Pathways of Psychosomatic Diagnosis: A Psychoanalytic Elaboration of Failures of Symbolization and the Destinies of Bodily Symptoms.

Abstract

The diagnosis of psychosomatic disorders places clinicians before a fundamental epistemological tension: the tension between the medical drive toward somatic objectification and the subjective, dynamic economy of the psyche. This article offers a distinctly psychoanalytic framework for psychosomatic diagnosis, foregrounding failures of symbolization, désaffectation, and disturbances in mentalization. Drawing upon the seminal contributions of Freud, Alexander, Marty, McDougall, Green, Smadja, Winnicott, and Bion, it argues that psychosomatic bodily symptoms cannot be adequately grasped either as straightforward organic causality or as classical hysterical conversion. Instead, they emerge at the point where psychic linkage collapses and what psychoanalysis has termed “the work of the negative” takes over. Psychosomatic diagnosis is therefore reconceptualized not as a static classificatory act but as a living, elaborative clinical process that unfolds within the transference and the unique temporality of the therapeutic relationship. A detailed clinical vignette illustrates this process, while recent advances in mentalization-based treatment and neuropsychoanalytic research are critically examined and integrated.