J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.298 on 1 March 1984. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1984;47:298-301

Personal paper Idiopathic Parkinson's disease and depression: a psychosomatic view

CECIL J TODES From the Paddington Centre for Psychotherapy, Department of Children and Parents, London, UK

SUMMARY The link between idiopathic Parkinson's disease and depression is examined in the light of psychosomatic theory. A view of the condition is offered as a manifestation of chronic emotional disorder in an organic sense. Predisposition arises from bereavement and/or maternal failure in early emotional development.

James Parkinson,' in the original comprehensive the locus coeruleus being implicated in both.7 description of the disease that bears his name, con- In the preface to his classic monograph of 1817, cluded that "senses and intellect" were left unin- Parkinson offers an apology that "mere conjecture jured in the process. However, the literature in takes the place of experiment", but he felt it war- Protected by copyright. recent years, admirably reviewed by Tune et al,2 rantable in order to "excite the attention of those reveals that psychiatric disorder, including depres- who might be in the best position to obtain more sive illness, psychoses and cognitive deficits are a information about the malady". Stimulated by this frequent occurrence among patients (see also ref. 3). pragmatic viewpoint, I felt supported in presenting Mindham4 has shown that 90% of Parkinson my own personal experience of the illness.8 Though patients admitted to a psychiatric hospital had some only a single case, I thought a study in depth might degree of depression, while two-thirds of them were reveal useful clues about the illness in general. In diagnosed as having affective disorders. this present paper, I propose briefly to explore the The disablement and chronicity of Parkinson' s psychological consequences of bereavement in disease understandably produce a depressive reac- childhood, and to trace the connection through tion, but there exists a significant group of patients resultant endogenous depression to the emergence where the depression is an endogenous one. Celesia later on of the somatic condition of idiopathic Par- and Wanamaker5 in a study of 153 patients found kinson's disease. that one third had a form of depression. Warburton6 The concept of significant life events in the in a study of 140 patients referred for thalamotomy pathogenesis of illness, including depression, is one found that 60% of males and 18% of females had which has been developed and researched by Brown contemplated suicide and needed psychiatric treat- et al.9 In Depression and Loss he underscores the http://jnnp.bmj.com/ ment. In their review of the literature associating significance of death of the mother, experienced depression and Parkinson's disease Tune et al con- before the age of 11 in the genesis and quality of cluded that, although there is a disagreement as to subsequent depressive disorder. Quality refers to the relationship of the severity of Parkinson's dis- the profundity of an endogenous/psychotic depres- ease and the incidence and severity of depression, all sion in contrast to a reactive, that is, neurotic de- the studies they review had documented a relation- pression. The latter, less profound, Brown associates ship between Parkinson's disease and depression. with the loss of a mother by separation rather than Some authors have used this relationship to support the finality of death. on October 2, 2021 by guest. the catecholeamine hypothesis of depression with My personal experience of such a life event was the relatively sudden death of my mother when I Address for reprint requests: Dr CJ Todes, 38 Clifton Hill, London was 7 years old. Retrospective study revealed a fail- NW8 OQG, UK. ure to mourn, a pattern so frequently found in Received 7 June 1983 and in revised form 1 September 1983. chronic depressive disorders. An aphorism attri- Accepted 14 October 1983 buted to Maudsley says: "The sorrow that has no 298 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.298 on 1 March 1984. Downloaded from

