Cushing's Disease as a Psychosomatic Disorder: A Selective Review of the Clinical and Experimental Literature and a Report of Ten Cases

CUSHING'S DISEASE AS A PSYCHOSOMATIC DISORDER: A SELECTIVE REVIEW OF THE CLINICAL AND EXPERIMENTAL LITERATURE AND A REPORT OF TEN CASES SANFORD CIFFORD, M.D* and JOHN G. GUNDERSON, M.D.f I. Introduction The following clinical hypothesis is proposed: Cushing's disease represents a psychosomatic disorder, defined as a pathophysiological reaction to bereavement that occurs in predisposed individuals with lifelong disturbances in personality structure, homeostatic self-regulation, and neuroendocrine responsiveness. This hypothesis is based on our observations of ten patients, whose histories are presented. It is limited to Cushing's disease, as a clinical entity among variants of hyperadrenocorticism due to all other causes, and designates, according to the current concepts of Thorn [l] and Liddle [2], a hypothalamic-pituitary disturbance in adrenocortical regulation. Our clinical observations are introduced by a selective review ofclinical, experimental, and theoretical literature, which includes references to other forms of adrenocortical overactivity and data from other fields of investigation that have an indirect bearing on a psychosomatic concept of Cushing's disease. Although the relation between normal growth and development and the effects of early experience on adult behavior and psychoendocrine maturation is still a speculative one, these data from other fields provide the materials from which an adequate developmental theory ofadrenocortical disturbances may emerge. The introductory review will include: (1) Cushing's 1913 address on psychoendocrinology and his original observations on the syndrome that * Assistant clinical professor of psychiatry, Harvard Medical School, Boston, Massachusetts. Present address: Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, Massachusetts 02115. We are grateful to the Proctor Fund Committee ofHarvard Medical School for financial assistance. t Teaching fellow in psychiatry, Harvard Medical School, Boston, Massachusetts. I69 bears his name, (2) clinical studies of Cushing's syndrome by internists, surgeons, and psychiatrists that describe emotional disturbances, (3) the pituitary-adrenocortical stress response and its relation to the pathophysiology ofCushing's disease, and (4) the theoretical implications ofresearch in related fields for a psychosomatic concept ofCushing's disease. From the records ofsixty patients with Cushing's syndrome due to all causes, hospitalized between 1951 and 1963, the ten patients with the fullest psychiatric data were chosen for presentation. All ten patients proved to represent Cushing's disease, with a hypothalamic-pituitary basis for increased adrenocortical secretion. Nine patients showed diffuse, bilateral hyperplasia at adrenalectomy or autopsy, and in the tenth patient, who had a unilateral adrenocortical adenoma, there was evidence that she also had a hypothalamic-pituitary disturbance. A concept ofCushing's disease as a psychosomatic disorder implies that both the emotional disturbances and the physical changes ofhypercorticism are the end-results ofpreexisting emotional conflicts that disturb the neurophysiological regulation ofthe pituitary-adrenal system. Three components in this complex psychophysiological interaction will be described: (1) predisposing features of individual personality structure, usually lifelong and including the effects ofchildhood trauma; (2) precipitating life experiences, usually ofseparation or bereavement, that mobilize preexisting conflicts and induce an excessive adrenocortical response; and (3) acute psychophysiological and metabolic effects of increased adrenocortical activity, influenced by the patient's individual personality and current life situation. Some speculations about other predisposing factors will be offered , including individual variations in neurohumoral reactivity to stress and in the tissue response to a given Cortisol level. II. A Review ofthe Clinical and Experimental Literature a. cushing's original concepts In 1913, Harvey Cushing first presented his concept of an interaction between emotions and endocrine secretions in his address [3] at the opening ofthe Phipps Psychiatric Clinic. He assumed that his audience, already familiar with Cannon's discoveries of 1911, would readily agree that "psychic conditions profoundly influence the discharges from the glands of internal secretion." But, he continued, "we are on a much less secure footing when we come to the reverse, namely the effect on the psyche and 170 Sanford Gifford andJohn G. Gunderson · Cushing's Disease Perspectives in Biology and Medicine · Winter 1970 nervous system ofchronic states ofglandular overactivity and underactivity ." Emphasizing both aspects of a psychoendocrine interrelationship, Cushing suggested that for each "primary secretory derangement . . . there may lurk in the background, particularly in the case ofthe glandular hyperplasias, either some underlying biochemical disorder of nutritional, infectious or otherwise toxic sort, or some primary derangement of the...