Meeting of the Psychoanalytic Association of New York

February 24, 1975. THE BOOK OF THE "IT" REOPENED: PSYCHOANALYSIS AND PSYCHOSOMATIC MEDICINE (First Annual Melitta Sperling Memorial Lecture). Peter H. Knapp, M.D.

After reviewing the development and growth of psychosomatic medicine, Dr. Knapp suggested that we attempt to integrate the concepts of learning theory with psychoanalytic concepts in order to understand the conundrum of psychosomatic symptoms. The contributions and ideas of Groddeck were considered, particularly Groddeck's emphasis on the body's symbolically expressing psychological conflict and on illness as having a purpose—"to resolve conflict, repress it or punish sins." Knapp then pointed out that in the "dual Freudian heritage" ("meaning" and "force"), meaning deals with the symbolic aspects of behavior while force focuses on the energies assumed to be inherent in the organism and problems of release and management, especially in conflictual states. The concept of "meaning," Knapp feels, was developed by Freud to explain conversion symptoms, while "force" led to the Aktualneurose. The symbolic manifestations of the purpose and conflict in psychosomatic illness are illustrated in several clinical vignettes which pinpoint psychological factors as causative in physical illness.

Knapp then postulated that the appearance of psychophysiologic manifestations of selective learned dysfunction "represents a symbolic learned reflection of an individual's past experience or the expression of learned and planned future intentions." The two major paradigms in learning theory are the Respondent (also known as Pavlovian, classical, or Type 1) and the Instrumental (also known as operant, Skinnerian, or Type 2). In respondent conditioning, "the stimulus precedes the response; it is initiated by the environment and follows as an automatic, quasi-passive response by the organism." In instrumental conditioning, "the response precedes the stimulating or reinforcing event; it is initiated quasi-actively by the orga