Theoretical Models in Psychoanalytic Psychosomatic: a Review

ISSN 1413-389X Trends in Psychology / Temas em Psicologia – Março 2017, Vol. 25, nº 1, 41-51 DOI: 10.9788/TP2017.1-03En

Theoretical Models in Psychoanalytic Psychosomatic: A Review

Maíra Bittar Galdi1 Faculdade de Ciências da Universidade Estadual Paulista Júlio de Mesquita Filho, Bauru, SP, Brazil Érico Bruno Viana Campos Departamento de Psicologia da Universidade Estadual Paulista Júlio de Mesquita Filho, Bauru, SP, Brazil

Abstract This article is a theoretical study of the psychoanalytic literature on the subject of psychosomatic that aims to review the approach models this phenomenon seeking to understand their differences and similarities in terms of theoretical basis. The results point to two different ways of looking at psychosomatic illnesses. In the French side, linked more or less directly to the Lacan perspective, the main references were Jacques-Alain Miller and Pierre Marty, the phenomenon is not a representational shift, but a failure in symbolization processes. In a second aspect, which brings together from the Psychosomatic School of Chicago to French authors not Lacanian, the main references were Joyce McDougall and Christophe Dejours, the psychosomatic phenomenon is understood in a divergent line, relating the formation of the symptom the unconscious conﬂ icts. They are symbolized in the disease, but in a more precarious form of symbolization from the model of hysteria. Despite the differences, it is understood that no compromise on the principles towards the treatment, which is to deﬁ ne a meaning for the symptom, not by the rescue of an unconscious fantasy as in the classic model of hysteria, but building a sense where there was no historical narrative thread. Keywords: Psychoanalysis, psychosomatic, somatization, symbolization.

Modelos Teóricos em Psicossomática Psicanalítica: Uma Revisão

Resumo Este artigo é um estudo teórico da literatura psicanalítica sobre o tema da psicossomática que tem por objetivo revisar os modelos de abordagem desse fenômeno buscando a compreensão de suas diferenças e similitudes em termos de fundamentação teórica. Os resultados apontam para duas maneiras distintas de ver as doenças psicossomáticas, ligadas a duas tradições em psicanálise. Na vertente francesa, ligada mais ou menos diretamente à perspectiva lacaniana, cujas principais referências foram Jacques Alain- Miller e Pierre Marty, o fenômeno não constitui um deslocamento representacional, mas sim uma falha nos processos de simbolização. Em uma segunda vertente, que congrega a Escola Psicossomática de Chicago até autores franceses não lacanianos, cujas principais referências foram Joyce McDougall e

1 Mailing address: Rua Christiano Pagani, 8-51, Apto 53ª, Bairro Jardim Auri Verde, Bauru, SP, Brazil 17047- 144. Phone: (14) 3204-8979/(14) 98111-6015. E-mail: [email protected] This work is the result of a scientiﬁ c initiation research “Essentials of Psychosomatic Psychoanalytic” developed by the ﬁ rst author and guided by the second author in the Getting Started program without Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP Exchange (Programa de Iniciação sem Bolsa - PIBIC- ISB). 42 Galdi, M. B., Campos, E. B. V.

Christophe Dejours, o fenômeno psicossomático é compreendido em uma linha divergente, relacionan- do a formação do sintoma a conﬂ itos inconscientes que são simbolizados na doença, mas em uma forma de simbolização mais precária em relação ao modelo da histeria. Apesar das divergências, entende-se que há conciliação quanto aos princípios na direção do tratamento, que consiste em deﬁ nir um sentido para o sintoma, não por meio do resgate de uma fantasia inconsciente como no modelo clássico da histeria, e sim construindo um sentido onde não havia encadeamento histórico-narrativo. Palavras-chave: Psicanálise, psicossomática, somatização, simbolização.

Modelos Teóricos en Psicosomática Psicoanalítica: Una Revisión

Resumen Este artículo es un estudio teórico de la literatura psicoanalítica sobre el tema de psicosomática que tiene como objetivo revisar los modelos de aproximación a este fenómeno que tratan de comprender sus diferencias y similitudes. Los resultados apuntan a dos formas diferentes: En el lado francés, vinculado más o menos directamente a la perspectiva Lacaniana, las referencias principales fueron Jacques-Alain Miller y Pierre Marty, el fenómeno no es un cambio de representación, pero un fallo en los procesos de simbolización. En un segundo aspecto, que reúne en la Escuela Psicosomática de Chicago a los autores franceses no Lacanianos, las referencias principales fueron Joyce McDougall y Christophe Dejours, el fenómeno psicosomático se entiende en una línea divergente, relativa a la formación del síntoma los confl ictos inconscientes Ellos están simbolizadas en la enfermedad, pero en una forma más precaria del modelo de la histeria. A pesar de las diferencias, se entiende que hay compromiso en los principios hacia el tratamiento, que consiste en defi nir un signifi cado para el síntoma, no por el rescate de una fantasía inconsciente como en el modelo clásico de la histeria, pero la construcción de un sentido en que no había ningún hilo narrativo histórico. Palabras clave: Psicoanálisis, psicosomática, somatización, simbolización.

