On the Axis of Psychosomatic Totality

The axis of psychosomatic totality, the concept of psychosomatic conversion, and the Process of somatic Disorganization

Psychoneurosis and Actual Neurosis: The Cornerstones of Modern Psychosomatics

In the second circle of hell (l’inferno), Dante espies a pair of lovers amidst a multitude of “sinners of the flesh”. The Poet, who is striding through the afterworld in the company of Virgil, wishes to speak with them; they detach themselves from the other buffeted souls, and Francesca da Rimini speaks for the couple. She speaks of her adultery, and of the murder committed when the couple were caught in flagrante by Francesca’s husband. And Dante, gripped by pity and horror, collapses (Flasch 2018, p. 17):

E caddi come corpo morto cade.

And [I] fell as falls a body that is dead.

In the following thoughts, we are interested in the psychosomatics of the poet’s collapse and similar symptoms. Quite obviously, the collapse is a response to this inauspiciously abysmal love story. Here some psychosomatic questions arise: Would this symptom be the response to the conflictual threat of castration being initiated by the superego? Or would it be the response to the break-in of the “real” (as Lacan said)? Is it the poet’s oedipal conflict, or does the story remind him of the unfortunate time when as a five-year-old, he lost his mother? Today, the views of how the psychosomatic field should be defined could not be any more different: Aisenstein (2006) holds the view that psychosomatic practice consists primarily of the psychoanalytical approach to bodily ill patients. On the other hand, Sami-Ali (2006, p. 34) begs to differ: For him, hysteria is the original field of the psychosomatic. Bronstein (2011) suggests the adoption of Whitlock‘s (1976, p. 19) sight, which states that in any case emotional influences play a significant role in the aetiology, recurrence and potentiation of psychosomatic complaints. But already at the beginning of psychosomatic discourse, Freud (1895a) marked a very differentiated and complex aetiological field. He noted in his “Studies on Hysteria” both a traumatic and phantasmatic aetiology of hysterical symptoms (Freud 1895a):

In the famous case of Miss Lucy R., the young au-pair from Scotland, now living in Vienna, reported subjective odour perceptions and analgesia of the interior of the nose. Lucy repressed the erotic desire, which she experienced as inadmissible: the erogenous zone was displaced, the prohibition being manifested in the analgesia. Thus, the shape of the symptom stems from the desire as well as from the defence, rooted in the prohibition that was erected against this wish-fulfilment (Freud 1895a, p. 117, cf. Groddeck 1923, p. 275). In the story of Katharina, Freud describes an 18-year-old woman, sexually abused by her father and suffering from fears of suffocation as well as nausea, vomiting and dizzy spells (Freud 1895a, p. 125). Katharina – her original name was Aurelie K. – the daughter of the landlady, had the courage to address Freud for her disturbing symptoms when, in the late 19th century, he undertook a hike to the “Erzherzog-Otto-Schutzhaus” in the Austrian Rax massif (Fichtner & Hirschmüller 1983). It was here, that Freud discovered the direct relationship between trauma and symptom, which can be understood as “indicative of a particular psychical excitation“ (Freud 1895a, p. 179).

Against this background, Freud (inter alia 1898, p. 267 ff) developed two nosological concepts: He distinguished between “psychoneuroses” and “actual neuroses”, and he explained psychoneurotic symptom formation as follows, likewise in Studies on Hysteria: A phantasy accompanied by reluctance is pushed into the unconscious, and the excitation sum belonging to this phantasy is transformed into the body over the course of the conversion (Freud 1895, p. 116). The symbolism of the bodily symptom results from the fact that the phantasy (forbidden kissing) is replaced by a bodily symptom (analgesia of the inside of the nose; in the case of Dante, it may be allowed to speak of a hysterical fainting).[1] Definitively, we are dealing here with a “failed repression”, since what is pushed away returns in the form of a bodily symbol (Sami-Ali 2006, p. 16). Sami-Ali (2006, p. 41) speaks of a “hysterical somatization”. In “The Function and Field of speech and language in Psychoanalysis”, Lacan (2006, p. 215) called the hysterical body-symptom as a “monument” that can be deciphered as a linguistic inscription:

„The unconsciousness is the chapter of my history that is marked by a blank or occupied by a lie: it is the censored chapter. But the truth can be refound; most often it has already been written elsewhere. Namely, in monuments: this is my body, in others words, the hysterical core of neurosis in which the hysterical symptom manifests the structure of language, and is deciphered like an inscription which, once recovered, can be destroyed without serious loss.“ (Lacan 2006, p. 215)

The function of this symbolic transformation into body language is to obtain a certain stabilization of the repression. The repressed is only realised in a bodily symbol, whilst the subject achieves an unburdening, such as a symbolic wish-fulfilment.

