NEURASTHENIA AND HYPOCHONDRIASIS

Gerard Chrzanowski
 e-Book 2016 International Psychotherapy Institute

From American Handbook of Psychiatry: Volume 3 Silvano Arieti

Copyright © 1974 by Silvano Arieti and Eugene B. Brody

All Rights Reserved

Created in the United States of America

 Table of Contents

NEURASTHENIA AND HYPOCHONDRIASIS

Neurasthenia

Hypochondriasis

Current Etiological Concepts

Considerations of Social Psychiatry

Management and Therapy

Bibliography

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 NEURASTHENIA AND HYPOCHONDRIASIS

Gerard Chrzanowski

Neurasthenia and hypochondriasis are descriptive concepts, dating

back to an era when mental disorders were obscure, inexplicable phenomena

whose origin was almost exclusively linked to non-psychological aspects. In

the intervening years, the discrepancy has widened between the original
terminology and our current understanding of neurasthenic and

hypochondriacal manifestations. Today, the nosological boundaries of

neurasthenia and hypochondriasis have become vague to the point of being

more of a burden than a diagnostic help.

Optimally, psychiatric terms serve as sophisticated, professional

working tools designed to aid in the task of providing information about the

nature and the expected outcome of a particular mental disorder. They

represent a coded language pertaining to difficulties in living with the

capacity of evoking appropriate thoughts in skilled psychiatrists as to how

best to deal with the prevailing situation therapeutically, as well as to offer an

educated guess about the prognosis. In addition, the terms are essential for

interprofessional communication, as well as for epidemiological

considerations. It is mandatory to establish a working consensus about the

proper usage of terms, lest one diagnostician’s neurasthenia become another

American Handbook of Psychiatry 5

diagnostician’s schizophrenia.

One can appreciate the significance of nosological concepts in realizing

the powerful impact on psychiatric theory and practice when Eugen Bleuler

rejected the fatalistic term dementia praecox in favor of the diagnostic

category schizophrenia. In spite of Bleuler’s fundamentally organic point of

view, the change of term opened the door to a broad exploration of

schizophrenic disorders as a basically human condition, rather than an a

priori organic defect. It paved the way for consideration of interpersonal,

sociocultural, chemical, hereditary, and other components within the totality

of human transactions.

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 Neurasthenia

When we come to the nosological classification of neurasthenia, we are

confronted with a confusing picture. There is not even complete agreement in

regard to the definition of the clinical syndrome. It is usually characterized by

a wide variety of symptoms. Ordinarily, there are chronic feelings of

weakness and fatigue, various aches and pains, as well as strange physical
sensations. Insomnia and irritability may occur in conjunction with a feeling

of more or less chronic distress in an organ or organic system of the body.

Whereas some patients experience vague, general discomfort, others center

their attention upon a particular organ. Any part of the body may be affected.
However, there is a high percentage of gastrointestinal symptomatology. The

clinician who is compelled to arrive at a psychiatric diagnosis does not have

an easy task when confronted by a multitude of symptomatic manifestations.

When Freud dealt with the syndrome of neurasthenia, he considered

the following symptoms to be characteristic: headache, spinal irritation, and

dyspepsia with flatulence and constipation. In regard to hypochondriasis he

said, “It is the form favored by true Neurasthenics when they fall victim to

anxiety neurosis as they often do.”

In “An Attempt at Analysis of the Neurotic Constitution,” Adolf Meyer

stated that the term “neurasthenia” should be reserved for the cases

combining the symptoms of great exhaustibility and irritability, depending

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largely on the mental attitude of lack of repose and of ready recoverability,
frequent head pressures, palpitations and uneasiness of the heart, gastric

disorders, phosphaturia and oxaluria, and in men especially, abnormality of

sexual responsiveness. He went on to state:

Frequently, associated with other traits of nervousness, we meet with

hypochondriasis, usually built on a feeling of ill-health which leads to self-
observation and explanations. These are apt to become the center of
thought and interest, are elaborated, or the person merely is troubled with
vain fears over trifles, consults quack literature, etc. On the whole, the
impressions are apt to become dominating.

Neurasthenia means literally nervous debility or weakness. The notion

of weakness of the nerves harks back to the nineteenth-century concepts of

mental disorder.

