I've just finished reading the charmingly written It's All in Your Head: True Stories of Imaginary Illness by Suzanne O'Sullivan. This popular medical work offers anecdote ensconced in clinical experience, rather than the phenomenologically thin, watered-down sciencey stuff one gets in the popular psychology literature, and in my opinion is much the better for this. The result is we get a clear sense of or feel for how O'Sullivan understands various hysterical/psychosomatic/somatising/neurasthenic/conversion/functional disorders and conditions and, to the extent that we are right to trust her expertise, a clear sense too of the living character of that which she describes.

What the book acknowledges it does not try to do is to theorise the conditions it engagingly brings to life. Some cursory suggestions are made regarding causation and maintenance (hypochondriacal somatosensory hyper-vigilance; secondary gains from attention others give the afflicted), but these are clearly far removed from the existential core of the conditions themselves. (They remind me of those theorisations of mental health problems that CBT theorists often provide: accounts which skirt over the surface of the phenomena, relying only on such meagre and point-missing entries to an understanding of human existence as are offered up by experimental psychology, to give us their breezily unphenomenological vicious cycles and other such boxological pathways.) And this existential core is, as O'Sullivan herself acknowledges, a psychodynamic core: that is, it has to do with issues of the intolerability of powerfully painful emotional experience. 

So, somehow these intolerable emotions inappropriately 'end up in the body', or perhaps are somehow 'converted' from a psychic to a physical form. What I want to consider here, though, is the question of how to theorise such somatisation. What is implicit in the very idea of somatisation, and what is conceptually unimpeachable because paradigmatic in this and what instead is misarticulated gloss, is what I would like to sort out.

Consider first the fact that psychological disturbances including psychosomatic disturbances will  involve a range of neurological, immunological, endocrine etc. alterations. At the least it is hard to imagine a psychological change not being 'realised' in neurological change of some sort. And given that we may be dealing with conditions which are entrenched and long lasting, it is surely also likely that changes in function may also change the form of the organism's physiology. 

It may be tempting to suppose that the eschewal of dualism, and perhaps the embracing of a form of physicalism such as functionalism, is enough to solve the issue of how to theorise psychosomatic disturbance. I believe however that this would be a massive and rather lazy mistake. It helps us not at all to grasp the distinct being of a psychosomatic disturbance. To suppose thus is to act like those breezy theories that eschew an attempt to really understand anything by offering us a 'biopsychosocial' 'model' of the phenomenon under investigation: here we have all surfaces collated together and no eidos whatsoever.

'Conversion', then, remains a mystery. What does it mean to talk of the 'conversion' of emotional distress into an experience of physical disability? And how could that even happen?

It seems to me that, as with theorisations of the unconscious in general, we do much better to avoid imagining that someone for whom a certain emotional experience is intolerable is someone who is now having that experience yet, somehow, unconsciously. The person does not avow such emotions, and they do not even show straightforwardly in their behaviour (that, after all, is the force of the idea that they have been converted into physical symptoms). What we have, instead, is a theory of unconscious emotion that could be cobbled together out of, say, observations of the presence of traumata which one would at least expect to have had a lasting emotional impact, the activation of brain centres associated with emotional experience, and the otherwise inexplicable illness experience itself.  

If you are more satisfied by inference-to-the-best-explantion type explications in the philosophy of psychology then perhaps this little collection will do for you. For me however it helps not at all: I want ontological elucidation of what is distinctive about the being of the phenomena, not generic schema of causal explanation applied to individually assayable symptoms. I want to know about the being of that to which inference is being made - if it is even being made; after all, without such an elucidation I wouldn't even be able to understand what the force of the explanation is (aside from a vague appeal to a merely general idea of 'causation'). So, without beating about the bush I now present my own theorisation.

The first point I want to make is that the hysteric is perhaps best described as suffering not from unconscious emotion (which is a concept apt to confuse us - which is yet not to say that it can't be put to good uses) but from an inability to tolerate emotion as such. The emotion is neither born nor borne: there is here just not enough ego capacity yet. A metaphor may help: In the normal human way of things the river of experience that comes from a particular encounter or realisation would flow through an open emotional channel, but for some people this channel is greatly constricted. The river is then diverted into subsidiary channels - those for the experience not of emotion but for physical illness.

