Autoimmunity and its expression in the analytic situation: A contemporary reflection on our inherent self-destructiveness

ABSTRACT

This article explores the psychical expression of autoimmunity in the analytic situation; it is informed by biological theories of autoimmunity in contemporary immunology. Several of my patients developed autoimmune conditions in the course of their analyses, leading me to consider the role of psychical change in disrupting one’s somatopsychic equilibrium. In the psychoanalytic literature, autoimmunity is used metaphorically for attack against what is foreign or unwanted in ourselves. Contemporary immunology, however, suggests a somewhat different metaphor. “Self-reactive” cells present in the body may attack self unless suppressed by inhibitory mechanisms. Biologically, limited self-destructiveness is necessary, but in autoimmune disease it becomes excessive and pathological. I suggest that the presence of biological “self-reactivity” implies an inherent self-destructiveness in line with Freud’s thinking on the death instinct; the notion that this self-destructiveness also has adaptive aspects may contribute to our understanding of Freud’s ideas. In three vignettes I illustrate clinical application of a modified metaphor of autoimmunity, finding that not only is the fusion of life and death instincts important for psychic development, but so is defusion when contained within the analytic relationship. The analytic task is to restore the balance between constructive and pathological self-destructiveness. Implications regarding controversies in psychosomatic theory are briefly considered.

L'auto-immunité et son expression dans la situation analytique : une réflexion contemporaine sur notre auto-destructivité intrinsèque

L'auteure de cet article explore l'expression psychique de l'auto-immunité dans la situation analytique, en s'appuyant sur les théories biologiques de l'auto-immunité de l'immunologie contemporaine. Un certain nombre de ses patients ont développé des maladies auto-immunes dans le cours de leur analyse, ce qui l'a conduite à considérer le rôle perturbateur du changement psychique dans l'équilibre somato-psychique. Dans la littérature psychanalytique, l'auto-immunité est utilisée métaphoriquement pour désigner des attaques contre ce qui est étranger à nous-mêmes ou non désiré. Cependant, les théories contemporaines de l'auto-immunité nous inspirent une métaphore sensiblement différente. Des cellules « auto-réactives » présentes dans le corps peuvent attaquer le self à moins qu'elles ne soient supprimées par des mécanismes inhibiteurs. Biologiquement parlant, une auto-destructivité limitée est nécessaire, mais dans le cas des maladies auto-immunes, elle devient excessive et pathologique. L'auteure suggère que la présence de cette « auto-réactivité biologique » implique une auto-destructivité intrinsèque dans le droit-fil de la pensée de Freud sur la pulsion de mort. L'idée que cette auto-destructivité renferme également des aspects adaptatifs peut éclairer notre compréhension des conceptions de Freud. L'auteure illustre, à l'aide de trois vignettes, l'application clinique d'une métaphore modifiée de l'auto-immunité, en découvrant que ce n'est pas seulement l'union des pulsions de vie et mort qui est importante pour le développement psychique, mais également leur désunion, à partir du moment où celle-ci demeure contenue au sein de la relation analytique. La tâche de l'analyse est de restaurer l'équilibre entre l'auto-destructivité constructive et pathologique. Enfin, l'auteure passe brièvement en revue les implications que cela entraîne sur les controverses animant le champ de la théorie psychosomatique.

Autoimmunität und ihr Ausdruck in der analytischen Situation: Eine zeitgenössische Reflexion über unsere inhärente Selbstzerstörungsfähigkeit

