1954) had
previously found would allow occasional recognition of one
or more of the pictures. The task was to find the "picture
of Blacky with Mama" (Oral Eroticism). The response sheets
were marked in the same manner as for the preceding se rie s.
I t was presumed th a t perceptual defense, i f i t were opera
tin g , would in te rfe re with the task of finding the crucial
p ic tu re .
Additional Measures
I n te lle c tu a l Level
Following the perceptual experiment, the subjects
were administered the vocabulary portion of the Shipley-
Hartford I n s titu t e of Living Scale (Shipley, 1940) in order
to obtain a rough measure of i n te lle c tu a l le v el for the
purpose of equating groups.
O rality Questionnaire
An o ra lity questionnaire followed the adm inistra
tio n of the Shipley-Hartford. This was an instrument de
signed by Frieda Goldman (1948-49) in connection with her
study of the re la tio n sh ip between breastfeeding and age of
weaning on the one hand and character formation on the
o th e r .
The questionnaire composes 150 s e lf - r a tin g items
which go to make up 19 non-overlapping scales. Each
scale represents an oral character t r a i t hypothesized from
culling the l i t e r a t u r e on oral character types. Fourteen
of the 19 scales are, as are many of the items th a t make
them up, borrowed from Murray (1938). These scales are:
Exocathexis, Endocathexis, Nurturance, S o cia b ility , Aloof
ness, Autonomy, Aggression, G u ilt, Dependence, Ambition,
Impulsion, D eliberation, Change, and Conservatism. The
remaining fiv e, Optimism, Pessimism, Passivity, Oral Ag
gression, and Desire for the Unattainable, were specially
constructed for her study.
Part I, 33 items, contains common sayings or aphor
isms. Part I I, the remaining 117 items, c o n sists of s t a t e
ments about fe e lin g s, social behavior and in te r e s ts . None
of the items pertain to food or eating. Each item has a
fiv e-p o in t scale associated with i t , ranging from -2 through
4-2 . The subject indicates the extent to which he agrees or
disagrees with the statement by marking a p o sitio n on the
s c a le .
In her o rig in al in v estig atio n , Goldman administered
the questionnaire to 115 adult subjects (college students,
housewives, clerks, social workers, etc. Then she took 20
subjects at each extreme of the d is trib u tio n for each
t r a i t and in te rc o rre la te d th e ir scores. As a r e s u lt, she
59
came up with a bipolar fa c to r which accounted for 11 of the
19 scales. At the positive end, which she labeled oral
optimism, were found: Optimism, Ambition, Exocathexis,
Nurturance and S o c ia b ility . At the negative end, Oral
Pessimism, were clu stered : Pessimism, P assiv ity , Aloofness,
Endocathexis, Autonomy, and Oral Aggression. These clus
t e r s she in te rp re te d as corresponding to the psychoanalytic
o ra l character types described by Abraham, Glover, Jones,
and Bergler.
CHAPTER IV
Results
I n te ll e c t u a l Level
The purpose of the Shipley-Hartford t e s t was to
obtain a rough measure of in te l l e c t u a l level in order to
control for th a t variable. Table 1 shows the group means
and variances of the raw scores on the Shipley-Hartford.
The formula used for the t r a t i o of difference between
means was th at designed by Fisher for use with small sam
ples (Guilford, 1956). All subsequent _t's were also calcu
la ted with the Fisher formula. The ra tio n a le for the use
of th is formula w ill be presented in connection with the
r e s u lt s of the perceptual experiment.
The Perceptual Experiment
According to the hypotheses sta ted in Chapter I I I ,
both experimental groups, Obese and Ulcer, should show evi
dence of perceptual vigilance on the dimension of Oral
Eroticism. Perceptual vigilance is operationally defined
in t h i s experiment as a lowered threshold to the perception
of the Oral Erotism picture in the tachistoscopic presenta
tio n . Each subject was assigned a score representing the
60
Table 1
I n te lle c tu a l Level:
Differences among Control, Ulcer, and Obese Groups
Groups N
Raw Score
Means
Variances IQ Groups
Equivalents Compared
Degrees of
Freedom
t Significance
Control (C) 25 28.80 22.68 116 C-U 48 .530 N.S.
Ulcer (U) 25 29.52 22.43 118 C-0 38 1 .1 1 1
N.S.
Obese (0) 15 26.60 61.83 110 U-0 38 1.459 N.S.
O ' -
62
frequency with which he had indicated the Oral Eroticism
picture as the most outstanding of the four pictures in
each pattern. Each subject received two scores, one repre
senting the baseline (B) or pre-exposure s e rie s, the other
representing the perceptual vigilance (P.V.) or post-expo
sure series {exposure meaning the experience of having
taken the Blacky Test). Higher scores on the P.V. series
than on the B series would indicate th a t perceptual v igi
lance was operative. Table 2 shows the mean scores for
each group for each condition. I t w ill be noted th a t the
score for the P.V. series for each group was lower than for
the B se rie s. This change was in the opposite d ire c tio n
from th a t predicted for the two oral groups, the greatest
change occurring in the Obese group.
The array of scores would seem to lend i t s e l f to a
two-way analysis of variance design wherein one could t e s t
differences between groups and between experimental condi
tio n s . However, inasmuch as each subject served as his
own control, i t was necessary to remove the within subject
variance. The design decided upon was a type I mixed de
sign described by Lindquist (1953). In th is design there
are two main sources of variance: (l) the variance between
subjects and (2) the variance within subjects. Each main
source of variance has i t s own error term which serves as
the denominator in the F r a tio equation. The between sub
je c ts variance contains the between groups variance and an
63
Table 2
Baseline and Perceptual Vigilance
Mean Scores and Variances
Groups
Mean
B Scores
Variances
Mean
P.V. Scores
Variances
Control 12.36 34.16 11.72 34.04
Ulcer 12.24 13.11
11.64
35.32
Obese 12.20 15.74 9.47 33.84
64
error term. The within subject variance contains the be
tween experimental conditions variance, an in te ra c tio n term
for groups x conditions and an e rro r term.
One of the assumptions underlying the analysis of
variance technique is th a t a l l the sample measures are
drawn from populations having the same variance. In order
to t e s t th is assumption, i t was necessary to demonstrate
that there was no sig n ific a n t difference between population
variances. H artley's simple preliminary t e s t of t h i s as
sumption is described by Walker and Lev (1953). In t h i s
t e s t , the la rg e st sample variance is divided by the small
est sample variance and a maximum F is obtained. If the
maximum F r a t i o is not s ig n ific a n t, then a r a tio between
less disparate variances w ill not be sig n ific a n t. The sam
ple variances are presented in Table 2. The F r a t i o be
tween the Ulcer group B scores and Its P.V. scores was
2.69, which with 48 degrees of freedom proved to be s ig n if
icant at the .01 level.
A more refined technique for te s tin g the assumption
of homogeneity of variance is B a r t l e t t 's chi square t e s t
(Walker and Lev, 1953). This t e s t yielded a chi square of
9.99, which with five degrees of freedom (the number of
samples minus one) is s ig n ific a n t between the .10 and .05
l e v e l s .
The two te s ts described above cast considerable
doubt on the appropriateness of an orthodox analysis of
65
variance treatment of the data. Accordingly i t was decided
to use a nonparametric technique described by Dossett
(unpublished a r t i c l e ) . This technique makes no assumptions
about normality or homogeneity. I t is sim ilar to the type
I mixed design in th a t i t yields an estimate of variance
based on (1) groups, (2) conditions, (3) in te ra c tio n of
groups x conditions, and also an estimate of the population
variance based on correlated measures. This l a t t e r estim
ate takes into account the within subject variance. Each
estimate of variance is obtained by dividing i t s modified
sum of squares by the estimate of population variance based
on correlated measures to obtain a Table 3 shows the
re s u lts of th is analysis. A sig n ific a n t difference was
found between the B se rie s and the P.V- se rie s. This fin d
ing indicated th a t as a re s u lt of having taken the Blacky
Test between the two ta ch isto sco p ic presentations there was
a sig n ific a n t change which cut across group lines.