In the nineteenth century, the emergence of consciousness, and it was through these laws cases of hysteria brought diffi cult questions to that Freud uncovered the conversive mechanism the fi elds of scientifi c and naturalistic medicine. that was behind the hysteria symptoms. In a historical context, where reason and the The conversion was described by Freud cult of conscience prevailed, symptoms such as an unconscious mechanism, present in the as paralysis and inhibitions that had no organic clinical matrix of hysteric neurosis, wherein correspondence intrigued and posed a challenge the drive connected to an idea is repressed and for the epoch. This allowed other sciences, which converted into ideational representatives on the were not enclosed in positivist logic, to cast them body. However, it is not the biological body into the guidelines of a theoretical framework but the erogenous body that is endowed with that could cope with this reality. Accordingly, in an imaginary anatomy, which subverts the real the context of Freud and Breuer’s (1895) studies body so that the erogenous order is comprised on hysteria, the concept of the “unconscious” as a double of the biological order created from will be outlined as well as the techniques and the body surface area (Leclaire, 1979/1992). The methods that allow for its research, leading to the erogenous body is one that has, in its imaginary composition of a new science – Psychoanalysis anatomy, specifi c sexual fantasies that somehow – constituted by an object and a specifi c method. are connected to a corresponding organ. It is Initially investigated through hypnosis tech- therefore a desiring body, which exceeds the niques, the “unconscious” was discovered as biological determinism: the organs are not only having its own operating laws fl eeing fully to used to meet the survival needs, as in the animal, Theoretical Models in Psychoanalytic Psychosomatic: A Review. 43 but also meet, express, and evoke desires and perspective, there are diseases that involve the that is what makes a man stand out from the psyche and others that do not (Mello & Burd, animals: he has drive impulses and not instincts. 2010). With regard to the latter aspect, we see However, the erogenous body is not born that even with the split in medicine in which psy- with the human being. In order for it to exist and choanalysis appeared in some respects they still develop, someone else must invest in it sexually. approach, such as the description and categori- In other words, to wish for it, is as to imagine zation of these diseases, correlating them with a story and direct his eyes to the body. This specifi c unconscious confl icts undertaken by the whole process is not simple – it runs from the Chicago School (Casetto, 2006). stage of primary narcissism till the later stages Thus, the fi ne line between physiological of sexuality construction – and always, by some and psychological processes is again questioned misfortune of life to which all are subject, it can with the reintegration of psychoanalysis in the be stopped if it is disrupted or regresses to earlier issues regarding the real aspects of the body. stages of development. The erogenous body is From this line of research appears the notion that, also likely to fail. The libidinal investment is in addition to the fantasies that are symbolized never uniform: one can invest too much in a on an imaginary anatomy, the biological body region, as in hysteria, or fail to invest in another, may also serve as outlet for unnamed fantasies as is supposed to happen in the psychosomatic and even support poor symbolizations or phenomenon. This issue is a result of some more archaic modes of representation as those theoretical differences in the fi eld. considered in the classical neurotic model. Thus, psychoanalysis, in its discovery and However, the different strands of psychoanalytic research of the conversion mechanism, shook schools are divided as to the specifi c nature of the pillars of the Cartesian rationalism, defi nitely this phenomenon, bringing convergences and breaking apart from medicine. It introduced the divergences between them. concept of the erogenous body, ushering in a The main points of discussion lie in the elu- new form of knowledge: the unconscious. It is cidation of (a) if there is a specifi c clinical en- for this reason that speaking in psychosomatic tity present in psychosomatic cases; (b) how the psychoanalysis proves to be a thorny issue. symbolic processes are articulated in them; (c) How is it possible to theorize about what psy- the still-current challenge to write a metapsy- choanalysis itself denied in its origin as a fi eld of chological description of this kind of phenom- knowledge? While this denial of the real body set ena. For this, we studied some of the leading on its break with positivism, it now divides and theorists in this subject: Franz Alexander, leader stands as a contemporary challenge, currently, as of Psychosomatic School of Chicago; Pierre the psychic malaise has its various expressions Marty, from the Psychosomatic Institute of Paris in the biological body. (IPSO); and Jacques-Alain Miller, Joyce Mc- However, the question “what is psychoso- Dougall and Christophe Dejours. matics?” arises. This issue is also presented in a diffused manner. Even in medicine we can see Description differences in its defi nition. A