The aetiology of the actual neurosis, however, lies in a somatic-sexual excitation expressing itself in fear (“anxiety neurosis”) or in physical sensations (“neurasthenia”) (Freud 1898, p. 268 ff). Freud’s concept of actual neurosis was adopted primarily by the “Parisian School” (inter alia Marty, de M’Uzan, David, Aisenstein and Smadja)[2]. The actual-neurotic pattern consists of the inability of somatic excitation to be transformed into psychological excitation, it being instead directly discharged into the body (Smadja 2010, p. 150). It was a related line following the idea of actual neurosis that Sifneos (1975) and Nemiah (1978) advocated with the concept of alexithymia. They said, it would be typical for alexithymic patients to perceive the physiological aspects of their emotions physically, whilst not being able to either recognize or name the psychological quality of these emotions (Krystal 1988, p. 242 ff.; cf. also de Greek et al. 2013). Now, it is at exactly this point, where Sami-Ali (2006, p. 16) adopted Freud’s original distinction between psychoneurosis and actual neurosis by differentiating between a “hysterical” (psychoneurotic) and “non-hysterical” (actual-neurotic) somatization. This fundamental distinction is based on the capacity for mental processing: Patients with a tendency towards non-hysterical actual-neurotic somatization exhibit a highly specific, concretist and non-imaginative mindset with a factual overload, termed pensée opératoire (= operative thinking) (Marty, de M’Uzan & David 2017, p. 258; Marty & de M’Uzan 1963). Today, alexithymia is regarded as a risk factor for the development of somatoform disorders, and – unlike the concepts of operative style – has also been operationalized within the scope of validated questionnaires (e.g. the Toronto Alexithymia Scale, TAS-20). So, if we look at the empirical research, the following facts apply: For example, compared to healthy control groups, patients with somatoform disorders exhibited higher alexithymia values, particularly in terms of difficulties identifying feelings (Waller & Scheidt 2004). Research also applies some evidence that patients with somatoform disorders are more alexithymic than those with bodily ailments (Bach & Bach 1998). Neurobiologically, alexithymics exhibit reduced activity in frontal brain structures, when confronted with affect-inducing material (Leweke & Ball 2016). According to Pirlot & Corcos (2012), from a psychoanalytical point of view, an early resistance to overwhelming affects may be the shared denominator of alexithymia and operative thinking. In any case, it can be said that with non-hysterical, actual-neurotic somatization, there is a positive correlation between the inability to process a somatic excitation (= alexithymia, operative thinking) and the tendency towards somatization.

However, the psychosomatic pathways are even more complicated: Pierre Marty (1968) distinguished – within the very plain and solid field of operative thinking – between a regressive, i.e. a reversible and transient somatization, and a progressive somatization which in the worst-case scenario is fatal. Regressive somatization leads to reversible fits in the form of asthma attacks, headaches, backache or hypertension (Stora 2007, p. 38 ff.; Aisenstein & Smadja 2010; Marty, de M’Uzan & David 2017, pp. 260 – 262). Progressive disorganization is already evident in childhood and adolescence as a sporadic and polymorphous symptomatology. Later, this disorganization may be triggered by an external trauma, or an internal traumatic cause. As a result of the initial dissolution of emotional ties, a chain reaction occurs that leads to a decathexis of the psychic life in the form of an ‘essential depression’. This depressive state is characterized by the on-going experience of emptiness without symptoms of sadness. The whole life of such individuals is predominantly operative (without emotions, fact-based: in a broader sense alexithymic) and without self-care. According to this model of somatization, narcisstically painful events such as loss of job, divorce or interpersonal conflicts may trigger a severe somatic crisis, because these (essentially) depressive and alexithymic patients have no resources to cope with these assaults by means of an emotional as well as differentiated cognitive processing. In other words: These vulnerable patients would have no buffer to protect themselves against a disorganizing somatization. As illustrated, one essential difference between the hysterical and non-hysterical somatizations consists in mentalization capacity (Sami-Ali 2006, p. 16). Accordingly, Marty (1968, 2010) distinguishes between patients who are capable or incapable of adequate mentalization. From a semiotic perspective, we can distinguish between a literal somatization (actual-neurotic) and a figurative-performative somatization (psychoneurotic), it being entirely possible for both forms to coexist more or less simultaneously (Sami-Ali 2006, p. 43).

Against the background of these approaches, we propose a model of psychosomatic symptom formation which presents the core idea of the axis of psychosomatic totality. In terms of categorization, we shall distinguish between the different types of conversion defining the symbolic and asymbolic poles of the axis. Principally, we place these considerations in the context of the Lacanian concept that the subject’s world is composed of the Real, Imaginary and Symbolic, and that metonymy and metaphor are among the fundamental operations of the human mind.[3] Thus, we take Lacan’s model as a conceptually strong framework, which provides a creative approach to psychosomatic phenomena. However, within this framework, we would like to trust in our clinical intuition and experience with psychosomatic patients, especially with regard to the technical implications. Using this twin-pair of intuition as well as experience, we are open to technical implications of further psychosomatic theories – against the background of the Lacanian model – in weaving a narrative and incorporating the bodily symptom into the conversation of analysis. Thus, the paper concludes with references to the therapeutic approaches along this axis of psychosomatic totality.

The Axis of Psychosomatic Totality, the Creation of an Imaginary Space, and the Unity of Body and Mind

Sami-Ali’s multidimensional model, which presents the axis with an imaginary and organic pole, serves as the basic figure of the “axis of psychosomatic totality”. In two respects, however, the symptomatology is more complex: 1.) The imaginary pole should be differentiated into the symbolic pole, at which bodily symbols are formed, and the imaginary zone in the centre of the axis. 2.) The relationships at the organic pole should be contemplated in terms of the regressive and progressive somatization. Restricting ourselves first to the scaffolding of the axis, we can say the following: We distinguish between the asymbolic pole I, at which a regressive and reversible somatization occurs, and the asymbolic pole II, with a progressive, potentially lethal somatization. Since an organic lesion actually occurs here (in contrast to the dysfunction at the asymbolic pole I), we describe the asymbolic pole II as “asymbolic organic pole”. A further line should be drawn to the logical pole, which shows hypochondria and sublimation. Figure 1 provides an overview of the “axis of psychosomatic totality”:

Figure 1

The Axis of Psychosomatic Totality

We might imagine that this “axis of psychosomatic totality” rests in an imaginary space surrounded by a real, i.e. non-representable space.[4] Now, the prerequisite for the emergence of such an imaginary space in the baby’s world would be the sufficient presence of the mother (Sami-Ali 1974): Originally, there was without exception the real space between the child and the mother, who affirmed her emotional presence through an empathetic and mirroring relationship (Winnicott 1971, pp. 111–118). Shortly, two – more or less synchronized – operations took place: In the course of these mirroring effects, the space between mother and baby was transformed from the Real (which would be unbearable) to the Imaginary.  Secondly, the baby should have acquired the very precious ability to retain an idea of the mother even when she was absent. Sami-Ali (1974, p. 50) demonstrates this transformation by means of the “fort/da” (“gone/there”) game. Let us now recall Freud’s (1920, p.15) observation of his grandson Ernst Wolfgang’s game with a cotton reel:

