A Critical Enquiry into the Psychoanalytic Theories and Approaches to Psychosomatic Conditions

This panel consisted of three contributions from Marilia Aisenstein, Elsa Rappoport de Aisemberg and Philip Muskin with the discussion by Gustavo Delgado-Aparicio. The Chair, Betty Denzler, and the audience had a challenging task to integrate the complex presentations and the discussion to create a balanced view of modern psychoanalytic approaches to psychosomatic conditions that could be the basis of a critical enquiry.

Dr Aisenstein discussed her theoretical position and illustrated her views by reference to two clinical cases, the second read by her colleague Marina Papageorgiou. Both of these clinical vignettes focused on the patients’ dreams, which threw some light on symbolic aspects of the patients’ psychosomatic symptoms. Dr Aisenstein's view is that psychosomatic medicine cannot be regarded as a rather distant branch of psychoanalysis but is an integral part of it. She bases this on Freud's definition of the instinctual drives as the psychic expression of somatic excitation. Although Freud laid the foundations for the psychosomatic approach, he did not explicitly deal with psychosomatic medicine as a psychoanalytic approach to somatic diseases.

She referred to Freud's idea that thought first emerged at the sight of a dead body, both loved and hated. In the discussion Dr Delgado-Aparicio linked this to Bion's words, ‘Where there is no breast a thought can emerge and a creation starts’, emphasising that loss is the beginning of thought and the capacity to differentiate the self and the object. For a patient with psychosomatic symptoms, the problem is that the thought has been split off to appear as the bodily symptom, which Dr Rappoport concludes is a defensive regression to cope with psychic pain, the individual returning to the somatic code of infancy. Dr Aisenstein pointed out the difficulty of patients suffering from physical illness who show very little or no psychic elaboration with an apparent absence of conflict, although this is not entirely true of he