AND PSYCHOGENIC .

A PSYCHIATRIC STUDY OF , DISEASE CONVICTION AND SOMATIC PREOCCUPATION.

G.N. BIANCHI.

M.D. THESIS, SUBMITTED FEBRUARY, 1971. LIST OF CONTEt-.l'fS.

INTRODUCTION 1.

REVIEW OF THE LITERATURE (a) DISEASE PHOBIA 2. (b) DISEASE CONVICTION 11. (c) SOMATIC PREOCCUPATION 20.

METHODS 53.

RESULTS (a) DISEASE PHOBIA 61. (b) DISEASE CONVICTION 73. (c) SOMATIC PREOCCUPATION 81.

DISCUSSION (a) DISEASE PHOBIA 93. (b) DISEASE CONVICTION 101. (c) SOMATIC PREOCCUPATION 105.

AN ANALYSIS OF VARIANCE 114.

A PRINCIPAL COMPONENTS ANALYSIS 118.

SUMMARY AND CODA 129.

APPENDICES I CASE HISTORIES 133. II PSYCHIATRIC INTERVIEW FORM 155. III PRINCIPAL COMPONENTS FROM PSYCHIATRIC INTERVIEW 164. IV MATCHING DETAILS 168.

REFERENCES 174.

ACKNOWLEDGMENT S

--oOo-- 1.

INTRODUCTION

Hypochondriasis and though recognized as connnon and important have not been accorded the extensive study that their ubiquity and prominence might be fairly thought to require.

They inhabit the borderlands of and other specialties and possibly because of this detachment are neglected. Another reason may be that people who have troubled bodies but no organic lesion lack popularity with the doctor or even provoke rejection by him.

Hypochondriasis ls only beginning to emerge from the morass of non-definition and uncontrolled observation. To promote this development the subvarieties of hypochondriasis are here specifically defined and their characteristics compared with those of control psychiatric patients having no disease phobia, disease conviction, somatic preoccupation or psychogenic pain.

Psychiatric patients, the subjects of this study, are a specialized group, but the principle of control may decrease any objection to this selectivity. Obviously replication will be needed from general practice and other settings. As a first step however, it is more practical to heed Jane Austen's advice to employ the material closest at hand "as a small bird builds its nest from the mosses and twigs of the tree it lives in". 2.

REVIEW OF THE LITERATURE (a) DISEASE PHOBIA

Disease phobia, one variety of hypochondriasis, has not been systematically studi~d. It is used here to mean "a persistent unfounded fear of from a disease, with some doubt remaining despite examina­ tion and reassurance". Most people experience disease fears at one time or another. When persistent or disruptive they are called disease . Usually the fear is brief and not consuming. Disease fear is so common among medical students that it is referred to as medical students' disease (Woods et al., 1966). It responds well to reassurance and only a small number attend a psychiatrist. Indicative of its mild ubiquity is the observation of Hunter et al. (1964) that the physicians to whom the nosophobic students turn, react with tolerance and even good natured indulgence. Disease fears commonly lead people to seek medical advice, not from the psychiatrist but from the general practitioner or in a hospital outpatients' department. In a paper on in 1948 Ryle made the point that "physical and fears are the two primary dis-eases which our patients bring to us; and the latter are generally-brought to us in the guise of the former". In disease conviction the patient is resistant to reassurance from the doctor, despite thorough examination and subsequent discussion. He is convinced beyond all doubt. In the disease phobic patient the disease fear may temporarily subside with thorough reassurance but usually the patient continues to harbour a doubt. Stenback and Jalava (1962) defined nosophobic hypochondria as "an unfounded fear of suffering from a disease". It seems necessary for operational purposes to add to this time and severity qualifica­ tions giving the modified definition above. Lack of definition has plagued the study of hypochondriasis generally and of disease phobia in particular. As Marks (1969) states in his book Fears and Phobias, "systematic study of nosophobia has rarely been attempted and the definitive status of illness phobias awaits further clinical and psychophysiological study". Indication of this neglect is that only a little over three of the 270 text pages of his book are needed to deal with the subject. Wolf (1966) diagnoses the impasse thus, "only after everyone understands what is being referred to by the term will it be possible to consider what hypochondriasis is, what brings it about, how it is to be treated and what its relationship to other psychopathological manifestations may be". 3.

CULTURAL FACTORS. Drug taking and drug prescribing are part of our popular health culture and characterise almost all transactions between doctor or shop-counter and patient. A popular song Lilly the Pink reflects our optim­ ism regarding oral prophylaxis - "We'll drink a drink a drink to Lilly the Pink, the pink, the pink the saviour of the human race, for she invented medicinal compound, most efficacious in every case." Bittner (1967) sums up the changed attitude of modern man, "As once we have searched the heavens to tell us our fate, so are we now attuned to the quivers of our body." If an individual has no immediate explanation for these "quivers" it is natural that he will label this condition and describe his feelings in terms of the cognitions available to him in his culture. As Kerry (1960) remarked in an article on phobia of outer space "it appears that the contents of phobias are more liable to reflect common anxieties than are other neurotic symptoms". Lauter and Schon (1967) studied the symptom components of and how they have changed from 1910 to 1963. Though there had been an increase in somatic complaining, incidence of disease fears and phobias had not changed. Though they did not mention whether the form of the disease phobia had changed one would certainly expect a shift. Laughlin (1956) commented that broad cultural influences have affected the "popularity" of certain phobias instancing the switch from 16th century fears of demons, witches and sorcery to fears of and heart disease. A campaign to educate the public about caused many patients to present with fears of that disease (Pope, 1911). Venereal disease fears too, once had a strong vogue and still do in some populations with a high incidence of gonorrhoea. German and Arya (1969) for example, report that a third of patients with anxiety states in a Uganda student population had fear of venereal disease. Venereal disease, does not appear to be the popular basis for phobia it once was. Macalpine (1957) quotes that the incidence of "venereal disease " had not declined with the incidence of disease, and suggests that "this trend will continue until such time as venereal disease has lost its significance in the popular mind as the last word in doom and dissolution". 4.

The prevalent fears and phobias today are more of cancer and heart disease. In "primitive" societies the sufferer from inexplicable pains or mysterious bodily events tends to blame the environment. Risso and Boker (1968) describe how in Switzerland the emigrant worker from southern Italy may ascribe his bodily symptoms to a love potion brewed by a wicked woman; "in his cultural background does not exist so that the only way that he could account for the physical symptoms of his anxiety was to suppose that he was a victim of a love po~ion". A similar tendency has been observed among Australian Aborigines - instead of becoming introspectively sensitized to the somatic concomitants of anxiety that lead people in our own society to have disease phobia, Aborigines in their world of traditional beliefs become more projectively sensitized with increased affirmation of a hostile and magical environment. They fear evil beings and vicious medicine men rather than cancer and heart attacks (Bianchi et al., 1970). Among south-east Asian Chinese, concern abcut penile shrinkage is a common neurotic symptom (Ngui, 1969). Some racial groups seem more prone to develop disease phobias than others. For example, the Irish are said to deny illness and pain whereas to the Italians, who complain vociferously, pain is important and easily leads to fear of having an illness (Opler and Small, 1968; Zola, 1966). Religion is another aspect of culture which could possibly influence the readiness of a person to fear himself diseased. We might expect this to occur in those pessimistic, hell and brimstone religions which dwell on the expectancy of doom (Tolsma, 1968). EPIDEMIOLOGICAL BACKGROUND. Clinical samples are not representative of the distribution of phobias in the general population, being over­ represented. Agras et al. (1969) found that fears of death, injury and illness reached a peak prevalence at the age of 60 years. These authors noted a change in relative frequency for each type of phobia as its intensity changed from mild to severe. Fears such as of snakes and heights declined in position, while fears of illness and injury and agorapi1obia increased so that the latter two were the more connnon of the severely disabling phobias and were present in 2.2 per thousand of the population. By severely disabling was meant the person became absent from work or unable to manage the household. Pratt (1945) studied the fears of rural children aged four to 11 years. 757. ~f their fears were of animals and only 87. were of and 5. illness. Girls reported more fears of illness and darkness than boys. Fears of illness increased with age. The response Maurer (1965) elicited by asking children "What are the things to be afraid of?" rarely included disease. It was mentioned by only four of the 112 children. Rutter et al. (1968) screened the total child population of the Isle of Wight aged 10 and 11 years for psychiatric disability. Disease or dirt phobias were found in only three boys and two girls. As children reach early adolescence the form that a phobia takes becomes more closely tied to learned or experienced objects and situations. Epidemic hysteria, which has dominant components of disease phobia and somatic anxiety, is usually germinated among adolescent girls. One classic account (Moss and McEvedy, 1966) refers to the predisposing emotional vulnerability induced by a poliomyelitis epidemic earlier in the year. In response to the example of a few girls fainting at a prolonged school assembly, one-third of the 550 girls went "sick". FAMILIAL AND SOCIAL FACTORS. "We are moulded and remoulded by those who have loved us and though the love may pass we are nevertheless their work for good or ill." Franc;ois Mauriac. The importance of modelling and imitation in acquiring personality is underlined by this quotation. Even by the time a baby is six months old the type of reaction he makes to pain depends considerably on the nature of handling he has received from his parents (Mccandless, 1967). What makes a model attractive for imitation is its power or its provision of nurturance and vicarious rewards. Nurturance and rewards are probably more relevant in this context. Many authors the importance of maternal overpro­ tection and oversolicitude in the genesis of hypochondriasis though ·they do not specifically cite disease phobia as the variety of hypochondriasis. However, there is a significant tendency for children to report the same kind and number of fears as their mothers. For example, Hagman (1932) found a correlation in the total number of fears by children and mothers was 0.67. He also found that in an experimental fear situation children tend to look at the adult who is with them at the moment the fear stimulus is presented. The presence of a given symptom upon which the disease fear may be based is also influenced by the existence of the particular symptom in the parents. Stern and Higgins (1969) showed that the occurrence in the parents of a particular symptom pattern greatly increases the probability of the child reporting th~t same reaction. Siblings were not as important in determining this association. 6.

The death of a sibling provokes death phobias and disease phobias in the remaining siblings. Cain et al. (1964) told how the parents' phobic vigilance and the extremely dependent phobia-breeding relationship into which the remaining child was often pressed tended to heighten further the child's death phobia. Binger et al. (1969) found that childhood leukaemia had a great emotional impact upon siblings, with the not unnatural common develop­ ment of the fear of also developing leukaemia. Bakwin (1948) states that problems presented by the children of dominating overprotective mothers are principally shyness, anxieties, fears and submissive behaviour. Levy (1943) suggests that the source of the overprotectiveness stems from their own childhood deprivation of parental love. Of Levy's 20 overprotecting mothers, nine had lost both or one of their parents by death by the age of 12 years. It is easy to see how overprotectiveness and disease orientation could become intertwined. One sign of this among the children of these overprotecting mothers was an increased frequency of tonsillectomy in their children compared with the control group's. Levy (1932) viewed the most suitable framework for the development of hypochondriasis as: 1. exposure to a long series of illnesses in others, 2. strong identification with the objects of illness and 3. frequent contacts with physicians, clinics and hospitals. (Item 3 may be a result rather than a cause). In line with these considerations one might predict that the youngest of a sibship would be more prone to development of a disease phobia, as they are more likely to be babied and overprotected and in addition tend to lose their parents at an earlier age than older siblings. Bergman and Stamm (1967) found "cardiac non-disease" to be present in 0.15% of school children. The most decisive factor in determining whether or not a child with an innocent murmur was to be restricted appeared to be the advice of the physician, illustrating the importance of iatrogenicity in evoking disease phobias. Those most at risk were children whose parents were overprotective and who had close relatives with heart disease. In Ryle's series of 31 cases of cancerophobia, 12 had lost a near relative or acquaint­ ance from cancer or had intimate knowledge of such a case. It appears therefore and not surprisingly, that the occurrence of a given disease in relatives determines the form of disease phobia as well as its nascency. As Wahl (1963) expressed it, "it is hard for a child to feel stronger and more adequate unconsciously than they perceive the parents".

Other evidence illustrating identification theory at work is provided by several American psychiatrists who studied the effect of a 7.

soldiering companion's death. Grinker and Spiegel (1945) saw the soldier's intense fears of personal harm as deriving from the consideration "what happened to his buddy, may well happen to himself, since they are so much alike". Beck and Valin (1953) found identification importantly involved in some of the physi~al symptoms and bodily fears of psychotically depressed soldiers who had accidentally killed their friends. One developed psycho- genie regional pain in the right lower abdomen one week after shooting his mate in the same area, and just after dreaming of this event. The pain was present for at least one year thereafter. Another who had shot his platoon sergeant in the genital region had a fear of losing his genitalia. The authors saw these symptoms as "retaliative anxiety" and as favoured by the existence of covert hostility. "The soldier is blaming himself for his wanting the buddy to be the victim rather than he." Honeyman et al. (1968) used the M.M.P.I. to record the symptomatology of the offspring of parents who had suffered myocardial infarction. They were compared with controls on M.M.P.I. hypochondriasis, hysteria and de­ pression scales. The children of the infarcted parents scored higher on these except for males on the hysteria scale. Thus somatic identification was demonstrated. This was independent of sexual identification, that is, offspring of the same sex as the afflicted parent were not more affected than offspring of the opposite sex. It would be interesting to know if this identification could possibly be swayed by the presence of repressed hostility to the sick parent. PERSONAL FACTORS. Just as a ship's engineer wakes to a slight change in pitch in noisy engines a disease phobic "wakes" to a slight change in the pitch of a noisy body. He too has been programmed by his life·experiences. As Lipowski (1969) mentioned "the interpretation of a symptom as a threat is influenced by specific susceptibility conditioned by previous life exper­ ience. Some individuals will react with alarm to harmless or any somatic perception which is new to them." It has been noted how the form of a disease phobia may be based upon identification with illness in a close relative. It may also be based upon previous health problems of the patient which may have fixated anxiety on a particular body symptom. The patient may become victim of a personal as well as a family mythology of bodily vulnerability. The reverse situation is illustrated by the Romeo and Juliet saw, "he jests at scars who never felt a wound". In this context it is worth mentioning a paper by Kessel and Shepherd (1965) on the health 8. and attitudes of people who seldom consult a doctor. These super-healthy infrequent attenders had as much minor illness but they professed less worry about health. It is significant that these people moved in a less medical orbit and had had less illness in their households. Melzack and Soctt (1957) in a paper on the effects of early experience on the response to pain of puppies who had no experience of the rough and tumble of canine life, noted how these restricted pups did not react to stimuli which were painful to puppies that had been unrestricted. Collins (1965) in a study of pain sensitivity in relation to childhood experiences found that overprotected children had a more aversive response to noxious stimuli. One can imagine this association deriving from the mother kissing her child's pain better. The child learns that pain is not only a source of dread as confirmed by his mother's over-reaction but also of reward. Stoicism in adult life is hardly to be expected if the band-aid and loving aspirin are proffered excessively as some advertising would have parents do (Bean, 1969). Myers and Roberts (1959) showed that after contact with psychiatry middle social class patients are more likely to recognise psychological bases for their symptoms, but lower social class patients tend to retain their organic explanations. With respect to psychiatric symptoms before treatment, they found that many patients feared their symptoms to be an expression or organic illness. In a study contrasting people having a higher awareness of autonomic distress with those having a lower awareness, Mandler et al. (1958) found the higher awareness group tended to over-estimate the degree of autonomic arousal whereas the lower awareness group underestimated it. The·positive association between parental disease and patient disease phobia may be fostered not only by environmental factors but also by inherited patterns of autonomic responsivity. That these exist is suggested by the observacion that soon after birth there are large stable individual differences in, for example, reflex circulatory dilatation to loud sounds (Richmond & Lustman, 1955; Di Cara, 1970). It may be that the future disease phobic has a similar pattern of autonomic responsivity as a dead parent so that the subject may have a good basis autonomically for his identification. CLINICAL RELATIONSHIPS. Paskind (1931) says that three of the most common fears which patients bring to a psychiatrist are fears of public places, of physical disease and of going insane. An analysis by Marks (1970) 9. supports this opinion; 60% of his phobic hospital population were agora­ phobic and about 15% had illness phobias this being the second most common phobia. 9% of the agoraphobes also experienced disease phobias and 22% had a fear of dying. Stenback and Jalava (1962) found that 19 of 105 depressive patients had disease phobias. They reported that fears con- cerning the heart were much more frequent among young adults than among the aged, which is in accord with Levine's work (1962) who found that one fears diseases appropriate to one's age. In a factor analysis of a fear schedule, Rubin et al. (1968) reported the of four factors, one concerning death and illness. It is not surprising that the fears of dying and illness load on the same factor. It is a common clinical experience to observe that the person with a phobia of heart disease is acutely fearful of dying. Fears of losing a job and not being a success were also found in this factor, and these fears relate to low self-esteem. Pilowsky (1967) isolated a factor which he called disease phobia from the responses of a mixed hypochondriacal group to a questionnaire designed to tap hypochondriacal thoughts and attitudes. The questions loading heavily on this factor were - "Are you afraid of illness", "Does television and radio advertising of disease bring on a fear of getting the disease yourself", "Do you worry about your health more than most people". There is little careful controlled work substantiating the opinions which many authors offer about the personality attitudes which predispose towards disease phobia development and the clinical features which accompany it. Mechanic (1962) has shown that, given the same disability; patients who are lonely seek medical aid more often than do other patients. Grayden (1959) noted a connection between feeling unloved and hypochondriasis which interestingly was borne out by Grinker et al.'s (1961) factor analytic study of . The Grinker factor in which feeling unloved and hypochondriasis appeared also included the patient being agitated and demanding. Sullivan (1953) noted a connection between low self-esteem and hypochondriasis. Lazarus & Kostan (1969) studied psychogenic hyperventilation and death anxiety and found that the disease phobia occurred in association with object loss. They reported underlying dependency, ambivalence and repressed emotion. Th~ importance of anxiety as an evocative clinical feature is borne out by several authors. Schwab et al. (1966) have noted among medical 10. in-patients that those with greater anxiety worried more about their illnesses and believed that their illnesses were more severe than did those with lower anxiety levels. which involves a fear and/or conviction of penile shrinkage and fear of dissolution is an anxiety state evolving in subjects with low intelligence and a long ~istory of anxiety, weakness and hypo­ chondriacal concern. For obvious reasons, koro is mostly a condition of men (the females fear nipple and breast retraction) as is the case with syphilophobia. Macalpine (1957) described 24 cases of this latter condition, 23 of whom were men, and these patients were in many ways similar to the sufferers from koro, that is, solitary and self-conscious young men, mostly bachelors. Patterns of disease phobia are usually in lagging synchrony with the medical preoccupations of the age. Tuke (1892) mentions apoplexy as a favourite fear and defines nosophobia as a "form of monomania in which through fear of a malady from which the patient is not really suffering, he adopts most stringent precautions and undergoes dieting and medical treatment quite unnecessarily. For example, some individuals diminish their food and become anaemic and dyspeptic through fear of apoplexy." This, of course, is not the fashion 30 years later. Just as it is now almost trite to remark that past experience determines those things regarded as threatening, so also some might consider it unnecessary to remark upon the pathoplastic effects of sex, age, social class, culture, religion, occupation, and so on. 11.

(b) DISEASE CONVICTION

CLASSIFICATION. Differentiation of disease conviction from disease phobia becomes difficult only where there is a non-fixity of basic affect. The pattern has been referred to as a "mobile " (Bumke, 1924). Stenback & Rimon (1964) suggest that in spite of this occasional oscillation between phobia and delusion the distinction has theoretical as well as practical advantages. Stenback in using the term "hypochondria" means disease phobia and for disease conviction recommends "somatic delusion". Others (Meltzer, 1964) use "somatic delusion" to describe the dysmorphophobias (Hay, 1970). Gillespie (1929) when he uses the term "hypochondria" means disease conviction. In view of this semantic chaos, it seems preferable to use 'disease conviction' or 'disease delusion'. An expanded and historical discussion of hypochondria­ cal is provided by Ladee (1966) and Retterstpl (1968). Cardona (1950) has pointed out that the line between a true delusion and a hypochondriacal idea is not at all sharp and that the degree of conviction is the arbiter, not merely the presence or absence of con­ viction. Hamilton (1967) in defining the item hypochondriasis of his depression scale seems to suggest that there are only quantitative differences rather than differences of form. "The severe states of this symptom, concerning delusions and hallucinations of rotting and blockages, etc., which are extremely uncommon in men, are rated as 4. Strong convictions of the presence of organic disease which accounts for the patient's condition are rated 3. Much preoccupation with physical symptoms and with thoughts of organic disease are rated 2. Excessive preoccupation with bodily functions is the essence of a hypochondriacal attitude and trivial or doubtful symptoms count as 1 point." Patients were included for study in this section if their concern was of bodily disease, usually internal, but not if their concern was about cosmetic, morphological and body-image "defects". Ladee (1966) describes this group as "beauty and body-image hypochondriacs" and this is compatible with his definition of hypochondriacal which requires merely that a person be "absorbed in the experience of his bodily state". In these patients, described by Morselli (1886) as dysmorphophobics (and more recently by Hay, 1970) the feature of concern is variously the nose, the penis, the mouth and smile, the breasts, lines under the eyes, the hair and other external parts. It is easy to separate these from the disease delusion or conviction 12. patients in the typical case. Overlap however, may occur and of course admixtures. It seems difficult for instance, to classify patients with convictions concerning orificial abnormalities, for example, concerning blockage of the anus or of the vagina. Here however, the patient might specify cancer. as the cause of blockage, allowing easy classificatory allocation. This dilemma did not require solution in the present study, for where dysmorphophobia was present, the patient had some defined form of hypochondriasis in addition. These monosymptomatic dysmorphic concerns are seen by some as forme fruste and indeed are often called monosymptomatic schizophrenic hypochondriases. (Korkina, 1959; Anderson, 1964). In line with this study's practice in defining the forms of hypochondriasis would be a system of classification such as dysmorphic preoccupation, dysmorphic phobia and dysmorphic conviction or delusion. Another thorn concerns the subdivision of disease conviction according to underlying psychiatric diagnosis, in particular, whether to analyse separately the schizophrenics and the depressives. To justify clearly my policy of separate analysis is not easy, especially as no separa­ tion was made on the basis of diagnosis for the disease phobic and somatic preoccupation groups. Firstly there were only three and they were all grossly deluded paranoid schizophrenics in whom the hypochondriacal delusion was not even the paramount delusion. (There were in addition three dysmorphic convictions - one reactive paranoid and two querulous forme fruste "schizophrenics"). It seemed it was schizophrenia rather than disease con­ viction that commanded attention. Lucas et al. (1962) studied the delusions in schizophrenia. They showed a 20% incidence of hypochondriacal ones but unlike the other categories studied (sexual, grandiose, paranoid) there were no correlations between them and sex, marital status, religion or social class. As the source of patients was a general hospital unit and as also not too many schizophrenics entered the present study, the number of schizo- phrenic disease convictions is too small for analysis. Nevertheless it is worthwhile to review briefly some of the literature concerning the connections between schizophrenia and hypochondriasis. SCHIZOPHRENIA AND HYPOCHONDRIASIS. Dysmorphic and hypochondriacal preoccupa­ tions are comrJon harbingers of overt schizophrenia (Chapman, 1966). Hypochon­ driacal delusions as the main delusion occurred in only 5% of the paranoid psychoses adm:tted to the Psychiatric Department, University of Oslo (Retterst-1, 1968). He points out that, "in psychoses with hypochondriac delusions, the 13.

is dependent on the basic type of disease more than on type of the hypochondriac delusions". Of the 15 cases, nine were called reactive psychoses and six . Delusions of persecution, jealousy and grandeur were more fixed and less likely to disappear than the disease delusions. Only depressive delusions were more ephemeral. The psychotic forms of hypochondriasis have been much written about by French and German authors starting with Cotard's (1880) "Du d~lire hypochondriaque dans une forme grave de mllancholie anxieuse", a remarkably apposite title. They were especially interested in hypochondria disguised as a paranoid psychosis, so-called ' hypochondriaca'. This was a form in which the subject allied his disease delusions with external attack rather than with well-deserved messianic retribution. Wernicke (1900) called one an allosomatopsychosis and the latter autosomatopsychosis. Astrup and Noreik (1966) in studying the delusions with functional psychoses found that hypochondriacal delusions implied a less favourable prognosis than delusions of guilt and inferiority, and a slightly better one than pure delusions of persecution. Ladee (1966) noted the importance of diagnosis as a prognostic guide in discussing his patients with disease delusions (according to Retterst~l's calculation, 30% of the 108 with hypochondriac delusion in Ladee's total sample of 225 patients were schizophrenic or suggestively so. This high proportion of the severe form of hypochondriasis supports the impression that Ladee's cases were severe varieties of hypochondriasis. They represented a mere 0.4% of his patient attendance). The finding of Hollingshead and Redlich (1958) for neuroses that patients in the two lowest social classes somatize to a greater extent than the upper classes is also borne out in a study of schizophrenics (Myers and Roberts, 1959). They found that social class V schizophrenics showed more psychosomatic symptoms in the prodromal period than those in social class III. Opler (1959) matched 30 Irish schizophrenics against 30 southern Italian schizophrenics, both immigrants to New York and their descendants. The Italian group had significantly more somatic complaining but less preoccupation with sin and guilt. He explained the forms in terms of the Italian's propensity for bodily action, "Italians express emotion more freely and in bodily action. The Irish have a rich compensatory life". Lenz (1964) observed that in the past 100 years the frequency of hypochondri~cal complaints in schizophrenia had remained constant at a level of 25%. As in the case of depression, there was a decrease in feelings of transcendental guilt, but not of secular guilt. 14.

The association of paranoia, paraphrenia and paranoid schizophrenia with disease conviction has been commented upon by many and so Stenback and Rimon's paper (1964) on hypochondria and paranoia surprises one at first by its finding that hypochondria is uncommon in paranoid reactions and much more common in schizc,phre_nic or schizophreniform patients. It is the old problem of each man using a common term for his own purpose. Fortunately they defined hypochondria and it was equated with disease phobia. The paradox then evaporates, for it makes sense as Rado (1953) is quoted "fear and rage are antagonistic responses .... when the paranoid reaction is dominated by aggressiveness, there seems to be no room for overt fear". In the case of disease conviction this incompatibility does not arise, for the dangerous outsider can be invoked as causing the bodily disease by whatever diabolic method - laser, implant, radiation or even old-fashioned poison. DEPRESSION AND HYPOCHONDRIASIS. The classic literary statement of the patient suffering from disease conviction is provided by de Mandeville (1711). "I have sent for you, doctor, to consult you about a distemper of which I am well assured I shall never be cured". The firmness of conviction, the importunity of the patient and the lack of effective therapy all favoured the establishment of hypochondriasis as an insanity in the old literature (Griesinger, 1876; Tuke, 1892). In fact Gillespie (1929) recommends that the term hypochondriasis be used only for the disease conviction form. The delusion is clearly interpretative, a delusion of explanation "In no other form of insanity is the explanation of morbid feelings so clearly seen to be the foundation of the insanity. Diseases are coined to suit the sensations of the patient" (Tuke, 1892). One might also add that they are coined in accordance with sophistication, experience of others' illnesses, cultural preferences and no doubt iatrogenic caprice. Even in western culture some strange habits are ascribed to deluded depressives. Tuke (1892) describes the patient with delusions of anal blockage by cancer - "One of the most trying symptoms is that the patients are constantly introducing their fingers into the bowel and keeping them up the passage for some time, thus the finger nails are frequently stained an orange colour". This patient was exposed to a culture whose doctors approved colectomy as a valuable cure-all, surely one of the most lethal treatments 15.

for hypochondriasis. His undignified digital devotion made some sense in a society loving its purges and . The bowels were of prime concern not so very long ago and along with this concern went an extensive use of cathartics and laxatives. This abuse kept the appendicitis death rate at a dangerously high level. Any pain in the belly was deemed to justify purging so that if the pain was from a diseased appendix, peritonitis and death could result. The victim of projective magic among Australian Aborigines suffers a disease conviction equivalent, though here the 'delusion' is not at odds with what his fellows also believe. In one form the sufferer believes his kidney fat has been stolen, in another that various objects have been pro­ jected into him to his bodily detriment (Elkin, 1964). Each culture has its own hypochondriacal hang-ups, for example, for the French, 'ma foie' and impotence, for the Italians spermatorrhoea, for the Germans muscular wasting. It could be expected that ~nder the influence of a severe depression the appropriate disease delusion would emerge. Orelli (1954) in Switzerland studied the changes in content of depressive delusions over the period from 1878-1951. He found that over this period of time there occurred a significant shift away from delusions and feelings of guilt toward feelings of personal inadequacy as well as toward more paranoid and hypochondriacal symptoms. The latter increase could be a consequence of improved advertising and mass propaganda concerning the detection of cancer, heart disease and so on (Brown, 1963). Cotard in 1880 described a psychotic state characterized by anxious depression, suicidal tendencies and bizarre hypochondriasis progressing to such an extreme negativistic delusion that the patient feels he no longer has a body. Kraepelin (1921) describes such patients well and it is worth quoting his words at length for we rarely ~ee such far gone cases in these days of electroconvulsive therapy and anti-depressants "In the patient everything is dead, rotten, burnt, petrified, hollow; there is a kind of putrefaction in him. He has syphilis in the fourth stage; his breath is poisonous; he has infected his children, the whole town •.•. In his skull there is filth; his brain is melting; the devil has displaced it backwards by a discharge of blood. His heart is a dead piece of flesh; his blood­ vessels are dried up, filled with poison; no circulation goes any longer; the juices ar€ gone. Everything is closed; in his throat a bone is sticking, a stone; storuach and bowel are no longer there. There is a worm in his 16. body, a hairy animal in his stomach, his food falls down between his intestines into his scrotum; neither urine nor faeces are passed; his entrails are corroded. His testicles are crushed, have disappeared; his genitals are becoming smaller •... There is pus in his jaw, in all his limbs, and it passes away in great quantity with his motions and with hawking; his palate stinks. His skin is too narrow over the shoulders; worms are lying under it and are creeping about". Tait et al. (1957) did not find many of the depressed women aged 40-55 years, so-called "involutional melancholics", to have bizarre hypo­ chondriasis _though most authors who salute the concept hoist disease delusion to the mast-head. Stenstedt (1959) found that hypochondriacal, negativistic delusions were present in only 10% of cases of involutional melancholia and moreover found that they were without special aetiological significance. De Alarc6n (1964) studied 152 depressed patients over the age of 60 years and recognized that "one has to distinguish between a somatic complairtt for which no physical cause can be found (hypochondriacal complaint) and unfounded belief of suffering from a certain illness or affliction (hypochondriacal conviction)". He found that close to one-third of his patients suffered from each variety. He reveals however that he does not really mean the words he uses, namely belief and conviction, by equating his categorization with that of Stenback who clearly is referring to disease fears rather than disease conviction. De Alarc6n's conviction group appears to be an admixture of disease phobia and disease conviction. Even so the group had an increased risk of . Stenback et al. (1965) found an inverse relationship between disease phobia and suicide. They remark that one aspect of.hypo- chondriasis, that is disease phobia, is "a fear of getting killed", whereas in suicide there is "a wish to be killed". Sainsbury (1968) in discussing the clinical symptoms of depression which are commonly believed to be associated with a proclivity to suicide mentions agitation, persistent , marked feelings of guilt or inadequacy and delusions of disease. He then mistakenly confuses Stenback's hypochondria with delusions of disease and is surprised at the association of disease phobia with low suicide rate. This is a clear example of the need for precision in phenomenology. Lewis (1934) adopted Bleuler's view that a depressive was the essential basis for the development of delusional hypochondriacal ideas. In my opinion this is not often so for the schizophrenic group and not always so even in non-schizophrenic patients. Lewis based his opinion on 61 cases of depressive illness. It is hard to see how he could arbitrate the issue of whether delusional hypochondriacal ideas could occur with other mood conditions if all of his cases were in fact fundamentally of a depressed mood. The figure derived from data quoted by Beck (1967) portrays this relationship of delusions to depth of depression (Fig. 1). He does not make clear that circular reasoning may be at work in the definition of what is mild, moderate or severe depression.

30

UJ ~ i--=z UJ u , 0:::: UJ 0... • • 20 I • Cf) • z • 0 • Cf) :::> _J UJ 0 )( .. • • LL. • • 0 • . • 10 >- .,.. . . Uz UJ :::> 0 UJ 0:::: LL OEAO

NONE MILD MODERATE SEVERE Figure 1. DEPTH OF DEPRESS ION

FREQUENCY OF DELUSIONS WITH DEPRESSIVE CONTENT AMONG PSYCHOTIC PATIENTS VARYING IN DEPTH OF DEPRESSION. (N = 280). (FROM TABLE 2-7 BY BECK 1967) 18.

SUICIDE AND DISEASE CONVICTION. Pessimism and suicidal wishes are frequent companions (Beck, 1967; Pichot & Lemplri~re, 1964). The connection between depression and suicide is well-known as is the tendency of the physically ill to kill themselves. One would expect therefore that a severely depressed person, often old, who is absolutely convinced he has a fatal illness might very likely kill himself. There are depressed persons who commit suicide believing they have an illness, absent at autopsy. Sainsbury (1956) in his study of in London found that "many alleged they had cancer, of which no signs were found post mortem". Leonard (1967) discusses the pre-suicide medical contact. He refers to Yessler et al. (1961) who studied 272 suicides among an armed forces population. A recent medical contact had been made by 117 of the suicides. The great majority of these communicated suicidal intent, al­ though 27 did not. Of these 27, 17 evidenced unrealistic almost irrational concerns. De Alarc6n (1964) drew attention to the increased risk of suicidal attempts among elderly depressives if they had hypochondriacal complaints. If the hypochondriasis was a dominant symptom, the likelihood of an attempt was 36% as opposed to 7.3% in those free of hypochondriacal symptoms. By dominant the author appears to imply a conviction rather than a phobia. It is important to distinguish these phenomenological variants. As Macalpine (1957) stated in her paper on syphilophobia "The noisiest, most anxious, and most agitated patients are not always the most seriously disturbed. On the contrary, while the patient anxiously seeks help he has not fully accepted his morbid fears. Once he has accepted them and they have become fixed in his mind as delusions, he often becomes calm, although he is now more seriously and even dangerously ill mentally than before. In fact, it is in this out­ wardly deceptive stage that patients most frequently commit suicide, which then seems to occur unexpectedly and out of the blue". The presence of delusions in a depressive illness militates against a favourable response to anti-depressants (Hordern et al., 1965). Thomas (1954) found that the recurrence rate with electroconvulsive therapy was higher for depressions of hypochondriacal flavour - 33% recurrence rate versus the 23% overall recurrence rate at 13 months after the final E.C.T. This poorer response to treatment may be what fosters the higher suicidal risk of the hypoc~ondriacal depressive. Some idea of the pre-E.C.T. and pre­ days is provided by Lewis (1934) who reported on cases he personally collected. His data, which he does not collate in regard to 19.

this point, indicate that there was no higher risk of an attempted suicide for the present psychiatric illness among his 25 hypochondriacal depressives, not even for those 15 who felt they would never get well. About 40% had attempted suicide and this percentage applies overall to non-deluded and deluded depressives.alike. Is it that treatment of the hypochondriacal depressive has not advanced at the same rate as the non-hypochondriacal? Is this the explanation for the differences between, for example, the results of Lewis and de Alarc6n? Lewis' sample of hypochondriacal depressives, younger than de Alarc6n's had a mean age of only 34.6 years. So it may be that old age is a requisite additive. Lewis did not see any wisdom in distinguishing between the various points on the range of hypochondriasis, not even on the grounds of degree of conviction. It seems he has no better basis for refusing to distinguish than that it is diffic_u_lt or metaphysical. "There is in these cases a wide range, from fussy, old-womanish valetudinarianism to gross and grotesque delusions. To differentiate them according to the accompanying affect would be misleading. There are gradations from "as if" constructions .... through verbal forms, not essentially different .... and anxiety expressions .•.. to definite delusions. It is therefore equally difficult to distinguish between them on grounds of degree of conviction .... The degree to which "the senti­ ment of the real" is lost has been urged by French writers, and even so long ago as 1857 Witmaack wrote with gusto "Severe hypochondriacs can exchange themselves more and more from the reality of their bodies, until at last they pass beyond all possibility of reawakening, and the soul buries itself well-nigh irredeemably in the murky depths of misanthropy". But estimations of the strength of the sentiment of the real are apt to turn into questions of metaphysics, and are not in place here." On this point I am more in sympathy with the "French writers" than with Lewis. The estimation is no more bedevilled by inexactitude and metaphysics than other distillates from clinical data. It is worth remembering in seeking the link between suicide and delusionary hypochondriasis that "if men define situations as real, they are real in their consequences". The incidence of cancer among Sainsbury's London suicides was twenty times that expected in a normal comparable population. 20.

