Towards a Psychosomatic Conception of Hypochondria The

Impeded Thought

Visit the link below to download the full version of this book:

https://medipdf.com/product/towards-a-psychosomatic-conception-of-hypochondria-t
he-impeded-thought/

Click Download Now

Foreword

What a surprising title! ‘‘The Impeded Thought.’’ But by whom? By what? An

external censorship imposing a norm that replaces reality? An internal censorship
confused with the norm it strives to recreate? Asking such questions about a
concept like hypochondria suggests the uncommon liberty of an unfettered
reflection, free to get to the heart of things: questioning itself as well as questioning
its object. Extreme approach but only possible way to recognize that ‘‘obvious
things,’’ isolated from the objectification process that produced them, have become
inescapable epistemological obstacles, and that, to go beyond the resulting locked-
up thought, only a radical reflection on locked-up thought itself can help. This
double motion exemplarily animates this work that simultaneously describes a
closure, more and more totalizing, and an opening toward a counter-thinking
which is also a thought of the object.
Why is this approach so complex?
Because the concept of hypochondria, which Freud said remained ‘‘a dis-
graceful lacuna’’ in the psychoanalytical edifice, has many times been used to
justify proliferating theoretical constructs referring to the same energetic model.
A model that considers hypochondria as an internal process caused by the fixation
of anxiety, which is said to correspond to the direct transformation of libido, on to
the affected part of the body. We then realize that this process has no end:
whenever the hypochondriac is told that he has nothing, this ‘‘nothing’’ cannot put
an end to his suffering, which is real; whenever his real suffering is recognized, its
origin cannot be found. ‘‘Imaginary’’ perhaps, but still there, inscribed in the real
body and defeating all therapeutic attempts. What is found here is an impasse that
we really should define as relational, for organic complaint implies the other
person’s presence and decisive role.
Hypochondria thus seems to be an impasse-related pathology, as well as a
psychosis and an organic pathology, consistent with a conception of psychoso-
matics that the author adopted and which posits that the most elementary psy-
chosomatic phenomenon is not a process in itself, but a process linked to a conflict
situation that may sometimes result in an impasse.
Henceforth, everything is clear: in hypochondria, therapeutic failure, instead of
an accident, is the specific form taken by impasse in a pathology derived from
impasse and that has to be thought as such. From what, for the first time, the
possibility of appropriate therapeutic action emerges.

v
vi Foreword

Thanks to the extreme care taken in its construction, whose every movement is
associated with the pleasure of thinking, this book maliciously appears like a lasso
whose formation we gradually follow until it is finally thrown to capture the
object. And the thought that we have here does not close on itself, but provides an
unhoped-for opening where thought and object freely develop, to consider, for
instance, that the phenomenon of hypochondria, could be found outside of its
association, developed here, with paranoia.

M. Sami-Ali
Acknowledgments

I am thankful to the ‘‘friends’’ who help me,

to the ‘‘villains’’ who stir my conscience…

I particularly thank Prof. Sami-Ali,

Prof. Albert Cattan,

Honorary Director of the Anti-Cancer Center of Reims,

Dr. Christian Pozzo di Borgo,

my partner at the Pain Consultation.

The headlong stream is termed violent,

but the river bed hemming it in is termed violent by no one.

Bertolt Brecht

vii
Contents

Part I Questions and Problems

1 Questions. . . . . . . . . . . . . . . . . . . . . . . ............. . . . . . . . 3
1.1 Adjective Rather than Substantive . . ............. . . . . . . . 4
1.2 Problem Rather than Entity. . . . . . . ............. . . . . . . . 7
1.3 Negative Representation Rather than Positive Content . . . . . . . . 12

2 Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1 Hindrance to Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2 The Dimension of Thought . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3 Thinking Differently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Part II The Obliged Thought

3 Problem Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1 Object of this Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2 What are ‘‘Negative Reports’’? . . . . . . . . . . . . . . . . . . . . . . . . 34
3.3 A Guiding Thread: The Register of Hypochondria. . . . . . . . . . . 40

4 Negative Reports or ‘‘A Certain Discourse Used

in a Certain Way’’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.1 Stories, Briefly Told . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.1.1 Case I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.1.2 Case II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.1.3 Case III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.1.4 Case IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.2 Finding Complaint Invariants and Naming the Unnamable . . . . . 54