Idiopathic Parkinson's disease and depression: a psychosomatic view 299 vent in tears makes other organs weep." causal relationship between the two, but rather an Mourning and grieving are not readily experi- analogical one.'4 The psyche/soma functions as a enced by children of that age, probably because the whole with reverberations in both directions. expectable psychological internalisation of parental McDougal writes about a group of patients in figures is not yet sufficiently complete to allow the whom there has been a failure in the infant-mother real parents to be relinquished, without overwhelm- relationship, producing the syndrome, alexithymia ing the labile ego. Psychological defences are (originally described by Nemiah and Sifneos'5), an automatically resorted to, including splitting and absence of affect which results from an inability to projection'° as the basis of magical thinking to deny put feelings into words and to cope with unconscious the underlying sense of hopelessness. Another fears, more akin to psychotic than to neurotic- outcome of loss referred to by Deutsch" is complete anxiety. inhibition of feeling. In severely alexithymic patients, all awareness of A normal child makes use of its fantasy and sym- affective pain or pleasure is eroded and a survival bol in order to deal with ordinary absence and sep- struggle is maintained against the experience of both aration from important people. The actual loss of pain and pleasure. The underlying disorder is mother during the critical phase of emotional masked and the most frequent presentation is in the development can have the effect of so stirring these psychosomatic realm. Marty, de Muzan, and David'6 fantasies, particularly aggressive ones, that they highlight the significance of what they call "opera- become replaced by inner deadness. In this way the tional thinking" as characteristic of the psychosoma- child avoids the primitive fear of inward collapse tic pattern. For example a patient when asked: and disintegrative abandonment. Growing up after " Were you upset when you ran over this woman and such. a loss, it may then proceed to restrict and sever baby?" (killed in an accident) replied, "No, I am affective links with people and to drain relationships insured against third party accident". Unlike of their meaning. It may further produce a super- psychotic patients they remain closely adhered to Protected by copyright. adaptation to reality with a deadened imagination facts and realities, but with marked lack of affect. and destruction of feeling in order to obliterate pain. In psychiatric literature, the term psychosomatic I subsume these effects under the rubric of "Emo- is employed in three different ways: processes, reac- tional Flat Earthers", people whose limited imagina- tions and diseases. Psychosomatic medicine may first tion forces them not to let go for fear of falling over deal with the psychological concomitant of physical the edge or destroying the boundary of their cir- disease, for example depression accompanying cumscribed world. Engel'2 in discussing the mind- myxoedema. Secondly, the psychological reaction body relationship contends that it is a principal func- subsequent to organic disease may be seen for tion of the mind to buffer the body by testing reality example in Parkinson's disease where the response and modifying experience in such a way that a threat follows the habitual way of coping with threatened can be perceived as symbolic rather than existen- debility. Perhaps the term somato-psychic is more tially present. The paradigm for this buffering role, appropriate. Finally "psychosomatic" is increasingly is of course the mother. She mediates the total used in understanding the production of a disease by physical and psychological needs of her infant in the the interaction of psychological and somatic factors. pre-verbal symbiotic phase.'3 This then moves This has barely been documented or explored for increasingly into psychological mediation with the Parkinson's disease which is generally regarded in child differentiating itself from its mother and text books as a pure organic disorder. http://jnnp.bmj.com/ becoming an individual in its own right. Possibly because Parkinson's disease is predomin- This developing mother-child interactive process antly an old persons' disease and because patients has vicissitudes within itself, producing strains and experience the illness in their sixties and on, not failures. Failure leads to an activation of anachronis- much thought is given to the pre-morbid personality tic flight/fight (manic) and conservation/withdrawal and life-events. This is further compounded by the (depressive) categories of innate neuro-biological assumption that if the organic explanation exists, patterns. These in turn provide a necessary, if not a then no psychological factors need be sought. It is sole condition for the emergence of somatic disor- my view, based on personal experience, that there is on October 2, 2021 by guest. ders later on. a group of patients in whom the psychosomatic ele- Somatisation can be defined as the visceral ment in the origins of their idiopathic Parkinson's expression of emotional conflict. It requires no great disease may be established. They will have had leap of the imagination to move from depression to long-standing endogenous depression emanating somatisation. The area of the psyche and the soma is from bereavement at an early age and/or failure of highly complex, mental and physical, being inexor- emotional development. That this view may or may ably bound, yet essentially different. There is not a not have helpful consequences in their treatment is J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.298 on 1 March 1984. Downloaded from