(c) SOMATIC PREOCCUPATION.

INTRODUCTION. Somatic preoccupation is a prominent manifestation of psychiatric illness.. It is the variety of hypochondriasis most physicians understand by the derogatory terms crock and hypochondriac. The A.P.A. classification now includes the category hypochondriacal neurosis which subsumes cases where manifold and non-organic bodily complaints dominate the symptomatology. Leighton et al. (1963) felt that "from the orientation of epidemiology and symptom pattern .... hypochondriasis appeared to be an entity and one frequent enough to warrant tabulation".

Only a few of the patients with somatic preoccupation actually are diagnosed as hypochondriacal neurosis, not because the symptom-pattern is absent or peripheral but because of the diagnostic tendencies now current to accentuate other compor-2nts such as depression or anxiety leading to a diagnosis of depressive neurosis or anxiety neurosis. As Pilowsky (1969) comments concerning the diagnostic problem presented by the patient with physical complaints for which no adequate organic cause can be found, "These patients roam a sort of medical no man's land •... It has almost become a matter of taste whether a condition characterized by unexplained physical symptoms (in particular pain) will be labelled hysterical, hypochondriacal, functional or psychosomatic".

Patients with this symptom pattern in gross amounts are frustrating to family and doctor. Lipsitt (1970) suggests that physicians feel there appear to be more of them around than there actually are. It is the milder and less chronic forms of somatic complaining which need recognition if the chaos of excessive prescribing, investigating and operating is to be avoided. Even skilled observers may miss "hidden psychiatric morbidity" which in one general practice was found to account for one-third of all psychiatrically disturbed patients. These "missed" patients usually presented a physical symptom to the general practitioner (Goldberg & Blackwell, 1970).

Missed cases suffer needless misery ~swell as dubious treatment. Some are their own physicians and pour large quantities of analgesics into their bodies. One large study (Abrahams et al., 1970) showed that 8.7% of 21.

a "normallf population attending a chest clinic for routine microfilms were analgesic-dependent and a further 4.6% were regular users. These analgesics were taken for pain by 70-90% of the patients. It is mandatory for the medical profession to take account of this enormous group of people, even if only to avoid the complications attendant on analgesic abuse (Murray et al., 1970).

Hitherto each specialty saw a selected group and labelled it in terms of their own diagnostic biases. Epidemiologists and psychologists used to be the main students in this field, as witnessed by the various rating scales (Wahler, 1968). With the advance of liaison psychiatry and psychopharmacology this area of symptom distress has started to receive investigation focussed on treatment rather than only on ascertainment (Schwab, 1968; Lipman et al., 1969).

An added impetus has come from cross-cultural studies through which it became obvious that classical neurotic patterns tended to be replaced in many non-European societies by hypochondriacal disorders.

There is a great financial premium on organic disease and with doctors mainly understanding illness on the basis of named disorders it is easy for the overcomplaining (and the undercomplaining) to be poorly examined and treated. Von Mering & Earley (1965) rightly draw attention to how poorly the western medical environment copes with the "undifferentiated, life in ill-health disorders", exemplified by the various forms of abnormal illness behaviour.

CULTURAL FACTORS. It is difficult enough to establish cross-cultural incidence rates for recognized psychiatric illnesses let alone for somatic preoccupation because different cultures have differing vocabularies of discomfort, sick role behaviours and acquiescence response sets.

Illness is not an objective fact but fluctuates in incidence with diagnostic fashion (Annotation, Lancet, 1962), patient-doctor ratio (Bunker, 1970), health preoccupations of the particular culture (Editorial, Amer. J. Psy~hother., 1962), sophistication of the patient and so on. These various influences have linkages with cultural myths. Graham (1967) has argued that the "psychological" and the "physical" are just two different languages to describe the same events. 22.

Lauter & Schon (1967) provide p~rcenteges from which Figure 2 has been constructed. It shows that somatic complaints as a feature of endogenous depression have increased considerably in the past 50 years. Balduzzi and Alberti (1966) mentioned the increased incidence of the somatic-type neuroses and advocated their recognition.

60

~ ~ -40 ~ ii; UJ I t- (.!) z ~ 0 a.. UJ 0:: UJ ~ 20 i--.::z uUJ 0:: UJ a..

...... Jt··. x··· ......

FREQUENCY SHIFTS OF SYMPTOMS IN ENDOGENOUS DEPRESSION Figure 2. 1910 1928 1946 1963

THE FIRST 60 MALE ANO THE FIRST 60 FEMALE PATIENTS ADMITTED IN EACH OF THE FOUR INDEX YEARS WITH A DIAGNOSIS OF ENDOGE"-OUS OE PRESS ION. MANIC - DEPRESSIVE PSYCHOSIS (CYCLICAL). OR INVOLUTIONAL DEPRESSION WERE USED FOR THE ANALYSIS. (MUNICH. DATA FROM LAUTER & SCHON. 1967) 23.

Hypochondriacal preoccupations of this type are connnon among various African races (Annnar, 1967; Okasha, 1966; Okasha et al., 1968) and among many deprived minority groups, for example, poor indigenous groups (Wittkower & Rin, 1965; Cawte et al., 1968). Maoz et al. (1966) found in a community of newcomers to Israel that the European patients showed the more classic forms of psychoneurosis and the Asian ones gave more 'psychophysiological' complaints. Lerner & Noy (1968) found in an Israeli psychiatric outpatient service that for the patients hailing from oriental countries there was an inverse relationship between and level of education. Somatic complaining appears to be more common among refugees and immigrants than in indigenes. Gordon (1965) found a higher incidence of somatic complaints of a hypochondriacal kind among mentally ill West Indian innnigrants to Britain. He cites various studies which lend weight to the association, namely Eitinger (1960), Mezey (1960) and Tyhurst (1951). Murphy et al. (1963) reported from a cross-cultural survey of schizophrenic symptomatology that members of "primitive" cultures accentuate somatic aspects of hallucinatory experience more than do westernized patients. Various authors (Zborowski, 1952; Sternbach & Tursky, 1965; Wolff & Langley, 1968; Mackenzie, 1968) have written on the varying algic behaviours of different nationalities. These pain threshold and pain tolerance character- istics underlie whether a sensation is construed as a pain,or a normal physiological event as a complaint. Opler (1959) found that among Irish and Italian schizophrenics in New York the Italians accentuated somatic com­ plaining. Portelli & Jones (1969) even gave the name "Mediterranean Guts Ache" to non-organic symptoms and attention-seeking behaviour among Italian patients. They noted an absence of the British stiff upper lip in time of crisis. Stoker et al. (1968) in a careful controlled study found that their 25 Mexican-American patients had almost four times as many somatic complaints as 25 Anglo-American patients, despite cue-for-one matching on income and education. Similar to the Italians in Zola's (1966) Irish versus Italian analysis, the Mexican-Americans had a relatively wider symptom spread throughout the body. Statistically significant differences were found f~r complaints involving the gastrointestinal system and the head. EPIDEMIOLOGICAL BACKGROUND. Somatic preoccupation and hypochondriacal neurosis are poorly defined and the difficulties inherent in obtaining their epidemiology are self-evident. Quantification is one barrier to meaninr,ful 24. comparability - when does 'subclinical' somatic preoccupation merit promotion to neurosis? What severity, multiplicity and duration of non-organic bodily symptomatology can be used to provide a cut-off point for classificatory purposes? Another hurdle is the cross-cultural significance of symptoms and its interplay with response tendencies to questionnaires. Also •~he construction of questionnaires for use in comparisons among groups requires the collaboration of physicians who are aware of the significance of a given symptom to members of the various groups" (W.H.O. report, 1967). Despite the difficulties it is proper for one to look beyond the focus of the particular subset being investigated. Failure to look at the entire universe is a common error in clinical research and as Weiss (1970) observed, results frequently disagree when different physicians select different subsets. (The epidemiologists' problem is that he sometimes misses a truth because it is buried in a mass of data). Zealley & Aitken (1970) spoke on this theme in relationship to breathlessness and anxiety among asthmatics. They referred to a study which found asthmatics more obsessional, sensitive, anxious and underconfident than controls and warned that "these are the very traits which might be associated with failure to adapt to distress, and with a tendency to reiteration of complaint". Rawnsley (1968) studied the Cornell responses of a rural Welsh population and found that the people with a symptom who consulted about it had similar psychological scores to those with the symptom who did not consult. Probably the contribution of sick role behaviour to attendance for treatment is not uniform, but is dependent on the meaningfulness to the patient of the given symptom. One of the few direct epidemiological reports on the incidence of hypochondriacal neurosis is that of Mazer (1967) who found it to account for 22.4% of psychoneurotic reactions in the general practice of an island community off the East Coast of U.S.A. He said that the term was "in common use by local general practitioners to describe the symptom pattern seen in patients who complain of a great variety of bodily symptoms, which frequently appear to be expressive of an underlying depression". is a fashionable diagnosis these days. However if depression is absent in the eyes of a careful observer the term is not justified even if appear curative. Serry & Serry (1969) adduce the fact that in their general practice series the "masked depressives on relapse became overt depressives in 46% of the cases" as support for the somatic masking being a depressive equivalent. This is not convincing 25. enough, for the superficial aspect of neuroses can vary from one episode to the next and in particular might be expected to change to overt depression in response to the conditioning received from "an everything is depression" doctor during the first episode. Serry & Serry did illuminate the epidemiology of somatic complaining. What they refer to as "masked" depression occurred in 84 of each 1000 cases they saw in 12 months ("overt" depression occurred in 48 per 1000). It was three times as common in females. The common bodily symptoms were headache, fatigue, diarrhoea, other pains, migraine and palpitations. Baker & Merskey (1967) found pain to be a very common symptom in general practice patients. Nearly 20% of the patients had pain of psycho­ logical origin, mostly headache. 15% of the total sample had more than one pain and this multiplicity characterized pains of psychological origin, particularly in the elderly. They found no relationship to social class perhaps partly because of the inclusion of physical pains in the analysis. Hollingshead and Redlich (1958) reported that heightened concern with bodily symptoms was most pronounced in those patients who were socially and economically deprived. Low social class groups have increased amounts of "real" bodily illness and it is possible that their psychologically based bodily complaining is in part determined by the extra burdens of a deprived life as well as by the more traditionally espoused mechanism, that they speak a different language, a language of the body. Spear (1964) mentioned that psychogenic pain tended to present more in winter and this associa­ tion is consonant with the socioeconomic deprivation viewpoint that the poor cannot afford adequate heating in winter and so suffer aggravation of aches and pains. Gillis et al. (1968) found from random sampling of a coloured people in South Africa that bodily preoccupation occurred in nearly 20% of the 500 sampled. In only 1/5 of these was there moderate to severe impair­ ment. The 'purely subjective conditions without clear physical illness' included headaches (28%), gastro-intestinal complaints (28%), subjective bodily sensations (24%) and complaints referable to the musculo-skeletal system (20%). There was a social class differential with 'psychophysiologic' symptom patterns occurring more in the lowest of the three social classes; 42%, 42% and 57% were the respective incidences. Cawte et al. (1968) found much somatic compl4ining among Australian Aborigines and showed that it was increased in amount among the females and the more deprived members of the 26.

settlement. These authors used both questionnaire and census approaches in the ascertainment of psychological morbidity. Each set of data revealed one of the four ethnic subgroups, the most deprived and socioculturally dis- integrated one, to be the subgroup most troubled by·"hypochondria". Both sets of data showed·depression to be a distinctive feature of these Kaiadilt Aborigines. Most epidemiological studies have not used a diagnostic approach and usually provide percentage "yes" answers from questionnaires, in which there are some "more somatic" questions and some "more psychological" ones. It is not easy to determine whether the somatic questions tap non-organic somatization or whether they are veridical. Those with least age effect can be more trusted in ascertaining non-organic complaint areas though it should be remembered that intense body concern is commoner in the neuroses of old age (Busse et al., 1960). One of their findings was that over half of neurotic elderly peopl~ with mixed depressive-hypochondriacal symptoms had shown a different type of psychoneurotic symptomatology earlier in life. A study more apposite to western society is that of Dohrenwend & Crandell (1970). They sampled various sections of an American conmrunity including clinic and mental hospital populations and analysed the responses by breaking the community section into two, leaders and others. Table 1 shows the affirmative percentages on six questions that are building-bricks of somatic preoccupation. TABLE 1. Somatic preoccupation in an American community (data from Dohrenwend & Crandell, 1970).

Symptoms of Leaders Community Out-patients somatic preoccupation Sample N=41 N=124 N=59

Headaches often 2.4% 8. 9% 23.3%

Hot all over 9.8% 21.8% 40. 7%

Clogging in the nose 7.3% 19.4% 30.5%

Sour Stomach 7.3% 19.4% 37 .3% I

Mental worries get me down physically 7.3% 21.0% 42.4%

All kinds of ailments 4.9% 16.1% 25.4% The latter two questions mirror the incidence of somatic preoccupation showing the lowest incidence among the leading citizens and the highest among the psychiatric out-patients. Taylor & Chave (1964) considered the group in the connnunity who have various chronic symptoms but no discrete neurosis to have a 'subclinical neurotic syndrome'. As well as many bodily symptoms this group suffers from 'nerves', depression, undue irritability and insorrmia. In any epidemiological survey these subclinical entities must be responsible for much of the affirmative replying. To obtain an estimate of whether patients see symptoms as requiring action one can record their analgesic consumption (or extent of "unnecessary" surgery). Because analgesics are taken mostly for pain, this information allows an indirect approach to the epidemiology of bodily preoccupation. Admittedly it is indirect and provides probably an overestimate of the amount of definite hypochondriacal neurosis. Males favour alcohol as a remedy and their abuse of analgesics relates more to obtaining a boost than to relief of pain; especially is this so for male psychiatric patients. Also not all of the somatically preoccupied abuse analgesics so that their consumption is a vague reflection of the epidemiological pattern. The rate rises from about 10% for the general population to about 20% for the psychiatric popula­ tion and to over 30% for patients with chronic neurosis and inadequate personality. It must not be overlooked that what a patient is prescribed, drug or surgery, is influenced by the ritualistic beliefs and ethics of the doctor, not just by the patient's eagerness for something to be done. The variation in the incidence of tonsillectomy is so well recognized as to be called the Glover phenomenon. The same phenomenon obtains for appendicectomy and even herniorrhaphy. Appendicectomies in 10 regions of Kansas under the same health insurance scheme varied from 14.6 to 61.8 / 10,000 of the populace per year, suggesting to Lewis (1969) that "the dollar volume that surgery represents to those who perform it must be considered by those concerned with workings of surgical services". Elsewhere reasons behind "victim" particip- ation will be examined. 30,000 tons of aspirin are consumed annually. The prevalence of aspirin ingestion is greater among women than men, increases with age, and is greater among persons of low social class (Gillies & Skyring, 1969). Shep~erd et al. (1966) and Jeffreys et al. (1960) found that the habit of self-medicati~n did not seem to be related to the frequency of medical 28. consultation, at least in the moderate dose range. Aspirin, laxatives and antidyspeptics were the substances mostly connnonly consumed whereas when doctors prescribe, hypnotics and sedatives come first, followed by stomachics and tonics with aspirin fourth and laxatives tenth. The prescribing pattern of physicians is directed in most general practices to 'trivial' complaints and with only 'hopeful' or 'possible' therapeutic intent. Eimerl (1962) also showed that his highest level of prescribing was directed at middle­ aged females, many with trivial illnesses of the somatic preoccupation type. The patients of mesmerists in a Dutch study of ~eviant illness behaviour (Cassee, 1970) were also predominantly middle-aged. 12% of a random sample of the adult population of Utrecht had at least once been under treatment by a non-medical healer, mostly practitioners of "animal magnetism". They were mainly consulted for chronic complaints, often of the type being discussed. Reidenberg & Lowenthal (1968) determined the spontaneous or baseline frequency of symptoms which are often regarded as adverse drug reactions. Their group comprised 414 healthy university students and hospital staff who had had no illnesses and taken no for the previous three days. Only 19% had none of the 25 symptoms listed. 7% had six or more symptoms. Of the original sample of 670 from which the 414 "healthy" group was extracted 12% had taken acetylsalicylic acid, two-thirds of them for headache. Despite the elimination of these "sick" people, 14% of the "healthy" residue complained of headaches, 39% of fatigue, 7% of joint pains, 10% of muscle pains and 23% of nasal congestion. This general problem of "adverse nondrug reactions" is the subject of a leading article (Brit. med. J., 1969) in which reference is also made to other apocryphal m~nifestations of bodily preoccupation such as "non-myxoedematous hypometabolism", "normocalcaemic hypoparathyroidism" and "sideropenic non-anaemia". Royal Free disease has been suspected of flying under the false colour of organicity (McEvedy and Beard, 1970). Another indirect approach to its epidemiology is via placebo side-effects. Rogge (1963) found the most connnon placebo side-effects to be drowsiness, headache, nervousness, nausea, constipation, vertigo and dry mouth. They occurred in up to 6% of plac~bo ingesters. Green (1964) observed their presence before and after treatment with placebo. Symptoms present before and increased after placebo included heartburn, nausea and vomiting, dizziness, palpitations, cramps and blurred vision which are symptoms on the periphery of somatic preoccupation. Symptoms became so 29.

severe that three of 25 women receiving placebos were unable to complete the course. Green suggests that giving a may so focus the subject's attention introspectively that some complaints previously given little or no attention are magnified to a degree where they become regarded as "side­ effects" of the medication being given. The incidence was higher in females and in older persons. For aches and complaints generally, Langner (1965) has commented on the striking consistency for a female excess, across nationalities, social strata, and in country and city. He relates it to status and prestige discrepancies and in support showed that as women's prestige status approaches that of the men, women report only slightly more symptoms than men. Brody (1966) views the excessive female complaining as based upon the related concept, 'cultural exclusion'. It must also be substantially consequent upon the paramenstrual vicissitudes of women (Moos et al., 1969). One final guideline is the work of Apley & Naish (1958). The periodic syndrome pentad of abdominal pain, limb pains, headache, recurrent vomiting and fever is connnon in childhood. They found recurrent abdominal pain to occur in one of every nine unselected school children and recurrent limb pain in one of every 25. Recurrent headache was recorded in one of every seven school children in another survey (Hughes & Cooper, 1956) and was one of the commonest excuses for repeated absence from school in older children (Bransby, 1951). Apley (1959) followed up 30 of the children with recurrent abdominal pain between eight and 20 years after they had attended a children's hospital. Two-thirds were bodily preoccupied and only one-third were well and symptom-free. One-third still had the abdominal pain and in addition other bodily symptoms, particularly headaches. This is a most valuable prognostic study and important in the literature of somatic pre­ occupation. Richards (1941) offers some contrary and more cheering evidence. He reexamined 22 children and adolescents 11 years after they had been treated for hypochondriacal invalidism. 19 ( 86%) "showed absolutely no somatic complaining" and were well adjusted. Nowhere in clinical psychiatry does the iceberg analogy apply mo~e than to somatic preoccupation. It is this coverture of bodily complaining which demanded the above indirect evaluation of its epidemiology. FAMILIAL AND SOCIAL FACTORS. Vocabularies of discomfort affect the manner in which patients present themselves. Bart (1968) compared women who entered a neurology Gervice (but who were discharged with psychiatric diagnoses) with JV.

women entering a psychiatric service of the same hospital and found the former to be less educated, more rural, of lower socio-economic status, and less likely to be Jewish. 52% of the psychiatric cases on the neurology service had had a hysterectomy as compared with only 2% on the psychiatric service. These findings suggest that such patients are somatizing their and receiving "unnecessary" surgery and medicine in response to what is really a plea for help. Lorr et al. (1968) found that a "body symptom subgroup" in an M.M.P.I. study of symptom profiles had less education and more children. Bianchi et al. (1970) found that a group of sornatically preoccupied dispensary over-attenders scored lower on a test of intelligence than matched controls and also had more children. It is not obvious whether less education and intelligence act by favouring the use of physical language to describe psychic stress or whether a third connecting variable such as extra physical burdens (rural work and many children) sensitize the person to somatic clues. It is more important for a manual worker to be physically strong than for a sedentary one. Mechanic (1969) in an excellent review of the sociological pers­ pective of hypochondriasis also offers the thought that the lower social class, more poorly educated person would feel it a sign of weakness to admit to psychological difficulties and so pleads for help in the societally sanc­ tioned way of bodily complaining. Thus an unacceptable disability becomes what Weinstein (1969) calls an acceptable disability. If a person with personality difficulties and a troubled life situation regards his distress as an inadmissible "weakness" then to make it respectable he must become truly ill and develop bodily pains, perhaps in a similar way to the placebo reactor's sensitization to his previously ignored afferent messages. In addition to its development in the service of respectability, somatization may be used in the pursuit of money, love or comfortable dependency. Predisposition to these avenues of behaviour and comes from the processes of identification, imitation and sociocultural indoctrination. The process of identification is most clearly seen in the bereaved. It is connnon for those bereaved to begin to have the same disease symptoms as the one \.ho has died. Hinton ( 1967) reports that "physical symptoms, newly acquired, are not the only manifest signs that the bereaved is un­ consciously i~corporating some features of the dead person. It is not har

this rate of emergency admission was significantly high. Buck & Laughton (1959) found an excess of behavioural and psychosomatic illnesses among children of psychoneurotic mothers. Kreitman et al. (1965) showed that depressives with somatic symptoms had mothers with similar symptoms with whom they had presumably identified, though interpretations perforce enter the speculative realm of nature-nurture. Bandura (1967) looks upon hypochondriacal complaints as a problem of social learning. He says that just as abnormal behaviour persists because it leads to rewarding outcomes so it can often be eliminated simply by withholding the usual positive reinforcement, namely the solicitous concern it usually evokes. Di Cara (1970) mentions the possibility of a mother reinforcing the autonomic responses of her child, for example, by keeping him home when he has a headache, looks pale or feels nauseated. He too, hesitantly acknowledges the contribution of "nature" - "presumably genetic and constitutional differences among individuals would affect the susceptibility of the various organ systems". Gold & Eisen (1969) in an amusing and insightful book demonstrate the parent as victim. "How to handle your parents when you get turmny aches" is the title of one section. They look at the motives for somatic complaining and consider avoidance of school and chores, and the gaining of love and safety at times of stress. These learned attitudes have their counterpart in adult life. As Ziegler et al. (1963) observe, some are professionals in the unconscious simulation of illness. "In men, conversion reactions of very long duration involving multiple symptoms are usually found in circumstances where the possibility of dependency gratification is especially high, as in the Armed Services, Veterans' Hospitals, and compensation cases". (This chronic hysteria form of somatic preoccupation occurs in 26-39% of the female relatives of hysterics versus 1-2% of the population at large (Guze, 1967)). Somatic complaining is reflective of an unhealthy adaptation to life and may serve as a principal mode of coping. Kahn et al. (1958) found that the extent of somatic complaining among aged and infirm residents of a home was less in those who were active in the institution and assuming some sort of responsibility. PERSONAL FACTORS. The depressed and the deprived show various intractable disorders as evidence of adaptive failure, often admixtures of physical, psychological and somatopsychological complaints. What determines particular "organ weaknesses" is obscure. 33.

Merskey (1968) surrnned up the angst of the somatically preoccupied thus - "The most typical patient •... is a married woman of the working or lower-middle class, possibly once pretty and appealing, but never keen on sexual intercourse, now faded and complaining, with a history of repeated negative physical examinations and investigations, frank conversion symptoms in up to 50% of cases in addition to the pain, and a sad tale of a hard life; together with depression which does not respond to antidepressant drugs". 'A sad tale of a hard life' is the poetic equivalent of what is referred to variously as loneliness, lack of environmental satisfactions, lack of social and economic well-being, life change, menopausal threat or deprivation crisis. All of these have been proposed as provocative of somatic preoccupation though the connection appears to be in no way specific. Personal failure, disappointment and role crisis predispose to illness. Jacobs et al. (1969) see the illness as a temporary escape from unpleasant life circumstances. The professional patient has learned to use his symptoms to fulfil the emotional needs consequent to an unsatisfying life adjustment (Mead, 1965). Thoroughman et al. (1967) studied psychological factors among those with surgically intractable peptic ulcers (what some call the albatross syndrome in allusion to these patients' medical marathons). They saw them as persons receiving little environmental satisfaction and having poor early relations with parents. These people they assessed as a sick role behaviour group. Ely & Johnson (1966) compared the results of gastrectomy and conservative therapy in the management of peptic ulceration. 80% of the non-gastrectomy controls had recurrent ulcer symptoms. None of the gastrectomy group did but instead 87% complained of various somatic preoccupations and anxiety, suggesting that if the stress remains, a new focus of complaint is developed. As an example of the generality of environmental dissatisfaction in the causation of illness is the work by Fanning (19~7) on families in flats. Two groups of families of members of the Armed Services uere compared, one group living in flats and the other in houses. The flats had no elevators and so women living higher up and with young children suffered from confint- ment and social isolation. They had more psychoneurosis and more physical ills, for example, respiratory infections. Frequent sickness spells resulting in absence from work occurred more in thos~ men with a memory of an unhappy childhood and with dislike of the job or frustrated ambition (Taylor, 1968). Their symptoms were 34.

back pain, frequent colds, troublesome constipation, and peptic ulceration. Smiley (1955) studied a group of accident-prone workers. After deducting time lost as the result of accidents these men still lost twice as much time as controls. Excluding organic illness, both acute and chronic, on the average the accident-prone lost 22 days (as compared with the controls who lost six days) as the result of conditions either not covered by medical certificates or diagnosed in vague terms like "fatigue", "", "gastritis", suggesting the absence of organic disease. They were more often to be found in the 26-35 years age group and there was often a back­ ground of threat to personal security. The above two paragraphs pertain chiefly to women and men in their twenties and thirties. Middle age and old age bring different environmental threats. Lesse (1967) reports somatic preoccupation as occurring mainly in middle-aged females in response to the symbolic threat of the menopause. He sees their switch to the body as an aggressive compulsive need to dominate the environment. Additional to these subdued "sad tales of a hard life" is the evidence from disasters, sudden or severe, which are followed by chronic neurosis, often of the hypocho~driacal type. Leopold and Dillon (1963) made a long term study of post-traumatic neuroses in survivors of a marine explosion and found that the somatic involvements changed from the mainly gastrointestinal soon after the disaster to more numerous and largely musculo­ skeletal complaints four years later. Well over half had continuous headaches. More regression in work capacity was apparent in those aged 36 year~ or more. The nature of the disaster appeared more important than the premorbid personality. Concentration camp victims evidence mixed neurotic patterns, including the hypochondriacal, many years after the stress of extreme im­ prisonment (Hocking, 1965). Much of what has been said so far in this section expresses the generalized tenor of the work of Hinkle & Wolff (1958) who related cluster periods of illness to environmental stress and dissatisfaction. This concept of disharmony with the environment is usefully reviewed by Thurlow (1967). The key source of resentment for many people is interpersonal conflict, often with the spouse or a parent. Hostility which must be bottled up or only minimally expressed is particularly likely to be generated in the 35.

marital situation and it is this suppressed hostility which triggers psychogenic pain and more generally somatic preoccupation. Various workers mention the chronic resentment of those somatically preoccupied. Engel's (1951) paper illustrates the theme very well by extended case histories. He shows that these masochistic sufferers maintain a tyrannical control over their resented family. Masochism is a more accepted role for women in our society and it seems possible that males fly more to the bottle than to martyrdom. Weiss (1947) found in cases of psychogenic rheumatism that a marital problem was the most frequent source of a chronic resentment of which the patient was usually totally unaware. Psychiatric illness among physicians' wives commonly takes the form of somatization (Evans, 1965). A precipitating factor in many appeared to be a feeling of increasing exclusion from the husband's life, as he became more and more involved in his profession. Evans regarded their pains as a manifestation of hostile-dependency that demanded the husband's attention. Submariners' wives according to Isay (1968) manifest a reactive depression with multiple somatic symptoms just before and soon after the submariner's return. He suggests it is a silent protest in retaliation for being deserted and is the product of unacceptable rage. Various authors allude to this derivation of bodily symptoms from marital friction, including 0kasha (1966) who studied 100 females attending a healing cult, one-half of whom had marked hypochondriasis, Kreitman et al. (1~65) who reported more marital discontent among somatically preoccupied depressives than other depressives and Kemp (1963) who found that "thick-file cases" tended to be middle-aged women with dissatisfactions concerning marriage, sex, money and work. The literature on persistent psychogenic pain confirms the difficulties bodily tormented patients have with resentment and aggression. Merskey (1965) found that the type of patient most likely to have persistent pains has more resentment than others but no history of more overt aggression. Sternbach (1968) suggests that "from the point of view of dynamic psychiatry, this chronic resentment is unacceptable to the patient and, should it approach awareness, would give rise to unbearable anxiety. Consequently, rather than direct the resentment toward others it is turned on the self". He cites the physiological studies of Funkenstein et al. (1957) on the direction of anger as relevant in this regard. It is necessary to put restraints on the interpretation of these reports, for it may equally be true that depression with somatization occurs 36.

de novo, and secondarily results in a feeling of frustration and resentment. A 'bear with a sore head' is loathe to regard her environment as satisfying. This viewpoint is thoroughly discussed by Paykel et al. (1969). They used a life-change inventory to divine the precipitants of depression and having found a marked excess of marital disenchantment apparently preceding the depression, in comparison with a c_ontrol group, wondered what the association signified. Probably it is a two-way feedback process. There is evidence that the sick role behaviour of couples is more concordant if they have no children, which suggested to Picken & Ireland ( 1969) that "without the health problems of children to influence them, the influence of spouses upon each other becomes more apparent". Many of the personality conflicts discussed in this section are results of an unsatisfied need for intimacy. Loneliness elicits, according to Van den Bergh (1963), narcissistic defense mechanisms including hypo- chondriasis. These people are unable to communicate within themselves and with others either because of their basic personality or because of a hostile entrapment. They do not have available the vicarious donation of other people's strength to lean on; they have no basic trust to sustain them. Just as they are dissatisfied with their environment and inter­ personal relationships so too are they dissatisfied with their bodies. Schwab & Harmeling (1968) administered a self-report inventory measuring conscious, verbal attitudes about the body and found that dissatisfaction is related to an increased number of somatic complaints. The more negative body-image scores of women were also significantly associated with dependence on others, higher manifest anxiety and more anxious concern about the illness. Increased familiarity with illness in general correlated with negative body image (r= + .36, p ( .01). "The Athlete's Neurosis" (Little, 1969) occurs in men who "to the exclusion of other interests .... overvalue health and fitness, revealing an inordinate pride in their previous sickness-free progress through life and in their excess physical stamina, strength or skill''. Little found it to occur in nearly 40% of neurotic males. These men become exquisitely vulner­ able on approaching the fifth decade of life, to threats of their overvalued but waning physical prowess so that an apparently trivial stressor, for example a physical assault, can be a major crisis. The neurotic symptoms are mostly a:ixiety-depressive but they show more "general somatic symptoms of 3 7.

hypochondriacal type" (p ( .Ol) and more panic attacks (p ( .003) than a non-athletic male neurotic group. Little saw the illness as a "deprivation neurosis", a bereavement reaction to loss of part of oneself. He quotes Lorenz (1966) who sees athleticism as a manifestation of the diversion of aggression into ritualised socially innocuous channels. No longer able to divert their aggression as adequately, they suffer from its inhibition. The twin themes of and tension are mentioned by various authors in connection with the personalities of those somatically preoccupied (Harris, 1951; Ziegler, 1970). The reporting of perceptual experiences during sensory deprivation was shown by Leff (1968) to be correlated with Cattell 16PF factors categorized as schizoid, surgency and high ergic tension. The somaesthetic experiences included paraesthesiae, sensations of movement and depersonalization. The somatic experiences were reported as if they were real whereas the visual and auditory ones were considered by the subjects to be imaginary. Schizoid factor A which had the strongest association with perceptual experiences has similarities to the repressive personality. Its most highly loading traits are aggressive, critical, obstructive, aloof, precise, suspicious, rigid and cold. Limited intelligence in overachievers is an underlying stress operative in some of the bodily preoccupied (Martin and Swenson, 1966). It is by no means a necessary cause but is sufficient to make an already stress­ ful environment even more so. In a group of Australian Aborigines who had much somatic preoccupation and who "over-attended" the available dispensary, limited intelligence was found to be an extra burden (Bianchi et al., 1970). Another stress was their excessive fecundity. They believed more in the supernatural delivery of benefice, especially in cure of illness by medicine­ men. It is worth quoting in length an opinion of Bean (1969) who feels that the belief in magic is perhaps the most important determinant of contemporary behaviour. "The fostering of a belief in magic, inherent in most early cultures, survives in our western society, perpetuated by our patterns of upbringing .... What do I mean by belief in magic? Our very haziest early recollections contain a lot of cut fingers, bumped knees and broken toys. We got great help from our early appreciation that mother would kiss it away or father could fix it. Parents were magicians. The magic of Santa Claus lasted for a time. When we got sick the doctor came and gave us magic in the form of a bottle with beautifully colored, sweetened, cherry-flavored material. Though sulphur and molasses had gone out of style by the time of my childhood, the strong parental belief in the magic of various forms of cod-liver oil leaves a vivid, rancid memory. We accepted the words of authority. We took the stuff and waited. The physician was the magician. The medicine was magic". For some troubled people hope comes in the form of medicine and for some in belief systems that comfort. In t_he section on disease phobia the association of bodily symptoms with low self-esteem was mentioned. People with low self-esteem are more sensitive to criticism and do not tend to have independent opinions (Coopersmith, 1968). These characteristics intermesh with the above beliefs in magic, medicine and conventional religious platitudes and with the sensitive inter­ nalizing of anger. Each worker in the field follows a particular idea and it is difficult to obtain an overview of the matrix showing how all the pieces intercalate. "UNNECESSARY" OR "NON-ORGANIC" OPERATIONS. Some surgery is governed by motives other than medical necessicy, for example, by financial gain or as a thoughtless way of coping with 'cold' cases of psychogenic abdominal pain. This is not to be taken as condemnation of the removal of all normal appendices or unflawed uteri. To echo Merskey & Spear (1967), the use of the word "unnecessary" "should not be taken as a criticism of the present practice of surgeons faced with a very serious and frequently urgent clinical problem; although we suggest that sometimes and especially with non-urgent cases the possibility of obtaining psychiatric or at least, social, information might be entertained". Cosmetic surgery is not being considered here for it is an aspect of dysmorphic rather than of hypochondriacal preoccupation. The patient's motivations in obtaining polysurgery are various - for the secondary gains of nurturance and a feeling of safety, for masochistic satisfaction or for obscure sexual delight (Wahl & Golden, 1966). But the spectacular polysurgical patient is the victim of "unnecessary" operations writ large and is accordingly unconnnon. The operations principally performed for non-organic reasons are appendicectomy and hysterectomy. Zwerling et al. (1955) found that in nearly 50% of people corning to surgery "there was a significant relationship between the surgical status of the patient at the time of presentation to the surgeon for treatment, and emotional disorder". Oleinick et al. (1966) found that a children's hospital population of those who had had minor surgical procedures, acute minor illnesses and simple re­ fractions were more behaviourally disturbed than an outside population sample. They had a stronger history of parental loss or separation. The authors suggested "it may be that there is a greater likelihood of the child appearing at a medical or surgical clinic for elective treatment of a minor disorder if there is tension in the household". Similar "admission tickets" may be proffered by adults as an escape from equivalent tensions. Neurosis is the connnon background diagnosis. Coppen (1965) found a history of appendicectomy in 24.5% of a neurotic group versus 9.6% for an affective disorder group, and a history of dilatation and curettage in 20.4% and 14.6% respectively. Tonsillectomy rates were also higher among the neurotics even though they were a mean eight years younger than the affectives. Sainsbury (1960) studied scores at various clinics and recorded the percentage of patients with scores above the median. After the psychiatric clinics (77%) the proportion was highest in the combined medical clinics ( 52%); next in ·order were the skin ( 50%), and gynaecological (l~ 7%). There is a largt: amount written on the topic of "unnecessary" surgery. Merskey & Spear (1967) provide a useful bibliography and refer to their own work which showed that the somatically preoccupied have had an excess of such operations. It should not astonish, for surgery is the approved path in our society for sufferers - once innumerable investigations or treatments have failed. It is worth referring to papers since 1967 which shed light on somatic preoccupation and to a few not mentioned by Merskey & Spear. The incidence and prognosis of unexplained abdominal pain requiring admission to hospital have been investigated by Rang et al. (1970) in the Oxford region of England. It was the tenth connnonest cause of admission to hospital in males and the sixth in females. Sutton (1965) thinks that psychological disturbances (anxiety in 70%) are the principal cause of functional uterine bleeding during the prime reproductive years (not in the pubertal or perimenopausal years). About two-thirds of his subjects had at least one other severe somatic complaint, such as pylorospasm, chest-wall pain, "migraine" and globus. Various authors have connnented upon this association between operations and other somatic distress notably Engel (1951), Guze and Perley (1963) and Schwab et al. (1965). In addition to pain syndromes these patients in some 50% of cases give a history of prior conversions or dissociations. Barker (1968) investigated psychiatric illness in relation to hysterectomy. The incidence of previous psychiatric referral was five times 40. greater in 'non-organic' than in 'organic'. Twice as many referrals to the psychiatrist came from the group whose uteri were without significant organic pathology. He cautioned against operating if the patient "complained of menorrhagia or pelvic pain, and where there was no anaemia or significant finding either on pelvic examination or on curettage, especially if the patient had a previous psychiatric referral or had a history of marital disruption". As well as being the result of psychological malaise so too can hysterectomy bring malaise in its train. Whitlock (1970) compared 100 female patients with severe barbiturate dependence with 100 female psychiatric patients matched for age _and, as far as possible, for personality and diagnosis. Of the drug-dependent women 57 had had gynaecological operations versus 34 of the controls (99 operations versus 46 operations). He thought from considering the case histories that the operations appeared to have precipitated barbiturate dependence in 39 patients, 27 after gynaecological surgery. Another common drug abuse in the somatically preoccupied is that of analgesics. Fellner & Tuttle (1969) studied 35 patients with analgesic nephropathy. 85% had long-standing headache, 46% had various musculoskeletal problems. Of the 25 women, 14 had had pelvic surgery. Interestingly the patients had shown concern for other organs such as the thyroid (six of the 35) and the breast (four of the 25 women). The authors remark that these are organs frequently self-examined by neurotic individuals with multiple complaints. Atypical pelvic pain, one of the symptoms propelling a patient towards ablative surgery, is said to occur in those having difficulty in accepting the feminine role (Boyd & Valentine, 1953; Gidro-Frank et al. 1960). The technique of laparoscopy for the woman complaining chronically of pelvic pain has been recommended. It is indicated where organic disease has already been excluded as far as possible, to confirm negative clinical findings (Jeffcoate, 1969). The question of exploratory laparotomy is interesting. Devor and Knauft (1968) in a study of 28 women and 12 men suggest laparotomy is an unsatisfactory shortcut to diagnosis. "The patient is likely to acquire imagined or real problems that may be as disabling as abdominal pain". The average age at laparotomy of the group was 41 years, after an average duration of pain of two years. 55% had had previous abdominal surgery, mostly appendicectomy (nine) and female reproductive 41.

