Aisenstein, M., Gibeault, A. (1991). The Work of HypochondriaA Contribution to the... Int. J. Psycho-Anal., 72:669-680.

[Print] [Previous Document] [Previous Hit] [Next Hit] [Next Document] International Journal of Psycho-Analysis (1991). International Journal of Psycho-Analysis, 72:669-680 The Work of HypochondriaA Contribution to the Study of the Specificity of Hypochondria, in Particular in Relation to Hysterical Conversion and Organic Disease Marilia Aisenstein and Alain Gibeault Author Information Toi seul, oh mon corps, mon cher corps, Je t'aime, unique object qui me dfend des morts! [You alone, my body, my dear body, I love you, my sole protection from the dead!] Paul Valry, Fragments du Narcisse, III, Posies, Gallimard, 1929, p. 72. The link between the soul and the body is not now parallelism , nor is it absolute opacity It is to be understood as the link between the convex and the concave, between the solid arch and the hollow it creates. M. Merleau-Ponty, Le visible et l'invisible, Gallimard, 1964, p. 286. While hypochondria nowadays generally means imagined illness in popular usage, the psychopathological definition of this word is more problematic: is it a nosographic entity which, by virtue of its chronic nature, resembles a psychosis. Or is it rather a temporary psychical state that is found in both the neuroses and the psychoses, which can appear at different times in a person's life (adolescence, mid-life crisis, ageing), or which might be associated with certain phases of psychoanalytic treatment? Our intention here is not to take away from the multiplicity of meanings of this term but to emphasize the metapsychological dimension of hypochondria as anxiety. From this point of view, the relative imprecision of the concept of hypochondria is confirmed by the evolution of Freud's ideas about it. The absence of a single firm definition of the term is indicative of the complexity of its status within the mind. Hypochondria is mentioned for the first time in Draft B (8 February 1893), as one of the chronic symptoms of anxiety neurosis, which Freud was to classify in 1898 as one of the two actual neuroses, 1 the other being neurasthenia. Freud's linguistic hesitations at this time are a striking illustration of the difficulty experienced in locating hypochondria, as a manifestation of anxiety, correctly between soma and psyche: he in fact defines hypochondria as 'anxiety relating to the body'. We may wonder what he means by 'relation to the body', knowing as we do that, in the context of the first theory of anxiety, actual neurosis involves a strictly somatic sexual excitation which cannot be bound to psychical representations and whose accumulation leads to an essentially somatic discharge, which characterizes anxiety. It may be noted that Freud refers, in

connexion with anxiety neurosis, to 'a kind of conversion' as in hysteria, but not with the same relationship or direction between psyche and soma (Freud, 1894, Draft E, p. 195). Again, Freud does not hesitate to use the term 'hypochondriacal phobia' (1895, p. 78) in relation to a female patient who was afraid of going madthis, of course, would be a psychical outcome, which he nevertheless attributes to sexual frustration. These two aspects, the psychical and the somatic, thus lead Freud to regard hypochondria as a third actual neurosis and also to see in actual neurosis 'the nucleus of the psychoneurotic symptomthe grain of sand at the centre of the pearl' (1912b, p. 248). The introduction of the concept of narcissism constitutes the second stage in the theoretical (MS. received November 1990) Copyright Institute of Psycho-Analysis, London, 1991 1 Freud introduced the concept of 'actual neurosis' for the first time in 'Sexuality in the aetiology of the neuroses' (1898). He had referred to it until then in terms of 'sexual neuroses', this for him being a way of noting the sexual factor in any neurosis, including the psychoneuroses.

- 669 elaboration of the concept of hypochondria, which becomes the object of the new instinctual antithesis between ego libido and object libido. Organic disease and hypochondria become two analogous forms of withdrawal of libido on to the ego. Freud emphasizes how close the hypochondriacal anxieties are to the paraphrenias, and hence to psychosis. In this connexion, he postulates (1914) a damming up of libido in the ego as a source of unpleasure; as Freud himself suggests, the question of the explanatory value of this economic process remains entirely unresolved. This does not mean, however, that he abandons the idea that a hypochondriacal organization, be it neurotic or psychotic. Again, his reflections on the hypochondriacal symptom allow him to equate the somatic excitation tension of the painful organ with the excited genital organ. This automatically implies an extension of this 'erotogenicity' to all organs, both internal and external. In this way the subject's body, through hypochondriacal pain, takes on an erotogenic quality, whose evaluation nevertheless remains dependent on the distribution of a quantity of ego libido. From this strictly economic viewpoint, it becomes difficult to distinguish the various possible somatic outcomes: hysterical conversion symptoms, organic disease or hypochondria. Our aim is to consider this problem in greater detail and to obtain a better grasp of the forms of psychical work involved. HYPOCHONDRIA AND DRIVE

