Hypochondria as an actual neurosis^*

* This paper has been typeset and published by the previous publisher and hence differs in appearance to other papers in this issue.

Abstract

Freud defined hypochondria as an actual neurosis. In this paper the actual neurosis will be interpreted as unbound traumatic elements which threaten the self. In severe hypochondria, breakdowns have occurred, as outlined by Winnicott. The nameless traumatic elements of the breakdown have been encapsulated. The moment these encapsulated elements are liberated, an actual dynamic takes place which threatens the self with annihilation. Projective identification is not possible because no idea of containment exists. The self tries to evacuate these elements projectively, thus triggering a disintegrative regression. However, the object of this projection, which becomes a malign introject, is felt to remove the remaining psychical elements, forcing the worthless residue back into the self. In a final re-introjection, the self is threatened by unintegration. To save the self, these elements are displaced into an organ which becomes hypochondriacal, an autistoid object, protecting itself against unintegration and decomposition. An autistoid dynamic develops between the hypochondriac organ, the ego and the introject. Two short clinical vignettes illustrate the regressive dynamical and metapsychological considerations.

L'hypocondrie comme névrose actuelle

Freud a défini l'hypocondrie comme une névrose actuelle. Selon l'auteur de cet article, la névrose actuelle se compose d’éléments traumatiques non liés qui menacent le self. Les formes graves d'hypocondrie sont sous-tendues par des états d'effondrement, comme l'a montré Winnicott. Les composants de cet état d'effondrement ont été encapsulés. Dès lors que ces éléments encapsulés se trouvent libérés, on assiste à la mise en œuvre dans l'actuel d'une dynamique qui menace le self d'annihilation. L'identification projective s'avère impossible, car il n'existe pas d'idée de contenant. Le self tente d’évacuer ces éléments en les projetant, ce qui déclenche un processus régressif de désintégration. Tout se passe comme si l'objet de cette projection, qui devient une introjection à caractère néfaste, s'emparait des éléments psychiques restants et forçait le retour de ces parties nuisibles dans le self. Dans un mouvement final de réintrojection, le self se voit menacé par la non intégration. Pour sauver le self, ces éléments sont déplacés vers un organe qui devient hypocondriaque, revêtant l'aspect d'un objet d'allure autistique qui protège contre la non intégration et la décomposition. On assiste alors au développement d'un mouvement autistique entre l'organe siège de l'hypocondrie, le moi et l'objet introjecté. Deux vignettes cliniques servent à illustrer cette dynamique régressive, comme à étayer des considérations métapsychologiques.

Hypochondrie als Aktualneurose

Es wird versucht, Freuds Konzept der Hypochondrie als Aktualneurose neu zu interpretieren. Bei schweren Formen der Hypochondrie haben sich frühe Zusammenbrüche (breakdown) ereignet, wie Winnicott sie beschrieben hat. Diese namenlos-traumatischen Elemente werden eingekapselt. Kommt es zur Freisetzung dieser Kapselinhalte, entsteht eine aktuale Dynamik, die das Selbst bedroht. Das Aktuale kann damit als traumatische Entbindung begriffen werden. Diese Bedrohung kann nicht projektiv-identifikatorisch mitgeteilt werden, da kein containment existiert. Das Selbst versucht, diese Elemente projektiv loszuwerden, damit einen regressiven Zerfall einleitend. Doch das Objekt dieser Projektion entkleidet die letzten seelischen Reste und zwingt den verbleibenden Rest zurück, wird so zu einem malignen Introjekt. Die finale Reintrojektion in dieser desintegrativen Regression bedroht das Selbst, das zur Rettung die Elemente in ein Organ verschiebt, das hypochondrisch besetzt und zu einem autistoiden Objekt wird. So schützt es sich vor Unintegriertheit und Zerfall. Zwischen dem hypochondrisch besetzten Organ, dem Ich und dem Introjekt entfaltet sich eine autistoide Dynamik. Die metapsychologischen und dynamischen Überlegungen werden an zwei Fallvignetten illustriert.