organ surgery (eight). At a minimum follow-up time of one year 35% were asymptomatic. Eventually four (all men) were shown to have a duo.:lenal ulcer and another male to have gastric carcinoma. So it appear~ to be especially the female in whom laparoscopy might be a help, especially as it presents less hazard than laparotomy. Meyer et al. (1964) discovered a connection between removal of a normal appendix in young females and subsequent gynaecological surgery. Besides having more major gynaecological surgery as an aftermath they had more dilatations and curettages and more major surgical procedures altogether than did the numerically greater group with pathological appendices. They had predicted this excess "on the assumption that the normal-appendix population would contain more young women who would continue to translate emotional distress into physical symptoms". In their study a recorded history of dysmenorrhoea prior to operation correlated significantly with removal of a normal appendix. Levitt & Lubin (1967) reported that psychosomatic and mentrual complaints were modestly correlated. The menstrual complaints occurred more in those with an un- wholesome menstrual attitude, neurotic and paranoid tendencies and a lack of understanding of motivations and feelings. However Spear (1964) found dysmenorrhoea to occur with equal frequency in patients with and without psychogenic pain. Merskey's (1965) patients with persistent psychogenic pain were more often married than control psychiatric patients but nevertheless their sexual adjustment was relatively poor. Attitudes that pregnancy is an "illness" results in a longer period of active labour, especially if doctor and patient have discrepant perceptions of the n~rmality of pregnancy (Rosengren, 1961). The higher the education and family income of the woman, the less likely was she to equate pregnancy with sickness. These various studies point to the sensitivity of the uterus to the stress of female role crises. In one investigation of men having an appendicectomy the Taylor Manifest Anxiety Scale differentiated those with normal histology from those with pathology. The main discriminating questions concerned constipation, insomnia, worry, life stress and tension (Barraclough, 1967). Strangely he did not find this for women (Barraclough, 1968). A recent leading article (Brit. med. J., 1970) provides a review of operations on normal appendices. It quotes several studies indicating the poor operative results. The group of bronchitics with disproportionately severe breathless­ ness (Burns & Howell, 1969) as well as being somatically preoccupied in other ways also had a history of more surgical operations, major and minor (41.9% versus 6.4% of control bronchitics). Aside from sanctioned 'mutilation' two studies give suggestive clues to the masochistic needs of those somatically preoccupied. Firstly there is a clinical study of self-mutilation in female psychopaths (women self-mutilate more than men). McKerracher & Watson (1968) found that the mutilators were more preoccupied with bodily complaints than the non-mutilating psychopaths. They were also more phobic and more obsessive-compulsive in personality. The mutilation occurred more on days of boredom. An inkblot study by Endicott & Jortner (1967) found that the number of Holtzman Inkblot Technique anatomy responses, animate mutilation responses and blood responses were significantly correlated with clinically rated somatic preoccupation in a hospitalized group. That the bodily preoccupied in the clinical study were the mutilators allows the tentative suggestion that the animate mutilation responses of the somatically concerned in the inkblot study may be more than just a consequence or unconnected association of being bodily introspective. It may point to the psychodynamic need for mutilation of this group. The psychopath with her cuttings and needle insertions and swallowings adopts a related but more immediately tension-discharging and available outlet than her more subtle and conforming sisters. 4 .. L

CLINICAL RELATIONSHIPS. The somatically preoccupied are often called 'crocks'. This word derives from the Norwegian KRAKE, meaning a sickly beast and is akin to the source of the Middle English CROK, an old ewe. In modern usage it means one that is worn-out, decrepit, or impaired. The decrepitude is mainly evidenced by pain (Klee et al., 1959), but Burton informs us that "the Tower of Babel never yielded such confusion of tongues as this chaos of melancholy doth variety of symptoms". He was referring to depressed 'crocks' but the cap fits elsewhere too. Factor-Analytic Studies. Most of these analyses have been of the answers of depressed patients. Kessel (1968) refers to five studies in which a factor of 'hypochondriasis' was derived. The covarying symptoms were somatic complaints, hypochondriasis, anxiety, irritability and demanding behaviour (Hamilton, 1960; Grinker et al., 1961; Friedman et al., 1963; Cropley & Weckowicz, 1966; and Rosenthal & Gudeman, 1967). Hordern et al. (1965) found that somatic preoccupation loaded (0.38) on the factor of anxiety-agitation and was separate from a factor of general somatic and genital symptoms (disturbed rhythmic body functions). Hunt et al. (1967) mention that somatic complaints and disturbed rhythmic body functions sometimes "separate into two factors". They found that social isolation clustered with somatic complaints. Lorr et al. (1967) also thought that "preoccupation with physical health may be a specific factor itself", separate from decreased appetite, weight and sex drive and from constipation. Kay et al. (1969) derived a "neurotic" cluster from 104 depressive cases and this cluster included prolonged ill-health and multiple somatic complaints. The chief factor of symptom distress extracted from ratings of anxious neurotic outpatients was one that Lipman et al. (1969) called somatization. The other four factors were irritability-oversensitivity, cognitive-performance difficulty, depression and fear-anxiety. The somatiza­ tion symptoms were in decreasing order of their factor loadings:- "soreness of your muscles, numbness or tingling in parts of your body, heavy feelings in your arms or legs, weakness in parts of your body, pains in heart or chest, cold or hot spells, pains in lower part of back, sweating, trouble getting your breath, feeling low in energy or slowed down, difficulty in speaking when excited, faintness or dizziness, a lump in your throat, headaches and heart pounding or racing.'' Poor appetite and constipation travelled with the depressi0n factor. The somatization factor correlated 0.49 with the anxiety factor and 0.34 with the depressive. 44.

De Bonis (1968) was able to differentiate such somatization symptoms of anxiety further into muscular and neurovegetative components. The mus- cular symptoms were cramps, restlessness and muscular shaking; the "neuro­ vlg{tatifs" symptoms were piloerection, palpitation, pallor and dizziness. This further subdivision is supported by the work of Cassell and Richman (1968) who found that external and internal symptom clusters were negatively correlated in both males and females. 'Response specificity' allows that each individual is characterized by a different mode of reaction, some res­ ponding primarily by means of the autonomic nervous system, some by muscle tension, and others by overt muscle activity. Goldstein et al. (1964) found that specificity of change is less prevalent among autonomic than among muscular responses. Fenz (1967) found that the autonomic arousal pattern correlated with an inhibition of energy factor but striated muscle tension did not. Clinical Reports. Kenyon (1964) in a study of 512 patients with a diagnosis of hypochondriasis seen ac a mental hospital concludes that it is always part of another syndrome, most commonly an anxiety or depressive state, and is not a condition with a single cause. There was no attempt at definition but somatic preoccupation appeared to be the symptom complex studied. Many other papers demonstrate that depression is the background affect, though anxiety too is part of the depressive symptomatology (de Alarcon, 1964; Lindberg, 1965; Blinder, 1966; Schwab, 1968; Dasberg & Assael, 1968; Jacobs et al., 1968). Blinder in classifying depression differentiates a tension depression, usually accompanied by somatic pre­ occupation, and a physiologic retardation depression, usually accompanied by visceral complaints. Schwab compared depressed and non-depressed medical inpatients and found that in addition to anorexia, weight loss and loss of libido the three symptoms of greatest value in were upper gastrointestinal complaints, headache and tachycardia. When severe symptoms only were considered fatigue, chest tightness or pain and inson:nia were added as strong differentiators. What the pathophysiological mechanism may be is a matter of con- jecture. The insomnia of depression may be an intervening variable between the affective disorder and somatic preoccupation rather than just a co-symptom. Johns et al. (1970) showed that those complaining of multiple physical symptoms as a result of neurotic illness have significantly increased degrees of sleep disturbance at all ages. Fatigue is a common accompaniment of bodily 45.

preoccupation and associates logically with insomnia (Shands et al., 1948). It makes sense that perception of bodily discomforts should be heightened by fatigue and lack of sleep. Persons with chronic fatigue syndromes obtain similar questionnaire neuroticism scores to neurotic patients, and much higher scores than matched short-duration myasthenics (McNamee, 1970). Anxiety showed itself in the whole life pattern of psychological attenders among preclinical medical students (Lucas et al., 1965). They reported bodily symptoms such as fatigue, headache, backache, dizziness and joint pains. They engaged less often in sports, were more uncertain about their careers, worried more and generally felt themselves to be hard­ pressed. Stone et al. (1966) studied adolescents aged 13-16 years comparing 44 who had somatic symptoms secondary to organic disease with 29 who had similar somatic symptoms but without an organic basis. The M.M.P.I. scores of the 'functional' group had significantly higher mean scores on the hysteria, depression and hypochondriasis scales and the girls had a higher mean score on the psychasthenia scale. The males appeared more depressed, the females more hysteroid. Pilowsky (1968) has drawn attention to a group of young histrionic females with many previous non-psychiatric consultations. This group was hypochondriacal and did poorly. Sometimes bodily preoccupation occurs in association with psycho­ pathy (Maddocks, 1970) or with acting-out behaviour (Bucove & Maioriello, 1970). Slater & Roth ( 1969) also comment upon the passage of "unstable drifters" into chronic invalidism. Maddocks in a five year follow-up of untreated psychopaths found that 30-40% showed "marked hypochondriacal traits" whether their behaviour had settled or not. Lindner et al.· ( 1970) have written on a sub-group of the antisocial personality type in which subjects evidence cardiac lability. Whether this group was somatically preoccupied is not stated. Multiple somatic complaints have been reported as a precursor of schizophrenia (Offenkrantz, 1962) and as early symptoms (Chapman, 1966). Of 455 schiz0phrenics of a Veterans' Hospital whose charts were searched by Offenkrantz, 144 had been evaluated psychiatrically while still in service. 99 of these 144 had no demonstrable schizophrenia when initially evaluated. Two-thirds of these people had multiple somatic complaints at that time, neuromuscular, gastrointestinal, eye, ear, nose and throat. Possibly this is an early result of the flooding with se~sory data that schizophrenics are thought to suffer. Chapman reviewed the three chief presenting complaints of 40 young schizophrenics. In 15% bodily preoccupation occurred as a chief presenting complaint and an additional 10% reported dysmorphic pre­ occupation. Somatic preoccupation occurs in other psychiatric syndromes such as the and organic psychosyndromes and indeed in association with bodily illness. A high reporting of somatic illness accompanies a higher incidence of psychiatric illness and in explanation Mechanic (1963) suggests that "persons who are likely to bring mood and behavior complaints to a psychiatric clinic are also likely to be sensitive to physical symptomatology". Despite this recital of syndromes underlying somatic complaining, there are patients in whom the primary diagnosis of somatic preoccupation neurosis or hypochondriacal neurosis is justified. It is largely a matter of fashion, for to quote Cameron (1947), "Is hypochondria an independent disease entity or only a syndrome? This controversy has never been settled but there is reason to hope that it has been outgrown. For we all recognize today that no one of the neuroses meets the criterion of an independent disease entity". PERSONALITY TYPES. Aspects of premorbid personality imputed to the somatically preoccupied hypochondriac include the obsessional, the anxious, the histrionic and the hypochondriacal. Dasberg & Assael (1968) suggest that "patients who are inclined to bodily expression of underlying depression show a compulsive life style". Roth (1959) mentioned that "the obsessional personality is generally agreed to provide a fertile breeding ground for hypochondriacal preoccupations as its ruminative tendencies are prone to cause a compelling self-scrutiny in the presence of mild bodily malaise". Lindberg (1965) thought that "hysteroid personality elements combined with a depression seem to be an excellent breeding ground for hypochondriasis". Providing some evidence for the hysteroid or histrionic personality is the prognostic study by Pilowsky (1968) in which he referred to a histrionic group of young females with bodily preoccupation. Even so this appears to be only a subset of the possible underlying personalities and in the absence of a controlled study it is not possible to decide even whether it i~ truly associated with a predisposition to somatic preoccupation. Slater & Roth (1969) suggest that for the persistently hypochondriacal males the personality is obsessional and for the females hysterical. 47.

Kreitman et al. (1965) refer to a lack of anxious premorbid characteristics. However these authors studied not "the familiar mental hospital inpatient with an obvious depressive illness which includes prominent hypochondriacal features, but the patient referred only after prolonged specialist investigation or treatment along general medical lines has been unavailing". Selective forgetting may be the explanation for the alleged deficit of premorbid anxiety. Just as with hypochondriasis, hypochondriacal personality means a different thing to each author. It too would benefit from nosological subdivision, for example into the over-athletic, the body-building narcissists and the food-faddist, disease-concerned personalities. Little(1969) showed that the conspicuous characteristic of the life history of male neurotics of athletic personality was the relative absence of neurotic markers and a minimal incidence of psychiatric and physical morbidity within a large child- hood family. As a group these patients were highly extroverted and sociable and had usually enjoyed excellent health all their lives. This sharply contrasts with what one imagines would be the history of the food-faddist, health-preoccupied personality. The athletic personalities were not given to food-fads or body-building, and were more engrossed in their body's action than in its appearance. McNair et al. (1968) related the trait of social acquiescence to a tendency to report considerably more somatic distress at the beginning of drug treatment, to expect more somatic emphasis in treatment and to focus more on somatic issues during interview. They defined acquiescers as persons scoring above the median on the Bass Social Acquiescence Scale (Bass, 1961). Bass thought the scale measured a tendency towards excessive behavioural conformity though others favour it being primarily indicative of noncritical thinking and thoughtlessness in responding to personality inventories. This relationship will be discussed more fully later in connection with E.P.I. Lie Score differences between somatically preoccupied and controls. SOME AETIOLOGICAL SPECULATIONS. Because each researcher sees with his own specialty's vision it is hard to marshall an overview of this field. Often viewpoints apparently unrelated are seen to converge once their "linguistic parallelism" is appreciated. Graham (1967) proposed this term with reference to how a single event or state may be described in different but parallel languages and Sternbach (1968) developed the concept with reference to psychogenic pain. 48.

Yet another influence hampering a total assemblage is the piece­ meal approach, the reverse of a systems analysis. Roth (1969) in discussion of seeking commonground in contemporary psychiatry was a little pessimistic about a systematic approach and for some obscure reason was loathe to combine relatively hard data with softer data. Observations from the various physical fields deserving adumbration concern the biochemistry of anxiety (Pitts, 1969), increased beta-receptor responsiveness (Frolich et al., 1969), electroencephalographic correlations (Ging et al., 1964), somatic symptoms after apparently mild head injury (Lishman, 1968), skin sensory afterglows (Melzack & Eisenberg, 1968) and the connection between giddiness and neck tension (Eadie, 1965). From the psychodynamic angle, somatic identification with a deceased relative is worth rementioning. Conversion continues to occupy a central position as a mechanism explaining many somatic manifestations. Engel (1968) comments that "any body experience which is perceived leaves behind memory traces which have the potential of becoming associated with other mental content and thereafter being used (reactivated) as body language He refers to insights into how vegetative systems may become involved in conversions, alluding to the work of Miller and Banuazizi (1968) who demon­ strated in rats the instrumental learning of specific visceral responses. By stimulation of the medial forebrain bundle they were able to condition intestinal contractility and heart rate activities. Engel deduces, "the implication of this finding for conversion is that if a fantasy of a wish fulfilled can be regarded as a reward, then the perception of a visceral process (for example, hyperperistalsis or tachycardia) which happened to have been temporally associated with the wish may become equivalent to it." Rodgers and Ziegler (1967) also talk on this point in regard to the orthodox non-vegetative conversions. "Conversion symptoms almost always reflect some previously learned pattern of illness and are triggered by some life circumstance that the patient associates with illness or a desire for illness". Yet another language that can be invoked is that of information theory (Slater & Roth, 1969). The reticular system computer, by failing to filter trivia, results in a hypochondriacal steering so that the hypo­ chondriac never adapts to sensory information. Prognostic Import and Therapeutic Considerations. Mead (1965) remarks that "in terms of physician frustration, few patients are more difficult to treat than the dem~~ding, fussy chronic neurotic who confronts his doctor with an 49.

endless recital of functional complaints". In the same fashion Wahl (1963) states that "the hypochondriac occupies a low position on the scale of 'disease respectability' ". When doctors have a tendency to reject patients, it is often because the patient has an incurable but non-fatal illness, resistant to the healer's majesty, intellect or charm. Therefore one might predict a long course, at least for some varieties of somatic pre­ occupation. Greer & Cawley (1966) did a four to six year follow-up of 175 neurotics. 160 (88%) were successfully traced. The final outcome was no change or worse in 44% of hypochondriacal neurotics, in 27% of patients with dP.pressive neurosis and 24% of those with anxiety neurosis. Their sample with hypochondriacal neurosis was more often male and older, and had fewer precipitants, a longer symptom duration and a worse prognosis than the other neurotic groups. The broader category of "somatic symptoms" was not related to outcome. It was principally composed of autonomic and con­ versional symptomatology. The work of Kay et al. (1969) on a group of 104 depressed in-patients confirmed the adverse prognostic significance of somatic preoccupation. They refer also to people whose personality can be considered to have "narrow interests" as the most important personality indicator that readmission will occur. This trait is possessed in abundance by the type of patient Mead and Wahl described in the last paragraph. Pilowsky (1968) followed up 147 patients with mixed hypochondriacal disorders. A group corresponding to disease conviction had a poor outcome as did a group of histrionic and somatically preoccupied young women. He related clinical items to outcome though did not express the relationship in terms of form of hypochondriasis. The favourable prognostic items were in descending order:- 1. fear of illness 2. anxiety-prone personality 3. endogenous depression 4. sexual guilt 5. made anxious by information in mass media.

Except for item three these clearly relate to disease phobia and its associations. 50.

The unfavourable prognostic items were in descending order:- 1. spontaneous complaints 2. no response to reassurance 3. unremitting symptoms 4. musculoskeletal symptoms 5. complaint of pain. These unfavourable clinical items are a mixture of disease conviction and somatic preoccupation, "no response to reassurance" being part of the definition of disease conviction. Chronic somatic preoccupation in a demanding, dependent patient is a way of life. Mead reasons that as for other chronic diseases the only feasible therapeutic goal is a limited one. He recommends a controlled but accepting relationship in which the symptoms are shown up as related to stress and feelings. Intermittent usage of medications is sanctioned to "offer an excuse for impr0~ement to the patient who never really accepts the idea that his complaints may be related to emotional factors". Each specialist "carries" his own load of such patients and to retain them rather than have them drift from specialist to specialist he must function in some such firm but cheerful way. There is some evidence that placebos help them more than do active psychopharmaceuticals. Porter (1970) compared imipramine and placebo in the treatment of general practice depressives and found the hypochondriacal patients did better on placebo. McNair et al. (1968) found, comparing diazepam and placebo in anxiety states, that placebo helped but that diazepam did not benefit those with somatic concerns. Further, in discussirig the acquiescent personality (prone to somatic preoccupation) they mention "Acquiescers on placebo report so much improvement that a minor tranquilizer probably would have little chance of surpassing such an effect". If medica- tions are to be supplied to the chronic inadequate personality with long-lived bodily preoccupation, a placebo capsule would appear preferable to the habituating preparations and the analgesics. Merskey (1968) notes the lack of response to antidepressant drugs of the depressed female with chronic psychogenic pains. A &tudy by Rogers & Reese (1967) comparing aspirin and placebo for minor illness in adolescents found that reported improvement appeared to be largely a plncebo ~ffect. Moreover the pupils with the symptoms of headache, 51.

, general malaise, dysmenorrhoea and upper respiratory infection reported less improvement or even worsening if given no treatment. Maybe it is the offering of loving concern in some culturally reified form that works. Certainly anger in the therapist provokes patient drop-out (Salzman et al., 1970) and the whining hypochondriac is the enemy par excellence of anger-prone or busy doctors. Joyce (1966) studied the personality differences between cooperating and non-cooperating patients. "Men are as likely as women to default, but it is the younger women and older men who are the worst offenders: female backsliders are prone to dose themselves (especially with purgatives) to a greater extent than cooperators. They also pay rather more attention to their own bodily processes, but are not noticeably more neurotic or intro­ verted". It will be recalled that Pilowsky ( 1968) also found prognostic categories relating to old males and young females. Hesbacher et al. (1968) think that anxious patients with a "somatic dominance profile" improve most with tybamate, followed by phenobarbital, and least with diazepam (vice-versa with patients of "psychological dominance profile"). Their technique of assessing the profile was to obtain the patient's list of his three chief complaints (target symptoms). If these were headaches, heart pounding and nervousness, that is, somatic, somatic, psychological, the patient was allotted to the "somatic dominance profile". Earlier work by Raab et al. (1964) suggested that tybamate is indicated primarily for the patient who exhibits a high degree of anxious neurotic symptomatology, including somatizing and hypochondriacal complaints. Replication is needed. Little is known about the effective treatment of this chronic group, almost by definition. One wonders if a token economy or group therapy for hypochondriacs only or a cultural equivalent of the El-Zar cult (Okasha, 1966) could be applied. When fear accompanies somatic preoccupation 'delabeling' can be effective. Landtman et al. (1968) did this to childreu with mistakenly diagnosed cardiac conditions. The most common symptom was precordial pain (70%). Following 'delabeling' the symptoms experienced by the children usually disappeared or diminished. Kreitman's patients were somatizing depressives and it was learned that "over-emphatic statements to the patient that he was physically quite well could sometimes lead to a state of 52.

psychological hypochondriasis in which somatic fears were replaced by fears of insanity". The orthodox prescriptions for treatment are well expressed in Slater & Roth (1969). Their view is that a full course of treatment with antidepressive drugs is well worth while even in patients when the hypo­ chondriasis appears to be primary. They recommend modern forms of prefrontal leucotomy for the very resistant case. Prophylaxis is a principal hope, for the constitutional hypochondriac's therapy is difficult and unrewarding. 53.

METHODS.

The subjects of this study were in-patients from the Psychiatric Unit of Prince Henry Hospital, Sydney, which is a general and teaching hospital of the University of New South Wales. The project which formed part of a larger cooperative study began in April, 1966. Intake of new patients to a total of 235 continued until February, 1969. The author was one of three psychiatrists involved in this larger study and employed the same patient material for his separate study of hypochondriasis and psychogenic pain. Precedence was given to those patients with a depressive illness or depressive symptoms because of a concurrent interest in the phenomenology of depression. As only one person could be adequately assessed each day, the more depressed or more recently admitted of several available patients was the one included for investigation. On about one-third of the days only non-depressed patients were included, owing to a lack of any depressed ones. Other criteria for acceptance were: 1. willingness and ability to cooperate, 2. capacity to answer verbal and written questions meaningfully, 3. cessation of psychotropic medication and non-essential drugs for at least 24 hours before entering the study, and 4. living within about 50 miles of Sydney or if not, readily available for follow-up visits. Data collection and testing took two days and in this time treatment was withheld. The approximate time sequence of interviews and tests are here tabulated with connnents: Day One, 9.15 a.m. - Psychiatric interview, at first free-flowing and then structured. The interview form is reproduced in Appendix II. One psychiatrist did all of these interviews and recorded them on tape for assessment and scoring by two other psychiatrists, of whom the author was one. The basic psychiatric interview lasted on average about 50 minutes. For the 63 questions requiring a direct reply from the patient "no" was scored zero, and "yes" was scored two; one was allotted for replies such as "sometimes", "a little", "I'm not sure" and "I don't know"; a score of three was marked when the patient gave a strong affirmative reply, su~h as "Oh, Yes, very much so" or "Yes, Yes, a tremendous amount". 54.

For the 66 judgment items which depended on the psychiatrist's assessment, the method of zero, one, two or three scoring if not specified on the interview sheet was as follows: if the item was not present the score was zero; if it was definitely present and in substantial amount the score was two; a score of one indicated mild, some, a little, though certainly present, and a score of three indicated a great amount of, or very strongly present. Day One, 10.30 a.m. Hypochondriasis interview. Twenty-two items tapping personality characteristics and life experiences postulated by various authors as related to the phenomena of psychogenic pain and hypochondriasis were assessed at this interview, prior to the interviewer's knowledge of their form of hypochondriasis. (See Engel (1959), Kenyon (1965) and Merskey (1965) for sources). That is, the author tried to avoid the potential bias of knowing what particular hypochondriacal classification the patient had. They were rated zero, one, two or three according to the criteria previously outlined. The items were: 1. Do you have a great need to be loved and liked by people? 2. Do you have a great urge for power and importance? 3. Can you be easily made to feel ashamed? 4. Have you suffered a lot of painful disabilities in your life? 5. Have you suffered a large number of defeats, humiliations or other unpleasant experiences?, 6. Did your parents punish you much physically? 7. Was your mother warm and loving? 8. If you did something naughty would she become cold and hurt, rather than physically punish you? 9. Do you feel it is necessary to take vitamin pills for your health? 10. Do you often take medicines or tonics you don't get from the doctor? 11. Do you feel you are more apt to catch infectious or contagious diseases than most people? 12. Were you babied, mollycoddled ar.d overprotected to a later age than is usual? 13. Do you keep your angry aggressive feelings to yourself, bottling them up inside? 14. Even when well do you have a basic poor opinion of yourself as a person? 55.

15. If you are justly criticized, do you nevertheless reject the criticism? 16. What operations have you had? (scored if "unnecessary") 17. Are you accident prone? 18. In your life have you had a lot of contact with doctors and hospitals? 19. Have your relatives and loved ones had a lot of illness and ill-health? 20. As a child were you weak, sickly and lacking in vitality? 21. Do you like rough sex that is even a bit cruel? 22. Illnesses of allergic or "psychosomatic" nature before the age of 20 years. Items 16, 19 and 22 incorporate an element of judgment. The word "unnecessary" in item 16 concerning "unnecessary" operations implies an absence of organic pathology. A typical patient to whom a score of "one" was allotted would have a history that went something like "various abdominal pains for several years culminating on one occasion in removal of an appendix which the patient was not told to have been diseased." Hyster- ectomy for mild or persistent abdominal discomfort and some menstrual irregularity and "heavy" bleeding would also receive a score of "one". A score of "two" would require two or three such operatj_ous and a score of "three" would be reserved for the polysurgical patient (Wahl and Golden, 1966). Item 22 concerned psychosomatic and allergic illness. This was assessed positive if the patient gave a story of illnesses like hayfever, asthma, irritable colon syndrome, psychogenic abdominal pain (prior to the present illness) and duodenal ulcer. It is realised that the issue of psychosomatic illness has not been satisfactorily resolved in terms of definition and remains a vague concept. Following this questionnaire assessment, the patient was further interviewed and scored for the presence or absence of disease phobia, disease conviction, somatic preoccupation and psychogenic pain. These four items were also rated "zero", ''one", "two" or "three", in the aforementioned manner. Disease phobia was considered to be present when the patient had nn unfounded fear of suffering from a disease; the fear had to be more than a passing thought and one that did not easily disappear despite thorough examination and reassurance. Dis~ase conviction was considerec ?resent when the patient was convinced th~t he had a disease or bodily disorder in the face of evidence to the contrary. Somatic pv~occupation was assessed as present when the patient had a plethora of symptoms without an organic basis, typically many aches and pains and other forus of undue bodily awareness. The patient is not necess3rily also disease phobic or convinced he is diseased. Psychogenic pain was defined as pain which is independent of peripheral stimulation or of damage to the nervous system and due to emotional factors, or else pain in which any peripheral change such as muscle tension is a consequence of emotional factors. Information was obtained concerning the site and form of hypo­ chondriasis or pain, length of episode, fluctuation, symptom upon which the hypochondriasis was based, organ involved and significance of the condition to the patient, mainly in terms of identification. The four items are presented as rectangles in Figure 3 to demonstrate the extent of their overlap. Only the 139 patients who obtained a score on at least one of the four hypochondriasis and pain symptoms are represented. The 96 controls are excluded.

DISEASE PHOBIA \ DISEASE CONVICTION

4 I 4 /

SOMATIC 2 2 0 16 ...-- PREOCCUPATION

16 5 4 25

PSYCHOGENIC 49 7 I 3 PAIN

Fieure 3. • THE CLINICAL SPECTRUM OF HYPOCHONDRIA Distribution 1n a series of /39 psychiatric patients 57.

Table 2 illustrates the principles used to allot patients to one of five possible groups. This classification was based upon the presence or absence of the four symptoms defined above. TABLE 2. Basis of classification.

Classificatory Symptoms

Group Disease Disease Somatic Psychogenic Phobia Conviction Preoccupation Pain Disease Phobia + ( D.P. +- +- Disease + + Conviction { D.C. + - - Somatic 0 0 + Preoccupation + - Psychogenic 0 0 0 Pain + Control 0 0 0 0

+ signifies that the symptom is present, 0 that it is absent,± that it is present or absent. ( D.P. indicates that the score on disease conviction is less than the score on disease phobia. -' D.C. indicates that the score on disease phobia is less than or equal to that on disease conviction. This system placed 30 of the 235 patients in the classificatory group of disease phobia, 19 in disease conviction, 41 in somatic preoccupation, 49 in psychogenic pain and 96 in the control group. In the afternoon of Day One, a psychologist administered the Raven's Matrices as a simple test of intelligence. Two scores were obtained, firstly "free", meaning the patient was not encouraged or persuaded to do better, and secondly a "driven" score in which pressure was applied upon the patient to perform well. For some patients measures were taken of barrier and penetration indices of body image using a Rorschach test. Measurements were taken of sensation threshold and pain tolerance using an electrical current. This was done on a reduced sample of 144 patients, random except that 32 with schizophrenia or organic brain damage had been excluded. The stimulus was a one-second electrical current deli·Jered from a Grass S4 generator to the index and middle fingers of the dominant hand via eutectic solder electrodes, 1 cm. in diameter and covered by cardiotrace E.C.G. electrode paste. The current had a rectangular pulse train, with 100 pulses per second and pulse duration of 5 rr.sec. The sensation threshold was 58.

that voltage at which the subject first felt the current and the pain tolerance was that level at which the patient demurred from any further increase. In the morning of Day Two, patients filled in various questionnaires including the Eysenck Personality Inventory and the Zung self-rating depression scale (Zung, 1965), measures of salivary excretion rates were taken and somatometry scores were obtained according to the Parnell technique (Parnell, 1964). Follow-up at six months was made either by a psychiatrist or a psychiatric social worker. The two items of interest taken from six months follow-up were present and working capacity in the past two months. Present mental health was scored "zero11 , 11 one 11 , "two11 or 11 three". "Zero" equals stable, "one" equals symptoms present but caused no incapacity,

"two" equals symptoms handicap and limit, "three 11 equals symptoms disable and incapacitate. Working capacity was scored in a similar fashion with "zero" equalling did all expected and had surplus energy. "One" equals did expected tasks only, "two" equals did some work but was supported by relatives, work­ mates, friends, "three" equals did not contribute usefully. Matching Design. Each subject having psychogenic pain or hypochondriasis was matched one for one against a control subject having neither disease phobia, disease conviction, somatic preoccupation nor psychogenic pain. The matching was for sex, age and occupational prestige. Congalton (1969) in Status and Prestige in Australia gives as appendix B of the book a status ranking list of 134 occupations in Australia. For matching purposes, his four-point system was used. Matching was exact for sex, and as close as the available control sample would allow for age and occupational prestige. The large control sample allowed close matching as can be seen from Appendix IV. Defective recall of childhood events seems to characterize increasing age. Therefore in interpreting retrospective data it becomes necessary to have an age-matched control group. This became obvious upon examining some of the correlates of increasing age. There seems no reason that old age should not have been preceded by events such as being babied in childhood, having a father of poor personality, having a poor work record, having a family history of neurosis, and yet the correlation coefficients of age with these variables were -.165, -.215, -.294 and -.339 respectively, all significant and some highly significant. This tendency of the old to falsify the reporting of childhood events (desirability response set) fits in with the very high correlation of age with Eysenck Personality Inventory 59.

Lie Score in this sample (+.364). (Significance at the .001 level was achieved by correlation coefficients of .233 or higher). It happens that the hypochondriasis groups have a higher average age than the control group and so if no matching were used the relationship of hypochondriasis to childhood events would possibly be hidden or certainly made less obvious. Under these circumstances case-for-case matching can improve the design efficiency (Bross, 1969). Even so "the principal role of matching techniques is in minimising the effects of troublesome artifacts or sampling biases encountered in retrospective studies". Data Examination and Statistical Analysis. (a) Interview schedule items The replies to questions dealing with mood, and cognitive difficulty, anxiety, externalised anger, shame and guilt, and habit changes were subjected to principal com­ ponents analysis with the aim of condensing the data, that is, of summarising most of the variation in a multi-variate system in fewer variables. To obviate the :;,roblem of undecipherable "noise", the analysis was done on each of the six clinical sections separately, unities were used in the leading diagonal and the only components examined were those with an eigenvalue above "one", except in one instance where the factor loadings were high and easily interpretable. The unrotated factors obtained were descriptive and so rotation was not necessary. As each patient had answered the interview schedule questions, it was possible to obtain the computer's print-out for each individual's score on the various eigenvalues. The system of matched pairing as a control measure was applied with t-testing (related samples) as the most appropriate statistical measure. (b) Hypochondriasis and Pain Questions. The Wilcoxon Matched-pairs Signed-ranks Test was used. This is a non-parametric test almost as power- ful as the t-test. It gives more weight to a pair which shows a large difference between the two groups than to a pair which shows a small difference. (c) Other Data (for example sibship position, prognosis, intelligence and sensation threshold). For non-parametric data, Chi-square, Fisher Exact Probability and Wilcoxon Tests were variously used. For parametric data t-testing was used. Where a probability value is given and the test of statistical ~ignificance is not mentioned, it can be assumed that the Fisher Exact Probability test was used. All tests were two-tail unless specified as one-tail. 60.