“The child had a wooden reel with a piece of string tied round it. It never occurred to him to pull it along the floor behind him, for instance, and play at its being a carriage. What he did was to hold the reel by the string and very skilfully throw it over the edge of his curtained cot, so that it disappeared into it, at the same time uttering his expressive “o-o-o-o” [= “fort”, “gone”].  He then pulled the reel out of the cot again by the string and hailed its reappearance with a joyful “da”’ [= “there”]. This, then, was the complete game—disappearance and return. As a rule one only witnessed its first act, which was repeated untiringly as a game in itself, though there is no doubt that the greater pleasure was attached to the second act.”

According to Freud (1920, p. 16) the game allowed the child to cope with the separation from his mother: The mother goes away, or is sent away. The thread of the reel indicates that a binding relationship exists. The imaginary space is created by the distance – specifically, by the moving or throwing away of the cotton ree (Sami-Ali 1974, p. 50). The crucial point is that the child will project his bodily and emotional experience into this imaginary space. This “proto-self” (cf. Damasio 2011, p. 33 ff.) is composed of experiences of warmth, security, and stability. However, it might also be a primordial congregation of coldness, abandonment, tormenting agitation, pain, and helplessness. It’s the very core of this imaginary space that is situated at the centre of the axis. It’s like a zone of “presence”, in which body and mind form a chimera (cf. Gumbrecht 2004), containing early experiences that can implicitly be reactualized over a lifetime. In this state, there is no defence needed, and there is no conversion of the mental to the bodily. In the centre of the axis we find a point in which container and contained may be in even balance: It is here that the imaginary space is intact, and an equilibrium exists between bodily experience, affects and primordial thoughts.

However, this equilibrium is constantly disturbed by somatic excitation / hyperarousal, i.e. minimal or larger deviations towards the symbolic and the asymbolic poles are constantly occurring. Freud had outlined this tendency in his letters to Fliess (1894b, p. 187). He spoke of “disturbances of equilibrium owing to increased difficulty in discharge” and “attempts at adjustment, limited in their efficiency.” It is clear that the defence at both poles or in the sections between the centre and the poles takes place in the form of a conversion of the sum of excitation into the bodily (Freud 1894a, p. 49), and, in fact, irrespective of whether the situation is traumatic or conflictual (cf. Verhaege & Vanheule 2005): both, traumatic events and neurotic conflicts can lead to an increase in excitation (Verhaeghe 1998). The excitation, which in neurobiological terms is conveyed via the neural-sympathetic or humoral-endocrine stress axis (Roth & Egle 2016), is nothing more than the quantitative portion of the bodily symptom being discharged into the body. By contrast, the qualitative portion exists in its symbolic, psychoneurotic form at the symbolic pole. This qualitative dimension is lacking at the asymbolic poles; the symptoms remain quantitative (Freud 1894a, p. 49). In his letters to Wilhelm Fliess, Freud (1894c, p. 195) had noted that “there is a kind of conversion in anxiety neurosis just as there is in hysteria“ and drew a distinction: „But in hysteria it is psychical excitation that takes a wrong path exclusively into the somatic field, whereas here it is a bodily tension, which cannot enter the psychical field and therefore remains on the bodily path.“ – Accordingly, in his Studies on Hysteria, Freud differentiated between a non-symbolic and symbolic conversion (Speidel 1977). It is the break-in of the real – meaning of the drives and their manifestations in the form of stress, tensions and overwhelming proto-affects – that forces a conversion. Thus, this conversion either takes place in the imaginary at the symbolic pol or asymbolic pole I or it slips away into the real register of the asymbolic pole II in the form of a conversion to disease and death. At this point, we would like to have a break for a moment and summarize: We might say that at the symbolic pole, the subject possesses a high capacity for symbolization (psychoneurosis) owing to an intact imaginary space, whilst at the asymbolic pole I, the capacity for symbolization is limited (actual neurosis) owing to a damaged, only-rudimentarily-developed imaginary space. At the asymbolic (organic) pole II, the imaginary space is empty, laid waste, and no symbolization occurs there. Exactly these circumstances predispose the individual to developing serious bodily disorders. In the following section we will describe the conditions and processes of the different types of conversion.

Conversion at the Symbolic Pole

Towards the symbolic pole, a symbolization of experience is possible, i.e. the excitation, for example anxiety, arising from conflicts will be processed in the form of bodily symbols on the basis of the subject’s mental capacity. However, we should keep in mind: Lacan’s concept of the Symbolic – in the sense of the introduction of structure, i.e. the Other – is very different from Freud’s conservative symbolism (Evans 1996, p. 203). With the concept of the “symbolic pole” we adhere to the Freudian conception – namely, that a latent, conflictual phantasy is represented by a manifest symptom[5]. Lacan (2006, p. 421 ff.) speaks of metaphors along the same lines. Here, we introduce a bodily signifier into Lacan’s system that is structured like a metaphor (or like a Freudian symbol). This theoretical innovation allows that  – to build up a bodily metaphor – the (mental) signifier in the unconscious would be substituted by a bodily signifier, i.e. the bodily symptom. As Figure 1 shows, a repression occurs at the symbolic pole. At the same organ, both the desire itself and the prohibition of the fulfilment of the desire are vividly rendered: Lucy R., the young lady from Scotland, wishes for a relationship with the widowed father, and complains about anosmia, i.e. her frigidity. A double defence takes place: first the repression, then the displacement. As a result of the repression, within the imaginary space, an unconscious sector is formed, i.e. the production of the unconscious occurs, which, as far as the current situation of the subject is concerned, stands for the present unconscious (Sandler & Sandler 1994). We should keep in mind: At the symbolic pole the imaginary space is mainly intact, and because of this spatial integrity, the subject is capable of employing the bodily symptom as a symbol. A bridge to the neurosciences can easily be established: The results of the working group around Vuilleumier (2014) show, that – in the case of hysterical paralysis of the extremities – the activity in prefrontal-limbic sections of the cerebral cortex has an inhibitory effect on the motor cortex. This inhibition causes contralateral paralysis of the extremity in question. Regarding to the symbolic conversion disorder, areas of the brain whose function is associated with the biographical memory (e.g. in the region of the precuneus) are likewise activated, and the motor control appears to be under the influence of internalized relationship experiences.

