Psychosomatic medicine III: Actual neurosis and psychosomatic structure
This structure leads to serious life threatening sickness. Traditional medicine cannot explain its etiology. Asthma, ulcer (despite being caused by a bacteria it has a clear psychic influence). Reumathoid arthritis and all the autoimmune deseases where there is an aggression of the subject against his own cells. There is an aggression, an auto injury. Autoimmune system is very sensitive to the psychic situation of the human being. All the autoimmune pathologies need a psychoanalytic treatment APART from the medical one.
What is psyco somatic sickness?
“Psychosomatic” term was used for the first time in 1818 to design the influence of the sexual passions on tuberculosis, epilepsy and cancer. In 1940 Chicago School set 7 diseases considered to be the main psychosomatic diseases: asthma, rheumatoid arthritis, peptic ulcer, neurodermatitis, colitis and hypertension. According to traditional medicine, all of them are chronic diseases, potentially life threatening, which can be incapacitating and mortal in the worst cases. Another characteristic of these diseases is that their seriousness varies a lot from case to case and depending on how serious the condition is, they will affect more or less the quality of life of the patient.
We can say that “psychosomatic” is another structure like hysteria, neurosis or psychosis, with certain characteristics. Psychoanalytic listening is able to distinguish each of the structures. Same sentence “ I fear my mum die” is different if the individual is in a hysterical or psychosomatic position: in hysteria, we can read desire behind a fear: “ I fear my mum die” — “I wish my mum die and I fear my wish will come true”. However, in the case of the psycho - somatic (and anxiety neurosis) the quantum of floating anxiety gets attached to the feared representations, fears are what matter, we can not read in this case desire for death of the mum.
In Psychoanalysis, diagnosis is a posteriori and takes place at the same time than treatment. This means, that when a patient diagnosed by a doctor with one of the diseases considered by tradicional medicine as psychosomatic diseases, we can not say that the underlying structure behind that desease is the psychosomatic one. For example, asthma which has been traditionally considered a psychosomatic disease, in therapy it has been observed that the patient can be on phobic, psychosomatic or hysterical position (in which the symptom comes from an identification). “Only afterwards we will know”.
We will address the psychosomatic estructure using Freud work about actual neurosis (anxiety neurosis, neurasthenia and hypochondria) differentiating them from psychoneurosis or transferences neurosis (phobia, hysteria and obsessive neurosis). Exactly the same as Freud uses the dream to study the hysterical phenomenon, we will use actual neurosis to study the psychosomatic structure.
It has been observed that psychosomatic patients, present a history of actual neurosis. This means that if we dont treat the actual neurosis, one of the possibilities is to develop a psychosomatic disease in the future. Not all the neurotic will develop a psycosomatic disease, but all the patients with a psycosomatic condition present a history of actual neurosis. In the psyco- somatic structure there is a lesion of the organ, however, in actual neurosis there is not a lesion of the organ yet. The actual neurotic patient can have a tachycardia but heart muscles are not damaged (as opposed to the psycho - somatic). In anxiety neurosis, the lesion is functional.
We believe actual neurosis are at the base of the psychosomatic structure. Lets have a look at them now.
1. Anxiety neurosis
In 1894 Freud described a set of symptoms and named them “Anxiety neurosis” because all of them can be grouped under a main one: anxiety. This contribution was key to traditional medicine who until then, had put neurosis in a grab- bag with many other psychic conditions. Being able to isolate it and recognise it is the first step to be able to approach it via therapy.
When Freud described actual neurosis, depending on how affection is managed, he established three mechanisms of developing mental disease:
Conversion : transformation of the affection (repressed idea) into a somatic innervation (hysteria).
Displacement of the affection: Obsessive neurotic individuals can feel guilty. Main affection is guilt which initially is linked to an unbearable representation and it is then displaced into a neutral one.
Transformation of the affection in anxiety: anxiety neurosis.
