Hypochondriasis: An Intrapsychic Phenomenon
By Abne EisenbergFrom a clinical perspective, hypochondriasis is described as a neurotic disorder characterized by a preoccupation with bodily functions and a morbid fear that one is suffering from serious disease. Paul Mac Lean, MD, describes such a psychosomatic condition as follows: "Emotional feelings, instead of finding expression and discharge in the symbolic use of words and appropriate behavior, must be conceived as being translated into a kind of "organ language." As such, the diagnostician must be on constant alert for nonverbal signs; e.g., hypertension, gastrointestinal distress, vertigo, cephalagia, etc. A plethora of symptoms may be elicited by a patient suffering from hypochondriasis -- all are expressions of what is being referred to here as "organ language."
When both sender and receiver occupy the same body, it is called intrapsychic communication (IPC), also referred to in communication theory as intrapersonal communication. Consciously or unconsciously, we all communicate with ourselves on a verbal, nonverbal, and vocal level. When we think, write in a diary, meditate, or rehearse a speech, it is called verbal IPC. When we make faces in a mirror, exercise, or pace back and forth, it is called nonverbal IPC. When we moan, groan, cry, laugh or sigh, it is called vocal IPC. When we bite our nails, rub a sore muscle, or pick particles of food from between our teeth, it is called tactile IPC. When we check to see if our underarm deodorant is working, it is called olfactory IPC. Each of the aforementioned employs a sensory pathway enabling us to experience a sense of self.
In an age where stress has become a household word, and practically everyone has experienced it to some extent, it is essential that we understand which biologic system it preempts -- especially, when it is taken to an extreme. The symptoms a patient manifests will depend upon which system is selected as a channel for the expression vehicle for stress. Some break out in a rash, others develop diarrhea, while still others get light-headed and faint. Only a small proportion of our thoughts find their way into verbal or iconic form; the greater percentage are internally retained and stored as memory.
Becoming sensitive to one's own nonverbal IPC can be an asset or a liability. In the case of hypochondriasis, it is a liability. Acting as an asset, it enables us to enjoy a more total sense of self. We constantly get feedback from all parts of our body. The professional athlete, in particular, depends upon such feedback for maximum muscle coordination and split second timing.
When you awoke this morning, how did you know you were awake and that everything was OK? Autonomically, a routine check was made to determine whether all of your senses were in good working order and that your muscles will obey the commands they are given by your brain: all of this accomplished through feedback.
For a dramatic example of negative intrapsychic feedback, we must think of the first-time speechmaker. Stage fright almost invariably evokes such reactions as dryness in the mouth, weakness in the knees, profuse sweating, and the proverbial lump in the throat. Any of these symptoms, taken to an extreme, characterizes the behavior of a hypochondriac -- someone who works himself up into an inappropriate state of anxiety and apprehension. The reason they give may be real or imagined.
Perhaps you know people who have a perpetual need to know how they look. They spend inordinate amounts of time in front of a mirror. With meticulous care, they examine themselves in great detail. Then there are those whose preoccupation is with movable body parts; they habitually wiggle their fingers, shrug their shoulders, and stretch. Fortunately, the majority of us require only a modest amount of such nonverbal intrapsychic feedback to have a sense of well-being. Only when this need becomes distorted, or exaggerated, is there a basis for concern.
Abraham Kaplan's Law of the Instrument states: "Give a small boy a hammer and he will find that everything he encounters needs pounding." This penchant for hammering could be analogous to Pasteur's germ theory. Prior to 1868, before bacteria became the target for organized medicine, humors of the body received their undivided attention. Then came the microbe hunters; with few exceptions, a search for the offending organism was on. In 1895, D.D. Palmer gave birth to subluxation hunters; with few exceptions, a search for the offending subluxation was on. In both instances, the axiom: one-cause, one-cure, prevailed. Only the more sophisticated in each profession approached disease from a more holistic (multi-dimensional) perspective.
It is fitting that we now address something called somatization, the phenomenon whereby cognitive imprints experientially generate inimical symptoms in various body parts. Once these noxious impressions manifest themselves in the musculoskeletal system, neural feedback via proprioceptors qualify as an integral part of the intrapsychic communication network.
Regardless of which culprit health care professions choose to single out as their prime suspect, susceptible patients in each field quickly become habituated. Talk to anyone who has been in analysis for years; their rhetoric is often stereotypical. The same indictment may also be applied to medicine as well as chiropractic. People have a compelling need to know what is causing their discomfort or disease. Whenever an etiology is unknown, rather than simply admitting ignorance, the tendency is to say something -- regardless of whether or not it is clinically valid.
Carl Jung suggests that the "self" is the product of intrapsychic communication, or the behavioral result of a dialogue between unconscious values and conscious experience that is going on within every person. It is with this perception of self that the hypochondriac has difficulty: that is, a problem keeping the self-image intact.
To the hypochondriac, symptoms are very real. Although objective findings are not always available to validate a given complaint, there are cases in which physical manifestations leave doctors in a quandary. Pseudocyesis is one such phenomenon. It is seen in women who fantasize that they are pregnant and present a visibly enlarged abdomen. Under anesthesia, however, the enlargement disappears.