The corresponding semiotic mechanism had been described by Freud in his Project for a Scientific Psychology (1895b, p. 349 ff), insofar as an unconscious element (B) is replaced by a symbol (A) that is capable of becoming conscious. In order to make this replacement or substitution possible, B and A should have things in common (cf. Moser 2005). A can be not only a thought, an action or a pictorial idea, but also a bodily sensation such as heart twinges or back pain. Moreover, the bodily substitute – by way of a “somatic compliance” (Freud 1905, p. 40) – may be damaged, i.e. a bodily lesion may indeed be present, and it is precisely the injured or damaged nature of the organ which, in the form of a shared feature between symbol and internal situation or field of conflict, qualifies the injured organ as a substitute. To this extent, the “Real” of the body is used as a substitute in the chain of signifiers, and introduced into the imaginary order (cf. Kaltenbeck 2013, p. 107). The semiotic link between symbolized and symbol varies in complexity, i.e. the substitution can either be simple and primitive, with substitute and substituted – in other words, to speak with Freud of the Project, with B and A – being quite similar (someone who takes a tumble has “lost his footing” psychologically, perhaps after a death; someone with a globus sensation must “bite the bullet” or “swallow a bitter pill”). Dovetailing with the primitiveness of these links is the fact that the language develops from the bodily experience, and that corresponding body metaphors, which are based on somatomorphic features, are widespread in the language (Johnson 1987). In the case of Lucy R., the mouth or the vagina, which are among the bodily orifices which can be penetrated, could be replaced by the nose, which is now assailed by paraesthesia (smells) and anaesthesia (analgesia). However, towards the symbolic pole, the substitution becomes increasingly complicated and incomprehensible. There is another, well known and among doctors very notorious aspect, that needs to be mentioned. Miller (1997) emphasises this aspect in this way: “The symptom possesses a meaning to be deciphered, it is belief in the symptom insofar as it is an entity that could speak, an entity animated by a wanting-to-say.“ – Unlike the symptoms at the asymbolic pole, body symbols have a distinctly communicative quality. Embedded in the triad which actually renders symbolization possible, body symbols, as is typical for hysteria, are often to do with encrypted messages and appeals, cries for help, originally directed at the primary objects (Israël 2014, p. 59).  They are part of a staged production whose purpose is to mobilise the environment by drastic means. Unfortunately, the patient’s environment – not least the doctors – reacts to this encrypted message in a dismissive manner, only perceiving the dramatics and not the suffering. In this respect, the environmental reaction forms a part of the hysterical repetition compulsion. Because of the symbolic nature of these symptoms, we propose classifying the corresponding ailment as a symbolic-expressive type of conversion disorder – in contradistinction to the asymbolic-operational type of conversion disorder at the asymbolic pole I. In both cases, the excitation – caused by conflict or trauma – is transformed into symbolic or non-symbolic symptoms (cf. Goetzmann, Siegel, Ruettner, 2019).

Conversion at the Asymbolic Pole I and II

As far as the imaginary space is concerned, we find a completely different situation at  the asymbolic pole I and II. Towards the asymbolic pole I, the imaginary space is damaged. Either it could not be developed at all, or it is pervaded with crypts containing encapsulated affects or cognitive fragments of later traumatic experiences (cf. Abraham & Torok 1994, p. 162 ff). In these splintered sectors no symbolization takes place, and the force of the excitatory hyperactivation affects the bodily organs. The defence consists of a splitting, with the production of splintered crypts. Thus, the imaginary space is only insufficiently formed or traumatically damaged, i.e. it consists solely of approaches, since, owing to the pull of the mental abyss of the unbearable, traumatic absence of early objects, the child was unable to develop such a transitional space in a projective and playful manner. The fabric of the Imaginary is defective; the representations are only embryonically or fragmentarily developed (McDougal 1974). On the other hand, Krystal (1988, p. 227) emphasized that later traumatic states may also affect this space. Either way, patients who become alexithymic owing to early mirroring defects (unbearable absence of the object) or serious traumatic damage (damaging presence of the object) will neither perceive the unity of body and mind, nor symbolize differentiated mental conflicts.

As shown in neurobiological studies, these individuals feel only the physiological portion of the affects, or the physiological impact of their excitation in the form of bodily ailments (cf. de Greck et al. 2013). Thus, the excitation is discharged directly into the body in the form of a regressive, transient somatization. This reversible somatization then manifests itself in changes in bodily functions. Stress-induced hyperalgesia, which is understood as a consequence of early stress experiences, is a typical example of this (Roth & Egle 2016): through activation of the dorsal anterior cingulate cortex (dACC) and the reduced modulatory effect of various neuropeptides such as oxytocin or endogenous opioids, social rejection may cause an intensified pain experience. Distress also appears to trigger proinflammatory processes in the periphery, e.g. in the musculature area. Actual-neurotic excitation (distress) therefore causes an intensified pain experience both at the central nervous level and in the peripheral musculature. Moreover, psychosomatic disorders in the gastrointestinal tract may be a further example of regressive somatization: There are specific affects that influence the motility of the gastrointestinal tract in patients with irritable bowel syndrome (IBS): anxiety and helplessness cause diarrhoea; anger and irritation, constipation (Almy 1951; Welgan et al. 1985, 1988). Unlike the cardiovascular system, the colon has affect-specific reaction types. In addition to the central nervous processing of stress-induced pain, inflammatory and immunological processes also contribute to intestinal hyperalgesia (Cuntz 2014). As far as cardiovascular disorders are concerned, transient hypertension is a common example of regressive somatization (von Känel 2012).

