Psychological Management of Multiple Sclerosis An Overview
Authors: J.W. Paulley
Journal: Psychotherapy and Psychosomatics (1976)

Eight case histories demonstrate features of the predisposing childhood background met with in patients with multiple sclerosis (MS) together with the passive dependent coping mechanisms adopted by the child to ensure short-term survival, but which perpetuated into adult life are inadequate and somatically damaging. First, there is pathological dependence on a parental key figure later transferred wholly or partly to other key figures. The pathological dependence leads to ambivalence over separation from the key figure(s) and the attainment of an independent emotional existence. The childhood of MS patients is overwhelming because it is either turbulent or excessively cloying, and the child's response passive and docile. Other siblings, for reasons such as position in the sibship, or their sex, or inherited toughness, escape the full rigour of parental dominance, or successfully rebel against it. MS subjects are thus especially vulnerable to threats of illness, death or irretrievable severance from key figures but, while detachment is perilous, they also fear and resent engulfment and the loss of any small measure of identity they may have gained. With their infantile attempts at separation at age of 2–3 frustrated, or too feeble for success, and having learned the 'giving-up' response as their only defence against what they see as hopeless odds, it is hardly surprising that bids for independence at adolescence are equally unsuccessful. They often recall a few attempts at adolescent rebellion painfully and quickly put down by the threat of withdrawal by the key figure. Often these adolescent or adult attempts at independence are associated with sexual relationships bedevilled by guilt from early libidinous fantasies, and fears of being trapped into parenthood and responsibility thereby threatening their own position as the dependent child. It is, therefore, no accident that the onset and relapses of MS are commonly associated with the crises courtship, marriage and birth. The women, if they are childless, which is often the case because of their own hang-ups, not infrequently fantasise their sisters' or friends' babies as their own. Because of their superficial affability, men and women are vulnerable to the trauma of being made unwilling confidants especially in the sexual misdemeanours of their neighbours, friends, parents, siblings, children and grandchildren, and identify closely with injured parties; such experiences are frequently provocative of onset nd relapse of MS. MS patients conceal emotions, particularly aggressive emotions, behind a mask. The mask they wear is either smiling, or 1 Based on a paper read to the Society for Psychosomatic Research, London 1976. Paulley 27 unsmiling and flat. The flat mask may incorrectly be interpreted as depression. The moria seen with the brain damage of GPI parallels the gross euphoria of advanced cases of MS, but both are caricatures of the basic mood antedating the disease. Relatives and friends as well as the patient will confirm that the smiling or unsmiling mask is premorbid and an early learned defence to conceal real feelings too dangerous to reveal. In this series there is a predominance of eldest and youngest children, and the histories reveal that they are often the most exposed to the damaging factors mentioned. However, the figures are just below the level of statistical significance. Likewise, the number of only children seemed to be more than one would expect. Psychotherapy is directed to helping these patients in the therapeutic situation to show their feelings, sometimes for the first time in their lives, and bring into consciousness their unconscious habit of hiding more intense feelings behind a smiling or unsmiling mask, and then to learn to lower their defensive mask, not only in the therapeutic situation, but later in their interpersonal relationships. Of necessity this programme also involves helping the patient wherever possible to separate emotionally from his key figure and surrogates. Experience has shown that this is more effectively and rapidly achieved by couple therapy in which the spouse or fiancé(e) affords an empathetic extension of the therapeutic situation beyond the consulting room. It is necessary to maintain therapy over the dangerous period during which dependence becomes attenuated first by substitution of the therapist for the key figure and later by incorporation of the 'good parent' and extrusion of the 'bad'. Subsequently, the link with the therapist may be weakened by spaced interviews but with easy access to the therapist in the event of relapse. Successful psychotherapy is punctuated by substantial remissions of the somatic symptoms of MS. Period of study 1946–1976, number of patients 300+, case notes traced and examined 227 (males 88, females 139). Where sufficient data available: separation and engulfment problems 192/192, smiling mask 112 and unsmiling mask 79.