The Pain Without a Name: Fibromyalgia and the Freudian Legacy of Hysteria, a Psychoanalytic Reading

Introduction: when the body says what the mouth keeps silent

Fibromyalgia is one of the most challenging clinical conditions in contemporary medicine. Characterized by widespread chronic pain, persistent fatigue, non-restorative sleep and what patients describe as “brain fog”, the syndrome affects between 2.5% and 5.5% of the Brazilian population, being the second most common rheumatological disease in the country. In Brazil, the public health system (SUS) recently expanded its guidelines for the treatment of fibromyalgia, recognizing the need for a multidisciplinary approach that includes not only medication management but also psychological and emotional support.

But there is something in fibromyalgia that modern medicine often neglects: its deep resemblance to the clinical pictures that led Sigmund Freud to found psychoanalysis at the end of the 19th century. It is a condition in which pain exists, is real, intense and disabling, but there is no inflammation, no anatomical lesion, no deformity. The body suffers, but tests do not find the cause. It is precisely here that the history of fibromyalgia intertwines with the history of hysteria, and it is here that psychoanalysis offers a path of listening that traditional medicine, alone, cannot follow.

Fibromyalgia: definition, prevalence and the enigma of diagnosis

According to the Brazilian Society of Rheumatology, about 3% of the Brazilian population has fibromyalgia, and of every ten patients, between seven and nine are women. The syndrome appears mainly in women between 30 and 50 years old, although it can also affect men, older adults, adolescents and children. Symptoms include widespread and recurring pain, fatigue, lack of energy, difficulty maintaining deep sleep, irritable bowel syndrome, hypersensitivity to environmental stimuli, headache and emotional and psychological disturbances.

The specific cause of fibromyalgia remains unknown. It is known that serotonin levels are lower in people with the condition and that hormonal imbalances, tension and stress may be involved in its onset. Diagnosis is clinical, based on the patient’s history and the exclusion of other diseases, since there are no laboratory or imaging markers that confirm the syndrome.

This absence of a verifiable anatomical substrate is what brings fibromyalgia close to a question Freud faced more than a century earlier: how to treat a suffering that the body expresses but that anatomy cannot explain?

Freud and hysteria: the birth of psychoanalytic listening

At the end of the 19th century, hysteria was one of the most common disorders in European medical offices. It was characterized by symptoms such as paralyses, anesthesias, convulsions and pains that did not correspond to any identifiable anatomical lesion. Patients presented pseudoneurological deficits that were genuine but were not related to any known organic disease.

It was precisely this “anatomical incoherence” that challenged the medicine of the time and attracted Freud’s attention. In Studies on Hysteria (1895), written in collaboration with Josef Breuer, Freud demonstrated that the hysterical symptom was not the negative of the organic, that is, it was not a simulation or a moral weakness, as many believed. On the contrary, the hysterical symptom was the symbolic expression of a traumatic idea or memory that had been repressed and that emerged in the body as a form of communication.

Freud theorized that the affect linked to the repressed idea was “converted” into a physical symptom, hence the term “conversion hysteria”. The body thus became a stage where the unconscious played out what consciousness could not elaborate through words.

The continuity hypothesis: fibromyalgia as contemporary hysteria?

Several Brazilian studies have explored the hypothesis that fibromyalgia represents a contemporary form of the hysteria described by Freud. A comparative study between the contemporary clinical picture “fibromyalgia” and the clinical picture “hysteria” described by Freud in the 19th century argues that subjects diagnosed with fibromyalgia are, in fact, patients presenting hysterical symptoms. Another study, published in the Revista de Psicossomática Psicanalítica, reviews the literature on the relationship between fibromyalgia and hysteria, suggesting that fibromyalgia can be understood as a contemporary form similar to Freudian hysteria.

The similarity is not only symptomatic but also historical. In the 19th century, hysteria was considered a “disease by representation”, a suffering inscribed in the body without anatomical correspondence. Today, fibromyalgia occupies an analogous place: it is a condition recognized by the World Health Organization since 1992, but one that still raises controversy in the health field and remains in a process of “framing”.

The historian Danielle Fialho, in an article published by Fiocruz, observes that fibromyalgia “seems to be close to the field of psychiatry and/or psychology”, and that both patients and medical discourse point to depression as an important symptom associated with the syndrome. This proximity to the psychic field is not a coincidence: it is an invitation to take up the listening that Freud inaugurated.

The psychoanalytic listening of pain: from symptom to word

The psychoanalytic treatment of fibromyalgia starts from a fundamental principle: pain is not only a neurophysiological phenomenon, but also a subjective experience crossed by language. As the psychoanalyst Santiago Castellanos observes, fibromyalgia lies in a “border zone” between the body and language, a territory where “body, pain and subjectivity are knotted together”. It is not a matter of opposing body and mind, but of recognizing that between them there is an intertwining, a knot, that psychoanalysis can help to untie.