Matched-pairs design has been retained in most cases, even where there is some missing data. The commonest reason for missing data was a patient leaving hospital before completion of the assessment. The Pearson product-moment correlation coefficient was sometimes used. In the week following the interview, the psychiatrists met along with the social worker who had interviewed relatives of the patient. They discussed discrepancies in their scoring and where new information was obtained, made appropriate adjustments. Group discussion had a stabilising influence on raters who had a response tendency in a given direction on some items. For some few questions or judgments, discrepancies between the three raters of more than "two" steps on the "zero", "one", "two", "three" system of scoring occurred. These items became of particular interest in the discussion and usually, as a result of the clarification obtained either from the social worker or the relevant psychiatric registrar, the discordance was reduced. Statistical analysis of the interview data was based on the summed opinion of the three rating psychiatrists. (Only the author rated hypochondriasis and pain items). In addition to the matched-pairs design, other techniques have been used to amplify interpretation of the data. One method has been to use four matched groups each containing 30 subjects, the four groups being disease phobia, somatic preoccupation, psychogenic pain and control, that is, foursome matching rather than pair matching. For this arrangement of the data, an analysis of variance technique was used for statistical assessment. These four matched groups are shown in Appendix IV; the disease conviction group was not included for want of adequate numbers. As a minor digression at this point, it is worth noting that the disease conviction group really represented two varieties of disease delusion, one, a depressive kind and the second a schizophrenic kind. Only the depressive will be examined extensively, there being too few schizophrenics, Another technique used to examine the data was a principal components analysis of all pain and hypochondriasis subjects (except for patients with schizophrenia or organic conditions). 24 variables were included in the matrix. The variaules selected were mostly chose which showed up as important in differentiating the hypochondriasis and psychogenic pain groups from coutrols. Extra comments regarding methodology appear at points in the text where their relevance is more apparent. 61.

RESULTS (a) DISEASE PHOBIA

Thirty of the 235 patients had disease phobia as the main subvariety of hypochondriasis. Matching and diagnostic profiles. The age, sex, occupational prestige and diagnostic differences between the disease phobic, and unmatched control group were minimal. Diagnosis of non-depressive neurosis was more connnon amongst disease phobics. TABLE 3. Matching and Diagnostic profiles.

Disease Phobics Unmatched Matched Controls Controls N = 30 N = 96 N = 30

Female 67% 63% 67% Age in years (mean&S.D.) 39.9 (15. 5) 38.8 (15. 9) 39.3 (15. 6) Occupational prestige (mean & S.D.) 3.2 ( 0.8) 2.9 ( 0.9) 3.2 ( 0.8)

Diagnosis Endogenous depression 27% 24% 30% Neurotic depression 23% 27% 33% Other neuroses 40% 14% 10% Asthenic 33% .23% 27% Obsessional personality disorder 13% 4% 0%

Disease phobics and matched controls showed up only a few differences in terms of biographical details. Disease phobics were more often of protes- tant religion (8 to 2, p(.05), and the youngest sibling (15 to 6, p(.05). In examining some sources of bias in birth order studies Price & Hare (1969) recommended the possibility of comparing the sample with a control group matched for age. They stated "However, the problem of matching for other relevant variables such as social class would probably be prohibitive". Their criteria have been met in this study and their advice taken to count as a sibling only individuals who have survived to the age of one year. Non­ significant trends were an excess of being single (11 to 5) and of being born outside Australia (6 to 2). 62.

Features of the disease phobias.

In 47% cancerophobia was the principal disease phobia, in 30% it was of heart disease, and in 7% of infective disease. Other disease phobias were of hypertension, brain damage, and in one "something bad destroying the brain". The mean age of the cancerophobics was 42.9 years; those with a phobia of having heart disease had a mean age of 38.2 years. In terms of system involvement the feared process was thought to be cardiovascular in 37%, cerebral in 30% and alimentary in 17%. The principal symptom causing patients to focus upon phobias of disease was pain in 60%, other sensations in 17% and a change in some bodily function in another 17%. The other sensations included numbness, pins and needles, headiness, a rushing feeling to the head, sickness in the stomach and a lump in the throat. Of the 30 cases, two had disease phobia for less than one month, 16 for from one to 12 months, five for from one to three years and seven for more than three years. On a 0, 1, 2 or 3 scoring system for fluctuation of the symptom, six scored O, eight scored 1, nine scored 2, and seven scored 3.

Identification.

Identification with relatives' illnesses appeared to play a clear role in the phobic development in 16 (53%) of the patients, father being the identificatory model in five of the 16 subjects and mother in six of the 16. At the time of admission 16 of the disease phobics' mothers had died versus nine of the controls' mothers. This just falls below the ,05 level of significance. The 16 mothers of disease phobics had on average died eight years before the patient's admission and the nine mothers of controls had died on average twelve years before. This difference was not significant, t = 0.690. Paternal deaths were in the ratio 18 to 14.

Table 4 demonstrates the importance of identification in determining the form the disease phobia takes. Cancer and heart disease as the cause of death in first and second degree relatives is compared for the 14 cancer­ ophobcs and their controls and for the nine heart-disease phobics and their controls. Specific mention of cancer or heart-disease was required and when only sudden death was mentioned no assumption was made as to the under­ lying disease process. 63.

TABLE 4. Identification and the form of disease phobia.

Family history of Family history of a cancer death a heart death

Cancer phobics N = 14 8 ) 1 ) p ( • 01 ) Matched controls 1 ) 0 N = 14

Heart phobics 1 5 ) N = 9 ~ N.S. Matched controls 1 2 ) N = 9

Phobias other than of disease. Fears of going m.ad or insane were excluded from disease phobia in accord with the somatic orientation of the study. The other fears are shown in Table 5. One question not on the list is "Do you have fears about what may happen?". The disease phobic affirmative excess (23 to 10) was significant at the .01 level.

TABLE 5. Other fears of disease phobics.

Disease Phobics Matched Controls N = 30 N = 30

agoraphobia 30% 0% p ( .01 dying 20% 0% p ( .02 being harmed 13% 0% N.S. harming others 7% 0% N.S. going mad 10% 3% N.S. being enclosed 7% 3% N. S. family harm 0% 7% N.S.

the dark (childhood) 20% 20% N.S. 64.

Clinical features of current illness. Scores on the principal components obtained from the patients' actual replies to questions were available for each subject. Disease phobic and matched control differences on these compressed scores are seen in Table 6. With at test for related samples, degrees of freedom being 29, t = 2.045 gives two-tail significance at the .OS level. The minus value oft in one instance signifies a matched control excess on that component. TABLE 6. t tests of disease phobic - matched control differences on various clinical features.

Principal Components Value of p t

Depressive mood (life not worth living, end of rope, hopeless) 1.806 N.S. Suicidal component (suicidal attempts, suicidal ideas, can lau5h) -1. 840 ( .OS (one-tail) Cognitive performance difficulty (loss of interest, can't cope, poor concentration) 2.895 ( .01 Anxiety (tense, jittery, worrying for no reason) 5.159 ( .001 Self-pity (loneliness, envy, self-pity) 3.386 ( .01 Guilt (ashamed, unworthy, full of guilt) 1.503 N.S. Habit change (anorexia, insomnia, weight loss) 2.700 ( .OS

The items in brackets represent the three questions with highest loadings on the particular principal component. N.S. = not significant.

It was decided to look more closely at guilt because many writers, whom Merskey (1965) lists and mildly chides for their anecdotal and un­ controlled allusions to pain as expiation for guilt, refer to it as inter­ twined with hypochondriasis, pain and repressed hostility. A guilt questionnaire derived from Schanberger (1959) was administered so that the patient could say in private what he might be daunted froru admitting in a routine, somewhat formal interview with a strange doctor. Ten of his 20 factorially extracted statements (factors III and A) were selected using a Guttman analysis. The coefficient of reproducibility was 85%. 0.).

The items were:-

1. I have frequently been troubled by pangs of conscience.

2. I hate myself for things I have done.

3. My mind keeps thinking "I shouldn't have done it."

4. I wish I could do away with the remorse I feel about my past.

5. I feel I should do something to make amends for what I have done.

6. My mind will never rest until I satisfy my conscience.

7. The thought goes through my mind that I have been given responsibility and failed.

8. I have a vague feeling of uneasiness, as if I had done something wrong.

9. I feel that I have failed my own self, that I have not been true to myself.

10. At times, I think I am no good at all.

"Yes" replies were scored 1, and "no" 0. There were completed forms for 28 matched pairs. The disease phobic mean and standard deviation were 5.89 (3.47) and the matched controls' were 3.32 (2.78). t = 3.059, p ( .01, (related samples, d.f. = 27).

Figures 4 and 8 examine the importance of anxiety and depression, and dissect out the contribution of each. The steeper the slope the stronger the association. They bear witness to the crucial role of anxiety and the lesser role of depression in the development of disease phobia. 5-0

•D.P.

)( S.P.

U) .. ~. ~ o.c. 0 X .. . . -xP.P, ~ 1·0 oc

c( 0,: 0 _, zo 0 0,: ... I,- .. uZ . . 00 /.. . x· 0·5 0.. u x• • :c>-

x•

SEVERITY OF ANXIETY 0·1'----....L..~------l------__J 0.1 2-4 5-9 X t f t Figure 4. THREE PSYCHIATRISTS RATED EACH PATIENT 0.1. 2 or 3. SEVERI [Y OF ANXIETY IS. THEIR SUMMED SCORE. THE PATIENT GROUPS OF DISEASE PHOBIA (DP). NON-SCHIZOPHRENIC DISEASE CONVICTION (D.C.). SOMATIC PREOCCUPAT!ON (S.P) AND PSYCHOGENIC PAIN (PP) WERE EACH COMPARED TO THE RESPECTIVE CONTROL GROUP TO OBTAIN THE RATIO PLOTTED ON THE Y AXIS (SEMI- LOG SCAL~l. AS THERE IS ONE-FOR-ONE MATCHING A STRAIGHT LINE AT A RATIO SCORE 1 WOULD INDICATE ZERO RELATION­ SHIP FOR THE PARTICULAR VARIABLE. Features of the Personality.

TABLE 7. Features of the personality.

Wilcoxon p P.M.P. hypochondriacal N = 14, T = 16~ < .05 p. M. p. obsessional N = 23, T = 69 ( .05 P.M. P. anxious N = 24, T = 86 < .10 Prone to inhibit anger N = 21, T = 22 < .001 Chronic low self-esteem N = 19 1 T = 30\ < .02 Prophylactic attitude (vitamins) N = 15, T = 13 ( . 01 Low childhood vitality N = 13, T = 16 (. 05 Lack of accident proneness N = 6, T = 3 ( . 20

Means and S.D.s of: Disease Matched t p Phobics Controls

E.P.I. Neurotic ism 16.77 (4.67) ll. 43 (5.18) 4. 56 7 ( .001 E.P.I. Extraversion 9.47 (3. 74) 10.23 (4.60) 0.644 N.S. E.P. I. Lie 4.10 (1.97) 3.63 ( 1. 94) 1.174 N.S.

P.M.P. = premorbid personality. E.P.I. = Eysenck Personality Inventory. The Wilcoxon test was used to examine the significance of disease phobic - matched control differences for the first eight items. The t test, related samples was used for the E.P.I. values. For each significant value of p, the disease phobic group scored higher than did the matched controls'. Because of the very strong relationship between inhibition of anger and disease phobia, some of its other significant correlations are given. Inhibition of anger was represented by a positive answer to the question ''Do you keep your angry agressive feelings to yourself, bottling them up inside?". At the .05 level were negative relationships with E.P.I. extraver­ sion and current irritability and a positive one with hypochondriacal premorbid personality. At the .05 level were positive associations with Eysenck Personality Inventory Lie Score, good work capacity at follow-up, somatic preoc~upation, widowed status, obsc5sional premorbid personality, anxiety and number of psychogalvanic spontaneous fluctuations. 0 /.

Figure 5 is a Venn diagram with the circles containing people with combinations of tendency to inhibit anger (scores of 2 or 3), chronic low self-esteem (scores of 2 or 3) and prophylactic attitude regarding vitamins (scores 1, 2 or 3). Where the three features overlap 100% of the patients in the subset have disease phobia; where none occur only 17%. Had these variables not disctiminated between the two groups, all eight subset areas would have had 50% with disease phobia and 50% without, by virtue of the one­ for-one matching. (See Feinstein (1967) for a discussion of Venn diagrams).

INHIBITION OF ANGER

17%

LOW SELF-ESTEEM BELIEF IN VITAMINS

Figure , . DISEASE PHOBIA - PERSONALITY TRAITS.

Subset area is approx. proportional to the number of patients it contains (n=56; ½ d.p., ½ matched controls). Percentages indicate proportion in the subset having disease phobia. 68.

Figure 6 illustrates the strong relationship of inhibition of anger to disease phobia and its ~eaker connections with psychozenic pain and somatic preoccupation. (Scores of 2 and 3 were c~alesced because too few patients had scores of 3. Strictly speaking the ooints should be connected by lines not curves).

5·0

(/) 0 ~ P.f?. .. -······ 1-0 0::: lV < 0::D _, zO 0 ex: J: 1- u Z 00 Q.. u >- :I: . 0·5 I'

INHIBITION OF ANGER 0-1------~------' 0 2&3

Figure 6. RATINGS OF 0. l.2 OR 3 WERE GIVEN TO INDICATE EXTENT TO WtilCH THE PATIENT HABITUALLY "BO~T~ED UP" ANY ANGER. THE PATIENT GROUPS OF DISEASE PHOBIA (OP.). NON-SCHIZOPHRENIC DIS~ASE CONVICTiON i_DC). SOMATIC PREOCCUPATION (S.P.l. AND PSYCHOGENIC PAIN IP P1 WE~E EACH COMPARED TO THE RESPECTIVE CONTROL GROUP TO OBTAIN THE RATIO PLOTlE') ON THE Y AXIS 1SEMI-LOG SCALE). AS THERE IS ONE-FOR-CNE MATCHING. A STRAIGHT LINE AT A RATIO SCORE 1 WOULD INDICATE ZERO RELATIONSHIP FOR THE PARTICULAR VARIABLE. 69.

Prior Experiences.

TABLE 8. Prior experiences.

p

Much family illness Wilcoxon (N = 21, T = 17) ( .001 Many painful disabilities Wilcoxon (N = 12, T = 18) < .10 Allergic/psychosomatic illnesses Wilcoxon (N = 14, T = 22) ( .10 Life de feats and humiliations Wilcoxon (N = 17, T = 43) .10 Parental punishment Wilcoxon (N = 6, T = 2) '< .10 Poor paternal personality Wilcoxon (N = 19, T = 52) ( .10 Maternal oversolicitude Wilcoxon (N = 14, T = 29) <.20 Chi2 test (with 1, 2 or 3 = 1) ( .02

In the two foregoing tables a two-tail test is quoted. As the items were chosen with the suspicion that disease phobia was related to them a one-tail test would be allowable; this would elevate most values of p to the .OS level.

Figure 7 is a Venn diagram summarising the contributions of moderate or severe anxiety (combined rating of Sand above), being the youngest sibling and having much family illness (scores of 1, 2 or 3) to the development of disease phobia. With none of these three, there is no disease phobia. Where all three are present, 100% are nosophobic. Where two circles overlap, there are values of 67%, 67% and 80%. Where a patient has only one of the features his chances are 25%, 37% and 50%. 70. FA:-l! LY ILLNESS '

0%

YOUNGEST SIB

Figure 7. DISEASE PHOBIA - clues to its origin.

Subset area 1s approx. proportional to the number of patients it =ontains (n=56; ½d.p., ½ matched controls). Percentages 1~a1cate proportion in the subset having disease pr.obia.

Sensation Thresh~ld and Pain Tolerance. Table 9 sho~s the partial correlation coefficients of sensation thr~shold and pain tolerance. Age was the variable partialed out - its correlation ~as .431 with sensation threshold and .076 with pain tolerance (for sensation threshold and pain tolerance r = .313). Another reason for I L,

removing the effect of age is that defective recall of childhood events occurs with ageing. This was a reason for having an age-matched control group and in this instance for using the partial correlation coefficient. Increasing age and Eysenck Personality Inventory Lie Score were strongly related in this sample as were age and of socially undesirable events in early life.

TABLE 9. Partial correlation coefficients, age effect removed, of sensation threshold and pain tolerance.

Sensation Pain Threshold Tolerance

Current Clinical Features: Disease phobia -.154 -.248 Disease conviction - .158 -.200 Somatic preoccupation -.105 -.032 Psychogenic pain -.209 -.052 Depressive mood (principal component) -.022 -.109 Anxiety " " -.199 -.083 Habit change " -.186 -. ll8 Depersonalization -.194 -.079 Agitation -.003 -.191

Past History of: An excess of family illness -.162 -.234 Maternal oversolicitude - .171 - . ll 7 "Unnecessary" operations -.195 -.090 Analgesic abuse -.166 -.052

Significant correlations are underlined.

For N = 144, d.f. = 141, r = ± 0.164 gives two-tail significance at the .OS level; r = ± 0.138 gives one-tail significance. 72.

Some negative results.

There were no significant differences on Raven's Matric~s, Parnell So~atotype Scores, salivary excretion rate, morning 11-hydroxy­ corticosteroid blood levels or on body barrier and penetration indices derived from Rorschach responses.

Duration of stay in hospital.

It was predicted that disease phobics would stay longer in hospital than their matched controls, in accord with their care-taking and fearful attitude. Disease phobic mean and S.D. = 6.10 (4.6) weeks, control mean and S.D. = 4.67 (3.0) weeks. t = 1.379 (N.S.)

Mental Health at six nonths after discharge. (0, 1, 2, 1 scale).

There was no prognostic import for disease phobia in relation to mental health. The matched controls did very slightly worse, not significantly so (Wilcoxon, N = 16, T = 54). 73.

(b) DISEASE CONVICTION.

Twelve of the 235 patients received a primary classification of disease conviction, non-schizophrenic, There were three schizophrenics with disease conviction and four, of whom three were schizophrenic, with dysmorphic convictions. These schizophrenic disease convictions and the dysmorphic convictions have been excluded from this study and the reasons have been given in the preceding review of the literature. Matching and Diagnostic Profiles. The 12 patients were an older group than the unmatched controls (t = 2. 751, p ( ,01) and older than the other groups of hypochondriasis. Their lower occupational prestige was not significantly lower than that of the unmatched controls (t = 0.835). TABLE 10. Matching and Diagnostic profiles.

Disease Unmatched Matched Conviction Controls Controls N = 12 N = 96 N = 12

Female 67% 63% 67% Age in years (mean and 52.3 (16. 6) 38.8 (15. 9) 49.9 (16. 2) S. D.) Occupational prestige 3.2 ( 0.9) 2.9 ( 0.9) 3.0 ( 0.9) {mean and S.D.)

Diagnosis. Endogenous depression 50% 24% 50% Neurotic depression 8% 27% 17% Other neuroses 33% 14% 0% Asthenic personality disorder 25% 23% 17% Obsessional personality disorder 8% 4% 17%

After matching, each group had one-half with a diagnosis of endogenous depression, One-third (4) had "other neuroses" - in two, hypochondriacal and in two, hysterical. One patient had neurotic depression and one was ~ifficult to classify. He was a dementing old man with a querulous and obsessional personality, Following surgery for carcinoma of the colon he became horrified that the surgeon had put his bowels back in upside dm•.':1, He was very depressed and probably had an admixture of organic and affective psychoses, 74.

Case histories of seven of the 12 are given in Appendix I (patient numbers 27, 111, 124, 127, 160, 216 and 226). There were no significant biographical differences though there were trends in the same direction on protestantism (3 to 1) and on being the youngest sibling (3 to 1) as had been shown by the disease phobics. Similarities to the somatic preoccupation group were an excess of admissions in the winter months (3 to 0, N.S.) and an excess of deaths among first­ degree relatives in the month before onset of the illness (2 to 0, N.S.). Features of the Disease Convictions. Cancer was thought to be the disease process by four, infection by two, and muscle disease, drug toxicity, a cockroach in the brain, and faulty surgical replacement of the bowels in one each. In two the destructive process was not specified except as an unrecognized but dangerous disease, unknown to medical science. The four with delusions of having cancer all had a close relative or friend with a history of cancer. Six of the 12 had a lesser severity of disease phobia, nine had somatic preoccupation and 10 had psychogenic pain. Disease phobias and disease convictions had similar durations but the latter were less fluctuant. 24 of the 30 disease phobics showed some fluctuation versus only five of the 12 with ciisease conviction (p ( .05). Clinical features of the current illness. There were as many controls with depressive diagnoses but it was depression that chiefly differentiated disease conviction patients from matched controls(Table 11 and Fig. 8). TABLE 11. t-tests of disease conviction - matched control differences on various clinical features.

Principal Components Value of t p

Depressive mood 2.247 ( . 05 Suicidal component -0.121 N.S. Cognitive performance difficulty 1. 557 N.S. Anxiety 1.124 N.S. Self-pity 1.101 N.S. Guilt -1.498 N.S. Habit change 1.412 N.S. 75.

The components are detailed in Appendix III. N.S. = Not significant. Fort test, related samples, d.f. = 11, t = 2.20 gives significance at the .05 level. The minus values oft indicate a matched control excess on those components.

50

.,.

en 0 S.P. .... l·O ~ er:: ...... ~- .. 0: . . . . . 0zo _, 0 0: :r z UO 0·5 ~lu

X •

PRINCIPAL COMPONENT OF DEPRESSION 0·1 ...____ _.______.. ______,

QUARTILES QUARTILE QUARTILE 1&2 3 ,4 Figure 8. ANSWERS TO 12 QUESTIONS CONCERNING DEPRESSIVE MOOD WE~E FACTOR­ ANALYSED EACH PATIENT RECEIVED A FACTOR SCORE. THOSE IN QUARTILE 4 HAD THE HIGHEST SCOi.ES ON TH~ PRINCIPAL COMPONENT. THOSE IN GUARTILE l THE LOWEST.

THE PATIENT Gl

The principal component of depressive mood was based on 12 questions (Appendix III; questions 20-31). Three of the questions were especially important in separating the two groups, namely, 23. Do you feel hopeful about getting better? 27. Do you feel hopeless? 28. Do you feel at the end of your rope? Nine of the disease conviction group answered yes to the last question as against only one of the matched controls (p ( .001). On two other depressive questions non-significant trends occurred, 29. Do you feel life is not worth living? 8/4 30. Have you thought of connnitting suicide? 4/1 These differences are evidence of greater hopelessness in the depressive mood of the disease conviction group. The first principal component of depression represents a sad, hope­ less, suicidal factor. The second represents a more hopeful suicidal factor, a "giving-up" but still appealing-for-help aspect rather than the "given-up" suicidal brooding of the first factor. It is only the latter which character- izes the disease conviction patient. One of the 12 had connnitted suicide by the time of follow-up at six months, but none of the controls. In six the depression was totally unresponsive to normally cheering events, though resistant in only one of the controls (p ( .05). Other clinical features were agitation and absence of phobias. At least two of the three psychiatrists rating the psychiatric interview noted some agitation in eight disease conviction patients versus three controls (p ( .05). (This excess of agitation will be used to explain their lower intelligence scores). The lack of agoraphobia contrasts with its 30% prevalence among disease phobics. Likewise there was no significant excess of anxiety or guilt. As one might expect they did feel sorry for themselves, more so than did the controls (6 to 2, N.S.). They did not report their illness as resulting from environmental loads nor did they feel they had brought the illness on themselves (questions 11 and 84, both significant). These opinions are consistent with their belief that they have a physical disease. Five of the 12 had definite paranoid feelings at interview and an additional two were thought by the nursing staff and medical officers to evidence moderate suspicion, which they so scored on the Bunney-Hamburg scale (Bunncy & Hamburg, 1963). Only one matched control showed the symptom and she was a paranoid schizophrenic. This is a significant excess, all the m0re remarkable io that schizophrenics were excluded from the disease conviction 77. group. (All of the schiz~phrenics with disease conviction or dysmorphic conviction showed pronounced paranoid traits). A subsequent factor analysis extracts a component with high saturations on disease conviction, paranoid feelings, poor prognosis, maternal oversolicitude and depression. Early life events. Maternal oversclicitude appeared on the disease conviction factor - 40% of the disease conviction patients reported receipt of much babying in early life (rating 2 or 3). 25% of the controls reported some (rating 1) but none reported much maternal overconcern. Fig. 9, because the cut-off point is between O and 1 rather than between 2 and 3, does not portray this relationship to strongest advantage. 5·0

D.P.

CJ) 0 ~ 1·0 c::: ~

~ 0 _, z 0 ~ 0 I- J: u z 0 0 a.. u >- 0·5 J:

MATERNAL OVERSOLICITUDE O · \ ---- _..______...,______0 1-3

Figure 9. RATINGS 0~ 0.1.2 OR 3 WERE GIVEN TO PATIENTS TO INDICATE EXTENT OF BEING BABIED T':) A. LATER AGE THAN IS USUAL. THE PATIENT GROUPS OF DISEASE PHOBIA(DP.), NON-SC.-1IZOPHPENIC DISEASE CONVICTION (DC.). SOMATIC PREOCCUPATION (S P). AND PSY(rlOGENIC PAIN (PP) WERE EACH COMP.1'.RED TO THE RESPECTIVE CONTROL GROUP TO OBT.AIN THE RATIO PLOTTED ON THE Y AXIS (SEMI-LOG SCALE).AS THERE IS ONE-FOR-ONE MATCHING. A STRAIGHT LINE AT A RATIO SCORE 1 WOULD INnltATF 7FR() RFIATIONC:.HIP FOR THF PAOTlrlll /10 VAOIAnlC:: 78.

On "excessive illness among relatives" (Fig.11) the disease conviction group is show~ to have higher scores than do the matched controls. 80% reported an excess of family illness versus 25% of the control group. Features of the oersonalitv. The premorbid personality was more frequently hypochondriacal (4 to 0, p ( .05). Their propensity to analgesic consumption and vitamins and to having "unnecessary" operations is drawn attention to in table 20. Eysenck Personality Inventory scores are shm-m in the next table. TABLE 12. Eysenck Personality Inventory Scores revealing disease conviction - matched control differences.

Means and S.D.s of: Disease Hatched t p Conviction Controls

E.P.I. N'euroticism 14.45 (5.09) 11. 00 (5.20) 2.103 N.S. E.P. I. Extraversion 9.18 (3.12) 9.45 (5.59) -0.142 N.S. E.P.I. Lie 5.91 (2.59) 4.09 (1.92) 1.971 N.S.

Scores were available for 11 matched pairs. For d. f. 10 (related samples), t = 2.23 gives significance at the .05 level.

Intelligence. "Free" and "driven" results on Raven's Matrices showed a trend for the disease conviction group to score lower. When the six depressed disease conviction patients aged more than 60 years are compared with the six matched controls the difference reaches statistical significance. This method of looking at the data was suggested by Post (1966). The six pairs were matched on diagnosis (as it happened) as well as on age, sex and occupational prestige (Table 13). TABLE 13. Raven's Matrices and elderly disease conviction patients.

Raven's Matrices Disease Matched t p Conviction Controls N = 6 N = 6

"Free" mean 12.5 22.5 2.210 ( .05 S.D. 3.7 10.5 ( one- tail) "Driven" mean 17. 7 31. 2 2.930 <. .05 S.D. 5.3 10.0 ( one- tail)

For six matched pairs t = 2.02 gives one-thil significance at the .05 level. 79.

Somatotype. Somatotype was calculated from height, weight and skin-fold thickness measurements (Parnell, 1964). There was a trend (p ( .10) for the disease convictiou group to be less lean (11 matched pairs). However just as the small sample size allows one to miss a real difference so too many measurements can turn up differences that are of chance occurrence. No somatotypic differences from their matched controls were observed for the disease phobics (30 matched pairs measured), for the somatically preoccupied (39 pairs) or for those with psychogenic pain (45 pairs). The means and standard deviations are tabulated below. TABLE 14. Parnell Somatotype and Hypochondriasis.

--FAT DP MC DC MC SP MC PP MC Mean 4.13 3.83 3.82 3.68 3.68 3.68 3.81 3.86 S.D. 0.96 1. 29 0.78 0.93 1.05 0.85 1. 59 1.00 t 1.353 0.504 0.000 -0.200 --LEAN Mean 3.55 3.55 3. lli 3.70 ~1 • 6 7 3.65 3.40 3.63 S.D. 1. 20 0.54 0.83 0.86 C.68 o. 73 0.67 0.68 --- t -0.037 -2.106 0.125 -1. 546

LINEARITY Mean 3.38 3.78 3.91 3.68 3.60 3. 71 3.84 3.47 S.D. 1. 27 2.33 1. 28 1.45 1.36 1. 83 2.83 1.27

t -1.083 0.374 -0. 236 1.526

DP= disease phobia, DC= disease conviction, SP = somatic preoccupation, PP= psychogenic pain and MC= respective matched controls.

Other Observations. The disease conviction group had a lower pain tolerance (8 matched pairs; disease conviction 87.5 volts (S.D. 22.2), matched controls 108.1 volts (S.D. 9.2) t = 3.31, p ( .01). They also showed a trend towards having lower sensation thresholds (Table 9). On the Zung self-rating depression scale they i:;cored higher than matched contr ol!l ( p ( . 05, one-tail). 80.

The:y showed a trend towards lower 11-hydi_·oxycorticosteroid levels. Their dexamethasone "suppressibility" was not evaluated though this would have been of interest as is discussed later. Salivary excretion rate did not discriminate between any of the hypochondriasis or pain groups and their respective controls.

Prognosis. In addition to the one suicide in the disease conviction group, two more had disabling and incapacitating symptoms at six months after discharge versus one of the controls. Longer follow-up and a larger sample size are needed to answer the question of prognosis definitively. 81.

(c) SOMATIC PREOCCUPATION

Somatic preoccupation implies a multiplicity of bodily complaints for which no organic cause can be found. The 41 patients in this group by definition did not have disease phobia or disease conviction. 25 of them had psychogenic pain as part of their preoccupation (Fig. 3). Table 15 shows the matching and diagnostic profiles.

TABLE 15. Matching and diagnostic profiles.

Somatically Unmatched Matched Preoccupied Controls Controls N = 41 N = 96 N = 41

Female 59% 63% 59% Age in years(mean & S.D.) 42.7 (15.7) 38.8 (15.9) 42.1 (15.3) Occupational prestige 3.2 ( 0.7) 2.9 ( 0.9) 3.2( 0.7) (mean & S.D.)

Diagnosis Endogenous depression 22% 24% 39% Neurotic depression 24% 27% 34% Other neuroses 39% 14% 12% Asthenic personality disorder 37% 23% 24% Obsessional personality disorder 17% 4% 7%

The somatically preoccupied were on average four years older than the unmatched controls (t = 1.320, N.S.) and were of a somewhat lower socioeconomic position (t = 1.890, p ( .05, one-tail). Compared with the matched control group they were more often diagnosed as having a non­ depressive neurosis (39% versus 12%) and less often as having a depressive illness (46% versus 73%). The somatically preoccupied had fewer people ~ith a history of previous psychiatric illnesses (19 to 30, p ( .05). This deficit was especially noticeable for a history of endogenous or manic- depressive depressio~ (4 to 17, p ( ,01). However, in terms of personality disorder it appeared that they were more often disordered (30 to 21, p ( .05). Also they rerorted more often a history of family neurosis (25 to 16, p (.05). The only biographical detail distinguishing the groups significantly was religious affiliation. 11 somatically preoccupied were protestant ~nd 82.

only 2 of the controls. The somatically preoccupied more often attended church regularly (24 to 16; Wilcoxon, N = 29, T = 170\, N.S.). 12% were left-handed as against none of the controls. An additional 3% of each group were ambidext~ous. Sib position and number in sibship were similar, as was number of their own children. Somatic preoccupation overlaps with disease phobia and disease conviction. In addition to the 41 classified patients there were 29 more who had either disease phobia or disease conviction as well, and were classified under that category (Fig. 3), that is, a total of 70 out of the 235 total sample, approximately 30%. Features of the somatic preoccupation. In those with psychogenic pain, the principal pains were in descending frequency situated in the head, upper abdomen, back, neck, chest and pelvis. With all pains considered 47% of the somatically preoccupied had headache, 24% backache, 21% limb pains, 12% upper abdominal pain, 12% and 12% pain in the face. Upper abdominal pain when present was usually the chief pain. Face pain and limb pain tended to be the less severe varieties. Many of the somatically preoccupied patients with no score on psychogenic pain mentioned minor aches and pains. Some of the complaints were:- ( i) "a blood pressure sensation, as if hypertensive. Chest feels strange. I notice the forehead, possibly an osteoma. I worry about this naevus." (ii) "My mouth is as though pepper has been rubbed in it. I have blood pressure, circulation troubles, , pernicious anaemia and dyspepsia. I have a feeling I can not breathe. Numb tingling hands and legs feel as if they will give way." ( iii) "Sinus allergy with nausea, headaches and constipation. Eack trouble - I need a spinal fusion." (Patient a weight-lifter). ( iv) "My teeth, nag, draw, ache. Teeth, teeth, teeth. I had

them 13 ll out." (v) "I am completely absorbed in what I feel. My body is worn out, particularly the abdomen. Aches and pains there. I had an intraven~us pyelogram." 0..1.

(vi) "I run rather a low blood pressure and have poor circulation to the head. I have a little bit of liver trouble." (A past history of invalid pension for a nervo~s h~arc). (vii) "Belly pains, hot spells, I go very red. I feel a scream coming on in the lump in my abdomen. Migraine and headaches all the time, hot feeling all over me, heavy arms." (viii) "Pain in chest, back, right temple and top of the head. Curved spine. Urine a strange colour. Worries about blood pressure." (Cancerophobic 2 years before when had anal pruritus and haemorrhoids). Sometimes these patients had minor physical complaints but mostly not. Autonomic symptoms featured more in this group than in the painful somatic preoccupation subjects. The few fears concerning the implication of the symptoms did not become durable or severe enough to merit classi­ fication with disease phobia. Mostly the fears were ephemeral and any beliefs seemed to have the sanction and tacit agreement of their regular doctors, for example, low blood pressure, anaemia, arthritis, sinus and liver trouble. The Current Illness. (i) Precipitants. They are more likely to be admitted during the three winter months (June, July, August) (17 to 6, p ( .02). Spring admissions were less common, in the ratio 6 to 14. The winter excess was a little more common for those with pain as part of their preoccupation. It appeared that physical illness or injury much more often preceded the onset of the psychiatric condition (Wilcoxon, N = 28, T = 48, p ( .001). Some examples of the type of illness follow:- a colostomy for carcinoma of the colon, being unconscious for three days from a head injury, epilepsy, hepatitis, nose-bleeding requiring cautery following , a back injury with financial settlement already made, severe kyphosis due to tuberculosis of the spine, back injury at work, arthritis and an operatic~ for rectal prolapse, damage to head, neck and back after a roof caved in at w~rk. The death of a first-degree relative in the month prior to the commencement of the illness occurred in five of the somatically occupied and one of the controls. 84.

(ii) Duration The illness is more likely to have been long-lasting in comparison with the illness of a matched control (Wilcoxon, N = 30, T = 91, p < .01). The illness had been present for more than three years in 42% of the somatically preoccupied and in only 15% of the matched controls. There is a trend towards it having a slower onset (Wilcoxon, N = 30, T = 162). ( iii) Clinical Features Scores on the principal components derived from the patients' actual replies were compared for the somatically preoccupied and their matched controls (Table 16). With at test for related samples, degrees of freedom are 40, and t = 2.02 gives two-tail significance at the .05 level. The minus values oft indicate a matched control excess on those components. TABLE 16. t tests of somatic preoccupation - matched control on various clinical features.