The next step was to take each group and compare
i t s B scores with i t s P.V. scores in order to determine
which group, if any, showed a s ig n ific a n t change. The t e s t
decided upon was the Wilcoxon Matched-Pairs Signed-Ranks
t e s t described by Siegel (1956). This t e s t is a nonpara-
metric t e s t which is , like the sign t e s t , applicable to
data obtained from matched pairs of subjects. In th is ex
periment, the matching occurred by v irtu e of each subject
serving as his own control. I t has the ad d itio n al advan-
66
Table 3
Nonparametric Analysis of Variance
of Baseline and Perceptual Vigilance Scores
Source of
Variation
Modified Sum
of Squares
(SS« )
Degrees
of
Freedom
Signif icance
Groups 2.1290 . 0788 2 N.S.
Conditions 120.9880 4.4810 1 <.05
In teractio n
Groups X
Conditions
23.7410 .8792 2 N.S.
Total 146.8580 5.4391 5
67
tage over the sign t e s t , in th at i t takes into account the
magnitude of a change as well as the direction.
In order to set up the data for the t e s t , the sub
je c ts were ranked according to difference scores regardless
of sign. Signs were then assigned to each rank according
to the direction of change. Pairs which showed a d iffe r
ence score of zero were dropped from the analysis. The
smaller sum of like signed ranks determines the level of
significance. The null hypothesis predicts no difference
between the two series of ranks. In other words, if there
is no difference between the B scores and the P.V. scores,
some of the larger ranks w ill come from the plus scores and
some from the minus scores and the two w ill tend to cancel
each other. In Table 4, which compares baseline and percep
tu a l vigilance scores, i t w ill be noted th at only the Obese
group showed a sig n ifican t change. The p values are based
on a tw o-tailed te s t since the scores changed in the oppo
site directio n from th a t predicted. The null hypothesis
being tested then is simply the probability of a difference
as large as the observed one regardless of direction.
McNemar (1955) points out th a t, in an experiment
involving changes where more than one group i s involved, i t
is necessary to t e s t the significance of the difference be
tween the changes for the various groups. I t w ill be re
called th at for the Wilcoxon t e s t each subject received a
sign, plus or minus, based on the direction of his d iffe r-
68
Table 4
Wilcoxon Matched-Pairs Signed-Ranks Test
for Significance of Differences
between Baseline and Perceptual Vigilance Scores
Groups *N
Sign
+
Smaller Sum of
Like Signed
Ranks (T)
S ignif icance
Control 24 11 13 129.5 N.S.
Ulcer 25 9 16 122.5 N.S.
Obese 12 3 9 11.5 <.05
*Subjects with zero difference scores were elim inated from
the sample.
69
ence score. That is , i f his P.V. score exceeded his B
score, he received a plus. I f his P.V. score was smaller
than his B score, he received a minus. In order to te s t
the difference between the d ifferen ces, in other words,,
the d i f f e r e n c e 'between groups, the data were arranged in a
2 x 3 table and subjected to the chi square t e s t . A p of
1.626 with two degrees of freedom proved to be n o n -sig n ifi
cant .
The hypothesis re la tin g to perceptual defense
sta te d th a t the ulcer group should be more defensive on
Oral Eroticism than the control group. Another way of s t a t
ing t h i s is th a t the ulcer group should have a higher
threshold to the perception of an oral stimulus than e ith e r
of the other two groups. The task in th is part of the ex
periment was to find the Oral Eroticism picture. This was
considered to be a more ego-involving task than merely de
signating which of a pattern of four pictures stood out
the most. Also, because the duration of the fla s h was
longer than i t had been on the previous presentation ser
ie s, i t was possible for the subjects on occasion to recog
nize the pictures. Thus, the task was presumably more ego
involving and the stimulus closer to the conscious level.
Under these circumstances i t could be predicted th a t sub
je c ts who were orally fixated and who attempted to deny
t h e i r oral needs would have more d i f f i c u l t y in finding the
Oral Eroticism picture. On the other hand, control sub
70
j e c t s , presumably having minimal co n flic t in t h i s area,
should experience no d if f i c u lt y in finding the picture. In
the case of the obese subjects, a strong drive in the direc
tio n of o r a lity with no need to deny i t , should f a c i l i t a t e
the perception of the oral p ictu re.
Blum (1952), on the basis of a battery of t e s t s
including the Blacky, found two d iffe re n t types of peptic
ulcer patien ts. On the basis of th e ir responses to the
inquiry items on Oral Eroticism, he divided his ulcer pa
t i e n t s into a primary and a rea c tiv e group. The primary
group seemed to be concerned with d irect g r a t i f i c a t i o n of
oral demands, while the reactive group were defensive with
regard to o r a lity . This corresponds to the two types
described by Alexander (1947, 1950) and found in other pep
t i c ulcer studies (Blum and Kaufman, 1952; Friedman, 1949;
Marquis et a l . , 1952).
The f i r s t question to be resolved then was th a t
of the homogeneity of the ulcer group. Blum had reported
th a t the primary ulcer type tended to choose the "disturbed"
items, the reactive group the neutral items, on the in
quiry on Oral Eroticism. Because of the smaller number of
subjects involved (six in each subgroup) he cautions the
reader th a t his findings are only suggestive.
Inasmuch as th is material was avilable in the
present study, i t was decided to sort the protocols of the
ulcer group according to th e ir responses to the inquiry
71
items. Those subjects .who scored strong ( f ) or very strong
(++) on these items were placed in the primary category.
Those subjects who scored zero on the same items were
placed in the reactive category. As a r e s u lt of t h i s so rt
ing, 14 protocols were designated primary ulcer types,
while 11 were called reactive types.
Mean perceptual defense (P.D.) scores were then
obtained for each subgroup, and the means were compared by
means of F is h e r ’s t r a t i o for small samples. Since the
re su ltin g t, of 1.760 was not su ffic ie n t to r e je c t the null
hypothesis, the two subgroups were tre a te d as representa
tive of the same population as fa r as perceptual defense
phenomena were concerned.
Means and variances were obtained for the Control,
Ulcer and Obese group P.D. scores. H artley's t e s t for
homogeneity of variance was sig n ific an t beyond the 5 per
cent level (F - 2.84). This ruled out the p o s s ib ility of
using a one-way analysis of variance. Accordingly i t was
decided to t e s t the significance of differences between
groups by means of F ish e r's jt t e s t . This t e s t allows for
the comparison of means of samples with disparate varian
ces by u t il iz i n g a single estimate of the population var
iance based on combining the two samples. This technique
reduces the p robability of overestimating the significance
of an obtained t^. Table 5 shows the means and variances of
the Control, Ulcer, and Obese groups and the two subgroups
Table 5
Perceptual Defense:
Differences among Groups
Groups N Means Variances
Groups
Compared
Degrees of
Freedom
Signif icance
Control (C) 25 31.40 74. C8 G-U 48 .734 N.S.
Ulcer (U) 25 29.84 38.81 C-0 38 1.267 N.S.
Obese (0) 15 27.53 110. 27 li-0 38 .876 N.S.
Reactive
Ulcer (R)
11 27.46 52.40 R-P
23 1.760 N.S.
Primary
Ulcer (P)
14 31.71 19.15
-o
t o
73
of ulcer subjects as well as the t_ r a tio s for comparison of
means. None of the obtained jt's attain ed a level required
for significance.
