The Body Speaks

Body Image Delusions and Hypochondria

David Rosenfeld

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429920226
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book explores the author's pioneering work with severely disturbed patients, to show what it means to work and think as a psychoanalyst about transference and the internal world of a psychotic patient, with all the difficulties involved in continuing to treat and engage with even severely ill patients. As the author suggests, to be a psychoanalyst is to think about transference, the patient's internal world and projective identifications onto the therapist and onto persons in the external world. In particular, the author examines patients who express their mental state through fantasies about their body image. For example, the fantasy of an emptying of the self is discussed through the case of the patient Pierre, who asserts that he has no more blood or liquids in his body. Similarly, the fantasies of a young man who says that bats are flying out of his cheeks incarnate the anxiety of his first months of life expressed through his body. Indeed, the author's particular focus is on the importance of the first months and years in the life of these patients.

CHAPTER ONE
Body image models and theories

In psychoanalytic practice one may sometimes find examples like those I present, and that is why the primitive psychotic body image is a useful explanatory model for a variety of clinical cases. There may be different explanatory models, but for the time being I find the primitive psychotic body scheme the most useful and comprehensive, in so far as it is perfectly suited to many of the clinical phenomena I observe. It helps me to incorporate into a single model developmental genetic and transference concepts, both with schizophrenic and with psychosomatic patients. When we construct a model, we find it useful first for one particular patient but then often for other patients as well. To this we might add, provided it is consistent, a developmental genetic theory of infantile bonds that must be empirically demonstrated in the transference with the psychoanalyst.

The primitive psychotic body image is a non-observable entity, but when we construct the model it becomes powerful from the explanatory point of view. This does not mean that the model represents the ultimate truth, as is the case with theology, but only that is a useful model for the time being.

Atomic physicists see the effects of atoms, not the atoms themselves; in the case of psychoanalysis and the primitive psychotic body image, we can observe the effects of the model on various types of patients. Science is the capacity to discover facts beyond observation (for example, atomic theory). The power of science (Klimovsky, 1980) lies in the theoretical models of what is beyond observation, and how those models may be observed in the empirical basis. And of the atom, I say that it is something that cannot be observed directly and about which we know a number of things through indirect inference. These are models of non-observable entities but of great explanatory power as regards what is being observed.

The specific explanation of what happens in each case is legitimate and undeniable: each phenomenon seeks its explanation.

Body image definition

The concept of the primitive psychotic body image is a theoretical one, based on clinical work with psychotic patients going through acute crises.

By primitive psychotic body image I mean the most primitive notion of the body image to be observed in certain patients with whom work begins while they are already regressed or who regress during their treatment. In my view, the extreme notion of what can be conceived of as primitive psychotic body image is the thought that the body contains only liquid, or vital liquid, one or another derivative of blood, and sometimes it is coated by an arterial or venous wall or walls (not always). There is only a vague notion of a wall that contains blood or vital liquids.

In turn, as can be seen mainly in crises associated with acute psychosis, this membrane containing the blood may be perceived to have broken or to have been otherwise damaged and to result in a loss of bodily contents, leaving the body empty, without either internal or external containment and/or support (Rosenfeld, D., 2006a).

I always work in the transference researching patients’ object relations in the internal world, especially in the first years of life.

These are the clinical cases I will present in this book:

• Pierre, who believes he has no blood.
• Katherine, who has suffered a traumatic event, a car accident, which has changed her fantasy about her body image.
• Philippe, who experiences a psychotic hypochondriac delusion.
• The young man who said that bats are flying out of his cheeks.

CHAPTER TWO
Pierre

The following fragments of clinical material pertain to Pierre, at a time three years earlier. In it, we are able to observe the way in which I intervene and interpret the transference in a post-operatory psychosis rooted mainly in fantasies about the primitive psychotic body image. It is worth pointing out that the tumour for which he was operated turned out to be encapsulated and benign—a glioma—and it was entirely removed.

It is my intention to show the analyst’s role in the transference, and also to highlight a rich and clear material on the fantasies that the patient Pierre reveals to us regarding the image and fantasies about his body, especially those referring to his body fluids to which we refer as the primitive body scheme or psychotic body image.

The first unexpected incident, which startled neurologists, surgeons, and me, was a post-surgical psychotic episode—a delirium in which the patient affirmed with conviction that liquids were being extracted from his body. These included the encephalic/spinal fluid, blood, semen, and urine as vital fluids.

The third night after the operation, Pierre sought to verify that he had not been completely drained of liquids; for this purpose, he had sexual intercourse with his girlfriend, who was with him at the time. His intention, according to his own words, was “to see if any liquid came out ...” One can imagine the expression on the faces of doctors and nurses when the patient, with the bandage on his head awry, said what he had done.

An example of his primitive psychotic body image during his delusional episode after the removal of the (benign) brain tumour is shown in this fragment.

PIERRE: I’m afraid of having leukemia ... I have begun to despair ... to worry because of the destruction of the red cells by the tumour. As if I were afraid of becoming empty ... emptied of blood ... as if I were soft all over ...

THERAPIST: Soft?

(What a coincidence with Freud’s description of the Schreber case. He said: “... that he had softening of the brain ...” (Freud, 1911c)).

PIERRE: Yes, everything soft ... like a sack full of blood ... I’m afraid of having a haemorrhage, and that everything ... will come out ...

The accuracy with which he expressed his fantasies concerning his body image is remarkable. The conception of the body as a sack full of vital fluids or blood (primitive psychotic body image) is clearly formulated here by the patient on a verbal level.