Stora (2007, p. 38) proposes the following stages of regressive somatization (asymbolic pole I): (1) excessive excitation; (2) mild mental disorganization (possibly accompanied by depression); (3) psychical regression (with anxieties, phobias, behavioural changes); (4) Indications of somatic disorganization, with isolated somatic symptoms; (5) Development of a somatic syndrome (e.g. hypertonia, headache); (6) Cessation of the disorganizing impulse and abatement of the somatic syndrome. Because of the non-symbolic nature of the symptoms, we term these ailments “conversion disorder, asymbolic-operational type”, caused by excessive and mostly traumatic distress-excitations and shaped by an operative way of processing.

At the asymbolic (organic) pole II a very special way of conversion takes place whose consequences are catastrophic, since it does not lead to a reversible fluctuation, but there is a progressive somatic disorganization. We proposed to label this psycho-somatic process as “conversion to disease and death”. Again, this transformation in two stages: first, there is a foreclosure of the Psychical. Green (1999, p. 161 ff.) describes this defence as a “negative hallucination”: the imaginary space is devastated over wide areas, and empty. There is a state of “essential depression”. Then, if a psychological wounding occurs in this impoverished area, e.g. a severe narcissistic insult or a separation, a loss that seems to be unbearable, a very risky avalanche is unleashed: the so called “progressive somatization”, with leads to lesions in the organ structure (Marty 1968). At both, the asymbolic poles I and II, the somatization can be understood as a “vertical” metonymy. There is a “top-down” displacement within the chain of signifiers from the (affective, protomental) signifier of excitation to the (physical) signifier of bodily dysfunction or bodily lesion. In terms of the progressive somatisation, Aisenstein & Smadja (2010) speak of a process which becomes derailed through the separation of the life and death drives, i.e. through the supremacy of the death drive. These patients are often in their life very successful. They sacrifice themselves, e.g. as doctors, or run large successful companies. However, they do not perceive their distress until they suffer a heart attack or stroke, e.g. in connection with the loss of a job, a financial failure or a sudden divorce. The following stages of progressive somatization are observable at the asymbolic (organic) pole II (cf. Stora 2007, p. 38): (1) strong accumulation of excitation, with no significant opportunity for mental processing or behavioural discharge; (2) mental disorganization; (3) development of an essential depression; (4) development of diffuse anxieties; (5) outbreak of various atypical ailments (e.g. non-specific signs of a common cold, muscular aches and pains, indisposition); (6) severe progressive disease (e.g. myocardial infarction) potentially leading to death. In a large-scale, well-known study, Felitti and his colleagues (2002) proved that early childhood traumas go hand-in-hand with an increased risk of becoming bodily ill. In psycho-cardiology, it is known that stress states contribute to the development of coronary heart disease or the triggering of a heart attack, e.g. through stress-related reduced fibrinolysis and plaque formation in the coronary arteries (von Känel 2012). Stress cardiomyopathy is particularly impressive, with both emotional and bodily stress considered typical triggers of this psychosomatic disorder (Paur et al. 2012). In psychophysiological terms, this stress causes an activation of the adrenergic hormonal system, with an increased release of stress hormones, the so-called catecholamines (especially adrenaline, noradrenaline and their derivatives). The concentration of catecholamines is many times higher in patients with stress cardiomyopathy (takotsubo cardiomyopathy or broken-heart syndrome) than in healthy individuals, or in patients suffering from acute myocardial infarction (Goldstein et al. 2003). An explanation for this points to the possibility of stress hormones therefore having a surprisingly relaxing effect on the cardiac myocytes in the apical and mid-left ventricle, in order to prevent further stress-related excessive contraction of these muscle fibres, with accompanying cell necrosis (Lyon et al. 2008, Paur et al. 2012)[6]. Atony would therefore function as protection for the heart. From this perspective, stress cardiomyopathy would represent the benchmark preventing further bodily disorganization; on the other hand, it is known that stress cardiomyopathy most definitely has long-term negative somatic consequences, which manifest as reduced bodily and mental quality of life (Goetzmann et al., submitted).

Parallels with Jean Laplanche’s Model of the Psychic Apparatus

Here, we should point out the parallels with the model of Laplanche (2004): According to Laplanche’s general theory of seduction, every child is confronted with a sexual seduction on the part of adults. The seduction is not pathological at the outset – Laplanche speaks of the “fundamental anthropological situation”. Originally, the child itself may have no sexual fantasies; rather, the adult’s unconscious sexuality, watered-down in its manifestations, is conveyed to the child. It is now a matter of the extent to which the child succeeds in translating these enigmatic messages into its own language within its psychical apparatus. At first the message is simply inscribed without being understood, kept under the thin veneer of consciousness. Only at a later point in time is an understanding added to the message in the form of a “translation”. Generally speaking, however, this translation leaves behind remnants, which form the child’s unconscious. In our opinion, it is not only the enigmatic nature of the message, but also the incestuous entanglement triggered by it, which makes its repression additionally necessary. Laplanche distinguishes here between a neurotic and a psychotic or borderline situation. In the neurotic situation, the translation has only partially failed; in the psychotic or borderline situation there is a “complete failure”, i.e. the message remains implanted in a largely unchanged form in the psychical apparatus. The untranslated message leads to a “trapped unconscious” (inconscient enclavé) on the part of the child.

