Actual Neurosis Research Articles

Hypochondria as an actual neurosis

Freud defined hypochondria as an actual neurosis. In this paper the actual neurosis will be interpreted as unbound traumatic elements which threaten the self. In severe hypochondria, breakdowns have occurred, as outlined by Winnicott. The nameless traumatic elements of the breakdown have been encapsulated. The moment these encapsulated elements are liberated, an actual dynamic takes place which threatens the self with annihilation. Projective identification is not possible because no idea of containment exists. The self tries to evacuate these elements projectively, thus triggering a disintegrative regression. However, the object of this projection, which becomes a malign introject, is felt to remove the remaining psychical elements, forcing the worthless residue back into the self. In a final re-introjection, the self is threatened by unintegration. To save the self, these elements are displaced into an organ which becomes hypochondriacal, an autistoid object, protecting itself against unintegration and decomposition. An autistoid dynamic develops between the hypochondriac organ, the ego and the introject. Two short clinical vignettes illustrate the regressive dynamical and metapsychological considerations.

Hypochondria as a self-destructive attack on the subject’s vitality

There is much to be said for Nissen’s (2017) model of “hypochondria as an actual neurosis,” which sees the genesis of hypochondriacal anxieties as the end-product of a long series of defensive oper...

Unrepresented states and the challenge of historicization

Bernd Nissen has been developing a metapsychology of hypochondria and ‘autistoid’ states for 20 years, working within the Kleinian object relations tradition to formulate the earliest events of psychic life. His imaginative work shows careful thinking about early catastrophic developmental experiences which may lead to various forms of psychopathology. In the current paper, Hypochondria as an actual neurosis, Nissen extends his progressive work on hypochondria and joins his evolving theory of autistoid encapsulation to a revival of interest in Freud's concept of actual neurosis, the experience of unrepresentable early trauma, the problems of historicization, and to Winnicott's description of the fear of breakdown. I first summarize Nissen's theoretical work in the area of hypochondria and autistoid encapsulation, and then comment on his current paper including the challenge of historicization in unrepresented states. Finally I consider the question of parsimony in Nissen's metapsychology.

A Model for Integrating Actual Neurotic or Unrepresented States and Symbolized Aspects of Intrapsychic Conflict

In psychoanalytic theory, the importance of actual neuroses—considered to be devoid of psychic content—diminished as Freud and subsequent analysts focused on unconscious intrapsychic conflict. This paper explores the relationship between actual neurotic and unrepresented states, which are believed to be best addressed through attention to countertransference, intersubjectivity, and enactments rather than interpretation of intrapsychic conflict. Models suggesting how actual neurotic states and symbolized intrapsychic conflict may interact with each other and environmental stressors are described. Symbolizing actual neurotic states and establishing meaningful linkages between somatic/affective experiences and intrapsychic conflict are viewed as necessary for effective treatment of many disorders.

Breakdown and transformation – work with a severely depressed patient

In this article, Winnicott’s concept of breakdown is discussed in relation to Freud’s ideas of “actual neurosis.” This provides the theoretical underpinning for understanding of severe depression. The case of a severely depressed woman illustrates how the deadened core of the depression is not communicable to an object. The question is raised as to how the psychic ability of perception is hindered.

Unmentalized aspects of panic and anxiety disorders.

Somatic or emotional experience that has not been symbolically represented, referred to as unmentalized experience, has been given an increasingly prominent role in understanding psychopathology. Panic and anxiety disorders provide a useful model for exploring these factors, as the affective and bodily symptoms can be understood in part as unmentalized experience. The authors explore models of Freud's actual neurosis, Marty and DeM'uzan's pensee operatoire, Klein's unconscious fantasy, Bion's alpha function, Bucci's multiple code system, and relational models to describe how somatic and affective experiences can be translated into symbolic representations, and what factors can interfere with these processes. Approaches to unmentalized aspects of panic and anxiety include symbolizing somatic symptoms, identifying emotional states, and identifying contextual and traumatic links to symptoms.

