Comments on the Metapsychology of Somatization1

In 1946, while I was engaged in a pilot study which attempted to investigate various dermatological entities by analysis of representative cases, a twenty-two-year-old female in her fifth month of pregnancy was admitted to the skin ward of Bellevue Hospital with the diagnosis of a generalized atopic eczema. Her extremities and her face were affected most, but hardly any part of her body was free of lesions. There was extensive lichenification and secondary infection. Her skin was so thick that it was difficult to find a vein for a blood test. She suffered from intolerable itch, culminating in attacks which mostly occurred at 8 or 11 P.M. and were accompanied by extreme anxiety. Only very high doses of chloral hydrate brought some relief. She was not aware of cases of dermatoses or of any manifestation of the allergic state in her family. She did not know exactly when her skin lesions started but remembered being treated for them at the age of six. During her analysis it became apparent that she had had the first skin eruption at the age of one and had started with typical lesions in the cubita and poplitea at the age of three. At nine the lesions appeared on her face. The first generalized outbreak occurred when she was fourteen and a half years old. Since then she had spent a good part of her life in various hospitals.

During the initial trial period it seemed rather doubtful whether this case could be approached analytically. It was extremely difficult to get this patient to talk. She spoke in very primitive short sentences, with a peculiarly harsh voice. It sounded a little bit like barking. She was extremely distrustful. Her intelligence seemed limited, her educational level was quite low. It soon became evident that she was putting up the strongest possible defense against any positive transference. She was unable to follow the basic rule.

The present severe exacerbation of her disease had coincided with her marriage. She had been