The Blacky Test
Mention has already been made of the Blacky t e s t
r e s u lts in connection with the te s tin g for the homogeneity
of the Ulcer group. The Blacky t e s t yields a score on each
of 13 dimensions (Oral Eroticism, Oral Sadism, Anal Expul
siveness, e tc .) (Blum, 1949, 1951). Each dimension score
is composed of four p arts: (l) the spontaneous story, (2)
the inquiry, (3) r e la te d comments (on cartoons other than
the one representing the dimension being scored, such as an
oral reference on the Sibling Rivalry cartoon), and (4)
cartoon preferences. The subject receives one of three
possible scores on each of the four parts: very strong
(+-*)» f a i r l y strong (-t), weak or absent (0), and the f in a l
dimension score is the sum of the pluses for a l l four com
ponents.
For the sake of i l l u s t r a t i o n , the scoring of a
protocol on the dimension of Oral Eroticism w ill be de
scribed. The spontaneous story is given a score of e ith e r
(*■+) or (0) based on normative data which is appended to
the scoring in stru c tio n s. For example, a story wherein
reference to feeding is completely evaded would receive a
score of (++). Another i l l u s t r a t i o n of a u o story is one
74
which in d ic ates r e j e c t i o n on the p art of "Mama," such as a
statement to the e f f e c t th a t "Mama" i s re lu c ta n t to feed
Blacky.
The inquiry is a multiple choice task . Certain of
the a l te r n a ti v e s are scored (4-), others (0). However,
only four out of the six items on Oral Eroticism are
scored. A subject choosing a t o t a l of two (+) a lte r n a
t iv e s receives a score of (•*) on the inquiry. Three or
four (4.) item se le c tio n s y ie ld s a score of (4 4 ) for the
in q u iry .
For the re la te d comments p a r t, two oral references
on other cartoons scores a (4-), three or more, a (-fr4-).
The l a s t procedure in the adm in istra tio n of the
t e s t c o n sists of asking the subjects to indicate for each
cartoon whether they like or d is lik e i t , and f in a l l y to
se le c t the cartoon they liked the best and the one they
d islik e d the most. I f Oral Eroticism is selected as
e i th e r the "best" or "worst," the subject receives a score
of (-) for card preference.
In order to derive the o v erall dimension score, a l l
the pluses from each of the four t e s t components are
to ta le d . For Oral Eroticism four to seven pluses y ield a.
t o t a l score of (— ), "very strong d istu rb an ce." Three
pluses given an Oral Eroticism score of ( - ) , " f a ir ly
strong d istu rb an ce." Two or less scores (0), "weak or
a b s e n t."
Table 6
Blacky Test—Oral Eroticism
Differences among Groups
Dg gre es
Groups N Disturbed _. of Groups Significance
Disturbed Freedom Compared
Control (C) 25 16 9 6.185 2 C-U-0 < .05
Ulcer (U) 25 8 17 4.977 1 C-U+O < .05
Obese (0) 15 5 10 3.926 1 G-U <.05
Total 65 29 36 2.412 1 C-0 <.20
o ->
75
The only part of the scoring th a t might conceivably
have an element of s u b je c tiv ity is th a t of the spontaneous
story. Blum (1949), on the basis of 25 protocols scored
independently by himself and another in v e stig a to r, claims
100 per cent agreement on Oral Eroticism and 96 per cent on
Oral Sadism, as opposed to chance p ro b a b ilitie s of 56 per
cent and 61 per cent respectively.
All the protocols in the present study were scored
by the in v estig ato r. The response sheets were coded so
th at the in v estig ato r had no knowledge of who the subject
was or to what group he belonged.
Only five of the 11 cartoons were used, the four
which were reproduced on the slides used in the perceptual
experiment plus Oral Sadism. The scores on Oral Eroticism
and Oral Sadism were of d irect in te r e s t in the study.
Table 6 shows the chi square t e s t for differences
between groups on Oral Eroticism. The chi square of 6.185
was s ig n ific a n t beyond the .05 le v el, indicating th a t the
Control group had a sig n ific a n tly greater proportion of
individuals who showed "disturbance1 1 on Oral Eroticism than
the Obese and Ulcer groups. This difference was in a
d ire c tio n opposite to th a t predicted. In other words, the
non-oral subjects were more oral than the oral subjects.
Chi square was also calculated for the difference
between groups on the Oral Sadism dimension. The value of
.736 f e l l far short of the level required for significance.
77
The O rality Questionnaire
Table 7 shows the means and variances for the Con
t r o l , Ulcer,. and Obese groups on each of the 19 t r a i t s
represented in the scale. F ish er's ;t was used to compare
means. Out of 07 possible t_'s only two were sig n ific an t at
or beyond the .00 level. The Control group scored s i g n i f i
cantly higher on Ambition than e ith e r the Ulcer group
(t = 2.28) or the Obese group (t. - 2.12). Two other d i f
ferences approached significance. The obese group scored
higher than the Ulcer group on p as siv ity (t_ = 1.98) and
lower than the Ulcer group on Change (t ■ 1.99). The 0 per
cent level for 38 degrees of freedom is approximately 2.03.
The significance of these findings is quesrionable, however,
in the lig h t of the chance expectancy of three s ig n ific a n t
differences out of 57 possible comparisons.
A more promising line of in v e stig a tio n was prompted
by the observation that the Ulcer and Obese groups tended
to have co n sisten tly larger variances on each t r a i t than
the Control group. Goldman, in her preliminary work with
th is questionnaire, had in te rc o rre la te d a l l the t r a i t
scales. She found that certain of the t r a i t scales tended
to c lu ste r in a pattern which she labeled Oral Optimism,
while th e ir polar opposites clustered in another p attern
which she labeled Oral Pessimism. Then she selected 20
subjects representing each type. The oral optimists were
78
Table 7
O ra lity Questionnaire:
*Means and Variances of Oral T ra it Scores
T ra its
Means Variances
Control. Ulcer Obese Control. Ulcer■ Obese
Optimism 29,09 28.64 28.01 16.60 31.57 37.86
Pessimism 20.08 20.52 22.28 31.12 47.17 52.06
P assivity 18.83 18.56 22.48 23.10 24.51 57.69
Desire for the
Unattainable
24.34 24.00 25.68 29.80 48. 00 50.95
Displaced Oral
Aggression
18.63 18. 52 17.01 27.55 31.84 19.43
Aggression 23. 09 23.08 23.14 21.82 51.74 46.98
Aloofness 26.54 25.28 26.35 22.17 32.79 47.67
Ambition 25. 09 22.52 21.14 16.78 14.51 57.27
Autonomy 27.59 30.52 29.08 17.30 61.09 52.07
Dependence 17.67 17.28 18.14 21. 01 15. 21 38.27
G uilt
21.25 21.92 22.41 31.67 30.16 45.69
Change 24.25 25.64 21.81 24.11 23.41 53.74
Impulsion
31.84 31.84 29.08 27.10 64.31 79.07
Table 7— Continued
79
T raits
Means V ariations
Control Ulcer Obese Control Ulcer Obese
D eliberation 28.34 29.80 31.35 30.75 29.17 49.24
Exocathexis 23.04 23. 08 22.61 15.78
15.91 25.97
Endocathexis 27.75 28.12 27. 08 28. 02 49.44 65.07
Conservatism 19.13 18.12 18.41 13.51 14.94 18.69
Nurturance 25.29 26. 24 25.95 27.52 17.52 51.07
S o c ia b ility 21.21 20.32 20.34 20. 09 29. 23 29.95
*In order to avoid the use of negative numbers a constant
of +3 was added to each item score.
80
those who had the highest scores on the five t r a i t s making
up the Oral Optimism c lu ster and the lowest scores on the
Oral Pessimism cluster. Conversely, the 20 o r a l pessimists
were those who had the highest scores on the six Oral Pes
sim ist t r a i t s and the lowest scores on the Oral Optimist
t r a i t s . Thus the oral characters represented the extreme
scores on each of the 11 t r a i t s .