Principal Components Value of t p

Depressive mood 0.700 N.S. Suicidal component 0.170 N.S. Cognitive performance difficulty 1.315 N.S. Anxiety 2.504 ( .02 Focussed anxiety (phobic anxiety, somatic anxiety as opposed to worrying about nothing) 3.339 ( .01 Self-pity 1.043 N.S. Guilt -0.515 N.S. Habit change -0.760 N. S. Sleep impairment (initial insomnia and frequent waking as opposed to anorexia) 2.163 ( .05

Items in brackets represent the three questions with highest loadings on the particular principal component. The three questions of "focussed anxiety" are:- "Do you have unreasonable fears about everyday things?"(+ ve saturation). "Is your worry leading to bodily trouble such as sweats, indigestion, headaches, constipation, diarrhoea, chest or bladder trouble, faints or blackouts?"(+ ve saturation). "Are you often worried for no reason?" (- ve saturation). The three questions of "sleep impairment" are:- "Do you have difficulty getting off to sleep?" (+ ve saturation). "Do you wake much during the night?"(+ ve saturation). "Have you lost interest in sweets, or smokes or drinks?" (- ve saturation). The other factors are illustrated in Appendix III. Guilt levels were similar for the two groups both on the principal component and on the questionnaire derived from Schanberger (1959). On the latter the somatic preoccupation mean was 4.29, standard deviation, 3.82; matched control mean was 4.50, standard deviation, 3.18 (t = 0.241, N.S.). The psychiatrists' judgment of anxiety was in accord with the principal component difference (Wilcoxon, N = 30, T = 97, p < .01). Their assessment of hysteria as a symptom also was found to excess among the s~matically preoccupied (Wilcoxon, N = 22, T = 48~, p ( .01) though a formal dlag~osis of hysterical neurosis was allotted to only six of the somatically preoccupied and four of the controls (anxiety neurosis was diagnosed in four somatical.ly preoccupied and one control). Fatigue was more often a concern of this group also (Wilcoxon, N = 27, T = 114, p ( .05, one-tail). In categorising psychogenic pain various authors have adduced the accompanying presence of classical hysteria as evidence for the pain being of conversional origin. Whatever the logic of this deduction it seems necessary to report the nature of the "hysteria" excess that the present somatically preoccupied group has shown. The symptom of hysteria was rated in the 0, 1, 2, 3 fashion by three psychiatrists (summed score can thus range from 0-9). 17 of the 41 patients with somatic preoccupation scored 3 or more on this item, but only four of the 41 controls. The sy~ptoms were:- ( i) arm goes dead up to shoulder ( ii) legs give way ( iii) after an argument (iv) amnesic episodes. Left arm and leg funny or numb on a number of occasions - even hemiplegic. (v) abdominal pain - constant for years. Mind goes blank (past history of dissociations) (vi) memory blackouts at work (vii) pain ~verywhere (past history of paralysis one side of body) (viii) hands cramped and numb. Hemian~~sthetic, right iliac fossa pain, (history of coma for one W2f.k) (ix) had to be supported, could not use legs (x) left leg weak and useless (xi) amnesic for a weekend (xii) body feels numb, experienced seeing a phantom of herself (xiii) forgetful, sometimes anmesic (xiv) blackouts, overbreathing (xv) left arm useless and immobile after accident involving compensation (xvi) legs paralysed, staggers like a drunken man (xvii) left leg anaesthetic and paralysed for several months Note that as a symptom of the present illness amnesia was reported by 17%, paralysis by 17% and anaesthesia by 12% of the somatically preoccupied group. Thus the clinical items important for differentiation are anxiety and hysteria but not depression (Figures 4 and 8). Features of the Personality. TABLE 17. Features of the personality.

Wilcoxon p

P.M.P. hypochondriacal N = 16, T = 12 ( .01 P.M.P. obsessional N = 29, T = 172% N.S. P.M.P. anxious N = 30, T = 166% N.S. Prone to inhibit anger N = 22, T = 70 < .05 (one- tail) ~ervous as a child N = 29, T = 131 ( .10 Great need to be loved N = 25, T = 133 N.S. Relates poorly with opposite sex N = 30, T = 179% N.S. Consumer of analgesics and patent medicines N = 10, T = 0 < .01 Means and S.D.s of Soma t ically Matched t p preoccupied controls

E.P.I. Neuroticism 15.85 (5.36) 12.50 (4.73) 2.938 (. .01 E.P. I. Extraversion 8.70 (4.72) 9.65 (4.36) 0.638 N. S. E.P.I. Lie 4.68 (2.38) 3.55 ( 2. 04) 2.475 ( .02

P.M.P. = premorbid personality. E.P.I. = Eysenck Personality Inventory. At test, related samples, was used to test the significance of E.P.I. differences. Wit~ each significant value of p, the group scoring most heavily was somatic preoccupation. This vas so for the trends also, except for extraversion. 87.

On a scale modified from a nine-item obsessionality questionnaire (Lascelles, 1966) the somatically preoccupied group scored significantly higher than their matched controls. Two of his items were rejected following a Guttman analysis leaving seven ( coefficient of reproducibility only 80%).

1. "Does everything you do have to be thoroughly done?" 2. "Do you find you keep to a regular routine throughout the week and that changes are unwelcome?" 3. "Do you tend to check things you do more than once before you are satisfied?" 4. "Do you believe in adhering closely to rules and regulations?" 5. "Are you very house-proud? for example, could you find your way around your house blind-fold without bumping into furniture and fittings?" 6. "Do you save as much as you can, denying yourself pleasures rather than spending what you earn?" 7. "Are you always punctual? Does unpunctuality upset you?" These items were scored by the investigator as 0, 1 or 2 (0 = definite no, 2 = strong yes, 1 = unstressed yes or somewhat). The range of scores possible is thus 0-14. The mean scores and standard deviations are recorded in comparison with their respective matched control groups (Table 18). Note some missing data, therefore t test for independ- ent samples becomes appropriate. TABLE 18. Obsessicnality questionnaire scores.

N Mean S. D. t p

Somatic preoccupation 34 6.06 3.04 2.068 (. 05 Matched controls 33 4.61 2. 71

Disease phobia 28 5.46 3.05 1.441 N.S. Matched controls 27 4.33 2.76

Psychogenic pain 45 4. 91 2. 73 o. 904 N.S. Matched controls 45 4.38 2.87 The somatically preoccupied appear to have many needs which they attempt to satisfy by grasping for the solace of church, medicines and operations. A Venn diagram (Fig. 10) illustrates this point. The circles represent regular church attendance, usage of analgesics and patent medicines, and history of "unnecessary" operations.

22%

MEDICINAL OPE TIVE

Figure 10. NEEDS OF THE SOMATICALLY PRC:OCCUPIED.

Subset area is approx. proportional to the number of patients it contains (n=68; ~ s.p., ½ rratched controls). Percentages indicate proportion in the subset who are soraatically preoccupied. 89.

Prior Experiences.

TABLE 19. Prior experiences. (There was an excess for the somatically preoccupied in each instance).

Wilcoxon p

"Unnecessary" operations N = 14, T = 11 ( .01 Many painful disabilities N = 18, T = 18 < .01 Much visiting of doctors N = 25, T = 80 ( .05 Much family illness N = 19, T = 54 ( .05 ( one-tail) Allergic/psychosomatic illnesses N = 15, T = 33~ N.S. Punishment by parents N = 10, T = 13 N.S. l'oor paternal personality N = 26, T = 126 N.S. Maternal over solicitude N = 17, T = 64 N.S.

Table 20 analyses the usage of operations, analgesics and vitamins by the five groups,

TABLE 20. History of "unnecessary" operations, regular analgesic use and regular vitamin taking.

Classification "Unnecessary" Analgesics Vitamins operations

Somatic preoccupation A 6 N = 34 38.2% G 7 35.3% 20.6% 0 0

Disease conviction A 2 N = 10 30% G 1 40% 50% 0 0

Disease phobia A 3 N = 28 25% G 3 28.6% 46.4% 0 1

?sychogenic pain A 3 N = 46 21.7% G 5 10.9% 8. 7% 0 2

Controls A 5 N c= 87 11.5% G 5 5.7% 16.1% 0 0

A~ appendictctocy, G = gynaecological operation, 0 = other operations. 90.

Haemoglobin levels. Th~ abuse of analgesics by the somatically preoccupied behoves one to examine the haemcglobin levels (analgesics cause gastric ulceration and hence blood loss). As this abuse is especially a female vice, one would predict that any difference from controls would be amongst females rather than males. Somatically preoccupied women are also more prone to menorrhagia. A list of the 41 somatically preoccupied and their 41 controls w3s given to a member of the haematology department without the hypochondriacal or control category being specified. They examined the records of the index admissions and transcribed the haemoglobin values. TABLE 21. Haemoglobin values at time of admission.

Somatically Controls t p preoccupied

Females N = 18 N = 14 Mean haemoglobin (G%) 13.6 14.6 1.817 (.05 Standard deviation 1.5 1.4 (one- tail)

Males N = 12 N = 8 Mean haemoglobin (G%) 15.7 15.6 0.045 N.S. Standard deviation 1.3 2.0

t test of independent samples. N = number of patients. Some negative findings. Mean Raven's matrices scores were about equal for the somatically preoccupied and their matched controls as were salivary excretion rates, 11- hydroxycorticosteroid levels in the blood, response of mood to intrave~ous methedrine, and severe pain tolerance. There were 18 matched pairs tested for pain tolerance and sensation threshold. Pain tolerance means were 109.4 and 109.7 volts. On sensation threshold the mecn voltages and standard deviations were 30.8 (8.6) for the so~atically preoccupied and 33.9 (14.4) for the matched controls (t -· 0.93,N.S.). With age partialed out of a correlation matrix, somatic preoccupation and sensation threshold have a correlation of -0.105 (0.138 gives significance at the .05 level, one-tail). It is worth recalling the -0.209 correlation of psychogeni, pain with sensation threshold (Table 9). B&1rier Rorschach score and somatic preoccupation correlated to the extent of -0.162 (N = 92, p ( .10, one-tail). Prognosis:

Both groups stayed a mean of five weeks as in-patients and on discharge 11 of the somatically preoccupied were not improved versus six of the controls. 32 matched pairs had been followed up at six months and fewer of the somatically preoccupied were in good mental health (4 to 13, p ( .05). This difference applied only to the females (Table 22). Of the 19 pairs of matched females followed up, there were 11 patients in good mental health, only one of whom was from the somatic preoccupation group. In terms of work capacity the groups were not differentiated.

TABLE 22. Mental health rating at six months.

Good Indifferent Bad Very Bad

Females - somatic preoccupation 1 7 9 2 Females - matched controls 10 3 3 3

chi-square= 12.2, p ( .01. It is appropriate to close the section on results with Fig. 11 which illustrates the general relevance of "much family illness" to all subvarieties of hypochondriasis and even to psychogenic pain. The steeper the slope's ascent from left to right, the more positive the association.

100 .• P. P.

S·0

c./) 0 .. ·· ~ .. ·· 1·0 a::: .. ,c,••· ~ .... "() ..J 7. £ () .... :c z 2vvo :I:► 0·S

..·

EXCESSIVE ILLNESS AMONG RELATIVES 0·1 '-----.L-.-,______...... , ______,1 0 2&3 Figure 11. RATINGS OF 0.1.2 OR) WERE GIVEN TO PATIENTS TO INDICATE AMOUNT OF ILLNESS AMONG RElAT IVES AND LOVED ONES.

THE PATIENf cr:ouPS OF DISEASE PHOBIA (D.P,) NON-SCHtZOf'HRENIC DISEASE CON­ VICTION ,D.C.). SOY.AT IC PREOCCUPATION IS.P.l. AND PSYCHCG[NIC PAIN (P. P). WERE EACH CO!,•.i'.:.RED TO THE RESPECIVE CONTROL G~:)!..J? 10 OBTAIN THE RATIO PLOTTED 01' Thi: Y AXIS (SEMI-LOG SCALE). AS TH~RE I~ ONE-FOR-ONE MATCHING. A STRAIGHT LINE AT A RATIO SCORE 1 WOULD INDICA'[ ZERO RELATIONSHIP FOR THE PARTICULAR VARIABLE. 93.

DISCUSSION (a) DISEASE PHOBIA

We learn to fear disease, but to develop sustained disease phobia, the lesson has to be firmly impressed. Current mental turmoil acts upon personality predispositions resulting in the phobia. Some part of whatever favours disease phobia production also fosters agoraphobia, as indicated by its occurrence in 30% of the disease phobics. Figure 3 shows th3t the disease phobia usually develops in company with a bodily symptom or sign, rather than in response to a mere idea as in the so-called ideo-hypochondriac described by Leonhard (1961). Besides the agoraphobia these patients have a general doom expectancy. This unease about the future carries over into their interpretation of bodily symptoms. As the patients report the sequence, the phobia follows upon the bodily symptoms; this is also the opinion of Stenback and Jalava (1962). They studied the incidence of disease phobia in an unselected group of mental patients and showed that it was higher in patients with somatic symptoms. 44.3% of 122 patients with somatic symptoms also had disease phobia as against only 6.4% of 78 patients who had no somatic symptoms. This relationship was found too, among hospitalized patients with depression, 29.4% of 51 having somatic symptoms had the phobia versus only 7.4% of those without somatic symptoms. Concern about health is evoked largely even in the normal person by pain and discomfort so that those most tolerant of unpleasant sensations would be less likely to become preoccupied and fearful when symptoms appeared. Petrie (1967) has conceptualized people in terms of their tendency to augment or to reduce stimuli and this idea of augmentation and reductim, appears to have some conceptual relevance to hypochondriasis. Solon et al. (1968) in an investigation of 93 "normal" females obtained a significant negative correlation between the degree of reduction of stimuli and a high score on the hypochondriasis scale of the M.M.P.I. The augmenters showed a more frequent use of health services for ailmects in which pain was a prominent symptom. Thus, in that population sample, the prediction was borne out that those most tolerant of pain were least preoccupied with of ill-health. In accord with this is the present finding that the disease phobics were more intolerant of electrical pain than their matched controls. (15 available matched pairs. dean pain tolerances were 92 vclts and 109 volts respectively, mean standard c~viations 23 and 17; t = 3.04, p ( • 01). 94.

Carlson (1966) asks, "Do persons with hypochondriacal concern have a greater degree of functional discomfort on which to build their preoccupation, or is it within normal ranges? Do they simply attend to cues that are not ordinarily brought to consciousness?" Not only do the disease phobics tolerate pein poorly but they also have low thresholds for sensation (Table 9). This would suggest in answer tc Carlson's questions that they attend to cues normally ignored. The basis for this attentiveness is considered in Figure 12, a th~oretical model which limns the origins of disease phobia in conformity with the correlation evidence of Table 9.

ASTHENIC CHILDHOOD MATERNAL OVERSOLICITUDE .. UNNECESSARY" OPERATIONS HYPOCHONDRIACAL MUCH FAMILY ILLNESS ANALGESIC ABUSE PERSONALITY

PROCRAMMED lAUCM£NTATION

l '---...., LOW SENSATION DftSEASE LOW PAIN THRESHOLD PHOSBA TOLERANCE I 1 CURRENT AUCMENTATION

1 ANXIETY PSYCHOGENIC AGITATION ANOREXIA + INSOMNIA PAIN E.P.I. NEUROTICISM

Figure 12. Augmentation and disease phobia. A theoretical model based upon correlation evidence. 95.

This figure condenses to the simpler diagram:-

Low Sensation Threshold Much family illness l Current anxiety Disease Phobia ~ The view of augmentation referred to in Figure 12 as of two types, programmed ar-d current, is a useful way of considering disease phobia. The subject augments sensations and pains as well as his interpretation of their significance. There was a trend (21 to 13) for them to report a greater intensity of dry mouth than did the controls in spite of having the same salivary excretion rate; it remains to see if they ''turn up the volume control" in other ways and if this altered contrul is an enduring trait. If augmentation or reduction occurs with one sensory modality there is evidence that it can cccur in the same subject for disparate modalities. Spilker and Callaway (1969) found a strong positive correlation between the size of visual evoked responses and the kinaesthetic appreciation of width. Reason (1970) found motion sickness susceptibility related to the persons's estimate of the subjective intensity of various types cf input - loudness, brightness, angular velocity and so on. The augmenters are r.1ore "tuned in" to their sensations, and may be more "tuned in" to appraisal c,f threat generally. Some differences relating to life experiences and nature of up- bringing were observed that s~emcd predeterminants of the phobia. Events of early life likely to impair a person's confidence in his bodily health were shown to excess among the disease phobics. These included a low vitality in childhood - meaning the person regarded himself and was regarded by his relatives as weak and sickly and n~t suited to the harsh games of childhood, and~ past history of more painful disabilities and more defeats in life. Superimpor,ed upon this acceptance of a personal weakness is belief in a family vulnerability, created by the witnessing of much family illness. That this abundance of family illness was not just the fearful of a disease-attentive worrier- is shown by the "hard" evidence of more maternal deaths. Thus identification or better called "mis- identification" forms an unholy alliance Hith bodily self-doubt. This 96.

alliance becomes re-invoked in adult life under the pressures of a psychiatric illness laden with anxiety. The formation of this union is an interesting study in bodily "realpolitik". Fearful overprotectiveness by a doting parent leads to the efficient implantation of doubts concerning the body's integrity. Recency of the mother's death appears to predispose to disease phobia, not her death at a "sensitive" period in the subject's early life. The disease phobics report more babying and overprotective maternal behaviour; 50% of them are the youngest siblings of the family, versus 20% of the matched controls (21% is the average for the population at large; data quoted by Price & Hare, 1969). It is the mother/child rather than the father/child relationship which appears prejudicial. They brand their fathers as having poor personalities by which the subject means a pot-pourri of bad temper, meanness, stubbornness, cruelty, alcoholism or fecklessness. This may well be in part the biased observation of a victim of mother/child monopoly. A doting mother devoted to the child but not to her husband could easily imply the latter to be a blackguard. As youngest sibling the chances of being privy to family illness are increased. There was an excess of maternal deaths among the disease phobics, though this just failed to reach the .05 level of significance on two-tail testing. This relationship was not observed for paternal deaths. Being a victim of maternal oversolicitude, very often a happy victim, would make a person more sensitive to the mother's death. If one regards her as a bulwark, the analogy can be made - not only do the disease phobics need this protection but also alas it has become unavailable. As has been discussed previously, people who know a victim of a disease, particularly someone close to them, are more likely to say they fear the maladies "a lot" than those who do not know a victim. As Levine ( 1962) puts it, "familiarity breeds fear". The data demonstrate that excessive family illness increases the predisposition to disease phobia in subsequent psychiatric illness and in addition governs its content. The latter influence was noted in particular for those with a family history of cancer. Characteristics of the pre-morbid personality associated with disease phobia involved bodily introspection, the tendency to inhibit anger and chronic low self-esteem. In terms of the formal assessment of personal­ ity there was in addition to hypochondriacal an excess of obsessional features. In childhood these patients did not regard themselves as being 97.

more nervous or having more fears of the dark. The personality character- istics of low self-esteem and inhibition of anger have been mentionP.d by Janis (1953-4) as personality correlates which increase susceptibility to persuasion. Primed as he is by his previous life experiences, the nosophobic is already candidate for self-persuasion that a given pain has some dreadful import. Rosenberg (1965) found among high-school students a strong neg~tive relation between level of self-esteem and the reporting of psychosomatic indicators. For example, 69% of those with a very low self-esteem reported four or more psychosomatic symptoms, only 19% of those with very high self­ esteem. The correlation with inhibition of anger may, like all the others, be not a cause-and-effect relationship. It may be that it is just another consequence of the particular parental upbringing. The subject learns from his mother to be good and dutiful and not to be a "bad-tempered pig" like his father. Thus to obtain hts mother's largesse he must learn to suppress his feelings of anger, that is he must learn to destroy the angry father in himself in order to reap the rewards of coddling maternal safety. Greenfield (1959) suggests that inhibition of affective expression is a connnon nuclear correlate of behavioural pathology. He makes reference to its importance in the development of psychosomatic illness stating that "there is a growing body of clinical opinion which suggests that one of the primary dimensions of is an inability to freely express feeling at subsequent cost to the individual". This credo is acted upon by behaviour therapists in treating those with "inhibitory" personality patterns and appears to underlie the rationale of encounter groups. Wolpe and Lazarus (1966) reconnnend the use of assertion "to overcome neurotic habits of anxiety res?onses in interpersonal contexts''. The various items found here to correlate with inhibition of anger support the reasonableness of their approach. Harris (1951) showed that suppressed aggression, even if the level of anger was not high, predisposed to somatization. Looff (1970) found that 40 children with psychophysiological and/or conversion reactions ex­ perienced considerable difficulty in verbally expressing affects, including rage. Their parents also had this difficulty. The other 60 of 100 successive cl~ildrt-n referred for psychiatric consultation, in whom psycho­ logical rather th~~ somatopsychological symptoms were prominent, experienced much less difficulty. His results supported the contention that blocked verbal expres1ion determines the subsequent emergence of conflicted feeli~gs 98.

in body language as a somatization re&ction. From these somatic complaints the "~enso-hypochondriac" elaborates his phobia. The disease phobics were more often protest~nt. The meaning of this association is not at all clear, though it may relate to the increased intropunitivene ss of protestants ( Brmm, 1965; Fernando, 1969). Disease phobics did not attend church more often than the controls. However, when a contrast was made between somatically preoccupied subjects who were also disease phobic as against those only somatically preoccupied, it was found that the latter group more frequently attended church (p = .025). Gillespie (1929) speaking of epidemic hypocho~driasis suggested that the decay of belief in personal immortality has influenced humanity to cling more closely to the present life and to develop an exaggerated attention to health. The data might be interpreted to mean that church attendance provides comfort and safety to those somatically preoccupied decreasing their tendency to become nosophobic. Approximately half of each group had a diagnosis of depressive illness. The disease phobics had significantly more often been labelled non-depressive neurosis, the predominant form being anxiety and phobic neurosis (20% versus 0%). The principal differentiating clinical feature was anxiety (Figure 4). This showed up in both the patient's self report and in the combined psychiatric rating of three observers. Twenty-two of the phobics had moderate or severe anxiety versus only six of the controls. Other principal components which differentiated the groups were three factors, self-pity, cognitive performance difficulty and general habit change. The three questions loading highest on the anxiety principal component are "Do you feel tense mt:ch of the time?", "Do you often feel jittery?", "Are you often worried for no reason?'', The three with highest loading on the self-pity factor are "Have you felt more lonely lately?", "Do you envy others these days?", ar.cl "Have you felt somewhat sorry for yo~r-i~elf:". For cognitive performance difficulty, the highest loading questions are "Have you lost interest in things?", "Do you fe1cl unable to do things?" and "Is it difficult to concentrate?". For general habit change the relevant questions concern lo~s of appetite and sleep disturbance. It is noteworthy that the princiral components neither of depression nor of guilt are discriminating, though depression does discriminate at the 5% 1£vel ifs one-tail test is used and que~tion~aire-assessed guilt differ­ entiated the groups at the .01 level. Per~aps part of this latter 99.

association's neurotic logic is that guilt merits punishment and in the folklore of our society, atonement is to be made by the suffering of disease or injury. Therefore the guilt-ridden person is primed to have forebodings. Wahl (1963) felt that "in the unconscious, only suffering alleviates guilt" and that "the foremost unconscious need subserved by all hypochondriacal suffering is the assuagement of a conviction of guilt". If this is so it is an inefficient process. For disease conviction, depression becomes the important underlying affect (Figure 8). Using a one-tail test brings the lower suicidal factor scores of the disease phobics to significance. The one-tail is justified by the demonstration (Stenback et al., 1965) that mental hospital patients with disease phobia had lower rates of suicide. They hypothesized that one aspect of nosophobic hypochondriasis is "a fear of getting killed", whereas in suicide there is"a wish to be killed". Though the phobics "giving up" have a lower risk, patients with disease conviction who have "given up" are at high risk. Even though discrimination is occasionally difficult, it is important to recognize these prognostic implications. The lesser tendency of the phobics to contemplate or attempt suicide is congruent with their "safety-first" attitude manifest in other ways by the taking of vitamins, by a tendency co be less risk-taking and by their supression of any anger ("if I shut my mouth, I won't get hurt"). Lending support to the consideration of disease phobia in the context of augmentation are the observations cited by Petrie (1967) and relating to those here, that reducers of stimuli are more accident prone and that augmenters of stimuli prefer nutritionally valuable foods at breakfast. Sixty-three percent of the disease phobics were also somatically preoccupied and, by definition. none of the control group. A question that arises is what makes the somatically preoccupied patient cross over into disease phobia as well. The 19 patients with both disease phobia and somatic preoccupation were matched one-for-one with 19 patients having only somatic preoccupation (same matching procedure as for the larger samples). The principal compo1,ents on anxiety and general habit change were found to occur more strongly with tbe combined phobic-preoccupation patients (p < .02 and p ( .05 respectively). Again. too, there was an excess of younger siblings in the combined group (12 to 5, p ( .05). Ordinal position has been shown here to influence the symptomatology of a r,sychiatric illness. This suggests that birth orJer studies should examine th!~ association too rather than only 100.

the connection of sibling position with diagnosis. Brain fl963) saw that "psychiatry needs many languages, because none of them is sufficient alone''. He looked to physiology for the development of a language to bridge the gap between the brain and the mind, "that is, a language which can be used to describe direct correlations between physiological and psychological functions". In pursuing the origins of disease phobia it has been necessary to seek connections of the sort Brain prescribed. Some have been found and the discussion has traced what seem to be logical and meaningful linkages between childhood, personality, clinical and experimental characteristics. In summing up, declamation becomes the appropriate language, for the disease phobic acts as if in obedience of Laertes' advice to Hamlet - "Be wary then, best safety lies in fear." and his body remembers old emasculation and undermining, or as Henry Longfellow expresses the notion - "There are feuds yet unforgotten, Wounds that ache and still may open!" 101.

(b) DISEASE CONVICTION

This variety of hypochondriasis has been poorly studied and the present small sample again precludes any embracing corrnnentary. The 12 patients representing approximately 5% of the sample seem nevertheless an important subset and not one to be ignored because of expediency. A hopeless depression was the key underlying affect but was not found invariably - there was one patient, an intelligent demanding pro­ fessional woman, whose life involved a total conviction that she was danger­ ously ill and who had a need to have her histrionic role sanctioned by believing doctors. She overlapped the Munchhausen syndrome. Barker (1964) has alluded to the features this syndrome shares with hypochondriasis. Figures 4 and 8 demonstrate the interplay of anxiety and depression in determining whether a patient displays a disease phobia or disease con­ viction syndrome. Where anxiety predominates the trend is towards the phobia, where depression towards the conviction. Because of the small numbers in the disease conviction sample, this relationship cannot be fathomed with certainty. Aside from depression the disease conviction group was an older population. Blaser et al. (1969) found that 'severe hypochondria' occurred more in the elderly and in the depressed. This is in agreement with the present findings though for their assessment of hypochondriasis they merely depended on the Beck self-rating depression scale. On the 'hypochondria' item of this scale the highest score involves assent to "I am completely absorbed in what I feel". With the combination of old age and depression it would be natural to expect a heightened risk of suicide. There was a trend for more frequent suicidal thoughts and attempts in comparison with their matched controls. Indeed one of the 12 subsequently corrnnitted suicide "out of the blue", within the dangerous one month of discharge from hospital. Robins et al. (1959) made a careful investigation of a group of suicides by interviewing appropriate relatives and others soon after the death. Of the 60 manic-depressive suicides, 52 were aged over 40 years and 42 were men. 27% suffered from depressive delusions, somatic, nihilistic or of poverty. Of the 57 manic-depressive (endogenous depressive or manic­ depressive, cepressed phase) in the present psychiatric in-patient sample, 50 were aged Jver 40 years but only 19 were men and less than 9%suffered from disease delu&ions. 102.

Reading back over the intake interviews one could find evidence of other distorted cognitions beside the disease conviction. This in particular concerned pb.ranoid feelings which the patient in answer to a direct question often denied but gave evidence of during free verbalisation. The Lie Score on the Eysenck Personality Inventory averaged 5.67 versus 3. 75 for the matched controls (p ( .10) and this score, which some feel represents excessive behavioural conformity and the wish to appear in a respectable }ight, may explain their tendency to disclaim such "reprehensible" feelings as the paranoid and the suicidal. The resemblance to Grinker's factor 5 is striking, for in that factor are "the hypochondriacal, somewhat suspicious patients who have no somatic disturbances but only complaints. They insist that their troubles are due to organic disease and have or gain little insight into the de­ lusionary basis of their complaints''. It is well to remember that an in-patient sample is a special group and part of any findings may be a concomitant of sick role behaviour or of self-selection. Busse et al. (1960) showed that subjects in the connnunity who were extremely concerned with their health did not have feelings of neglect and persecution. This distinguished them from the hospitalized hypochondriac patients who felt strongly that they were being mistreated. It is quite possible that their paranoid attitude is not based on distorted interpretation but on an insightful realisation that people including staff do not like them. Reluctant as one is to conjure up the wraith of involutional melancholia one cannot help but notice the association of disease conviction with agita~ion, paranoid feelings and a hopeless depression resistant to environmental gaiety; and this despite age, sex and socioenonomic matching and a similar diagnostic composition for the disease conviction's matched control group. A likely explanation in view of this matching, is that severity of the illness accounts for the pattern. Carroll & Davies (1970) and McLeod et al. (1970) found for severe depressive patients whose plasma 11-0HCS did not suppress with dexamethnsone that agitation ~as significantly greater and that they appeared to respond poorly to antidepressants. One might expect the disease convinced (also more agitated than controls) to belong in this group of non-suppressors. Certainly the lite~ature confirms their poor response to antidepressants. Carroll & Davies (1970) have kindly reexamined their data at my

request. Of the 25 depressives whose 11-rHCS Jid not suppress with 103.

dexamethasone six had nihilistic delusions or disease conviction; of the 25 suppressor3 only one had this variety of hypochondriasis (p ( .05). This obscr~ation was initially missed because Hamilton's hypochondriasis item is scored as a unitary phenomenon varying on intensity from Oto 4. Scores of 3 and 4 appear to be equivalent to disease conviction. Hamilton ( 1967) advises "the severe states of this symptom, concerning delusions and hallucinations of rotting and blockages, etc., which are extremely uncorrnnon in men, are rated as 4. Strong convictions of the presence of some organic disease which accounts for the patient's condition are rated 3." There could not be better evidence than this fresh finding for refining the use of the blanket-term hypochondriasis. Post (1966) found that 11 of 68 depressives over 60 years of age scored below the highest level reached by dementing patients on a Synonym Learning Test involving the learning of words previously unfamiliar to the patient. Seven of these 11 with "pseudodementia" were delusionally depressed versus only 17 of the 57 ordinary depressives. It was Post's paper that suggested the value of examining the Raven's matrices scores, "free" and "driven", of the disease convinced depressives over 60 years in comparison with their matched controls. The former scored lower, especially on the "driven". Some of the clinical features that might influence scoring on such a test of intelligence are concentration, fatigue, psychomotor retardation, anxiety and agitation. The disease deluded depressives differed principally on the feature agitation from the six matched controls. Their score on agitation was three times as great and it is quite possible that this was the basis of their lower score on the matrices. It is consistent with this surmise that bustling and "encouraging" the patient as occurs in the "driven" matrices shows up the deficit even more. The matched controls complained a little more of poor concentration and were judged somewhat more retarded. "Driving" them would aid performance. Fatigue and anxiety levels were similar for the two groups. There is little of value in the literature on the connection between intelligence and hypochondriasis. Even the brief comments available do not examine the influence of possible interconnecting variables - there tends to be an automati~ assumption that correlation ~r association implies causation. 104.

In discussing "psychogenic and developmental hypochondrias" Ladee (1966) reported the intellectual and educational levels of 101 cases. "In eight cases (six men and two women) the pathogenic weight of the mental deficiency is such that it detennines the classification: hypochondriasis or hypochonddHc psychosis with mental deficiency. The hypochondriacal substancts ..... are of a delusive nature, are monotonous and poor, and are generally quite understandable in the light of the life history. Five of the six men are paranoid as well''. Ladee quotes one author as finding ''decidedly more hypochondria among feeble-minded and mentally deficient melancholics" and another who found that hypochondriacal depressives "do not belong to the category well-endowed with mental capacities". However in only about 10% of these hypochondriacal depressives was there a frank disease delusion. To sum up, it seems that the dullard crosses over to disease delusion more readily. It is not the lower intelligence of the disease conviction patients however which accounts for the present study's findings. The selection procedure at initial intake was such as to exclude persons who could not read or understand the interview questions. The coexistent agitation seems the best explanation for their lower scores on Raven's Matrices. (c) so~~ PREOCCUPATION

Backgro~nd Chdracteristics. The importance of background variables in accounting for vari3tion in symptomatology has been given prominence by Schwab ( 1968) and by Overall & Hollister (1969). Schwab remarked upon the influence of sex and social class in the determination of how depression presents. Overall & Hollister berate investigators for neglecting "these important sources of variance in clinical research .... when time comes to analyse the data and to report results, the background data are disregarded." The sex ratio was much the same for the somatically preoccupied and the unmatched control groups. Greer & Cawley (1966) reported that compared with other neuroses, hypochondriacal (somatic preoccupation) neuroses occurred relatively more often in males. Hubble (1953) noting that "it is in the nature of women to bestow affectionate solicitude and it is in the nature of children and men to receive it", used this argument to explain what he thought was a masculine disposition to hypochondriasis. He did recant a little by observing a chang~ in the 20th century, especially waxing eloquent concerning "the childless woman who has been coddled into hypo­ chondriasis by a well-trained husband." He blamed it also upon "The accidie which comes to those who deprive head, hands and gonads of their proper business." The four years difference in average age between the somatically preoccupied and the unmatched controls was not statistically significant but was in the predicted direction. The somatic preoccupation group ranked lower on occupational prestige (the common index of socioeconomic position) and this difference was significant at the .05 level, one-tail. This tendency of the lower social class to sornatize is well recognized though its mechanism is not certain. It may not just be that body language is the lower social class way of reporting psychological illness. Part of it may in fact be the consequence of subtle somatic impairment not recognized as of organic origin. The uinter excess gives a clue here, for winter would be more of a stress to those materially deprived, eliciting aches and pains not likely to arise in a house of comfort. The somatically preoccupied act upon their pains. Analgesic consumption is higher among the lower social cl~sses, especially the women (Gillies & Skyring, 1969) and hence they have more peptic ulceration and 106.

blood loss. This -:.bservation directed attention to the haematological differences between the groups and for the women whose haemoglobins were available the prediction that the somatically preoccupied would have a lower haemoglobin than controls was confirmed (see later discussion concerning sex, prognosis and iron deficiency). The excess of protestants (11 to 2) may be related to this group's increased intropunitiveness. There was no Jewish excess for any of the hypochondriasis groupings. It was also a little surprising that there was no overabundance of those widowed among the somatically preoccupied. There was, however, a trend towards more deaths of first degree relatives in the month preceding i 11 n e s s on s e t. Intelligence as measured by the Raven's matrices did not dis­ criminate between the somatically preoccupied and their matched controls. Bianchi et al. (1970) found that a group with somatic preoccupation and sick role behaviour scored lower on a similar intelligence test than did controls with, as it happened, little of bodily complaining or of sick role behaviour. These findings in two different studies can be construed as indicating that low intelligence favours production of sick role behaviour rather than of somatic preoccupation. 107.

Personality and Past History.

It appears that those with somatic preoccupation have a long illness of which the beginnings emerge obscurely from a pattern of illness behavi0u~ ~nd personality disorder. The matched controls have discrete, more clear-out illnesses, both current and past. Neuroticism is present to excess as indicated by the Eysenck Personality Inventory scores, increased nervousness as a child and even the occurrence of f~rmal personality disorder. This pattern also charac­ terised their first-degree relatives who had an excess of neurosis in comparison with the matched controls. The personalities were more often hypochondriacal in the sense of health-preoccupied and doctor-attending. The distinction between personality and illness is often arbitrary. In the chapter which describes the results of a factor analysis, this is underlined by the two factors of somatic preoccupation - the first, stronger in males, has high saturations on hypochondriacal premorbid personality and current somatic preoccupation, and the second, stronger in females, has high saturations on current psychogenic pain and somatic preoccupation and a past history of polysurgery. 108.