The second point concerns the inverse correlativity of bodily and emotional experience. This will take a while to spell out... When emotional what I am understanding in my emotion is my encounter, my situation, what I have lost, how you have slighted me, etc. There are a massive range of physiological changes in the body (tears, heat, heaving,  tensing, increased blood pressure, hormonal and endocrine changes, etc.), but when I am really 'in touch with' my feelings I am not focally aware of any of these. I am not in an experiential relation to my own body, nor to my own emotions, but attend from this body and its physiological modifications to my situations. This attending from a particular lived state of arousal to a certain interpersonal interaction whose meaning it unfolds for us is called 'emotional experience': I do not attend to my emotions themselves - this is one reason why the metaphor I just used of 'being in touch with' an emotion can itself be misleading... if for example we took that contact as epistemic (as a matter of coming to know of the emotion) rather than as embodying (oneself pulsing with the living form of the emotion - in a sense 'being' the emotional experience). In ordinary language we call this 'having' an emotion; that is of course unimpeachable because paradigmatic, but we mustn't mislead ourselves here either into thinking of the having as possessive or as implying that once we have it we then may make its acquaintance. Our emotions are existential modes of us ourselves; we could say that we are, in normal emotional experience, identified with our emotions - we do not stand over against them but, rather, they constitute our selfhood itself. (By identification I mean, here, taken up as part of selfhood.) I am this man now who is saddened by your rejection of me; my sadness is the spontaneous living form taken by my grasp of the meaning of the fact of your spurning; and it is not an effect of my grasping something in emotion-free cognitive appraisal, but rather is itself the entry point to a genuine understanding of matters of human significance - it is itself the form such understanding takes.  

When by contrast I am poorly and able to recognise this as such, I am not thus identified with my body. The illness is an affliction; it is not a mode of interpersonal sense-making but instead an impairment of human functioning.

To grasp the point about correlativity let's start with poorliness. Speaking purely for myself, I often struggle to recognise at first when I am poorly. I seem to suffer for a while from an inverse of the problem of the somatiser: I may develop a neurotic belief that my loss of energy and aches are symptoms of a depressive neurosis. I realise that I am 'off colour', unenthusiastic, somewhat hopeless, but see this as due to an ego deficit. Then I realise that I am poorly, and instantly feel much better about myself! (My 'neurosis neurosis' is partly right: I do have an ego deficit, but it is a matter of failing to adequately internalise a nursing consciousness rather than a matter of emotion intolerance...) Anyway, the point is that we are not typically identified with our illness - or, better put, the very idea of an illness is of something with which we are not identified, but rather of something with which we are afflicted. (In the language of the British idealists: the relation between ourselves and our illnesses is, in virtue of what an illness is, external not internal.)

So here is the basic existential situation: we have a certain state of physiological arousal - HPA axis and ANS activation etc. - and the 'question for us' is: are we to identify with it or not? If we do thus identify with it then it constitutes part of an emotional experience: we attend from it to our relationships. If we do not identify with it then it constitutes an affliction - an illness.

Clearly this is no question or choice that we are making as decision-making beings. I use the language of choice but could equally use the passive language of, say, attractor basins, or of how we are drawn to existentially self-constitute. The point here is, though, that we tend to go one way or the other - either identifying with it and attending from it or disidentifying with it and attending to it. (Bodying forth somehow or other - which some people call (I believe unhelpfully) 'sense making' - is after all simply of the human condition.) This is the inverse correlativity I mentioned above. 

Now this is understood, the nature of 'conversion' should be clearer. In truth it is not a matter of emotional experience being converted into physical experience at all, but rather of physiological arousal that couldn't get taken up into the form of emotional experience (because, say, of incompatibility with the ego ideal) and so instead gets attended to as affliction. There is, I think, a real sense in which there is nothing particularly wrong or right about any of this: the existential situation we are dealing with - i.e. one of the constitution of the self itself - is too primordial to be aptly framed in such terms. (Rather it is only once we have selfhood off the ground that normativity can enter the picture.) However there is also a real sense in which certain 'choices' are yet poor, and this is in terms of their consequences. The consequences of disidentifying with stressed arousal which is yet not caused by disease is that it cannot be assimilated and we are deprived the opportunity to adjust to the meaning of the interpersonal situation that has kicked off the arousal response. We cannot grieve; we cannot take assertive action against an oppressor. And this is because the other is not truly being experienced as dead or oppressing. They may be understood to be thus in some thin, 'merely verbal', sense, but this understanding is not one which can propagate upwards from an emotional experience to adjust the weightings throughout the whole system of instinctive reactions and expectations. The somatiser's selfhood is depleted through their disidentification from certain aspects of their physiological state.

The question that I would want to put to the somatiser is, then, not 'Really you are emotionally hurting aren't you?' but rather 'Shall we try to understand together why you aren't emotionally hurting when you need to be?' 

Contra Freud the hysteric does not suffer from reminiscences, but from an inability to reminisce in an affectively rich manner.


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