Introductory observation: hypochondria is obviously an indisputable clinical reality, always inseparable from the medical context; however, it seems questionable but also unlikely to find a single and univocal place for it in nosography. It is not a definite entity which can really be diagnosed as such. At the very most, it is a sort of assembly which tends to bring together various clinical pictures, only from a descriptive but never etiological point of view, which all bring out the same concern for the body experienced as ill.

Hidden depression, dejection, and melancholia: since Hippocrates, medical experience, for the specialist as well as for the general practitioner, constantly meets the hypochondriac. This meeting generally results in a shared dissatisfaction between helpless doctors and complaining patients. This constellation of negative affects which endlessly repeats the same sequence is a guiding principle, tenuous but major. For, from extreme confidence—“I’ve heard of you, you’re the only one who can help me”—the suspicious patient switches to defiance—“do you think your treatment will help?”—and then completely nullifies his faith in the next interview—“I feel worse than before.” Then exasperation and bad moods will eventually be exchanged as a prelude to rejection, toward a possible elsewhere. Hypochondria as a “climate,” at the crossroads of impairment and otherness. But, beyond these shallow responses, what is hypochondria?

Between a phenomenological definition and a more semeiological approach, literature is rich but hesitating and leaves the problem unsolved. Symptom pathology? Relational pathology? The first perspective which is the most usual and remains consistent with the classical medical tradition objectivizes signs which pertain to a self-contained system: overstated concern for physical condition, subjectivity of a complaint lacking the weight of the somatic, interpretation of impairment as a simplistic threatening process, withdrawal of concern for the outside world, internal tension and experience of catastrophe. Internally focused on his painful body, the character described as hypochondriacal, locked in and existing as such is, above all, alert to the messages of his coenaestheses even to the most contingent ones. And he interprets them in a negative way. Step by step, opposed to this first intrapsychic approach, the second perspective is inter-psychic. Here, no definition is acceptable unless it implies an interlocutor who, being mute, eloquent, or psittacistic, is nevertheless the one who takes part in the drama. Obligatory partner of his doctor in an inseparable and extremely tragic couple, the character described as hypochondriacal is above all relational (Maurel 1973).

Strange relationship to oneself and/or to another person? This bipolarity can curiously be found on other levels and it seems to insistently underline how hypochondria is linked to ambiguity and even to duality. Double causality, biological or mental, major or minor, delusional or simplex, has always remained out of the reach of any unitary, either nosographic or etiopathogenic, approach. Dual rooting, between body and language: it still remains an object of debate and controversy, located between organogenesis and psychogenesis, genuine illness and mere thematic issue, established delusion and coenaesthesiopathy. Beyond understanding and classification. Alternately neurosis or psychosis. It is no wonder therefore that hypochondria can be found at varying degrees in the whole psychopathological field so that it seems to be its core, but also sunken in it as sheer entity. Center and periphery.

Nevertheless in all cases, whether it is rejected as single entity (Greenfield and Roessler 1958) or considered as an iatrogenic disease of medicalized cultures (Kenyon 1976), it exemplifies the possible links between soma and psyche and cannot be disjointed from a relationship to the world that uses the body as an apparent support medium (Ey 1950). There is then a first question: being an affect-conveying configuration, is hypochondria an unsatisfied demand or a possible genuine label?

This question has no direct and univocal answer. It would imply the possibility of isolating a single underlying process or, at least, of inducing a precise unifying conception. Yet literature shows that this major requisite cannot be met. This is evidenced by Kenyon in a very good 1966 article (Kenyon 1966), where he listed 18 possible usages of the word “hypochondria.” Therefore, a purely nosographic conception is invalidated.

Synonymous with mad or senseless; a mental disease due to a disorder of the digestive tract; term of abuse, i.e., either actually malingering…; general sense of preoccupation with bodily or mental health or functions; personality trait or attribute; a mechanism of defense; neurotic manifestation, especially in lower social classes or in those of poor endowment; an anxiety substitute or affective equivalent; an actual neurosis; closely allied to or a manifestation of neurasthenia or depersonalization; the same as hysteria, only in the male; transitional state between hysteria and psychosis; a nosological entity, primary or essential hypochondriasis; a symptom of almost any of the other commonly recognized psychiatric syndromes, especially depression; prodromal stage of another illness, e.g., schizophrenia; a form of schizophrenia; a form of coenaesthesiopathy; part of a symptomatic psychosis or exogenous reaction.

To which we should add the functional or psychofunctional disorders, as well as dysautonomia, and even the so-called psychosomatic disorders.

As hypochondria is polysemic, it is impossible to a priori endow it with a nosological specificity as such, this impossibility being especially reinforced since the medical discourse is increasingly important in our society. Anyway, historically, this recourse to the doctor has replaced the recourse to the priest; unsurprising replacement, as Freud put it as he thought this change was only the abandonment of a so-called “demonological” garment and the taking of another one which was a mere disguise. In this perspective, after Kenyon, we can say that the overflowing extension of the word “hypochondria” undoubtedly justifies that it is no longer really used as a noun but only as an adjective which has a descriptive use. A careful literature review clearly exemplifies this proposal: we have noted down 27 common usages for the adjective “hypochondriacal;” they can be distributed around three major lines: semeiological (neurosis, psychosis, character, delusion, constitution, syndrome, symptom), phenomenological (presentation, recourse, form, idea, concern, theme, worry, grievance, complaint, component, dimension, episode, event, disorder, trend, state, phenomenon, complex), or even ontological (work, drama). Being an adjective more than a substantive, hypochondria is a cross-cutting notion. All the attempts to reduce it to a symptom regularly confronted the nosographic obviousness of their senselessness: that is why hypochondria keeps wandering as a stranger who has his seat at the tables of hysteria, depression, psychosis, and actual neurosis.