L'ipocondria come nevrosi attuale

Freud ravvisava nell'ipocondria un tipo di nevrosi attuale, categoria che in questo lavoro viene interpretata come serie slegata di elementi traumatici che minacciano il Sé. Come descritto da Winnicott, i casi più gravi di ipocondria sono preceduti da breakdown i cui elementi sono stati incapsulati; tuttavia, nel momento in cui tali elementi vengono liberati, si verifica una dinamica che minaccia di annullare il Sé. L'identificazione proiettiva non può aver luogo in quanto manca qualsiasi idea di contenimento. Il Sé tenta di evacuare questi elementi proiettivamente, attivando in tal modo un processo di regressione disintegrativa, ma l'oggetto della proiezione, introiettato come oggetto cattivo, sottrae nella percezione del soggetto gli elementi psichici rimanenti riversandone le parti senza valore dentro il Sé. Attraverso un ulteriore processo di reintroiezione, il Sé avverte a questo punto una minaccia di disintegrazione. Per salvare il Sé questi elementi sono allora spostati su un organo del corpo che diventa oggetto dell'ipocondria – un oggetto autistoide che ha la funzione di proteggere dalla disintegrazione e dalla decomposizione. Prende forma a questo punto una dinamica di tipo autistoide tra l'organo ipocondriaco, l'Io e l'oggetto introiettato. Facendo riferimento a due brevi vignette cliniche verranno svolte, rispetto a questo particolare tipo di regressione, alcune considerazioni di carattere psicodinamico e metapsicologico.

La hipocondría como neurosis actual

Freud definió la hipocondría como una neurosis actual. En este trabajo se interpreta la neurosis actual como elementos traumáticos no ligados que amenazan al self. En la hipocondría severa, ha ocurrido un derrumbe (breakdown), como lo esbozó Winnicott. Los elementos del derrumbe han sido encapsulados. En el momento en que estos elementos encapsulados son liberados, se desarrolla una dinámica actual que amenaza al self con la aniquilación. Al no existir la idea de contención, no es posible la identificación proyectiva. El self intenta evacuar estos elementos de manera proyectiva, desencadenando así una regresión desintegradora. El objeto de esta proyección, que se convierte en un introyecto maligno, es sentido como que elimina los elementos psíquicos restantes y fuerza a las partes despreciables a retornar al self. En una reintroyección final, el self es amenazado por la falta de integración. Para salvar al self, estos elementos son desplazados hacia el interior de un órgano que se vuelve hipocondriaco, un objeto austitoide, que protege contra la falta de integración y la descomposición. Se desarrolla una dinámica autistoide entre el órgano hipocondriaco, el Yo y el introyecto. Dos viñetas clínicas ilustran las consideraciones dinámicas y metapsicológicas de la regresión.

Keywords:

• hypochondria
• actual neurosis
• autistoid
• breakdown
• projective-introjective dynamic
• introject

Notes

* This paper has been typeset and published by the previous publisher and hence differs in appearance to other papers in this issue.

2 This thesis was already championed by Paul Schilder (1925) in his reflections on hypochondria. He proceeds from a phenomenology of the ego-experience and embraces many central aspects like fixation in the narcissistic phase, the role of projection, compulsive introspection and sexualization. He notes: “Self-observation [of the body] therefore means: eavesdropping on one's feelings” (p. 29). The feeling is then turned into perception (p. 34). He adheres to Freud's view that organs which contain an excess of libidinous tension are observed. His phenomenological approach then allows him to establish that the observed organ is made “partly into external world” (p. 30). Then again the close link between hypochondria and depersonalization is evident (p. 32). However, the alterations to the body image follow mental paths “whose symbolic meaning bears a relation to the conflict concerned” (p. 37). For Schilder, then, hypochondria as well as the other actual neuroses are not entirely disconnected from the unconscious meaning.

3 In extremely simplified form, one might say: every breakdown is traumatic, but not every trauma is a breakdown.

4 It is important to mark the scientific reference system clearly: it is the endopsychical world, that is, the sources of the relationship disorder can also be located in the child; for example, constitutional envy, frustration intolerance, autistic predispositions and so on, or abnormal development is to be sought in dispositions on both sides.

5 The complicated correlation of historicization (“Nachträglichkeit”/“afterwardsness”), actual neurosis and breakdown cannot be developed here. Winnicott's concept of the breakdown and the Freudian concept of afterwardsness (see also Laplanche and Pontalis, 1972) has been discussed by various authors, however, such as Faimberg, 2005. Eickhoff (2005) also examines this relationship, interprets Winnicott‘s breakdown – though close on psychosis, if anything – postulating, like Loch (1988), that “there is only the subsequent context-dependent attribution of meaning; the primary vestige … is not discernible“ (2005, p. 151). Dahl (2010) comes closer in my view, acknowledging the dual-phasedness, the linear-deterministic reconstruction as also retrograde-hermeneutic construction, in my view leaving what has actually happened to come into its own. For me the breakdown remains ‘actual’ and eludes ‘historicization’ (Baranger et al., 1988) as long as it is not sublated in the transference relationship (see below).