In psychoanalysis, anxiety is not a negative term, it is constitutive of the psychic apparatus. All anxiety, is castration anxiety. It is facing castration that the subject is divided 1. It is a sign that there is something that deeply concerns the subject. When there is anxiety, it means the desires of the individual are involved. It is a sign that indicates desire, we cannot eliminate it, we have learn to live with it.
Anxiety neurosis can occur with all the set of symptoms or only with a few of them (example: tachycardia). It can occur in a pure or a mixed form. (Freud points out that it is common to find a patient struggling with both hysteria and anxiety neurosis. This would be an instance of the mixed form).
What is the etiology of anxiety neurosis? Freud explained it is linked with the deviation of sexual excitement and psychic elaboration. In anxiety neurosis there is a disorder of the actual sexuality (gentility) as opposed to hysteria where there is a disorder in the childish sexuality of the individual.
It has been observed that the anxiety neurotic individuals always have harmful sexual practices such as coitus interruptus, forced abstinence, frustrated excitation and another deviations from sexual excitation such as thinking about something different to extend erection and postpone ejaculation.
Clinical picture of anxiety neurosis present the following features:
Anguished wait: it is a quantum of anxiety, freely floating which can get attached to any idea at anytime. Example: Woman, everytime she listens to her husband (prone to colds) coughing, she imagines he get a mortal pnemonia and he dies. Anguished wait also occurs in healthy individuals, in their case it would be a pessimistic view of life. In reality, the clinical picture generally known as “anxiety” is in reality a light version of anxiety neurosis. However, in anxiety nerurotic individuals it is exaggerated, sometimes even described as an obsession. In the anguished wait of anxiety neurosis, the concern is always about someone else health as opposed to the anguished wait in hypochondria in which the concern is bout their own health. We will analyse in more detail hypochondria
Anxiety attack: It can occur in the form of anxiety only or anxiety linked to the idea of death or madness. It can also be accomppaigned by physical sensations like: paresthesias, dyspnoea, sweats , bulimia… These symptoms can occur in many different combinations: may of them or only one of them.
Many of these symptoms can become chronic and it makes it very difficult to find out that it is a case of anxiety neurosis as the feeling of anxiety is less precise than the symptoms of the anxiety attack. That is the case specially with diarrea, vertigo , paresthesias , chronic tiredness and depression.
Psychic apparatus cannot work with zero tension. It needs to cumulate a certain amount of tension, excitement, energy in order to be able to do the daily activities. There is a constant threshold of tension. In the case of the neurasthenic patient, it is very low. Why? Because of his intolerance to cumulate energy due to his difficulty to elaborate stimulus via psique (it is very difficult to think for them) so he elaborates them via soma. Example: he can not elaborate excitement so he unleashes it by masturbating.
As in other actual neurosis, neurasthenic individuals have harmful sexual practices. In this case repeated masturbation when facing excitement, no matter of which type. Any activity, which implies excitement, for example, studying, will have to be interrupted the moment it reaches the threshold. Example: patient who when facing more pressure at work, has the need to masturbate repeatedly. This intolerance to excitement makes it impossible to cumulate the necessary energy to do the daily tasks without tiredness . Due to that, the patient shows exaggerated tiredness, exaggerated difficulty to perform the task and incapacity to have sexual relationships (impotence is a feature of the neurasthenic).
Neurasthenia presents a well defined set of symptoms: fatigue and tiredness which does not correspond with the activity and doesn’t go away with rest (they wake up already tired), heavy head, constipation.
Freud explains that there are two types of representations with which the floating affection can be attached:
Things we do, aims: what we aim to give to the world
Things we expect will happen to us, expectations. What we expect from the world
In the case of an aim, contrary ideas to that aim will appear: distrust in his capacity. In the case of the expectation, all the possibilities that can happens instead of the desired one.
When facing something new, a decision a normal individual experience certain doubt, hesitation. In neurasthenia, this doubt is exaggerated. This is another example on how neurosis show the normality, exaggerated.
