Asthma, Melancholia, and Death // . Psychosomatic Considerations

During two periods, serial 24-hr, urine levels from a psychoanalytic patient with severe, ultimately fatal asthma were compared to "blind" ratings of four emotions (anxiety, anger, sadness, and erotic affect) and four complex, largely unconscious constellations of self-other fantasy ("Progressive" compliance; "Depleted" empti- ness; "Somatized" bodily preoccupation; and "Perverse-pseudogratified" im- pulsivity). The 17-OHCS output fluctuated and, at times, was abnormally high, probably as a result of repeated ACTH treatment and possibly also as part of emotional turmoil, which may characterize asthmatic relapse. "Perverse pseudogratified" and "anxiety" ratings showed a significant inverse relationship to 17-OHCS output in the first period of study. An additional variable, "Loss of Defensive Control," rated during the second period, showed significantly positive correlation with 17-OHCS levels. Fragmentary data from five further asthmatic fatalities and from cases reported by others suggest that, although specific biologic factors may play a role, so may overt despair and hidden self destructiveness. Autopsy in ours and other cases has generally shown diffuse bronchiolar obstruc- tion by thick mucus. Explosive parasympathetic nervous influences, possibly leading to cardiac dysrhythmia, may act in concert with the inflammatory pul- monary process to produce a rapidly fatal course.