trend of Hippo- cratic-infl uenced medicine considers psycho- Psychoanalysis, in general, considered psy- somatics as a philosophy – a vision of man and chosomatic illness to be every phenomenon that world where the body and mind are not divided. is not restricted to medical biological explana- It all covers the psyche and soma, that is, both tions that insists on appearing as a symptom health and disease are part of unifi ed mental and but one that does not fi t the classic features of somatic processes that constitute humans as a neurotic conversion. It is a diagnosis, therefore, whole. Another trend considers that only cer- by exclusion, which is why so many rumors tain types of diseases are psychosomatic, which emerged – mainly from authors near Lacan – withdraws dualistic discussions, as from this because otherwise, we would be facing a new 44 Galdi, M. B., Campos, E. B. V. clinical matrix other than the classical neuroses, neurosis, and then subdivided the latest in badly psychoses, and perversions. mentalized neurosis, uncertainly mentalized From this group of researchers, Pierre neurosis, and well mentalized neurosis” (Caset- Marty is the most representative of this line of to, 2006, p. 12). thought. Known as the leader of the IPSO, his Perhaps an infl uence of his biologicist work is basically divided into three periods. In phase, Vieira (1997) points out to Marty, that the fi rst, the more biological, psychosomatic the psychosomatic illness does not have the role disorganization process is considered as a result that the death drive has to Freud because their of tension between life and death instincts. ultimate goal is not death; however, it can be These would have a somatic source and death a defense, preventing more severe disruptions, was not the end; however, the consequence of working to ensure the body’s integrity. Gradual- this biological imbalance is contrary to what was ly, the concepts of mentalization and operational claimed by Lacan’s theory and other members thinking stood out if compared to other theoreti- of the institute. Thus, the disruptions fi rst hit cal aspects of his journey, such as the concept of the areas of the erogenous body to protect the essential depression, even on the more focused body from major disruptions until the psyche is phase of biological description. His theoretical re-established. If the disruption is more serious, contribution is quite marked by highlighting the it can compromise the biological body and lack of symbolization of the psyche in psychoso- can even cause death. According to Marty, the matic patients, and this aspect will be thoroughly psyche is evolutionarily more recent than the examined and questioned in this study. somatic points (Casetto, 2006), and, therefore, it Another major aspect in psychosomatic is the fi rst to be hit in the result of a trauma. psychoanalytic was the School of Chicago, led The second part of Marty’s work focused by Franz Alexander. It limits psychosomatic on a more psychoanalytical theoretical construct diseases in seven classical disorders: bronchial with the introduction of his key concepts: asthma, gastric ulcer, rheumatoid arthritis, ulcer- mentalization, operational thinking, and essential ative colitis, dermatitis, tireotoxicoses, and hy- depression. For him, a low mentalizing ability, pertension. Unlike what happens with hysteria, that is, the capacity of metabolizing trauma Volich (2000) points out that Alexander does not through symbols, takes the subject to what is consider the phenomenon as a compromise, that called essential depression. This is characterized is, the phenomenon is not an attempt to cure and by a depression without specifi c object, very solve psychic confl ict. Alexander developed the different from mourning, for example, that notion of specifi c psychodynamic constellation generally has the object lost a component with to explain the origin of the disease. It proposes the consequent uninvestiment of its libido. The that certain internal confl icts are directly related psychic devitalization of essential depression to specifi c emotional reactions, each correspond- has its corresponding investment in suicidal or ing to each confl ict, although the relationship be- detractor thoughts, as occurs in cases of classic tween emotions and disease is not causal. depression. There is a massive disinvestment; These two great schools played a very im- it is not so much of sadness, but of apathy, portant role, both in practice and the construction thus increasing the frequency of illness and of a psychoanalytic theory about psychosomatic psychosomatic accidents. diseases. They were responsible for building a In the last phase of his work, Marty formu- theoretical body – these buildings blocks were lated a nosological classifi cation of psychoso- later supported, modifi ed, and problematized by matic, according to different categories in rela- psychoanalysts – contributing to the advance- tion to mentalizing ability. They would be lower ment of knowledge in this relatively new subject. as compared to the symbolization capacity on In subsequent discussions, we fi nd important the neurotic, psychotic, and perverse subjects: theoretical frameworks in Jacques-Alain Miller, “Initially called them behavior and character Joyce McDougall, and Christophe Dejours. Theoretical Models in Psychoanalytic Psychosomatic: A Review. 45

