302 PSYCHOTHERAPY : SCIENTIFIC AND RELIGIOUS chap.
psychotherapy is attempted in such a case, the therapist must refuse to look after the physical side of his case. If he does, he will find the patient produces a stream of hysterical or anxiety symptoms, which he demands should be investigated, and psychotherapy becomes impossible.
Hyperthyroidism and exophthalmic goitre have an obvious similarity to anxiety states in their symptoms. It is well recognized that these disorders may be precipitated by a shock or some other psychological event, such as emotional stress. An interesting question which arises is, can an apparently psychogenic anxiety state develop into a true hyperthyroid condition ? If so, at what point can a definite diagnosis of the latter condition be made ? Flushing, an increased metabolic rate, and a continuously raised pulse-rate, remaining high in sleep, would be diagnostic of the latter. Conrad,36 has reviewed the subject, and cites cases showing a definite psychological cause for the onset of the illness. He finds hysterical and anxiety symptoms occur in hyperthyroidism, but that obsessional types are rare. He reports that both men and women are ' mother fixated \ An interesting point to which he draws attention is that the flushing of the face and neck which occurs during history-taking is often a direct pointer to some psychological ' sore point \ He also considers it is a danger signal, as the hyperthyroid signs may become very much worse afterwards. From this it might be argued that deeper psychological stresses may be important in causing the condition, or at any rate causing exacerbations, in persons with a constitutional predisposition. He finds that psychotherapy helped certain cases, both before and after surgical treatment. He makes no attempt, however, to suggest that the former can in any way replace the latter type of treatment.