In our model, the enigmatic message can now be processed at both the symbolic and asymbolic poles. The unconscious in which the remnants return as bodily symbols is formed at the symbolic pole. At asymbolic pole I, we find the trapped unconscious in the form of splinters, as affective crypts or enclaves. This applies in particular to superego-like messages from the adult which are implanted in the child with no possibility of their translation into the child’s own mental language. They manifest directly as bodily pain. At the asymbolic pole II, the message is completely rejected, i.e. negatively hallucinated. Laplanche, who is aiming to create a general model of psychological functioning, argues accordingly that the neurotic model has two stages, and that at the first stage the message is not yet translated, but rather inscribed in a “truly subconscious state”. Hence, he argues, there is a remnant of untranslated messages, with the result that neurotic individuals may form bodily symptoms at the asymbolic pole I or may become seriously bodily ill at the asymbolic pole II, whilst on the other hand, even individuals with early-onset borderline or psychotic impairment are capable of a certain translation of enigmatic messages whose remnants are shunted into the unconscious.

Aspects of the treatment technique

Below, we present a number of techniques suitable for initiating creative and healing processes in psychosomatic patients. As will be suggested, various therapeutic interventions are possible which, according to the situation and subject, can be used intuitively and flexibly, especially since the semiotic quality of bodily symptoms may change not only over the course of a treatment, but also during the session, or since, in the matter of semiotics, different bodily symptoms may occur simultaneously. In this respect, as regards the individual patients, we might speak not only of an axis, but of a circle or spiral of psychosomatic totality.

The Jump into the Imaginary

Somatic symptoms lying on the imaginary section of the axis are especially easy to incorporate in the psychoanalytic process. One senses that the symptom or bodily experience is alive, and that it gives the impression of something present and of the present. One option is to adopt an open, impartial attitude, and, as it were, to leave aside all expectations, theories and concepts in order to plunge into the symptom. i.e. to surrender to a bodily-empathic identification. We have compared this therapeutic attitude with epoché, an impartial phenomenological access to the patient’s experience (Ruettner, Siegel, Goetzmann, 2015). This epoché prepares the “jump into the Imaginary”, namely, a plunging into or entering into the early unconscious life of the patient. To this extent, the bodily symptom can be understood as a gateway, entrance or path leading into the early imaginary experience. This jump enables the sensory experience of a cold felt in the bones: interpersonal and bodily coldness are identical. It can take place in the patient himself, e.g. under the analyst’s supervision. Alternatively, with the help of his bodily empathy, the analyst goes ahead, thereby achieving genuine insights into the patient’s experience. Thus, the analyst becomes a container that absorbs the psycho-somatic experience of the patient through a process of identification.

At a stroke, however, this dwelling in the Imaginary in the cold of the bones, in the noise of the tinnitus, etc. will be disturbed: A sort of “flip” takes place, an aporia of the sensations, or in any case a change that could be explained by a touch with the underlying Real: the cold in the bones or the noise of the tinnitus become intolerable. The perception of these sensory qualities becomes brittle, loses its richness. This shock, or in any case this irritation validates the imaginary experience of the analyst, it is as if the Real were “responding”. This response of the Real that is touched is twofold, consisting of a validation and boycott of the identification with the imaginary chimere. At this point, symbolization begins: the pondering, structuring, putting into words, i.e. the Unspeakable is transformed into a symbolic reality. One could say that the body feeling or symptom is like a “surface abyss” (cf. Baudrillard 2012, p. 59):  the symptom as a surface that opens up an abyss: the unbridgeable, real space between mother and child. The value of this bodily empathic identification, which takes place in the imaginary space of the early body-self, lies in the fact that this touch with the Real lends the imaginary experience credibility, authenticity, in short, the intensity of an experience, which charge the further words – those spoken by the analyst – with sensory melody, and determine their emotional timbre. It is only from this authenticity-laden point onwards that the further laying of trails of understanding, guessing and associative exploration becomes legitimate, creative and fruitful.

Interpreting at the Symbolic Pole

At the symbolic pole we refer to Freud’s substitution theory: the somatic symptom relates to a latent situation. Atmospherically, one feels the aura of the preconscious-meaningful, the significant, but also the symbolic and expressive nature of the body symbol. The symptom encourages us to develop ideas and fantasies about this latent situation. With these “neurotic conversion” symptoms in the original sense of the term, it is appropriate to explore and frame in words the latent conflictual situation, composed of desire, prohibition and defence, which chose the bodily disorders as a means of expression. The first steps towards an interpretive understanding of the conflicts underlying the somatic symptomatology allow us to intuitively feel our way towards this field of conflict, towards the patient’s inner situation: it is a conjectural, speculative guessing that attempts to follow the trail of displacements and substitutions (cf. Vassalli 2001), the transference and further material stemming from dreams and associations. At this point, symbolization begins: the pondering, structuring, putting into words. Considering the defence, it makes sense to first of all establish contact with the internal situation, i.e. with the patient’s field of conflict – to put this into words, and perhaps only then, over the course of the process, to suggest, or work out with the patient, the meaning for the body symbol.

As Meltzer (1995, pp. 163–168) suggests with respect to the analysis of dreams, the clarification and analysis of body symbols can also be a sort of game – in any case, it is not a “systematic exploration”, but rather a spiralling discourse until an interpretive fabric is created in which the body symbol is embedded. In the case of body symbols, bodily empathic identification with the symptom, i.e. the attempted jump into the Imaginary, will tend to follow a wrong track that deviates from the field of conflict. Here, it is especially important for the interactive, communicative aspect of the body symbology to be included in the transference: The desperate search for support (e.g. in the case of gait disorders), the longing for primary care (stomach pain) or the reference to intrusion anxieties (pains) should be included in the interpretation of transference. When treating conversion disorders of the symbolic-expressive type, it is therefore important to perceive both the substitutional nature of the bodily symptoms – i.e. the hidden conflict, the latent, veiled topic – as well as the “outrageous message” (Israël, 2014) that the patient sends out in order to receive help, unable to express this other than through the impact of his performative body language.