Each item in the questionnaire is a fiv e point
scale ranging from -2 to +2 with zero in the middle. Thus
the t r a i t scores themselves can be e ith e r a plus or minus
q uality. For example, an ideal oral optimist would be ex
pected to have high plus scores on the Oral Optimism clus
te r of t r a i t s and high minus scores on the O ral Pessimism
c lu s te r.
In the present in v e stig a tio n , there was no attempt
to classify the ulcer and obese subjects as optim ists or
pessimists. However, i t seemed lik e ly , based on the magni
tude of the variances, th a t each group contained both op
tim is ts and pessim ists, in other words, individuals who
tended to c lu s te r at the extremes of each t r a i t d is trib u
tio n . On the other hand, the Control group apparently con
tain ed a preponderance of individuals who clu stered at the
means. This would account both for the absence of d if f e r
ences between means, t \ a extreme positive and negative
scores of the obese and ulcer subjects tending to cancel
each other out, and for the larger variances fo r the Ulcer
81
and Obese groups.
To t e s t th i s hypothesis a single measure of O rality
was obtained for each subject. Scores were recorded on
each of the 11 t r a i t s . Then each s u b je c t’s O ra lity score
was determined by adding his 11 t r a i t scores irre s p e c tiv e
of sign. Thus the derived scores take into account the
v a r i a b i l i t y of the raw scores.
Group variances of the derived scores were obtained
in order to t e s t for homogeneity. The F r a t i o between the
variance for the Obese group and th a t of the Control group
was 2.26, which was s ig n ific a n t beyond the .05 lev el. Ac
cordingly, i t was decided again to use F i s h e r ’s t t e s t for
small samples in order to t e s t for the significance of d if
ferences between group means. Table 8 shows th a t the d i f
ference between the Control group and the Obese group was
s ig n ific a n t beyond the 5 per cent le v e l, in d ic atin g th a t
the Obese group was s ig n i f ic a n t ly more oral in reporting
th e ir i n t e r e s t s , a t t i t u d e s and a c t i v i t i e s than was the Con
t r o l group.
Summary of R esults
In preparation for the discussion to follow the
r e s u l t s and t h e i r bearing on the hypotheses are summarized
below:
1. On the perceptual vigilance portion of the ex
periment, a l l three groups selected the Oral Eroticism
82
Table 8
O ra lity Questionnaire:
Differences among Groups
on Single Measure of O rality
Groups N Means
V ari
ances '
Groups
Compared
Degrees
of
Freedom
t
S ig n if
icance
Control (C) *24 53.54 196.52 C-U 47 1.359 N.S.
Ulcer (U) 25 60. 00 353.08 C-0
38 2.174 < .05
Obese (0) 15 65.73 444.50 U-0 48 .892 N.S.
*One protocol unscorable.
83
p ic tu re s less frequently a fte r having taken the Blacky t e s t
than they had prior to taking the t e s t . However, only the
Obese group showed a s ig n ific a n t difference between pre
te s tin g and p o s t- te s tin g . Although a r e l a t i v e l y higher
proportion of obese and ulcer subjects than of control sub
je c t s showed the change, the d ifference between groups was
not s ig n ific a n t. Hypothesis 1, which stated th a t o ra lly
fix ated individuals should have a lowered threshold (per
ceptual vigilance) to oral stim u li, was not supported.
2. Hypothesis 2 stated th a t the Ulcer group should
show a higher th resh o ld to oral stim uli (perceptual de
fense) than e ith e r the Obese group or the Control group.
This hypothesis was prim arily concerned with the reac tiv e
ulcer subjects inasmuch as the primary ulcer subjects were
predicted to be more sim ilar to obese subjects than to re
activ e ulcer subjects on the perceptual defense phase of
the experiment. None of the d iffere n ce s between the three
groups was s ig n ific a n t. Thus, hypotheses 2 and 3 were not
supported.
3. The Control group had a s ig n ific a n tly greater
proportion of in d ividuals showing disturbance on the Blacky
t e s t response to Oral Eroticism than e ith e r the Ulcer group
alone or the combined oral groups. This was contrary to
the hypothesis th at the oral groups should show more d is
turbance on the Oral Eroticism dimension than the Control
group. There was no difference between groups on Oral
84
Sadism.
4. An analysis on the Blacky t e s t protocols failed
to delineate two peptic ulcer sub-types. Thus i t was not
possible to t e s t hypothesis 4.
5. The Obese group and the Ulcer group each showed
more evidence of oral i n te r e s ts , a ttitu d e s and behavior
than the Control group. However, only the difference be
tween the Obese group and the Control group was s i g n i f i
cant .
CHAPTER V
Discussion
The re s u lts of the experiment f a i l to support any
of the major hypotheses. In f a c t, the trends th a t approach
significance tend to go contrary to the hypotheses, which
leads to speculation about some of the assumptions under
lying the formulation of the hypotheses and the nature of
the operations defining perceptual vigilance and o r a lity .
F i r s t , however, i t is in order to discuss the lim ita tio n s
of the study and the bearing th a t such lim itatio n s may have
had on the re s u lts .
Limitations of the Study
Like many other c l in ic a l stu d ies, the present one
suffers from the bias of selective sampling. This natur
a lly requires caution in in te rp retin g r e s u lts based on
s t a t i s t i c a l t e s t s which assume random sampling. Those sub
je c ts who were outpatients were, in e f f e c t , volunteers.
They were contacted by mail and could e ith er respond or
not according to th e i r own in c lin a tio n s. There was a v a ri
ety of uncontrolled variables inherent in th is method of
selectio n . Those who appeared for che te stin g were in te r
ested enough to respond to the l e t t e r in the f i r s t place
85
86
and were able and willing to take time off from th e i r jobs
and come to the V. A. Regional Office. The hospitalized
p atie n ts, on the other hand, were in a sense a captive
group. In most cases, they were obtained by personal con
ta c t with the experimenter. This enabled him to persuade
a number of more or less r e c a lc i tr a n t subjects to p a r t i c i
pate who, if l e f t to th e ir own devices, might not have
taken part in the experiment.
Another lim ita tio n is the rath e r small number in
the obese group. The original Intent was to have 25 sub
je c ts in each group. However, only 15 obese subjects could
be found who met a l l the c r i t e r i a .
A further lim ita tio n stems from the use of an a l l -
VA p atient population in a study of o ra lity . G enetically,
according to psychoanalytic theory, dependent needs and a t
titu d e s have th e ir origin in the oral period of develop
ment. Without attempting to pass judgment on the Veterans
Administration h o s p ita liz a tio n program, or on the motives
of i t s patient population, i t could be argued that the sys
tem tends to fo s te r dependency in i t s policy of free hos
p ita liz a tio n , and in i t s d is a b i l i t y pension system. For
the service-connected veteran, there looms the secondary
gain of continued monthly d is a b i l i t y payments which amount
to a reward for ill n e s s . The non-service-connected veteran,
on the other hand, although not e n t itle d to outpatient care,
can expect free h o s p ita liz a tio n on a beds-available basis.
Inasmuch as not a l l veterans report to a VA h o sp ital when
they are i l l or require surgery, the VA hosp italized vet
eran is probably d iffe re n t in ways th a t are pertinent to
th is study from the hosp italized veteran who pays for his
treatment in a private h o sp ital e ith e r out of his own
pocket or out of a prepaid health insurance policy. The
fa c t th a t a l l the subjects in the study were under t r e a t
ment from Veterans Administration medical f a c i l i t i e s could
conceivably blur the d is tin c tio n s between groups on the
experimental variable.
F in ally , the e ffec t of in p atien t vs. outpatient
status is unknown due to the f a c t th a t a l l the control
subjects were h o sp italized , whereas the obese group was
predominantly outpatient.
