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The observations and concepts presented in this paper were made and formulated over a period of some fifteen years, during an attempt to understand better the relationships between psychological variables in the so-called psychosomatic disorders. In those years as a teacher, psychiatrist, and analyst I had grown more and more dissatisfied with what I read, heard, or said myself on the subject. Yet I realized that I had collected and kept talking about a number of seemingly disconnected clinical observations and theoretical ideas which I felt were related in some way. But try as I might I did not know how to make them fit together. About eight years ago I undertook the analysis of a young married woman who had a phobia about becoming pregnant, and who developed, during her analysis, symptoms of rheumatoid arthritis. It was in the course of this analysis that most of my amorphous thoughts crystallized for me.
This paper is mostly concerned with reporting the analysis of that woman, and how her associations inevitably led me to the conclusion that sleep as a gratification and withdrawal into sleep played a major part in her symptomatology and character structure. As I understood that fact, I gradually realized that the unrelated observations and ideas which I had collected over the years admitted a common denominator: they were or could be an unconscious attempt in the face of intolerable stimuli to protect oneself by falling asleep fully or partially at the symbolic as well as the physiological level.
I now understood, for example, why many years ago in Rochester, while observing Monica W., the baby with oesophageal atresia so carefully and extensively studied by G. Engel and F. Reichsmann (1956), I found myself vaguely dissatisfied when she or her mechanisms of defence were described. I felt that somehow, somewhere, a part was missing in that picture. I reasoned that the maintenance of life requires positive elements; gratifications and pleasure are necessary