Here is a compilation of essays on ‘Neurosis Disorders’ for class 11 and 12. Find paragraphs, long and short essays on ‘Neurosis Disorders’ for school and college students.
Essay on Neurosis Disorders
- Essay on Anxiety States
- Essay on Phobic Disorders
- Essay on Obsessive Compulsive Disorder
- Essay on Hysterical Neurosis
- Essay on Neurasthenia
- Essay on Hypochondriasis
- Essay on Reaction to Stress and Adjustment Disorders
- Essay on Grief Reaction
1. Essay on Anxiety States (Anxiety Neurosis):
Anxiety states are among the most common neurotic syndromes. They consist of a combination of physical and psychological manifestations of anxiety, not attributable to real danger, which occur either in attacks (panic disorder) or as a persisting state (generalized anxiety disorder).
Anxiety neurosis has been known by many names viz:—cardiac neurosis, Da Costa’s syndrome, Nervous exhaustion, Neurocirculatory asthenia, Soldier’s heart, Nervous tachycardia, vasomotor neurosis, vasoregulatory asthenia, disordered action of the heart, somatization psychogenic cardiovascular reaction, somatization psychogenic asthenic reaction. Le nevrose d’ angoisse.
The term ‘anxiety neurosis’ was first used by Sigmund Freud in 1895.
Prevalence of about 2-4% in normal population. This constituted about 25-30% of psychiatric consultation in general practice and about 8-10% of psychiatric outpatients.
(See Table 18.2)
It is characterized by recurrent anxiety (panic) attacks that occur at times unpredictable through certain situation e.g., driving a car.
The panic attacks are manifested by the sudden onset of intense apprehension, fear or terror, often associated with feelings of impending doom. The common symptoms experienced during an attack are dyspnoea, palpitations, chest pain or discomfort, choking or smothering sensations, dizziness, vertigo or unsteady feelings, feelings of unreality (depersonalization or derealization), paresthesias, hot and cold flashes, sweating, faintness, trembling or shaking and fear of dying, going crazy or doing something uncontrolled during the attacks. Attacks usually last minutes, more rare hours.
Generalized Anxiety Disorder:
‘The essential feature is generalized, persistent anxiety of at least one month duration without the specific symptoms that characterize phobic disorders or panic disorder, or obsessive compulsive disorder.
There are signs of:
i. Motor tension:
Shakiness, jitteriness, jumpiness, trembling, tension, muscleaches, fatiguability and inability to relax.
ii. Autonomic hyperactivity:
Sweating, heart pounding or racing, cold, clammy hands, dry mouth, dizziness, light-headedness, paresthesias (tingling in hands or feet), upset stomach, hot or cold spells.
iii. Apprehensive expectations:
The individual continually feels anxious, worries, ruminates, and anticipates that something bad will happen to himself.
iv. Vigilance and scanning:
Apprehensive expectation may cause hyperattentiveness, impatient or irritable, distractibility, difficulty in concentrating, insomnia, difficulty in falling asleep, interrupted sleep and fatigue on awakening.
i. Hyperventilation syndrome:
Symptomatology includes periodic attacks of respiratory distress, giddiness, paresthesia, weakness, numbness and tingling, especially around the lips and fingertips, palpitations, chest pain, weakness and momentary loss of consciousness and even tetany. These effects appear to be related to decreased pCO2 leading to respiratory alkalosis (due to hyperventilation), decreased free ionized calcium and decreased cerebral blood flow. Either, breath holding or the bag treatment in which the patient breathes in the accumulation of CO2 from a bag held over the mouth and nose can be used for management of acute symptomatology.
ii. Post Traumatic neurosis:
This disorder is seen in veterans exposed to battle front conditions, natural disasters, car wrecks, fire, rape, torture, riots or internment in a concentration camp. Excessive alcohol and drug use are common and suicidal ideation or attempts are also common. They are treated with abreactive or restitutive therapies or drugs.
I. Biological Theories:
(1) Catecholeamine theory:
Elevated plasma levels of epinephrine and monoamine oxidase (that catabolizes catecholeamines)
(2) Locus coeruleus theory:
This nucleus is located in the pons and contains more than 50 per cent of all noradrenergic neurons in the entire nervous system. Electrical stimulation of the animal locus coeruleus produces marked fear and anxiety response.
(3) Carbon dioxide hypersensitivity:
Giving these patients a mixture of 5% carbon dioxide in room air to breathe causes panic attacks.
(4) Lactate panicogenic metabolic theory:
The infusion of 10 mg/kg of 0.5 molar sodium lactate infused over 20 minutes will provoke a panic attack in most patients with panic disorder but not in normal.
II. Genetic Theory:
Anxiety states occur in about 2% of the general population and about 15% to 25% of the relatives of patients with anxiety. In a twin study, 41% of monozygotic and 4% of dizygotic twin pairs were concordant for anxiety neurosis.
III. Psychoanalytic Theories:
Psychoanalytic theories describe the anxiety states as the result of castration-anxiety (Sigmund Freud); aberrant function of the biological substrate that underlies normal human separation anxiety (Melanie Klein); failed repression (Freud) or the outcome of failure to master the hypothesized development stage of separation-individuation.
IV. Learning Theories:
Anxiety may be regarded as a fearful response which has become attached by conditioning to a stimulus which is not normally anxiety provoking.
It must be differentiated from:
(a) Functional Psychiatric Disorders:
Functional Psychiatric Disorders e.g., phobia, hyperventilation, chronic anxiety state, early schizophrenia, mania, agitated depression etc.
Neuropsychiatric., e.g., Presenile dementia, cerebral tumor etc.
Medicopsychiatric e.g., Hyperthyroidism, Hypoparathyroidism, Mitral valve prolapse, prophiria, drugs (stimulants, sedative withdrawal) etc.
Both tricyclics and MAO inhibitors have been used.
These are safe and effective anxiolytics but because of the risk of dependence, they should be stopped after a few weeks.
c. Other medications:
Beta adrenergic blocking drugs like propranolol, are useful in a variety of anxiety disorders.
2. Psychological Treatment:
(a) Supportive Psychotherapy:
Discussion and reassurance are often sufficient.
(b) Psychodynamic psychotherapy:
It might be helpful in identifying the significant unconscious conflict.
(c) Cognitive behaviour therapy:
Behavioural treatment of panic attacks involves breathing retraining to eliminate both acute and chronic hyperventilation, relaxation and cognitive restructuring to give physical symptoms a more benign interpretation.
Most anxiety states are brief and resolve spontaneously. If they last more than a few months, the outcome is poor.