Baby Talk and Mirroring at the Asymbolic Pole I + II

The bodily symptoms at the asymbolic pole I are impervious to both the Imaginary and the Symbolic. They appear lifeless, impersonal, and in no way encourage us to ascribe a particular significance to them. They lack the aura of meaningfulness; the patient worries about his bodily health, desires an ideally quick and comprehensive reduction in symptoms. In the countertransference, the analyst feels something vague stirrings to action, or an emptiness that is typical of alexithymic patients (Marty and de M’Uzan 1963). Jacques Press (2016) interprets Marty’s clinical concept, especially as regards the emptiness of the inner life, as a defence against a countertransference shock. Somatizing patients at the asymbolic pole I confront us with our own areas of inability to mentalize, i.e. with the limits to the own transformative capacity. Green (2010, p. 18) reminds us that we must take an interest in the strenuous phenomenon of emptiness when working with these patients who have devoted themselves to a vie opératoire, since their inner space consists of this emptiness with an overcrowding of the factual. According to Aisemberg (2010, p. 114), a flexible setting should first of all be configured for patients with these somatizations, and only with time a classic setting would be possible with the further unfolding of transference, dreams, oedipal themes, and infantile sexuality. Especially for bodily ill patients (at the asymbolic Pole II) seeking psychoanalytic help, Aisenstein & Smadja (2010) recommend a modification both of the setting and the interpretive technique: face-to-face sessions, which make it easier to delve into the affective state of the patient. Basically, the same technical rules apply for patients at the asymbolic pole I as for patients at the asymbolic pole II; it should be borne in mind, however, that the latter patients have been confronted with the catastrophe of a progressive disorganization, including confrontation with their mortality. This “break-in of the Real” should be taken into account meticulously and empathetically in the treatment. Being embedded in the intersubjective relationship, however, it is essential that both patient groups learn to get in touch with their emotions. Krystal (1988, p. 331) points out the immense significance of a sensitively adjusted, mirroring attunement. Early interaction patterns of the patients should be transformed in terms of a “restorative tuning”. With the allowing of emotions, their naming, and the understanding of which situations these emotions arise in, an inner affective and mental world develops with time, and thus a greater affect tolerance, as well as the ability to empathize with other people. The primordial mode of baby talk, which is close and comforting for the patients, as well as the affective attunement of the analyst, constitute the first steps into the patient’s own affective world. In our experience, as part of this sensitive adjustment, it helps the patient to invent a common language, to palpate words, to find images that match archaic bodily feelings. Often, a narrative is contained in a gesture (e.g. in a “throwaway gesture”) or a sigh. The language should then cling to the feeling: from this type of onomatopoeia, something that is more involved in syntax, in formulated words, is then able to develop. The allowing of emotions should be gradually encouraged: the patients should be able to understand that their emotions are signals for inner, unperceived conflicts, demands or injuries (Krystal 1988, p. 318 ff.). One should not, however, lose sight of the fact that these somatizing patients perceive chiefly the physiological part of their emotions, which are experienced as threatening. Aisenstein & Smadja (2010) recommend restraint in the use of classic interpretations, proposing instead the cultivation of an “art of conversation”. This procedure means interesting the patients in the type of psychoanalytic thinking, and involving them in the process of that thinking. Long periods of silence should be avoided. Plassmann (2008, p. 113 ff.) speaks here of the “practice of process interpretation” with the understanding of a temporal sequence of the (inner) biography, e.g. based on photographs viewed together, a development of the patients’ own symbolic language, and the interpretation of their own disorder, and indeed their autobiography. Everything should be done to support and stimulate the preconscious work, and to help the patients discover and share the pleasure of constructing emotional experiences in the discourse (Aisenstein & Smadja 2010).

The axis as sinthomal

For Lacan, in the initial stages of his theory development, the symptom was a “completely decipherable message”. Then followed his discovery that the symptom contains a sort of “enjoyment” (jouissance in French) which binds the subject to his symptom. In his “Television” lecture, Lacan spoke of “jouis-sens”, i.e. of an equivalence between enjoyment and signifier – thereby qualifying the entire theory of signifiers (Turnheim 2009, p. 58). In his late seminar, “The Sinthome”, Lacan (2005) no longer speaks of the “symptom”, but draws on “sinthome”, an earlier etymological variant. The sinthome does not contain a decipherable message. Its job is to hold together the three rings of the Borromean knot, especially since these rings were originally unconnected, and traumatic experiences can loosen the cohesion of a psychological reality which develops in the dimensions of the Real, the Symbolic and the Imaginary. The rings – to stick with this metaphor – are carelessly or wrongly knotted (Turnheim 2009, p. 56). Where such a fundamental mistake, i.e. a traumatic vulnerability exists, the sinthome generates a force that holds the three rings of the Real, the Symbolic and the Imaginary together in a makeshift fashion. Of course, the bodily sinthome is primarily imaginary by affecting the body image. Its core, however, is real, optional having a strong metaphorical component at the symbolic pole. Nevertheless, its very function is to hold together the world of the subject. It is as a sort of repairing ring for counteracting a somato-psychic disorganization governed by the death drive. Should this fourth ring become a vital necessity, it is used as a fetish, in the manner in which Winnicott speaks of the fetishization of the indispensable transitional object. In this sense, the fetishized or – in a broader sense – bolted sinthome holds together the three rings that would otherwise be lost as individual threads in the Borromean matrix and either plunge the matrix into a psychotic abyss, or lead to bodily death. If, however, the fourth ring can be used freely – i.e. to maintain a somato-psychic equilibrium, we would speak of a breathing sinthome, which can be established instead in the centre of the axis.