Until then, the theoretical constructs on the There was no further information about what psychoanalytic psychosomatic did not consider can lead to psychosomatic, psychotic, or autistic the possibility of the development of psychoso- outputs because for Miller (1987) these struc- matic diseases in other subjective structures than tures are very close. Moreover, it is not explicit those that function in the operational thinking why a failure in symbolization in any confi ned mode. On this point, Miller (1987) considered area may not have the return in form of delusion the existence of the phenomena in other subjec- or acting outs. What is noticed is that these phe- tive structures; however, he did not cease to the- nomena have a resemblance to psychoses, both orize about a possible psychosomatic subjective in their mechanisms, as in the family structure. structure of its own. The lack of symbolization, the fact of not having According to Miller, the psychosomatic can been conceived and signifi cantly represented by be a very primitive structure, close to psycho- their parents, is common to these two structures, sis and mental retardation. The opposite relation resulting in a gap in the answers that might exist between a psychosomatic phenomenon and the on the choice of one way or another. hysterical symptom becomes quite evident. The Joyce McDougall, somehow, overcomes difference lies in the fact that, unlike what oc- these theoretical elucidations to recognize that curs in the phenomenon, the conversion symp- there is not a specifi c subjective structure of psy- tom does not focus on the real (biological) body chosomatic phenomena. Moreover, in her book but on the erogenous (imaginary) body. Ac- Body Theatres (McDougall, 1996), the author cording to Miller, the symptom lies in the fi eld discusses somatization as any kind of acting out, of neuroses and obeys an underlying language including the use of substances, increased vul- structure, which operates through metaphor and nerability to physical accidents, and failures of displacement processes and, therefore, full of the immune system. unconscious meanings that do not occur in the To name this very common mechanism psychosomatic phenomena. in psychosomatic subjects in which affection Certainly, it is crucial, and essential, distin- is not thought, McDougall coined the term guishing symptom, especially hysterical, disaffection. Affection is a limit concept, as well from psychosomatic phenomenon, precisely as a drive concept, standing between somatic in this relation to the Other that is constitu- and psychic. Basically, the state of disaffection tive of the hysterical symptom, which is in consists in an inability to think about intensely no way the case of psychosomatic phenom- experienced emotions. The fact that these people enon, if it exists. (Miller, 1987, p. 89) experiences strong emotions is not as impaired, The phenomenon is not inserted in a lan- although there is always an attempt to escape guage structure; however, it is not completely from these experiences. However, the ability of out of it. This is what characterizes it as a thresh- naming, differentiating, and refl ecting on their old phenomenon. This means that, although most intense emotional states is almost null. there are some aspects of this language, its for- In addition to the projection of affection, the mation mechanisms are not yet clear to him be- disaffection is a mechanism that also projects cause they belong to a more archaic symbolism, out the representation. At this point, McDougall which is outside the fi eld of neuroses. Although defi nes a new destination for the affections, Miller acknowledged that the phenomenon is not the repudiation out of ego, to add to the three restricted to only one type of personality, he did already existing ones (shift, conversion, and not get much attention in the theoretical concept, transformation into anxiety). The affection that which was developed entirely under the notion was ejected in its psychic part, remains only to of a specifi c psychic structure that presents diffi - express itself through its organic dimension, as culties in symbolic processes and had somatiza- in early childhood, thus reducing the psychic tion as the consequence. message to a non-verbal performance. 46 Galdi, M. B., Campos, E. B. V.