Freud's hesitations give rise to an ambiguity about the status of the hypochondriacal symptom: is it a somatic sensation which has to do with vasovegetative and vasomotor innervation, or a representation (the fear of illness, the fear of going mad, etc.) which gives rise to painful sensations? Following Freud (1894), (1895), (1914) and Ferenczi (1919), Schilder (1950) seems to be postulating interactions between the two, implying a model that is both dualistic and positivistic. This model of the actual neuroses leads to a psychophysical parallelism; as Freud (1891) put it at the very beginning of his career, 'the psychical is a process parallel to the physiological''a dependent concomitant', in Hughlings Jackson's phrase (p. 105). It is important to note here that this is the model used by Freud in his biological conception of drivedrive being defined as the psychical expression of a somatic excitation (Freud, 1915a); this of course leaves entirely open the question of what is transformed in this passage from the somatic to the psychical. However, Freud extricates himself from this difficulty by developing a metapsychological conception of instinct, which is then defined as the somatic excitation represented on the psychical level in psychical representatives, the quota of affect and the representation-representative (Freud, 1915b), (1915c). From this point of view, the drive is in reality unknowable in itself, reification of the concept of somatic excitation thereby being avoided. By means of the drive's relationship to it's psychical representatives, the links between the somatic and the psychical can then be viewed as a historical process of construction of the body in the mind. Pain plays a predominant part in this process; Freud rightly points out that 'the way in which we gain a new knowledge of our organs during painful illnesses is perhaps a model of the way by which in general we arrive at the idea of our body' (1923, pp. 256). This may imply that the economy of masochism is essential to this work of representation. We must, after all, follow Freud in considering primary masochism as a sufficient cathexis of unpleasure relative to the hallucination of satisfaction to allow the transition from the pleasure principle to the reality principle. However, hypochondria shows that it is important to distinguish between unpleasure and pain. In our view, therefore, hypochondriacal anxiety corresponds to an insufficient cathexis of unpleasure, which prevents the organization of a delay in satisfaction, thus resulting in the hypercathexis of pain in its ahistorical dimension. Was Schilder therefore right to suppose that pain gives rise at one and the same time to a sadistic-anal regression and to a narcissistic regression involving the use of magical thought (1950, p. 176) ? There is no doubt that hypochondria includes a sado-masochistic component and a desymbolization of the body, in consequence of which Freud (1915c) says that

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the language of hypochondria is organ speech. The result may be a disappropriation of the painful organ, which, while still being exhibited in the body, may be experienced as alien to the subject and as needing to be expelled. This expelling impulse may even extend to disavowal of the organ, as in Cotard's syndrome. There are, after all, different forms of hypochondria and this disappropriation may be taken to the point of splitting of the ego. To take a famous example, the Wolf Man's hypochondriacal anxiety (Freud, 1918) about his nose was understood by Ruth Mack Brunswick (1928) as a disavowal of the patient's transference history with Freud. The same patient clearly illustrates the specificity of the language of hypochondria compared with that of hysteria, as described by Freud in the Studies of Hysteria. The hypochondriac for his part is absolutely intent on convincing his interlocutor of the quality and intensity of his pains: 'He is clearly of opinion that language is too poor to find words for his sensations and that those sensations are something unique and previously unknown, of which it would be quite impossible to give an exhaustive description' (Freud & Breuer, 1895, p. 136). This explains the impression he conveys of remaining for ever misunderstood and of being totally absorbed by his bodily pains. The hysteric, on the other hand, affects a belle indiffrence regarding his physical symptoms and seems in his descriptions to be more concerned with the thoughts about his pains than with the pains themselves. Hence the feeling of closeness of the subject's history that is the hallmark of repression. This implies an anticathexis of unpleasure connected with the hallucination of satisfaction, and the binding of affects within representations. If the hypochondriac is invaded by affects and does not have representations at his disposal, the hysteric on the other hand succeeds in causing the affect to disappear while retaining the representations. We are, of course, here only discussing models: clinical reality often shows quite a different complexity.2 What then is the situation regarding the economy of masochism in this third bodily outcome, somatization Unlike hypochondria, organic pain is in general, it seems, not sufficiently cathected masochistically, so that a discontinuity arises between the body and its representations in the mind. This tends to bear out the functional model of actual neurosis, confirming Freud's idea that a nucleus of actual neurosis underlies every psychical organization. A traumatic state may thus at any time call into question a neurotic or psychotic form of mental functioning and give rise to a somatization. Freud suspected this when he referred to the possibility of a temporary disappearance of the characteristic symptoms of melancholia or schizophrenia because of 'intercurrent organic illness' (1920, p. 33). Pace Schilder, organic pain in somatizations does not give rise to a specific recourse to sado-masochism or to magical thought. The absence of cathexis of the pain might remind one of the indifference of conversion hysteria but excludes the procession of repressed representations inherent in this symptomatology. Somatizations thus involve a drastic suppression of affects (Green, 1985), in contrast to hypochondria, which lives on their exhibition.

What then are we to make of the hypothesis of the damming up of ego libido as an explanation for hypochondriacal anxiety? Freud (1912a) had already used the term 'damming up of libido' to take account of the type of onset of neurosis. Since the concept of narcissism was not yet available to him, he at that time placed the damming up of libido in relation to object cathexis. From this point of view, the withdrawal of libido, described by Freud as introversion towards the 'life of phantasy', correlates with repression and psychoneurotic symptoms. However, it must at the same time be supposed that the damming up of object libido is at the root of the processes of identification and sublimation which preside over the creation and functioning of the ego. All the same, Freud is obviously embarrassed at using this quantitative hypothesis 2 Freud himself notes that, in conversion hysteria, the permanent symptoms connected with motility illustrate this disappearance of the affect, while the intermittent symptoms and those affecting the sensory sphere may be accompanied by pains of sometimes excessive intensity (1926, p. 112). This is why it is difficult to distinguish between hypochondriacal pain and hysterical pain except by referring to the patient's language and by an understanding of psychical topography.