Historically speaking, it is significant that earlier considerations in

regard to the etiology of mental disorders did not distinguish between

somatic aspects and metaphysical conceptualizations. This mode of thinking

gave way to rationalistic and mechanistic models of mental disorders. Thus,

in his Elementa Medicina, published in England in the eighteenth century,

John Brown described the nervous system in terms of eighteenth-century

mechanistic concepts, and postulated that “irritability” of the nervous system

could cause mental illness. Following this theory, neurasthenia came into

existence as a diagnostic syndrome that referred to a weakness or exhaustion

of the nervous system. As such, neurasthenia was regarded as the forerunner

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of all the more severe nervous disorders, e.g., hysteria, epilepsy, locomotor
ataxia, general paralysis, etc.

The term “neurasthenia,” to denote nervous exhaustion, was

subsequently introduced into American psychiatry by George Miller Beard in

1869. Beard maintained that the nerves might “run down” as a result of

overexertion or overwork. Thus, according to Beard’s theory, the nerve cells

operated in much the same way as a battery: When their supply of stored

nutriment was depleted, they lost their natural “charge.” As an outgrowth of

this concept, S. Weir Mitchell developed his rest treatment which prescribed

complete rest to cure “anemia of the brain.”

The influence of George Miller Beard’s hypothetical model is evident in

Freud’s early formulations concerning the etiology of neurosis. Freud

believed that Beard’s concept of neurasthenia was too inclusive, and

proposed instead the broader classification of “actual neuroses,” which would

encompass three separate syndromes, namely, neurasthenia, anxiety

neurosis, and hypochondriasis. (Hypochondriasis resulted when an anxiety

neurosis was superimposed on neurasthenia.) At the same time, however, like

Beard, he attributed these phenomena to physicochemical forces, rather than

psychological factors. Thus, in Freud’s first theory of anxiety, he distinguished

between the etiological factors which produced anxiety in specific clinical

entities: The psychoneuroses were psychogenic in origin whereas actual

American Handbook of Psychiatry 9

neuroses had a physical basis. More specifically, in the actual neuroses,
abnormal sexual practices prevented the adequate somatic discharge of

chemical substances, or “toxins.” Concomitantly, there was an interference

with the adequate discharge of the psychic component of sexual tension,

which gave rise, in turn, to anxiety. In contrast, in the psychoneuroses, the

abnormal sexual functioning which produced anxiety was due to psychic

factors, specifically, to repression.

Subsequently, Freud recognized the psychological nature of anxiety and

neurosis. Throughout his life, however, he continued to believe that psychical

and physical processes were closely interrelated and that physical processes

preceded psychological manifestations. Accordingly, Freud’s later theory of

anxiety did not rule out the possibility that there was a direct somatic
relationship between sexual conflicts and anxiety in certain neurotic

conditions or, more accurately, that these conditions resulted from the toxic

effect of dammed up sexual energy.

He also maintained that there was a potential link between actual and

psychoneurosis, that the symptoms of an actual neurosis might precipitate

psychoneurotic symptoms in many instances. And, in this connection, he

postulated a possible relationship between neurasthenia and conversion

hysteria on the one side, and between hypochondriasis and paranoia on the
other. For example, initially, the pain which accompanies a

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neurophysiological symptom, such as a headache, is “real”; that is, it is
somatic in origin and due to sexual “toxins.” This actual physiological

disturbance may then become a future source of focal irritation which might

serve as the basis for psychoneurotic symptom formation. Freud further

postulated that hypochondriasis represents a withdrawal of interest or libido

from objects in the outside world; instead, the libido formerly connected with

the ideas of objects now intensified all ideas concerning body organs. In

paranoia, too, an organ becomes the representative of an external object, as a

result of narcissistic regression. Thus, Freud hypothesized that hypochondria

is the somatic basis of paranoia, just as the anxiety neurosis, that is, a

continual readiness to “explode,” is the somatic basis of hysteria.

Freud’s theoretical foundation for the relationship between the

conditions mentioned above is to be found in his concept of narcissism. He

distinguished between ego libido and object libido. The former is a

withdrawal of interest from object relations and runs counter to the capacity
of gaining genuine satisfaction. Freud stated in “On Narcissism:”

The relation of hypochondria to paraphrenia is similar to that of the other

actual neuroses to hysteria and the obsessional neurosis: which is as much
as to say that it is dependent on the ego-libido . . . and that
hypochondriacal anxiety, emanating from the ego-libido, is the
counterpart of neurotic anxiety.