Dieser Artikel untersucht den psychischen Ausdruck von Autoimmunität in der analytischen Situation. Er stützt sich auf biologische Theorien der Autoimmunität in der modernen Immunologie. Mehrere meiner Patienten entwickelten im Laufe ihrer Analysen Autoimmunerkrankungen, was mich dazu veranlasste, die Rolle der psychischen Veränderung bei der Störung des somatopsychischen Gleichgewichts zu untersuchen. In der psychoanalytischen Literatur wird Autoimmunität metaphorisch für den Angriff auf das Fremde oder Unerwünschte in uns selbst verwendet. Die zeitgenössische Immunologie legt jedoch eine etwas andere Metapher nahe. Im Körper vorhandene "selbstreaktive" Zellen können sich selbst angreifen, wenn sie nicht durch Hemmungsmechanismen unterdrückt werden. Biologisch ist eine begrenzte Selbstzerstörung notwendig, bei Autoimmunkrankheiten ist sie jedoch übermäßig und pathologisch. Ich gehe davon aus, dass das Vorhandensein einer biologischen "Selbstreaktivität" eine inhärente Selbstzerstörung impliziert, die mit Freuds Gedanken zum Todestrieb übereinstimmt. Die Vorstellung, dass diese Selbstzerstörung auch adaptive Aspekte hat, kann zu unserem Verständnis von Freuds Ideen beitragen. Anhand dreier Vignetten illustriere ich die klinische Anwendung einer modifizierten Metapher der Autoimmunität und komme zu dem Schluss, dass nicht nur die Verschmelzung von Lebens- und Todestrieb wichtig für die psychische Entwicklung ist, sondern auch die Defusion, wenn sie in der analytischen Beziehung contained wird. Die analytische Aufgabe besteht darin, das Gleichgewicht zwischen konstruktiver und pathologischer Selbstzerstörung wiederherzustellen. Die Implikationen für die Kontroversen in der psychosomatischen Theorie werden kurz erörtert.

L'autoimmunità e la sua espressione nella situazione analitica. Una riflessione contemporanea sulla nostra intrinseca autodistruttività

Traendo spunto dalle teorie biologiche sull'autoimmunità elaborate dall'immunologia contemporanea, il presente lavoro esplora l'espressione psichica dell'autoimmunità nella situazione analitica. Diversi miei pazienti hanno sviluppato malattie di tipo autoimmune nel corso delle loro analisi, portandomi a interrogarmi su quale ruolo possa avere il cambiamento psichico nell'alterazione dell'equilibrio somatopsichico di ciascuno. Nella letteratura psicoanalitica il concetto di autoimmunità è utilizzato in senso metaforico per designare gli attacchi contro ciò che è alieno o non voluto dentro noi stessi. L'immunologia contemporanea suggerisce però una metafora piuttosto diversa. Le cellule "autoreattive" presenti nel nostro corpo possono attaccare il Sé a meno che siano soppresse da meccanismi inibitori. Sul piano della biologia un quantum di autodistruttività è quindi necessario, ma nelle malattie autoimmuni questa quantità diventa eccessiva e patologica. Sulla base di queste considerazioni suggerirò qui che la presenza nel nostro organismo di un'“autoreattività” biologica implica un'intrinseca spinta autodistruttiva, in linea con il pensiero di Freud sull'istinto di morte; l'idea, d'altra parte, che questa autodistruttività abbia anche degli aspetti adattivi può aiutarci a comprendere meglio le idee di Freud. Presentando tre vignette procederò a mostrare l'applicazione in sede clinica di una metafora modificata dell'autoimmunità, sottolineando come non sia solo la fusione degli istinti di vita e di morte a essere importante per lo sviluppo psichico, ma anche la loro de-fusione - purché contenuta all'interno della relazione analitica. Il compito dell'analisi è quello di ripristinare l'equilibrio tra l'autodistruttività costruttiva e quella patologica. Verranno anche discusse brevemente le implicazioni di quanto qui argomentato rispetto ad alcune controversie nella teoria psicosomatica.

La autoinmunidad y su expresión en la situación analítica: una reflexión contemporánea sobre nuestra autodestructividad inherente

El presente artículo explora la expresión psíquica de la autoinmunidad en la situación analítica, en base de las teorías biológicas de la autoinmunidad de la inmunología contemporánea. El desarrollo de condiciones autoinmunes en el curso del análisis de varios de los pacientes de la autora, la llevó a interesarse en el papel que desempeña el cambio psíquico en la perturbación del equilibrio somato-psíquico de las personas. En la literatura psicoanalítica, el término autoinmunidad se usa metafóricamente para referirse al ataque contra lo que es extraño o indeseado en uno mismo. Sin embargo, la inmunología contemporánea sugiere una metáfora algo distinta. Las células “autorreactivas” presentes en el cuerpo pueden atacar al self, a menos que sean suprimidas por mecanismos inhibitorios. La autodestructividad limitada es necesaria biológicamente, pero en la enfermedad autoinmune se vuelve excesiva y patológica. La autora sugiere que la presencia de la “autorreactividad” biológica implica una autodestructividad inherente acorde con las ideas de Freud sobre el instinto de muerte. La idea de que esta autodestructividad también tiene aspectos adaptativos puede contribuir a la comprensión de las ideas de Freud. Tres viñetas ilustran la aplicación clínica de una metáfora modificada de la autoinmunidad, en las que se encuentra que para el desarrollo psíquico no solo es importante la fusión de los instintos de vida y de muerte, sino también la defusión cuando es contenida en la relación analítica. La tarea analítica es restaurar el equilibrio entre la autodestructividad constructiva y la patológica. Se aborda brevemente las implicaciones de las controversias en la teoría psicosomática.