Regarding the aims, hysteria and neurasthenia behaves in a totally different way. Lets see it with an example: A mother has a baby to feed.
A neurasthenic mother will suffer all type of fears and will overthink about all the possible accidents that could happen, however, she will manage to breed the baby successfully (unless the opposite representation wins over, in which case she wont manage to breed the baby).
In the hysterical mother, the oposite representation remains unconscious, repressed. The patient notices with surprise how despite her apparent wish to breed the baby, she finds it impossible. Hysterical patients are not aware of their fears. She asserts she wants to breed the baby but from that moment on, she behaves as if she didn’t. this provoques on her all the necessary symptoms for not to breed the baby, for example: terrible pain in the breast.
(See blog about hypochondria).
Clinical experience has probed that these three actual neurosis are at the base of the psychosomatic phenomena.
Freud spoke about the oneiric phenomena or the hysterical phenomena (“Psychic mechanism of the hysterical phenomena”) and Lacan introduces the term “psychosomatic phenomena” to distinguish it from the way of producing the neurotic symptom, no matter if it is related to hysteria or obsessive neurosis.
Psychosomatic phenomena is not a formation of the unconscious, it can not be decompound in analysis like the hysterical symptom, it is not the fulfilment of a wish. Actual neurosis, dont have a psychic mechanism. In the formation of the psychosomatic phenomena there is not condensation and displacement (psychic mechanism of the unconscious work) there is a transformation of the affect.
Hysterical patients talk through their symptoms. However, what happens in the psychosomatic phenomena is related to writing but in most cases, it is not read properly. It is like if something was written in the body, like an enigma. There is an organic lesion.
There is a first identification, not sexual, identification to the kind, before any choice of object. This is the identification that funds the Name-of-the-Father, we need to establish the psychosomatic in relationships to this one. Hysteria is related with a second identification, one in which there is already sexual different, it is hence after the choice of the object. The question of the hysterical would be: what is to be a woman? In the psychosomatic, there is an answer without a question: I am asthmatic, I have an ulcer.
The jouissance is frozen, there is a sort of fixation. It is an auto erotic jouissance (in the sense of narcissist) more similar to the psychotic one. Like if both sexs were in the subject because source and object are merged.
Psychosomatic is deeply ingrained with the imaginary (with the body as image).
Lacan says, the psycho somatic patient “holophrases himself”. Himself is the holophrase, it is written on him.
In order to understand this, we need to take a look to the formule: “a significant represents a subject for another significant”. A psychic subject is produced each time. Lets say we have two significants S1 and S2. S1 is the lapsus, the forgotten word, the word repeated over and over again, but there is only production of subject from S2: we will have to wait to the next sentence, or session (or several after) to give S1 a sense, and there, there will be production of subject, production of unconscious wish, from S2. The remaining of this operation is the a object.
For this to happen, we need to have an interval S1 S2.
S1 <> S2
S1: Significant 1
S2: Significant 2
a: a object
What happens in the psychosomatic phenomena is the interval S1 S2 doesn’t exist, S1 and S2 are merged. There is then no production of subject nor a object. However, remember that psychosomatic structure (like the other psychic structures) is a position in the language, so the individual can position himself as a normal individual or as a psychosomatic one. It is not possible to be psychosomatic (nor neurotic, nor psychotic) 24h a day . No matter how sick someone is, there is always certain normality in every individual . That is why, when we say there is no production of subject in the psycho somatic phenomena, we refer to the phenomena, but other than that, the psycho somatic individual is a subject capable to establish transference (and hence be treated via psychoanalysis). Everything related to his disease wont be initially in the transference, that is what he has not passed through the word yet (because of his incapacity to symbolise, because of his tendency to resolve somatically).
In the psychosomatic phenomena, the subject is represented directly by S2, S1 is S2. That is why, traditionally it has been said that the psychosomatic individuals have a lot of ambition and very little capacity to work: he wants S2, without S1, without doing the necessary work.