Since Bleuler’s day, there has been an increasing awareness of the

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clinical observation that neurasthenia and hypochondriasis may serve as a
mask for severe mental illness. Both symptoms occur frequently as

precursors of depressions, schizophrenic states, obsessions, and hysteria. In

other situations, hypochondriasis and neurasthenia serve as a displacement

for a wide variety of difficulties of living, as well as indicating the existence of

miscarriages in human relations.

In regard to hypochondriasis, Bleuler stated categorically that “we do

not know a disease hypochondriasis.” He found the occurrence of

hypochondriacal phenomena in schizophrenia, depressive states, in

neurasthenia, in early organic psychosis, and in all forms of psychopathy.

A glance at our present psychiatric textbooks does not add much to the

picture. Henderson and Gillespie contribute little to our knowledge of

neurasthenic and hypochondriacal conditions. They allude to heredity,

constitution, autointoxication, and prolonged emotional disturbances as

major etiological factors. Noyes is dissatisfied with the term “neurasthenia”

which he attributes to deep-lying personal maladjustment. Hypochondriasis

is, in his opinion, an organ neurosis. Masserman speaks of neurasthenia as an

exhaustive-regressive state, which he believes to be due to unrecognized,

cumulative, internal tensions. Harry Stack Sullivan states that, as a student of

personality, he finds no virtue in the conception of neurasthenia. From a

psychiatric viewpoint, chronic fatigue and preoccupation with fancied

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disorders which cannot be explained on an organic basis form merely a
panoply, obscuring the nature of various interpersonal events. Although

Sullivan rejected the concept of neurasthenia, he referred to certain

interpersonal phenomena related to this syndrome. In particular, he

described somnolent detachment, apathy, and lethargy in this connection.

The appearance of psychogenetic fatigue assumes special significance in

regard to the concept of hostile integration. This phenomenon is akin to a

sadomasochistic transaction in which both partners relate to each other’s

insecurities, rather than to their respective strengths. The integration centers

on the mutual capacity to evoke anxieties in the other person and markedly

lowers their respective feelings of self-esteem. In a hostile integration, neither

party can give encouragement, comfort, or support. A hostile integration is a

mutual dependency on undermining each other. The result is frequently a

manifestation of security operations, ranging from “not feeling well” to

“feeling excessively tired,” “fatigued,” and what have you, as a mask for the
malevolent interpersonal atmosphere.

In addition, we have a host of protective devices which are designed to

attenuate tension and lower the threshold of painful awareness. Here we

encounter the phenomena of apathy, lethargy, and somnolent detachment.

Each of the above mentioned manifestations occurs in the face of inescapable

and protracted severe anxiety. The result is a decrease in vulnerability to

American Handbook of Psychiatry 13

profound interpersonal stress and strain. In apathy and lethargy, the person
is out of touch with his most elementary needs after a state of severe

frustration. In other words, fatigue is a complex phenomenon with many

different faces. It may reflect a variety of interpersonal malintegrations in

which both partners tend to undermine each other’s basic security.

From a historical viewpoint, it seems appropriate to include Janet in a

discussion of neurasthenia and hypochondriasis. He introduced the term

“psychasthenia” in denoting practically all neurotic manifestations which he

did not group as those of hysteria. Janet described neurasthenia as a

prolonged state of fatigue, without somatic basis. He postulated the notion

that neurasthenia was due to a psychic depression in which there is a general

depletion of mental energy and a lowering of mental tension.

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 Hypochondriasis

In its general usage, hypochondriasis or hypochondria denotes the

subjective preoccupation with suffering a serious physical illness which

cannot be verified objectively on a physiological or organic basis.

Hypochondriasis refers also to a chronic tendency of being morbidly

concerned about one’s health and of dramatically exaggerating trifling

symptoms, as if they were a dreaded disease. The name “hypochondriasis”

stems from a topographic, anatomical point of view. It was once thought that

the soft part of the abdomen below the ribs and above the navel was the seat

of the disorder.