- 671 alone for explanation, as he needs to specify 'that it is not a question of an absolute quantity, but of the relation between the quota of libido in operation and the quantity of libido which the individual ego is able to deal withthat is, to hold under tension, to sublimate or to employ directly' (1912a, p. 236). In other words, this economic hypothesis of the damming of libido is meaningful only by virtue of the reference to the topography of the mind. With the introduction of narcissism, his conception of damming up appears in a different light. The study of this process would allow an understanding of the excess of affective tension inherent in all the narcissistic pathologies. Freud here uses hypochondria as a model for taking account of the withdrawal of narcissistic libido and its accumulation on the ego. It must therefore be borne in mind that in this process the ego in fact loses its capacity to bind and is confronted with the accumulation of an excessive amount of unbound excitation which Freud (1926) was to describe later as automatic traumatic anxiety. Hence the idea that loss of the object in this situation also entails loss of the ego. According to this hypothesis of damming up of the ego, hypochondria does indeed then appear as a pathological process. In our view, the inadequacy of this concept has to do with Freud's difficulty in seeing in it also a form of binding. This would mean that hypochondria no longer belongs solely to the 'pathological processes' of ego withdrawal, as Freud believes, but also to the processes of 'restoration, in which the libido is once more attached to objects' (1914, p. 86), which Freud confined to delusional states. Hypochondria can now be seen not only as a symptom but as a psychical solution. This takes account of the fact that hypochondria

is indicative of the use of projection into the body, which, as Tausk (1919) pointed out, becomes the first external object. Another implication is that the withdrawal of narcissistic libido is never complete and that a link with the object is always preserved. This is what Freud was to discover at the end of his career, when he came to emphasize the role of the process of splitting of the ego in narcissistic symptomatologies. If damming up of the ego appears insufficient on the topographical level, it is equally so in economic terms. Since Freud did not yet have at his disposal the concept of primary masochism, he was unable to take account of the pleasure in unpleasure, the pleasure associated with the accumulation of excitation, and the progressive function of masochism in psychical life. From this point of view, the hypochondriacal outcome assumes its full validity as a dynamic solution, which, in the very process of decathexis of the object, maintains a minimum of object cathexis. The latter is admittedly not an end in itself, but it opens the way to a possible recathexis of the object. Clinical experience confirms that Freud was right in seeing here a possibility of modification during treatment, as 'the transition from physical pain to mental pain corresponds to a change from narcissistic cathexis to object-cathexis' (1926, p. 171). HYPOCHONDRIA IN PSYCHOANALYTIC TREATMENT Charles had been suffering for six months from agonizing anxieties and hypochondriacal pains when he embarked on psychotherapy at two sessions a week with one of us. Since then he had been complaining that his life had become hellish: 'I feel as if I am at the end of my tether, as if I am about to go completely mad. For the last six months, I do not know what has been happening. It came on all of a sudden. I have lapses of memory and disturbances of vision. I get unbearable stomach pains. I am absolutely certain I have got cancer'. Charles then gave a detailed account of his 'physical problems', of the doctors he had consulted, and of the many examinations he had undergone in order at last to find out 'the truth' about his condition. All the same, he felt that the doctors were declining to tell him everything they knew. In focusing in this way on the violence of his pains and the urgency of being finally delivered from a nightmare, Charles could not think of anything else. This obsession was intended to exclude any idea that might make him aware of the many losses he had sustained in recent times. The first of these was the separation from a girlfriend he had met by chance in a caf eighteen months earlier. He remembered their time together as an extremely intense love relationship such as he had never before known 'she was a

- 672 woman with a vibrancy about her'and, although he had experienced enormous gratification, he had begun to be afraid of her erotic demands, especially when she assumed an active position in their sexual relations. The resulting passivity had confronted him with a homosexuality which had called all his identifications into question. His anxiety had been so massive that he had attempted suicide by overdosing and ended up in hospital. He had felt momentarily

reassured in the ward and retained a very positive memory of those few days: 'I had never felt so well, I had no more anxieties and no more pains'. Protected from this woman, he had felt whole again and sheltered from a castration anxiety which had overwhelmed him and which had taken the form of a pain in the genitals in the later stages of this relationship. After his suicide attempt the girlfriend had left him, and at the beginning of his therapy he was constantly calling for her to return and dreaming of her. In this context he had begun to suffer from physical pains, mainly in the stomach, back and head. This was six months before his psychotherapy began. However, this was not the first time he had been confronted with hypochondriacal anxieties in this way: the break with the girlfriend had revived the relatively recent loss of his wife, who had died of cancer two years earlier. After her death, he had developed a massive anxiety that he himself might be struck down by a generalized cancer. He had 'recovered' suddenly after consulting a specialist and commencing his relationship with this second woman. In a similar way, his hypochondriacal anxieties were to be spectacularly cured as soon as he began his psychotherapy. Charles felt new life flowing into him after the difficult few years of his wife's illness and death, which had themselves been preceded a little earlier by his being made redundant. The onset of the first episode of hypochondria could be seen as resulting from a combination of situations that were effectively traumatic and a period of psychical reorganization, Charles at the time having been nearly 50 years old. He actually looked 15 years older than that, as his hair and beard were completely white; his awareness of this also tended to make him feel inadequate in the face of the emotional and professional challenges of life. However, this magical remission of the hypochondriacal symptoms was of short duration only. Charles again found himself in a passive situation, this time in the psychotherapeutic relationship, and resorted afresh to hypochondriacal selfobservation, spending several sessions complaining of his physical pains, connected in particular with what he called his 'dysentery'. He now ascribed his stomach pains first to an alleged syphilis of his father, who had 'contaminated' him, and then to a parasitosis he thought he had contracted during his military service in Tunisia by drinking from watering points 'contaminated by Arabs'. This led him to undertake a search for doctors who might deliver him from all his troublesdoctors who were at first idealized but then always proved unsatisfactory. This search reproduced the transference relationship with his psychotherapist, as a dream showed: I have a glass of beer in my hand, I am with you, and I blow on the head. I say: look out, the head stains'. This dream was a warning against a contamination that condensed heterosexual and homosexual objects and the genital, urethral and anal erotogenic zones (head = semen, beer = urine analyses, the stain that soiled, the drink that poisoned). It also represented an active impulse which reversed the patient's feared passivity in relation to the analyst. Again, all dreams were premonitory for Charles. The manifest content of the dream includes a pun (mousse tache = moustache as well as head stains), intended perhaps to gain a little more distance because of the danger involved.

