L’hyperémèse gravidique se caractérise par des vomissements incoercibles qui peuvent durer tout le long de la grossesse. Au regard des symptômes associés (perte de poids, déshydratation, demande d’IVG), elle nécessite le plus souvent une hospitalisation. De nos jours, la prise en charge de ces femmes peine à trouver un consensus et des modalités de soins véritablement efficaces. L’étiologie de ce symptôme reste inconnue et aucune des hypothèses (médicales, génétiques ou psychologiques) ne parvient à résoudre l’incompréhension qu’il suscite et confronte les équipes à un sentiment d’impuissance. D’autant qu’après l’accouchement, les vomissements disparaissent instantanément, sans répercussion sur le lien mère–enfant. À partir du cas clinique d’Ayem, souffrant d’hyperémèse au cours de ses deux grossesses, nous proposons d’explorer les effets de cette pathologie sur l’ensemble de l’équipe de la maternité et les modalités de prises en charge qui ont pu être élaborées avec et pour la patiente.

À partir des entretiens cliniques, de la passation du Rorschach et du TAT, nous interrogerons la place du symptôme dans son fonctionnement et son économie psychiques, qui invitent d’ores et déjà à penser l’hétérogénéité et la complexité de la vie psychique dans cette clinique.

Cette recherche ouvre une nouvelle lecture de l’hyperémèse gravidique en la concevant non plus comme une hystérie de conversion classique, mais comme une problématique psychique plus primitive et plus complexe, exigeant du clinicien un engagement total de sa présence au service de l’unification du Moi.

L’analyse discutera en particulier l’hypothèse de la névrose hystérique avancée par les médecins et psychanalystes du XIX ^e siècle, ainsi que par les professionnels de santé qui accompagnent ces patientes. Nous proposons de penser l’hyperémèse gravidique non pas comme une hystérie de conversion où le Moi serait assez différencié pour donner lieu à une solution corporelle portant la signification inconsciente de désirs sexuels refoulés, mais davantage comme une forme d’hystérie archaïque dans laquelle prédomine une problématique bien plus primitive où le sujet souffre davantage d’un blanc psychique.

L’absence de consensus quant à l’étiologie de l’hyperémèse gravidique appelle à des considérations plurielles et au dialogue interdisciplinaire. Dans cette contribution, le symptôme est envisagé à travers les enjeux intrapsychiques engagés dans ce saut vers l’expression somatique, il interroge également les modalités de prise en charge et le cadre nécessaire à penser pour chacune de ces femmes et enfin, les modalités relationnelles qui se mettent en scène autour et avec la patiente.

Hyperemesis gravidarum, characterized by uncontrollable vomiting, appears to have always existed, as a description of the condition was found in a papyrus dating back to 2000 BC. While motherhood represents a profound psychological crisis, it also represents, more rudimentarily, a significant somatic crisis during which the body transforms and functions according to a unique logic. Normally, nausea and vomiting are common but benign during the first trimester of pregnancy. However, in the case of hyperemesis gravidarum, vomiting is massive, severe, and uncontrollable, leading to fasting, dehydration, and significant weight loss; it often necessitates hospitalization because it is potentially lethal for both mother and fetus. Early psychoanalytic texts, from the nineteenth century, placed this condition within the category of hysterical neuroses; the treatment administered during that period involved isolation in darkness, devoid of any external contact. At present, there is little consensus around how to best treat women with hyperemesis gravidarum, and no truly effective treatment methods have been identified. The etiology of this condition remains largely unknown, and none of the existing hypotheses (medical, genetic, or psychological) have managed to resolve the resulting confusion. Researchers examining this pathology and mothers enduring these symptoms have criticized the excesses of psychoanalysis and its diagnosis of hysterical neurosis, yet they have been unable to propose an alternative framework of understanding. At the same time, in maternity wards, healthcare providers are left feeling helpless, and the notion of hysteria is often expressed, perhaps more as a criticism of the patient. After childbirth, vomiting disappears instantly, with no observed repercussions on the mother–child bond.

We conducted a literature review focused on the history and current knowledge of hyperemesis gravidarum, and we explored the clinical case of Ayem, whom we encountered and supported during her two pregnancies, during which she was hospitalized for hyperemesis gravidarum. Using information from regular clinical interviews carried out during the patient's hospitalization in the maternity ward, we examined the effects of this pathology on the entire healthcare team as well as the healthcare modalities that were developed with and for the patient. Furthermore, drawing on the results of the Rorschach Test and Thematic Apperception Test (TAT) conducted during Ayem's second pregnancy, we particularly explored the space occupied by the condition in her psychological functioning and budget. These projective tests were administered for diagnostic purposes because of a disagreement among the healthcare providers in the maternity ward team. An additional objective of the assessment was to support the patient and help her to describe her ailments in words, in a moment of great distress where there was misunderstanding within her entourage and herself. We observed that the psychodynamic analysis of the protocols encouraged us to reflect on the heterogeneity and complexity of psychological dynamics in this clinical case.

Our research provides a new interpretation of hyperemesis gravidarum, viewing it not as a classical conversion disorder, but rather as a more primitive and complex psychological issue, requiring the clinician to be fully present in order to help unify the ego.

The psychodynamics and psychopathology of pregnant women with hyperemesis gravidarum remain very little studied. We aimed to re-examine the hypothesis of hysterical neurosis proposed by nineteenth-century physicians and psychoanalysts as well as by the somewhat frustrated healthcare professionals accompanying these patients. We questioned what within this psychological transition from woman to mother fails to be sufficiently mentalized and instead takes the path of somatic expression. When the child appears, either mentally for the mother or in the physical world, the related symptoms no longer seem to be necessary. We then wondered what and whom the condition protects: the future mother? the fetus? both? Finally, we also questioned the frequent references to hysteria, which opened the door to a reflection on the “archaic hysteria” described by J. McDougall, where the somatic condition would be the manifestation of a “fantasy in action of a body for two.” The somatization arising from this “archaic hysteria” would be triggered by primitive fears and infraverbal anxieties, at a time when the psychic survival of the child depended on its mother, with whom it shared a single body.

We propose that hyperemesis gravidarum should not be viewed as a conversion disorder where the ego is differentiated enough to produce a bodily solution carrying the unconscious meaning of repressed sexual desires. Instead, it should be viewed as a form of archaic hysteria in which a much more primitive concern predominates. If a person with hysteria suffers from too much reminiscence, a person with archaic hysteria suffers from a psychic void, and the challenge of all therapeutic work seems to be the quest for the unified ego. Hyperemesis gravidarum calls for us to explore the intrapsychic stakes involved in this leap towards somatic expression; it also asks us to revisit the healthcare modalities and framework that must be designed for each patient, as well as the relational modalities that unfold around and with the patient.