2. Essay on Phobic Disorders:
Phobias are characterized by intense, persistent irrational and recurrent fear of a specific object, place, or situation that results in a compelling desire to avoid the dreaded place, activity or situation (the phobic stimulus). The fear is recognized by the individual as excessive or irrational in proportion to the actual dangerousness of the object.
‘Phobos’ was a Greek God who frightened one’s enemies. ‘Phobia’ first appeared in medical terminology in Rome 2000 years ago. Westphal described agoraphobia.
(See Table 18.3)
Related to External Stimuli:
It is the most severe and pervasive form and is the most common, among those seeking treatment.
The clinical picture consists of:
a) Fear of being alone
b) Fear of leaving home
c) Fear of being away from home
Typical fears are of using public transportation (buses, trains, subways, planes); being in crowds, theaters, elevators, restaurants, markets and departmental stores; waiting in line, travelling a distance from home.
In addition to panic attacks, multiple phobias, chronic anxiety, depersonalization, secondary depression, multiple somatic complaints and alcohol, barbiturates or antianxiety medications abuse may occur.
(b) Social Phobia:
In social phobia, the essential feature is a persistent, irrational fear of and compelling desire to avoid situations in which the individual may be exposed to scrutiny by others. Typical social phobias are of speaking, eating or writing in public; using public lavatories and attending parties or interviews.
Spontaneous panic attacks may occur.
Individuals are prone to be episodic abuse of alcohol, barbiturates and antianxiety medication.
Social phobias constitute about 5 to 10% of phobic patients seen by psychiatrists. It often begins in late childhood or early adolescence and is more often diagnosed in females.
(c) Simple Phobia:
It is the most common type of phobic disorder in the general population. The central feature is a persistent irrational fear of and compelling desire to avoid an object or a situation other than Agoraphobia or social phobia.
The most common simple phobias involve animals. Other simple phobias are claustrophobia (fear of closed spaces) and acrophobia (fear of heights).
They are common in children and may persist into adult life.
Related to Internal Stimuli:
Illness Phobia (Nosophobia):
It constitutes about 10 to 20% of phobic patients consulting psychiatrists. It occurs equally in both sexes.
(i) Psychoanalytic Theory:
Freud hypothesized that phobic symptoms occur as a part of the resolution of a conflict between the impulses for libidinal or aggressive gratification and the ego’s recognition of potential danger that could result from this gratification. Ego uses repression and displacement to avoid the anxiety produced by both intrapsychic conflict and potential external danger.
(ii) Conditioned Reflex Theories:
Phobic anxiety in conditioned response acquired through association of the phobic object (the conditioned stimulus) with a noxious experience (the unconditioned stimulus).
(iii) Biological Theories:
Social phobic symptoms are accompanied in perhaps 50 percent of cases by a surge of plasma epinephrine distinguishing them from panic attacks, in which adrenaline surge is not regularly seen. Phenlylethylamine (PEA) or similar endogenous amines may be involved in mood response to social approval and disapproval.
About 32 per cent of first-degree relatives of agoraphobics had an anxiety disorder. Nine percent of the first-degree relatives had agoraphobia.
Schizophrenia, major depression, obsessive compulsive disorder, paranoid and avoidant personality disorder.
The tricyclic antidepressant, imipramine, the MAO inhibitor, Phenelzine and the high potency bendodiazepine Alprazolam have been shown to be effective blockers of spontaneous panic attacks. Beta- blocker, propranolol, is effective in social phobias particularly when used acutely prior to a performance.
(i) Systematic desensitization:
It involves gradual exposure to phobic stimulus along hierarchy of increasing intensity until patient habituates and avoidance response is extinguished. Relaxation training is used before situational exposure.
(ii) Flooding (implosion):
It involves supervised maximum exposure to feared stimulus until anxiety reduction/exhaustion.
It involves observation of therapist (model) engaging in non- avoidance behaviour with the feared stimulus.
(iv) Paradoxical Intention:
It is another type of therapy conceived by FrankI to help patients overcome their phobic fears by deliberately exaggerating them.
It consists of learning coping strategies and readjustment of life-style.
b. Psycho dynamic:
It is aimed at exploring conflicts.
3. Essay on Obsessive Compulsive Disorder:
This is an uncommon form of neurosis in which the outstanding symptoms are of obsessional thoughts or compulsive behaviours. Obsessions are recurrent persistent ideas, thoughts, images or impulses that are ego-dystonic, that is, they are not experienced as voluntarily produced but rather as thoughts that invade consciousness and are experienced as senseless or repugnant. Attempts are made to ignore, or suppress them. Compulsions are repetitive and seemingly purposeless behaviours that are performed according to certain rules or in a stereotyped fashion.
The various terms used for obsessive compulsive disorder are—obsessional state; obsessional ruminative state; constitutional syndrome or neurosis; compulsion neurosis; Phobic rumination state; psychasthenia. The term ‘Anancastic’or ‘Anancasm’. includes obsessive, compulsions, obsessive compulsive neurosis and obsessional personality.
Jean Pierre Falret named it as ‘The illness of doubt’. Morel (in 1866) first used the term ‘Obsessive compulsive neuroses’.
Of general population, 0.05% suffers from this disorder at a particular time. Obsessive compulsive disorder constitutes less than 5 percent of psychiatric inpatients and outpatients.
This disorder usually begins in adolescence or early adulthood. Sex prevalence is usually equal.
(i) Obsessional doubts:
This form of obsession is most common.
(ii) Obsessional thoughts:
These are usually unpleasant and repetitively intrude into consciousness (words, phrases, rhymes), interfering with the normal train of thought.
(iii) Obsessional images:
Vividly imagined scenes, often of a violent, sexual or disgusting nature (images of a child being killed, cars colliding, parents having sexual intercourse) that repeatedly come to mind.
(iv) Obsessional convictions:
Notions that are often based on the magical formula of thoughts-equals-act (‘Thinking ill of my son will cause him to die’).
(v) Obsessional rumination:
The subject is often religion or metaphysics- why and where; of questions which are as unanswerable as they are endlessly ponderable, (e.g., Who created world? What is the purpose of life?).
(vi) Obsessional impulses:
Typically related to self-injury (leaping from a window).
(vii) Obsessional fears:
B. Compulsions are of two types:
i. Yielding compulsion.
ii. Controlling compulsion.
The common complications include—depression and the abuse of alcohol and antianxiety medications.
Psychoanalytic theorists suggest that obsessive compulsive disorder develops when defense mechanisms fail to contain the obsessional character’s anxiety.
