The Body Speaks: Body Image Delusions and Hypochondria

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This book explores David Rosenfeld's pioneering work with severely disturbed patients, to show what it means to work and think as a psychoanalyst about transference and the internal world of a psychotic patient, with all the difficulties involved in continuing to treat and engage with even severely ill patients. As Rosenfeld suggests, to be a psychoanalyst is to think about transference, the patient's internal world and projective identifications onto the therapist and onto persons in the external world.In particular, the author examines patients who express their mental state through fantasies about their body image. For example, the fantasy of an emptying of the self is discussed through the case of the patient Pierre, who asserts that he has no more blood or liquids in his body. Similarly, the fantasies of a young man who says that bats are flying out of his cheeks incarnate the anxiety of his first months of life expressed through his body. Indeed, Rosenfeld's particular focus is on the importance of the first months and years in the life of these patients. For the treatment of severely disturbed patients he maintains that it is both useful and necessary to supervise these clinical cases, since psychoanalysts are only human beings who may receive powerful projections on a psychotic level from these patients. Rosenfeld persuasively suggests that psychoanalysts can only write papers about countertransference once they have been able to put into words and decode what the patient has inoculated with these projections. Without this, the psychoanalyst can become ensnared in powerful projections and unable to decode what the patients oblige them to "feel" happened to them at a time when they had no language to express it in words. The book is the result of many years of experience studying and supervising in Paris, London, and America.

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Chapter One: Body Image Models and Theories

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

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

 

CHAPTER ONE Body image models and theories

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CHAPTER ONE

Body image models and theories

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n psychoanalytic practice one may sometimes find examples like those I present, and that is why the primitive psychotic body image is a useful explanatory model for a variety of clinical cases. There may be different explanatory models, but for the time being I find the primitive psychotic body scheme the most useful and comprehensive, in so far as it is perfectly suited to many of the clinical phenomena I observe.

It helps me to incorporate into a single model developmental genetic and transference concepts, both with schizophrenic and with psychosomatic patients. When we construct a model, we find it useful first for one particular patient but then often for other patients as well. To this we might add, provided it is consistent, a developmental genetic theory of infantile bonds that must be empirically demonstrated in the transference with the psychoanalyst.

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

 

CHAPTER TWO Pierre

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CHAPTER TWO

Pierre

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he following fragments of clinical material pertain to

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

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

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

 

Chapter Two: Pierre

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

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

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

 

Chapter Three: Philippe and Countertransference

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

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

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

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

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

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

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

 

CHAPTER THREE Philippe and countertransference

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CHAPTER THREE

Philippe and countertransference

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

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

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

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

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

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

 

Chapter Four: Katherine: Body Image Transformations

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I received a female patient, age thirty, tall, thin, with a sad facial expression. She told me that she had had a car accident months ago when she was on a business trip. She was not the driver; it was a company employee. The accident was the fault of a truck that crossed in front of them. The collision was terrible, on a lonely road in the north of Argentina. Luckily a farmer appeared just when the accident occurred, and told her not to move, not to move her neck or back, that they would get her out on a stretcher. When the ambulance arrived, they rescued her and at the hospital diagnosed the fracture of cervical vertebrae, especially C1. It was only a few millimeters away from entering her brain, which would have provoked respiratory paralysis within the brain stem.

The patient spoke of how lucky she had been to encounter the farmer who had treated her so well and had kept her from moving until the ambulance arrived. She said that she is recovering after long months of being in bed with apparatuses on her back.

 

CHAPTER FOUR Katherine: body image transformations

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CHAPTER FOUR

Katherine: body image transformations

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received a female patient, age thirty, tall, thin, with a sad facial expression. She told me that she had had a car accident months ago when she was on a business trip. She was not the driver; it was a company employee. The accident was the fault of a truck that crossed in front of them. The collision was terrible, on a lonely road in the north of Argentina. Luckily a farmer appeared just when the accident occurred, and told her not to move, not to move her neck or back, that they would get her out on a stretcher. When the ambulance arrived, they rescued her and at the hospital diagnosed the fracture of cervical vertebrae, especially C1. It was only a few millimeters away from entering her brain, which would have provoked respiratory paralysis within the brain stem.