In te rp re ta tio n of Findings
The Blacky t e s t and the O rality Questionnaire were
intended to provide au x iliary measures of o ra lity . In turn
they were t o be used to evaluate the r e s u lt s of the percep
tu a l experiment. The expectation was th a t the experimental
groups would score s ig n ific a n tly higher on both measures
than the Control group.- In the discussion to follow, the
Obese and Ulcer group scores w ill be considered together,
in comparison with the Control group, since the scores were
more sim ilar to one another than they were to the Control
group scores. The r e s u lt s of these two measures are in
88
apparent c o n tra d ic tio n . The Control group showed s i g n i f i
c a n tly more disturbance on. the Oral E roticism p o rtio n of
the Blacky t e s t than the experim ental groups. On the other
hand, the experim ental groups showed more .evidence of o ra l
i n t e r e s t s and a t t i t u d e s on the q u es tio n n a ire .
In an attem pt to reso lv e t h i s apparent co n tra d ic
t i o n , l e t us f i r s t examine and compare these two i n s t r u
ments. The Blacky t e s t purports to measure unconscious
d riv e s . Scores are re p o rte d in terms of these basic
d riv e s . That i s , the su b je c t re c e iv e s what amounts to a
p r o f i l e . He may be very strong on O ral Eroticism , f a i r l y
strong on Oral Sadism, weak on Anal E xpulsiveness, e tc .
The stim ulus in each case is a f a i r l y obvious r e p r e s e n ta
t i o n of the drive which is to be measured. The theory is
t h a t the su b je ct w i l l fe e l fre e to give p e r tin e n t fa n ta s y
m a te ria l because he can d isp lace h i s f a n ta s ie s onto animals
which are in psychosexual s it u a t i o n s perm issible for a n i
mals in p u b lic but not for humans. The s tr a te g y of the
t e s t , as in most of the p ro je c tiv e d e v ices, is t o give the
su b je c t the opportunity to drop h is guard so t h a t the in
v e s t i g a t o r can catch a glimpse, however b r i e f , of h is un
conscious motives or on the other hand, to keep up h is
guard and d isp la y h i s . d e fe n s e s ,
In the scoring of the Blacky, pluses are awarded
for strong evidence of the d riv e . Pluses are a ls o awarded
fo r defensive maneuvers such as d e n ia l and r e a c tio n forma-
89
tio n . Projective devices, such as the Blacky Test, create
a r t i f i c i a l s tr e s s s itu a tio n s . The subject can e i th e r
respond by revealing the drive or he can fig h t back de
fensively. One may in fe r the existence of a problem in a
p a rtic u la r area from observing the struggle between impulse
and defense on the t e s t and generalizing to the r e a l life,
s itu a tio n .
The o r a lit y questionnaire provides a d iffe re n t set
of data e n t ir e ly . This instrument provides information not
about defenses th a t are directed against impulses, but
ra th e r character defenses, or they are sometimes ca lled
character t r a i t s . I t provides information not in terms of
repression, denial, and re ac tio n formation, but r a th e r in
such terms as p a s s iv ity , ambition and autonomy. The de
fenses against impulses are not peculiar to any one im
pulse. Moreover, they only come into play when the in d iv i
dual fe e ls himself to be in danger of a breakthrough of
impulse. The feeling of danger, the cue, is called anxiety
and the defense is designed to p ro te c t the individual
against anxiety.
The character defenses or t r a i t s on the other hand
are in d icatio n s of a way of l i f e . They represent the t o t a l
adjustment of the individual to ea rly problems in psycho-
sexual development. For example, the person who has .devel
oped a passive o rie n ta tio n -is one who learned the lesson in
the i n f a n ti le feeding s it u a ti o n th a t a l l good things come
90
to him who w aits. He has learned th a t he is e n t i t l e d to
the good things in l i f e without having to work for them;
th a t the world w ill provide.
The o r a l i t y questionnaire, then, produces a d if fe r
ent type of p r o f il e . The in d ividual is described in terms
of scores on each of several t r a i t s . These t r a i t s are on a
d escrip tiv e level ra th e r than a dynamic one. They do not
portray the individual in terms of the in te rp lay of forces
and counterforces, of cathexes and countercathexes, of
drives and defenses. The in dividuals who scored high are
those who are d e s c rip tiv e ly the most sim ilar to the oral
types which emerged from Goldman'S c lu s te r an aly sis (1948-
49) and to the oral types, in terms of combinations of
t r a i t s , described in the psychoanalytic l i t e r a t u r e .
This leads us to the apparent co n tra d ictio n in the
two sets of data, the Blacky t e s t and the questionnaire.
According to the r e s u l t s , the Control group appears to be
more disturbed by oral c o n flic ts than the experimental
groups. On the other hand, the experimental groups seem
t o f i t more closely the oral character prototype than does
the Control group.
Perhaps.the paradox can be resolved by conjectur
ing about the meaning of h o s p ita liz a tio n and medical care
for each group. Let us assume th a t medical care repre
sents being cared fo r, nurtured and being the passive
re c ip ie n t of supplies. The h o s p ita l p atie n t is in many
ways helpless. He cannot do for himself but must depend on
others to do for him. This is reminiscent of the experi
ences of infancy. I f h o sp ita liz a tio n fosters regression,
then i t is lik e ly to awaken long dormant passive oral fe e l
ings and th eir attendant c o n flic ts. For the oral charac
te r , however, h o s p ita liz a tio n may be e n tire ly consonant
with h is passive o rie n ta tio n because he -expects to be taken
care of. Even i f he is inclined to p ro test h is independ
ence as Alexander (1950) claims, h o s p ita liz a tio n enables
him to "sneak in a certain amount of th i s taking in"
(Renneker, 1956) by being trea te d for a p erfectly resp ect
able physical i l l n e s s . One is reminded of Alexander's ob
servation that u lc e r p atien ts frequently remit spontane
ously when they are hospitalized simply because the tension
producing conflict is temporarily removed, or ra th e r, the
p atien t is removed from the conflict-arousing environmental
situ a tio n . Thus one could say that h o s p ita liz a tio n may be
ego syntonic for the oral character, e ith er because he feels
he has i t coming to him or because i t provides a socially
acceptable way of reliev in g tension. Even for the outpa
t i e n t s , who were a l l service-connected, and who were report
ing regularly for checkups, the -se.curity of having a place
to go i f they were i l l , the knowledge th a t they would be
cared fo r, may have been equivalent for them t o being in
the hospital.
For the /control subjects, on the other hand,
92
h o sp ita liz a tio n may have awakened old oral dependent con
f l i c t s . For a normally activ e, independent individual, the
experience of enforced passiv ity could conceivably 'arouse
tension. Thus i t would seem th a t oral co n flic ts are more
in evidence in individuals who have not developed oral
character defenses.
Let us now see what application the above formula
tion has for the present perceptual experiment. ' Inasmuch
as the re s u lts are in the main inconclusive, they must be
interpreted even more cautiously and te n ta tiv e ly than were
the r e s u lt s of the two au x iliary measures.
The comparison between the pre-Blacky t e s t (base
lin e ) scores and the post-Blacky t e s t scores (perceptual
vigilance) was intended to demonstrate subliminal percep
tio n of an oral stimulus. Inasmuch as the scores on the
post-Blacky presentation ’ were lower than on the baseline
s e rie s , one can say th a t there was no evidence t h a t percep
tu a l s e n s itiv ity to oral e ro tic stim ulation occurred. The
differences between groups which might well have occurred
on a chance b a s is, seemed to favor the control group.
That i s , of the 25 subjects in the control group, 11 in
creased th e ir scores on the second presentation, 13 scored
lower and one subject showed no change. The t a l l y for the
obese groups shows three plus differences, nine minus d if
ferences and three no changes. The ulcer group showed nine
pluses and 16 minuses. In other words, the control group
93
came the closest to showing no difference on the basis of
a comparison of signs, while the experimental groups tended
more in the d ire c tio n of lower post-Blacky t e s t scores.