Other personality traits QOre frequent in the bodily preoccupied ~ere the tendency to inhibit anger (confirming Harris, 1951), obsessionality (confirming Roth, 1959) and the characteristic of high scoring on the Eysenck Personality Inventory Lie section. Six (15%) of the somatically preoccupied had a histrionic personality disorder versus one (2.5%) of the matched controls. Though this is a non-significant difference it is in the direction suggested by Lindberg fl965). Reference was made in the review section to the Bass Social Acquiescence Scale and how people who scored high on it were found by McNair et al. (1968) to be somatically preoccupied. The questions on the Eysenck Personality Inventory Lie Scale can also be viewed as sampling Babbittism, a tendency towards excessive behavioural conformity. The other school of thought held that high acquiescers might merely be responding noncritically and thoughtlessly to an 'impersonal' personality inventory. To arbitrate on this it is worth examining the "E.P.I. Lie factor" of table 29 obtained from a correlation matrix in which age has been partialed out. (Age and the Lie Score have a strong positive correlation of 0.364, N = 200). Matching has prevented age from giving a spurious association between somatic pre­ occupation and the Lie Score. The factor contrihutes 6. 7% of the variance and the items with highest saturations are:- E. P. I. Lie Score 0.818 Agitation 0.514 Sensation Threshold 0.414 Inhibition of anger 0.388 The items consorting with the Lie Score in this factor suggest that both explanations may apply. Those who are agitated do tend to respond automatic- ally to personality inventories, which they curse as impositions. Some can hardly even sit down to the task of putting a cross in the proper box let alone give considered thought to the question. And on the other side is the item inhibition of anger which is a form of excessive behavioural con­ formity. In this study the somatically preoccupied were more prone to­ inhibit anger but vere not more agitated than their matched controls. If they are behavioural conformists, is it that they readily conform to the bodily role which our society advertises and encourages? Is it that undue 109.

behavioural confirmity is merely a general addition to the problem environment? Or is it the inhibition of affective expression(mentioned elsewhere in connection with somatization) which encourages somatic preoccupation and psychogenic pain? Kay et al. (1969) have reported the long duration of illness among depressives who have somatic complaints. Just as it is difficult to define the demarcation line between personality disorder and frank illness so is it hard to decide whether a past history of operations, doctor-shopping, and analgesic abuse is the beginning of the present illness or represents a forme fruste, a "life in ill-health disorder". Real physical illness or injury did precede the onset of a somatic preoccupation illness more often than it did the control illnesses (p ( .001). The subjects (by definition) do not react with dis~ase phobia to their symptoms and in agreement with this is their low percentage taking vitamins, almost the same as the control subjects'? For them the symptoms provoke the immediate action of analgesic intake rather than a concern over future implications which the disease phobics attend to with vitamins and analgesics. Though the excess of family illness still differentiates the somatically preoccupied from their matched controls, the separation is not as marked as for the disease phobics. Nor does anxiety occur to the same extent. It is probably these two features which account for the low phobic response of this group to their symptoms. In addition they did not receive fear-"progrannning" in their childhood, that is there was no excess of maternal oversolicitude, no special position in the sibship and no emphasis on personal afflictions as a child. Clinical State. The symptoms of hysteria, anxiety, sleep impairment, fatigue and in the case of females, decreased libido, were those present to a statistically significant excess among the somatically preoccupied. Guilt and habit change were if anything less intense. In the interests of classification one must remark on the concateu­ ation of psychogenic pain, classical dissociative and conversional symptoms and fatigue. Is psychogenic pain a hysterical symptom or should one refP.r to it as psychogenic regional pain (Walters, 1961) or by some such name? Certainly there is evidence of an association between having a psychogenic 110.

pain and having current or previous conversional symptomatology. Merskey

& Spear, (1967)venture that "the ability of pain to serve as an acceptable symptom, which also answers the need of many patients to suffer or to be considered as suffering, provides the most plausible explanation for the frequent conjunction of pain and hysteria". They emphasize that this view is one which aims to account for the data rather than one which is proved by them. Rodgers & Ziegler (1967) have likewise classified fatigue as a hysterical symptom. It is perfectly possible for a somatically preoccupied patient to have classical hysteria, psychogenic pain, fatigue or decreased libido without it being valid to deduce that all are conversions or dissociations. Nevertheless it is clinically useful to be aware of the associations.

The two habit change eigenvectors. The possibility that somatic preoccupation and disturbed body rhythmic functions are two separate phenomena was raised in the review of factor-analytic studies. The data support the differentiation for the somatically preoccupied group scores lower on a principal factor of habit change. The somatically preoccupied score higher only on the second principal component. This has positive saturations for items concerning insomnia and negative saturations for anorexia and weight loss, that is, sleep loss without loss of interest in food and without weight loss. (The questions used in this section of the interview and their factor saturations are shown in Appendices II and III). Decreased interest in sex was reported only by the women who were somatically preoccupied (46% versus 21% of the matched control females) not by the men. A past history of frigidity was present to approximately the same extent in both groups (in 25% of each group there was a premorbid moderate or marked frigidity among the women). Brown (1936) commented that the invalid reaction is particularly common in "the dissatisfied wife situation" and Kreitman et al. (1965) found marital conflict to be a feature of their group of depressives with many somatic complaints. This study noted only e trend in that direction. 44% of the somatically preoccupied reported some difficulty in their relationships with the opposite sex compared with 27% of the matched controls. The highest loading on the sleep factor was for initial insomnia and it was on this alone that the somatically preoccupied reported more 111.

change than did the matched controls (78% versus 51%, p ( .01). Twice as many of the controls had lost more than seven pounds in weight (22% of somatically preoccupied versus 46% of matched c~ntrols, p ( .05). Johns et al. (1970) found that among non-psychiatric hospital patients those complaining of multiple physical symptoms as a result of neurotic illness had significantly increased degrees of sleep disturbance at all ages. Some speculations upon the nature of this relationship can be made. The present study notes that the disturbance is of initial sleep and as the somatically preoccupied group take "A.P.C." and other compounds containing caffeine it is possible that caffeine contributes to the insomnia. Likewise the somatically preoccupied are more fatigued and therefore again likely to quaff more frequently the ritualized tea or coffee (plus a carbohydrate accompaniment, explaining the lack of weight loss). Possibly feedback operates in the reverse direction too so that the sleep deprived person feels more fatigue and magnifies his bodily trib11lations. That this may be true is shown in table 9; the correlation of habit change with low sensation threshold is significant at the .05 level. Muscle tension, a common aspect of somatic preoccupation may disturb sleep. An addition,1.J explanation could be that the underlying psychological disorder initiates both the insomnia and the bodily preoccupation. It is worth commenting that guilt is present more in the disease phobics (than in matched controls) but not in the patients merely somatically preoccupied who do not suppose they have some dire physical disease. Ladee (1966) noticed that if hypochondriasis and guilt both occur, these themes are often connected with one another, either because the supposed disease induces guilt .... ("the others will be infected too") or because the disease is the result of guilt ("from onanism, leading an immoral life, venereal disease ... ") or because the disease is experienced by the patient as a punishment for his guilt. Thus where the subject merely complains excessively concerning his bodily complaints there is no question of disease and no reason to fee 1 guilt. Stern & Prados (1946) found among 50 menopausal women with many varieties of bodily pains that "guilt feelings or tendencies towards self-accusation v.'erc completely absent." Prognosis. The finding of an unfavourable prognosis in relation to mental health for those somatically preoccupied r~plicates the work of Greer & Cav.'ley (1966), Pilowsky (1968) and Kay et al. (1969). 112.

A factor with appreciable loadings on somatic preoccupation and poor prognosis extracted by principal component analysis portrays a patient entity which any psychiatrist consulting in medical and surgical wards would recognize. It is worthy of classification as a syndrome, for psychiatric nosology does not do it justice. The items which have high saturations on this factor are "unnecessary" operations, psychogenic pain, somatic pre­ occupation, much family illness, life defeats, low sensation threshold, sex-female and poor prognosis. This factor draws attention to the poor prognosis of the females with this constellation of somatic complaining and on analysing the prognosis for the sexes separately, it was seen that the rmles with somatic preoccupation have the same prognosis as their matched controls. These "polysurgical, polymedical" women have as yet received no accepted eponymous classification, being one of the Von Mering & Earley (1965) group with "undifferentiated, life in ill-health disorder". Perley & Guze (1962) refer to them as having hysteria by which they mean a polysymptomatic disorder of females beginning before the age of 30 years with recurrent or chronic ill health and overuse of doctors. In a review of their work Guze (1967) quoted results showing the bad prognosis of such patients. "When the diagnosis of hysteria is based upon the presence of the clinical picture already described, the same diagnosis will be applicable six to eight years later and no other disorder will have become manifest to explain part or all of the original symptoms in 90 percent of the cases." These problem women have a prevalence of just under two percent in the general femnle population. The syndrome would appear to be present in up to 40 per,;ent of their first-degree female relatives. 5ex, prognosis and iron deficiency. These sex-related factors indicate the occasional importance of sex as a source of heterogeneity in psychiatric studies (Blumenthal, 1967). The question that these results invite is why do the females who are somatically preoccupied have a poor prognosis but not the males. It may be that hyster­ ectomy has so □ e permanent effect on their body image or that men have occupation as a prophylaxis. 1he answer is not clear. Two facets of somatic preoccupation, sleep disturbance and headache, were shown by Hagnell ( 1966) to be prognostical ly unfavourable for women but not for men. In his discussion of the greater morbidity of women in the decade follo\.:ing th,2 initial recording of symptomatology in 1947 Hagnell relies l. L1.

upcn the sociological concept of the sex roles. He quotes one author who pointed out that "the role of the patient is also a social role, which has many elements common with the female role: helplessness, desire for pro­ tection and passiveness". The female proclivity to loss of iron stores has been discussed. This loss does not occur with males possibly because men who are tense use alcohol rather than analgesics and beer contains iron. Serum iron levels and tissue levels of iron were not measured but the lower haemoglobin found and a coexistent trend towards lower mean corpuscular haemoglobin concentrations suggest that tissue iron deficiency may occur in these women compounding their problems. Taymor et al. (1964) produce suggestive evidence from a double-blind trial with iron and placebo. They admitted to the trial patients with menorrhagia and low serum iron levels who had no demonstrable organic pathology. Decreased menorrhagia occurred in 75% of those on iron versus 39% of those on placebo (p < .01). (They do not specify how improvement was assessed. One must also have reservations about how double-blind the trial was). They felt that "chronic iron defic­ iency can be a cause as well as a result of menorrhagia". This possibility is of interest in view of the high hysterectomy rate among chronically complaining women, it being remembered that excessive bleeding often precipi­ tates hysterEctomy. Some hope in their treatment is offered by oral anti­ fibrinolytic agents for example tranexamic acid (Callender et al., 1970). Wood & Elwood (1966) have shown that it is only when haemoglobin levels fall below 8 - 10 G.% that fatigue and other bodily symptoms result. Attention has now swung to the problem of chronic iron deficiency existing even with normal haemoglobin levels (Robertson & MacLean, 1970). It is not suggested that this chronic somatic preoccupation in women is strongly related to the deficiency of iron but it may be one extra burden encouraging chronicity as part of a vicious circle. 114.

A1{ ANALYSIS OF VARIANCE OF THE CLINICAL STATE.

In the preceding sections the sub-groups of hypochondriasis have been co:npared with their o~,m matched controls. To afford a more extensive comparison an analysis of variance (two-way without replication) was performed with the inclusion of a psychogenic pain group. These latter patients complained only of pain at a single site and lacked sufficient other bodily symptoms to be called somatically preoccupied. Psychogenic pain was defined by l-lerskey & Spear ( 1967) as "either pain which is independent of peripheral stimulation or of damage to the nervous system and due to emotional factors, or else pain in which any peripheral change (e.g. muscle tension) is a consequence of emotional factors". Four groups of 30 patients (matched foursomes) were formed as shown in Appendix IV. There were too few patients with disease conviction so that the four groups examined were disease phobia, somatic preoccupation, psychogenic pain and control (Table 23). The actual matching can be seen in Appendix IV. It was exact for sex of patient. Any discrepancies in occupational prestige were minor and balanced. For age the greatest mean difference was that between the somatic preoccupation group and the control group, namely one year. TABLE 23. Age and occupational prestige of matched foursomes.

Disease Somatic Psychogenic Control Test of Phobia Preoccupation Pain Significance

Age in years mean 39.9 40.4 39.9 39.3 F1==0.66 standard deviation 15.5 16.6 16.1 15.6

Occupational prestige categories 1 & 2 5 4 5 4 CHI 2=o .26 category 3 14 16 18 16 CHI 2==1.07 category 4 11 10 7 10 CHI 2=1. 39

An F ratio for this sample reaches the .05 level of significance when F=2.71. It reaches the .01 level at F=4.0l. For age the between-columns value of F1 equalled only 0.66 so that matching has been close (the between-rows value of F2 ~as 113.6). None of the chi-square values on occupational prestige re~otely approach s,atistical significance. For three degrees of freedom, chi-square valu~s of 7.81 and above become significant at the .05 level. Principal Components.

Eigenvector values on the principal components shown in Appendix III were used in the assessment of the clinical state. These components had been derived from ans;,ers given in the psychiatric interview (AppEndix II). In the following table F1 is column variance ratio and F2 is row variance ratio. F2 approachEs or exceeds F1 in value when the particular component is not important in differentiating between the four groups.

TABLE 24. Analyses of variance on principal component scores (matched foursomes).

Principal Component Interpretation Significance F Fl 2 of the factor of F1

Mood 1 Depression 1.45 N.S. 0.85 Mood 2 Suicidal 2.19 N.S. 2.02

C.P.D. 1 Cognitive per- fcrmance difficulty 3.00 ( .05 0.58

Anxiety 1 General anxiecy 8. 75 ( .001 0.92 Anxiety 2 Irritability 1. 65 N.S. 1. 69 Anxiety 4 Focussed anxiety 3.64 ( .05 o. 72

Self-pity 1 Self-pity 4.33 ( .01 1.-33

Guilt 1 Guilt and shame 0. 60 N.S. 1. 23

Habit change 1 Anorexie. - insomnia 2.85 < .05 0.86 Habit change 2 Insomnia - no ar.orexia 3.19 ( .OS 1.16

The means of th~ four groups on these principal components appear in table 25. These values have no readily explainable clinical equivalence.

In g1:r.eral it will be seen that (on the components which dis­ criminate) th~re is a descent from disease phobi3 to somatic preoccupation to psychogenic pain, with controls scoring lowest. 116.

TABLE 25. Mean scores on principal components concerning clinical state (matched foursomes).

I Principal Component Disease So □ atic Psychogenic Control Phobia Preoccupation Pain

Depressive 5.17 5.21 4.40 2.57 Suicidal 4.41 5.16 5. 97 5.55 Cognitive performance difficulty 11.40 10.43 9.64 7.54 General anxiety 13.12 11.71 9.51 7.53 Irritability 1. 78 1. 78 2.90 1. 54 Focussed anxiety -0.16 -0.01 -0.78 -1.86 Self-pity 8.17 7.25 6.34 4.62 Guilt and shame 7.30 6.61 6.14 5.68 Anorexia-insomnia 10.41 8.53 8.42 7.63 Insomnia - no anorexia -0.44 1.19 -0.07 -0.80

Anxiety is seen to be the prime differentiating clinical feature for these four groups. Depression is not a significant distinguishing feature. Nevertheless the Zung self-rating depression scale did differentiat~ the groups (F1 = 5.33, p ( .01). The four mean scores were 12.53, 12.00, 10.46, and 8.43 respectively (maximum possible score= 20). The item content of this so-called depression scale is heavily represented by anxiety and habit change items rather than by depressive mood per se. Mean Neuroticism Scores on the Eysenck Personality Inventory and the related clinical feature of anxiety are strong discriminators (for the former, F1 = 9.86, p < .001). The mean Neuroticism Scores were 16. 77, 16.03, 14.43 and 10. 77 respectively. Six of the factors discriminate to at least the .05 level between the four clinical groups. They are, in decreasing order of differentiating strength, general anxiety, self-pity, focussed anxiety, insomnia with appetite unimp~ired, cognitive performance difficulty and general habit change. Notably l~cking in statistical significance are the depressive ~ood and the guilt components. On all the first factors from each clinical section there is a uniform tren~ for decreasing factor scores as oue passes from disease phobia 117.

to somatic preoccupation to psychogenic pain to co~trol. This is possibly a reflection of the selection procedure with severity of hypochondriasis responsible for the spread of means. It will be recalled that in the allocation of patients to a particular group the psychogenic pain patient suffered one pain, the somatically preoccupied had more bodily complaining but no disease phobic addition, whereas the disease phobic person often had somatic preoccupation plus the phobia. It may be this severity coDtinuum which underlies the mean factor scores' stepwise decrease from disease phobia to control. The complexities will be teased out in the factor analysis which now follows. 118.

A PRINCIPAL COMPONENTS ANALYSIS.

Factors of Hypochondriasis and Psychogenic Pain.

One of the main functions of factor analysis is to reduce a mass of inter-relationships between variables to a simpler and more comprehensible pattern. "Factor analysis is nothing more than a set of mathematical aide to the examination of patterns of correlations, and for that purpose, it is indispensable" (Nunnally, 1967).

A routine principal component analysis, unity in the diagonal of the correlation matrix was performed on the data from 118 patients who had one or more of disease phobia, disease conviction, somatic preoccupation and psychogenic pain. To decrease '1noise" and to aid interpretation of the components only 24 variables were selected for the analysis. Even this number would be considered too many by some who recommend that there be approximately ten times as many patients as the number of variables (Nunnally, 1967). Further simplification was hoped for by the exclusion of patients with schizophrenic and organically­ based illnesses (to avoid clouding of the factor structure).

The 24 variables are listed in Table 26. 119.

Table 26. PRn;CIPAL co:-~PO:'.\ENTS A~ALYSIS DISPLAYING UNROTATED CO:MPO~El'.1S WITH LATE~T ROOTS ABOVE UNITY.

Principal Components

I II III IV V VI VII VIII

Disease phobia 0.377 -0.227 -0 .104 -0 .292 -0.433 -0 .115 -0.050 0.194 Disease conviction 0.581 -0.001 0.061 -0.485 0.271 0.004 0.168 -0. 167 Somatic 0.429 -0.207 0.559 -0.035 -0.1.45 0.293 0.133 0.169 preoccupation Psychogenic pain 0.072 -0.463 0.444 -0.087 0.203 0.001 0.043 0.206 Dysmorphic beliefs 0.242 -0. 142 0.028 0.269 -0.276 -0. 126 0.518 0.148 Hypochondriacal 0.348 -0.095 0.277 0.093 -0.436 0.379 -0.348 -0 .084 personality Sex (+=Male) -0.197 0.273 0.017 -0. 296 -0.244 0.649 -0. 167 0.012 Age 0.577 0.526 0.099 0 .198 0.132 0.105 -0. 138 0.141 Depression E.V. 0.462 -0. 198 -0.584 0.175 0.077 -0.052 0.210 0.010 S..iicidal E.V. -0.475 -0. 2 92 -0.417 0.109 0.141 0.081 -0. 139 -0.186 Anxiety E.V. 0.345 -0.245 -0.374 0.114 -0.276 0.085 0.050 0.449 Habit change E.V. 0.576 0.073 -0.379 0.000 0.237 -0.018 -0 .111 0.239 Agitation 0.574 0.460 -0.268 0.051 0.225 -0 .140 -0.143 -0.054 Paranoid feelings 0.377 -0.229 -0 .196 -0.268 0.274 0.452 0.155 -0. 191 Pain tolerance -0.258 0.205 0.136 0.373 0.014 0.327 0.552 0. ;~ 35 Sensation 0.134 0. 613 0.007 0.461 0.024 0. 360 0.134 -0. 193 threshold E. p. I. Lie Score 0.361 0. 34L~ 0.469 0.167 0.137 -0.237 0.0(,9 -0. 2 36 Inhibition of 0.291 0.049 0 .156 0.153 -0.456 -0.361 -0.083 -0.323 anger Poor paternal 0.102 -0.352 -0.212 0.479 -0.329 0.129 -0.071 -0.290 personality Life defeats 0.057 -0.541 -0.096 0.488 0.286 0.134 -0.033 -0.1.49 Maternal 0.270 -0.299 -0.070 -0.273 -0.293 -0.034 0.359 -0.421 oversolicitude "Unnecessary" 0.054 -0.370 0.458 0.242 0.250 -0.289 -0.019 0.130 operations Excess of fa:ni ly 0.288 -0.368 0.140 0.238 0.107 0.103 -0.583 0.066 illness Poor prognosis 0 .119 -0.419 0.189 -0.054 0.346 0.300 0.131 -0. 188

Percentage of 12. 8% 11.0 8.8 7.2 6.9 6.6 6.0 4. 7 variance 120.

The item dysmorphic beliefs which was obtained from the Beck self-rating depression scale (Beck et al., 1961) was included to see its relationship to the "internal" forms of hypochondriasis. The patient assented to one of the four statements following:-

(a) I don't feel I look any worse than I used to. (Scores 0). (b) I am worried that I am looking old or unattractive. (Scores 1). ( C) I feel that there are permanent changes in my appearance and they make me look unattractive. (Scores 2). (d) I feel that I am ugly or repulsive looking. (Scores 3). The four clinical items expressed as eigenvalues (E.V.) were derived from questionnaire-based interviews. Agitation and paranoid feelings were from the pooled judgmental scores of three psychiatrists. Paranoid feelings were not necessarily delusional in intensity. The experimental variables of pain tolerance and sensation threshold were entered as voltages. In addition to the hypochondriacal, two other aspects of personality were examined, the Eysenck Personality Inventory Lie Score and the propensity to inhibit anger. Early life events and prior experiences were represented by poor paternal personality, life defeats, maternal oversolicitude, history of "unnecessary" operations, and excess of family illness. Finally a prognostic criterion was included - the mental health at six months after discharge. These 24 variables were chosen because they seemed to differentiate the various forms of hypochondriasis from their control groups. Complete data were not available for a few patients and so a correlation matrix allowing for missing data was formed. This matrix was analysed by the principal components method. The factors extracted and rotated (varimax) were those with latent roots above unity (Tables 27 and 28). Because old people selectively forget some early life experiences, age was partialed out of the correlation matrix and a new factor analysis performed (Tahle 29). Likewise E.P.I. Lie Score was partialed out (Table 30) and then both age and E.P.I. Lie Score (Table 31). (In Table~ 28-31 the rotated factors are rearranged in descending order of variance magnitude). 121.

Table 27. PRINCIPAL COMPONENTS ANALYSIS WITH VARIMAX ROTATION OF COMPONENTS WITH LATENT ROOTS ABOVE UNITY.

Principal Components

I II III IV V VI VII VIII

Disease phobia 0.202 -0.078 0.065 -0.195 -0.558 -0.012 -0.244 -0.265 Disease conviction -0.040 -0.670 -0.305 -0.307 -0.050 -0. 105 -0. 187 -0.142 Somatic 0.557 -0. 271 -0.061 -0.157 -0 .125 -0.446 0.223 -0 .132 Preoccupation Psychogenic pain 0.123 -0 .185 0.181 -0.056 -0.020 -0.644 -0.020 0.094 Dysmorphic beliefs -0.069 -0.0ll 0.011 0.032 -0.376 -0.173 0.466 -0.373 Hypochondriacal 0. 772 -0.018 -0.084 0 .144 -0.082 -0.004 -0.094 -0. 194 personality Sex (+=Male) 0. 53.'.:> -0.080 0.149 -0.204 0.120 0.478 0.057 0. 328 Age 0.226 0.028 -0. 806 -0 .117 -0.016 0.011 0.102 0.007 Depression E.V. -0.300 -0.284 -0.274 0.348 -0.535 0.109 0.029 -0 .101 Suicidal E.V. -0.257 0.036 0.375 0.465 0.077 0.217 -0.156 0.273 Anxiety E.V. 0.098 0.022 -0.072 0.130 -0. 762 0.008 0.066 0.044 Habit change E.V. -0. llO -0. 182 -0.567 0.048 -0.434 0.013 -0 .171 0 .142 Agitation -0 .140 -0.083 -0. 777 -0.042 -0.084 0.192 -0. 162 -0 .080 Paranoid feelings 0.085 -0.753 -0.095 0.127 -0.122 0.077 -0.030 0.158 Pain tolerance -0.006 0.093 0.059 -0.001 0.067 0.005 0.825 0.188 Sensation 0.173 0.061 -0.513 0.158 0.291 0.358 0.507 -0.017 threshold E. p. I. Lie Score 0.035 -0.028 -0.484 -0. 135 0.401 -0.237 0.101 -0.420 Inhibition of 0. 142 0.180 -0. 116 0.045 -0.001 0.009 -0 .131 -0. 706 anger Poor paternal 0.185 0.036 0.106 0.666 -0.176 0.106 0.050 -0. 2 97 personality Life defeats -0.061 -0. 160 0.035 0. 727 -0.028 -0. 3ll 0.047 0.086 Maternal -0.005 -0.501 0.244 0.001 -0.160 0 .108 -0.018 -0. 536 oversolicitude "Unnecessary" -0.057 0.092 0.015 0.116 0.094 -0. 730 -·O .008 -0.070 operations Excess of family 0.377 0.051 -0 .188 0.410 -0.082 -0.376 -0. 387 0.121 illness Poor prognosis 0.086 -0.536 0.110 0.221 0.136 -0.316 0.041 0 .121

Percentage of 7.3% 7.8 10. 8 7.7 8.0 8.6 6.6 7 .0 variance Table 28. PRINCIPAL COMPONEN·.i'SANALYSIS WITH VARIMAXROTATION. N N ~ I II III !V

Age -806 "Unnecessary" operations -730 Anxiety E.V. -762 Paranoid feelings -753 Agitation -777 Psychogenic pain -644 Di::iease phobia -558 Disease conviction -670 H~bit change E.V. -567 Sex - female -478 Depression E.V. -535 Poor prognosis -536 Sensation threshold -513 Somatic preoccupation -446 Habit change E.V. -434 Maternal oversolicitude -501 E.P.I. Lie Score -484 Much family illness -376 E.P.I. Lie Score +401 Depression E.V. -284 Suicidal E.V. +375 Low sensation threshold -358 Dysmorphic beliefs -376 Somatic preoccupation -271 Disease conviction -305 Poor prognosis -316 Low sensation threshold -291 Depression E.V. -274 Life defeats -311 10.8% of variance 8.6% 8.0% 7.8%

V VI VII VIII Life defeats 727 Hypochondriacal P.M.P. 772 Inhibition of anger -706 Pain tolerance 825 Poor paternal 666 Somatic preoccupation 557 Maternal oversolicitude -536 Sensation threshold 507 personality Suicidal E. V. 465 Sex - male 535 E.P.I. Lie Score -420 Dysmorphic beliefs 466 Much family illness 410 Much family illness 377 Dysmorphic beliefs -373 Much family illness -387 Depression E.V. 348 Depression E.V. -300 Sex - female -328 Disease phobia -244 Disease conviction -307 Poor paternal -297 personality Suicidal E.V. +273 Disease phobia -265

7. 7% 7.3% 7.0% 6.6% Table 29. l'RINCIP:\L COMPONENTS ANALYSIS WITH VARlMAX ROTATICN. <"'I -(~~ Eartialed cut from the correlation matrix):- -N .-1 I II III -IV "Unnecessary" operations 728 Anxiety E.V. 756 Poor paternal personality 708 Naternal oversolicitude 609 Psychogenic pain 642 Depression E.V. 717 Life defeats · 684 Dysmorphic beliefs 577 Somatic preoccupation 477 Habit change E.V. 627 Much family illness 481 Inhibition of anger 505 Low sensation threshold 417 Agitation 533 Suicidal E. V. 464 Disease phobia 471 Sex - female 412 Disease phobia 273 Suicidal E.V. -444 Poor prognosis 382 Poor paternal 330 personality Much family illness 350 Sex - female 274 Life defeats 332 9.2% of the variance 8.8% 7.9% 7 , 9'7o

V VI VII VIII Paranoid feelings 770 Pain tolerance 817 Hypochondriacal P.M.P. 795 E. p. I. Lie Score -818 Disease conviction 694 Sensation threshold 586 Somatic preoccupation 571 Agitation -514 Poor prognosis 499 Much family illness -408 Sex - male 536 Sensation threshold -414 Maternal oversolicitude 385 Dysmorphic beliefs 355 Anxiety E.V. 300 Inhibition of anger -388 Disease phobia -307 Much family illness 268 Sex - female -245

7. 8'1/., 7 .4'1/o 7.2% 6. 7% Table JO. PRINCIPAL COMPONENTSANALYSIS WITH VARI.MAXROTATION. -.j (E. P. I. Lie Score E.artialed -;-~tfrom correlati.::m matrix). <'-l - I II III IV Age 839 "Unnecessary" operations 686 Disease conviction 762 Life defeats 733 Agitation 690 Psychogenic pain 666 Paranoid feelings 740 Poor paternal 677 personality Habit change E.V. 590 Somatic preoccupation 522 Maternal oversolicitude 531 Much family illness 495 Suicidal E.V. -393 Low sensation threshold 464 Poor prognosis 391 Suicidal E.V. 436 Sensation threshold 354 Much family illness 385 Depression E.V. 280 Depression E.V. 282 Much family illness 321 Sex - female 364 Maternal oversolicitude -297 Poor prognosis 358

9.7% of the variance 9.2% 8.4% 7, 9'1/o

V VI VII VIII Inhibition of anger 694 Hypochondriacal P.M.P. 767 Anxiety E.V. 862 Pain tolerance -819 Dysmorphic beliefs 462 Sex - male 642 Depression E.V. 645 Sensation threshold -567 Disease phobia 446 Somatic preoccupation 517 Disease phobia 335 Dysmorphic beliefs -459 Maternal oversolicitude 420 Much family illness 258 Habit change E.V. 313 Much family illness 329 Poor paternal 372 Disease phobia 263 personality Suicidal E.V. -352 Poor prognosis -332 Sex - female 271

7 ,4?o 7.4% 7.3% 7 .0% Table 31. PRINCIPAL COMPONENTSANALYSIS WITH VARIMAXROTATION. (Age and E.P.I. Lie Score partialed out from the correlation matrix). ''"'N .-4 I II III IV "Unne:cessary" operations 712 Anxiety E.V. 746 Paranoid feelings 770 Life defeats 699 Psychogenic pain 633 Depression E.V. 717 Disease conviction 743 Poor paternal 644 personality Low sensation threshold 558 Habit change E.V. 632 Poor prognosis 470 Suicidal E.V. 512 Somatic preoccupation 437 Agitation 576 Maternal oversolicitude 431 Much family illness 494 Sex - female 419 Disease phobia 278 Somatic preoccupation 252 Much family illness 357 Poor prognosis 347 Agitation -317 Life defeats 311 9.8% of the variance 9.4% 8.5% 8 • 3fo

V VI VII Inhibition of anger -642 Hypochondriacal P.M.P. 778 Pain tolerance 802 Maternal oversolicitude -557 Somatic preoccupation 571 Sensation threshold 520 Dysmorphic beliefs -512 Sex - male 565 Dysmorphic beliefs 445 Cisease phobia -456 Anxiety E.V. 344 Much family illness -400 Poor paternal -419 Much family illness 271 Agitation -262 personality Suicidal E.V. 370 Disease phobia 269 Sex - female -305

8.2% 7. 7% 7.5% 126.

DISCUSSION. The disease phobia factor associated with maternal oversolicitude, inhibition of anger, poor paternal personality and low scoring on the suicidal eigenvector was the principal one requiring Eysenck Personality Inventory Lie Score and/or age to be partialed out from the correlation matrix. Disease phobia was the sympton most preceded by early life events that excessive conformists are wont to disown or that the aged are prone to forget. It is interesting to see in the following table how disease phobia comes into closer association with such variables when the cloaks of age and Lie Score are removed.

Table 32. The disease 2hobic factor of "programmed au~entation" Variable None P.O. Age P.O. Lie P.O. Age & Lie P.O. Inhibition of anger 0. 706 0.505 0.694 0.642 Maternal oversolicitude 0.536 0. 609 0.420 0.557 Dysmorphic beliefs 0.373 0.577 0.462 0.512 Sex - female 0.328 0.274 0. 271 0.305 Poor paternal personality 0.297 0.330 0.372 0.419 Suicidal E.V. -0.273 -0.444 -0.352 -0.370 Disease phobia 0.265 0.471 0.446 0.456

(P.O. = partialed out). This is the only one of the eight factors rotated that needed the partialing out, for it was the only factor dependent on proper recall of slightly opprobrious details. This hazard of retrospective investigation has been discussed in the chapter on methodology. Aside from this factor and for the sake of brevity, only the rotated analysis with no variables partialed out will be discussed (Table 28. Table 28 is an abbreviated version of 27). The chief factors relating to hypochondriasis are seen to be 1. A psychogenic p-in - somatic preoccupation factor with a history of "unnecessary" operations (stronger among females). 2. A somatic preoccupation - hypochondriacal personality factor (stronger among males). 3. A disease phobic factor (demonstrating "current augmentation"). 4. A disease phobic cum dysmorphic beliefs factor (demonstrating "proeram'!l:c:d augmentation"). and

5. A diFease conviction or disordered cognition factor. 127.

There is an age-agitation factor in which disease conviction obtains a small factor saturation and there is a factor of high pain tolerance and high sensory threshold in which disease phobia and much family illness are at the opposite pole. An interesting factor not particularly associated with hypochondriasis is an environmental load - suicidal constellation. THE DISEASE P}!OBIA FACTORS. The factors encompassing disease phobia can be compared with the theoretical model (Fig. 12) which is a composite of items that can be understood as current clinical state, upbringing and personality, and experimental characteristics. Each of these areas can be seen to favour disease phobic occurrence and each is separately represented by a factor (Table 28; components III, VII and VIII respectively). The three as?ects of disease phobia make approximately equal contributions and together account for around 22% of the variance. The dysmorphic beliefs item travels with disease phobia except on the "masochistic" or "tolerant of pain" factor (Table 28; component VIII). Low self-esteem was found to associate with disease phobia and as people who think themselves of vile appearance often are low in self-esteem the association is not surprising. The pain tolerance factor tells the story of how the disease phobic person with much family illness has a low pain tolerance and a low sensation threshold (Table 9). There is an aspect of dysmorphic belief that brings it into relationship with high pain tolerance and high sensation threshold. Some people who have an image of themselves as ugly are of masochistic, self­ reviling and martyric bent and one wonders if this is the group loading high on this factor. THE TWO sm!ATIC PREOCCl:PATIO;\ FACTORS There are two factors of somatic preoccupation, one pertaining more to females and the other more to males. Together they contribute about 16% of the variance. A typical patient scoring h~gh on the former could be described as - a woman burdened by life and by the spectacle of much family illness. She has a low sensation threshold and experiences her body as painful and intrusive. She is the recipient of much so-called "unnecessary" surgery and is prone to remain chronically un~ell. The chronic hysteric of Perley and Guze (1962) would score high on this factor. Th~ nale version also involves a "noisy" body and the upsetting evidence of much family illness but instead of being surgery-prone the male tends to be more clearly seen as a hypochondriacal personality. Perhaps he visits the doctors seeking similar solace bu.: his anatomy being what it is, 128.

surgery is not such an easy reco~rse for the baffled doctor. The patient is a health-conscious, self-medicating physician to himself. THE DISEASE CO'.\'/ICTIO:: FACTOR. The other clear-cut hypochondriacal factor is that of disease conviction. Besides having disease delusions the patients with high loadings on this factor would have disordered cognitions of the paranoid type. As children they would have been babied and overprotected and as part of the current illness would have a hopeless depression. Disease conviction also appears (with low saturation) on the old age-agitation-habit change factor. These computer-assisted analyses have been an added help in the more accurate clinic al definition of hypochondriacal syndromes. The main hope of such efforts was to isolate subcategories which when related to other information might further our knowledge of aetiology, prognosis and eventually therapy. The factors refer to relationships between rating items, not individuals. They do not necessarily reflect groupings of patients. If it becomes apparent that patients with a high score on a particular factor are poorly classified by orthodox psychiatric nosology it is reasonable to suggest that the particular component or factor describes a syndrome, especially if it accords with clinical judgment. It is proposed that one of the components fits this situation, naQely, the female somatic preoccupation factor. Its other loadings are for psychogenic pain, "unnecessary" operations, much family illness, low sensation threshold, poor prognosis and life defeats. Clinicians are familiar with the people who have high scores on this component as . treatment problems and yet they find it difficult to append a psychiatric diagnosis. The other components obtained most probably do not represent separate disease entities. Patients scoring high on these factors are readily classifiable. For example those scoring high on the disease conviction factor mostly have endogenous depression and those scoring high on the disease phobic factors commonly have anxiety neurosis. Nevertheless it is valuable to recognize them as subvarieties of hypochondriasis ror the aid they sometimes give in predicting outcome of an illness, and again for the aetiological clues to hypochondriasis they provide. For these components, the analyses have been only a supplement to the preceding work that utilised matched controls. 129.