In regard to hypochondriasis, Freud was greatly dissatisfied with the

obscurity of the concept. He complained to Ferenczi about it in a letter dated

March 18, 1912. Freud formulated hypochondriasis as a withdrawal of

interest and libido from the objects in the outer world. The relatedness of

certain hypochondriacal symptoms to schizophrenia was recognized early.

Freud thought that hypochondriasis has the same relation to paranoia as

anxiety neurosis has to hysteria.

The concepts of neurasthenia and hypochondriasis have remained

relatively unchanged in analytic literature. Fenichel gave a lucid description

of these syndromes but stuck closely to the economic concept of libido theory.

He affirmed that many an actual neurosis required only adequate sexual

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outlets. It is interesting that he recognized alterations in the muscular
attitudes of people with neurasthenia. He appreciated the inability of such

people to concentrate, because they are unconsciously preoccupied with

defensive activities. He pointed to the impoverished life activities leading to

restriction of the personality, etc. There were many other important insights
offered by him, including the appearance of apathy against aggressiveness.

However, he still considered an improved sexual technique to be an adequate

treatment in some of these patients. The fact that a change in sexual pattern
indicates a reorientation in the total personality was not mentioned.

As far as hypochondriasis is concerned, Fenichel saw it primarily as a

transitional state between reactions of a hysterical character and those of a

delusional, clearly psychotic one.

Regardless of how misleading the terms may be, the fact remains that
neurasthenic and hypochondriacal manifestations are almost ubiquitous in all

types of psychiatric practice. Furthermore, the phenomena associated with

these concepts are widely represented in our culture, without being given
much psychopathological significance. Feeling excessively tired, as well as

being deeply concerned about one’s health, are relatively conjunctive aspects

of our social pattern.

Many people feel righteous about being entitled to a reactive state of

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weariness as a result of labor and exertion. For instance, it is considered quite
respectable for a professional person to feel worn out at the end of the day;

for the housewife and mother to be exhausted from her many chores; for the

businessman, after a day of pressure at the office, to be very tired. On the

other hand, we can frequently observe how certain interpersonal aspects can
aggravate the fatigue markedly, whereas others can make the person forget

how tired he is. I am not talking here about occasional states of overwork, etc.

What matters is the recurrent nature of the syndrome—a state of affairs

where feeling exhausted forms a more or less consistent pattern. As far as the

reaction of the environment is concerned, it ordinarily does not seem to be

practical or in good taste to quarrel with people’s justification for being tired,

regardless of the circumstances. Furthermore, it is to be understood that

special allowances are to be made for the person who is afflicted by debility

and potential ill health. The victims of neurasthenic and hypochondriacal

symptoms can always claim that they wish it were otherwise, but they just
can’t help feeling the way they do. Obviously, the more absorbed a person is

with his mysterious predicament, the less available is he for personal

relatedness to others. The “I don’t feel myself” preoccupation impoverishes

the nature of all other communication and insulates the person from more

direct contact with the environment.

Despite this obvious dilemma, the nature of the insulation is such that it
still permits a tenuous relatedness to others at a time when more meaningful

American Handbook of Psychiatry 17

contact might not be possible. As long as at least one marginally structured

channel of communication is preserved, this may suffice to prevent a

disintegration of the personality.

Another significant aspect is demonstrated by the fact that almost every

practicing psychiatrist has seen patients who seemingly feel tremendous

relief when a “real” organic villain is found. The patient who gets X-ray

evidence of duodenal ulceration, kidney stones, herniated disk, etc., may be

almost pleased. The point is that he has something which he considers to be

beyond his personal control. It exonerates him from a peculiar kind of blame
by himself or others. Such people often are hounded with the illusion of

imaginary ailments. They frequently believe that they can turn symptoms on

or off at will, if there is no specific organicity involved. Everything is done to

conceal from themselves and others long-standing, unhappy life experiences

involving the total personality. The compulsion to negate personal

misfortunes is so great that some of these patients readily submit to a

surgeon’s knife, painful treatments, prolonged use of medication, etc., in

situations that therapeutically do not demand drastic steps.