The above trends were al.so in evidence in the com
parison of the group means for the more ego-involving,
task-oriented" phase of the experiment. The ta sk of finding
the oral picture was designed to t e s t the hypothesis of
perceptual defense. Here the differences between groups
did not a tta in the re q u is ite .05 le v e l but the differences
were in the same d ire c tio n as on the previous se rie s , the
control group receiving the highest mean score.
In the lig h t of the above r e s u lt s , one might con
je ctu re th a t instead of measuring two d iffe re n t phenomena,
namely perceptual vigilance and perceptual defense, the two
sets of operations may have been measuring the same phenom
enon. This in tu rn raises the question as to what the per
ceptual experiment was measuring.
The ra tio n a le for the use of the tach isto sco p ic
procedure was the assumption th a t perceptual defense is the
experimental equivalent of the psychoanalytic concept of
ego defense. More sp e c ific a lly , perceptual defense is
alleged to be the counterpart of repression. That is , the
same mechanism th a t accounts for the fa ilu re to r e c a ll ac
counts for the fa ilu re to perceive since perception in
volves a frame of reference or an apperceptive mass.
If perceptual defense does indeed imply repression,
then i t is p e rtin e n t to discuss fu rth e r the nature of re -
*
pression and i t s r e l a t i o n to character development and
symptom formation. The f i r s t point to be m a’de is th a t r e -
s
pression is not a pathological phenomenon per s e . A cer
t a i n amount of rep ressio n is to be found in the h e a lth ie s t • -
of in dividuals. I t can be considered a device designed to
p ro tect the ego from being bombarded by excessive stimula-' •
tio n both from w ithin and .without.. .What is pathological-
is the f a ilu r e of rep ressio n , the r e tu r n of the repressed.
One might i l l u s t r a t e the process by using the time honored
p rin cip le of hydraulics. Repression might be thought of as
a dam with the basic impulses representing the water. The
dam may develop a slow leak and allow impulses to tr i c k l e
through, r e s u ltin g in a c e rta in amount of anxiety.. As th e .
crack in the dam becomes wider, more anxiety is aroused.
When the level of anxiety becomes unbearable, secondary •
barricades in the form of defense mechanisms, or symptoms are
erected. If these should f a i l , then the .dam b u rs ts , t h e ’
ego becomes flooded and p s y c h o s is .r e s u l ts .
To apply these principles, to the present .study, the
d ifferen ce s between groups on the Blacky t e s t and on the
O ra lity questionnaire may represent d ifferences between
successful and unsuccessful rep ressio n . That i s , for the
oral ch aracters, the high scorers on the -questionnaire,
there was l i t t l e t h a t was th rea ten in g for them in the en
forced dependency of h o s p ita liz a tio n or o u tp atien t t r e a t -
95
ment. T herefore, t h e i r performance on the Blacky t e s t
f a ile d to re v e a l s i g n i f i c a n t breakthroughs of o ra l e r o t i c
o •
im pulses. In o th er words, the low le v el_ o f d istu rb a n ce
r e l a t i v e to the Control- group may re p re s e n t su c c e s sfu l re -
• " *
p re ssio n . ’ * .
•_ On the other hand-, the Control group, a l l of whom
. . c
were, h o s p it a l patients-, was r e l a t i v e l y non-oral in charac
ter- s tr u c tu re according to the. o r a l i t y q u e stio n n a ire . For
them, the r e g re s s iv e experience of h o s p i t a l i z a t i o n may
have been more th re a te n in g than fo r the o ral groups. In
other words, o r a l i t y may not have in te g ra te d in to t h e i r
c h a ra c te r s tr u c tu r e the way i t would seem to have been for
the o ra l groups. Thus, the r e l a t i v e l y high r a t e of d i s
turbance of the Control group may re p r e s e n t a p a r t i a l
f a i l u r e of re p re s s io n .
This argument might a lso be applied to the percep
t u a l experim ent. Again, because of the f a i l u r e of group
m ean 'd ifferen ces to achieve the re q u is ite , s ig n ific a n c e
.le v e l, the follow ing statem ents must be ..regarded-as. specu
la t i v e ..If perceptual' defense is th e co u n terp art of r.e-':
p re s s io n , then i t is* re a s o n a b le ' to s u g g e s t'th a f t h f dire'c-
tio n of d iffe re n c e s (lower scores f o r the o ra l groups on
both p a r ts of th e p e rce p tu a l experim ent) may, a s 'h a s been
suggested fo r the Blacky t e s t r e s u l t s , re p re s e n t the d i f
ference between su c c e s sfu l and u n su c cessfu l re p re s s io n .
That i s , the same mechanism th a t on the Blacky t e s t sue-
96
c e s s f u lly warded o ff th e p ro d u ctio n of o r a l f a n ta s ie s a n d /
or such a s s o c ia te d mechanisms as d en ial and re a c tio n forma
t i o n may have p r o te c te d the o r a l c h a ra c te rs from p e rc e iv in g
« a
the s o - c a lle d tra u m a tic p ic tu re when i t was presented
t a c h i s t o s c o p i c a l l y . Tha't .is," i f r e p r e s s io n were success
f u l l y o p eratin g on the Blacky t e s t , th e re would be r e l a
t i v e l y l i t t l e in the way of breakthrough o f o r a l im pulses,
and consequently l i t t l e n e c e s s ity for d e fe n siv e maneuvers.
S im ila r ly , r e p r e s s io n may have p a i n le s s ly screened out th e
p e rc e p tio n of o r a l i t y on the t a c h is t o s c o p i c experim ent.
Inasmuch as th e d if fe re n c e between th e Ulcer group
and th e C ontrol group on the q u e s tio n n a ire and on the p er
c e p tu a l defense phase of the experim ent was not as g r e a t as
t h a t between th e Obese and the Control group, the q u e s tio n
is ag ain r a is e d concerning the homogeneity of the Ulcer
group. When th e Blacky p ro to c o ls were s o r te d in to prim ary
and r e a c tiv e c a te g o r ie s , a d if fe re n c e in th e mean P.D.
sco res between the 14 primary s u b je c ts and the 11 r e a c tiv e
s u b je c ts of 3 .25 was found. The r a t i o of 1.76 was not
s u f f i c i e n t to r e j e c t th e n u ll h y p o th e sis. However, in -v iew
of th e sm all N's r e s u l t i n g from t h i s categorization", i t is
conceiva’ bTe t h a t , a l a r g e r i n i t i a l sample of u lc e r p a t i e n t s
* 0
may have p o in ted up th e presence of the two d i f f e r e n t v a r i
e t i e s of u lc e r s u b je c ts . I t i s of i n t e r e s t t h a t the mean
score for th e " re a c to r s " was v i r t u a l l y i d e n t i c a l w ith t h a t
of th e Obese group, w hile the mean for th e "prim aries" was
97
alm ost the same as t h a t of the Control group. This r a i s e s
i n t e r e s t i n g questions about the o p eratio n of re p re s s io n or
the absence of i t in th e two ty p es of u lc e r p a t i e n t , es
p e c ia lly in view of the fa c t t h a t both groups were eq u ally
n o n -d istu rb ed on the Blacky t e s t . I t might be th a t the
o r ig in a l hypothesis about the obese p a tie n ts may apply in
s te a d to the primary u lc e r p a tie n t. That i s , the accep t
ance of o r a l i t y obviates the need for r e p re s s io h of per
c e p tu a l defense. The s im ila r scores of the primary u lc e r
s u b je c ts and the c o n tro l su b je c ts may mean two d i f f e r e n t
th in g s . Since the c o n tro l su b je c ts showed strong c o n f lic t
over o ra l e r o t i c impulses on the Blacky t e s t , t h e i r P.D.
sco res may re p re s e n t th e f a ilu r e of re p re s s io n . For the
primary u lc e r s u b je c ts , on the other hand, with the r e l a
t i v e absence of c o n f lic t over o r a l i t y , the P.D. scores may
r e p re s e n t the lack of a need to re p re s s .
