Some Observations on the Psychopathology of Hypochondriacal States1

Hypochondriacal states have always been a puzzling problem, both to psychiatrists and psycho-analysts. They are found in the neuroses and psychoses, as in hysteria, obsessional neurosis, in depressive and neurasthenic conditions, in schizophrenia, and also in the initial states of organic psychosis. They are common in adolescence and in middle age. While some hypochondriacal states are of short duration, others are very chronic and are considered to have a bad prognosis.

It is interesting to note that whilst hypochondriacal anxieties appear to be a frequent symptom in psycho-analytic patients in analysis, there is relatively little psycho-analytic literature on the subject. Freud, in 1911 and 1914, discussed hypochondriasis as a narcissistic condition intimately related to paranoia. He described hypochondriacal anxiety emanating from the ego libido as the counterpart of neurotic anxiety (which he connected with object libido). Schilder stressed the conversion of mental conflicts into physical ones by means of projection from the mental sphere into the body and body organs. He emphasized that hypochondriasis had an unconscious meaning and was not an 'actual' neurosis. Melanie Klein has opened up our understanding of both narcissism and hypochondriasis by her research on internal objects. She has always emphasized the concreteness of the unconscious phantasies of the infant and has shown that the infant relates his physical sensations to objects. For example, physical pain may be experienced by the infant in unconscious phantasy as an attack by a bad internal mother or breast. She has related the hypochondriacal anxieties of the adult to early experiences of the infant, where persecutory attacks, first of all by part objects, are felt to be concretely going on within the body.

In trying to formulate my own views on hypochondriasis, I find myself in agreement with both Freud's and Melanie Klein's view that in hypochondriacal states there is always some regress