Medical research over the last decades has shed light on almost everything that needs to be known on the pathogenesis of malignant tumours. They are genetic mutations which cause certain cells, which had differentiated into different tissues, to return to an embryo state. Significantly, in oncology this process has been called s-differentiation. Instead of differentiating, like embryo cells do, these cells function in an anomalous way: because their growth is not inhibited by contact with other cells, they tend to multiply inordinately and invade surrounding tissues. It is this uninterrupted reproduction and renovation that has originated the name neoplasia.

This knowledge on the cells’ pathogenetic dynamics has not been integrated by knowledge of aetiology; on the contrary, on this very topic a number of hypotheses appear which seem to depend on the researchers’ training background more than on empirical evidence. A few factors which may act as causes of neoplasms have been identified, but none of them seems to be a single sufficient cause. Among them are ageing, genetic vulnerability, hormonal, immune, behavioural, environmental (e.g. pollution), social and psychological factors. The main problem seems to be that the studies carried out in different fields are not of much interest to those who look at the same problem from a different cultural perspective.

Because of their pathogenesis and of the similarities existing between a neoplastic cell and the totipotent embryo cell, tumours have given rise to a number of aetiological hypotheses in the field of psychoanalysis. One of the psychoanalysts who first developed an interest in the psychological variables entailed in the onset of tumours was Groddeck, who argued that the Es had the potential to develop a symptom in the body in the same way as it produces a dream, thus extending the concept of hysterical conversion to all the diseases of the body (on this topic, see also Felix Deutsch’s work). However, it was Alexander’s work that originated most of the studies which identify a psychosomatic area. All these studies, although in different ways, consider somatic symptoms as the secondary expression of an emotion which will never be “staged” on the psychic scene. This concept started a new trend in research-at first at the Chicago school (with Alexander and his followers) with the concept of “specific conflict models”, then in Paris with the introduction of the pensée operatoire notion by M’Uzan and Marty (1963)–and tends to highlight a specific and stable psychic functioning mode in the subjects who become ill mainly in the body [1].

Actually, some articles from the Chicago school which became known in Europe in the early 1950’ stimulated, especially in France, a criticism of these theoretical stances, thus contributing to further define the psychosomatic phenomenon. The work done at the Ecole de Paris de Psychosomatique (following several different approaches) started defining two main interpretation categories of somatic symptoms: on the one hand, they appear as carriers of a meaning, on the other they are viewed mostly as the result of a given psychic structure, whose main effect is the disgregation of the meaning-producing psychic processes.

Alexander himself, although he never worked on tumours directly, coined the phrase vegetative neurosis, which-differently from conversion neurosis, seems to be a physiological reaction of vegetative organs to an emotional situation. The rise of arterial pressure in a case of anger, for example, would be the physiological vegetative expression of a (psychological) state of anger. The basic difference would be that while conversion concerns the voluntary motor and perceptivesensorial systems, vegetative neurosis concerns the organs governed by the vegetative nervous system. In addition, the somatic symptom seems not to express a psychic content but to designate the psychological component of an emotional state.

Therefore, if originally the reference model was essentially that of the psychic conflict (used by Alexander), later on the “deficit model” made its appearance: it is a deficiency of the psychic system, whereby it cannot mentalise intense emotional experiences which could thus not translate into a somatic damage [1-3]. Drawing on a certain interpretation of Bion’s thought, whereby the mother’s alpha function paves the way to the transformation of the child’s beta elements, thus enabling them to be “digested”, and on infant research studies on affective regulation [4], the concept of affective dysregulation has been introduced [5,6]. This seems to originate in a mother-child interaction where the former’s emotional expression is not comprehended and regulated by the latter. The “incomprehensible” emotion seems to be released in two ways: either through acting or through the body. These points to the similarities existing with the alexithymia construct, which expresses the difficulty of perceiving and expressing one’s emotions.

The earliest studies aimed at testing these hypotheses empirically on neoplastic subjects were carried out by Le Shan [7,8], who identified a connection between personality traits-namely the inability to express hostile feelings-and the development of neoplasia. These studies showed that the life of a neoplastic patient seems to be characterised by the loss of an important affective relationship, which seems to precede the onset of the disease [9] and to produce an intense emotional experience. These studies opened up a new research field focused on the role that emotional factors can play in the genesis and development of a neoplasia. In the second half of the 20th century several interpretative models were designed, among which the one put forward by Bahnson, based on the theory of psycho-physiological complementarity [10], whereby the cancer-prone personality would be characterised by denial, repression, reduced emotional expression and strict abidance with social norms (Figure 1).

Bahnson, using a graphical representation (Figure 1), illustrates the psycho-physiological complementarity assuming, starting from conflictual drives or emotions, two ways of pathological solutions depending by the used defensive mechanism: one lead to the psychoneurotic and the psychotic solutions, the other to the psychosomatic and the somatic solutions. Following Le Shan, Bahnson also stressed that the loss of an important affective relationship can be crucial for this type of subjects. According to this author, these patients are not able to show the alterations induced by the mourning process and keep their social life unaltered. The tragic event is not processed at the conscious level, and therefore seems to lead to a somatic regression which in the most serious cases could lead to a neoplasia.