The comparison of the r e a c tiv e u lc e r su b je c ts with
th e obese s u b je c ts re v e a ls s tr ik in g s i m i l a r i t i e s . Not only
•were t h e i r P.D. means v i r t u a l l y id e n tic a l but they showed
p r a c t i c a l l y the same r a t i o of d istu rb a n ce to n o n -d istu rb -
ance (1 :2 ). This would seem to in d ic a te th a t the absence
of d istu rb a n ce on the Blacky t e s t and the r e l a t i v e l y low
P.D. scores may re p re s e n t for both groups su c cessfu l re
p re s s io n of o r a l i t y r a t h e r than i t s acceptance. This in
t u r n suggests th a t th e obese person, in c o n tra s t to what
was hypothesized, may be more of a re a c tiv e c h a ra c te r lik e
98
the c l a s s i c a l u lc e r p a tie n t. I f so, one would expect to
o
fin d a high incidence of masculine s tr iv in g among obese
a
persons.
<
I t would be presumptuous, in the l i g h t of the wel
t e r of c l i n i c a l evidence to the c o n tra ry , to conclude, on
0
f t
the b asis of 11 -cases, t h a t A lex an d er's th eo ry of the
fo c a l c o n f lic t in p ep tic u lc e r is in c o r r e c t.= I t seems more
reasonable to* question the value of the. highly" s tru c tu re d *•
Blacky t e s t as a depth instrum ent’. i f the hypothesis' ad- ‘
vanced in th e d isc u ssio n about th e e f f e c t s of h o s p it a li z a
t i o n on the Cbntrol group is c o r r e c t, then i t would seem
t h a t the t e s t is more s e n s itiv e to s i t u a t i o n a l fa c to rs than
i t is to deep dynamic fo rc e s. This might a ls o account for
the f a i l u r e of the p e rc e p tu al experiment to dem onstrate
v ig ila n c e . I t w ill be r e c a lle d t h a t Blum’ s experiment with
co lleg e stu d e n ts involved im planting suggestions in the
s u b je c ts in order to dem onstrate p e rc e p tu a l v ig ila n c e
(1954). This would seem to in d ic a te th a t the ta c h is t o -
scopic use of the stim uli, as w ell as the stan d ard t e s t
method of p re s e n ta tio n may be su b je c t to experim ental manip
u la tio n or t r a n s i e n t changes in s e t , but not n e c e s s a rily
s e n s itiv e to b asic dynamic p a tte r n s .
Conclusions
The foregoing d isc u ssio n seems to bear out the f o l
lowing co n clu sio n s, some of them ad m itted ly q u ite specula-
99
t i v e .
1. Obese and u lc e r p a tie n ts seem to be more
ty p ic a lly o ra l as fa r as t h e i r i n t e r e s t s and a t titu d e s are
concerned than the Cbntrol group with which they were com
pared. They are also le s s d istu rb e d by exposure to oral
s tim u li. The obese and re a c tiv e u lc e r p a tie n ts are simi-
• °
la r in th a t .th e ir lack of disturbance seems a t tr i b u ta b l e
to the su c cessfu l operation of re p re ssio n . The primary
Ulcer p a tie n t is n e ith e r d isturbed by* the' c o n fro n ta tio n o . .
w ith an o ra l stim ulus nor does he fin d i t necessary t o . r e
p ress. These observations are n e c e s s a rily q u a lifie d by
the absence of an adequate co n tro l fo r the e f f e c ts of
h o s p it a li z a t io n . H o s p ita liz a tio n seems to have aroused
o ra l c o n f lic t in the co n tro l su b je cts while i t m 3ty have
had a te n sio n reducing e f f e c t on o ra l c o n flic t for .the .
o ral p a tie n ts . ‘ •
2. ° The conclusions, are.' fu r th e r q u a lifie d by the
apparent lim ita tio n s of the Blacky t e s t as an instrum ent
fo r re v e a lin g unconscious c o n f lic ts . I t seems lik e ly th a t
the t e s t may be s e n s itiv e to tr a n s i e n t moods and experi
ences but r e l a t i v e l y in s e n s itiv e to basic drives and con
f l i c t s .
CHAPTER VI
Summary
The purpose of the study was to explore s i m i l a r i
t i e s and d iffe re n c e s in p erce p tu al th resh o ld s of obese and
u lc e r p a tie n ts . Alexander (1948, 1950) ‘and the. Chicago
school of psychoanalysis have s ta te d on th e basis of th e i r
clin’ica.l in v e s tig a tio n s th a t male 'p ep tic u lc e r .p a tie n ts
are o ra lly ' fix a te d in d iv id u als whose p h y s io lo g ic .dysfunc
tio n is the end r e s u l t of a .c o n flic t between o r a l ■ dependent
* . ° .j ^
s tr iv in g s and the pressure th a t th e c u ltu re brings to b e a r "
on these, in d iv id u a ls to be. a g g re s s iv e , masculine and inde
pendent. . Alexander (1947) a l s o ■ id e n t i f i e s a subgroup o f .
u lc e r p a tie n ts, who«haye the same o ral yearnings but have
not in te r n a liz e d the c u ltu ra l, emphasis on m asculinity. In
these i n d i v i d u a l s t h e c o n f lic t i s not an in te rn a l one but
r a th e r with an e x te rn a l environment which refu se s to y ie ld
the needed o ra l su p p lies. In both .groups, the d ep riv atio n
of a f f e c tio n a l needs in infancy is seen as an important
c o n trib u tin g f a c to r to the fixation..
Bruch (1957), Bychowski (1950), and Rascovsky
(1950) have d escrib ed th e obese person as being an o ra lly
f ix a te d , em otionally starv e d in d iv id u a l who, lik e the ulcer
p a t ie n t , has su ffe re d sim ila r d ep riv a tio n of in f a n ti le
100
101
a f f e c t io n a l needs. In the case of the obese person, the
dysfunction is one of increased a p p e tite r e s u ltin g in the
s u b s titu tio n of food for a f f e c tio n .
* , *
Inasmuch a s .o r a l f ix a tio n im plies' the s tr iv in g of
6 •
* • " •
o ra l impulses to reach consciousness, i t was p red icted th a t
. * * ( .
.both u lc er and obese p a tie n ts would show a heightened sen-
. s i t i v i t y to ora‘ 1 s ti m u li.’ However, the. re a c tiv e u lcer
• • * . > » * '
p a tie n t w ould'also tend to -w a rd 'o ff the perception of o ra l
s tim u li "because, of h is in te rn a liz e d s tr iv in g fo r independ
ence, while- the primary u lcer p a tie n ts and the obese p a t i
e n ts , who are more acceptant of t h e i r o ral needs, would be
le s s defensive about them than the re a c tiv e u lc e r p a tie n ts .
, S p e c ific a lly i t was hypothesized: (1) On an uncon-
scipus .level, the o r a lly f ix a te d groups (the obese and the
•two‘groups of u lc e r p a tie n ts ) would have a lower perceptual
•.threshold to’ o ra l s tim u li than a co n tro l group. (2) On a
preconscious :l'eve_l, =the. re a c tiv e .ulcer p a tie n ts would show'
a -higher p erceptual th re sh o ld than e ith e r the primary u lc e r
subje.cts, the obese su b je c ts, or the co n tro l su b je c ts.
• .