5 From Biological Body to Metaphorical Body. . . . . . . . . . . . . . . . . 59

5.1 Register of Actuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.2 Freud and Hypochondria: ‘‘Secondary’’ Narcissism . . . . . . . . . . 61
5.3 Somatic Complaint, Suffering of an Insomniac Body. . . . . . . . . 64
5.4 From Medicalized Body to Thought Body . . . . . . . . . . . . . . . . 68

ix
x Contents

Part III Thinking Hypochondria

6 A New Starting Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6.1 Symptom Pathology, Relational Pathology . . . . . . . . . . . . . . . . 76
6.2 Thinking the Somatic Differently . . . . . . . . . . . . . . . . . . . . . . 78
6.3 Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

7 Hypochondria, Projective Parenthesis . . . . . . . . . . . . . . . . . . . . . . 85

7.1 Projection, the Missing Conceptualization . . . . . . . . . . . . . . . . 86
7.2 The Schreber Case and its Hypochondriac Episode . . . . . . . . . . 88
7.3 The Limited Development of an Impasse . . . . . . . . . . . . . . . . . 91

8 A Different Relation to Oneself and to the Other Person . . . . . . . . 95

8.1 Intersubjective Dimension of Hypochondria . . . . . . . . . . . . . . . 97
8.2 The Relation to a Narcissistic Double . . . . . . . . . . . . . . . . . . . 99

9 Towards a Psychosomatic Conception of Hypochondria . . . . . . . . 103

9.1 As a Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Further Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Introduction

Abstract The study of hypochondria is likely to question theory and to generate

fruitful conceptual developments. Justification.

Described many times but seldom questioned, diversely controversial but hardly
explained, scandalously impossible to treat but little theorized, hypochondria is an
enigma. Or rather an ‘‘uncannily familiar’’ notion. Obvious and questioning at the
same time, combining overflowing extension and insufficient comprehension.
Obvious first. Ubiquitary syndrome as old as the medical speech itself, as it is
one of its most ancient terms, identified by Hippocrates, named by Galen,
hypochondria seems totally transparent, immediately understandable, subsumable
within such a character as Molière’s Argan, the Imaginary Invalid. Common-sense
comprehension seems sufficient for its understanding, blindingly sufficient thanks
to its spatial and temporal proximity, in terms of ‘‘always’’ and ‘‘everywhere’’.
Question then. If, which is remarkable, hypochondria has hardly ever been
precisely defined, its obviousness disappears as soon as you confront a patient
whose whole life is filled with an essential complaint expressing ‘‘pain’’ and ‘‘belief
that the body is affected’’. And when the conceptual frameworks of hysteria,
depression, or delusion (Ford 1983, p.76 sq.) are invoked to locate this complaint,
one cannot but notice the striking gap between the hypochondriacs on the one hand,
and the hysterics, the depressed, and the delusional on the other hand.
Finally, consistent with its commonplace meaning which excessively simplifies
the content of its clinical reality and turns it into an anonymous typical category—
i.e., ‘‘imaginary illness’’— hypochondria can only be given a status negatively,
i.e., through what it helps avoiding: as a lack of elaboration, a defense against
psychosis, an equivalent of depression. In short, everything that reinforces
transparency, so that only something else can be seen through it, something that
could have been and that is not.
Hypochondria: between a lack of definition and a definition through the lack,
between a thought deficiency and a thought of deficiency. As if its obviousness
prevented us from raising the real issues.
Can the double-centered paranoid schizophrenic, the paraphrenic who thinks
his body is invaded by countless enemies, the melancholic denier, the doctor-
persecuting paranoid, the ‘‘Argan’’-like subject affected with hypochondriac
‘‘neurosis’’ be categorized under the same ‘‘label’’? What distinguishes

xi
xii Introduction

hypochondria as a problem? How can we think the resolution of the contradictions

inherent to it as to the more general concept of actual neuroses? What positive
content can be given to an entirely negative designation which is a reality created
by a normative system of thought? There are many unresolved issues and they
reveal a theoretical gap.
In this situation, resulting from an obstacle to thought which revives an old
childhood tradition—preferring to veil one’s eyes instead of admitting that the
‘‘sexual theory’’ is inaccurate—there are several possibilities for the psychoan-
alyst: questioning clinical experience which cannot reveal anything unless asked
precise questions; resorting to history in order to understand the objectification
process rather than its result; considering the metapsychological basis of a process
whose modalities have formerly been determined. This is what we have tried to do
throughout the following pages, our subject being to say, as completely as
possible, how to think hypochondria.
 Part I
Questions and Problems