The Subject in an Uproar

From Jacques Lacan's theory of anxiety, principles are deduced for a Lacanian-oriented treatment of panic disorder. This Lacanian approach is related to Freud's theory of the actual neuroses, and is comparable in some ways with the approach taken in Panic-Focused Psychodynamic Psychotherapy (PFPP). The Lacanian conceptualization of panic retains the idea that both repressed material and unsymbolized mental states lie at its basis. People suffering from panic attacks are overwhelmed by signifiers, aspects of corporeal excitation, and/or existential questions that remain too Real. Psychoanalytic therapy aims to create a name for such Real elements. The three registers that Lacan situates at the basis of his psychoanalytic approach (the Symbolic, the Imaginary, and the Real) are discussed, as well as the treatment principles for conducting this clinical work. The case study of a young woman with panic disorder is presented to illustrate how a brief, Lacanian-oriented treatment (forty-eight sessions) progressed, and where the patient managed to both name and find a symbolic place for psychic experiences that were too Real. During this treatment, the patient overcame her avoidant-defensive mode of functioning and her persistent difficulties related to separation.

Contemporary perspectives on Lacanian theories of psychosis.

In contemporary Lacanian psychoanalysis, Verhaeghe's theory of actualpathology psychopathology in psychosis and the Millerian idea of “ordinary psychosis” provide diverging conceptual approaches to psychosis. In this paper, the two approaches to psychosis are examined with a particular emphasis on “mild psychosis” and compensatory mechanisms. Despite the shared focus on similar clinical phenomena, particularly body disturbances, these two theories provide different explanations of psychosis. Verhaeghe's theory of psychosis is a synthesis of Lacanian theory, Freud's idea of actual neurosis and psychoanalytic attachment concepts. Moreover, these ideas are situated in the “schizophrenia/paranoia dichotomy” an important heuristic device utilized in clinical practice with psychosis. In contrast, the Millerian field of ordinary psychosis aims to broaden the idea of psychosis by reviving the idea of “mild psychosis” and the different forms of stabilization possible in psychosis. Clinicians adapting the idea of ordinary psychosis aim to rethink pivotal Lacanian concepts—“untriggered” psychosis and stabilization—beyond the scope of the schizophrenia/paranoia dichotomy. Although the idea of ordinary psychosis requires further development, it promise greater utility than Verhaeghe's model, as it provides a broader and more nuanced approach to the complex vicissitudes of triggering and restitution in psychosis.

Dubois d'Amiens e a sua concepção sistemática da hipocondria e da histeria na França

Frédéric Dubois d'Amiens foi o vencedor do concurso da Sociedade Real de Medicina de Bordeaux em 1830, graças à apresentação da sua tese intitulada "História filosófica da hipocondria e da histeria". De um ponto de vista existencial, sistemático e por meio de um método histórico-filosófico, ele propõe uma descrição inédita da hipocondria, pois descreve passo a passo a constituição do sujeito afetado, revolucionando assim as concepções médicas e psicopatológicas dessa doença. Apesar das diversas críticas que lhe são apontadas, Dubois d'Amiens reconhece à hipocondria, desde 1830, um sofrimento psíquico e físico específico e vê nela uma forma de pensar, enquanto que Freud a classificará mais tarde como uma neurose atual.

Síntoma y discurso: las enseñanzas de “La moral sexual ‘cultural’ y la nerviosidad moderna”

Sobre el telón de fondo de la diferencia establecida hoy en día en el campo del psicoanálisis entre los síntomas clásicos y los llamados síntomas contemporáneos, el trabajo interroga la formulación misma de síntoma contemporáneo. A partir del alcance de la diferencia que Freud introduce entre el síntoma de las psiconeurosis y el síntoma de las neurosis actuales, el trabajo avanza la tesis según la cual resulta desacertado acordar el carácter de síntoma a las respuestas mediante las cuales el sujeto se somete sin resto al imperativo del discurso. Porque el síntoma da cuenta de una objeción al Otro y guarda con respecto al goce una relación de falta estructural: un menos de goce.

In search of a framework for the treatment of alexithymia

Clinical observations and controlled studies indicate that the treatment of alexithymic patients is most difficult. Moreover, stronger degrees of alexithymia predict worse therapy outcome. We argue that in order to make therapy for alexithymia-related disorders fruitful, a conceptualization of alexithymia in terms of interpersonally imbedded affect regulation is needed. Based on a re-interpretation of Freud's actual neurosis via Lacan's theory and contemporary attachment theory, we present a theoretical framework that incorporates these points. This framework helps us to explain why classic psychotherapeutic approaches fail, and to formulate principles for an alternative psychoanalytic therapeutic approach that addresses the theoretically discerned difficulties. A clinical vignette is used to examine how these principles can be implemented in clinical practice. Therapy with actual-neurotic alexithymic patients should focus on distressing situations, starting from which a three-step logic can be deployed. During therapy, mental representations on difficult situations in patients' lives need to be constructed by (1) putting into words the chain of events that makes up the distressing situation; (2) making the patient's appraisal of the difficult situation explicit; and (3) addressing affective responses and discussing the patient's way of dealing with the difficult situation.