CLOSING DI SCCSSION AND SU?-!1-ti\RY

From this study it would appear that disease phobia develops when anxiety is surgent in a patient program~ed to regard disease as an imminent risk. In comparison with the control psychiatric patients who have no pain or hypochondriasis, the disease phobics show more self-pity, complain more of poor concentration, fatigue and loss of interest, and have more general impairment such as anorexia, weight loss and insomnia. They have also an excess of guilt. Small stirrings of hypochondriasis have occurred before. In childhood they were weak and sickly and in adult life pallid inhibitors of anger, low in self-esteem. Even prior to the phobia they evidenced a prophylactic attitude with fixation upon vitamins and patent medicines. The carefulness is seen also in the trend towards less accident proneness and fewer attempts at sui~ide. They are more often the youngest sibling. From overprotection and excessive babying and from the kindling evidence of much disease and death among their loved ones, they are well schooled in the lesson of a personal vulnerability. With anxiety and its bodily turbulence added to the ferment, background disquiet becomes active disease phobia. Not only is there more bodily disequilibrium, but also, accepting the experimental pain and sensation findings, there is less tolerance of it and a lower threshold even for non-painful sensations. These patients augment bodily "dis-eases" and sensitised to these messages, fear their import. ~is,~se conviction springs from the mire of a hopeless depression. hs with disease phobia these patients have been witness to much family illn~ss and have more likely been babied. They tolerate experimental pain poorly and have a low sensation threshold resembling the disease pho~ics in this way too. In contrast the basic ~ood is depressive rather than anxious. One can speculate that disease conviction and disease phobia are related phenomena, the former having its evolution additionally dependent on depression. Ttcir mean age is some 12 years older than the other groups' and they show in consonance with this older age much agitation and resentful su~picion. It is probable that the agitation fosters the low~r pain tolerance. Agitation also appears to be the reason for the lower 130. intelligence test scoring of those disease deluded patients over 60 years of age. The paranoid outlook like the disease conviction itself is a disordered cognition appropriate to the intensity of what is often a psychotic illness. They have the severest form of hypochondriasis and can be conceptualized as having crossed over from "giving-up" to "given-up". A study newly evaluated has shm,m that disease conviction is more likely to occur in depressives whose secretion of 11-0HCS does not suppress with dexamethasone. One wonders if the "given-up" complex has this underlying endocrinological basis or equivalent. The bad prognosis it augurs and the risk of suicide it entails make the recognition of disease conviction most important. So~atic preoccupation is a common precursor of disease phobia and disease conviction and is itself an intermesh of psychogenic pain and other sensations. To disentwine the confusion of this overlap a group of somatically preoccupied patients with neither disease phobia nor disease conviction was studied. The principal vays in which somatic preoccupation illnesses differed fron their controls' were that they had been present longer and had gradu~lly e~erged from a previous pattern of behaviour characterized by analgesic abuse, "unnecessary" operations and occasionally true physical illness. Besides physical illness as a precipitant some had the burden of recent deaths of close relatives. Even prior to their slow illness they were different, being more nervous in childhood and more personality disordered (and of lower social class). As with the other forms of hypochondriasis there was a plentitude of family illness, though not to the extremes of disease phobic and disease conviction families. Diagnoses of non-depressive neuroses were more com.~only made for the somatic preoccupation group. This was mirrored in the surfeit of classical conversional and dissociative symptoms, even without including certain chronic psychogenic pains as such. Anxie:ry, initial insomnia and fatigue were other clinical f~atur~s s~ffered to a greater extent. Depressive mood was not characteristic and the diagnosis of depressive illness was made even less often than it wa~ for the matched controls. The females were more likely to remain troubled and complainin~ 131.

at follow-up than were matched controls. These bodily tormented women of poor prognosis with a life of conversions and dissociations, are what have been called "chronic hysterics" or said to demonstrate "abnormal illness behaviour". This adverse prognosis did not apply to the males. The somatically troubled women had a lower mean haemoglobin, possibly related to the analgesic erosion of gastric mucosa or to menorrhagia. Why the women entered upon a chronic course is uncertain though it may relate to the persisting upset of a "mutilated" body and the relative lack of occupational prophylaxis for women. Chronic iron deficiency and continuing dependence on analgesics may also have jeopardized recovery. The factors derived from the data by principal components dnalysis amplify the preceding commentary. Two disease phobic factors were found, one loaded with items from the formative years that appear to predispose to later disea~e phobia and the other characterized by present anxiety. These were interpreted as "programmed" and "current" augmentation in accord with their influence upon sensation threshold and pain tolerance. Two factors were found that were associated with an adverse prognosis - a disease conviction component and a female psychogenic pain­ somatic preoccupation component. The former had a strong saturation on paranoid feelings and on maternal oversolicitude. This babying item is also one of the programmers of disease phobia. What appears to swing disease phobia over to conviction is a change in mood from fearful but still hopeful anxiety to the pall of a doomed depression. This is more likely to occur if the patient is old. The female factor is a 'life-in­ ill-health' constellation representative of a syndrome well-known but little described. Much family illness and low sensation threshold both have moderate saturations on it. The remembrance of much family illness appears to be an important inducer of all forms of hypochondriasis and psychogenic pain. Anxiety is another. Both anxiety and excessive family illness have strong associations with an experimental measure of sensitivity to sensory stimuli. In turn this low sensation threshold typifies the psychogenic pain and hypuchonJriacal syndromes thus completing the circle. 132,

CODA

The goal of this research has been to bring clarity to the concept of hypochondriasis. The value of analysing the associations of its subcategories has been demonstrated. For subvarieties to be members of a larger class it is necessary that they have some things in com.~on. Importa~tly it has been shown that differences also are likely to exist, in the realms of aetiology and prognosis.

Evidence has been provided for logical and clinically meaningful linkages between nature of upbringing, personality traits, symptomatology and experimental characteristics of patients with hypochrondriasis and psychogenic pain. This is the type of synthesis that psychiatry has been wont to neglect.

Grinker et al. (1968) observed that we are in "an era when clinical diagnoses and classifications are derogated, diagnostic skills atrophying and the life-history of psychiatric entities of no great concern.'' When these interests were more esteemed, computers and the appropriate programs that can put order into masses of observations were not available.

These old e~thusiasrns are renascent. It is to be hoped that the improve~ents in co~puterized classificatory tactics in union with clinical wisdo~ will foster the continued emergence of hypochondriasis and other unclear syndromes from obscurity. 133.

APPENDICES.

APPENDIX 1.

CASE HISTORIES.

The 18 case histories that follow are provided to demonstrate methodology and to illustrate particular points. After the patient's classificatory nu~ber are his scores on psychogenic pain (PP), so~atic preoccupation (SP), disease phobia (DP) and disease conviction (DC). The range for each variable is from Oto 3.

(a) Classification PSYCHOG~IC PAIN. PAT r.nrr NO. 92. PP SP DP DC 1 0 0 0

Michelle is a histrionic girl of 18 years suffering an identity crisis. For two years she has been making overtures to death and the present ad~ission was the result of a barbiturate overdose. Some of her coITu-nents about death include "I've always wanted to die - to die spectacularly. I just like the idea of dying honourably". The thought of killing herself had an obsessional quality, "Once it gets in there, it takes root". As a child she had anxieties, fears, and sleep walking and was sent to a rest home. Her father, a carpenter, left home when the patient was 8 years old. The patient hates the idea of growing "old" and feels that she looks repulsive and unattractive. She indulged in hate sessions against boys, "Sexually I'd like to think nothing". During the two years of her acting-out behaviour she had been having many disputes with her boyfriend about sex and marriage. Her mother was coaxing her into marrying this boy. She had been having "earaches" since the age of 12 years and these were increasing in severity. From the time of going to work at the age of 16 years headaches had been an added complaint. "My head feels like a pressure cooker about to explode. It starts off across the top of the heai and the head feels as if it is lifting off and then I get a headache across my eyes''. The headache lasted only two hours a day and did not occur at ~eekends. It was of the typical muscle-tension variety and her mother had similar headaches. The patient was prone to develop conversion reactions on distress and these conversions included paralysis

of the arms, dist~~bance of vision so that everything became a white haze 1~4.

and the patient could not see, and feelings as if the face was paralysed down both sides. As an example of the connection between anxiety and visual conversion is her statement "When I get upset I can't see properly". In addition to the loads of work, sex and growing "old" there was the death of her grandmother from colonic carcinoma, 10 months before this admission. The grandmother was Jewish and the patient, in her search for an identity, had wanted to go to Israel and fight in its defence. In fact she ascribed her current overdose to being prevented from going. One year later, disentangled from men, she was doing well at nursing having topped a first year course. She happily occupied her leisure ti~e with swimming, walking, painting and contemplation. The social worker seeing her at follow-up thought she had a normal personality.

PATIENT NO. 99 . pp SP DP DC 1 0 0 0 Ashley is a popular but fragile 36 year old chauffeur with a ready grin and tearful eyes, diagnostically a classic example of neurotic depression in a dependent personality. His needs for security have been poorly met. He was farmed out by his parents at about the age of 9 years, his mother being prone to recurrent depressions and drinking episodes and his father being in the army's employ. He was an only child. His fiance'e was killed in a car accident when he was 18 years old. His mother died when the patient was 31 years, after being bedridden for 4 years, which was the occasion of one of his several depressive episodes. He married Kate, his second girlfriend, 3 years ago and moved to Sydney from a co:n.rnum;ealth job in Canberra in what was a pleasant package deal of Kate, mother-in-law and home, but he was acquiring new problems. Kate developed severe renal failure (chronic analgesic nephropathy) and then his mother-in-law, from whom he had obtained much needed affection and support died. His mai.n sy:nptoms were sadness, irritability, poor sleep, loss of weight, heavy drinking and constant headaches. He was working long hours and had beco~e quarrelsome with passengers. Beginning to brood about suicide he had rifles loaded for use but instead took about 10 pentobarbitone pills and was admitted to hospital.

Th~ heacache began just after •·1-,um" died. (Mu:n = mother-in-law). 135.

It had a circu::iferential hat-band distribution. It was "a dull ache, not a real headache in the proper sense. It's there practically all the time like a one-pitched headache. ~hen it worsens it comes to a higher pitch. It's continuous and nagging. It's worse at night when I'm not doing anything, for example lying in bed or watching television''. The pain became very much worse after his wife died. Analgesics were of no use though contentment and amitriptyline helped. In the two year follow-up period Ashley had several minor recurrences but remained well for most of the time on a maintenance dose of antidepressant. Eventually he went back to Canberra to live with his father. His few pleasures are keeping an excellent stamp collection and having a few beers after work with his boss.

PATIENT NO. 190. pp SP DP DC 2 0 0 0

Miss H. is aged 61, very thin but a "strong" woman. She is meticulous, repressive and masochistic. She was a saleswoman before her colostomy for carcinoraa of the bowel, nine years ago. She calls herself "i-1iss" but was married for five years. Her "playboy" husband, "skipped off" when she was 35 years old. She lives with her younger brother and looks after a niece's children. The nominal reason for hospital admission was a urinary infection. During her stay on the medical ward she developed a right-sided tightness of the chest which g~adually evolved to a peri-thoracic tightness. The E.C.G. was negative and the chest x-rays nonnal. For six to t;:elve months she had felt "run-down" suffering impaired concentration and a down-in-the-~umps feeling, worse in the morning. She had lost 10 pounds weight in three months, was tearful and slept poorly. In addition to the chest tightness there was pain in the face. She discussed the pain thus, "Like a throbbing, like a bad tooth. I had the tooth drawn and it was solid as any tooth. I put it down to tiredness. I used to get very tired by night-ti::'e". The tooth had been removed five months before admission. The facial pain lasted several hours each day and occurred for a few days each 1:eek. ''l..'orry over the kiddies would make it worse. If it looked like rain it 1,;ould co:ne upon me. It was worse when I was tired". The pain was relieved by analgesics and helped by heat, rest on a pillow and contentment. 136.

During her courtship of three years she suffered from abdominal pains and, at the age of 29 years, had an appendicectomy. Her father, a grazier with 1100 acres, was an alcoholic and he died as a result of liver damage when the patient was aged 28. Her mother spent seven years in bed with a broken hip. The patient did all the nursing and was 41 years of age before her mother died. Her personal confrontation with illness came in the form of a colosto:-ay which she says was for "a germ in the bowel". She was a very thin and weak wowan but there appeared to be no recurrence of the carcino:na. Treatment was with amitriptyline, 150 mg. per day. The facial pain left her upon ad:nission to hospital. The tearfulness and sad feeling ended after five days on the drug but the lethargy took two weeks to resolve. Her weight crept up above five stone and she was discharged after three weeks in hospital. This favourable response continued until she stopped taking the tablets. Her abundant energy ebbed and the facial pain recurred after one month of no medication but fatigue and pain disappeared on resumption of the antidepressant.

PAT IE!\i' NO . 304. pp SP DP DC 2 0 0 0

Peter is a 21 year old mechanic, newly married. He is taciturn, non-assertive and a "painter of rosy pictures". His complaint is epigastric pain. He staunchly denies any psychiatric symptomatology. The only addition~l symptoms include occasional nausea and loss of potency when in pain. The pain is mid line, nearer the umbilicus than the epigastrium. In his words it is "hot and burning. It feels like when you pour water on a hot plate on a stove and it fizzes. It is nauseating. The stomach feels as if it is full of co:npressed hot air. Worry makes the pain worse, for example having a ''blue". At first eating seemed to ease it, but nothing in the last twelve months has helped. When it first started, talking to people was a help. A cold glass of drink eases it while it is going down - it takes the heat out of it fo!" a minute or two. Sleep also stops it". The pain began shortly after the patient's 17th birthday (January, 1964). This was an occasion of some parental disharmony and as well his grand~~ther was dying of cancer. On the 2nd September, 1966 a cholecystecto:r,y was performed. Following this operation he was free of pain 137.

for three to six months but since May, 1967 he has had no relief. On 28th June, 1967 a laparotomy was performed and the pain was relieved ~bile the patient was in hospital. This was for 10\ weeks but the pain recurred as soon as he left hospital. The present admission in February, 1968 was under a gastroenterologist who referred the patient to a psychiatrist. At interview the patient was unusually free of symptoms but a record of much family illness was obtained. "There's a lot of cancer on Mum's side". He was very close to his mother and depended on her. (As she put it - he was "keen'' on her). His mother had "blood pressure" and "kidney trouble" and with each of her three children had a post partum haemorrhage allegedly due to fibroids. She had a hysterectomy at the age of 29 years and there is some mention of a malignancy of the womb. Prier to the patient's birth she had had a stillborn girl and was most concerned about the patient's birth in case something similar should happen. His father was an unpopular figure in the family and appeared to serv~ as a scapegoat. He was a nervy type with high blood pressure and ulcers and had been off work for 12 months because of his ulcer troubles. The patient remarked that his father's pain was in the same place as his own. Father, according to the patient was "determined, soft-hearted, thinks everyone is against him, sulky, doesn't say much". He is reputed to have had a mental illness at the age of 19 years. The patient's elder brother had a tumour of the testis and has since died. At the time of the interview the patient did not talk much about his brother's illness but a letter from the patient's wife subsequently revealed that this was a major source of concern, "Peter has had a lot of sadness over the past eight months as his brother died of cancer after a long illness". His young sister is reputedly "a bit anaemic". The patient's birth was full-term and he weighed eight pounds, six ounces. He was a cranky baby till four years of age. He would always wake up with a stomach full of wind and would cry until relieved. The main trouble appears to have been with feeding. He could never take cow's milk, orange juice or bananas. Even now he is fussy about his food. He had his tonsils out at the age of five years, and from the age of four years till eight years suffered from abdominal pains and, eventually, his appendix was removed. He was mildly school phobic but did we 11 at school. The family is said to have been a close-knit matriarchy with father excluded and denigrated. 138.

Despite his general denial of a psychological basis for the pain he did note that it becawe worse when he was upset and that the ti~es and situations which evoked it were when anyone close to him became sick or if he began a task which he could not finish. His family observed that he never co:nplained of the pain unless asked directly about it, but that nevertheless he did appear to expect to be asked about it. He refused to allow the pain to stop hi~ doing anything. Both his wife and his mother described him as a perfectionist. A leading interest was cars and most of his working time and spare time was spent upon the~. He worried intenninably that his car might break down. A situation which upsets him greatly is if he is given a job to do at the garage and is shifted to another job before the first job is finished; he also gets upset if bustled. Operations do not worry him and his mother says that he was never nervous about any surgical procedures and was in fact insistent that they be done. The pain has caused him to lose eight months work in four years. For a few months after discharge the pain was quieter under the influence of diazepan but with the downhill course of his older brother the pain increased again. On learning that his doctor felt it was a case of nerves the patient said "If it is those, I can it myself".

(b) Classification SO:1ATIC PREOCCUPATION.

PATIEKT ~O. 134. pp SP DP DC 3 2 0 0

Audrey is a sad, wrinkled matron of 34 years for whom bodily pain has become a way of life. She is dependent on analgesics and barbiturates. She has been married for 15 years and has two daughters aged 14 years and 7 yN1rs. To make up for her own unfilfulment she sets a very high standard for th~m. The elder child is anxious and obsessional like her mother. The husband is a young-faced toolmaker who to his wife's chagrin dotes on his mother. They all live unhappily in a pleasant house on the western out­ skirts of Sydney. She is a uasochistic martyr, very sensitive to hurts and slights, feeling that people are against her all tte time. She is the eldest of three siblings and has always borne responsibilities avidly. She was not nervous as a child and did well at school. When aged 14 years and after one year of abdominal pains, her appendix was removed. Next she had 139.

rheumatic fever. Even while sick she has thrown herself with vigour into co~~unity activities. She is one of those tormented people who like smoking but hate dirty ashtrays. Her obsessional personality persuades her to run a sterile house. In her younger days she had a craze for dancing, jazz­ waltzing six nights of the week. Her father was a happy dairy farmer until coming to the city for the sake of the children. He provided her with the support that her husband did not and protected her fro~ the rejection of in-laws. For ten years, until his death two years ago, the patient lived in fear of his sudden demise from heart disease. The doctor had made her the sole repository of the expectation that her father would die an early death. Her mother is still alive, two years after an operation for breast carcinoma. Her husband has a chronic skin disease and the children get bronchitis. This illness could be called hysterical neurosis in an obsessional personality. During her courtship she had frequent di£sociative episodes. She sees herself as being unwell since the day of her marriage, and for eight years the pain in her body has mirrored the perceived hostility of the environment. The death of her father made her grieve tremendously. She lost two stone in weight, suffered menorrhagia and then a hysterectomy (also three curettages in the past). She hated this operation because it put an end to the chances of having a premium son. Since then the pain has become even more a full time concern. She has developed pains in the neck, chest and back and also a pain down the left ann like her father had. (She happens to be left handed). Her main pain is a constant burning in the abdomen which never stops. Worry makes it worse and nothing but contentment helps. A barium meal was normal and the suspicion arose that she might have pancreatitis. On holidays early this year all the pains vanished as did sexual disinterest. On the holiday she had no in-laws to worry about and was able to receive the co:nplete devotion of her husband. However on return to the same noxious environ~ent, everything began again, including pain. She was referred to a gastroenterologist for investigation of possible pancreatitis. Tests of p3.,icreatic function \,·ere normal, urinary porphyrins were not detected and the barium meal revealed no abnormality. There was no evidence of duodenal ulceration past or present. She was referred for a psychiatric opinion. She was plaintive, self-pitying and played the brave invalid role. 140.

She co~plained of loss of energy a~d had an obsessive preoccupation with physical sy7:1ptoms. It seemed that secondary gains were paramount. She blamed things on her husband - he neglected her and danced attention on his mother, he was no lo~ger interested in her as confidante or lover, he refused to adopt a boy, he begrudged the children a good education. She was critical of everyone including doctors. A few months before an orthopaedic surgeon prescribed indocid and cortisone for the back pains. He and other doctors were blasted for not telling what the x-rays showed. She was sad and tearful, becoming more doleful as the day pro­ gressed. Food disgusted her and she had lost weight. There was difficulty in getting off to sleep and she woke too early. There were head and back pains. She expressec no guilt. There were self-destructive urges of the revenge-seeking kind, for example, she said that if she were ever driven to kill herself, she would also kill the children became she could not leave them with such a husband and relations. She had high scores on obsessionality and neuroticism. Object losses, actual, threatened and imagined have dominated this woman's life. ~hey include her father's angina and then his death, her mother's car.t.:inoma of the breast, the "stealing" of her husband by his mother 2nd the supposed serious lung disease of her children and their corruption by a rapacious world. In the two year follow-up period the patient did poorly. She had admissions for depression, took a barbiturate overdose, had the same abdominal pain and new pains in the teeth and gums. Her husband and elder daughter had left home and gone to his mother.

PATIEXf NO. 14 7. pp SP DP DC 2 1 0 0

Mrs. I. is a very fat dependent and unhappy woman of 35 years. She takes a lot of bromides and sees many doctors. She is a little dull and has four children to a de facto husband. Her ycu'1ger brother wai, killed by "a bullet in the brain" while serving in Korea and since this ti::-,e the patient has had several operations, many conversion reactions and continual bodily preoccupation. An idea of some of the problems that beset her is provided by remarks made on admis~ion "I just feel that I don't want to live at all. I have no interest in goi!1g places. I'm tired, my head hurts. I have had a lot of stomach operations, tests, diets. My husband has been belting me up. I seem to get nasty for nothing. I find I'm forgetting a lot. I'm not a woman since I had the hysterecto:ny. 1-1y husband has been having an affair with my sister". Current symptons of the body included right iliac fossa pain; the latter had been present for three years and felt like "a bearing down pain, it seems like when the head of a baby is engaged''. Headaches had been present for some eight years. A previous conversion reaction was a pseudocyesis to seven months of apparent pregnancy at the age of 19 years. At 29 years of age she had an episode involving paralysis of the left arm and leg and on another cccasion was comatose for one week, the latter possibly partly due to bromides and barbiturates. Her operative history began with tonsillectomy at the age of 10 years followed by appendicectomy two years later. (For three years she had been going back and forth to hospital because of aLdominal pain). She had various gynaecological operations in her mid-twenties including an emergency caesarian, tubal ligation and finally at age 30 years a hysterectomy. In the two year follow-up period the patient continued to take bromides and had several minor overdoses. She was admitted to a mental hospital several times, headaches continued and she was on capsules for arthritic pain. The swing away from the conversion symptomatology of earlier days to depression was consolidated.

PAT ID,'T NO. 209. pp SP DP DC 3 3 0 0

Mick is a 21 year old carpenter who came to Australia from Finland when he was 11 years old. He is the third of six siblings and all are worshippers of physical fitness. Mick lived entirely for sport and in particular, boxing, car racing and football. He had high hopes of being the Australian middle-weight champion. He was a veritable "Hr. Atlas", in desire if not physique. He was referred from the rehabilitation department one year after an accident in which falling wood had struck his neck and shoulders. He had pain in the neck, back, shoulders, arms, legs and chest. His hands remained paralysed for some time after the accident and he turned south-paw, still vainly hoping to be fit for the state championships he had decided to 142.

contest. His I.Q. was estimated as about 80 with a very poor verbal ability. During methedrine abreaction spasms developed and later weakness down the left side. He showed resentment at being responsible for much of the family's financial support. Unrealistically he had contracted to buy a $9,000 Alfa Romeo. He was hostile to the notion that any of his symptoms could have a psychogenic origin and he did poorly in hospital; at six months follow-up he was somewhat better but having pain in the shoulders and neck. He was still attempting to train for football and boxing, but because he could not manage the gears on his sports car, was intending to buy a speed boat. He had been in hospital for four weeks and had his neck in plaster for four months, following a car accident. Continuance of the sick role was favoured by his vulnerable "Mr. Atlas" personality and low intelligence. Identification may also have played some part in the perpetuation of his symptomatology. A close male friend (the patient has no time for women in his training program) had suffered an accident about six months before the patient's and this friend had a similar symptom pattern.

(c) Classification DISEASE PHOBIA.

PATIENT NO. 104. pp SP DP DC 0 1 1 0

Lionel is a disillusioned self-depreciating 50 year old ex-company director. He is Jewish and describes h.is mother, who died when the patient was 38 years old from a heart disease, as "soft,angelic and marvellous". He is the fifth in a family of six children and is the youngest son. He describes his father, still alive at 85 years, as "obstinate, determined, strong, wonderful in his own way". As a child he hated school and loved being with his mother. He reports that he rode on his father's back in business and was content to stay "small and safe". Several very close uncles had died frora carcinoma of the bowel when in their mid-fifties and as he was approaching that age, he brooded upon his own possibilities of developing cancer. This phobia concerning cancer intruded even more when pain secondary to diverticulitis occurred. Ever since the age of 23 years when he had a thyroidectomy for thyrotoxicosis he has been bodily preoccupied and often depressed. Palpitations have been a frequent symptom and he has attended doctors for 143.

the reassurance of innu~erable electrocardiographs. At bed-time he often fears he will not wake up in the morning. His mother, to whom he was extremely attached and who over-protected him, had many ischaemic heart attacks before succu~bing to her final one. At the time of ad~ission the predominant disease phobia was concerning the heart. An endogenous element had entered the depressive picture. He berated himself in tenns such as "I'm a disgrace, I should get out and try to help myself. My wife is forty times stronger than I am. She deserves better. I'm inadequate, stupid and have let my family down. It's only my own fault". He suffered from a lot of anxiety, remarking that he was constantly worried for no reason and that he very much feared what might happen. He was essentially a disappointed man with many regrets. One of his daughters also suffered from depression and involved herself in hetero­ sexual sadistic and then quieter lesbian relationships. She summed up her father's personality when in front of many bus passengers on a tour of Europe she abused him as "an impotent little prick". Another regret was that he sold his share in a company managed by his father. He left it because he resented his subservience but found, on resignation, that he could not cope with business on his own. The endogenous element cleared in hospital after treatment with imipramine. Two years after discharge his psychiatrist described him as "up and down. Still essentially anxious and self-depreciatory. No evidence of endogeaous depression. Just chronic asthenia".

PATIE?\'T NO. 140. pp SP DP DC 0 1 3 1

David is a friendless, part-time engineering student of 22 years, the second and youngest son of stern, Baptist parents. He is a mother's boy and strongly resents the two other males in the family. His personality is shy, obsessional and i:1'llature dependent. His father is strongly obsessional with such puritanical views that masturbation is bad that he would tiptoe to the bathroom to detect his son's indulgence. His very anxious mother often \.."arr,ed him that im.'llorality leads to "erosive" syphilis (she had once as a sales girl served a customer with ugly skin lesions and had been told it was syphilis).

The principal symptom was a consuming fear that he had syphilis. 144.

He was alanned that insanity and tabes would follow and guilty that he was passing genus on to other people. This fear began at the age of 12 years when he developed a skin rash. He imagined that he caught it in the bath from his brother, a libertine. The patient had a habit of sucking the bath flannel. He fancied that his brother's masturbated ejaculate, con­ taining treponemes, was transmitted on the flannel to his pharynx. At times he was able to point to white patches in the tonsillar area which he dreaded might be a healed chancre. The fear remained at a tolerable level for six years from when he was 12 years old but he then attended a prostitute and as an aftennath the phobia took stronger hold. Ever since he has chased after blood tests for syphilis, and has had something like 50 to 100 and managed to obtain several courses of penicillin. He would consult all the medical text books in the university library and each increase in partly understood knowledge heightened the phobia. He was exceedingly tense and jittery and occasionally so miserable that he came near to suicide. During hospital admission he was prone to sexual acting-out and heavy drinking. Other symptoms included impaired concentration, minor obsessions and folie de doute. As a child he was stable, placid and quiet, although when aroused, nervous. He had an episode of cancerophobia at the age of 11 years upon observing his mammary nodules. The enduring memories of his childhood involve his mother telling him that people shun you if you get syphilis and his father saying that masturbation produces madness. Another recollection was that his mother loved to fondle and comb his hair "She bestowed a lot of attention on me when I was good". Childhood illnesses included hay fever and hives. Treatment was by supportive psychotherapy with maintenance diazepam and fluphenazine. Three years after the index admission he is coping well at university, although intennittently experiencing return of the phobia. He is a lonely person and continues to need the support of a psychiatrist, and of a dennatologist-venereologist.

PATIENT NO. 178. pp SP DP DC 1 0 2 0

Tom is a 35 year old single clerk, a thwarted pilot. He is a younger son, engaged to a professional woman, but devoted to his mother. His complaints of lack of concentration and headaches have been present for 12 to 18 months. Tom's principal fear was that he had a brai~ tumour. He s~ated "I don't have any medical reasons to support it. The 145.

fears arise from hereditary brain tumours in the family, my mother's sister and one other relative. My sister died at 43 from something to do with her head. Every time I start getting a headache and I can't concentrate I get this strong thought that I have a brain tumour. Before 12 months ago I was very lucid". Anxiety and depression were both present, but anxiety was pre­ dominant. In addition he noced that he had become irritable, socially anxious and circumlocutory. He had lost one stone in weight in the two months before admission. Prior to the illness he was anxiety-prone and believed in taking vitamins as a dietary supplement. At the age of 15 years, after about three months of abdominal pains, his appendix had been removed. Depression followed an attack of hepatitis when he was 25 years old and lasted one year. He suffered two haematemeses probably related to an excessive intake of aspirin and ever since has had an unstable job record, a mixed consequence of ) poor concentration and unfulfilled ambition. The engagemenc of 18 months has been hard for him to manage. His fiancee's professional superiority highlights his own inadequacies. The impending marriage precipitated the request for psychiatric assistance. The E.E.G. and x-rays of chest and skull were normal. Bromide was not detected in the blood. Treatment was with amitriptyline 150 mg. per day and thioridazine 100 mg. per day. He was discharged after three weeks with no depression, minimal anxiety and no disease phobia. He married a few months later and has remained well for the follow-up period of two years. His wife was admitted recently suffering from schizophrenia.

PATIE}.'T NO. 189. pp SP DP DC 2 0 1 0

Catherine is a fragile 20 year old and was admitted because of attempts at suicide. She had been buffeted by the deaths of parents and loved ones, as well as by personal illness. Childhood ills included asthma, pneumonia, and rheumatic fever. Her mother, whom she characterized as timid, gentle and prudish, died from leukaemia when the patient was 16 years old. Two years later, her father, who had always been troubled by asthma, ulcers and e:nphysema, died from cancer which had "riddled his liver". The desertion beca~e complete when her only sibling, an elder brother, went to Brisbane. Cath~rine then lived with a close girl friend and she came to regard this girl's parents as her own. Fi-Je months ago this foster mother 146.

died from a brain tumour. In the new period of bereavement, she has become sexually interested in her girlfriend and this has added guilt to the depression. She cut her wrists and was admitted to hospital feeling lost, depressed and insecure. Tiredness was a principal physical symptom and she often feared that it signified leukaemia. Anxiety and irritability predominated over depression. For severe dysmenorrhoea, "sequens" was prescribed. Her sensitivity and overeaction to uterine pain were in accord with a very low tolerance of electrical pain. At 35 volts, a mere tickle for most patients, the patient reacted dramatically and would not continue the assessment. In the two year follow-up period she was depressed and anxious from time to time. The disease phobia had passed and she was pressing on successfully in journalism.

(d) Classification DISEASE CONVICTION

PATIENT NO. 124. pp SP DP DC 1 0 0 2

Marie was a 26 year old hospital laundress, married with a boy of three years. Following his birth, she had a depressive illness during which she was suicidal and required E.C.T. During that episode she kept thinking she was bleeding to death. She was the sixth child in a working class family of 10 children, was educated to the age of 14 years following which she worked in a textile factory. As a child she did not mix very well but for some reason was the favourite of her mother and stepfather. Her father had died when she was only four years old with a heart attack. Her mother also died from a heart condition and the patient then aged 17 years became enuretic for two weeks. She married at the age of 22 years and migrated to Australia from Northern Ireland 18 w.onths prior to the present illness. At the time of her admission, her illness had been present for one to two months. It started with disinterest in work and loss of love for her family. Anxiety and depression were prominent, and once she thought of taking an overdose of tablets. She suffered from the delusion that a cockroach was eating out her brain. After this delusion had faded, she explained its origin. "I had long hair and whenever we started to talk about cockroaches I worried because I wear hair spray and I thought they 147.

would go for the hair spray. The hair grips were hurting and I thought it was a cockroach right inside my head. I kept worrying about that all the time. I thought it was eating away the top of my brain, I thought it would kill me". Concurrently, she experienced pain and paraesthesiae over the occiput and vertex. ~ear the beginning of the illness the girls at work had gossiped about cockroaches being attracted to hair spray and also about this time her sister had suffered a fractured skull. Response to amitriptyline 150mg. per day was poor and a course of E.C.T. became necessary. At six months follow-up she was well except for worrying easily. PATIEXf NO. 216. PP SP DP DC 3 3 0 1 Ludwig is a 50 year old German-born toolmaker, married with two children. He had been living in Australia for 14 years. He describes his well self as ''always happy, I make jokes, sing songs, evPrybody knows me in the German Clubs", but according to his wife, he has always been stubborn, egocentric and moody. He had been a champion cyclist in Germany and kept up with sports until an accident in 1962. He was the youngest son of nine children and the family's pet. Two brothers were killed during the war and the patient served as a paratrooper in numerous, dangerous areas including Africa, Russia, Crete, Monte Cassino. In 1962 while lifting something heavy he stumbled bumping his head. Headaches ensued for six months followed by "collapse". He developed a hernia and had an operation for this but could not get the compensation claim settled. He has never been well since and has developed widespread pains. The main complaint was of high-pitched noises in the head which he assumed came from the spine. He was convinced that his nervous system was damaged. His sex life stopped and he ascribed this also to some damage, "maybe to the brain, maybe to the nerve centre in the back which affects the brain". He had been unable to work regularly since 1962 and his symptoms were resistant to treatment. He spent two months in the Psychiatric Unit a year previously, improved, but relapsed soon after discharge. He was in constant correspondence with the Minister fer Immigration about his "case" and intended writing a book about it. He felt particularly aggrieved with a certain co~p~nsation officer and mentioned in passing "sometimes I'd like 148.

to ki 11 sor:1ebody''. At six month follow-up he was still complaining of noises in the head and of back pain although there was some slight improvement which allowed him to sit watching television for two hours instead of only a few minutes. He was doing little except an odd bit of woodwork. He visited a psychiatrist every two months and a chiropractor every week.

PATIEXT NO. 226. pp SP DP DC 0 0 1 1

Mr. B. is a 64 year old storeman, widowed for 18 months. He had one daughter but lived alone. In 1958 he had a myocardial infarct and there­ upon developed bodily introspection which has persisted. In particular an old concern about bowel regularity increased. Following his wife's death from renal failure, he continued to work, living alone in the house, but after about six to nine months of housework and feeling lonely, he developed depression and dry vomiting. His appetite fell off and he became severely constipated. He became convinced that he had cancer of the bowel "I've got the feeling in my head I'm not going to get right. I've been sick so long, I can't eat. My stomach resists all food. It's a growth". While in the medical ward for investigation of the intractable vomiting, he became actively suicidal and was found in the lavatory with a cord around his throat. This attempt was made after being told he was to see a psychiatrist. He slept only from 10 p.m. to midnight and had lost over a stone in weight. Dismissing the diagnosis of hiatus hernia, he held adamantly to the belief that he had a cancer. His wife's sister to whom he was close had died with a cancer "down below" and his father had had an illness requiring E.C.T. He was given both amitriptyline and E.C.T. but made only a slow improvement and at one year follow-up remained depressed and suicidal. Retardation became so severe on one occasion that he was mute.

(e) Classification DISEASE CONVICTION but also exhibiting psychogenic pain, somatic preoccupation and disease phobia. PATIEXT NO. 27. pp SP DP DC 1 2 1 1

Bernard is a neurasthenic. He co~ld easily have been Omar 149.

Khayyam's vessel - •~fter a momentary silence spake Some vessel of a nore ungainly make; Men sneer at me for leaning all awry; What! Did the hand then of the potter shake?"

He was mentally dull and suffered from Klinefelter's syndrome. He had been on an invalid pension for 50 years since the age of 16 years and had been a devotee of institutions and recipient of charity. Treatment with male hor::iones made him aggressive and assertive. This brought him into disrepute with other inhabitants of the home run by the Little Sisters of the Poor and he came to hospital complaining that he was depressed and tired of life. Remarks of a suicidal nature on admission included "Windows seem to draw me - tablets I cannot help swallowing them - I want a long sleep". He had made two attempts at suicide in the previous three months. All his life he had been nervous and fearful and his current fears involved fear of strangers and disease phobia. The phobia had recently increased in intensity and obduracy and deserved the label of disease conviction. The fears had been present for some 18 years and this is how he relates the story. "One night I was lying in bed and I just felt this lump on the stomach (in fact a bladder diverticulum). At Katoomba in 1945 my doctor said "You're lucky it goes down". I thought it might have been a cancer. All along this thought has been wi.th me, it never leaves me. The thought or the lump. How are we going to prove it? The only thing to do is to open it up and have a look. I'd rather have an operation anytime than a bottle of medicine. Since the depression two years ago the fear has become much worse. I am sure it's a cancer. My father died of cancer of the throat and his four brothers did". He suffered pains nearly everywhere in his body from time to time, including the legs, feet, neck, jaw and hands. His present pains were a headache which he described as "a tingling headache across the top of the forehead and sometimes at the back of the eyes". In addition he had a pressing feeling across the top of the head. The pains had been present for 40 years and he related how "mother also gets the same headaches all her life. I identify with my mother - just like her, when I get near the door of a train I want to ju:r.p out too". 150.

