Abstract
Somatic illness always involves some object loss for the patient, which means that each somatic patient has his own task of mourning work to do. In order to support this, psychoanalytically understanding of somatic patients is essential in psychosomatic medicine. This report illustrates its clinical application and some findings are noted. First, key concepts are reviewed, such as object loss, mourning work and escape from it, especially through manic defense. Based on them, two clinical cases are shown, which had been brought in from physicians. (1) Case 1 : Nephrotic syndrome (minimal change group). At the onset, she was a junior college student studying to be a kindergarten teacher. She was attacked by anxiety and apathy soon after giving up her course, and was introduced into supportive psychotherapy and later, psychoanalytic psychotherapy. The general understanding would be that the loss of aim and health had brought about her condition as a reactin to object loss. Nevertheless, another former object loss was revealed through psychotherapy ; the inner loss of parents in adolescence. Her diligence to become a kindergarten teacher could be considered a kind of manic defense against that object loss. The aim itself could be an identification with her mother from whom she was separating. Her defenses were broken down by physical illness, and her mental symptoms emerged. This individual understanding was made possible from the psychoanalytic view. (2) Case 2 : Diabetes mellitus. The patient was a middle aged, active housewife. She fell into a depressive state after severe diet regulation for DM. Pharmacotherapy was applied at first. She was gradually recovering from the depressive state, when she suddenly broke down and receded because of her inappropriate exertion. Then intensive interviews were set up to assess her psychological problems and reconsider the treatment. She had found it difficult to deal with her adolescent offsprings before the onset of DM, which was accompanied with increased consumption of food and beverages. This seemed to be a manic defense against inner object loss as a mother. Diet regulation caused her to give up the defense way, which brought on the depressive state. Further, she had had several deprivations from the early stage of her life. Her way of coping with them was mainly by manic defense, and mourning work for them had been unfinished. What was demanded therapeutically was introducing her to mourning work so that she could abandon manic defense. On this understanding, psychoanalytic psychotherapy was started. In conclusion, with somatic patients, the role of past object loss which has not been worked through is emphasized. Some may lose mental stability when somatic illness deprives them of their defense mechanism against that object loss. Psychoanalytic understanding of their life history and their degree of maturity to manage object loss would contribute to providing adequate care, and give them an opportunity for mental maturation.