At fi rst glance, there are some similarities little is said about the metapsychological mecha- with operational thinking described by the Psy- nisms that dissipate it. Although the author has chosomatic Institute of Paris, especially with created a new concept, the disaffection, little is respect to the break on conscious/unconscious understood about its specifi city. The disaffec- systems, resulting in a pragmatic and concrete tion, defi ned as the rejection out of the ego, is a psychic functioning. However, in the case of mechanism similar to the psychotic use of fore- operational thinking, there is also an inability to closure (a term used by the Lacanian school), or experience these emotions, which can occur in projection (the term used by the English School). disaffection, but not necessarily as a rule. The author emphasizes the affective dimension There is some similarity between mecha- that is divorced – maybe that is the difference nisms of disaffection, foreclosure, and projec- to foreclosure – ejecting only the representation, tion as they have brutal effects and ideational with no emotional charge. Moreover, little is representation removing mechanisms. The dif- said about the formation of the disease based on ferences lie in the fact that on projection the con- this mechanism. Only a short passage appears, tent is deleted and drive is deformed, returning which states that when the psychic dimension of to consciousness as a representation connected affection is divorced, the organic dimension is to an external object. On disaffection, it is the expressed. Moreover, it states that the disaffec- affection that is rejected to not return to an ex- tion is not a return in the form of delusion, as ternal or hallucinatory object. Its destiny is to be on foreclosure or projection. If the disaffection, drained via somatic paths. Therefore, on projec- the whole representative chain is destroyed, how tion, the representation is not completely thrown can its return to the body in a precarious form out of the psyche, as some representations re- of symbolization be explained? It also begs the main in the external object. On disaffection, per- question of why the return does not come out in haps, the whole representative chain is deleted, a delusional form. with no return. Little has also been said on the elements that On behalf of the dominant anxieties within could be used in building a symbolical sense. the framework of psychosomatic illnesses, these We know that it does not confi gure symboliza- are much closer to psychotic anxieties than to tion form as in hysteria, being much more ar- hysterical ones, basically referring to loss of in- chaic, but we do not know what concepts can be dividual and sexual identity, as well as the body called to solve it. On this point, the next author limits. These early fears leave psychological adds very important theoretical contributions, traces on any individual, the ones related to fears sticking to the importance of not representing of every baby and which are mostly solved in aggressive dimensions in somatization, brought the phallic-oedipal phase. However, when they by a similar mechanism, which he called uncon- remain unresolved and psychotic anxiety domi- scious cleavage. Moreover, the author seeks to nates the clinical picture, we are no longer facing explain and offer a solution to questions that are a hysterical problem, although psychosomatic not answered by previous authors on the issue of patients also are not psychotic. “Perhaps, we are the element that differ between a psychosomatic in a position to ask ourselves if many neurotic, or psychotic output, based on the observation of hysterical, and obsessive organizations are not, differences between psychotic and psychoso- at heart, built from a psychotic core” (McDou- matic parents. But before it is necessary to ex- gall, 1996, p. 21). plain some basic concepts of his theory, as its A lot is said in the texts reviewed on the own defi nition of psychosomatic illnesses, the etiology of psychosomatic illnesses. Joyce Mc- notion of libidinal subversion and the construc- Dougall at this point does not differ much from tion of erogenous body. other authors. An aggressive family organization Dejours (1991) points out that, in his view, and consequent mental poverty that leads to a if there is a dualism it is that between erogenous disease are factors cited in almost all works. But body and physiological body, not from an op- Theoretical Models in Psychoanalytic Psychosomatic: A Review. 47 posite relation standing point, but in a way that psychosomatic because until now, no author had the latter can overcome the former. Nonetheless, mentioned the possibility of seeing somatiza- the construction of the erogenous body is never tion as a facilitator for rolling out the analysis completely successful, and there may be gaps in process. The violence of the analyzing patient the convening of an organ, or also unlinking the is not concretely expressed. More subtly, it is drive from some area, due to a trauma occurred perceived in a negative manner: missing words in the life of the subject. This is how the question that signify emotional experiences in his speech, of the organ of choice is treated: the body areas as well as more spontaneous and authentic body that have not been suffi ciently subverted are eas- and facial expressions. ily reached in somatization. Another defense mechanism is proposed Despite the similarity with the theory of in an attempt to explain the somatization Lacan, with regard to the issue of the organ of process: the suppression of aggressive affects. choice, there are different opinions regarding the This mechanism seeks to eliminate the affects origin of the drive. To Dejours (1991), the drive from its source, which, according to the comes from a biological, innate source, while to author, is biological. It differs from the regular Lacan – and post-Lacanian authors – the drive repression mechanism because it operates only comes from language and specifi cally from sig- on the representations at the pre-conscious/ nifi cance that the mother fi gure introduces to the unconscious level, preventing the repressed baby in his fi rst months of life. unconscious representations beyond the barrier After this initial approach to the basic to the preconscious. In this case, the conscious principles that guide his theory, some specifi c completely loses touch with the repressed questions about the problem of somatization content, while in repression, the representation will be addressed, such as the third topic appears sometimes intact to conscious and (cleavage topic), and