Here is a situation illustrative of the point made. I saw a sensitive and

troubled woman patient in her late thirties who had suffered a transient

psychotic episode. Part of this profound upheaval was triggered off by her
belated awareness that her husband had much in common with an older

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sibling of hers whom she despised. On the surface, it all started with an attack
of acute abdominal distress. She was admitted to a general hospital and kept

for ten days’ observation. There was some idea of a gall bladder disorder. The

findings, however, were inconclusive, and she was told that she was severely
run down. From the time she returned home, things went from bad to worse.

Finally, she accused her husband of having poisoned her food, and of similar

uncharitable acts. The situation deteriorated to the point where he felt

compelled to institutionalize her. Her hospitalization was relatively short.

During her illness, it was brought home to her that she owed deep gratitude

to her husband’s kindness and thoughtfulness. It turned out later that she had

never faltered in her conviction that the mental hospital had been a punitive
act on his part. At a later point, when my patient had made major strides

toward recovery, her husband began to ail. He had always been known as a

hypochondriacal person who suffered from headaches, backaches, gastric

ulcers, and neuralgias. Suddenly, he developed an excruciating back pain,

which his wife suspected to be psychogenic in nature. Despite her urging, he

refused to consult a psychiatrist. After several weeks of acute misery, he had

an orthopedic surgeon operate on him for a dislocated nucleus pulposus. The

result of the surgical intervention was miraculous. Now the dragon’s tooth
which had been bothering him for years had been extracted. His relief was so

great that he did not even complain about having to maintain prolonged

sexual abstinence. My patient was not unduly affected by this restriction. It

American Handbook of Psychiatry 19

soon came out that there had been no sexual relations for more than two

years prior to the operation. When my patient became fleetingly interested in

sex again, her husband’s physical symptoms reappeared temporarily.

As the history unfolded in therapy, several aspects in the situation

became clearer. In the past, my patient had experienced several spells of

depression and ill health, which usually coincided with her husband’s feeling

on top of the world. There were times when my patient had been highly

successful, and her devoted husband almost invariably came down with a

physical illness. Furthermore, it became clear that my patient’s feelings of

wellbeing were usually enhanced by feeling needed. This seesaw pattern had

been familiar to the patient within the setting of her own family. In their later

years, both of her parents had taken turns in feeling down in the dumps. At

such times, the low-ebb marital partner was taken to a shock therapist by the

solicitous spouse. As a matter of fact, there had been a similar interplay

between the patient and her oldest brother. She always came to his help when

he was physically ill or in a jam. Once he was well again, she felt all worn out.
He would, however, always make her feel she had not done enough for him.

On the whole, he led a glamorous life and had always been his parents’

favorite. Anyhow, certain aspects of the hostile integration between the

siblings had found their way into the marriage. We can see, then, a highly

intricate and morbid interplay in a family setting, where alternating

hypochondriasis and neurasthenia occur. By the time the husband seemingly

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blew a spinal fuse, a serious crisis had occurred which threatened to break up

the old, familiar pattern. The surgical removal of the man’s emotionally

exaggerated pain served as a deus ex machina. An obvious villain for much

obscure difficulty in living had been found. Everybody could point to the
tangible intervention and the resulting success. One might add sadly that the

patient’s psychosis had almost been suffered in vain. Nobody talked, however,

of mutual suspicions, resentment, power struggles, and humiliations. A cause

had been found that could be reactivated if necessary, but which was placed

outside of psychological boundaries.

So far, the terms “neurasthenia” and “hypochondriasis” have been used

separately. It is not always easy to draw a line of demarcation between these

two conditions. However, when we follow the respective roles these two
concepts have played in the evolution of psychiatric theory and practice, the

situation is somewhat different.

As pointed out previously, the notion of fatigue and overwork as a cause

for mental disorders was prevalent at one time. With the advent of

psychoanalysis, the etiological focus shifted to the area of sexual behavior. In

regard to neurasthenia, Freud wrote that “it arises whenever a less adequate
relief takes the place of the adequate one, thus, when masturbation or

spontaneous emission replaces normal sexual intercourse.” Freud thought

that every neurosis has a sexual etiology. However, he postulated a major

American Handbook of Psychiatry 21

difference between the actual neuroses and the psychoneuroses. The former
group of disorders has its origin in the here-and-now, while the

psychoneurotic conditions relate back to traumatic experiences in infancy.

Finally, Freud also contended that the actual neuroses (i.e., neurasthenia,
hypochondriasis, and anxiety neurosis) frequently functioned as a focus for

neurotic symptom formation.