300 Todes at present unclear. It should not impede exploration One hardly wants to drag idiopathic Parkinson's dis- of this dimension in the same way as epidemiology ease from an unambiguous organic basis to one and pathology are scrutinised and used as compara- within the psychosomatic fold in order that patients tive studies. Barbeau has initiated a study of Parkin- justify blaming themselves for the illness. This is a sonians in Canada whose illness commenced under hazard to do with the wish for control in the face of the age of 40. Such a study should be carried out growing helplessness that all patients experience. wherever the illness exists. In the prevalent multifactorial view of the illness, A helpful conceptualisation of psychosomatics predisposition needs further clarification. that could be applied to further study of Parkinson's Duvoisin' S20 twin studies offer evidence against the disease exists in the work of Ursin."7 The theory, hereditary element in Parkinson's disease. Twin built upon psychology, physiology, endocrinology studies, however, cannot be used in the area of pre- and epidemiology addresses itself to the general disposition referred to earlier because, even if simi- standardised somatic response to psychosocial lar, the experience of twins after birth cannot be events. The profound changes resulting affect all identical and must be personal. And it is precisely endocrine and autonomic processes, brain function within the personal experience that the somatic has and muscle tension. This activation is the final com- its roots. mon path for all phenomena that lead to higher The actual mechanism producing cell degenera- activity in the cental nervous system and persists tion remains to be explored and understood. It has until the problem is solved. been found that striatal dopamine is already Activation in turn relates to pathology in two depleted by 50% or more before the clinical fea- ways: normal short-acting activation may be too tures of Parkinson's disease emerge,2' which points great a load for a diseased organ. The other aspect, to a lengthy "incubation" of the disease. One might more relevant here, is that sustained, long-lasting speculate on there being an upset in the auto- activation may produce somatic change. Activation immune response as in the case of young diabetics Protected by copyright. depends on individual perception of the stimulus and as has been suggested, as a link between some situation, the available response and previous cases of cancer and depression.22 The clue as to why experience with stimuli and responses. Processes the striatum is affected in Parkinson's disease may that he identifies as defence and coping are decisive lie in the recently-discovered association of peptide for resulting activation and the internal state of the neurotransmitters of pain with basal ganglial cells.23 organism. Activation is multi-varied and should be Elliott, Jenner, and Marsden24 postulate that the studied as such. association enables a protective motor response to Individual variance is related to personality traits be made to painful stimuli. This pathway could well affecting defence and coping. Risk groups can be be utilised in the depressive withdrawal from identified based on personality, somatic response psychosomatic pain of loss involving the sort of and life situations. The theory explains why life threat to survival described earlier in the paper. changes are related to somatic disease, but only with The personality of the patient plays a vital part in low correlation. This is due to coping potential of the response to the established condition and its Man. When this is exceeded, sustained activation therapy. It has been said that we experience illness occurs, which may result in pathology. Sustained in the style that we live our lives. Failure to develop activation is a good model for distressful events and subtlety of emotion and modulation through experi- chronic insoluble conflicts. Ursin quotes Weiner'8 ence will involve the individual in gross reaction pat- http://jnnp.bmj.com/ that disturbed circadian rhythms may have a role in terns or sustained activation in Ursin's terms of producing psychosomatic disease. In his view, fight/flight variety, with accumulation of anxiety and bereavement and distress are important for the constant immersion in depression. The rigidity of development of psychosomatic disease. Finally, personality and poverty of imagination which are Henry and Stephens'9 suggest that cortisol pathol- frequently the hallmark of the group described is ogy, frequently seen in depression and distress may amenable to moderation in skilled psychotherapeu- be related to defective immune response mechan- tic hands, even though it is so assailed by the con- isms. tinuing illness in the form of a pathological somatic on October 2, 2021 by guest. The psychosomatic concept needs to be preserved process. against some misunderstanding and abuse. The Finally, this interactive view of psyche and soma is psyche in the link is not conscious, volitional psyche, presented as a contemporary attempt to resolve the and as such is not directly under the control of the ever-present problem of the interaction of personal- conscious mind. Therefore guilt and feelings of per- ity and the environment. It reminds us of the per- sonal responsibilities for psychosomatic illness hav- sonal experience accompanying and influencing all ing its roots in early development are misplaced. behaviour and seeks to redress the balance in the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.298 on 1 March 1984. Downloaded from

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