Owing to his habitual use of magical thought and sado-masochistic drives, it was less important to work on the content of his dreams than on their psychical functionin other words, the dreams were wish fulfilments and personal creations and not harbingers of a situation in reality that would identically reproduce that of the dream. Similarly, the fear of being ill convinced him that he really was ill; this aroused the most intense anxiety in him but had the advantage of protecting him from anything that might have surprised and overwhelmed him, as, for example, the events of life. However distressing, a hypochondriac's solution thus resembles the paranoic's interpretation of the world, whose systematization allows control of

- 673 self and others. It therefore comes as no surprise that, as a result of his frenzied search for medical specialists and medical knowledge from books, he ultimately felt more of a doctor than all of them and always misunderstood. This work on the functioning of his thought enabled Charles to find a psychical space in which he could forge new links with important events in his history (see Gibeault, 1989, pp. 158997 for more details): the death of his father, who had also succumbed to cancer, and for whom he had felt both admiration and disappointment; the death of his mother, whom he had always experienced as 'a woman with a vibrancy about her' and of whom he retained hardly any good memories; memories of a childhood troubled by his father's bankruptcy before he was born and by the war, which contributed to his feeling of having been an unwanted child; and a memory of having been left to cry as a baby in a cradle and comforted by an elder brother, which in his view confirmed his mother's absence and inadequacy. It was this work which enabled him, in his psychotherapy, to rediscover the historical overdetermination of his stomach pains. When this symptom returned after he arrived late for a session, he connected his current anxiety with that which he had experienced as a child when separating from his mother to go to school. The fear of being late and of being physically punished for it had given him 'butterflies in the stomach'. Charles's history was thus marked by a depression which dated back to his earliest childhood but which could not be tackled in the treatment until he had worked through his persecutory anxieties, which were experienced primarily in connexion with the father-doctors and secondarily associated with a deficient mother. This is illustrated by a short sequence from a single session. Having missed the previous session because of a change of time, Charles arrived a quarter of an hour late. As usual, he complained of stomach pains and said that he had only been able to come by taking a sedative: 'It is still my parasitosis, my amoebiasis, these things have Greek names you cannot keep in your mindit is making my stomach bloated; I am annoyed with Dr X, he is not God'. His analyst then pointed out: 'So he is the parasite, you expected him to give you everything, and he took a lot of money from you'. Charles was surprised by the double meaning of the term parasite and stressed that he had been thinking only of the medical sense; however, this led him to think that he too was a parasite on social security: 'You will tell me that I am living at their expense'.

Charles was indeed living on an invalidity pension and he had often blamed himself for using this money otherwise than to 'feed the doctors', and for receiving treatment free of charge at the Psychoanalysis Centre. His analyst then pointed out to him how he would not allow himself to use this money for his own pleasure, or to benefit from his free psychotherapy. This possibility of receiving brought him back to the idea of being something different from the child that was unwanted because envious and greedy. The fear of being a parasite had in the past often aroused the anxiety of being dispossessed of everything ('the social security people will cut off my means of subsistence') and of 'dying in abject poverty'. This fantasy of material dispossession was consistent with his hypochondriacal anxiety of being dispossessed of his body. Not surprisingly, he again associated in this session with his pains: 'Even if I am entitled to all that, I still have these pains, I have a backache here, it is like a crab gobbling me up, forward, backward, it makes no difference'. The analyst said to him: 'I do not by any means want to deny your pains, but it is important to understand the meaning you give to them. It seems as if there is something devouring you from inside, such as anger and envy'. Charles replied: 'Actually I would like to be the same as everyone else'. When his analyst pointed out that 'everyone else is something abstract', Charles responded vehemently: 'I would like to be like you, you are not bent over double like me'. This sequence illustrates the depressive component of his hypochondria, which had to do, as in melancholia, with incorporation of the lost object. The crab devouring him from inside was admittedly connected with cancer, but also with all the dead people feeding on him. This is borne out by a dream he recounted at the end of the same session: 'I had a dream after the last session when I told you about some Arabs who wanted to steal everything from my block of flats: there were three crows eating rotten meat'.

- 674 The rotten meat represented this painful body, racked by physical pain, but also the identification with the dead mother, whose 'beautiful body' was in fact an ugly body that resembled a decomposing corpse.3 The three crows were also a reference to young Arabs and to the three children of the family, represented as greedy, envious babies. Again, he could not stand the calls of the crows which used to wheel about his block of flats, because to him they were like children's cries, which he had long found unendurable. In the process of working through this depressive nucleus, the use of projection for the purposes of negation allowed him to establish a distance in case melancholia should gain the upper hand over him: 'You will tell me that I too am the parasite', or, on another occasion: 'You will think that I am racked with pains because you are going on holiday, but ' Seen in this light, the hypochondriac's solution lies between the models of paranoia and melancholia, but cannot be equated with either as the Kleinian interpretation of hypochondria suggests (Klein, 1934), (1940), (1952); (Meltzer, 1964); (H. Rosenfeld,