The following defense mechanisms are used:
Gruesome thought or fantasy, but denies any feelings of anxiety or disgust associated with it.
An act can be undone by its opposite such as turning on and then turning off a light switch.
(iii) Reaction formation:
People might behave in a passive or masochistic manner which opposes his impulses.
In obsessive compulsive disorder, regression is theorized to take place from a genital oedipal phase to an earlier, never fully relinquished anti-sadistic phase.
In obsessive compulsive neurosis, strong aggressive impulses are thought to reemerge towards love objects.
Two stage learning theory of obsessive compulsive disorder is important. In stage 1, anxiety is classically conditioned to a specific environmental event (classical conditioning). The person then engages in compulsive rituals (escape/avoidance responses) in order to decrease anxiety. If successful in reducing anxiety, the compulsive behaviour is more likely to occur in the future (Stage 2 or operant conditioning).
Obsessional symptoms are frequent in patients following head injury, or encephalitis lethargica.
Serotonin has been implicated in mediating impulsivity, suicidally, aggression, anxiety, social dominance and learning. Dysregulation neurotransmitter could contribute to the repetitive obsessions and ritualistic behaviour seen in OCD patients.
About 80 to 90 percent of monozygotic twins are concordant for obsessional illness versus a concordance rate in dizygotic twins of no more than 50 per cent.
Imitative learning, major life events such as pregnancy, delivery, illness, death of a close relative, frustration, overwork etc. may act as precipitants.
An obsession is ego- dystonic, resisted and recognized as having an internal origin. A delusion is not resisted and is believed to be external.
Depression may present with obsessions.
(iii) Phobic disorder:
Also, unlike the phobias, OCD patient can never avoid the obsession.
(iv) Obsessive personality disorders:
These can distinguished by the absence of any recognizable time of onset and the life long history of marked obsessional behaviour.
(v) Physical illnesses:
Obsessions have been observed in the following organic conditions:
Especially during oculogyric crises,
Early stages of arteriosclerotic dementia,
Post traumatic and post encephalitic stages,
Hearing loss with tinnitus,
Certain drugs like isoniazid, alcohol etc.
See Table 18.5 below:
(i) Exposure procedures that aim to decrease the anxiety associated with obsessions.
(ii) Response prevention techniques that aim to decrease the frequency of rituals or obsessive thoughts.
The most promising antidepressant clomipramine is mainly antiobsessional irrespective of depressive symptoms. The other specific 5 HT reuptake blockers Zimelidine, Fluoxetine, Sertraline and Fluvoxamine have also been demonstrated as specific antiobsessional.
Exploratory/Interpretative/Insight psychotherapy is contraindicated. Supportive psychotherapy is helpful for acute cases and for dealing with obsessive character traits of perfectionism, doubting, procrastination and indecisiveness.
It may lead to striking reduction in tension and distress. Cingulectomy is preferred over lobotomy.
Electroconvulsive Therapy (ECT):
The role of ECT in OCD without depression is not known and is relatively contraindicated.
See Table 18.6:
4. Essay on Hysterical Neurosis:
Hysteria is a mental disorder in which motives, of which the patient seems unaware, produce restriction of the field of consciousness, loss of memory or dramatic personality change (which may be called ‘dissociative states’) or disturbances of motor or sensory function (which may be called ‘conversion symptoms’).
This is derived from a Greek word ‘Hystera’ meaning womb or uterus. Freud used the word ‘conversion’. Janet coined the terms ‘dissociation’ and ‘la belle indifference’ (literally ‘beautiful indifference’).
Hysteria constitutes about 5-15% of psychiatric consultation services in general hospitals. The disorder is diagnosed much more frequently in women than men. It may be seen in any age-group.
The common physical (conversion) and mental (dissociation) symptoms of hysteria are given in Table 18.7.
The most frequent and important complications of hysteria are repeated surgical operations, drug dependence, marital separation or divorce, depression and suicide attempts.
Hysterical symptoms may therefore develop:
a) To permit expression:
To permit expression although in a masked form of a forbidden wish or impulse.
b) To impose punishment:
To impose punishment on oneself, via the disabling symptom for a forbidden wish
c) To remove oneself:
To remove oneself from an overwhelming threatening life situation.
The symptom is an ‘adaptation’ to a frustrating life experience.
There is no convincing evidence for a genetic aetiology.
The diagnosis of hysteria can be mistaken in three ways:
(i) The symptoms are of a physical disease which has not yet been detected (e.g., Porphyria).
(ii) Undiscovered neurological disease may ‘release’ hysterical symptoms in some unknown way (e.g., Multiple sclerosis, deep or midline brain tumours etc.).
(iii) Genuine physical disease may stimulate hysterical elaboration of symptoms in vulnerable personalities.
(i) Some physical disorders such as multiple sclerosis, systemic lupus erythematosus, acute intermittent porphyria, Polyradiculopathy, cervical spondylosis, parietal or thalamic lesions.
(ii) Undiagnosed physical disorder
(iii) Somatization disorder
(iv) Psychosexual dysfunctions
(v) Psychogenic pain
(vi) Hypochondriasis: In hypochondriasis, typically there are physical symptoms, but there is no actual loss or distortion of bodily function.
(vii) Factitious disorder with physical symptoms
See Table 18.8:
(ix) Histrionic personality disorder:
The patient with hysterical personality is characterized by the features that she is demanding, emotionally immature, manipulative, attention seeking, narcissistic, dependent and seductive or suggestible (Mnemonic ‘Demands’).
For differences between hysterical and epileptic fit see Table 18.9 below:
Immediate management involves reassurance and the suggestion of recovery combined with resolution of any stressful circumstances that provoked the reaction. The approach involves minimizing the factors which reinforce or reward the behaviour (i.e., reducing ‘secondary gain’) and encouraging normal behaviour, (i.e., reducing ‘Primary gain’).
With the use of Suggestion, Abreaction, hypnosis or the effect of intravenous barbiturates, the patient is encouraged to relieve the stressful events which provoked hysteria and to express the accompanying emotions.
The prognosis for conversion disorders that are associated with recent onset, clearly identifiable precipitating events, good premorbid condition and the absence of severe associated psychopathology is usually favourable and the spontaneous remission of symptoms tends to be the rule rather than the exception.
5. Essay on Neurasthenia (Fatigue Syndrome):
The term was given by Beard. Freud (1864) first separated anxiety neurosis from neurasthenia.
In one type, the main feature is a complaint of increased fatiguability after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks.