Introduction

Abstract The issue of the body invites us to question the Freudian theoretical
model. We show why this criticism is required for the study of hypochondria.
For two decades, ‘‘return of the body’’ and ‘‘return to the body’’ have been a
convergent focus for many psychiatric and psychoanalytic works; the research and
publications that followed vacillated between apology and depreciation, i.e., two
opposite forms of fetishization. However, one cannot but notice that this ‘‘con-
version’’ strangely resembles a diversion.
Simply put: we lack a theory of the body. Too famous and too fashionable
today, the body is indeed an impasse for thought. Established and obvious,
ideological and totalitarian, with no possible capacity not to be a thought, this
figure has joined the rank of the ‘‘obligatory’’ topics which build up the depressive
obsession of a culture and keep thought away from the discovery of its centers. It is
generally used with a vague and extremely diffuse meaning, which clearly evi-
dences a theoretical deficiency. Moreover, ‘‘body’’ is not a clearly defined and
well-bounded Freudian concept.
But, as the body has no theoretical status in a system which is exclusively
conceived in terms of psychical apparatus, the main difficulty is the continuing use
of the never questioned Freudian somatization model which opposes and unites the
concepts of actual and neurotic. It is also that the compelling questions generated by
the body invariably lead to the paradigmatic use of hysteria: as a model, it enables
the extension of the conversion process to the pregenital (Sperling 1978); as a norm,
it enables multiple conceptions of somatization, all expressed in terms of depri-
vation (Marty 1980; McDougall 1992). The problem is finally the resulting mar-
ginalization of a whole clinical field, both theoretical and practical, considered as a
fringe for it is linked to the concept of actual; psychosomatics, psychomotor
therapy, psychosis therapy all seem nonintegrable. Paradox of a thought which
simultaneously thinks soma as a sort of propping system and as a negative concept.
2 Part 1: Questions and Problems

Founding and constituent on the one hand, marginal and on the fringe on the
other hand, burrowed and covered then, the question of the body in psychoanalysis
is far from reduced to an internal problem that we would have to examine only
from inside, as an integral part of a fully perfected system; therefore, it also
constitutes the necessary confrontation which will help re-thinking a problematics.
This is a multiple issue: obsolescence and lack of coherence of the definition of
soma both considered as a center and an outside; impossibility to use hysteria as a
model as it, far from being a pure neurosis, regularly extends beyond the con-
versional level (Sami-Ali 1987, pp.32–61); frequent coexistence, clinically
observed, of multiple bodily symptoms on several levels. Extreme fragility of a
conceptual framework.
The only reference framework which clearly integrates hypochondria today
seems to be psychoanalysis, but it has to be re-examined and this cannot be done
without radically questioning the Freudian somatization model. What are its
guiding postulates? What does it objectivize? Thus, if we avoid getting locked in a
ready-made system, a new problematics can emerge, free from the prejudice of
dichotomy, that will enable us to think both psyche and soma.
Chapter 1
Questions

Abstract Preliminary reflections on the study of hypochondria. We explain that,

adjective more than substantive, hypochondria covers a wide nosographic and
etiologic spectrum and remains a theoretical blind spot, and also why, more than
an entity, it is a problem that questions the contradictions of Freud’s theory and the
weaknesses of its somatization model. Consequently, the issue of hypochondria
induces the need for rigorous and innovative conceptual research. We outline the
main features of the comprehensive, critical, and fertile approach that must be
defined to create new concepts that extend the frontiers of psychoanalysis and
overcome its contradictions while remaining consistent with it. This results in the
formulation of our initial questions.

Questions, internal as well as external, so that clinical practice can be interrogated

without being imprisoned in a theoretical option. Instead of continuing the previous
purely Freudian approach, they must confront all problematics, all contradictions,
all theoretical gaps. Negative process, counter-inductive effort. Circle-breaking
work whose lineaments can be discovered in literature, in the confrontation of data
and problems. Locating the remaining blind spots.
Patchwork of ideas, more often descriptive than explicative, multicolored
patchy Harlequin’s costume, mixing reflections on actual neuroses to develop-
ments on narcissism, the varied readings of hypochondria cannot but strike with
their color mismatch and sewing weaknesses…. When we list and question them,
we can identify the three research axes that we will have to problematize:
• Adjective rather than substantive,
• Problem rather than entity,
• Negative representation rather than positive content, hypochondria remains
quite unexplored.

