Hypochondria

Hypochondria is a psychopathological formation whose locus of suffering, anxiety, or even (fantasized) erasure is the body or one of its parts or functions, even though the symptoms in most cases appear to have no material cause. Symptoms can range from minor, transient forms to massive, debilitating forms. Despite some strong lines of evidence pointing toward a link with various specific structural organizations of the psyche, hypochondria is currently seen as transnosographic, as present as an element in a neuropsychosis or preceding certain psychoses.

For centuries, hypochondria has challenged medicine, philosophy, and even religion. Some ancient lines of inquiry are echoed by modern investigations, notably on the enigmatic link between psyche and soma and on similarities between hypochondria and melancholia. The absence of any material organic cause has elicited a variety of hypotheses from psychoanalysts, including accounts of pathogenicity that extend to delusions in the subject.

Has the enigma of hypochondria been fully deciphered by contemporary psychoanalysis? Freud acknowledged this poorly understood disorder as an awkward gap in his theories. Later it was deemed surprising that hypochondriacs had been the object of so little psychoanalytic research, but in the 1990s there were a number of studies on the topic. One reason that psychoanalysis has paid little attention to hypochondria is that the autocratic attitude of hypochondriacs has made analysts unreceptive to types of transference unconducive to analytic listening. However, a broadening of treatment indications seems to have made psychoanalysis more receptive to hypochondriacs, and this has allowed psychoanalysis to draw conclusions from them that go beyond Freud's hypotheses. It is also true that hypochondriacal behavior can emerge in the course of any treatment, as a displacement or means of discharge when the patient's psyche is placed under stress.

Freud encountered hypochondria early on in his work. On the basis of the semantics and nosology of his era as well as his own theories, he placed hypochondria among the pure forms of "actual neurosis," alongside neurasthenia and anxiety neurosis, and thus outside of the realm of the defensive neuropsychoses. His description of the actual neuroses contains the same elements as hypochondria: the patient's representational contents have a basis in current reality and not in what has been repressed into the unconscious; the patient's meaningful contents or unconscious overdeterminations capable of being symbolized do not indicate an internal conflict with current reality.

In "On Narcissism: An Introduction" (1914c), Freud revised his account of hypochondria in light of his theory that the libido is divided into the object-libido and the (narcissistic) ego-libido. He placed (bodily) ego-libido, the realm of hypochondriacal anxiety, in opposition to object libido, the realm of neurotic anxiety. As a function of this opposition, the more one realm absorbs, the more the other is impoverished. Therefore, the idea of excessive, dammed-up narcissistic libido is essential to understanding hypochondria. The chosen organ of hypochondria, which has strong erotogenic potential, is nevertheless a source of unpleasure, suffering, and anxiety owing to this increase in tension, this damming up of libido. Many authors have viewed this account, a schematic model of dynamic energies, as problematic and fraught with questions.

During the same period, Freud tried to understand the possible relationship between hypochondria and paraphrenia. In "On Narcissism: An Introduction" (1914c) he wrote, "We may suspect that the relation of hypochondria to paraphrenia is similar to that of the other 'actual' neuroses to hysteria and obsessional neurosis: we may suspect, that is, that it is dependent on ego-libido just as the others are on object-libido, and that hypochondriacal anxiety is the counterpart, as coming from ego-libido, to neurotic anxiety" (p. 84). In this perspective he viewed hypochondria as the first stage in delusion and linked it to narcissistic pathologies affecting the body. Three years earlier he wondered about the connections between hypochondria and paranoia. For example, in "Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" (1911c [1910]), his text on Daniel Paul Schreber, he wrote, "I shall not consider any theory of paranoia trustworthy unless it also covers the hypochondriacal symptoms by which that disorder is almost invariable accompanied" (pp. 56-57, n. 3). Freud thus viewed hypochondria as a precursor to psychosis and sometimes as an independent condition.

Some authors have interpreted hypochondria in terms of true projections that are no longer directed outward but instead are directed at the body, like an internal paranoia. In his subsequent writings Freud did not return to the comparison with melancholia, nor did he reexamine his hypotheses in light of his second theory of the instincts or in terms of the concept of primary masochism, as later authors did, thereby somewhat undermining Freud's classification of hypochondria as an actual neurosis.

Many others, notably followers of Melanie Klein, have emphasized the close relationship between hypochondria and melancholic depression. Others have inferred a masochistic dimension or a "locked-up" autoerotism. In the view of still others, the "hypochondriacal solution," despite its fragile and largely unstructured nature and despite being pregnant with the death instinct, is the subject's last bastion against madness.

ALAIN FINE

See also: Actual neurosis/defense neurosis; Body image; Eroticism, anal; Erotogenic zone; Erotogenicity; "On Narcissism: An Introduction"; "Neurasthenia and Anxiety Neurosis"; Organ pleasure; Persecution; Psychoanalytical nosography. Bibliography

   * Freud, Sigmund. (1898a). Sexuality in the aetiology of the neuroses. SE, 3: 259-285.
   * ——. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82.
   * ——. (1914c). On narcissism: An introduction. SE, 14: 67-102.