Martine DerzelleTowards a Psychosomatic Conception of Hypochondria2014The Impeded Thought10.1007/978-3-319-03053-1_4
© Springer International Publishing Switzerland 2014
4. Negative Reports or “A Certain Discourse Used in a Certain Way”
(1)
Institut Jean-Godinot, Reims, France
Abstract
Clinical observation allows us to identify invariants in hypochondriacal discourse. We notice that they belong to three categories that we define and interpret. In terms of content, complaint is characterized by a meaningful location of the said-to-be algic part of the body. The psychological aspects are mainly a tendency to conflict euphemization, a specific dynamic of depressive and paranoid traits and a basal fantasy inhibition. However, our interpretation of the centrality of complaint and the intensity of discourse experience, as well as the inevitable therapeutical failure in hypochondria induce new hypotheses.
4.1 Stories, Briefly Told
After the failure of the psychiatrist called to the rescue as the specialist of the invisible soul, the first medical action is to send the patient to the psychologist. The invariability of the moment when this happens is to highlight, which seems to endow this demand with the aim of repressing unconscious fantasies, specific to the department, which the somatic complainant has progressively revealed. It is in this context that we have worked on negative reports, in interviews which sometimes had limited possibilities because the discharge date was close. In a number of cases yet, we could continue our task in the form of weekly outpatient interviews which unquestionably enabled the accomplishment of real work, which even “resulted” in the displacement of a patient’s symptoms. We will try to draw the main features of these very dissimilar fates that are stories above all.
The four exposed cases relate to apparently quite ordinary people whose common point is, beyond their various individual issues, that they express pain and suffering while no diagnosis can be made. More exactly, if it is true that, as M. C. Célérier writes.
physical suffering, even the most hysterical or hypochondriac one, must have a physical substratum, at least a microchemical one (Célérier 1978, p.131),
these patients have first and foremost the characteristic of expressing a somatic complaint with no detectable organic substrate. Let us then make their words audible, words they uttered in laborious interviews whose grueling aspect evokes the accurate picture depicted by M. Balint when he speaks of complaint with a general meaning.
True, we do not give our patient – as doctors do – sedatives, tranquilizers, anti-depressants, and other drugs, but perhaps this makes it more difficult for us to bear unrelieved complaints. To be able to do something about them, to give something to stop them, we resort to giving interpretations, and if these do not stop the complaining, we try to fix the blame somewhere: on ourselves for our bad technique, on the patient for his incurable illness, for his destructiveness, his deep regression, for the split in his ego, and so on; or on his environment, and in particular on his parents for their lack of understanding, their unsympathetic ways of upbringing, and so on; recently an old scapegoat seems to have been resuscitated for this purpose: heredity. In this way, an endless spiral may develop… however no real change follows (Balint 1967, p.109).
4.1.1 Case I
Mrs. C., aged 40, entered the hospital on her attending physician’s advice, but this hospitalization also seemed to be her desire. She had been feeling very tired for a while and she presently suffered from pains, described as steady and shooting, in the left hypochondrium; for a certain time those pains had been related to gynecological problems which had been taken care of. Except for a light and varying anemia occasionally revealed by her blood count, nothing noticeable could be reported. Her previous medical history only revealed an eczema episode when she was four and benign adenopathies in childhood. She had decided to see her doctor because she had felt dizzy once, and only once, a few weeks before; she attributed her dizziness to the obstinacy of her pains which she said were beginning to completely exhaust her. After multiple investigations, Mrs. C. apparently had nothing thinkable from a medical point of view.