M. Derzelle, Towards a Psychosomatic Conception of Hypochondria, 3

DOI: 10.1007/978-3-319-03053-1_1,
 Springer International Publishing Switzerland 2014
4 1 Questions

1.1 Adjective Rather than Substantive

Introductory observation: hypochondria is obviously an indisputable clinical

reality, always inseparable from the medical context; however, it seems ques-
tionable but also unlikely to find a single and univocal place for it in nosography. It
is not a definite entity which can really be diagnosed as such. At the very most, it is
a sort of assembly which tends to bring together various clinical pictures, only
from a descriptive but never etiological point of view, which all bring out the same
concern for the body experienced as ill.
Hidden depression, dejection, and melancholia: since Hippocrates, medical
experience, for the specialist as well as for the general practitioner, constantly
meets the hypochondriac. This meeting generally results in a shared dissatisfaction
between helpless doctors and complaining patients. This constellation of negative
affects which endlessly repeats the same sequence is a guiding principle, tenuous
but major. For, from extreme confidence—‘‘I’ve heard of you, you’re the only one
who can help me’’—the suspicious patient switches to defiance—‘‘do you think
your treatment will help?’’—and then completely nullifies his faith in the next
interview—‘‘I feel worse than before.’’ Then exasperation and bad moods will
eventually be exchanged as a prelude to rejection, toward a possible elsewhere.
Hypochondria as a ‘‘climate,’’ at the crossroads of impairment and otherness. But,
beyond these shallow responses, what is hypochondria?
Between a phenomenological definition and a more semeiological approach,
literature is rich but hesitating and leaves the problem unsolved. Symptom
pathology? Relational pathology? The first perspective which is the most usual and
remains consistent with the classical medical tradition objectivizes signs which
pertain to a self-contained system: overstated concern for physical condition,
subjectivity of a complaint lacking the weight of the somatic, interpretation of
impairment as a simplistic threatening process, withdrawal of concern for the
outside world, internal tension and experience of catastrophe. Internally focused
on his painful body, the character described as hypochondriacal, locked in and
existing as such is, above all, alert to the messages of his coenaestheses even to the
most contingent ones. And he interprets them in a negative way. Step by step,
opposed to this first intrapsychic approach, the second perspective is inter-psychic.
Here, no definition is acceptable unless it implies an interlocutor who, being mute,
eloquent, or psittacistic, is nevertheless the one who takes part in the drama.
Obligatory partner of his doctor in an inseparable and extremely tragic couple, the
character described as hypochondriacal is above all relational (Maurel 1973).
Strange relationship to oneself and/or to another person? This bipolarity can
curiously be found on other levels and it seems to insistently underline how
hypochondria is linked to ambiguity and even to duality. Double causality,
biological or mental, major or minor, delusional or simplex, has always remained
out of the reach of any unitary, either nosographic or etiopathogenic, approach.
Dual rooting, between body and language: it still remains an object of debate and
controversy, located between organogenesis and psychogenesis, genuine illness
1.1 Adjective Rather than Substantive 5

and mere thematic issue, established delusion and coenaesthesiopathy. Beyond

understanding and classification. Alternately neurosis or psychosis. It is no wonder
therefore that hypochondria can be found at varying degrees in the whole
psychopathological field so that it seems to be its core, but also sunken in it as
sheer entity. Center and periphery.
Nevertheless in all cases, whether it is rejected as single entity (Greenfield and
Roessler 1958) or considered as an iatrogenic disease of medicalized cultures
(Kenyon 1976), it exemplifies the possible links between soma and psyche and
cannot be disjointed from a relationship to the world that uses the body as an apparent
support medium (Ey 1950). There is then a first question: being an affect-conveying
configuration, is hypochondria an unsatisfied demand or a possible genuine label?
This question has no direct and univocal answer. It would imply the possibility
of isolating a single underlying process or, at least, of inducing a precise unifying
conception. Yet literature shows that this major requisite cannot be met. This is
evidenced by Kenyon in a very good 1966 article (Kenyon 1966), where he listed
18 possible usages of the word ‘‘hypochondria.’’ Therefore, a purely nosographic
conception is invalidated.
Synonymous with mad or senseless; a mental disease due to a disorder of the digestive
tract; term of abuse, i.e., either actually malingering…; general sense of preoccupation
with bodily or mental health or functions; personality trait or attribute; a mechanism of
defense; neurotic manifestation, especially in lower social classes or in those of poor
endowment; an anxiety substitute or affective equivalent; an actual neurosis; closely allied
to or a manifestation of neurasthenia or depersonalization; the same as hysteria, only in the
male; transitional state between hysteria and psychosis; a nosological entity, primary or
essential hypochondriasis; a symptom of almost any of the other commonly recognized
psychiatric syndromes, especially depression; prodromal stage of another illness, e.g.,
schizophrenia; a form of schizophrenia; a form of coenaesthesiopathy; part of a symp-
tomatic psychosis or exogenous reaction.