If hypochondria, clinical picture referring to several diseases, cannot be identified as a medical entity and as it lacks etiological unity, could it find its unity on an exclusively descriptive level? Isn’t it, for example, an unsatisfied demand, present in various contexts? Indeed, a real specificity could be found in the complaint itself, in its wording and in the ambivalence of a demand for care whose unifying characteristic is that it is refused, more than in any attempt to give it an etiopathogenic or a nosological definition. Freud did not go into details about this articulation but he nevertheless found two axes in the hypochondriac’s very peculiar relationship to the other person: a reversed guiltiness on the one hand (objectal libido), a projected attack against oneself as well as against the other (narcissistic libido), on the other hand. Impossible destruction, impossible healing. Complaint is definitely the element to consider, that is what all authors mean when they persist in situating it in its structural analogy with other relational pathologies: melancholia–mania couple (Fedida 1971; 1975; Ferenczi 1955; Freud 1915[1917]b; Klein 1935; 1940; Araham K), paranoia (Tausk 1933; Abraham K; Klein M), obsessional neurosis (S. Freud). In spite of the variety of the clinical contexts, discourses converge.

As a result of this striking contrast, classification is difficult, that is why opinions diverge. Some authors assume that hypochondria is psychotic (Maurel 1973). Some others consider that no one is totally exempt from this kind of concern (Ey 1950). Some mention it as an irreversible neurosis or last barrier against psychosis. Finally, other authors, more cautious, affirm that theme cannot not prefigure structure. This difficulty is probably the consequence of the notable fact that the hypochondriac’s usual discourse is indeed a subversion of medical discourse. The confusion between the medical discourse on hypochondriacs and their own has frequently been noticed (Cottraux 1976). Does the unity of the hypochondriac’s discourse lead to a mise en abyme in which the doctor sometimes imagines a unity he can call nosological whereas the constant and essential unity is the one he provides without really knowing? The word “observation,” ordinarily medical, would not have a one-way meaning here. Discourse unity? Unity of a reduplicated partner? In both cases, the approach remains descriptive. In view of this highly insufficient perspective, let us also find if psychoanalysis can propose an explicative theory for the origin of the disorder of the patient who complains that his body is affected.

On this specific point we must acknowledge our ignorance. When we compare descriptive and explicative levels, we can notice a major discrepancy: superabundance of descriptions and lack of explanation show how difficult it is to establish a clear theoretical status for the hypochondriacal subject. The main contribution of the psychoanalytical theory is a polymorphous set of scattered words and notions which orderlessly evoke, Oedipus, castration, guiltiness, sadomasochism, anality too, fragmentation sometimes, narcissism mainly, and orality at last. Moreover, this kaleidoscope often sounds like, sometimes straightforwardly, the very hypochondria that it tries to explain. But psychoanalysis remains nebulous on the very strict problem of pathogenesis, quite often referred to with tautologies: “somatic complacency of the organs” (S. Freud), “organ-specific libidinal tonus” (V. Tausk), “yet unknown physiological factor” (O. Fenichel). We must first acknowledge Freud’s double contribution. We can sum up Freud’s view on hypochondria in the following terms: energetic, economic, cumulative, and quantifying. As for the organ said to be painful, he summons the notion of erogeneity and explains the painful part of the body is libidinally invested and experienced as a penis.

The psychoanalytical theory, either Freud’s or his successors,’ gives first and foremost a comprehension of the content of fantasy. But as the hypochondriac has a singular way of experiencing his body, his fantasies appear in a singular mode and this might lead us to consider as revocable the Freudian conviction which refuses any sort of “psychical” “signification” (Freud 1916–1917, p.387) to the Actual. Hypochondria is therefore a problem. More than a purely pathogenic explanation, the psychoanalytical theory exposes another version of the text to decipher, text that the hypochondriac tries his best to proclaim, it exposes an explanation that vaguely understands the hypochondriac’s experience. Hysterization by psychoanalysis of any pathology outside its scope? Could psychoanalysis be insufficient to grasp the shape and modifications of fantasies even if it is able to describe their content? For instance, the main idea is that, for many hypochondriacs, especially for the ones whose diseased area is in the abdomen or sometimes in the thorax, important pregnancy fantasies are involved. But this position seems incompatible with the Freudian considerations on the penis as prototype of the diseased organ. Unless you produce an amalgam as F. Perrier does when he refers to a “self pregnantified phallus-child.” (Perrier 1978, p.241) Interesting but not very clarifying point of view! Anna Freud’s point of view was perhaps more significant as she suggested to consider the hypochondriac as an ill child trying to influence his mother through his symptoms and his illness (Freud 1957). Objective description of a nosophobia? Cautious acknowledgement of purely subjective pain sensations? Search for explanation, for signification, for a strange and very paradoxical relationship between two partners? The question remains.