I will now reproduce parts of the material corresponding to the first weeks after the operation. These fragments underscore fantasies regarding Pierre’s bodily image or body scheme and show the way in which I intervene in connection with the delusional or psychotic transference.

PIERRE: (in muddled language and stuttering) ... yes ... I’m afraid to urinate, I’m afraid to bleed ... to have blood come out, you know? ... that when urinating blood might rush out and I could bleed to death ... I’m afraid that the tumour is lodged in the bladder, prostate gland, testicles ... I think I have bone marrow metastases.

In this material it becomes increasingly clear that the patient is convinced of the following: first, that the tumour was not removed; second, that he has malign metastases; third, that he is his father with myeloma; fourth, he had no fluids.

I began here to intervene in the transference. I must make clear that the transference with me increased every time that encephalic/spinal fluid was extracted from him for studies. I became someone who hurt him or took his vital fluids (Rosenfeld, D., 2006a).

CHAPTER THREE
Philippe and countertransference

Definition: hypochondria, traditionally described as a constant preoccupation with one’s own health, with self observation of organs that are thought to be diseased, may be regarded as varyingly severe, ranging from chronic hypochondria, which is closer to psychosis, to transient hypochondriac states. This also includes neurotic, confusional, and psychotic elements.

Body image is a fantasy about the body. It is not the real organic body.

Hypochondria also has a defensive function at the onset of paranoid and psychotic pictures.

For Melanie Klein (1957), hypochondria is more the fear relating to persecution within body attacks by internalised persecuting objects.

For Herbert Rosenfeld more important are the confusional anxieties projected into the body.

Confusional anxieties appear to be caused by a failure of the normal splitting or differentiation between good and bad objects and also in the self.

In hypochondria and the psychosomatic diseases, the confusional anxieties are split off into the body, a process which probably starts in early infancy. These confusional anxieties are projected into external objects and reintrojected into the body (Rosenfeld, H., 1965, 1987).

First interview

A family asked to come for an interview with their son, who at that time was twenty years old and had a severe clinical picture of violence and hypochondria localised in his face. He broke objects and furniture in his home and threatened that he wanted to kill the female doctor who had treated him for facial acne. The patient said that this doctor is ignorant, that she applied acid to him and that she ruined his face.

The father, the mother, and the patient came to my office and we had a first interview that lasted ninety minutes.

The patient, six feet four, was in the midst of a psychotic crisis organised delusionally. He said that the badly cured pimples on his face have left scars. The patient, Philippe, explained that since this scarring will never go away, in revenge, he was going to kill the doctor and her son. He told me all this in shouts that resounded in my office in a very violent way.

He stood near me and I was afraid he would hit me. When I told him that we would find out what scar it is that he has in his mind, besides on his face, the patient became even more violent. He continued with his unshakable delusion that the scarring will never go away because he reads medical studies from universities all over the world on the internet which say that this is incurable.

I tried to tell him that perhaps what bothered him more than the scar on his face was the scar that existed in his mind. I told him that a young man was not going to commit suicide because of a pimple or a scar on his face. It must be a scar on his soul or in his head; it is hate because they didn’t take care of him, they didn’t give him the right remedy, or because his family didn’t accompany him to the skin doctor, since they let him choose the specialist on his own. But Philippe insisted and repeated the same threat.

While I was interviewing him, I was thinking about the most important works on hypochondria and body image that I had studied, especially those by Herbert Rosenfeld (1965), Clifford Scott (1980), and in Schreber’s case (Freud, 1911c). And I quote how Schreber is said to use the same words as Philippe: “He asserted that his body was being handled in all kind of revolting ways …”

The patient repeated exactly the same sentence over and over again: that they didn’t take good care of him, that they treated him badly, and that he was going to kill the skin doctor and her son.

I thought that this was a hypochondria that was becoming a systematised somatic delusion (Rosenfeld, D., 1992). My definition of a somatic delusion is when it includes external persons and relations. For example, becoming isolated (see patient Paul) or like Philippe, who says that since he has a scar on his face, nobody is going to love him and that the treatment he is undergoing is not going to work; also when he avoids contact with other people.

My countertransference concern deepened in the course of the interviews, as I began to perceive the rigidity of the hypochondriac delusion. At the end of the interview, I asked him if he would accept hospitalisation for a few days so that he could be taken care of and medicated. To my astonishment, the patient agreed.

The next morning, his mother phoned me to say that Philippe had kicked the furniture and broken objects at home in spite of being medicated, and had said he was going to commit suicide. I ordered her to hospitalise him immediately. He was hospitalised for two weeks during which doses of antipsychotic medications were increased.

I remembered at this very moment Freud’s paper and what a coincidence there was with the Schreber case. Freud wrote: “He expressed more hypochondriacal ideas … On the other hand, they tortured him to such a degree th...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• ABOUT THE AUTHOR
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Body image models and theories
• CHAPTER TWO Pierre
• CHAPTER THREE Philippe and countertransference
• CHAPTER FOUR Katherine: body image transformations
• CHAPTER FIVE The boy who said that bats were flying out of his cheeks
• CHAPTER SIX Inés: bleeding lips and tongue when separation occurs
• CHAPTER SEVEN Somatic delusion: Hugo and Pablo
• CHAPTER EIGHT Luis: half of his body and brain are missing—in collaboration with Teresita Milán
• REFERENCES
• INDEX