Lacan (2005) had found the idea of the sinthome while reading Finnegans Wake. What is striking about this final opus, which Joyce worked on for over 10 years, up to his death, is its incomprehensibility; at first glance, the novel is reckoned to be virtually unreadable. According to Lacan, the sinthome lay here in the enjoyment of the linguistic-artistic composition, in the use of a meaning-free vocabulary, without it mattering whether the readership understood the – incidentally – sonorous, rhythmic, and extremely musical text. In other words, in Finnegans Wake, the symptom does away with the symbol (Turnheim 2009, p. 62). Lacan traces the necessity of the fourth ring, i.e. of the literary work as sinthome, back to a fundamental error, namely, the unreliable father’s absence in his function of assisting Joyce’s psychological development. Art is necessary to prevent the mental framework, i.e. the three Borromean rings, from coming apart; art replaces the Name-of-the-Father (cf. Turnheim 2009, p. 61). This viewpoint is only partially justified: Finnegans Wake is a text that is charged with meaning. Joyce employs various stylistic techniques, e.g. exchanging one letter for another (“load” for “lord”) or phonetically translating English words into foreign words (“over and over” into “Ufer und Ufer” (“shore and shore” in English) in order both to shroud the text in mystery and deepen its meaning (Reichert 1970, p. 10 ff). In short, Finnegans Wake is charged through and through with meaning, but the meaning is not the most important thing. What is crucial is its function as a repair ring. From a sinthomal perspective, the protective function of the sinthome is important: it is, for example, the fixed point at the asymbolic pole I and II (cf. Marty 1968) which saves the Borromean matrix from disorganizing break-up, or the corporeal phantasm of a psychoneurotic symptom at the symbolic pole that defuses the explosive force of an excessive excitation.

To this extent, a bolted sinthome can be both symbolic and asymbolic in nature. The more intense the traumatic excitation, the more necessary the fourth ring becomes in the sense of an indispensable fetish. With Joyce, it is conceivable that not only art, but also a part of his somatic symptoms served as a fixed point for preventing a somato-psychic disorganization, and that the luetic affections both formed part of the Threatening-Real and qualified as places where strong excitations were discharged.[7] Joyce would then have created sinthomal symptoms in both his body and his art in order to prevent the progression of disorganization. To this extent, it is not a question of whether the sinthome has a meaning, but rather of the explosive power of the subjective excessiveness being defused, i.e. of the actual-neurotic, excessive, traumatic core being contained in a symptom. Sinthomal bodily symptoms are fixed points at the asymbolic poles (cf. Marty 1968) which save the Borromean world from disintegration, or psychoneurotic phantasms at the symbolic pole which succeed at least partially in defusing the explosive power of an excessive excitation. – From the point of the sinthome, the creation of a symbolic and asymbolic symptom always leads to a special, radicalized type of consolidation. Thus, the “metonymy of desire” is interrupted, stuck or trapped in the bodily symptom, because the subject is too afraid of the more or less free unfolding of their mental activity within the chain of signifiers. If the subject were no longer able to build up a sinthomal symptom, their world would break apart: Then, the coherence of the Borromean knot would dissipate. Through the analyst’s linguistic intervention, there are basically two opposing movements induced: first, the analyst recognizes the consolidation, that is caused by the symptom. Ultimately, the symptom is recognized in its function as sinthome. It is a bodily lifebelt. Secondly, the analyst’s intervention initiates an act of dismantling by breaking down the symptom into its real core and its potential, symbolic or asymbolic dimension of meaning. As a result of this decomposition, the symptom can be inserted into the mental chain of signifiers, and the “horizontal” metonymy of desire is enabled to work again. Through the double step of recognition and dismantling we get a breathing bodily sinthome. It may emerge and disappear (“breathe”), becoming a living, fluid component of the further analytic cure.

Thus, there are three forms of sinthome: the bolted sinthome, the white sinthome and the breathing sinthome. The bolted sinthome manifests itself in bodily ailments, ideas, or repetitive actions; it is essential, i.e. the subject must cling to the bolted sinthome in order to survive. The white sinthome is essential depression, nothingness (cf. Marty 1969). The breathing sinthome originates in the zone of the Imaginary. It is essential for creating a psychosomatic balance: it would be unpleasant, certainly, but not life-threatening, if the subject were to abandon the breathing sinthome. If the threatening quality of the excitation abates, the sinthome can, so to speak, breathe easier. It becomes flexible, allowing for its interpretation at the symbolic pole, and its transfer into a world of symbols at the asymbolic pole. If the imaginary space is intact, i.e. if the requirements for an equilibrium between bodily experience, affect and thoughts are fulfilled, this ideal equilibrium might be disturbed in any person by somatic excitation / hyperarousal: in other words, deviations towards the symbolic as well as towards the asymbolic pole occur constantly. From this perspective, a sinthomal solution, e.g. in the form of a bodily symptom, is always necessary. We need the sinthomal repair rings on account of the constant interaction between traumatic fundamental error and actual-neurotic excitation. Consequently, the end of a psychoanalytic treatment, according to Lacan, lies in the identifying recognition of the sinthome, i.e. in the subject being able to freely deal with the – in this sense – “breathing” sinthome (cf. Verhaege & Declerq 2002, p. 65). The sinthome is allowed to exist, but should nonetheless contain the option of transformation in the world of the alpha elements, in the form of a breathing ring –  whether this is originally actual-neurotic or psychoneurotic in nature – and based (more or less) in the centre of the axis of psychosomatic totality.

Acknowledgement: We thank Sanjeev Balakrishnan, London, for the constructive and valuable feedback on the first versions of our work.