Posttraumatic stress disorder (PTSD), actual pathology, and the question of representability: A reply to "Attachment deficits, personality structure, and PTSD" (J. Mills).

Reading a reaction to one’s publication is usually a good thing for one’s narcissism. In the best of cases, it is a good thing for one’s thinking as well, as it obliges us to reconsider critically a number of our ideas. This is the case with the paper published by J. Mills, as a reaction to our “Actual Neurosis and PTSD” (Verhaeghe & Vanheule, 2005). In the first part of our answer, we will clarify certain of our ideas in the light of Mills’s critical remarks. In the second part, we want to address what we consider to be the main problem in matters of posttraumatic stress disorder (PTSD), that is, the question of representability. The title of Mills’s paper gives a good summary of his central objection to our reasoning. In his clinical experience, the predisposition to future PTSD profiles is predicated “on earlier deficits in personality structure due to developmental traumas.” In his latest book (Mills, 2005) he has generalized the idea of “structural deficits in personality organization due to attachment pathology constituted as a disorder of the self and maintained on unconscious representational levels.” At first sight, this seems to be a major difference with our reasoning, where the actual-neurotic structure, based on a failure of the Other during the early child–parent interactions, is put forward as the predisposition to future PTSD. Nevertheless, there are more similarities than divergences. Indeed, in our reasoning, the failed interactions between child and Other determine what we have called here the original trauma (Verhaeghe & Vanheule, 2005, p. 502) and elsewhere even the “structural trauma” (Verhaeghe, 2004, p. 317). When writing our paper and even right now, we are very much aware of the semantic difficulties. Stating that a disorder caused by a trauma is based upon a preceding trauma sounds too circular. That is why we considered it more important to elaborate the—indeed—structural context of this original trauma, based upon a reinterpretation and enlargement of Freud’s actual neurosis. The idea of “structure” is hereby quite important. There are at least two actors involved—the infant and the Other—around one central issue: the drive arousal, experi

Actual Neurosis as the Underlying Psychic Structure of Panic Disorder, Somatization, and Somatoform Disorder: an Integration of Freudian and Attachment Perspectives

Starting from a contemporary critique of the DSM-IV, this paper argues that the diagnostic categories of panic disorder, somatization, and undifferentiated somatoform disorders can be understood as belonging to a common type of psychopathology—i.e., the Freudian actual neuroses. In addition to their strong clinical similarity, these disorders share an etiological similarity; and the authors propose a combination of Freud’s focus on this type of patient’s inability to represent an endogenous drive arousal with the post-Freudian focus on separation anxiety. An etiological hypothesis is put forward based on contemporary psychoanalytic attachment theory, highlighting mentalization. Concrete implications for a psychoanalytically based treatment are proposed.

Structure et déstructuration à la sénescence

After having defined the structure of personality, the author examines its destiny late in life. If certain structures keep up in old age such as well internalised neuroses, others end up in actual neuroses or undergo a massive destructuring process, as in Alzheimer's disease. Using the psychosomatic theory of the Paris School (Pierre Marty), which emphasizes trauma and fixations, the author inquires into these different clinical configurations as well as into their possible relations.

Freud e as neuroses atuais: as primeiras observações psicanalíticas dos quadros borderline?

Ao admitirmos que os quadros borderline e as denominadas patologias da contemporaneidade freqüentemente associadas a esses quadros não são propriamente novos, resta saber como apareciam no passado. Um retorno a Freud sugere que as "neuroses atuais" correspondem às primeiras observações psicanalíticas dessas manifestações; ainda que a hipótese etiológica formulada por Freud sobre as "neuroses atuais", baseada no acúmulo de tensão sexual, precise ser revista. Atualmente seria difícil sustentar a idéia de que uma patologia psíquica encontra suas origens exclusivamente na falta de satisfações sexuais, em sua acepção genital. Contudo, se tomarmos "sexual" como sendo o propriamente pulsional, tal qual Freud parecia privilegiar, é bastante coerente afirmar que essas patologias resultam da transformação direta - não mediada pelo psiquismo - da pulsão não satisfeita. Neste retorno a Freud é também possível encontrar algumas pistas para a construção de uma nova hipótese etiológica, baseada nas neuroses narcísicas.