The psychoanalytic approach does not aim to “eradicate” pain at any cost, but to allow the subject to move from pain to suffering, that is, for pain to find a place in the psychic economy, so that it can be spoken, elaborated and, eventually, transformed. The psychoanalyst does not promise a cure for fibromyalgia, but offers a listening that enables the patient to build knowledge about their own pain.

Brazilian research has investigated the effectiveness of psychoanalytically oriented psychotherapy in the treatment of fibromyalgia. A study supported by FAPESP followed patients diagnosed with fibromyalgia in psychotherapy twice a week for three years, investigating the effects of psychoanalytic treatment on chronic pain. Another investigation, grounded in psychoanalytic theory, carried out ten psychotherapeutic intervention sessions with fibromyalgia patients, obtaining promising results in the elaboration of suffering.

Treating fibromyalgia with psychoanalysis: an integrative approach

The treatment of fibromyalgia requires multidisciplinary care. SUS guidelines recommend the use of analgesics and anti-inflammatories associated with tricyclic antidepressants, regular physical activity, massages and acupuncture, in addition to psychological and emotional support. Psychoanalysis belongs to this last axis, but with a specificity: it is not a supportive therapy or a skills training, but a listening to the unconscious that seeks the meaning of the symptom in the singular history of each subject.

The psychoanalytic treatment of fibromyalgia starts from the premise that pain, when it finds no words, finds the body. The task of analysis is, therefore, to restore to pain its dimension of language, to allow the patient to speak of what the body screams. It is not about denying the reality of pain, but about recognizing that it is also a message addressed to the Other, a form of address that psychoanalysis can welcome.

The French psychoanalyst Stéphanie Hertzog, who investigated therapeutic resistance in fibromyalgia, demonstrated that many patients do not obtain relief from pain despite conventional medical treatment. Psychoanalysis offers, in these cases, an alternative path: instead of insisting on eliminating the symptom, it proposes to listen to it, understand it in its economic and libidinal function, and open the possibility of a psychic elaboration that medicine, alone, cannot reach.

Curiosities: what you may not have known about fibromyalgia and Freud

1. The term “fibromyalgia” is recent, but the pain is old. The first mention of a widespread pain associated with “muscular rheumatism” dates from 1815, when William Balfour, from the University of Edinburgh, described nodules in the “rheumatic muscle”. The term “fibrositis” was coined by Sir William Gowers in 1904, and only in 1976 did it come to be called “fibromyalgia”.

2. Freud never used the term “fibromyalgia”, but he described something very similar. In Studies on Hysteria, Freud reports the case of Elisabeth von R., a young woman who suffered from leg pains that had no identifiable organic cause. The treatment consisted in making the patient speak, associate freely and reconstruct the traumatic history that was inscribed in the body. Elisabeth recovered, not because the pain was “cured”, but because she found words for what before only the body said.

3. Fibromyalgia affects more women, and so did hysteria. Of every ten patients with fibromyalgia in Brazil, between seven and nine are women. In the 19th century, hysteria was considered a typically female disease. This overlap is not accidental: both pictures point to the need to think about the relationship between body, gender and psychic suffering.

4. The WHO recognized fibromyalgia in 1992, but the debate continues. Fibromyalgia is a disease still in a process of “framing”, in the sense of C. Rosenberg’s concept, because it raises controversy in the health field. Some doctors doubt its reality; others treat it as a purely psychosomatic condition. Psychoanalysis offers a third path: neither denying the pain nor reducing it to the psychic, but listening to it in its complexity.

5. Fibromyalgia has been called the “emblematic disease of medically unexplained symptoms”. The historian Danielle Fialho observes that pain is simultaneously individual and socially learned: each culture has an understanding of painful sensations that differs across space and time. Fibromyalgia, in this sense, is also a cultural phenomenon, a contemporary way of expressing a suffering that the available language cannot name.

Final considerations: psychoanalysis as listening to the impossible

Fibromyalgia places us before an enigma that Freud faced more than a century ago: how to treat a suffering that the body expresses but that medicine cannot explain? The answer psychoanalysis offers is not the elimination of the symptom, but the listening to its message. It is not about denying the pain, but about recognizing that pain also speaks, and that, in speaking, it can be transformed.

As Castellanos observes, between the body and language there is a border zone, a territory to be traversed, where “body, pain and subjectivity are knotted together”. It is in this territory that psychoanalysis operates. Not to cure fibromyalgia, but to offer the subject the possibility of building knowledge about their own pain and, perhaps, finding another way of inhabiting it.

If Freud began psychoanalysis by listening to hysterical women who suffered from unexplained pains, perhaps fibromyalgia is, today, an invitation to take up that listening. Not to repeat the past, but to invent, in the present, a clinic that does justice to the complexity of human suffering.

References

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