In the other type, the emphasis is on feelings of bodily or physical weakness and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pain and inability to relax.
In both types, a variety of other unpleasant feelings are common, such as dizziness, tension headaches, feelings of general instability, worry about decreasing mental and bodily well-being, irritability, anhedonia, insomnia or hypersomnia and varying minor degrees of both depression and anxiety are common.
(i) Psychiatric disorders.
(ii) Somatoform disorders.
(iii) Physical Disease e.g., aftermath of a physical illness (particularly influenza, viral hepatitis or infectious mononucleosis).
(iv) Drugs, e.g., beta-blockers, antipsychotics, antidepressants, anticonvulsants, drugs causing myopathy (alcohol, lithium, cimetidine etc.) and other drugs abuse.
Bed rest, leave from office, short course of antianxiety drugs and psychotherapy have been used successfully in the treatment of this disorder.
6. Essay on Hypochondriasis: (Hypochondriacal Disorder):
Hypochondriasis is defined as a persistent preoccupation with a fear or belief of having one or more serious disease(s), based on person’s own interpretation of normal body function or a major physical abnormality.
Other important features are:
1. Complete physical examination and investigations do not show presence of any significant abnormality.
2. The fear or belief persists despite assurance to the contrary by showing normal reports to the patient.
3. The fear or belief is not a delusion. Patient may agree, regarding the possibility of his exaggerating the graveness of situation, at that time.
4. Preoccupation with medical terms and syndromes is common. Repeated change of physicians is common.
The usual age of onset is the late third decade. The course is usually chronic with remissions and relapses. Obsessive personality traits and narcissistic personality features are frequently seen in addition to associated anxiety and depression.
The cause of hypochondriasis is not known.
The important theories are mentioned below:
1. Psychodynamic Theory:
Hypochondriasis is believed to be based on a narcissistic personality, caused by a narcissistic libido. Here other parts of body become erotogenic zones, which act as substitutes for genitals. Hypochondriac organs symbolize the genitals. This is only a theoretical construct.
2. As a Symptom of Depression.
Hypochondriacal symptoms are commonly present in major depression. In fact according to some, hypochondriasis is almost always a part of another psychiatric syndrome, most commonly a mood disorder. Thus, hypochondriasis has been visualized as a masked depression or depressive equivalent. However, this has not been proven till now.
The treatment is often difficult.
It consists of:
1. Supportive psychotherapy.
2. Treatment of associated or underlying depression and/or anxiety, if present.
7. Essay on Reaction to Stress and Adjustment Disorders:
This category in ICD-10 consists of those disorders which are temporally related to an exceptionally stressful life event (acute stress reaction and post-traumatic stress disorder) or a significant life change (adjustment disorders) immediately before the onset.
1. Acute Stress Reaction:
According to ICD-10, in this disorder there is an immediate and clear temporal relationship between an exceptional stressor (e.g., death of a loved one, natural catastrophe, accident, rape) and the onset of symptoms. The symptoms show a mixed and changing picture. This disorder is more likely to develop in presence of physical exhaustion and in extremes of age. It is more commonly seen in females and people with poor coping skills.
The symptoms range from a ‘dazed’ condition, anxiety, depression, anger, despair, over activity or withdrawal, and constriction of the field of consciousness. The symptoms resolve rapidly (with in few hours usually) of removal from stressful environment is possible. If the stress continues or cannot be reversed, resolution of symptoms begins after 1 -2 days and is usually minimal after about 3 days.
The treatment consists of removal of the patient from the stressful environment and helping the patient to ‘pass through’ the stressful experience. IV benzodiazepines (e.g., clonazepam or diazepam) may be needed in patients with marked agitation.
2. Post-Traumatic Stress Disorder (PTSD):
According to ICD-10, this disorder arises as a delayed and/protracted response to an exceptionally stressful or catastrophic life event or situation which is likely to cause pervasive distress in almost any person (e.g., disasters, war, rape or torture, serious accident). The symptoms of PTSD may develop, after a period of latency, within 6 months after the stress or may be delayed beyond this period.
PTSD is characterized by recurrent and intrusive recollections of the stressful event either in flashbacks (images, thoughts, or perceptions) and/or in dreams. There is an associated sense of re-experiencing of the stressful event. There is marked avoidance of the events or situations that arouse recollections of the stressful event, along with marked symptoms of anxiety and increased arousal.
The other important clinical features include partial amnesia for some aspects of the stressful event, feeling of numbness, and anhedonia (inability to experience pleasure).
The treatment consists of the following measures:
Anticipation of disasters in the high risk areas, with the training of personnel in disaster management.
b. Disaster management:
The speed of providing help is of paramount importance. This is also a preventive measure.
c. Supportive psychotherapy.
d. Drug treatment:
Antidepressants and benzodiazepines are useful in treatment if anxiety and/or depression are important components of the clinical picture.
3. Adjustment Disorders:
Adjustment disorders are one of the most common psychiatric disorders seen in clinical practice. They are most frequently seen in adolescents and women. Although adjustment disorder is often precipitated by one or more stressors, it often represents a maladaptive response to the stressful life event(s).
In ICD-10, this disorder is characterized by those disorders which occur within 1 month of a significant life change (stressor). This disorder usually occurs in those individuals who are vulnerable due to poor coping skills or personality factors. It is assumed that the disorder would not have arisen in the absence of the stressor(s). The duration of the disorder is usually less than 6 months, except in the case of prolonged depressive reaction.
The various subtypes include brief depressive reaction, prolonged depressive reaction, mixed anxiety and depressive reaction, with predominant disturbance of other emotions, with mixed disturbance of emotions and conduct. Most patients recover within a period of three months.
1. Supportive psychotherapy remains the treatment of choice.
2. Crisis intervention is useful in some patients, by helping to quickly resolve the stressful like situation which has led to the adjustment disorder.
3. Stress management training.
4. Coping skills training.
5. Drug treatment may be needed in some patients for the management of anxiety (benzodiazepines) and/or depressive symptoms (antidepressants).
8. Essay on Grief Reaction:
Grief is the normal response of an individual to the loss of a loved object, e.g., a close relative or a friend, material values or non-material things such as reputation and self-esteem.
Grief is a universal phenomenon which is usually transient and self-limiting. Uncomplicated grief is not a psychiatric disorder and does not usually require psychiatric treatment. However, as physicians (and rarely psychiatrists) are sometimes called to intervene in cases with complications, the condition is discussed here.
Following the loss, there is often a state of shock. The grieved person feels a sense of bewilderment or numbness, or he may completely deny the loss. Although most commonly this state lasts for a few hours, sometimes it may extend up to 2 weeks.