Psychosomatic individuals do not tolerate contradiction nor paradox. He is the holophrase. However, in reality, a sentence does not have an only and closed meaning. Free association, should also be possible: with each of the elements of the sentence there is something that could intervene and that introduces in his place another significant which supersedes it. Something intervenes beyond his intention in the choice of the elements, this shows the presence of another significant chance, which cuts with the first one and enters there to implant a different sense.
Psychosomatic individuals speak with enunciation without subject thats is why all his psychoanalytic process is the production of a subject. His symptoms dont have to be interpreted, he has to be let speak so that he can produce a subject. He needs to discuss with the psychoanalyst so that he can learn to talk.
For the psychosomatic, the word concurs with the thing (like in the psychotic). This is visible on his speech: as if he could make concur what he is telling with what actually happened. When the psychoanalyst intervene to to cut the sentence where the patient has stopped or to open another meaning that the polysemy allows, he says: “I haven’t said that! , I have said this” and he repeats again the same.
The psychosomatic uses close phrases which define him: I have an ulcer, I am asthmatic. Why? Instead of dealing with the uncertainty (as human beings are subjects who are produced every time), he prefers the certainty of the disease. that gives him an identity. The psychosomatic has an issue with the own name. Only mortals have own names. Psychosomatic individuals , in the psychosomatic phenomena, deny their mortality, even if they need to pay the toll of the disease. Their disease gives them an identity: “I am asthmatic”.
There is no history behind those sentences. He doesn’t have the limits of the language but those from his body, a body which insists to scape from the drives. In psychoanalysis, overdetermination would allow the symbolic, to open the sentence, that the sentence “I am asthmatic” which defines him, could combine with other sentences and in that articulation, including the other ones, he doesnt need to be asthmatic.
The speech of the psychosomatic is mono tonal, he always have the same tone, without drive. For example, he tells in the same way the movie he watched than the death of her mother. Psychosomatic patients are affected at a drive level. Another feature of these patients is that they explain the facts as an imparcial observer, with no implication. It is very difficult that he makes a mistake, a slip. This lack of the implication of the psychosomatic in his speech is also visible on his attitude on reality: “ the world does this and that to him”, he is never implied in the production of his own life. In analysis, the subject is produced each time, in each of the formations of the unconscious, in the symptom, the slip…
The psychosomatic patient is a holophrase, there is no S1 and S2, they are merged, he does directly S2, he writes it on his body, he does the psichosomatic phenomena, there is no production of subject. The psychosomatic patient is himself the holophrase, he is the ulcer , for example. This does not mean that all the patients with ulcers are psychosomatic.
Regarding the constitution of the body, which is troubled in the psychosomatic, we know that the body is constituted from the image of the other one, in the psychosomatic there is an issue around the mirror stage.
As opposed to hysteria where we speak about “libidinized” organ, in the case of the psychosomatic, we need to talk about “deslibidinized” organ (like in the hypochondriac). In the psychosomatic, source and subject are merged in the body of the individual, there is an introjection of the libido. We can say that if in melancholya “the shadow of the object fell upon the ego”, in the psychosomatic phenomena “the object fell upon the organ”.
In the psychotic we say that the delirioum is an attempt to cure, in the sense that it is an attempt to be back to reality, to the objects, the libido which has been taken away from them and put on the ego, but in that attempt, the libido does not reach the objects and remain on the words. The words are the ones which are “libidinized”. In the case of the psychosomatic, there is an attempt to recover the relationship with the object, but because the object and the source are merged in the body of te subject, the libido remains in that object which is introprojected in that organ.
The psychosomatic patient is very intolerant to change. They are very rigid and have a lot of prejudices, ideas on how things should be and when these ones are not how they expected, they become very irascible.
They want to control reality with their conscience. Instead of letting their unconscious knowledge guide them, they want to intervene from his knowledge, from the conscience. His eagerness to control, reaches his organic functions and his partennaire (he only likes him when he does what he wants).