will not represent aggres- may disappear soon after. Unlike repression, sive dimension as the central problem of suppression operates at the conscious/pre- psychosomatic illnesses. conscious level. It more specifi cally opposes The aggressiveness that could not be repre- the development of affect and not the ideational sented is due to the unconscious cleavage in pri- representational element. Therefore, we can see mary/secondary unconscious. The author takes that repression operates more on the psychic up the Freudian hypothesis of the unconscious level of representations, while suppression as being also made up of phylogenetic features, operates more on the affective and body level. considering the primary unconscious as the host According to that, the author states that of inherited traits. The secondary unconscious, to interpret a psychosomatic symptom is, ef- in turn, is that linked to symbolic representa- fectively, to interpret the death drive. This is a tions. The death drive that is prevented from process that seeks to link the death drive with being represented by the pre-conscious oper- the life drive, emptying its traumatic potential. ates destructively on the organic body through The symbolization somatization should be iden- psychosomatic diseases. Thus, the subject re- tifi ed, according to the author, eliminating the mains unknown of his own violence. Trying to essential depression hypothesis. Therefore, he preserve the apparent normality in social bond- considers all the theoretical propositions of the ing, this violence is not acted out, but directed IPSO, but differentiates between types of soma- against the subject himself, which strikes a blow tization: progressive disorganization is different against the very unconscious body in the form of from symbolization somatization. In the fi rst, somatization. Dejours (1991) suggests that the the violence is partially inhibited, whereas in the somatization itself may act as symbolizing some second it is massively suppressed. What is ob- lost aspect of the history of these people. This is served, then, is that some somatization opens the another innovation in the fi eld of psychoanalytic way to reveal a confl ict or a part of the history of 48 Galdi, M. B., Campos, E. B. V. the subject that remained hidden, which he did Discussion not get into contact, due to its traumatic fash- ion. From this, it was observed that during the Although there are some theoretical dif- analysis, the one which once seemed apparently ferences, as already noted, the opinions about frozen, it began to unfold and also evoked the the psychosomatic phenomena follow a certain notion of “psychosomatic facilitation” (Dejours, pattern, concerning the characteristics of pati- 1991, p. 28). ents who have this type of suffering. There is Similarities were also very often found with consensus regarding the failure of symbolization the mother/baby relationships of psychotics. present in these clinical cases, although theories Dejours (1991) points out that the difference have followed a motion at the beginning, lies in the fact that the psychotic parents seek to considering the lack of symbolization as struc- divert the thoughts of the children, creating an turing these cases, unfolding to the notion that alienated child with no original thought. Parents this lack is not structural but limited to some of psychosomatics, however, seek to destroy any parts of the speech. Also lingers in general, kind of thought they might have, especially of the agreement regarding the lack of affection, a sexual nature. But it is not only in this respect references to the lack of dream and fantasy that in Dejours theory these psychopathologies life, and an extreme concreteness of thought, become close: he proposes a hypothesis that concomitantly with an extremely pragmatic mental illness, especially psychoses, should be lifestyle. All these factors are listed and called aggregated to psychosomatic illnesses. At this “operational thinking” by members of the IPSO point, the author takes into account the fi ndings and “alexithymia” by the Psychosomatic School of neuroscience, according to which these of Chicago. Joyce McDougall uses the defen- functions depend on the hereditary assembly of sive mechanism of disaffection to designate the nervous system. Thus, it is also thought that the same characteristic elements. Dejours does in the case of psychoses, the unlink with drive, not go far enough in creating a new concept instead of happening in visceral areas – as with to denote these personality characteristics, and psychosomatic illnesses – occurs in the brain, the emphasis of his theory lies in the uncons- affecting areas related to cognition and language, cious cleavage hypothesis and the size of the which are the most compromised functions in disclosed aggression. However, theoretical psychotics. incursions of post-Lacanian authors, as with Dejours (1991) and McDougall (1996) offer Miller, points to the consideration of other a greater advance in the technique, in the sense defensive mechanisms that can coexist with that an interpretative work is risky, and therefore foreclosure, giving the idea that the foreclosure more operative, although Dejours (1991) also of the Name of the Father does not establish the consider the relevance of the Marty therapy general logic of symbolization in psychosomatic procedure he called stop-excitation. The choice cases, as occurs in psychotic, but is a limited between the two treatment procedures, he said, mechanism that can coexist with repression, and depends on the willingness of the analyzing denial. However, still a psychosomatic patient subject to face his truth. From a clinical point of profi le is maintained, and this is very close to view, Dejours (1991) offers an innovative fi nding the psychotic profi le, which seems to remain that the somatization also occurs in neurotic a contradictory opinion with the rest of the personality structures. As regards the technique, theory, even missing more theoretical elements the author also asserts a new proposition that the to analyze the occurrence of somatization somatic subjects must be interpreted through within the well mentalized subjectivities. Mc- their aggressive and deadly contents. For him, Dougall’s ideas move toward the approach of therefore, an underlying meaning to the disease psychosomatic with hysteria, agreeing with can be unraveled, seeking to link the traumatic the symbolic dimension that the phenomenon dimension of the death drive into libido. offers, but more archaic than the symptom. Theoretical Models in Psychoanalytic Psychosomatic: A Review. 49