1965), (1987); (D. Rosenfeld, 1984). The Kleinian hypothesis that an object relation exists from birth leads to a conception of hypochondria as the result of the splitting of the object and of its projection into the subject's own body, a mechanism which is equally applicable to psychosomatic illness and to hysterical conversion. This makes it difficult to account for the specificity of the hypochondriacal solution. The immediate interpretation in terms of unconscious fantasies then tends to detract from the role to the preconscious and of mental functioning, which we have stressed in discussing Charles's treatment.4 In this situation we may postulate the existence of a transference hypochondria (to use Angelergues apt term), which seems to be borne out by Charles's psychotherapy. It was indeed when protected from complaints about his physical pains, expressed at the beginning of practically every session throughout his treatment, that he was able to discover the entire history condensed within them and thereby to allow himself the improvement in his way of living to which he had always aspired. He thus became able to confront the psychical pain which the physical pain was intended to disavow and to exchange the search for idealized narcissistic objects for object cathexes. Paradoxically, it was at the point when Charles was considering terminating his therapy that he had the following dream: 'He is with his analyst, who tells him that he can do nothing more for him'. Manifestly, Charles can contemplate this separation only on condition that he is sent away by his analyst and keeps his pains. It is obvious that this patient's hypochondria had had the function of avoiding mourning for his dead and opening the way to a possible recathexis of his body other than as a putrefied body. The psychical reappropriation of his body in this case went hand in hand with what was tantamount to a work of hypochondria, by virtue of the mediation of a transference object whose finitude was acknowledged. DREAMS AND HYPOCHONDRIA The hypothesis of a work of hypochondria suggests that a minimum of hypochondriacal cathexis of the body is necessary in any psychical organization. It would be correlated with the cathexis by the object, and in particular the mother, of unpleasure and physical pain during the first experiences of satisfaction; this requires a hypochondriacal cathexis on the part of the mother5 which must not be too intense but has to be intense enough. This process would be analogous to the 'magnification [that] is hypochondriacal in character' to which Freud (1917) refers in connexion with dreams. He mentions the '"diagnostic" capacity' of dreams, which 3 As appropriately suggested by Michael Fain at the 49th Congrs des Psychanalystes de Langue Franaise des Pays Romans, May 1989. 4 We here take a similar view to Jeanneau (1990) in his conception of hypochondria as an 'object connexion' and his criticism of the Kleinian interpretation.

5 This is the aspect, emphasized from a behavioural point of view by Klein (1934), (1940), (1952) and A. Freud (1965), each in her own way, of the importance of external factors in the development of hypochondriacal anxieties. One of these authors stresses the importance of parental anxiety about the child's health and the other the contribution of the absence of maternal anxiety and of the mother herself to hypochondria in orphan children.

- 675 can reveal 'incipient' physical disease, allowing it to be detected 'earlier and more clearly than in waking life'. The narcissistic regression of the dream, combined with the dreamer's narcissism, gives rise to the original and unwonted situation in which 'all the current bodily sensations assume gigantic proportions' (p. 223). a dream by a female patient in psychotherapy with one of us illustrates this hypochondriacal cathexis in the function of dreaming. Marie-Paule, an active, likeable woman of 36, had no hypochondriacal symptoms. She was in psychotherapy for attacks of depression into which she could lapse for no conscious reason and from which she could emerge as soon as she could cathect someone. As it happens, she had a wide variety of interests. At the time of the dream she felt herself to be in a state of inner conflict concerning the choice between two men with whom she had simultaneous relationships, an older man whom she respected and was fond of and another, whom she had met more recently, who excited her more erotically. The choice was also between cathexis of her analyst and her need to remain in control by limiting the number of sessions. She then had the following dream: 'She is lost in an African crowd but is not very anxious, scanning the crowd for a male friend who she knows is there. She cannot see him but she knows that she will find him eventually because he is white in this black crowd. However, she is disturbed by the idea that she has not got her sunglasses. She thinks she has left them in Paris. There is too much light and the sun is getting stronger and stronger. Her eyes begin to hurt. She goes on staring at the sun all the same and her eyes then hurt very much.' She said that she could not remember the end of the dream. On waking, she remembered the dream very clearly and felt the need to check in the waking state that there was nothing wrong with her. That very evening she suddenly felt a shooting pain in the eyeballs; she could no longer keep her eyes open and had an emergency consultation with an ophthalmologist, who diagnosed a sudden inflammation of the cornea. He told her that it would take about ten days for her to recover, but the condition in fact subsided very quickly, within 48 hours. The following evening she came to her session and recounted both the dream and the Previous HitsomatizationNext Hit. She was surprised at the premonition of the dream. Her analyst asked her if the dream might not for once have helped her to seek an early consultation and suggested that the dream was more diagnostic than premonitory. Marie-Paule was after all a hyperactive

woman who could not readily endure any regression that confronted her with her passivity, identifying with a mother who had herself been active and at times been insufficiently present to satisfy her child's needs. Marie-Paule associated with the opposition between the old and the new continents, 6 which for her were Europe and Africa, and this in turn made her think of the old and the new relationship. The geographical remoteness reminded her of a number of trips with her parents and Baudelaire's lines: 'Le vert paradis des amours enfantines est-il dj plus loin que l'Inde et que la Chine?' [The verdant paradise of childhood love: is it already further away than India and China?]. This shows her nostalgia for a nonconflictual narcissistic cathexis, of which the boyfriend who was not far away in the dream was the successor, as she had known him since her teens. With him she had had one of those loving friendships typical of that age, with a relative lack of sexual differentiation. The dark continent was also the femininity which Marie-Paule had difficulty in accepting in its passive aspect, and against which she fought by seeking out dazzling excitation like the sun. Attempting to explain a Previous HitsomatizationNext Hit is always risky; here, in the context of the session's associations, it became meaningful by virtue of the dream, which took the place of working through the loss; for every choice confronted her with the loss of the maternal object, which acted as a shield against stimuli, displaced on to the analyst (the dark glasses left in Paris). It may be presumed that the working through in the session of this dream, prior to the somatic episode, enabled MariePaule to recover faster from the illness. 6 This was a slip or condensation on her part, as the new continent is America and not Africa. America actually represents a childhood dream or paradise.