The patient spoke of how lucky she had been to encounter the farmer who had treated her so well and had kept her from moving until the ambulance arrived. She said that she is recovering after long months of being in bed with apparatuses on her back.

 

Chapter Five: The Boy who Said that Bats were Flying out of his Cheeks

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I interviewed patients at the Milwaukee, Wisconsin Children's Hospital. One of these cases was a young man about twenty years old who hallucinated that bats flew out of his cheeks. His lower limbs were also paralysed and he said he had cancer.

In the interview I was accompanied by neurosurgery and psychopathology teams. When I asked the patient about his family, he said he has a little daughter of one year old. He also told me that when he was small, a year after his birth, his mother died.

When I asked him why he is in the hospital, he answered that it must be because of the bats that fly out of his cheeks and the cancer that paralyses his feet.

Later, I asked him what his mother died of, and he answered that she died of lupus. I asked him if he knows what this illness is like and what it causes on the face and cheeks of people who have it. He said he does, that it causes marks on the face, and on the body, lesions.

A colleague asked him how he was able to get through his mother's absence, and he answered that he is very religious. They asked him if he knew where his dead mother might be, and he answered that she is in Heaven.

 

CHAPTER FIVE The boy who said that bats were flying out of his cheeks

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CHAPTER FIVE

The boy who said that bats were flying out of his cheeks

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interviewed patients at the Milwaukee, Wisconsin

Children’s Hospital. One of these cases was a young man about twenty years old who hallucinated that bats flew out of his cheeks. His lower limbs were also paralysed and he said he had cancer.

In the interview I was accompanied by neurosurgery and psychopathology teams. When I asked the patient about his family, he said he has a little daughter of one year old. He also told me that when he was small, a year after his birth, his mother died.

When I asked him why he is in the hospital, he answered that it must be because of the bats that fly out of his cheeks and the cancer that paralyses his feet.

Later, I asked him what his mother died of, and he answered that she died of lupus. I asked him if he knows what this illness is like and what it causes on the face and cheeks of people who have it. He said he does, that it causes marks on the face, and on the body, lesions.

 

CHAPTER SIX Inés: bleeding lips and tongue when separation occurs

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CHAPTER SIX

Inés: bleeding lips and tongue when separation occurs

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his patient’s psychosomatic clinical picture exemplifies

Winnicott’s hypothesis of undifferentiation or total nonseparation between the baby’s lips and the breast, in the sense that each separation or withdrawal of the mother, in this case the therapist who is going away on vacation, causes her to react with her body as if when the breast goes away, it would tear off part of her lips and tongue.

This is body language, without words, in which bleeding wounds are produced in her lips, tongue, and the mucous membrane of the palate. The baby’s sensitivity to separations is described in this way by Winnicott (1971). This was also elaborated by F. Tustin in her works with autistic children and the way they experience separations (1986).

To understand better the great sensibility of this patient

Inés each time she lost contact with her analyst, we can look to

Winnicott to express better what happens to the infantile part of the patient. Winnicott (1971) described the child’s possible responses to his mother’s absence while she is away, suggesting that for the child or the baby the mother is dead. From the point of view of the child, this is what dead means. It is a matter of days or hours or minutes. Before the limit is reached the mother is still alive; after this limit is overstepped she is dead.

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Chapter Six: Inés: Bleeding Lips and Tongue when Separation Occurs

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This patient's psychosomatic clinical picture exemplifies Winnicott's hypothesis of undifferentiation or total non-separation between the baby's lips and the breast, in the sense that each separation or withdrawal of the mother, in this case the therapist who is going away on vacation, causes her to react with her body as if when the breast goes away, it would tear off part of her lips and tongue.

This is body language, without words, in which bleeding wounds are produced in her lips, tongue, and the mucous membrane of the palate. The baby's sensitivity to separations is described in this way by Winnicott (1971). This was also elaborated by F. Tustin in her works with autistic children and the way they experience separations (1986).