Figure 1: Flowchart of the process of identifying and selecting studies.

Later on, Lydia Temoshok identified a personality profile typical of subjects developing neoplasm, which is opposed to Friedman and Rosenman’s [12] type A construct, which enables to predict the likelihood of heart disease; this profile was defined “type C” (Temoshok et al.) and is characterised by a tendency towards repression, whereby the subject does not report on negative or socially undesirable symptoms, and expresses emotions in a much weakened way when s/ he does not repress them altogether [11,12].

The contributions to the field over the last few years have focused mostly on the development of the disease, in the attempt to identify those factors which, from a psychological perspective, may contribute to improve the patient’s life conditions while the disease lasts. Spiegel and Fawzy have pointed out that some negative psychological states may speed up the progress of cancer, whereas social support seems to slow it down [13]. Other studies [14,15] have tested the effectiveness of psychological and group therapy on neoplastic patients. The debate on the possible association of personality and the occurrence of neoplasia seems to be still open.

The importance of the psychic conflict as cause for the development of a tumour is brought to the fore in medical and scientific literature also by studies which do no longer refer to the work of the Chicago school. Solano stresses that in 1995 the American immunologist Strauman showed through an experimental study that inducing a psychic conflict in the laboratory brings about an immediate and significant reduction in the number of NK (natural killer) cells which provide the most important immune barrier against the risk of developing a tumour. Although he did not refer directly to psychoanalytic theories, Strauman showed that results are more significant in anxious subjects if the induced conflict is one between “being and having to be” (Ego and Super-ego) and in depressed subjects if the induced conflict is one between “being and wanting to be” (Ego and ideal Ego; Strauman et al.). Following this study, other immunologists have developed different research branches thus giving life to psychoimmunology, which is today a very lively research field.

Let us now move to the more specific object of this paper: our research group has carried out an in-depth analysis of emotions (with special focus on anger), of characteristic defence patterns and of the presence of events which might be considered sources of stress in the two years preceding the onset of the neoplasia. In this paper the results of the research work will be used as a basis to discuss an issue which, in our view, involves psychoanalysis in its own specific field. Consequently, only a synthesis of the research will be presented hereafter.

A research sample of 53 subjects-27 males hospitalised for a lung carcinoma and 26 females hospitalised for a mammary carcinoma-and a control group of 42 subjects (20 males and 22 females) hospitalised for a chronic hepatitis were given the following:

A socio-demographic form which would provide us with demographic information alongside data concerning any “stressful” situations occurred over the two years preceding the onset of the disease (deaths, loss of job, economic problems, accidents, etc.). The subject was also asked to say whether s/he had ever suffered from one or more of the following diseases: ulcer, colitis, gastritis, recurring cephalgia, allergies, bronchial asthma, psoriasis, dermatitis or other – to be specified.

State Trait Anger Expression Inventory [16]: a questionnaire providing a qualitative assessment of state and trait anger and investigating the way in which anger is managed, whether it is introverted, expressed, acted-out or controlled;

Defence Mechanism Inventory [17]: an instrument which, by asking the subject to complete some stories, makes it possible to classify a typical defence style (turning against object, projection, principalisation, turning against self and reversal).

The two groups of subjects, who share a similar socio-demographic background, showed very different results in all the areas investigated. 60.3% of the cancer patients had suffered from at least one of the diseases typically considered as psychosomatic, in particular those affecting the digestive system, whereas only 33.3% of the subjects with hepatitis C had been affected by these diseases. In the two years preceding the onset of the disease, 41.5% of neoplastic patients suffered a death versus 16.6% of hepatopathic patients. Major differences were found also in terms of work-related problems (13.2% vs. 4.7%).

Subjects with hepatitis obtained significantly higher scores (p<0.0005) than neoplastic patients in the STAXI scales measuring state anger, trait anger and the predisposition to express anger when attacked without reason. As for the scales which assess different anger management styles, the subjects with hepatitis obtained much higher scores in the scales of anger expression and of agitus. Neoplastic patients, instead, obtained much higher scores in the scales which measure the tendency to control anger (p<0.001) (Table 1).

The DMI, which provides information on the use of some defence patterns and predicts that the healthy population tends to use several of the mechanisms identified, has pointed out that while subjects with hepatitis actually have recourse to the different defence patterns, 45.2% of the subjects with carcinoma have a reversal profile. This defence style characterises those subjects who deal with others in a pleasant and accommodating way, apparently with no problems or difficulties, who tend to minimise differences in opinion and to avoid confrontation. As shown by the high score on the TAS (turning against self) scale, oncological patients are also less prone than hepatopathic patients to use defence patterns such as tendency to aggression, identification with the attacker and shift. On the PRO (projection) scale, they have reached significantly lower scores than the control group (p<0.01). In this respect, it is important to remark that, as the authors of the inventory suggest, the PRO and TAO (turning against object) scales point to the presence of defence styles which are more likely to lead to psychic problems.