When the full extent of loss is realized, various physical and mental symptoms appear. These include repeated sighing and crying, difficulty in breathing, choking sensation, weakness, poor concentration and poor appetite. These symptoms usually last for 4-6 weeks but may sometimes extend up to 6 months.
Preoccupation with the memory of the deceased is a characteristic feature. This is associated with vivid mental images, vivid dreams and idealization of the deceased (ignoring his negative qualities). These preoccupations are of a comforting nature. This is often associated with a ‘sense of presence’ of the deceased in the surroundings and a misinterpretation of voices and faces of others as that of the lost person. Rarely, fleeting hallucinations may occur.
The grieved person often becomes depressed (see Table 18.10) and becomes slightly withdrawn socially. Guilt feelings, hostility towards others, panic attacks, sense of futility, tiredness, neglect of work and self, insomnia and suicidal ideas may occur. The person may identify with the deceased, taking on his qualities, mannerisms and characteristics.
Morbid or Pathological Grief:
When there is an exaggeration of one or more symptoms of normal grief, or the duration becomes prolonged beyond 6 months without spontaneous recovery, grief becomes morbid.
The various subtypes are chronic grief (duration more than 6 months); delayed grief (onset after 2 weeks of loss); inhibited grief (denial of loss); excessive anxiety, guilt, anger or religiosity grief; identification with the deceased; over-idealization of deceased and anniversary reactions (grief reaction on death anniversary).
Here, grief is complicated by specific neurotic or psychotic illness, in addition to grief reaction symptoms. The various subtypes are hysterical, phobic, obsessive-compulsive, manic or acute psychotic episode.
Stages of Grief:
See Table 18.11.
1. Normal grief does not require psychiatric treatment as it resolves spontaneously. Occasionally, mild anixiolytic or hypnotic may be needed for short-term use.
2. In morbid and (especially) complicated grief, medication may be needed depending on the presenting clinical features.
3. The emphasis should be on:
i. Making the person face for the loss by counteracting denial.
ii. Ventilation of feelings (catharsis).
iii. Ensuring the presence of significant others.
iv. Bringing together similarly grieved persons, to encourage communication, share experiences of the loss and to offer companionship, and social and emotional support.
v. Reinforcement of goal-directed activities.
‘One can feel well but one can never know one is well’ wrote the philosopher Kant, acknowledging his own inclination towards hypochondria. Told that he does not have an ulcer, one of Woody Allen’s neurotically anxious film counterparts simply retorts ‘they haven’t found one yet’. The hypochondriac may be in good health but remains tormented by supposed symptoms and the certainty of the illnesses to which they point. In Mark Haddon’s novel A Spot of Bother (2006), the central character finds a small lesion on his hip and plunges into hypochondriac panic; though diagnosed as no more than discoid eczema, he knows the spot is a fatal cancer. That tests indicate nothing wrong brings no relief to the hypochondriac; indeed, so-called health is a very doubtful state of affairs, which was Kant’s point. None of which makes hypochondriacs altogether welcome at their medical centre, arousing as they can impatience and professional unease with their unshakeable conviction that something is amiss. M, the title character of Graham Swift’s story ‘The Hypochondriac’ (1985), turns up repeatedly at his local surgery always to be reassured that all is well, until ordered never to return. Subsequently informed that M is seriously ill, his doctor delays a home visit, finally arriving to find that M has died in hospital—but of what? Autopsy reports ‘could reach no certain conclusions about the causes of M’s death’, which is a tribute to his hypochondriac identity: his hypochondria was justified and medical science failed him.
The medical term today is ‘hypochondriasis’, leaving ‘hypochondria’ as the lay term for more or less excessive health anxiety. The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) includes hypochondriasis among the somatoform disorders, defining it as preoccupation with fears of having, or the idea that one has, a serious disease based on misinterpretation of one or more bodily symptoms. Hypochondriacal concerns may be transient, prompted by specific circumstances (bereavement, for example); equally they may appear in the course of another mental condition (depression, for example). Where the concerns are primary and continue for over 6 months, the diagnosis of the specific mental disorder can be made. The iconic figure of the hypochondriac is the imaginary invalid fearfully obsessed with his health and his doctors depicted in Molière’s comedy Le Malade imaginaire (1673), or in Daumier’s 1841 lithograph of a haggard-faced sufferer anxiously taking his pulse (Fig. 1). Naturally enough, hypochondria has been linked to undue fear of death; hypochondriacs, as Darwin’s grandfather Erasmus put it, are ‘attended by so much fear, or expectation, of dying as to induce them to think of nothing but their own health’.
The hypochondriac seeks reassurance, yet reassurance is felt as rejection. Doctors have accredited knowledge, but hypochondriacs know better, and come armed with information gathered from available medical or pseudo-medical sources. One of Webster’s New World Dictionary’s 2008 ‘words of the year’ was ‘cyberchondria’, meaning anxieties about common symptomatology based on internet searches. A Microsoft study of the same year found that searches for such things as headache were as likely to lead to pages describing serious conditions as benign ones, with a consequent escalation of unfounded medical concerns. That commercial internet services now offer individuals genome sequencing and identification of disease-causing mutations can only bring new hypochondriac possibilities. Typically, the hypochondriac multiplies consultations, doctor-shopping for the ideal physician who will take his or her condition seriously, rather than dismissing it as ‘nothing wrong’, and thereby demonstrating obvious medical incompetence. The physician must face the hypochondriac’s fears and take responsibility for deciding there is no cause for concern, with the worry that nevertheless there might be. Moreover, the risk exists of iatrogenic illness: diagnostic investigations—‘just to be sure’—may lead to induction of a disorder, reinforcing the patient’s hypochondriac convictions.
‘Le Malade imaginaire’, a lithograph by Daniel Maclise. History of Medical and Allied Sciences 1969; 24(4): 474–75.
‘Le Malade imaginaire’, a lithograph by Daniel Maclise. History of Medical and Allied Sciences 1969; 24(4): 474–75.