When we met her for the first time, Mrs. C. told us, smiling brightly, that she had never had any psychological problem. She was a management executive in an advertising company, she looked much younger than her age and, apart from her illness on which she was unstoppable, she was only fluent and comfortable when speaking about her job. Giving a lot of technical details and pointing insistingly at the form of independence it provided her, she described it as very absorbing and demanding. She had divorced 3 years ago by mutual agreement with her ex-husband, because of “weariness” she said. She said that this separation was an inevitable fatality, because, as in all couples habit soon replaces affection. During this marriage, she had had a miscarriage after 7 months of pregnancy before giving birth to a stillborn child; those events seemed to have influenced the divorce but the patient did not say much about this. After her divorce Mrs. C. began a Bachelor’s Degree in Economic Sciences and then brilliantly obtained it, more to prove to herself that she could achieve something than because of genuine necessity. However she mentioned a lot of difficulties in her present work. As a sort of permanent backdrop, an “implausible fatigue” had been crushing her for a few months; she said that it was the result of a sleeplessness caused by noisy neighbors. Recent holidays had not helped her recover as she still had difficulties to fall asleep. In spite of a growing exhaustion, she had continued to work until dizziness and pain had appeared. Now on sick leave she was pleased to think that the cause of her problems would be identified but strongly deplored her “idleness.”
Interviews with Mrs. C. were, on the whole, extremely difficult: when she was invited to talk about herself, she tirelessly returned either to very general considerations or to an endless inventory of her internal somatic condition, as bodily life and medical prescriptions were obviously the only objects of her attention of the moment. Cold and aloof, she seemed to undergo a sort of police interrogation in which she would have had to cunningly dodge questions. All this, marked by the incessant to-ing and fro-ing of considerable paranoid anxieties alternately related to the inside, the body, (hypochondriac persecutions) and coming back from the outside where they had been projected (paranoid persecution), identified her as basically depressive, register to which the continuously expressed fatigue and sleep disturbance also pertained. Shortly before she left the hospital, Mrs. C. “confessed” that she sometimes felt “depressed” and would then have done “anything” but she was violently trying to defend herself against this suffering by a haughty attitude in the relationship similarly to her choice of an unbridled hyperactivity at work.
Manifested above all by a radical economic transformation of investments, the depression of Mrs. C. essentially appeared to us in perfect match with the notion of somatic depression proposed by P. Fedida (Fedida 1978b, p.76), as it seemed to share a genuine structural isomorphism with organic disease: same interest and libido withdrawal from objects in the outside world, same concentration of those on the so-called algic organ, in short, same narcissistic reorganization strongly auto-eroticized by the organic pains and suffering and economically protected by the patient’s somatic selfishness, with the difference that, in the second case,
the painful sensations are based on demonstrable changes.
There is no doubt therefore that this is an absolute “regression” in the topical and temporal meaning of the term (Laplanche and Pontalis 1967, pp.400–401), primitive narcissism being precisely considered by Freud as the sleeper’s and the somatic patient’s as well, but also as the hypochondriac’s.
The psychical state of a sleeping person is characterized by an almost total withdrawal from the surrounding world and a cessation of all interest in it (Freud 1915[1917]a, p.222),
formulation repeated in identical terms in On Narcissism: An Introduction when he speaks of organic disease before coming to hypochondria (Freud 1914, p.83sq). The depression-soma-sleep-hypochondria continuity seems to emerge, already suggested by the ancients, like Griesinger, in the form of a community of structure between hypochondria and depression named somatic neurasthenia. Mrs. C. thus seems, like the organic patient, to entrust her somatic evolution with the function of resolving the deadlock generated by her conflicts. The alternation noted by Freud between cessation of love life (withdrawal from object libido) and onset of disease (narcissistic libido) goes in the same direction, suggesting specific correlations between the two processes (Freud 1914, p.89). As somatic illness, the depressive state of Mrs. C. perhaps tells the disaster of a breakup.
4.1.2 Case II
Mrs. P., aged 39, entered the Department in a panic, for a right cranial pain that was precisely located at the level of the parietal bone; she was determined and asked for a CT scan in order to know what this “concealed.” As a former medical student, she feared brain damage and exposed to anybody available her multiple reasons to suspect a serious pathology. Very accurately, she described a fixed and persistent painful “point,” which she had suffered from, without climax or respite, for approximately 5 months, more precisely since her second delivery. Shortly before, she said, she had developed large scalp furuncles in the same location, now healed as the dermatologist called to her bedside rapidly confirmed it. Having, in her words, never experienced the single headache, she expressed her astonishment especially at being overwhelmed by pain, and tirelessly denounced the “remarkable weakness” of all “lame and pale” descriptions that the medical profession in vain tried to make to “perhaps” identify her problem. Strictly speaking, for her, the typical matter seemed, to be the Inexpressible and the Elusive. Convinced of being able to be understood only very approximately, she seemed in this to match Freud’s description of the hypochondriac evoking his pain:
the neurasthenic… (a hypochondriac or a person affected with anxiety neurosis) gives the impression of being engaged in a difficult intellectual task to which his strength is quite unequal (…). He struggles to find a means of expression. He rejects any expression of his pains proposed by the physician even if it may turn out afterwards to have been unquestionably apt. 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. For this reason he never tires of constantly adding fresh details, and when he is obliged to break off he is sure to be left with the conviction that he has not succeeded in making himself understood by the physician (Freud 1892–1895, p.136).