- 676 The use of something like magical thought which belongs to the dream work is here indicative of the narcissistic hypercathexis of the affected organ; in the hypochondriac this is exacerbated in the waking state, whereas it is often lacking in the somatic patient. In the latter case, the failure to attend to the manifestations of the disease confirms the lack of the minimum hypochondriacal cathexis of the body and may well be associated with a difficulty in accepting any regression. While in her life Marie-Paule tended, as somatic patients do, to banish any worries about her body, she was nevertheless resourceful enough in this case to have a hypochondriacal dream which alerted her in advance.7 Similarly, the premonition which has to do with magical thought and also belongs to the hypochondriacal cathexis of the body is treated differently according to whether the hypochondria appears in a dream as with Marie-Paule or in the waking state as with Charles. This 'magnified' attention is thus inherently a part of that minimum of necessary creative illusion which alone can make the acceptance of renunciations possible. HYPOCHONDRIA AND ORGANIC DISEASE

The clinical fragments presented above relate to two patients in psychoanalytic psychotherapy. The normal run of patients exhibit a wide variety of forms of hypochondria, some of them extreme. From the delusional hypochondriac who kills his doctor to the germ of hypochondria involved in every neurotic organization at periods of major change in life (adolescence, menopause, ageing, etc.), the field is exceedingly wide and often complex. We particularly wish to consider a typical case which, although frequently referred to, has been little studied, in our view probably because of its borderline situation between medical observation and the psychiatric and psychoanalytic approach. This is the case when a patient diagnosed as a hypochondriac suddenly and puzzlingly contracts the dreaded disease, or when a hypochondriacal patient concomitantly displays organic symptoms, which may also affect a different part of the body. We can discuss the first case only in general and theoretical terms as we have no material, but we should nevertheless like to emphasize its importance for an understanding of the economic function of hypochondria. If the somatic decompensation is taken as indicative of a failure of the hypochondria as a more psychical or mentalized solution, we are led to postulate that hypochondriacal anxiety may be an alarm signal. This idea has already been put forward by Stolorow (1977), who, however, does not mention organic disease. On the basis of Freud's parallel between hypochondriacal anxiety, 'the counterpart, as coming from ego-libido, to neurotic anxiety' (1914, p. 84), and the function of anxiety in the transference neuroses, Stolorow hypothesizes that hypochondriacal anxiety is an alarm signal warning of a danger that threatens the narcissistic sphere. It is true that Freud's second conception of anxiety (Freud, 1926), as emanating from the ego to warn of an intrapsychic danger, can potentially be extended to cover hypochondriacal anxiety, which would mark a state of alert concerning the narcissistic cathexis of the subject's body. These diffuse hypochondriacal anxieties seem to be familiar in clinical practice at critical times, such as the menopause in women, but the phenomenon remains more mysterious when it concerns precisely a specific somatic disorder. It may nevertheless be imagined that a narcissistic withdrawal might encourage a 'magnification [to] gigantic proportions' (Freud, 1917, p. 223) of as yet pain-free bodily sensations, as in the dream situation. Once the alarm has been raised in this way, this narcissistic hypercathexis might sometimes allow a further reallocation of libido distributions, whereas its failure would open the way to decompensations. Our aim here is merely to pose the question; many aspects of it certainly merit discussion, including 7 For Freud, preconscious thoughts, the stuff of dream formation, may be normal or may have the character of a pathological state which is repudiated and suppressed in the waking state (1922, pp. 22930). A dream may therefore, when interpreted, furnish a pathogenic process that is lacking in the patient's usual clinical picture.

- 677 not only the establishment of organic disease but also the onset of Previous HitpsychosisNext Hit. The idea that hypochondriacal anxiety contains an alarm signal led us to consider also the concomitant appearance of a somatosis and of hypochondriacal anxieties centred on another organ or part of the body. We were given access to some reports of psychiatric consultations involving patients in whom the hypochondria predominated and others in whom the hypochondriacal element was additional to a different pathology. We have decided to give a very brief summary here of a case8 in which a serious illness of recent onset (carcinoma of the larynx) coincided with the sudden appearance of a mixed symptomatology: while the patient's language and anxiety appeared hypochondriacal, vertigo and an atypical confusional state without organic aetiology made the consultant wonder whether a conversion mechanism was also at work. Justin was 63 years old when carcinoma of the larynx was diagnosed after a dysphagia and pain in the right ear. Chemotherapy was initiated and shortly afterwards he was recommended to have a partial pharyngolaryngectomy not involving loss of phonation; he was not at first opposed to this. The date of the operation was set but surgery was prevented by the sudden onset of a hemiparesis on the left side. After a number of examinations which ruled out organic pathology, the neurological symptoms declined in less than a week. A month later, a new suggestion for a throat operation was immediately followed by the reappearance of an atypical confusional state with vertigo and complaints of symptoms Justin felt 'in the head, the cerebellum'. This was the context of the consultation. Justin was described as pleasant and polite, readily able to make contact; he had no psychiatric history, did not express any delusional ideas and said that he was not depressed. He had anxious brooding ideas about the future and wanted to go into a 'rest home'. He was now opposed to the throat operation: 'It does not hurt me, I want to keep my larynx, you cannot speak properly, I don't want it to be removed'. Although not denying his cancer'diagnoses are usually right'the did not seem to be worried about its seriousness but was prepared to undergo chemotherapy. He told the consultant his life story 'with smiling indifference'. Justin had not known his father, and his mother had sent him to a religious orphanage when he was very young. His memories were neither happy nor unhappy. After military service, he had remained a career soldier, engaging in the Coloniale and taking part in the Indochina war. After returning to civilian life in unspecified circumstances, he had worked in the building industry. A bachelor, he had not wanted children and had been living for 20 years with a woman 15 years his senior. The record of the consultation indicates that his neighbours in his block of flats had asked for an investigation by the social services, whose file included a letter or petition signed by all the neighbours asking for the expulsion of Miss S, who, with a male friend of hers, was said to have 'cruelly