Bleuler, too, rejected Beard’s hypothesis that exhaustion of the nervous

system caused neurasthenia. On the contrary, he believed that work was

beneficial, and he noted that individuals who work hard seldom fall victim to

neurasthenia. Bleuler also noted that neurasthenia was frequently a

precursor of schizophrenia.

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 Current Etiological Concepts

Brenner summed up the situation as follows: “. . . the category of the

actual neuroses has ceased to be a significant part of psychoanalytic

nosology.” The same author, in collaboration with Arlow, expressed renewed

interest in hypochondriasis, which is the third of the actual neuroses.

According to Brenner and Arlow, “. . . hypochondriacal impulses are not

properly explainable as the result of libidinal regressions and displacement . .

. they are more satisfactorily explained in terms of the conceptual framework

of the structural theory, with its emphasis on anxiety, conflict and defense.”

Otherwise, current psychoanalytic literature has largely ignored the actual

neuroses, in spite of the great interest in ego psychology with its emphasis on

reality factors. For the most part, references to neurasthenia and

hypochondriasis in the current literature do not extend beyond the

description of these conditions. Concomitantly, when they are included,

discussions of etiology are usually limited to a brief allusion to heredity,

constitution, autointoxication, and prolonged emotional disturbances as

major etiological factors. There has also been a growing dissatisfaction with

outmoded terminology in recent years. Noyes, for one, has taken issue with

the concept that neurasthenia represents an exhaustion of the nervous

system. Rather, he believes that, invariably, neurasthenia is due to personal

maladjustment. On another level, Masserman has described neurasthenia as

an exhaustive-regressive state, due to unconscious, cumulative, internal

American Handbook of Psychiatry 23

tensions.

Harry Stack Sullivan’s concern with the etiology of neurasthenia and

hypochondriasis reflected his interest in the reformulation of psychiatric

syndromes in interpersonal terms. To begin with, he contended that the

diagnosis should pertain to an ongoing process which would be considered

indicative of the way in which personal situations have become integrated in

more or less durable patterns. The integration has its roots in significant

interpersonal constellations of the past, as well as of the present.

Furthermore, personal encounters in the immediate future are an integral

part of the situation, for past and present events tend to determine future

experiences. Viewed from this perspective, Sullivan could find no virtue in the

diagnosis of neurasthenia as a one-dimensional, somatic concept which made

no reference to maladjustments in patterns of living. He postulated, instead,

that certain factors, such as deficiency states, malnutrition, and chronic

intoxication, might produce neurasthenic symptoms that were purely

physiological in origin. On the other hand, psychiatric or interpersonal

phenomena might produce symptoms, such as fatigue, apathy, and somnolent

detachment, which resembled neurasthenia to some degree. Apathy and

somnolent detachment were conceived of as protective operations against a

lowering of self-esteem. More specifically, by taking refuge in sudden,

overwhelming sleepiness, the individual withdraws from a tension-producing

situation and is no longer vulnerable to feelings of inadequacy, worthlessness,

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or hostility. In apathy, all the individual’s responses become less intense as a

reaction to severe frustration.

Sullivan viewed hypochondriasis as a particular kind of security

operation. The self-esteem of the hypochondriac has been organized in such a

fashion that bodily phenomena are given a great deal of highly pessimistic
attention. For the hypochondriac, an intense, morbid preoccupation with his

body serves as a distraction from a stressful interpersonal situation. And,

concurrently, the recognition of anxiety is minimized or avoided. The

hypochondriacal person has difficulty in achieving any genuine satisfaction,

because he is constantly haunted by the shadow of impending doom.

Hypochondriasis is further characterized by an implicit symbolism which is

body-centered and reflects a regression of cognition. It is this regression of

the cognitive operations that links the hypochondriacal thought processes to

certain schizophrenic thought processes. Sullivan formulated his ideas on the

subject as follows:

It is as if the hypochondriacal patient had abandoned the field of

interpersonal relations as a source of security, excepting in one particular.
He has to communicate data as to his symptoms; the illness, so to speak,
becomes the presenting aspect of his personality.