To which we should add the functional or psychofunctional disorders, as well as

dysautonomia, and even the so-called psychosomatic disorders.
As hypochondria is polysemic, it is impossible to a priori endow it with a
nosological specificity as such, this impossibility being especially reinforced since
the medical discourse is increasingly important in our society. Anyway, histori-
cally, this recourse to the doctor has replaced the recourse to the priest; unsur-
prising replacement, as Freud put it as he thought this change was only the
abandonment of a so-called ‘‘demonological’’ garment and the taking of another
one which was a mere disguise. In this perspective, after Kenyon, we can say that
the overflowing extension of the word ‘‘hypochondria’’ undoubtedly justifies that it
is no longer really used as a noun but only as an adjective which has a descriptive
use. A careful literature review clearly exemplifies this proposal: we have noted
down 27 common usages for the adjective ‘‘hypochondriacal;’’ they can be dis-
tributed around three major lines: semeiological (neurosis, psychosis, character,
delusion, constitution, syndrome, symptom), phenomenological (presentation,
recourse, form, idea, concern, theme, worry, grievance, complaint, component,
dimension, episode, event, disorder, trend, state, phenomenon, complex), or even
6 1 Questions

ontological (work, drama). Being an adjective more than a substantive, hypo-

chondria is a cross-cutting notion. All the attempts to reduce it to a symptom
regularly confronted the nosographic obviousness of their senselessness: that is
why hypochondria keeps wandering as a stranger who has his seat at the tables of
hysteria, depression, psychosis, and actual neurosis.
If hypochondria, clinical picture referring to several diseases, cannot be iden-
tified as a medical entity and as it lacks etiological unity, could it find its unity on
an exclusively descriptive level? Isn’t it, for example, an unsatisfied demand,
present in various contexts? Indeed, a real specificity could be found in the
complaint itself, in its wording and in the ambivalence of a demand for care whose
unifying characteristic is that it is refused, more than in any attempt to give it an
etiopathogenic or a nosological definition. Freud did not go into details about this
articulation but he nevertheless found two axes in the hypochondriac’s very
peculiar relationship to the other person: a reversed guiltiness on the one hand
(objectal libido), a projected attack against oneself as well as against the other
(narcissistic libido), on the other hand. Impossible destruction, impossible healing.
Complaint is definitely the element to consider, that is what all authors mean when
they persist in situating it in its structural analogy with other relational pathologies:
melancholia–mania couple (Fedida 1971; 1975; Ferenczi 1955; Freud
1915[1917]b; Klein 1935; 1940; Araham K), paranoia (Tausk 1933; Abraham K;
Klein M), obsessional neurosis (S. Freud). In spite of the variety of the clinical
contexts, discourses converge.
As a result of this striking contrast, classification is difficult, that is why opinions
diverge. Some authors assume that hypochondria is psychotic (Maurel 1973). Some
others consider that no one is totally exempt from this kind of concern (Ey 1950).
Some mention it as an irreversible neurosis or last barrier against psychosis. Finally,
other authors, more cautious, affirm that theme cannot not prefigure structure. This
difficulty is probably the consequence of the notable fact that the hypochondriac’s
usual discourse is indeed a subversion of medical discourse. The confusion between
the medical discourse on hypochondriacs and their own has frequently been noticed
(Cottraux 1976). Does the unity of the hypochondriac’s discourse lead to a mise en
abyme in which the doctor sometimes imagines a unity he can call nosological
whereas the constant and essential unity is the one he provides without really
knowing? The word ‘‘observation,’’ ordinarily medical, would not have a one-way
meaning here. Discourse unity? Unity of a reduplicated partner? In both cases, the
approach remains descriptive. In view of this highly insufficient perspective, let us
also find if psychoanalysis can propose an explicative theory for the origin of the
disorder of the patient who complains that his body is affected.
On this specific point we must acknowledge our ignorance. When we compare
descriptive and explicative levels, we can notice a major discrepancy: super-
abundance of descriptions and lack of explanation show how difficult it is to
establish a clear theoretical status for the hypochondriacal subject. The main
contribution of the psychoanalytical theory is a polymorphous set of scattered
words and notions which orderlessly evoke, Oedipus, castration, guiltiness,
sadomasochism, anality too, fragmentation sometimes, narcissism mainly, and