Brian Dillon’s Tormented Hope opens with the lived experience of the hypochondriac, written from personal knowledge. His first book, In the Dark Room (2005), told of an unhappy childhood, the death of both parents while in his teens and his mother’s years of pain from scleroderma. Becoming obsessed with his own health, he developed ‘a prodigious medical imagination’ and took his supposed illnesses round numerous surgeries and hospitals. In Tormented Hope, he turns to ‘nine hypochondriac lives’, with chapters on each to exemplify aspects of ‘the hypochondriacal character’. Neither a history of hypochondria, nor an investigation into ‘what makes a hypochondriac’, the book is intended for the general reader, telling the hypochondriacal stories of James Boswell, Charlotte Brontë, Charles Darwin, Florence Nightingale, Alice James (sister of novelist Henry and psychologist-philosopher William), Daniel Paul Schreber (famously studied by Freud), Marcel Proust, Glenn Gould and Andy Warhol. Disarmingly, Dillon admits that the lives were chosen according to no exact criteria, save that their stories seemed compelling. All nine ‘wrote’ of their health, many indeed keeping meticulous records and Dillon draws on published diaries, letters, memoirs, novels, films even, as well as on existing biographies. The chapter-per-life format forbids substantial treatment, yet Dillon captures nicely the feel of these lives, mixing reflections on hypochondria with novelistic story-telling and scene-setting—recounting the precautions surrounding Proust’s breakfast croissant, or imagining the sun streaming into James’s bedroom and the fussings of her nurse when a renowned physician calls.
Hypochondria has been known as an illness for over two thousand years. First an anatomical term, the word referred (and still does) to the right and left regions of the upper lateral portion of the abdomen and the viscera situated therein (‘hypochondria’ being the plural term, ‘hypochondrium’ the singular, used for the whole area). The Greeks linked a pathology of these regions to the physiological theory of the humours and to a form of melancholia, a morbid entity with digestive symptoms caused by an abundance of ‘black bile’, the atrabile that was one of the cardinal humours of the humoral doctrine underlying ancient and medieval physiology. The Oxford English Dictionary’s first recorded anatomical use of ‘hypochondria’ in English comes from a mid-16th century physician writing of a medicine that ‘healeth flatulentnes of Hypochondria’; while the word’s use for a morbid state of mind, characterized by general depression and lowness of spirits, appears in the following century. Broadly speaking, the history of hypochondria is the movement from a physical or physiological condition to a mental or psychological one, though different kinds of explanation often overlap.
For Robert Burton in The Anatomy of Melancholy (1621; Fig. 2), the ‘hypocondries’ were one of the seats of melancholy. A frontispiece added to the third edition (1628) depicts the several types of the melancholic, among them Hypocondriacus shown in conventional melancholic pose, potions from his apothecary scattered around him: ‘Hypocondriacus leanes on his arme/Winde in his side doth him much harme/And troubles him full sore’, as a poetic ‘Argument’ explained in subsequent editions. As expected, the ‘Causes of Hypochondriacall or Windie Melancholy’ lie in the abdominal viscera, with symptoms that include ‘sharp belchings’, ‘fulsome crudities’, ‘heat in the bowels’, ‘comely fits’, ‘turbulent dreams’ and many more. Burton’s account is from within the theory of the humours; there may be psychological effects—fear and sadness—but they stem from excess of black bile and disorder of the hypochondria. Some few decades later, Thomas Willis replaced humoral physiology with an anatomical consideration of the brain and nerves, seeing ‘hypochondriacal affects’ as being largely ‘convulsions and contractions of the nervous parts’. Physical and mental symptoms—‘distractions of the spirit’—go together. Thomas Sydenham, Willis’s contemporary, made hypochondria a matter of the ‘animal spirits’, those conducting agents between mind and body whose action could be affected by either: lack of ‘firmness’ of the spirits brings ‘disturbance and inconsistency of both mind and body’.
The frontispiece to The Anatomy of Melancholy by Robert Burton. This was added in the third edition in 1632 and appears thereafter.
The frontispiece to The Anatomy of Melancholy by Robert Burton. This was added in the third edition in 1632 and appears thereafter.
The 18th century saw a growth in works devoted to hypochondria and related disorders, with differing accounts of the interactions between the mental and the physical. In Bernard de Mandeville’s Treatise of the Hypochondriack and Hysterick Passions (1711) a long-afflicted ‘hypochondriaticus confirmatus’ with gastro-intestinal symptoms is assured that ‘disorders of the chylifications’ are the cause of his hypochondria. Nicholas Robinson’s A New System of the Spleen, Vapours and Hypochondriack Melancholy: Wherein all the Decays of the Nerves, and Lownesses of the Spirits, are mechanically Accounted for (1729), as the title suggests, regards psychological processes as the expression of events in the nerves and fibres making up the brain, this providing the basis for a ‘mechanical’ explanation of hypochondria. While Robinson is a determined somatist, the trend is towards ideas of nervous organization that suggest the influence of mind on body. For Robert Whytt in his Observations on the Nature, Causes, and Cure of those Disorders which have been commonly called Nervous, Hypochondriac, or Hysteric, to which are prefixed Some Remarks on the Sympathy of the Nerves (1765) nervous disorders follow from either ‘a too great delicacy and sensibility of the whole nervous system’ or ‘an uncommon weakness, or a depraved or unnatural feeling, in some of the organs of the body’. The delicate balance of fibres between the nerves and the brain forms connections and correspondences that make organs or body parts sympathetic with each other. Such ‘sympathy of the nerves’ explains how changes in the body can be produced by ‘the several passions in the mind’, hypochondria resulting from the interaction of the two, a matter, so to speak, of pathological sympathy.
Burton mentions the case of a student who believed himself made of glass and lived in fear of being shattered, a case given major literary expression in Cervantes’ novella El Licenciado Vidriera (1613). For Burton and others, it exemplified hypochondria as madness; as it still did two centuries later when Samuel Taylor Coleridge cited the ‘glass graduate’ in his classification of hypochondriasis as a ‘division of madness’, that of ‘being out of one’s senses’ (distinct from ‘derangement of the understanding’ ‘being out of one’s wits’). The 18th century had largely separated hypochondria from insanity; it might affect the intellectual faculties but seldom resulted in lunacy. If Samuel Johnson could talk of his hypochondria as madness, Boswell insisted it was not—‘the mind itself was ever entire’. Coleridge’s out-of-one’s-senses hypochondriasis continues, however, in the 19th-century conception of ‘delusional hypochondriasis’ linked to a disturbance of brain function. For the psychiatrist Sir George Savage (1892), hypochondria covered a disorder ‘varying from slight over-sensitiveness to insanity with marked delusions and actively suicidal tendencies’. Today DSM-IV-TR keeps hypochondriasis distinct from delusional disorders: it lacks ‘delusional intensity’, though there is ‘often a thin line between preoccupation and fear which is a conviction and that which is a delusion’.