Hypocondrie

Hypochondriasis is a disorder defined by a hard concern felt by the patient, focused on the fear to be affected by a severe disease. Most of the time, this preoccupation is based on an erroneous self-interpretation of physical or psychical symptoms, which persists despite reassuring appropriate medical assessment. Recent reports highlight three principal clinical features: bodily concerns, fear of a disease, and the certainty of being ill associated with a lack of response to reassurance. The hypochondriac patient practises “medical shopping” and repeatedly undergoes vain medical visits and investigations. Psychopathological explanations refer to narcissism and actual neurosis. Cognitive-behavioural approaches underline the importance of pessimistic interpretations of insignificant somatic symptoms and that of false convictions regarding health. Pharmacological therapies consist of antidepressant drugs that act on associate depressions and hypochondriac symptoms per se.

Psicossomática: historicidade ou atualidade?

Procuramos aqui abordar a questão da concepção de historicidade em psicanálise, em contraponto ao conceito de neurose “atual”, o qual serve de base para a teorização contemporânea em psicossomática. Realizamos uma revisão crítica da neurose atual, sob o prisma de uma aglutinação neurose atual–psiconeurose, concebendo historicidade e sexualidade articuladas ao nível da linguagem. Finalmente, sugerimos que a neurose atual deve ser abordada a partir desse nível, visto sua ligação com a psiconeurose, o que pode nos fornecer novas bases para pensarmos o fenômeno psicossomático.

Actual neurosis and PTSD: The impact of the other.

is interpreted as the impossibility to process the arousal comingfrom the drive in a symbolic way. The reason for this impossibility is sought inthe failure of the primary caretakers in presenting the child with the necessarysymbolic tools for drive regulation. The therapeutic implications of the presenceof an actual-neurotic structure are important, because it can lead to a failure offree association. Suggestions for a more fruitful approach are formulated.

The psychodynamic of panic attacks: A useful integration of psychoanalysis and neuroscience

This article tries to explain, in the light of some neuroscientific and psychoanalytical considerations, the repetitive pattern of panic attacks. Freud considered the panic attack as an ‘actual neurosis’ not involving any conflictual process. Recent neuroscientific findings indicate that psychosomatic reactions, set off by a danger situation, depend on the primitive circuit of fear (including the amygdala) characterised by its speed, but lack accurate responses and may also be activated by harmless stimuli perceived erroneously as dangerous. The traumatic terror is stored in implicit memory and may be set off by a conditioned stimulus linked to a previous danger situation. In the panic attack, the traumatic event is created by the imagination and this construction (a micro‐delusion), built in loneliness and anxiety, has the same power as the real trauma. A mutual psychosomatic short‐circuit between body and psyche, in which terror reinforces the somatic reactions and the psychic construction, is established. Therefore, it is important to highlight these constructions in order to analyse and transform them. In the second part of the article the author reviews the main psychoanalytical theories about panic attacks, stressing how, in his opinion, panic attack is a consequence of the breakdown of the defence organisation at various levels and may appear during periods of life crisis. Two patients suffering from a deficit of personal identity are presented. The various organisations and the different levels (biological, neuroscientific, associative, traumatic) of the panic attack determine different kinds of therapeutic approaches (pharmacological, cognitive and psychoanalytical). While the psychopharmacological treatment is aimed at reducing the neurovegetative reaction and the cognitive method is attempting to correct the associative and perceptive processes of fear signals, psychoanalytical therapy represents both a specific means to free patients from panic attacks as well as an indispensable route for their emotional growth.

'Actual neurosis' and psychosomatic medicine: the vicissitudes of an enigmatic concept.

Out of the concept of neurasthenia, the main non-psychotic diagnosis of nineteenth-century psychiatry besides hysteria, and on the basis of psychophysiological problems of his own, self-diagnosed as neurasthenia, Freud developed the notion of 'actual neurosis', a 'contentless psychic state' manifested by various somatic symptoms and a depressive mood, which he attributed to a chemical factor associated with aberrant sexual practices and in particular masturbation. Rejected by post-Freudian analysts as such along with the diagnosis of neurasthenia, the concept of 'actual neurosis' has survived under various theoretical schemes that seek to explain psychosomatic illness and somatisation, in general, with its concomitant poverty of affects and dearth of fantasy life. In more recent years, the concept of 'actual neurosis' has resurfaced under the label of chronic fatigue syndrome, a medical entity thought to be an immunological deficiency, while in psychoanalysis Freud's idea of a contentless mental state has been replaced by that of unconscious fantasy and symbolisation at a pre-genital or pre-verbal level.