There was a strong family history of personality disorder, much violence being exhibited by his father and siblings. The patient's only conflict with the law was at the age of 18 years when he was sent to prison for housebreaking. From gaol he was shifted to a mental hospital but is amnesic for this event. No doubt however, he did make people feel hostile and antagonistic. He remembered clearly one day in 1932 "My brother-in-law called me an imbecile bastard for being on an invalid pension. I cannot wipe it off my mind. I just burst into tears when I think of it". His childhood was harsh and deprived and for three years from the age of seven he was in a state home. His mother was ill and when the patient was eight years old his father deserted the family. While in the boy's home he reports that he was punished severely and recalls one warder rubbing salt into his flayed back. He was enuretic until the age of 14 years and stuttered until then. He could not read or write. He has never worked for more than two weeks. At six months follow-up, depression and anxiety remained. He still felt life was not worth living. He remained frightened of cancer and newly feared that he had a tumour on the brain. Other fears were of the dark and of traffic. People were against him, including the police, informers and the nuns were he was staying.

PATIENI' NO. 111. PP SP DP DC 3 2 1 1

Regina is a 21 year old Chinese university student admitted because of anxiety and confusion. She was the dependent, clinging, youngest child of a large family in which the father had two wives. She was attractive and found many willing people to whom she could cling for interminable "psychotherapy". An extremely devout Roman Catholic, she wanted to become a Carmelite nun and to be a saint. She intimated that she would like Jesus Christ, even as a sexual lover but to have spiritual babies only. "I would like an oven1helming lover even if he were hurtful". She made great mention of an attachrJent to the local priest, whom she claimed had intercourse with her in the confession box. Needless to say the various religious orders were chary of having her in a convent. She complained of many bodily pains, in the head, under the breasts, in the back of the shoulders, right down the spine and in the bones. The bone pain was or.e of her main complaints. She thought the back pain was from cancer "becau::'.! I have it so often. I saw my friend die of cancer and they didn't notice it. I'm looking forward to my death". The friend was a nun who also had headaches. She died from a carcinoma of the kidney before the patient's admission. All the pains had become worse since coming to Australia two years before. She described the pains flamboyantly. Her backache felt "as if a hammer was beating it and like bones being stripped." Her head felt "as if a blank sheet of paper inside it had swollen. It's also like a crown of thorns forced dm-m on the head, feels like a blank, feels like an Easter egg being cracked". Other bodily preoccupations were with indigestion, constipation and dizziness. She was brought up by a maid who was fond of giving vitamin injections. From the age of eight years she suffered bone aches and pains. At 16 years of age her appendix was removed following several months of abdominal pain. A year later she developed a "rheumatic heart". The appendix, the "rheumatic heart" and increase in bone pain began at a time when she was having to prove herself in examinations but was unable to do so. A half-brother, also in Australia, had an obsessional neurosis. Hospitalization did not improve her condition; since returning to Hong Kong she has been able to do some teaching.

PATIENT NO. 127. pp SP DP DC 3 3 1 3

Constance is an example of disastrous widowhood. When she was 51 years old her husband died suddenly from a heart attack. For 12 months she scarcely left the house. Prior to this she had been a cheerful woman, close to her husband and two daughters and not preoccupied with bodily aches and pains. The only exception was an episode of "sciatica" at the age of 35 years when the pains lasted nine months and she received 11 injections of cocaine and later some . Bereavement lasted 12 months and at the end of this period to improve her appearance she had varicose veins ligated and stripped. She then took up dancing lessons and became an expert dancer. Her professional partner, a man 10 ye2rs younger than herself, became her amour. She had considerable guilt concerning the sexual pa~t of this relationship. Depress­ ion seems to have begun one year before the present admission (five years after her spouse's death) at a tine when her company was no longer attractive to the boyfriend. It first started with at!.acks of "burning head pains" and 152. these were "cured" by chlordiazepoxide. The illness recrudesced after a few months. It is worth quoting her actual words as they exemplify the intensity of bodily preoccupation and disease conviction. "I noticed burning and crackling in both feet under­ neath, and then pain would shoot up behind the legs encircling them and then up into the groin where the vein was stripped and then into the stomach and into the spine. The sto:-:-.ach was rumbling and burning all the while, then there was burning in the pit of the stomach and then a big hot fur ball on the side of the throat and it produced vomiting and nausea. Then the fur ball lodged in the front of the throat, then burning pains down both arms I thought oh, I must be getting arthritis. They burn and quiver. All the stomach seems to cave in and burn and rumble. My throat gurgles all night and I keep vo~iting up mucus. I think that it's an incurable disease, that I will die. In the last few days there's been a ghastly smell from the vagina. I think it must be deterioration there too. It's all a breakdown of muscle. I think it's a burning disease. A month agu I met a man at the hospital and told him my symptoms. He said it was a fatal muscle disease just like he had. He's right, there's no doubt about it. Soon I will die. I'll suffocate in a few weeks". These symptoms waned at night as did the depression. She felt much guilt, both about widowed sex and her mother's death 16 years before. Her mother had taken to drink after her husband's death and while drunk had been hit by a car. The patient felt responsible for letting her mother go unsupervised. She denied any suicidal thoughts and at first interview did not evince many paranoid ideas, although she did feel bitterly resentful towards her doctors. She had lost half a stone in weight in the preceding four months, did not enjoy her food and was sleeping poorly. There was much self pity and blaming of others. She was the only daughter of three children and was extremely spoilt by her mother. All her washing and ironing was done for her up until the age of 19 years. At the age of three months the patient had a vomiting illness which led to what she called a "wasting disease". As a child she was very quiet and rather timid. She had been molested by a stranger when nine years of age. She met her husband at the age of 17 years and after an eight-year courtship, had what she calls a perfect marriage. At 30 years an ovarian cyst was removed and at 35 years the prolonged attack of sciatica occurred. 153.

Her father, a pastrycook, died of cancer when she was in her late thirties. She recollects hin as a very good man. A year later her mother also died and 10 years later her final support died, her husband. In her words "I never had a day's trouble when I had my husband. If he was still alive, I wouldn't be like this''. E.C.T. was advised but the patient refused it and was treated with imipramine 250mg. per day. A ::aarked improvement occurred after two weeks, the various bodily sympto~s disappeared and she stopped complaining. To everyone's surprise, she dro;med herself a few months later.

PATIEi'-."T NO. 160. pp SP DP DC 2 l l 2

Mrs. R. is a 41 year old housewife from a western suburb of Sydney. Her father had died following a bladder infection which produced septicaemia. A week or two later in her own words "I seemed gradually to go to pieces. I was very close to my father. I've got no fluid in my mouth or eyes or anywhere. I'm very de:i:,ressed, tired and weak. My health is shocking. I can't go to sleep or eat. Hy eyes are dry. I'm losing weight. I can't keep it up any longer. I feel dreadful". The illness had been present for only six weeks before admission. She was full of self-pity, very anxious and agitated. The patient complained of pains under the left breast and across the front of the head, of a feeling of creeping and tight skin around the hips and of a fluttery heart which "sounds funny at times". She thought she was going to die and that it was inappropriate for her to be in a psychiatric hospital. "I think it must be physical. The whole body seems to be function­ ing poorly. The glands are upset, the thyroid. I've got no moisture in my eyes, or mouth or nose. I don't think it's a nervous illness, it's too chronic. I will not pull out of it - it must be my blood stream". The patient felt that her blood stream was toxic and said "if it's not toxins, it must be cancer". As a child she reports that she was jittery and a bit "weedy". H~r parents divorced when she was aged six years and she saw her father only every few years. She had one elder brother. She met her husband in the army and was married at the age of 20 years. She de'.::L:ribes the marriage as satisfactory. After two weeks on imipra::iine 20CJrng. a day, the patient had sho•,m 154.

no improve~ent and she left against ~edical advice. She was readmitted a week later and again left pre~aturely. On the third admission a month later E.C.T. was given immediately and after the first three she showed a dramatic improvement in mood and cooperation. At six month follow-up, she was co~pletely well. 155.

APPENDIX II

PSYCHIATRIC I'NTERVIEW

The actual interview form leaves much more space for the recording of a patient's responses. Some of the questions preceding sections are facilitators and are not to be scored.

The J items, boxed in, are dependent on the psychiatrist's judgment rather than only upon the patient's statements.

Except where specified O = no or absent, 2 = yes or definitely present. 3 represents a strongly positive reply or a great amount. A score of 1 indicates some, definitely present but not enough to obtain a rating of 2. (NA= Not applicable).

The questions represent our formulations of items used in the studies of Carney et al. (1965), Grinker et al. (1961), Hamilton and White (1959), Hobson (1953), and Kiloh and Garside (1963). 156.

Date ......

Patient's na.ne ...... Address ......

1. Age (in years) ...... 2. Sex (:nale = }1; female= F) ...... 3. Marital status ...... 4. *Social class ...... (see Congalton's scale) Occupation ...... (if married fe~ale, occupation of spouse ...... ) 5. Nominal religion ...... 6. Are you a religious person? 0 1 2 3 (agnostic, atheist= O; believer in God= l; intennittent practiser= 2; regular devotee= 3) What is it that troubles you? What has happened since you last felt really well? How long did it take to come on?

BJ. Onset of illness ...... (month) (O-24 hours= O; 1-7 days= l; 1-8 wks. = 2; longer ::: 3) 0 1 2 3 9J. Duration of illness ...... (O-1 mths. = O; 1-12 mths. ::: l; 1-3 yrs. = 2; longer= 3) 0 1 2 3 lOJ. Fluctuating course 0 1 2 3

What do you think really caused you to be this way? Was it a single thing? Was it a group cf things mounting up? 11. Is it the load of family and job demands that has led to your becoming ill? 0 1 2 3 (11) 12J. Relation of death of spouse or first degree relative to onset

(none= O; one year= l; one month= 2; one day ::: 3) 0 1 2 3 (12) 13J. Prior physical illness 0 1 2 3 (13) 14J. Other adverse environmental event 0 1 2 3 (14)

15J. Specific psychological significance 0 1 2 3 (15) ll6J. Known lack of ability to cope 0 1 2 3 (16) ~7. *Reactivity score (12 ~ 13 + 14 + 15 + 16) ...... 0 1 2 3 (17) Illness consistent with stress, significance and ability to cope 0 1 2 3 (18) l 9J. Stress perpetuates illness 0 1 2 3 ( 19) 157.

MOOD ~entory of concerns ar.d feelings immediately prior to admission) Tell me about your ~ood recently.

20. Do you have ti~es when you get moody and feel low? 0 1 2 3 (20) 21. Can you laugh at times? 0 1 2 3 (21) 22. Do you feel O?timistic? 0 1 2 3 ( 22) 23. Do you feel ho?eful about getting better? 0 1 2 3 (23) 24. Do you want to cry much of the time? 0 1 2 3 (24) 25. Are your feelings dominated by sadness and 0 1 2 3 (25) blueness? 26. Do you feel helpless and powerless? 0 1 2 3 (26) 27. Do you feel hopeless? 0 1 2 3 (27) 28. Do you feel at the end of your rope? 0 1 2 3 (28) 2 9. Do you feel life is not worth living? 0 1 2 3 (2 9) 30. Have you thought of committing suicide? 0 1 2 3 (30) 31. Have you tried suicide? 0 1 2 3 (31)

32J. Severity of depression 0 1 2 3 (32) 33J. Abnormal quality NA 0 1 2 3 (33) 34J. Depression responsive to situations NA 0 1 2 3 (34) 35J. Depressive delusions including nihilism NA 0 1 2 3 (35)

RETARDATION Has your ability to think and do things changed? 40. Is it difficult to concentrate? 0 1 2 3 (40) 41. Is it difficult to make decisions? 0 1 2 3 (41) 42. Do you feel mixed about important problems? 0 1 2 3 (42) 43. Do you feel unable to do things? 0 1 2 3 (43) 44. Do you feel constantly tired? 0 1 2 3 (44) 45. Have you lost interest in things? 0 1 2 3 (45) 46. How much has this interfered with your work? 0 1 2 3 (46)

47J. Retardation of thought, speech, activity 0 1 2 3 (47) 158.

ANXIETY

Have you been greatly worried lately?

48. Do you feel restless and have to keep moving? 0 1 2 3 (48) 49. Do you feel tense much of the time? 0 1 2 3 (49) 50. Do you often feel jittery? 0 1 2 3 (SO) 51. Are you often worried for no reason? 0 1 2 3 (51) 52. Are you worried by little things? 0 1 2 3 (52) 53. Do you have fears about what might happen? 0 1 2 3 (53) 54. Do you have unreasonable fears about everyday 0 1 2 3 (54) things? 55. Do you get irritable and angry too often? 0 1 2 3 (SS) 56. Are you concerned about getting older and more 0 1 2 3 (56) helpless? 57. Is your worry leading to bodily trouble such as 0 1 2 3 (57) sweats, indigestion, headaches, constipation, diarrhoea,chest or bladder trouble, faints or blackouts?

., 158J. Agitated 0 1 2 .J (58) 59J. Anxious 0 1 2 3 (59) 159.

A;-;"GRY WITH OTHERS Is it unfair that you have become like this? 60. Have you felt somewhat sorry for yourself? 0 1 2 3 ( 60) 61. Have you felt more lonely lately? 0 1 2 3 (61) 62. Are the demands of others becoming a burden to you? 0 1 2 3 ( 62) 63. Do you feel that you are becoming unloved? 0 1 2 3 ( 63) 64. Do you envy others these days? 0 1 2 3 ( 64) 65. Are you bearing up well under the load? 0 1 2 3 (65) 66. If your outside problems were solved would you 0 1 2 3 (66) be well again? 67. Are you concerned over the money you're losing? 0 1 2 3 (67) 68. Has coming to hospital taken a load from you? 0 1 2 3 ( 68) 69. Are others responsible for your illness? 0 1 2 3 (69)

70]. Secondary gains from illness 0 1 2 3 ( 70) 71J. Extent of self pity 0 1 2 3 (71) 72]. Blames others for illness 0 1 2 3 (72)

ANGRY WITH SELF 75. Are you concerned with how your family and 0 1 2 3 (75) friends will be now? 76. Have you caused others to suffer? 0 1 2 3 (76) 77. Do you feel you should have done more for your 0 1 2 3 (77) family or for those at work? 78. Are others beginning to despise you? 0 1 2 3 (78) 79. Have you done wrongs that should be made up to 0 1 2 3 (79) others? 80. Do you feel a failure? 0 1 2 3 ( 80) 81. Have you become a lazy person? 0 1 2 3 ( 81) 82. Are you now often ashamed of yourself? 0 1 2 3 ( 82) 83. Have you felt unworthy lately? 0 1 2 3 (83) 84. Do you think you brought this illness on 0 1 2 3 ( 84) yourself? 85. Is this illness a punishment that you deserve? 0 1 2 3 ( 85) 86. Do you feel full of guilt? 0 1 2 3 ( 86)

r7J. Guilt fee 1.;._ngs 0 1 2 3 ( 87) 160.

HABIT CHAXGES

88. Has your mouth been especially dry lately? 0 1 2 3 ( 88) 89. Have you lost your appetite lately? 0 1 2 3 ( 89) 90. Have you lost interest in sweets, or smokes or 0 1 2 3 ( 90) drinks? 91. Has you weight changed since you became sick? ...... 0 1 2 3 ( 91) (gain= O; no change= l; loss 0-7 lbs. = 2; loss 7+ lbs. = 3) 92. Has your interest in sex changed lately? 0 1 2 3 ( 92) (increase= O; no change= l; loss of interest= 2; extreme loss of interest= 3) 93. Have you becone concerned with this? NA 0 1 2 3 ( 93) (increase only) 94. Do you have difficulty getting off to sleep? 0 1 2 3 ( 94) 95. Do you wake much during the night? 0 1 2 3 ( 95) 96. Do you wake too early in the morning? 0 1 2 3 ( 96) 97. Do your symptoms vary during the day? 0 1 2 3 ( 97) When are they worst? (depression) 98J. Depression worse in a.m. NA 0 1 2 3 ( 98) 99J. Depression worse in p.m. NA 0 1 2 3 ( 99) OTHER SYHPIO>!S Have you any physical complaints?

!100J. Hypochondrias is 0 1 2 3 (100)

Do thoughts come into your mind that you can't easily get rid of?

!101J. Obsessions and compulsions 0 1 2 3 (101)

Have there been any times when parts of your body or your mind have stopped working?

I102J. Hysterical symptoms 0 1 2 3 ( 102) 103. Have you lost your feelings for people nowadays? 0 1 2 3 ( 103) Do things seem unreal?

l04J. Depersonalization, 0 1 2 3 (104)

Do you feel that people have been against you of late?

llOSJ. Paranoid sy::iptoms 0 1 2 3 (105)

l06J - 116J Schizophrenic and organic j udgmer~t items 161.

FAMILY HISTORY Parents Mother Father Age and status Occupation Psychiatric illness Patient's age at death Significant se?aration (list pt's age, duratio~, cause)

119J. *Maternal social class ...... 120J. Poor maternal personality 0 1 2 3 ( 120) 121J. Separation for 3/12 or more from mother 0 1 2 3 (121) (never= 0; 10-14 = l; 5-9 = 2; 0-4 = 3) 122J. *Paternal social class ...... 123J. Poor paternal personality 0 1 2 3 ( 123) 124J. Separation for 3/12 or more from father 0 l 2 3 ( 124) (never= 0; 10-14 = l; 5-9 = 2; 0-4 = 3) 125J. Nature of separation from parent 0 1 2 3 ( 125) (0 = not applicable or, temporary socially approved separation 1 = temporary separation due to marital discord, calamity 2 = permanent separation due to marital discord, calamity 3 = death)

Siblings (include patient in list) Na:ne Sex Psychiatric Illness

Children (mark step or adopted children)

Evidence in family history of: 126J. Depression 0 1 2 3 (126) 127J. Schizophrenia 0 1 2 3 ( 127) 128J. Psychoneurosis 0 1 2 3 ( 128) 129J. Character disorder 0 1 2 3 ( 129) PERSO~AL HISTORY Where were you born? Where did you grow up? 130. Born (Aust. = O; Brit.Cwth. = l; 0 1 2 3 ( 130) Europe= 2; other= 3) 131. Age when first domiciled in Australia 0 1 2 3 (131) (0 yrs. = O; 0-14 yrs. = l; 15-40 yrs. = 2; 41~ yrs. = 3) 162.

What were you li~e as a child? 132J. :;ervous 0 1 2 3 ( 132) 133J. Enuretic 0 1 2 3 (133)

How did you deal ~ith school? I 134J. Badly 0 1 2 3 (134) How have you done at work? I 135J. Badly 0 1 2 3 (135) When did you beco~e interested in boys and girls? How has this de~eloped? 136J. Unable to relate 0 1 2 3 (136) 137J. Frigid, impotent 0 1 2 3 (137)

Have you ever been troubled by your nerves before? 138J. Presu~ed earlier diagnoses( ...... ) specify (138) 139J. Severity of earlier episode 0 1 2 3 (139)

Do you take any tablets? ...... Do you drink any alcohol? 140J. Relevant intake of depressant drugs 0 1 2 3 ( 140) 141J. Alcohol or drug dependence 0 1 2 3 ( 141)

PREMORBID PEPSOXALITY When you are well what is your nature like? 142. Cycloid traits 0 1 2 3 ( 142) 143. Schizoid traits 0 1 2 3 (143) Were you a conscientious sort of person when you were well? 144J. Obsessional traits 0 1 2 3 ( 144) High standards - work, punctuality; high moral standards; orderliness; tidiness; rigid behaviour and ritualism; poor adaptability; caution, thrift; difficulty makir:.g decisions Were ou rone to ~orrv a lot before this sickness? 145J. Anxiet\· traits 0 1 2 3 (145) Tension, restlessness; easily worried; anxious when faced with responsibility; preoccupied with unlikely dangers; marked apprehension before events; marked vasomotor responses; lack of confidence; free-floating anxiety; phobias; depersonalization; depre~sive reactions 163.

Did you lean on your family a lot? Did you tend to tire quickly before this illness?

146J. Immature dependent traits 0 1 2 3 ( 146) Easily moved; upset; low frustration tolerance; impatience, irritability; frequent day­ dreaming; dependence on relatives, dependence on familiar environment; easily fatigued; poor persistence

Were you an enthusiastic person? Did you like being the centre of things when you felt well?

47J. Hysterical traits 0 1 2 3 (147) Attention-seeking, self-display; florid expressions and gestures; extravagant ambitions; evanescent enthusiasms; fabrications, exaggeration; shallow, egocentric emotional responses; exploitation of others emotions; possessiveness; seductiveness

Were you an easy-going, casual person? Had you ever been in trouble with the law?

148J. Psychopathic traits 0 1 2 3 (148) Low standards - work, punctuality; low moral standards; unscrupulous behaviour; failure to learn from experience; impulsiveness, lack of foresight; lying; delinquency; criminality; dishonesty

149J. Premorbid persoP.ality 0 1 2 3 (149) 0 = stable; no neurotic traits 1 = stable; neurotic traits evident, cause no incapacity 2 = handicapped; neurotic traits produce limitation 3 = disabled; neurotic traits incapacitate

150J. Diagnosis of present illness (WHO coding)

(WHO) (150) 164.

APPE:mIX II I Principal Co:-:1ponents of Psychiatric Interview Questions.

A principal corcponents ar.alysis was performed for each of the six blocks of questions using the replies of the 235 patients. These had been scored O, 1, 2 or 3 by three psychiatrists and summed scores were used as the raw data. Only co:"'.lponents relevant to the thesis are given in detail. Interpretation of the unrotated factors was obvious and it is the unrotated factors which are shcnm. \-:here eigenvector values (E. V.) from this inter­ view are quoted in the text it refers to subjects' factor scores on the unrotated components. The questions are shown in full in Appendix II. The numbers beside the abbreviated questions below are compatible with the numbering in Appendix II.

Mood Section Principal Components 1. 2. Depressive Suicidal

20. feeling low 0.64 0.10 21. can laugh -0.53 0.42 22. optimistic -0. 71 0.20 23. hopeful -0.64 0.26 24. tearful 0.51 0.21 25. sad and blue 0.64 0.00 26. helpless 0. 62 .-0.31 27. hopeless 0. 75 -0.14 28. at end of rope 0. 78 0.02 29. not worth living 0.80 0.04 30. suicidal thoughts 0.55 0.65 31. suicidal actions 0. 31 0.82

percenta~e of the variance 41% 13% 165.

Psycho~otor Retardation and Cognitive Performance Difficultv (C.P.D.) Section

Principal Components. 1. 2. C.P.D. Fatigue vs. Confusion

40. poor concentration 0. 74 -0.33 41. decisions difficult 0. 74 -0.42 42. "mixed up" 0. 57 -0.58 43. unable to do things o. 78 0.18 44. constantly tired 0.63 0.42 45. loss of interest 0.80 0.30 46. bored with work o. 74 0.35

percentage of variance 52% 15%

Anxiety Section Principal Components. 1. 2. 4. General Irritability Focussed Anxiety Anxiety

48. restless 0.50 -0.04 -0.18 49. tense o. 74 0.10 0.15 so. jitcery 0. 72 0.11 -0.16 51. worried - no reason o. 72 -0.08 -0.32 52. worried - little 0.63 0.03 -0.23 things 53. fears - future 0.61 -0. 36 -0.06 54. phobic anxiety 0.52 -0.32 0.61 SS. irritability 0.17 0.85 -0.01 56. concern-aging 0.44 -0.05 -0.19 57. so:natic. anxiety 0.57 0.31 0.49

percentage of 34% 11% 9% variance 166.

Self-Pity Section

Principal component 1.

Self-pity

60. sorry for self 0.61 61. lonely 0.64 62. feels burdened 0.53 63. feels unloved 0.55 64. envious 0. 62 65. bearing up well 0.37 66. outside problems 0.21 67. money concern 0.44 68. helped by hospital 0.18 69. blames others 0.40

percentage of variance 23%

Guilt and Shame Section Principal component 1. Guilt and Shame

75. concern for family 0.37 76. caused suffering 0.62 77. should do more 0.54 78. feels despised 0.44 79. done wrongs 0. 56 80. feels a failure 0.64 81. become lazy 0.62 82. ash.::,ned 0. 79 83. unworthy 0. 73 84. illness self-caused 0.50 85. feels punished 0.52 86. full of guilt o. 73

percer,tage of variance 36% 167.

Habit Changes Section

Principal Components.

1. 2. Disturbed Insomnia ~ vs. functions Anorexia

88. dry mouth 0.34 0.04 89. loss of appetite 0.67 -0.35 90. off sweets etc. 0.46 -0.58 91. weight loss 0.46 -0.32 92. loss of libido 0.44 -0.21 93. concern-lust -0.27 0.01 94. initial insomnia 0.52 0.52 95. fitful sleep 0.55 0.48 96. early waking 0.56 0.36 97. symptoms fluctuant 0.40 -0.02

percentage of variance 23% 12% 168.

APPENDIX IV

Patients were ~atched one-for-one on sex, age and occupational prestige (Congalton, 1969 - the four-point system). In this system 1 is the most prestigious and 4 the least. 96 controls were available for each variety of hypochondriasis. The patient selected as a control was that one of the 96 with the closest ~atch. In every instance controls were of the same sex as the hypochondriacal patients. If more than one control exactly matched the hypochondriacal subject's details then a coin was tossed to decide which control was used. Once a control had been allocated it could not be used again for ~atching in the same group.

Diagnosis based upon the eighth revision of the international classification of diseases is included for completeness. NN indicates a normal premorbid personality. The 301 for personality disorder is not included in the tables, only the nunber following the decimal point.

Some of the co::i:aon abbreviations used for this study are:-

Diagnosis Personality Disorder 296.2 Endogenous Depression 301.4 Obsessional 300.0 Anxiety Xeurosis 301.5 Histrionic 300.l Hysterical Neurosis 301.6 Asthenic 300.4 Depressive ~eurosis 169.

Disease Phobia (30) Matched Controls (3n)

Pt-No Sex Age 0ccunat- Diagnosis Pt-No Sex Age 0ccupat- Diagnosis ional ional prestige prestige "' 7 M 29 3 300.2/ 6 117 M 29 3 304.6/ 6 20 F 35 2 294.3/ 6 204 F 34 2 300.4/ 5 28 F 45 4 300.l/ 5 61 F 48 4 300 .4/:NN 36 F 41 4 300.4/ 6 182 F 39 4 295.3/NN 47 F 58 4 296. 3h'X 188 F 55 4 300.4/ 6 50 F 58 4 300.0/ 6 229 F 57 3 301. 5/ 5 66 M 61 3 2 96. 2/N~~ 197 M 59 3 296. 2/NN 68 F 21 3 300. 1/X:. 98 F 21 3 300.1/ 6 69 F 55 4 296.2/:,:.,;: 193 F 52 4 296.2/NN 83 F 74 4 300.4hX 32 F 71 4 296.2/NN 89 F 42 4 300.4/ 6 205 F 46 4 300.4/ 2 96 F 27 3 300.1/ 5 30 F 23 3 300 .1/ 5 104 M 50 1 296.2/ 6 207 M 50 1 303.2/NN 116 F 45 3 300.4/X'.>. 200 F 44 3 296.2/Ni'i 140 M 22 2 300.3/ 4 46 M 19 3 300.1/ 6 142 F 42 2 300.2/ 6 143 F 41 2 296. 3/NN 145 M 43 3 296 .2h:- 100 M 45 3 2 96. 2/:t--.'N 151 F 20 3 300.4/ 6 87 F 20 3 301. 5/ 5 155 M 28 3 300. 7 /XN 125 M 27 3 300.4/ 2 165 M 23 3 295.3/ 4 169 M 23 3 295.1/ 6 168 F 59 3 296.2/ 4 118 F 60 3 296.3/NN 176 F 23 4 300.0/ 6 103 F 23 4 309.3/ 5 178 M 35 3 300.0hN 214 M 34 3 300.4/ 7 186 F 49 3 300.4/ 5 80 F 49 3 300.4/NN 189 F 20 3 300 .4/F,N 206 F 18 3 300.4/ 6 191 M 34 4 300.0/ 3 84 M 34 4 307 /NN 211 F 43 2 296 .2h:- 107 F 46 2 300.td 6 221 F 25 4 300.l/ 5 223 F 23 4 300.4/ 6 222 M 22 3 293.4/ 6 51 M 22 3 300.4/ 3 224 F 67 4 2 96. 2/ 4 73 F 67 4 296.2/XN 170.

Disease Conviction (12) Matched Controls (12)

Pt-~~o Sex Age Occuoat- Diagnosis Pt-~~o Sex Age Occupat- Diagnosis ional ional prestige prestige

9 F 67 4 300. 7 /1'.'N 163 F 67 4 296.2/NN 23 F 64 3 296.2/NN 109 F 66 3 296.2/NN 26 M 68 2 298.0/ 4 101 M 59 2 296.2/ 4 27 M 63 4 300.4/ 6 57 M 58 3 300.4/ 6 95 F 40 2 300.1/ 5 218 F 40 2 304.3/ 6 111 F 21 2 300.l/ 6 183 F 2::.. 2 300.4/ 7 124 F 26 4 296.2/ 6 103 F 23 4 309.3/ 5 127 F 57 2 296.2/NN 56 F 56 2 304.3/NN 150 F 66 4 296. 2/:t--.1N 180 F 66 4 296.2/ 4 160 F 41 4 296.2/NN 182 F 39 4 295.3/NN 216 M so 3 300.7/NN 100 M 45 3 296.2/NN 226 M 64 4 296.2/NN 197 M 59 3 296.2/NN . -, , J.1 .... Somatic Preoccuoation (41) ½atched Controls (41)

Pt-~fo Sex Age 0ccupat- Diagnosis Pt-~~o Sex Age 0ccuoat- Diagnosis ional ional prestige prestige

1 M 21 3 295.1/ 2 14 M 21 3 300.1/ 7 3 F 67 4 300 .O/Y,N 163 F 67 4 296.2hm 10 F 55 4 296.2/ 6 188 F SS !~ 300.4/ 6 16 F 30 2 300.4/ 6 181 F 31 2 294.3/ 2 17 F 29 3 300.3/ 4 5 F 26 3 295.1/NN 18 M 24 4 309.2/ 3 74 H 25 4 300.4/ 7 21 F 54 3 300.4/ 6 120 F 52 3 2 96. 3/1.\"'N 34 M 34 1 296.2/ 4 102 M 42 1 296.3/NN 35 F 69 3 300.0/ 5 109 F 66 3 296.2/:r:m 44 F 28 3 300.4/ 6 115 F 23 3 300.4/ 6 58 F 29 4 304.3/ 6 223 F 23 4 300.4/ 6 63 F 52 2 300.3/ 6 219 F 52 2 296.2/NN 75 M 62 3 300.0/ 6 101 H 5 :i 2 296.2/ 4 97 M 35 3 300.2/ 4 214 M 34 3 300.4/ 7 106 F 45 4 300. Lf/ 5 205 F 46 4 300.4/ 2 113 M 51 3 296 .2/NN 57 M 58 3 300.4/ 6 121 F 59 3 296.2/ 4 118 F 60 3 296.3/NN ,.. 128 F 77 3 296.2/NN 32 £ 71 4 296.2/NN 133 M 16 2 295.0/NN 208 M 16 3 300.4/ 3 134 F 34 3 300.l/ 6 40 F 37 3 296.2/NN 135 F 24 3 300.4/ 6 30 F 23 3 300.1/ 5 136 N 49 3 296.2/ 4 100 M 45 3 296.2/NN 138 F 46 3 300 .1/ 5 37 F 47 3 296.2/ 4 147 F 35 4 304.3/ 6 182 F 39 4 295.3/NN 148 M 34 3 300.0/ 4 117 M 29 3 304.6/ 6 162 M 52 4 300 .1/ 7 167 M 45 4 300.4/NN 174 F 37 4 300.4/ 6 45 F 37 3 295.4/ 5 177 F 61 4 300.4/ 6 180 F 66 4 296.2/ 4 179 F 33 L1 300. 9/"i!..N 154 F 34 4 300.4/NN 185 F 21 3 300.4/ 5 98 F 21 3 300.1/ 6 194 F 44 !1 296.2h'N 61 F 48 4 300.4/NN 195 F 37 3 300.S/ 5 200 F 44 3 296.2hTN 199 M 56 3 296.2/~N 25 H 56 2 296.2/NN

(Cont'd.) 172.

Somatic Preoccupation Matched Controls (Cont'd.)

Pt-No Sex Age Occupat­ Diagnosis Pt-No Sex Age Occupat­ Diagnosis ional ional prestige prestige

202 M 59 4 300.l/ 6 164 M 54 4 296.2/NN 209 M 21 3 300.l/ 6 51 M 22 3 300.4/ 3 215 F 18 3 300.4/ 5 206 F 18 3 300.4/ 6 225 M 47 4 300.4/NN 175 M 42 4 300.0/ 6 227 M 48 3 296.2/ 1 161 M 43 4 300.1/ 6 230 M 69 4 296.2/ 4 197 M 59 3 296. 2/NN 302 F lf 7 4 300.1/NN 193 F 52 4 296.2/NN 305 M 42 3 300.7/ 6 38 M 39 4 300.4/ 6

I

For the analysis of variance study, four groups each containing 30 patients were arranged. Matching was as described above (though less exact). It was such that each disease phobic patient had three people matched with him for sex, age and occupational prestige, one having somatic preoccupation, one having only psychogenic pain and one being a control. (There were too few in the disease conviction group for its inclusion).

The 30 disease phobics and the 30 controls have been shown already. The somatic preoccupation and psychogenic pain groups which roughly match with each other and with the disease phobics and controls are as follows:- 173.

So~atic Preoccupation (30) Psychogenic Pain (30)

Pt-:\o Sex Age Occupat- Diagnosis Pt-!fo Sex Age Occupat- Diagnosis io:1al ional prestige prestige

305 :-1 42 3 300.7/ 6 4 M 33 3 296.2/ 2 16 F 30 2 300.4/ 6 39 F 34 2 300.4/ 5 302 F 47 4 300. lh'N 64 F 40 4 300. 1/ 6 174 F 37 4 300.4/ 6 91 F 35 3 3oo.4h-;:~ 177 F 61 4 300.4/ 6 213 F 59 4 300 .0/l{Y. 3 F 67 4 300.0/NN 190 F 61 3 296.2/1~ 75 H 62 3 300.0/ 6 94 M 63 3 309.3/NN 135 F 24 3 300.4/ 6 192 F 23 3 300.4/ 5 10 F 55 4 296.2/ 6 217 F 52 3 297.1/ 6 128 F 77 3 296. 2/NN 110 F 78 4 296.2/NN 194 F 44 4 296.2/tm 203 F 44 3 295.3/ 4 17 F 29 3 300.3/ 4 76 F 28 3 300.4/ 3 34 M 34 1 296.2/ 4 144 M 38 2 296. 2/NN 106 F 45 4 300.4/ 5 54 F 47 3 300.4/ 6 133 M 16 2 295.0/NN 33 M 17 3 300.0/ 6 195 F 37 3 300.5/ 5 187 F 37 3 296.2/NN 225 M 47 4 300.4/NN 156 M 48 3 300 .1/NN 215 F i8 3 300.4/ 5 92 F 18 3 307 I 5 1 M 21 3 295.1/ 2 184 M 27 3 300.0/NN 18 M 24 4 309.2/ 3 31 M 23 4 307 /NN 121 F 59 3 296.2/ 4 129 F 60 3 296.2/t-.'N 44 F 28 3 300.4/ 6 114 F 24 3 295.lh~ 97 M 35 3 300.2/ 4 119 M 35 2 293.2/ 3 138 F 46 3 300.l/ 5 228 F 50 3 296. 2/}.~ 185 F 21 3 300.4/ 5 67 F 20 2 296.2/ 6 148 M 34 3 300.0/ 4 99 M 36 4 300.4/ 6 63 F 52 2 300.3/ 6 71 F 51 2 296. 2/N~ 58 F 29 4 304.3/ 6 53 F 30 4 300 . 4h~i 209 M 21 .3 300.1/ 6 304 M 21 3 300. 1/X:\ 35 F 69 3 300.0/ 5 130 F 66 4 300.4/~:-i 174. R E F E R E ~; C E S .

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Zl·;ERLING, I. , T !:T CHENER, J. , GOTTSCHALK, L. , LEVINE, M. , CULBERTSON, W. , COHEN, S.F., and SILVER, H. (1955). 'Personality disorder and the relationships of emotion to surgical illness in 200 surgical patients'. Amer. J. Psychiat., 112, 270-276. I am grateful to the members of the School of Psychiatry, University of Kew South \·;ales, who have contributed to what is called "The Depression Study", on to which this work was grafted and of which it is the first fruit.

I particularly thank Professor L.G. Kiloh, Dr. J.G. Andrews and Mrs. M.D. Neilson for their collaboration and assistance.

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