To understand better the great sensibility of this patient Inés each time she lost contact with her analyst, we can look to Winnicott to express better what happens to the infantile part of the patient. Winnicott (1971) described the child's possible responses to his mother's absence while she is away, suggesting that for the child or the baby the mother is dead. From the point of view of the child, this is what dead means. It is a matter of days or hours or minutes. Before the limit is reached the mother is still alive; after this limit is overstepped she is dead. In between is a precious moment of anger but this is quickly lost or perhaps never experienced, always potential and carrying fear of violence.

 

Chapter Seven: Somatic Delusion: Hugo and Pablo

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Somatic delusion mechanisms

Part 1: Hugo and the white skin

Carlos Trosman and David Rosenfeld

Early in 2013, Carlos Trosman received Hugo, a patient who later continued in psychoanalytic treatment with him. This young man of twenty-four told him about his anxiety crises. For fear of being rejected by people because of white blotches on his skin, diagnosed as vitiligo, he isolated himself, was ashamed, put on a hat and dark glasses when he went out, applied creams to his face and hands to hide the blotches, and abandoned his university studies. He isolated himself because he was afraid that everyone would reject him because of his blotches.

He applied more and more creams to his face and hands to hide the blotches. He also transferred to a different university to be with different classmates, thinking that he would be able to adapt better. During our supervisions, Dr Trosman and I tried to understand the triggering factors of his anxiety crises. We observed features similar to those found in our experience both by Dr Trosman and Dr Rosenfeld in other vitiligo patients.

 

CHAPTER SEVEN Somatic delusion: Hugo and Pablo

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CHAPTER SEVEN

Somatic delusion: Hugo and Pablo

Somatic delusion mechanisms

1. The process begins with what we could call classic hypochondria, the patient expelling part of his ties with his internal world onto an external object.

2. There is a second reprojection with a special ego destructuring quality. Now the somatic delusion develops as an effort to endow the self with meaning and organisation.

3. There may be a second reintrojection: the delusion is reintrojected, and there is a marked increase of paranoia.

4. The patient may also try to project his delusion onto the analyst and thus establish a delusional or psychotic transference (Rosenfeld, D., 1992).

Part 1: Hugo and the white skin

Carlos Trosman and David Rosenfeld

Early in 2013, Carlos Trosman received Hugo, a patient who later continued in psychoanalytic treatment with him. This young man of twenty-four told him about his anxiety crises.

For fear of being rejected by people because of white blotches

 

Chapter Eight: Luis: Half of his Body and Brain are Missing—In Collaboration with Teresita Milán

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The patient is a drug addict with pathological mourning in which fantasies that half of his body and brain disappear.

Interview by David Rosenfeld

I interviewed a patient twenty-four years old that I had supervised for several years. His family asked for an interview with me while I was in a medical congress.

The first comment from the patient's mother was that her son, Luis, had been consuming cocaine for the last four years.

When Luis came in, I observed that he looks blankly into space. He looked at some pictures in my colleague Lila Gòmez's office in Mendoza. I called out to him, asking if he would like to chat with me or with the psychotherapist who was seeing him before. I said to him that maybe there are things he can tell me or her that he wouldn't dare tell his mamma.

While I was talking to him, he continued to have a blank expression, looking out of the window. At one point, he interrupted me and, pointing with his finger, asked me where the Aconcagua is. Afterwards, he said that he got disoriented.

 

CHAPTER EIGHT Luis: half of his body and brain are missing—in collaboration with Teresita Milán

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CHAPTER EIGHT

Luis: half of his body and brain are missing—in collaboration with

Teresita Milán

T

he patient is a drug addict with pathological mourning in which fantasies that half of his body and brain disappear.

Interview by David Rosenfeld

I interviewed a patient twenty-four years old that I had supervised for several years. His family asked for an interview with me while I was in a medical congress.

The first comment from the patient’s mother was that her son, Luis, had been consuming cocaine for the last four years.

When Luis came in, I observed that he looks blankly into space. He looked at some pictures in my colleague Lila Gòmez’s office in Mendoza. I called out to him, asking if he would like to chat with me or with the psychotherapist who was seeing him before. I said to him that maybe there are things he can tell me or her that he wouldn’t dare tell his mamma.

While I was talking to him, he continued to have a blank expression, looking out of the window. At one point, he interrupted me and, pointing with his finger, asked me where the

 

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