beaten' Justin for years. Justin had always refused to lodge a complaint; he remained vague, mentioning only the 'gossips' at the block of flats. This instructive report nicely illustrates the complexity of the clinical situation. Was this a case of a hypochondriacal element rather than an atypical nosophobia which would be in line with the hypothesis of a conversion hysteria? But can there be a conversion when the language appears to be hypochondriacal? Although we think it impossible to draw nosographic conclusions from a consultation, there is a great temptation for psychoanalysts to reconstruct the sequence as follows: cessation (imposed from outside) of a form of masochistic behaviourcancerthe threat of surgery experienced as traumatic (Justin's military past)appearance of mental symptoms with hypochondriacal anxiety centred on the head, here seen as a part of the body, which Justin wanted to be the focus of attention (he wanted to keep his voice intact). The material presented here 'as found' in the context of a psychiatric consultation is valuable because it demonstrates the extreme difficulty and importance of an approach 8 We should like to thank Dr J. C. Montfort for his notes on a patient seen in a psychiatric consultation at a general hospital.

- 678 to hypochondria that takes account of the psychosomatic economy. CONCLUSION In this attempt to determine the position of hypochondria relative to other physical options, we have avoided resorting to a single explanatory hypothesisalong the lines either of Freud's reference to the psychophysiological functional scheme or of Melanie Klein's splitting of the object and projection into a part of the body. Such an approach carries the risk of ending up with a psyche-soma dualism which fails to take account of the specificity of the concept of drive as 'a measure of the demand made upon the mind for work in consequence of its connexion with the body' (Freud, 1915a, p. 122). We considered this essential in order to distinguish between the different possible somatic outcomes. When we speak of hypochondriacal anxiety rather than symptoms, we do so because of our concern to take account constantly of the two aspects, somatic and psychic, of a concept which refers redundantly to the inside. Indeed, this predominance of the inside is borne out by the etymology: the word hypochondria comes from the Greek hypo-khondrios lateral parts under the cartilage of the breastbonebecause the Ancients already considered hypochondria to originate from an internal organ between the abdomen and the chest thought to be the seat of the humours. So they already knew about the somatic expression of anxiety, which really is manifested 'in the pit of the stomach', as Charles demonstrated to us so noisily. And they also sensed that hypochondria had to do with the invisibility of parts of the body (hypo = below,

behind)hence their demand for physical representation, as with drive. Now in both sexes this invisibility of parts of the body is associated with cathexis of the invisibility of the femalematernal. If hypochondriacal anxiety sometimes makes itself so conspicuous in its most pathological manifestations, this may perhaps be a defence against the terror of what is hidden'the dark continent'in woman. The language of hypochondria is illustrative of this defensive mode in which words take precedence over things. It is a language concerning the body which forms a screen against the possible intrusion of the objectadmittedly a protective barrier, but also a call to recathect thing presentations (of body and object).9 If this process is made possible, the hypochondria may become more discrete or be confined to the dream function. By contrast, the hysteric's body language is conditional upon the cathexis of thing presentations and the acquired differentiation which implies the organization of anality. Anality allows the experience whereby the child can for the first time locate a stimulus as internal.10 Hypochondriacal anxiety is also related to aspects of psychical bisexuality. Both sexes have to integrate passivity, which Freud connected with the female.11 Hypochondriacal complaints and suffering seem to be more frequent in women, and it may be wondered whether this has anything to do with the concealed, invisible character of the female genital apparatus. (From this point of view, complaints of menstrual pains in puberty could be said to allow psychical representation of the uterus.) By way of bisexuality and the diphasic onset of sexuality, the work of hypochondria thus partakes of the processes of symbolization of the body and the world in the mind. As both a necessary condition and source of psychical reality, the body at the same time belongs to the external world (Angelergues, 1988) and here becomes the privileged site for negotiation of the relations between subject and object and between the different psychical agencies. The self-observation of the hypochondriac is rooted in this 'quasi-reflection' of the body, as described by Merleau-Ponty, which maintains a separationwhich is, however, not a voidbetween 9 Fedida (1972) is thinking on similar lines in pointing out that in hypochondria, 'the organ is hallucinated in the word' and that 'language is thus the only possible projective surface of the somatic' (p. 237). 10 In the Three essays(1905), Freud refers to the primacy of the anal zone in the matter of erotogenic stimulation. 11 On the difference between the male and the female as non-identical with the antithesis between activity and passivity, see Gibeault (1988).