If hypochondria is associated with a particular nervous sensibility, special qualities can be attributed to the hypochondriac. Sir Richard Blackmore, author of A Treatise of the Spleen and Vapours: or, Hypocondriacal and Hysterical Affections (1725), describes hypochondriacs as having ‘quick Apprehension and Vivacity of Fancy and Imagination’, as well as possessing superior intelligence (the philosopher Hume called hypochondria ‘the Disease of the Learned’). So much so that moderate forms of the condition are ‘rather desirable than hurtful’ and best not treated. Johnson thought this a foolish notion; Boswell, his biographer, agreed, while nevertheless consoling himself and his fellows with the thought that their ‘sufferings mark our superiority’. The idea was found too in the most celebrated 18th-century work, George Cheyne’s The English Malady: or, A Treatise of Nervous Diseases of all Kinds, as Spleen, Vapours, Lowness of Spirits, Hypochondriacal, and Hysterical Distempers, &c (1733). Intended for ‘common intelligent readers’, especially sufferers like Cheyne himself, it was something of a bestseller. Health is again a matter of ‘strong Spirits and firm Fibres’; ill health one of ‘Weakness of Nerves’, with mental disorders stemming from a somatic disorder of the nerves. Cheyne thus always focused on the hypochondria, sure to find that ‘the Stomach, Guts, Liver, Spleen, Mesentery or some of the great and necessary Organs, or Glands of the lower Belly were obstructed, knotted, schirrous, or spoil’d’. The English were notably prone to hypochondria and other such ‘distempers’ as a result of such factors as damp air and unhealthy towns, but crucially too of the wealth and abundance of the contemporary society. Everything, from rich food to the growth of ‘Contemplative and Sedentary Professions’, made for the prevalence of nervous disorders amongst ‘People of Condition’—these disorders testifying indeed to their distinction; to their class.
Gender terms could also make a difference. Today hypochondriasis is common in both males and females. The recognition of hypochondria as a condition affecting females appeared early on, at the same time that hypochondria and hysteria were also gender differentiated, the latter continuing to be seen as particular to females. Johnson’s Dictionary (1755) conventionally defines hysteria as linked to disorders of the womb, hence female; though already a century earlier Willis had drawn the two together as disorders of the brain, while Sydenham had described them as alike ‘as one egg is to another’. In Johnson’s own century, Blackmore and Whytt considered them ‘the same malady’, though they also maintained hysteria’s relation to females, whose nervous system was ‘generally more moveable than in men’. Hypochondria was associated with males, but female hypochondriacs were recognized. Of the three hypochondriac young adults of Jane Austen’s Sanditon (1817), for example, two are female.
Treatments were various. Burton ended the ‘Anatomy’ with the precept ‘Be not solitary, be not idle’. Johnson thought the antidote was employment, though Boswell also favoured ‘the reading of lives’ and the pleasures of the metropolis. The Methodist John Wesley recommended quicksilver in the morning and elixir of vitriol in the afternoon, while Blackmore advocated ‘the most violent vomits’. William Buchan’s bestselling Domestic Medicine (1769) unhelpfully prescribed ‘cheerfulness and serenity of mind’, earning justifiable scorn from the hypochondriac Coleridge. In the 19th century, rest cures were popular, the more especially when attempts to locate corresponding brain lesions for hypochondria failed. Today, no specific psychotherapy has been identified for the condition, cognitive behavioural therapy being only moderately effective; pharmacological treatment using selective serotonin reuptake inhibitor (SSRI) antidepressants has known some success.
Dillon’s lives run from the 18th to the 20th centuries. His case is that hypochondria for these individuals was ‘a kind of calling, almost a vocation’, structuring their lives in a way that allowed them time and space: ‘At once crippled and cosseted by fear, the hypochondriac suffered in order to work, to write or to discover in solitude.’ This idea of ‘creative malady’ stems originally from the book of that title by the physician Sir George Pickering, who examined the positive role of psychoneurotic illness in six talented lives (Dillon’s Darwin, Nightingale and Proust among them). Dillon narrows the focus to hypochondria, proposing the ‘ambitious, if perilous, conjecture’ of an intimate link between the health anxieties of his subjects and their creative or intellectual labours. The lives share much as regards invalidism and suffering, though the meaning, reality and evidence of hypochondria as a diagnosis shifts in each case—‘what exactly was the matter with …?’ is a recurrent—and undecided—question from life to life.
Dillon introduces his creative hypochondria thesis with the textbook example of self-diagnosed hypochondriac James Boswell. Born with ‘a melancholy temperament’, Boswell was early seized by ‘a terrible hypochondria’ with which he struggled thereafter; that he should write the life of Johnson was fitting given the latter’s own ‘vile melancholy’ and ‘horrible hypochondria’. Boswell’s melancholy came with the classic digestive symptoms, his hypochondria both a physical condition and a state of ‘disordered imagination’ to be resisted. To which end he developed what Dillon characterizes as a ‘fraught, compulsive, hypochondriac relation to time’, forever making lists and timetables, filling his days with writing commitments, including monthly essays for the London Magazine written indeed in the persona of ‘The Hypochondriack’. The obsession with time served to control his hypochondria, shaking him from lethargy; but the hypochondria itself produced the obsession, generated his literary activity.
The other lives follow apace. The young Charlotte Brontë found life ‘a continual waking Night-mare’, with no repose for her ‘morbid nerves’ (‘sensation for them is all suffering’). Hypochondria, her word, continued over the years: intense depression, headaches, dyspepsia, troubled eyesight. Her novels reflect this: the autobiographical Villette (1853), for example, has a ‘low-spirited’ heroine who is similarly diagnosed, only too familiar with ‘that strangest spectre, Hypochondria’. Dillon reads Brontë’s hypochondria as her means of removing herself from family and social duties: ‘by falling ill … she can find for herself the right kind of solitude, in which to invent her future self’. Darwin, back in England after the years on the Beagle, developed a range of symptoms, primarily gastro-intestinal, and embarked on an invalid existence. In 1849, he spent time at Dr James Gully’s fashionable Water Cure Establishment in Malvern, where his condition was diagnosed as ‘nervous dyspepsia’ consequent on excessive mental exertion and attendant bad circulation. The cold water treatment to improve circulation and relieve the inflamed nerves of the stomach was effective enough for Darwin to endure it at home, submitting to daily drenchings in his garden, despite which his ill health continued; whether or not this was psychosomatic remains a matter of debate. Darwin himself, drafting The Origin of Species and dreading public controversy, declared his work to be the cause, ‘of the main part of the ills to which my flesh is heir’, though physical conditions—notably Chagas and Crohn’s diseases—have been proposed to explain his symptoms. The point, however, is not so much physical or mental as both together: somatic conditions and psychoneurotic disorder; or strategy, since the outcome was the isolation he needed. Illness was, in Pickering’s phrase, ‘a social weapon’, shielding him from public life.
