Psychological Responses to ACTH and Cortisone: A Preliminary Theoretical Formulation

Abstract

Pharmacological doses of ACTH and cortisone disturb the biochemical equilibrium. A new dynamic equilibrium is established: (i) when the quantity of ACTH and cortisone administered remains within the physiological capacity to maintain homeostasis; (2) when internal metabolic stores are adequate; or (3) when the intake of exogenous supplies is unrestricted.

ACTH and cortisone bring about an acceleration of the rate of biochemical interchange and promote the mobilization of energy for cellular work. The hypothesis is presented that these metabolic changes constitute physiological sources of instinctual tension and result in an increased drive to discharge energy or an increased need to obtain instinctual satisfaction.

The psychoanalytic meaning of instinct is described, with emphasis on the biochemical and hormonal sources of instinctual tension.

Ninety-eight patients receiving ACTH or cortisone were psychologically studied. Sixty-four of these were interviewed as part of a collaborative research enterprise, 56 with members of the metabolic group at the Peter Bent Brigham Hospital and 8 with the Medical Service of the Robert Breck Brigham Hospital. Fourteen patients were seen because of psychotic behavior directly related to treatment with ACTH or cortisone. Twenty had longstanding emotional problems unrelated to treatment with these substances.

The three most nearly constant findings and the three most regularly occurring together were alterations in appetite, sleep, and motor activity. The range of psychobiological response included changes in intellectual alertness and affect as well as in other highly integrated activities.

Most of the patients felt stimulated and experienced a sense of well-being. When the drugs were discontinued, most patients felt a sense of emptiness and depression.

Less usual patterns included mild hypo-mania, but also states of anxiety, denial of any response at all, and in some cases a "negative" response with increased inhibitions against specific activities such as walking or eating. Some patients became psychotic.

The clinical response to ACTH and cortisone represented a summation of three principal components: (1) the pharmacological effect of ACTH or cortisone on the total organism; (2) the meaning to the patient of an alteration in the symptoms of the disease for which he was being treated; and (3) the nature of the patient's fantasies about the action of the substance he has been given. A patient is described illustrating the influence of each of these three factors in terms of his personality structure and the available satisfactions in his life situation.

Refinements in biochemical methods will increase the precision of further investigation. An accurate knowledge of the patient's ego structure is also required and can best be developed within the setting of a relationship between the patient and the psychiatrist which has reached a certain degree of emotional intensity.