KEYWORDS:

• Metapsychology
• immunology
• psychosomatics

Notes

1 A more technical explanation by Root-Bernstein and Fairweather (2015, 6): “We distinguish between autoimmunity, a natural production of antibody and T/B cell responses to self-antigens as part of immune surveillance, and autoimmune disease, which is the production of self-reactive antibodies and T/B cells that result in abnormal cell and tissue destruction leading to chronic inflammation.”

2 Goodnow et al. (2005) write of this remarkable regulating capacity: “Between 20 and 50% of [immune cells] … bind with a potentially dangerous affinity to a self-antigen [substance in our body eliciting an immune response]. Since only 3–8% of the population develops an autoimmune disease, it is remarkable that this enormous burden of self-reactive [i.e. reacting against the self] receptors is so well regulated in most of us” (590–591).

3 I use the term instinct to stay with Strachey’s translation of “Trieb” in the SE of Freud and the citing of English-language papers that deal with this issue, and also to connote a somatic force (Conrad 2021).

4 In biology, the “stress response” is understood in neuroendocrine terms, but it is known to be mediated by subjective and affective factors. Press’s (2016) view that affect theory will ultimately unify psyche and soma recalls Freud’s notion that instinct is sensed as affect. Press’s view is reflected in contemporary psychoanalytic thought (examples include Green 1970; Matthis 2000; Solms and Bucci 2000).

5 The role of inflammatory pathways (e.g. the cytokine system) in autoimmune processes is an active area of research in immunology.

6 See Winters (2021), for my earlier thoughts on this.

7 “Somatopsychic” joins the somatic and psychic, referred to by Aisenstein (2006) as an “indissociable unity”.

8 The intention here is not to propose a one-to-one correspondence between the “non-suppression” of self-reactivity in autoimmune disease and the defusion of instincts, but to use biological principles as a clinical heuristic (Pragier and Fauré-Pragier, 1990).

9 Freud uses fusion/defusion differently from binding/unbinding. For Freud, fusion is the alloying of the life and death instincts into a new amalgamation, whereas binding/unbinding is an economic concept. As he writes (1920): “We may perhaps suspect that the binding of the energy that streams into the mental apparatus consists in its change from a freely flowing into a quiescent state” (31).

10 An exception is the suppressive mechanism, in which responsivity is lessened (Sakaguchi 2000).

11 I subsequently learned from Mr. C. that his ferocious scratching had exacerbated his autoimmune condition.

12 Although psychoanalysis has not observed this connection, in the popular press the medical profession’s failure to understand chronic illnesses in women (which often have an autoimmune component) has been compared to unfounded attributions of hysteria (O’Rourke 2022).

13 See also Abel-Hirsch’s (2010) discussion of a pathological defusion of the life instinct from the opposition of the death instinct, such that the patient experiences “severe anxiety that life-giving connections threaten to proliferate indiscriminately and to an overwhelming intensity and size” (1055).

14 Šebek (2019) describes “enlivening interventions when the treatment is blocked by impasses caused by the death drive influences … [these are] understood as facilitating life drives and have different names depending on various clinicians and their differing theories: reclamation (Alvarez), resuscitation (Šebek), the enlivening object (Director), rehabilitation (Fonagy, Target), a new beginning (Balint), a birth (Borgogno)” (1330).

15 As described by Naas (2006), Derrida referred to autoimmunity as “that ‘illogical logic … that turns something against its own defenses … Derrida attempts to show that our traditional notion of sovereignty always harbors within it or always in fact produces, secretes, so to speak, the very forces that would compromise or undermine it” (18). We might also consider Derrida prescient in anticipating internal attacks on democratic processes in the United States and other countries.