The same goes for Florence Nightingale, described by Lytton Strachey as employing ‘the machinery of illness’ against the world; by Pickering as ‘a beautiful case of a psychoneurosis with a purpose’. A young female given to depression and low self-opinion, she found her saving mission in the Crimea. Home again, she collapsed with severe cardiac symptoms, recovered, but remained depressed, afflicted by nausea, insomnia, laryngitis and palpitations. She too began years of reclusive invalidism, conducting her vigorous campaigns for hospital improvements from her bed, cut off from time-wasting social demands. If this was a strategy, she was nevertheless genuinely ill, probably suffering from chronic brucellosis, the myriad symptoms of which were easily attributable to ‘neurasthenia’. Dillon judges her ‘the most ambitious of high Victorian hypochondriacs’; saintly perhaps, but also ‘a monster of self-belief, self-delusion and expertly deployed enfeeblement’. After which it comes as something of a surprise to find Alice James celebrated as ‘a curiously fearless kind of hypochondriac’, worried less about what might be found wrong with her than about the ministrations of her physicians, who she was pleased to record nevertheless acknowledged her ‘abnormally sensitive nervous organization’. Given which, her position as a female, and this in a family of eminent males, took its toll. Biographers see her as turning victimization into a career, expressing anger through intractable illness, which brother Henry indeed declared ‘the only solution for her of the practical problem of life’. Treated for neurasthenia, she had what she called ‘violent attacks of hysteria’ and ‘squalid indigestions’, suffered spinal pain, and saw her life as a battle between body and will. She made illness, Dillon argues somewhat awkwardly, an intellectual and artistic work ‘comparable, in the domestic sphere, with the public labours of her brothers’; her hypochondria allowed her ‘to be just ill enough not to have to face the creative and emotional void at the heart of her short life’. When finally diagnosed with cancer, she gained an end to medical uncertainties and the relief of something concrete, to which she responded with such self-possession that Dillon declares to be itself pathological.
Proust thought of writing a book about doctors, which he could well have done given the number he consulted and his distrust of them. He suffered from asthma, was hypersensitive, and intensely hypochondriac, mostly confining himself to bed in his cork-lined room. One partial exception to his distrust was the neurologist Edouard Brissaud, whom Proust did think vastly intelligent, though a poor doctor—‘[he] thinks … one should live on trional’. For Brissaud, author of a book on the subject, asthma was a neurosis; Proust agreed, not doubting that his asthma and other ailments were linked to his nervous disposition. Dillon concludes that through invalidism he responded to his illnesses by living them as justification for the isolation needed to write A la recherche du temps perdu, the novel whose language and matter are grounded in his hypochondriac sensitivity.
Glenn Gould and Andy Warhol shared acute hypochondria. Gould kept a diary of his imagined symptoms, noting blood pressure, digestion, flatulence, spots on the tongue, whatever his anxiety suggested. Public recitals were abandoned for the safety of his home recording studio where he could create the best environment for his work, while avoiding the health hazards of the outside world; hypochondria thus became a condition of his artistic fulfillment. Warhol, who claimed three nervous breakdowns as a child, was obsessed with his health and appearance, longing for a ‘good body’, but tormented by his ‘bad’ one, a body open to illness, infection, ageing, in which he could never feel at home. Dillon sees in his films particularly a kind of diagnosis of his ‘style of hypochondria’. In Sleep (1963), for example, Warhol’s camera-eye contemplates for over five hours a sleeping naked man, a projection on screen of the longed-for, at-one-with-itself body, the positive to the negative in the hypochondriac two-bodies split that structures Warhol’s life and art, determining their chronic concern with beauty and death.
Written testimonies aside, what these eight lives have in common are combinations of symptoms, physical illnesses and nervous conditions with psychosomatic effects, illustrating versions of ‘the hypochondriacal character’, from the hypochondria of melancholy and depression to that of acute health anxiety. But what of the ninth? Pickering had Freud as one of his lives; Dillon takes the German jurist Daniel Paul Schreber, on whose Memoirs of My Nervous Illness (1903) Freud based an analysis of him as ‘a case of paranoia’. Schreber returns us to delusional insanity, to ‘glass graduate’ hypochondria, and Freud, indeed, came to understand hypochondria not in terms of neurosis but rather in those of paranoid psychosis. Paranoiacs ‘almost invariably’ become convinced that one or more bodily organs have been assaulted or removed; a conviction Freud described as the production of an ‘organ speech’ in which organs take on the representation of the underlying unconscious material. Amongst other things, Schreber believed that his stomach had been stolen, that his spinal cord was being pumped out, and that he was being turned into a woman by God (his rigidly controlling and demanding father, object of unconscious conflicts and desires). Not that Schreber regarded his mind as anything other than perfectly healthy, save for ‘some unimportant hypochondriacal ideas’; another delusion, and one that unwittingly falls in with Freud’s insistence on hypochondria as a matter of more than a few neurotic health anxieties (DSM-IV-TR, it can be noted, recognizes a ‘monosymptomatic hypochondriacal psychosis’ among its delusional disorders). Schreber is thus different from Dillon’s other lives: his condition did not free him, it confined him in asylums. That the Memoirs are an extraordinary record of his delusional paranoia, praised for their qualities as imaginative literature—for Schreber they were quite simply the truth—does not make him another hypochondriacal character like Brontë or Gould, another instance of creative malady. The Memoirs were themselves part of the delusional condition and that condition was not strategically negotiated in the interests of some separate purposeful pursuit, was quite apart from the hypochondria that Dillon explores in his other lives.
Hypochondria has now become the lifestyle of a world in which we are forever enjoined to look good, live healthy, be happy; a world, in other words, in which we are to be permanently anxious. Dillon hails Warhol as ‘our hypochondriacal precursor’: his living in one body while longing for another gives apt enough expression of our situation in an age of media-fuelled health preoccupations and body-image vigilance. The French surgeon René Leriche famously defined health as ‘life in the silence of the organs’. Hypochondria in its historical understandings has always been an emphatic loss of such silence. What we have today is a range and diversity of hypochondriac manifestations; as clinical condition, yes, but then much more too as culturally extensive anxiety and preoccupation; to which Dillon’s book itself bears witness even while helping us through the presentation of its chosen lives better to understand hypochondria on its past and present terms.
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