The organic functions regulated by the autonomic nervous system, are the ones which are affected in the psychosomatic individual: under normal circumstances, our heart beats automatically, with no action from the conscience. However, the psychosomatic patient seems to want to control these organic functions. This also applies to the sexual functions, eyacculation and erection. Remember that anxiety neurosis precedes psychosomatic phenomena. In anxiety neurotic patients, we observe coitus interruptus: it is the individual who decides when to remove, it is the individual who controls the function which in fact, should not be controlled at all.
Regarding the relationship with the object (with his partner), he wants the other person to be a photocopy of himself. The slightest deviation from what he expects from the other person leads to breaking up the relationship or disease. This is the way in which the psychosomatic patient wants to delete the difference. All the psychic structures try to delete the only difference that matters to the constitution of the psychic subject: the sexual difference. Hysteria does it through identification: ”I am equal to you, I have the same symptom”, Psychosomatic does it by trying to change the other one. However, the other one is a complex subject, with his desires, his ways of doing things… The psychosomatic, trying to change the other one, in reality is acting like god and he will find an impassable wall. He will react with rage every time the other one contradict his will. Psychosomatic patients tend to be irascible, as the ambition to change the other one is from the beginning impossible to achieve (without some work to change, there is no chance of transformation). When facing this incongruity between his desire and reality, he solves via soma: injuring an organ.
Psychosomatic patients turn the organ into a “deslibidinized” organ , he tries to take it out of the language, he turns it onto a “piece of meat”, as if the body was just a “biological” body, he puts the organ into the medical speech in his attempt to separate the psyche from the soma, both inseparables. In his obstinacy to separate psyche from soma, he shows something about normality in all the human beings. He shows us that psyche and soma, despite being different are inseparable. Platon in 400 b.c. already spoke about the impossibility to separate the body from the spirit.
If in the case of hysteria we can say, that hysterical patients talk with their body (each symptom is sustained by a sentence), the psychosomatic patients unvoiced with the body. Where they should say a sentence, there is an organic injury.
Remember we said, in hysteria there is a history of desires, in the psychosomatic structure, there is not such a hystory. It is more a repetition of encounters with the jouissance. It is an autoerotic jouissance, without anybody else.
For the psychosomatic patient, it is difficult to think about the future, as if every day was the last day of his life. They can not think of anything beyond that. Death is in the future, that is why it might be difficult to think for the psychosomatic. For the psychosomatic patients, thinking is painful. That is related to his inability to elaborate psychically their physical stimulus. And because thinking is so painful for them, they find it easier to elaborate via soma.
Psychosomatic patients operate castration in the organ, what should happen symbolically (symbolic castration of the phallic mother), he does it in reality: he injures the organ.
Phylogenically (in the history of constitution of the subject), the psychosomatic replaces the word by the act: instead of talking, he injures the organ.
If jouissance is autoerotic (object and source are merged in the body of the subject) and transsexual ( both sexs in the subject as he incorporates the object), he positions himself before the sexual difference, in a way, it is like if the name-of-the-father was foreclosed (as it happens in psychosis). In fact psychosomatic problems take place in the first identification, as in psychosis, and not in the one which constitutes the superego, sex-based, as in the psychoneurosis.
We can establish four stages in the constitution of the libido : autoerotism, narcissism, choice of object and castration complex. These ontogenetic 3 stages reciprocate to four levels of thinking: magic, magic - animist, religious and scientific 4.
In the first libidinal stage, in the autoeroticism, the magic thinking prevails: only by thinking, things happen. The existence of the outside world is ignored. For example, the baby is thirsty and water appears. He doesn’t know it is because he has cried and his mum brought him water. He thinks is magic.
As we have set out, the psychosomatic positions himself in the autoerotic stage. Himself, as any other individual, finishes the libidinal constitution but when he positions himself as psychosomatic, he undertakes the autoerotic stage. It is like if he had magic thinking, he imagines that only by thinking, things happen. He denies the necessary work to make them happen. He is an individual with a lot of ambitions and very limited capacity of work.