The Psychoanalytic Approach to Psychosomatics and Eating Disorders

The Newsletter of the Psychosomatic Discussion Group of the American Psychoanalytic Association.

Discussion by Marilia Aisenstein of

The Psychoanalytic Treatment of Patients with Inflamatory Bowel Disease

Charles C. Hogan, M.D., D.Med.Sc.

I am very pleased to be discussing Dr. Hogan's work for it seems to me that as far as clinical work and technique go our views converge, but that some of our theoretical frameworks differ. Our agreements and our disagreements become apparent in the first paragraph.Dr. Hogan states that psychosomatic medicine implies neither a linear progrcssion not a temporal succession. I agree with that. However, he goes on to say that according to the areas of observation, the somatic or the psychical, there are two separate sources of data. I would not put it this way I think we are dealing with two modes of observation which are totally separate from one another, but which derive from a unitary source.

Man is psychosomatic by definition. I therefore believe in his somato-psychical unity. Psychoanalysis, as a new discipline, brings an original revolutionary answer to the eternal psyche-soma debate. Freud was the first one to show that the pathways from mind to soma do not in themselves allow us to distinguish the psychical sphere from the somatic one. On the other hand, he early on contrasted the sexual drives with the instincts of preservation and, later on, the erotic libido with the death instincts, and he thus displaced the old psychesoma dualism with a drive dualism. We find different kinds of interpretations in thc same bodily locations, just as antagonistic forces are at work in the same place. In 1910 in "The Psychoanalytic View of Psychogenic Disturbance of Vision", Freud described an organ that is forced to serve two masters at the same time, which gives meaning to thc organic symptom, and forces us at a later stage to take several sets of data into account in different ways.

Regarding the second item in Dr. Hogan's article it is suggested that a large number of somatic patients present with archaic and pregenital defense mechanisms. This is often true. Yet none of us are safe from severe illness. I therefore prefer not to generalize and rather to think that any psychic apparatus can be suddenly traumatically disorganized. Disorganization inhibits any recourse to habitual psychological defenses, thus making room for alexithymia.

Alexithymia as described by Sifneos is a very close concept to that of "mechanical life" or "operatory thought" proposed by the Paris Psychosomatic School. It is true clinically that the syndrome of "mechanical life' often accompanies somatisations. However, for the authors Pierre Marty and Michel de M'Uzan, this syndrome is embedded in the dynamics of the individual's psychical economy. In some cases it may mean establishing a long-term radical and archaic defense mechanism, but it may also be understood as a transitory phenomenon needed for survival following a moment - even a brief one - in which the psychical apparatus was not able to integrate excitations.

As for the example of a patient suffering from hemorrhaging rectocolitis, I am in full agreement with Hogan's conclusions as well as with his technique. In my experience it is clinically very fruitful to help the patient get interested in his mental functioning and in his inner world, to work out figurations and establish links, and to refrain from making too incisive oedipal interpretations which cut through the work of the preconscious instead of sustaining it. I myself have treated patients suffering from Crohn's disease in the same way, with the questions and the results that Dr. Hogan describes so well. However, for me these technical modalities are thc consequence of an economical concept of psychical functioning where regression and disorganization are considered more important than archaic defense. The notion of archaic defense is of interest in certain structures, but of little heuristic value in accounting for the psychical dynamics of the large number of mental organizations that are confronted with somatic illness.

Also mentioned is the linguistic connection between emotional states and abdominal spasms and pains, which has existed since the dawn of history. Like Hogan, I think that we must refuse to take this as a sign of any causal connection. Language expresses something but does not imply causality Yet, here again, our views diverge. Hogan challenges the illusion of monism; I refuse any causality which subordinates the body to the mind, because I believe in the psycho-physical unity. If we think in terms of psycho-somatic dualism we infer causal links, e.g. organogenesis or psychogenesis, i.e. primacy of one over the other. In my opinion, this is a false debate, and we agree on that score. It is more difficult to think in terms of a unique source for clearly distinct data. We both do, but within different theoretical frameworks. Hogan's hypothesis of psychophysical parallelism is based on the simultaneity of phenomena occurring in different fields, whereas I believe that psychophysical parallelism, already imagined by Spinoza, implies unity of substance which some contemporary neurobiologists conceive of as well. I am referring to the work of Edelman (1990) and to Prochiantz (1992). In a recent book entitled "How the Brain Evolved" the latter takes psychoanalytic research into consideration hypothesizing new neural connections created by emotional experience in psychoanalysis. His views are based on the notion of "genetic flexibility of the human being" which allows for fantasy activity connected to thc cortex and thus for the singular history of each individual.

Like Dr. Hogan I think that our clinical work provides tangible evidence in favor of our psychoanalytic hypotheses~ but that at this point it is still difficult to accumulate "scientific" evidence because of the multiplicity of factors involved in psychosomatic phenomena. We have a long way to go, but it is a fascinating journey.


Edelman, G. (1990) The Remembered Present: A Biological Theory of Consciousness. New York: Basic Books

Prochiantz, A. (1992) How the Brain Evolved. New York: McGraw Hill.

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