The placebo effect is also known in therapeutic circles. Numerous studies have reported its effectiveness under controlled circumstances. Henry K. Beecher studied the effects of placebos on patients suffering from conditions including postoperative pain, angina pectoris and the common cold. He estimated that placebos achieve satisfactory relief for about 35 percent of the patients surveyed. In view of this, isn't it ironic that, according to Sissela Bok, a sample of 19 recent textbooks in medicine, pediatrics, surgery, anesthesia, obstetrics and gynecology, only three even mention placebos and none of them deal with either the medical or ethical dilemmas placebos present? I myself, have never encountered a discussion of the placebo-effect as it relates to the adjustment in any chiropractic textbook.
Thorough studies have estimated that as many as 35-45 percent of all prescriptions are for substances that are incapable of having an effect on the condition for which they are prescribed. Can a similar statistic be posited for the adjustment; what percentage of adjustments actually produce the biodynamic effect they profess to deliver? The age old question is begged: To what extent does a patient's mental attitude toward a particular form of treatment mediate its effectiveness?
In his book, "Language, thought, and reality," Benjamin Whorf describes us as cutting up Nature, organizing it into concepts and ascribing significances as we do, largely because we are parties to an agreement to organize it in a certain way. It is staggering to think that the pattern of living each of us embraces grows out of approximately the 100 million nerve impulses pouring into our nervous system every second of the day. In all probability, the hypochondriac organizes aspects of Nature, especially as it applies to the self, in a slightly different manner.
As we listen to our patients on a daily basis, patterns of communicative expression begin to emerge. Patients think and talk about their bodies differently. Opera singers, for example, when referring to their voice will say "the voice" rather than "my voice." Or, a patient with acute sciatica will say, "The leg is bothering me today," rather than "my leg." They tend to disown the offending part and repossess it when it is well.
How people perceive or misperceive themselves is a reality with which the physician must come to terms. Using both quantitative and qualitative language, patients describe their symptoms in various ways; they either exaggerate, understate, or distort what they think or feel. We, as doctors, can neither confirm nor deny subjective symptoms. Unlike body temperature or blood pressure, they cannot be measured with a thermometer or sphygmomanometer. We are obliged to accept what we are told on faith. Fortunately, experience teaches us to discriminate -- to discern whether what a patient tells us makes sense and is consistent with what we know about the body.
This should be our approach to hypochondriasis: First, we must recognize that it is a breakdown in intrapsychic communication (a mismanagement of the self). Second, that mind does influence body. Third, that we have a responsibility to acknowledge and therapeutically address the clinically significant nonverbal as well as the verbal messages the body transmits.
We all hear that inner voice telling us right from wrong, steering us in a particular direction, warning us of impending danger, and inspiring us to try something new. Whether we identify this source of information as coming from the id, superego, unconscious, innate or good old fashion instinct, the messages we get act like a compass or guidepost. The important thing is to develop an ability to distinguish between which messages to honor and which ones to ignore. Trial and error makes this differentiation possible.
Let me recapitulate by saying that we all talk to ourselves; it is perfectly normal. Every patient, on the way to your office engages in the practice. They ask themselves whether they really need to go, whether what they are feeling is really serious, or whether the treatment they are about to receive will make them feel better. This intrapsychic communication deserves both your respect and attention. Why? Because it will act as a baseline, a springboard for your ultimate evaluation of the patient's mental and physical condition. Once you have trained yourself to clinically recognize the allowable parameters for normal intrapsychic or intrapersonal communication, you will be better able to recognize the abnormal, i.e., the hypochondrical patient.
In closing, I propose that the extent to which mind affects body may also include something as final as death, i.e., that we choose "when" to die. Just as the hypochondriac chooses what, where, and how to feel, death may be but another choice.
Dr. David P. Phillips, a sociologist at the University of California, conducted a very interesting study. He sought to determine whether men or women who were gravely ill gave up the ghost before or after their upcoming birthday. The conclusion reached was that, in women, three percent more deaths than expected occurred in the week after their birthday than before it. Among men, however, death peaked just before their birthday.
Dr. Phillips theorized that more men died before their birthday because it may be perceived as a time of taking stock; with less successful men, deciding against living another year. Women, on the other hand, may be more family-connected and, therefore, take a more positive stand. It should also be noted that these attitudes are not restricted to birthdays, but to any other personally meaningful occasion, e.g., a son or daughter graduating from college, and anniversary, or the completion of some special project.
Whether one is speaking of the hypochondrical or ordinary patient, the bottom line is how they communicate intrapsychically -- the messages they send back and forth from mind to body. Careful clinical attention must be paid by every physician, both medical and chiropractic, to how patients talk about their bodies, i.e., whether the voice from within produces biologic harmony or discord (dis-ease) between their inner and outer worlds.
Abne Eisenberg, DC, PhD
Editor's note: Dr. Eisenberg is frequently asked to speak at conventions and regional meetings. For further information on speaking engagements, you may contact (914) 271-4441, or write to Two Wells Ave., Croton-on-Hudson, New York 10520.