While the subjects hospitalised with chronic hepatitis have been found to be quite heterogeneous and thus rather similar to a random sample, the cancer subjects seem to have in common a number of aspects which make them a somehow homogeneous group. Consequently, the sample which appears is characterised by a pronounced tendency to self-control and repression; this attitude seems to concern the area of negative emotional experiences, and of anger in particular. A greater presence of tragic events, especially deaths, is evident in the two years preceding the onset of the disease or, more in general, these subjects appear to have been always more sensitive to somatic suffering as compared to the control group.

Table 1: Statistical differences on the individual STAXI scales between cancer and hepatitis patients on one-way ANOVA.

These results seem to show that, with reference to the interpretation framework outlined in the first part of the paper, we can arguably think of a typical pattern of psychism organisation rather than of an “occasional” pattern of symptomatic solutions to a conflict. Nonetheless, the hypothesis of a typical and stable pattern which determines the economic organisation of these subjects does not prevent us from searching for a more specific psychic signification, even when significant effects fall into the “outside psyche” that is the somatic basis [18]. Also, despite the differences between the orientations which have been developed over about a century, since Groddeck’s inclusion in the “damned group” (Freud, letter to Groddeck dated 5 June 1917) contributed to highlight Freud’s position as opposed to the soma and thus to the somatic disease, even the most serious impairments of the body have been brought into a “logic” which, with its multiple forms, regulates unconscious psychic life.

The results of our research, together with an overview of the interpretative framework for the psychosomatic phenomenon, lead us to believe that the somatic symptom, as an overflow into the outside psyche, can find a new signification in the light of what some authors, namely Dejours and Laplanche, qualify as “third topography”. At the core of this conceptualisation of the psychic system lies the hypothesis of a vertical splitting separating the dynamic unconscious from a different category of unconscious psychic phenomena, which is more original and determined by the untranslatability of the components of that enigmatic message (because full of unconscious significations) which comes from the adult: this category of unconscious phenomena identifies an area of psychism which has been defined as amential [19,20] or intercluded [21] unconscious. It is a part of the unconscious which, according to Dejours, takes shape by virtue of the “violence of parents on the child’s thought” and which, according to Laplanche, refers to the part of the unconscious in which the untranslated bits of the adult/infant message are stored. The transformation of these contents into material subject to removal is the effect of the erotisation of the child’s body, a process that Dejours calls libidinal subversion.

The notion of libidinal subversion originates in a theoretical generalisation of the Freudian concept of anaclisis (Anlehnung), whereby the organs’ main function is to serve as erogenous zones and enable libidinal support or subversion. This subversion process, which transforms the physiological body into an erotic body, is affected by the parents’ ability to “play” with the child’s body on the different registers which Dejours defines “expressive acting”. The way in which a body precluded from the intersubjective exchange is used will thus be linked to the impasse of a subversion process which is based on the function and not on the organ. Within this framework, the “somatic decompensation does not wander through the body without direction, but selects the function which has been excluded, proscribed by expressive acting”. It is for this reason that Dejours prefers to talk about function choice rather than organ choice.

Using these categories, we can say that, with reference to the unconscious psychic life of these subjects, the time when the pathology occurs in the body represents a “pre-”, an avant coup, which is the time of the amential unconscious before its contents enter the process triggered by libidinal subversion. We may therefore argue that a failure of the libidinal subversion process in certain parts of the body leaves those organs under the dominant action of their functions [19,20]. In the subjects whose psychic organisation, following a primary subversion failure, corresponds to the characteristics identified in the population in our research work, the possibility of having recourse to action or behavioural hyperactivity as a defence style is nullified by a “current” relational event (e.g. a death) which releases an affection amount. Being unable to be transformed through psychic work, this brings about an overflow into the “outside psyche”, into the soma. In other words, what we have defined as “overflow” identifies the effects of a decompensation occurring when, in intersubjective dynamics, the other asks the subject something which will force him/her to trigger the proscribed action. In the light of what the case of tumours illustrates rather clearly, the body, with one of its functions rather than with one of its organs, appears as the field where the failure of the libidinising action of the adult-infant encounter becomes manifest: it is therefore a body which has never become an erotic body. Compared to the unconscious sensitivity zone which Dejours identifies within the third topography as a “zone of fundamental fragility” in every subject (Fain, Dejours), this failure constitutes an “implosion” because its effects do not overflow into the typical field of action of the unconscious. At the same time, however, it explodes in the “outside psyche” of the somatic basis and, even more, in the case of tumours, in the conformist “operating” preconscious which characterises, according to Marty, the overall relationship with the reality of these categories of patients. In this view, we can arguably state that the determination phase of the somatic disease in these subjects could be associated to the Freudian category of actual neuroses: the purely somatic symptom for the Ego does not have a sense, differently from hysterical conversion.

As a consequence, the search for significance, which constitutes the metaphorising work of the Ego, highlights a deficiency in these people. This search appears as a work that, especially in the immediate followup of a death, appears irresolvable: it needs a second time which can only come from the other, as it goes with what has been stored in the amential unconscious, in order for it to benefit from an “erotising” code enabling the hysterisation-and thus signification-movement. The need to establish a “second time” would represent the end of the work that psychoanalysis, as a therapeutic method, is called to introduce.