If there was, for Mrs. P., the equivalent of a double imaginary lesion, that of her brain echoing that of the medical ideal which had guided her once, investigations, often made on her request, did not however reveal anything abnormal. Then, labeled ‘negative report,” Mrs. P. could leave the hospital after 10 days.
When we met Mrs. P., we were struck by her physical appearance. Livid and tired, her face lit up with an indescribable smile, as soon as she spoke of herself, a little as if she was injured and endured in silence an inner suffering whose evocation would be forbidden. Her story also constantly presented her in a victim role. When she was 8-years old she had contracted poliomyelitis, as a result, according to her, of a vaccination error—which would have consisted in the inoculation of a stale product—but fortunately had no real handicap due to this condition, and she ceaselessly returned to the subject of this painful period of her existence. And the feeling, experienced very early, to be different from the others because of being “ill” occupied center stage. The evocation of this exceptional status made her immediately associate with the immense fatigue she said she had felt since the birth of her second child. She sometimes connected her cranial pain to this birth. Her second child, a girl, was however desired, especially by her because, she added “my husband already had his boy.” Recently however, fatigue had begun to make her nervous and sometimes she could not withstand her husband, her 3-year-old son either, whom she admitted, with a deep feeling of guilt, she had intended to hit many times. She also explained that in the past, and especially just after her marriage, the relationship with her husband, nice but very choleric, “tolerating no single moment of resistance,” had frequently been difficult and marked by a lot of violence. As she understood that her husband took “a certain pleasure” in such quarrels, she then tried to avoid them and not to respond to provocations. “Someone had to give in!” she said then, faintly giving her unruffled smile. Mrs. P. also spoke of many difficulties in her professional life. Having given up, after 5 years, medical studies that were “prodigiously boring and not a life for a woman,” she had folded back on pharmacy, learning the job of pharmacy technician. Her boss supposedly had recently threatened to dismiss her for having added her month’s holiday, without warning him, to her legal maternity leave. The patient seemed to accept this fact as inevitable and did not even consider the big financial problems, which would undoubtedly arise if she lost her job.
In this story repeatedly marked by the dimension of failure and suffering, the most prominent feature was the resigned, nearly submissive, attitude, of Mrs. P. toward the private and social conflicts of her existence. Invariably, at work as well as in her couple, she seemed to find herself in the position of the one who must withstand and remain silent, the one especially who, without having the means to respond, constantly has to face the aggression and violence of the other person. It is also without a word or reaction that she endured, as blows of destiny, the multiple external frustrations apparently tirelessly imposed by reality and external circumstances. No doubt we can therefore as a first approximation think that this docile and submissive attitude in which she seemed to be frozen, which is entirely subjection and passivity was very early rooted in our patient in the early experience of her illness, real fatum and injustice of destiny, probably felt as such. However, if we leave the point of view of the object for the one of the subject, the prevailing and determining role of frustration seen as internal is revealed to us in a very blatant way, Mrs. P. clearly refusing, as the result of fixation or internal conflicts, all forms of satisfaction that reality could offer. At this level, it was the effective satisfaction of her own desire, the satisfaction of her own drive demands that the patient refused to herself. And finally, less than the impossibility to receive a satisfaction of any kind, it was the response to a specific requirement involving a mode of satisfaction that is at stake. We must invoke the notion of moral masochism is necessary here, Mrs. P. seeking above all the victim position, be it indiscriminately imposed.
by someone who is loved or by someone who is indifferent is of no importance. It may even be caused by impersonal powers or by circumstances.Related posts:
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