. . o Method
0 *
The method fo r te s tin g the hypotheses concerning
v ig ila n c e and defense was th a t of ta c h is to s c o p ic presenta
tio n of the Blacky P ictu res (1950, 1954). Four Blacky p ic
tu r e s were flash e d sim ultaneously on a screen a t a speed
w ell below the p erceptual th re sh o ld of the su b jects for a
s e r ie s of 48 t r i a l s . For each t r i a l , the four p ic tu re s
were th e same but t h ^ i r r e l a t i v e p o s itio n d if fe re d from
o
th a t of the previous t r i a l . One of th e four .p ic tu re s was
Cartoon I , Oral Eroticism.^ The other th re e were s e le c te d
• o , *
• 9 *
on th e basi§ of approxim ately .equal p h y sic a l .stim ulus
• a • *
• • • . .
value. . For-the. f i r s t , s e rie .s 'o f 48 t r i a l s t h e * , su b je c ts •.
• • " • , . . . • , ’ • °
* . • • ’’ ‘ * * . • * . - *
■were "in stru c ted .to ".designate’ by pos-'itidn which p ic tu re ..
stood . out ;the-m ost The f i r s t se rie s' of t r i a l s 'w a s f o l
lowed by the stan d ard group a d m in is tra tio n of- the Blacky
t e s t on the cartoons used in the ta c h is to s c o p ic experiment
in o rd er to give the s u b je c ts .th e o pportunity fo r a f u l l
exposure to each cartoon. The second s e r ie s of t r i a l s f o l
lowed the a d m in is tra tio n of the Blacky t e s t w ith in s t r u c
tio n s id e n t i c a l to those of the f i r s t s e r i e s . For the
th ird - series., the speed of exposure was reduced to approxi
ma-te.ly th re sh o ld , value and the i n s t r u c tio n s were changed.
The* s u b je c ts were' asked -to. f ind’ .the' .O ral. Etbtic.ism• picture.
The purpose of s e rie s 1..w a s ’t o ‘e s t a b l i s h ‘ .a ba'seline 'for ... .
• » * . ^ ■ . . .
comparison with s e r ie s 2 .' I f a s ig n if i c a n t ’ -'number of .e x - .
• • ‘ :
p erim ental su b je c ts in c re a se d t h e i r O ral Eroticism" scores ’
1 « * * *
on s e r i e s 2 over t h e i r O ral E roticism scores on s e r ie s 1,
a f t e r exposure to the s tim u li, then th e hypothesis of per
c e p tu a l v ig ila n c e would be supported. The hypothesis con
cerning p e rc e p tu a l defense was to be t e s t e d by comparisons
of group means. A group mean fo r the u lc e r group s i g n i f i
c a n tly lower than the mean fo r the c o n tro l or obese groups
103
would support the hypothesis of p ercep tu al defense.
An a u x ilia ry measure of o r a l i t y was a q u estio n n aire
which concerned i n t e r e s t s and a t t i t u d e s ty p ic a l of oral
c h a ra c te rs (Goldman, 1948-49). The purpose of the ques-
♦
tio n n a ire was to determine how "o ral" the obese and u lc er
• o
groups were in comparison to the co n tro l group.
F in a lly , a rough measure of in te llig e n c e was ob
ta in e d -in • order .to c o n tro l for p o ssib le d iffe re n c e s in
• 0 • «
i n t e l l e c t u a l le v el... . ..
The su b je cts were 65 male p a tie n ts of Veterans
*
*
A dm in istratio n medical f a c i l i t i e s . The. Control group con
s is te d of 25 p a tie n ts h o s p ita liz e d on the s u rg ic a l wards of
° B O
a general medical and su rg ic a l h o s p ita l. The. Ulcer group
of 25 p a tie n ts co n sisted of 16 p a tie n ts frpm the sa°me hos-
a 0
p i t a l and 9 from a V.A. o u tp a tie n t f a c i l i t y ." The Obese
• group numbered, 15, 3 h o s p ita liz e d ^ a n d .12 o u tp a tie n ts . The
co n tro l; su b ject s'-'had., negative .ulcer, h i s t o r i e s ’ an°d were_
w ith in normal height and w eig h t.lim its according to the
M etropolitan Life Insurance ta b le s .(1950). The Ulcer group
* * • * • * •
also' f e l l w ithin'norm al height and weight lim its . The
Obese group had negative ulcer h i s t o r i e s and each su b ject
was a t l e a s t 25 per cent overweight. Medical h i s t o r i e s of
a l l su b je c ts were screened to r u le out psychosis or psycho-
n e u ro s is .
R esults
104
A ll th ree groups received lower scores on the post
exposure s e rie s than on the b aseline s e rie s . Hosever, only
for the Obese group was the d iffe re n c e s ig n i f ic a n t . The
d ire c tio n of change in scores was opposite to th a t” pre
d ic ted for p ercep tu al v ig ila n c e . D ifferences between
groups were not s ig n if ic a n t.
o
For the p ercep tu al defense phase, a t e s t for homo-
e
geneity of the Ulcer group was f i r s t mad°e. The Blacky t e s t
o
p rotocols were so rted on the. b asis of t h e i r responses in to °
6 ® 9
e ith e r a primary or" a re a c tiv e category. The perceptual
. •
defense scores for the two subgroups were th e n compared.
* G Q 6
Since the d ifferen ce between subgroups Was not s ig n if ic a n t,
th e hypothesis of homogeneity was accepte'd. Both the Ulcer
. ' ° . 0
group mean and the Obese group mean were lower than the
* • o
Control group mean but not’ s ig n i f ic a n t ly s# o.
* *
The Control group showed si*gnificantly more evi-
dence of o ral conflict* on fhe Blacky t e s t than e ith e r the
e
» e
Ulcer group alone .or the combined ojcal groups. This was
«
contrary to the hypothesis th a t the oral groups should show
more disturbance on the Oral E roticism dimension than the
o
Control group. There was no d iffe re n c e between groups on
e
the Oral Sadism dimension.
The Obese group and the Ulcer group each showed
>
more evidence of o ral i n t e r e s t s , a t t i t u d e s and re p o rts of
behavior than the C ontrol group. However, only the d if f e r
ence between the Obese group and the Control group was sig -
n i f l e a n t .
Conclusions
The experiment fa ile d to demonstrate a mechanism
of p erce p tu al v ig ila n c e . Rather i t is lik e ly t h a t both
th e v ig ilan c e and defense phases were measuring p erce p tu al
e «
defense. There was a tendency fo r the u lc er and obese sub-
e
o
j e c t s to show more p erceptual defense a g a in st b r a l i t y than
th e non-oral co n tro l^ . This tendency was re in fo rc e d by
°
th e r e s u lt s of the Blacky t e s t on the dimension of Oral °
• •
o
Eroticism . The Control group "showed more distu rb an ce in
t h e i r fan ta sy .productions than e ith e r 0 the Obese or Ulcer
groups.
I t was speculated th a t normally active" in d iv id u a ls
may fin'd h o s p it a li z a t io n more d istu rb in g than do „ individu-
• »
a l s ’ W ho are oriented toward passive r e c e p tiv ity , "Thus
h o s p i t a l i z a t i o n would be more lik e ly to arouse c o n f lic t in
o
the oral sphere for non-orally o rien te d people th a n i t
might for those who have a predominance of o ral in t e r e s t s
o
and a t t i t u d e s . The tendency for the Obese and Ulcer groups
o
on the one hand to show more p ercep tu al defense than the
Control group suggests su c cessfu l re p re ssio n on th e part of
the former as opposed to unsuccessful re p re ssio n on the
p a rt of the l a t t e r . These conclusions must be regarded as
106
t e n t a t i v e because of the f a ilu r e t o control fo r h o s p i t a l
iz a tio n .
The above fin d in g s fu rth e r suggest t h a t the Blacky
t e s t may be more s e n s itiv e to t r a n s i e n t f lu c tu a tio n s in
th e l i f e s it u a ti o n of su b jects th a n i t is t o b asic con
f l i c t s .
o
o
R E F E R E N C E S
o
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Perceptual Defense And Somatization: A Comparison Of The Perceptual Thresholds Of Obese And Peptic Ulcer Patients
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