The approach of psychosomatic with psy- nomenon would come to embrace the language chosis is also performed by Dejours; however, structure. Despite this seeming to be the opinion with the difference that, in the present day, there given by Lacan, Miller does not conclude the is- is a proposal to treat diseases known as “mental” sue, ranging from statement positions as the ab- as psychosomatic diseases, where there would sence of any symbolic element or admitting the be an unlinking of the drive and, therefore, a vul- possibility of an insertion in the language struc- nerability to the death drive. This would explain ture. This would open the possibility to classify why psychotic and autistic subjects can be dam- it as a border phenomenon, which is within the aged in language and cognition functions, while limits of the symbolic universe. their immune system remains extremely strong. Among French authors, it is only with the Dejours offers a clue to a better understanding of introduction of Dejours’ ideas that injury is the differences found in psychotic and psychoso- proposed, building a sense for the body; however, matic outcomes. Despite the similarities between unlike the hysterical symptom, which is inter- the two, we see that there is a difference with preted through the erotic fantasies repressed the destinies of the thoughts of patients in early by the subject, the psychosomatic phenomenon childhood. Moreover, the important role played should be interpreted from repressed aggressive by parents in body areas’ libidinization, which, drives. However, Dejours is not considered he said, could be decisive between a psychotic or a strictly post-Lacanian author, remaining a psychosomatic outbreak, is also notable. unknown positions taken by them today. With regard to discussions on the allocation McDougall, instead, carries an approchement of a symbolic meaning about the disease and the with Dejours´ ideas, stressing that somatization metapsychological mechanisms involved in it, is a hidden history of the life of a subject, which some progress was achieved in the course of the- was unable to be represented for himself and ories, such as making sense of the disease, which for someone. Hence, there is a need for (re) also offers a breakthrough in practice clinics and construction of this lost history, which would is shown in this way to be a little more opera- give meaning to somatization. Moreover, despite tional. Moreover, some important discoveries these advances in the theoretical and clinical about the aggressive dimension present in this framework, the symbolization of psychosomatic issue allowed more enlightening attempts to de- phenomena is much more archaic than those of a scribe the metapsychology involved in cases of hysterical symptom. It retains a certain diffi culty somatization, a fact that is verifi ed on the propo- in its unveiling. sition of the third topic by Dejours. On the movement traversed of the theo- Thus, although at the beginning the rela- retical constructs about a sense, Casetto (2006) tionship between the symbolization of disability notes that and the outbreak of a bodily disease had been . . . Putting up these differences in time addressed more directly; however, the presence perspective, it detects what appears to be of more metapsychological elements involved in a certain movement (dialectical): somati- somatization has been noted recently. For exam- zation moves from a model more strictly ple, disaffection mechanism and cleavage of the conversive to his own denial, and then to a imago, from McDougall, and topical cleavage third state which appears as a horizon of still and suppression of aggression, from Dejours, unfulfi lled meanings. (p. 17) are concepts which, in a way, problematized an Despite these advances in the trodden path, issue that apparently had a somewhat more sim- a theory that explains all metapsychological plifi ed and straightforward approach. mechanisms behind somatization has not yet Regarding the path followed by discussions been developed. Perhaps this diffi culty arises on the direction of the psychosomatic phenom- by the problematic itself, which is revealed in enon, we see that the classic initial discussions diffi cult cases by extreme neutralization with of psychoanalysis, carried out by members of these clinical patients. However, this strengthens the IPSO, led to the question whether the phe- the fi nding that a psychosomatic illness is a 50 Galdi, M. B., Campos, E. B. V. phenomenon that covers both the biological er time, that the fragmentary lifestyle that and psychological dimensions and is therefore gives us the contemporary society, after all, necessary to revise our conceptions of the doesn’t favor what you might call a good nature of the mind and body and the mode of mentalizing. (Ferraz, 1997, p. 172) interaction that occurs between these two. This This is an interesting and necessary debate was made very clear in the work by Dejours from for psychoanalysis, which offers the possibility his concept of libidinal subversion; however, to think about the construction of subjectivity although psychoanalysis has revolutionized with beyond what was established in the family the limit concept of drive, it has clung more to relationships during early childhood. It seeks to theories on psychic mechanisms, thereby lacking integrate present aspects of a subject’s life – both explanations when faced with biological and relational and psychological distress at work – psychological phenomenon. This diffi culty has with discussions of the historical and social con- been pointed out by Birman (2001), who considers text in which it is inserted. This is an important that this fact – much more than being translated factor, which establishes greater relationships by a theoretical failure – was established by an with the external and relational environment agreement between psychoanalysis and medi- without leaving aside the intrapsychic dynamics. cine, operating a separation between the psyche of the issues that must be investigated by the Final Considerations fi rst fi eld and body issues, which are restricted only to the second. This split occurred in the Discussions in psychosomatics have mostly emergence of psychoanalysis and its questioning followed a certain theorizing pattern, particu- of the positivist science and should be reviewed larly with regard to symptoms and psycholo- through a demand of the psychosomatic reality, gical functioning. These descriptions were cha- which has increased in clinics. racterized as a concrete work, pragmatic and Finally, there is also a need to consider other devoid of symbols and dream life. As we saw aspects of constituent psychosomatic phenom- in Miller and Pierre Marty’s works, the idea of a enon than only genetic, unconscious, and those psychosomatic personality structure is stronger. built from early relationships with parents. This The fi rst incursions of Lacan do not leave much refers to a greater search for answers in the so- clear, since he considered that psychosomatic cial life of a subject because, if psychosomatic illnesses would be analyzable in the limit to illnesses are increasing today, there would not be considered a phenomenon of the real body be elements in our contemporary society, which order. Perhaps, this is why he did not include contribute to a psychic malaise that is expressed psychic structures in the psychosomatic ratings. through the body increase. However, it implies the question of a structural The discussion extends to an observation mechanism of foreclosure of the Name of the of the functioning of our society in which labor Father who approaches the psychosomatic from relationships refl ect only one aspect of its opera- the psychotic and autistic structures. However, tion. The values spread by social media such as Miller says the psychosomatic phenomenon individualism, consumerism, and competition is a threshold phenomenon because it adheres would be contributing to the construction of in some respects – as yet unknown – to the fragmented, depersonalized identities: language structure. Would it be appropriate to The question is: does the contemporary consider, as from Lacan’s perspective, the pos- capitalist society, with its supreme link to sibility of thinking about psychosomatic as a consumption values, would not be produc- boundary arrangement, as it does not present ing a kind of depersonalization that come itself as a neurotic functioning but has exceeded along with mass culture phenomenon? Do the psychotic organization? It has been observed we live in a culture whose imperatives favor that the symbolization is not absent, as is the the appearance of normosis disease? Here is psychotic organization, but it is from a more a broader hypothesis, to be worked at anoth- archaic order than what happens with neurotics. Theoretical Models in Psychoanalytic Psychosomatic: A Review. 51