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the sentient body and the sensible body (1964, p. 326). While this work of hypochondria is manifested in pathological expressions close to Previous Hitpsychosis, it may also indicate the importance of a necessary hypercathexis of the body in the psyche in order to make possible the acknowledgement of the otherness of the object in its sexed body. SUMMARY The authors present a metapsychological conception of hypochondria. Following Freud, they contrast the complaints of the hypochondriac with the belle indiffrence of the hysteric, and they then enquire into the heuristic value of hypochondria as an actual neurosis; this leads them to a consideration of psychosomatic illness and the importance of the object cathexis in hypochondriacal anxiety. In the development of Freud's theory of the drives, the explanatory concept of the damming up of ego libido proves insufficient and has to be coupled with the notion of primary erotogenic masochism: from this point of view, hypochondria can be seen as a form of binding which thus distinguishes it from other somatic outcomes. On the basis of three case histories, the authors endeavour to show hypochondriacal anxiety not only as a pathological process but also as a type of necessary minimum cathexis of the body; this leads to the idea of hypochondria as psychical work. REFERENCES ANGELERGUES, R. 1988 Rflexions sur le corps, la sexualit, le sexe Les Cahiers du Centre de Psychanalyse et de Psychothrapie 17-18 7-22 FEDIDA, P. 1972 L'hypocondrie du rve Nouvelle Rev. Psychanal. 5 225-238 FERENCZI, S. 1919 The psychoanalysis of a case of hysterical hypochondria In Further Contributions to the Theory and Technique of Psychoanalysis London: Hogarth Press, 1926 FREUD, A. 1965 Normality and Pathology in Childhood New York: Int. Univ. Press. FREUD, A. & BERGMANN, T. 1955 Children in the Hospital New York: Int. Univ. Press. FREUD, S. 1891 On Aphasia New York: Int. Univ. Press, 1953 FREUD, S. 1893 Draft B (8.2.1893): The aetiology of the neuroses S.E. 1 [] FREUD, S. 1894 Draft E (undated). How anxiety originates S.E. 1 [] FREUD, S. 1895a Obsessions and phobias. Their psychical mechanism and their aetiology S.E. 3 [] FREUD, S. 1898 Sexuality in the aetiology of the neuroses S.E. 3 [] FREUD, S. 1905 Three Essays on the Theory of Sexuality. S.E. 7 [] FREUD, S. 1912a Types of onset of neurosis S.E. 12 []

FREUD, S. 1912b Contributions to a discussion on masturbation S.E. 12 [] FREUD, S. 1914 On narcissism: an introduction S.E. 14 [] FREUD, S. 1915a Instincts and their vicissitudes S.E. 14 [] FREUD, S. 1915b Repression S.E. 14 [] FREUD, S. 1915c The unconscious S.E. 14 [] FREUD, S. 1917 A metapsychological supplement to the theory of dreams S.E. 14 [] FREUD, S. 1918 From the history of an infantile neurosis (The Wolf Man) S.E. 17 [] FREUD, S. 1920 Beyond the Pleasure Principle. S.E. 18 [] FREUD, S. 1922 Some neurotic mechanisms in jealousy, paranoia and homosexuality S.E. 18 [] FREUD, S. 1923 The Ego and the Id. S.E. 19 [] FREUD, S. 1926 Inhibitions, Symptoms and Anxiety. S.E. 20 [] FREUD, S. & BREUER, J. 1895 Studies on Hysteria. S.E. 2 [] GIBEAULT, A. 1988 Du fminin et du masculin. Rflexions partir du livre de J. Cosnier 'Destins de la fminit' Les Cahiers du Centre de Psychanalyse et de Psychothrapie 16-17 107-128 GIBEAULT, A. 1989 Les destins de la symbolisation. Rapport au XLIXme Congrs des Psychanalystes de Langue Franaise des Pays Romans Rev. Fran. Psychanal. 43 1517-1617 GREEN, A. 1985 Rflexions libres sur la reprsentation de l'affect Rev. Fran. Psychanal. 49 773-788 HUGHLINGS JACKSON, J. 1878 On affections of speech from disease of the brain Brain 1-304, pp. 207-208 JEANNEAU, A. 1990 Les dlires non psychotiques Paris: PUF. KLEIN, M. 1934 A contribution to the psychogenesis of manic depressive states In Contributions to Psycho-Analysis 1921-1945 London: Hogarth Press, 1965 pp. 282310 KLEIN, M. 1940 Mourning and its relation to manic-depressive states In Contributions to Psycho-Analysis 1921-1945 London: Hogarth Press, 1965 pp. 311338

KLEIN, M. 1952 Some theoretical conclusions regarding the emotional life of the infant In Envy and Gratitude and Other Works, 1946-1963 London: Hogarth Press, 1975 pp. 61-93 [] MACK BRUNSWICK, R. 1928 A supplement to Freud's History of an Infantile Neurosis.Int. J. Psychoanal. 9:439-476 [] MELTZER, D. 1964 The differentiation between somatic delusions from hypochondria Int. J. Psychoanal. 45:246-250 [] MERLEAU-PONTY, M. 1964 Le visible et l'invisible Paris: Gallimard. ROSENFELD, D. 1984 Hypochondria, somatic delusion and body scheme in psychoanalytic practice Int. J. Psychoanal. 65:377-388 [] ROSENFELD, H. A. 1965 Psychotic States London: Hogarth Press. ROSENFELD, H. A. 1987 Impasse and Interpretation London and New York: Routledge and The Institute of Psycho-Analysis. [] SCHILDER, P. 1950 The Image and Appearance of the Human Body London: Kegan Paul, Trench, Trubner, 1953 STOLOROW, R. D. 1977 Notes on the signal function of hypochondriacal anxiety Int. J. Psychoanal. 58:245-246 [] STOLOROW, R. D. 1979 Defensive and arrested developmental aspects of death anxiety, hypochondriasis and depersonalization Int. J. Psychoanal. 60:201-214 [] TAUSK, V. 1919 On the origin of the 'influencing machine' in schizophrenia Psychoanal. Q. 2:519-556 1933 []

- 680 Article Citation [Who Cited This?] Aisenstein, M. and Gibeault, A. (1991). The Work of HypochondriaA Contribution to the Study of the Specificity of Hypochondria, in Particular in Relation to Hysterical Conversion and Organic Disease. Int. J. Psycho-Anal., 72:669-680 Copyright 2008, Psychoanalytic Electronic Publishing. Help | About | Report a Problem