The Psychopathology of Coughing
The Psychopathology of Coughing
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咳嗽的精神病理学
DOI：
10.1097/00006842-194304000-00013
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发表时间：
1943
期刊：
影响因子：
--
通讯作者：
O. Fenichel
中科院分区：
文献类型：
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作者：
O. Fenichel
今天，每个人都同意这个问题是易怒、不安、愤怒、准备指责他人;或者，通过过度补偿这些倾向，他可能会发展出相反的特征。所有这一切都是典型的病人心理，而不是咳嗽。(8)二、如果一些患者养成了以一种狭窄的、“夸张的”方式咳嗽的习惯，那就更具体了。这可能是对咳嗽或至少是对生病的无意识兴趣的表达。在这篇文章中，我们感兴趣的是一个特定的无意识的兴趣咳嗽。有些人甚至在器质性病因已不存在后仍继续咳嗽。如果一个由器质性因素决定的症状在器质性原因不再起作用之后仍然存在，我们就说器质性疾病之上有一种歇斯底里的上层建筑。在这种情况下，咳嗽无意识地服务于病人的目的，在某种程度上对他有利。这并不一定意味着病人“逃避疾病”或享受被照顾（尽管它可能意味着）。“目的”和“有利”这两个词在这里是以更一般的意义使用的。这种优势可能只在于他的精神能量的经济收益。心理机制总的来说倾向于摆脱紧张;外部刺激（或早或晚）会被释放兴奋并重新建立心理平衡的反应所回应。在“压制”的情况下，这种释放的某些方面受到了阻碍。有压抑的人处于一种无意识的冲突中，在一种释放内在紧张的倾向和一种倾向于阻止这种释放的压抑力量之间。压抑越强烈，内心的压力就越大，也就越倾向于寻找其他可以被允许的宣泄方式来替代被压抑的东西。咳嗽可能是这样一种潜在的发泄方式，可以缓解压抑所造成的内在压力。这是一种条件反射;咳嗽现在已经与其他刺激联系在一起，而这些刺激的存在会引起咳嗽。许多“精神分析机制”可以用“条件反射”术语来描述。但事实仍然是，只有某些人发展了这种“条件作用”，而另一些人则不正确地把某种现象的起源说成是躯体的还是心理的。没有非此即彼。任务是研究肉体和精神力量的相互关系。《心身医学》杂志把这项研究作为其主要任务。在研究咳嗽的特殊情况时，我希望避免倒退到我拒绝回答的那个问题上，并试图尽可能简短地说明精神分析在这个特殊情况中看到了什么类型的相互关系。神经性咳嗽很少是精神分析的主要指征。然而，这是一种相当常见的症状，通常可以在对其他适应症进行分析的过程中进行研究。然后，可以观察到以下六种可能性：1.一般来说，严重的器质性咳嗽是一种相当恼人甚至痛苦的症状。病人必须使自己适应它，而这种适应在某些心理环境下可能变得困难，甚至完全失败。在肺炎等急性发热状态下，咳嗽的精神反应会被其他更急性的疾病症状所掩盖;但在肺结核或慢性支气管炎等慢性状态下，咳嗽的情绪反应可能非常明显。这些反应可能会有很大的不同，但有一个因素总是存在的：令人讨厌或痛苦的咳嗽会引起注意;咳嗽的人更关心自己，变得更加内向，更不愿意对其他人做出反应。他要么变得对别人完全不感兴趣，要么仅仅通过要求关心或帮助来显示他的兴趣。弗洛伊德把我们对他人的兴趣比作伪足，伪足是变形虫延伸出来的，在疼痛的情况下又可能缩回。病人撤回他们的伪足。他们退缩的程度取决于人格的先前历史。一个人对紧张和疼痛的耐受力取决于未知的体质因素以及早期的经历。一个不耐的人与慢性咳嗽成为
Today everybody agrees that the question irritable, restless, angry, ready to accuse others; or he may develop, by overcompensation of these tendencies, just the opposite characteristics. All this is typical for the psychology of sick people, and is not specific for coughing. (8) 2. It is more specific if some patients develop the habit of coughing in a cramped, "exaggerated" way. This may be the expression of an unconscious interest in coughing or at least in being sick in general. In this article we are interested in a specific unconscious interest in coughing only. Some persons continue to cough even after the organic cause has ceased to exist. If a symptom which was organically determined continues to exist after the organic cause has ceased to be effective, we talk about an hysterical superstructure over an organic disease. In such cases, coughing unconsciously serves the purposes of the patient and is in some way advantageous to him. This does not necessarily mean that the patient "escapes into sickness" or enjoys being taken care of (although it might mean that). The terms "purpose" and "advantageous" are used here in a much more general sense. The advantage might consist only in a gain in the economy of his psychic energy. The psychic apparatus has a general tendency to get rid of tensions; external stimuli are (sooner or later) answered by reactions which discharge the excitation and re-establish the psychic equilibrium. In the case of "repressions," certain discharges of this kind are blocked. The persons with repressions are in an unconscious conflict between a tendency to discharge the inner tension and a repressing force which tends to stop this discharge. The more intensive the repression, the higher will be the inner pressure and the inclination to find other permissible discharges which might serve as substitutes for.what has been repressed. Coughing might be such a subslitulive vent far relieving an inner pressure caused by repressions. This is a kind of conditioning; coughing has now become connected with other stimuli whose presence provokes it. Many "psychoanalytic mechanisms" can be described by "conditioned-reflex" terminology. But the fact remains that only certain persons develop such "conditioning," whereas others whether a given phenomenon is somatic or psychogenie in origin is incorrectly put. There is no either-or. The task is to study the interrelationship of somatic and psychic forces. The journal "Psychosomatic Medicine" has made this study its principal task. In studying the special case of coughing, I hope to avoid a back-sliding into the very question which I have refused, and try to show—as briefly as possible—what types of interrelationship psychoanalysis sees in this special case. Nervous coughing is seldom the primary indication for a psychoanalysis. It is, however, a rather common symptom, which can frequently be studied in the course of analyses undertaken for other indications. Then, the following six possibilities may be observed: 1. A severe organic cough is, as a rule, a rather annoying or even painful symptom. The patient has to adapt himself to it—and this adaptation may become difficult or even fail entirely under certain psychological circumstances. Psychic reaction to coughing is overshadowed in acute, feverish states like pneumonia by the other, more acute symptoms of the disease; but in chronic states, like tuberculosis or chronic bronchitis, emotional reactions to coughing may be very plain. These reactions may vary considerably, but one factor is always present: that annoying, or painful, coughing absorbs attention; and that the coughing person is more concerned with himself, becomes more introverted and less ready to react to other persons. He either becomes entirely uninterested in others or else shows his interest merely by demanding care or help. Freud compared the interest we have in other persons with pseudopodia which an ameba extends and which it may withdraw again in the case of pain. Sick people withdraw their pseudopodia. The degree of their withdrawal depends on the previous history of the personality. The tolerance of a given person towards tension and pain depends upon unknown constitutional factors as well as upon early experiences. An intolerant person with a chronic cough becomes