Although McDougall and Dejours have that do not carry a trigger related to an emotional recognized the phenomenon beyond this type event. Finally, we reiterate the importance of psychic functioning, their theorizing is still of establishing a dialogue with the modes of transiting in this area, with McDougall dis- subjectivity production that are in course in our coursing on the disaffection and Dejours on society because psychoanalysis leads existing the suppression of aggression. Therefore, the discussions between the current capitalist way of mechanisms that were behind the somatization production and illness at work. in more neurotic psychic functioning are still lacking in explanations and metapsychological References elucidations. Regarding the diffi culties encountered in Birman, J. (2001). Corpos e formas de subjetivação the research process, these reside in the very dif- em Psicanálise. Estados Gerais de Psicaná- fi culty inherent in the subject: that little is ex- lise. Retrieved from http://egp.dreamhosters. com/encontros/mundial_rj/download/3_Bir- plored by psychoanalytic authors, and when they man_38020903_port.pdf do, they perform a directed theory for the negative and symbolic inability of such subjectivity Casetto, S. J. (2006). Sobre a importância de adoe- cer: Uma visão em perspectiva da psicosso- is cited by all authors reviewed. Moreover, while mática psicanalítica no século XX. Psychê, 10 acknowledging that psychosomatic diseases are (17), 1-22. Retrieved from http://pepsic.bvsalud. not restricted only to the operative mode, there org/scielo.php?script=sci_arttext&pid=S1415- are few elements to think about this problem out 11382006000100008&lng=es&nrm=iso of the framework set by Pierre Marty. Moreover, Dejours, C. (1991). Repressão e subversão em psi- the works related to this subject are often terse cossomática: Pesquisas psicanalíticas sobre o and somewhat didactic in his explanation. In this corpo. Rio de Janeiro, RJ: Jorge Zahar. sense, there was much diffi culty in the lack of Ferraz, F. C. (1997). O mal-estar no trabalho. In R. explanation of concepts and even concrete ex- M. Volich, Psicossoma: Psicossomática Psica- amples for a better understanding. Perhaps, in a nalítica II. São Paulo, SP: Casa do Psicólogo. broader sense, psychoanalysis is still a little lay- Leclaire, S. (1992) O corpo erógeno: Uma introdu- person when it comes to the subject of psycho- ção à teoria do complexo de Édipo. São Paulo, somatic and the works revised go in the same SP: Escuta. (Original work published 1979) direction of general mechanisms of explanation McDougall, J. (1996). Teatros do corpo: O Psicos- and description, thereby lacking some new con- soma em psicanálise (2nd ed.). São Paulo, SP: tribution elements to think about this problem. Martins Fontes. Our impressions agree with the view that Mello, J., Filho, & Burd, M. (Eds.). (2010). Psicosso- psychosomatic illnesses are much more fre- mática hoje (2nd ed.). Porto Alegre, RS: Artmed. quent and much less stringent than suggested Miller, J.-A. (1987). Algumas refl exões sobre o fenô- by the traditional authors of psychoanalytic meno psicossomático. In R. Wartel, Psicosso- psychosomatic. Perhaps, a clue to identify the mática e Psicanálise (pp. 87-97). Rio de Janeiro, occurrence of a psychosomatic illness is to RJ: Jorge Zahar. stick to the facts triggering injury in the life of Vieira, W. de C. (1997). A psicossomática de Pierre the subject, which differ from other diseases Marty. In F. C. Ferraz & M. R. Volich, Psicos- whose etiology may be attributed to more soma: Psicossomática Psicanalítica (pp. 15-22). organic and less psychological causes. We also São Paulo, SP: Casa do Psicólogo. believe that discussions about the defi nition of Volich, R. M. (2000). Psicossomática (2nd ed.). São psychosomatic and not psychosomatic diseases Paulo, SP: Casa do Psicólogo. should be reviewed, as it is also known that the occurrence of some trauma (mourning, separation) triggers organic diseases and they should Recebido: 08/10/2015 be considered more psychosomatic than those Aceite fi nal: 14/01/2016