It was also Sullivan’s opinion that, in all likelihood, paranoid, algolagnic,

hypochondriacal, depressive, and obsessional states were different

manifestations of the same maladjustive processes. He observed that in many

American Handbook of Psychiatry 25

patients there was a blending of these conditions and an alternation between
one state and another.

Another etiological basis for neurasthenic and hypochondriacal

preoccupations may be the existence of unexpressed anger, which leads to

concealed resentment. This concept has been stressed in particular by Rado,

who believes that hypochondriasis serves to obscure the feelings of repressed

rage and hurt pride.

Finally, symbolic feelings of rejection and worthlessness may be

communicated in characteristic patterns of nonverbal and verbal

communication. For example, Weinstein pointed out that the statement “I am

tired” results from a complex interpersonal transaction that expresses a

particular relationship to the environment. Similarly, a hypochondriacal

preoccupation may be understood as a symbolic expression of feeling

disliked, not approved of, and isolated from other people.

It has proved helpful to study human personalities on the basis of

mutual activities in a field. By stressing the operational aspects, our interest

has turned toward how people affect each other and what impact the social

and cultural setting has upon them. This has largely taken the place of being

predominantly preoccupied with intrinsic factors. There has been less need to

think in terms of strict causality alone. Today, it does not suffice to diagnose

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an organic disorder or rule out overt somatic involvement. Even in the
predominantly organic disorder there are involved some sociocultural as well

as some interpersonal components. The individual and his environment are

an interdependent system at all times. Any effort to isolate one or the other

produces major artifacts. Every disorder tells something about the persona in
terms of specific life experiences. It points to potential vulnerabilities or

sensitivities in the total life history. The area which is of interest to the

psychiatrist is always of a strictly personal nature. It has to do with

personalistic, experiential data which can become communicable in

increasingly more meaningful terms.

When we encounter neurasthenic and hypochondriacal manifestations

in our patients, we have to think largely in terms of symbol processes. They

tell something about what the patient thinks of himself and of his personal
world in his communal existence. There has been increasing interest in denial

of illness and bodily feelings in general. The nature of people’s self-image (“I

and my body,” visual, tactile, auditory modes of perception) is a wide-open

field for study. As a conceptual scheme, the notion of a nexus (as used by
Whitehead), a central relay station where all sorts of things get together, is a

fascinating concept.

The clinical study of neurasthenia and hypochondriasis brings another

consideration to mind. It is as if the person were attempting to cling to some

American Handbook of Psychiatry 27

reality when the world seems in danger of slipping away. There seems to be a
focusing on that which is closest as a means of warding off interpersonal

tension or losing oneself. Much of the bodily preoccupation has the

appearance of a miscarried effort at finding oneself. The more intrapersonal

fear is experienced, the less attention will be paid to interpersonal difficulties.

Some of the symptoms found in neurasthenia and hypochondriasis can best

be understood in terms of the patient’s role in his family constellation, in

addition to sociocultural and other factors. It is of interest that certain

somatic preoccupations are widely fostered in our cultures. The interest in

weight for reasons of health is highly acceptable. To climb on a bathroom

scale twice a day is not an unusual occurrence in the American family. For
women, the intense interest in the surface measurements and contours of

legs, breasts, waist, etc., is encouraged; the way eyelashes are curled, hair-dos

are fussed about—all these are deeply rooted in the culture. For this reason, it

may be more difficult to detect severe personality disorders in women where

there is a camouflage of socially acceptable preoccupations. Some people are

aspirin, laxative, patent-medicine, or Christian Science addicts. It may be

possible to get by on this basis without showing overt symptoms of

hypochondriasis or neurasthenia.

There has been an increasing awareness of the interdependence of

environmental factors and personal, adaptational aspects in the continuum of

an individual’s life space. We have a great number of variables to consider,

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and the conceptualization of static units closes the door to meaningful new

insights.

We have long been aware that fashions are not confined to the outer

wrappings of people, but that neurosis and psychosis, in all their diversity,

have something of “a latest look” of their own. The modern way of life in our
fast-changing culture will undoubtedly produce relatively novel aspects of

human aberrations which are not yet in vogue. It is that much more

remarkable how durable the phenomena called neurasthenia and

hypochondriasis have remained.

American Handbook of Psychiatry 29

 Considerations of Social Psychiatry

We still have a great deal to learn about the intricate relationship

between culture and symptomatology. However, several pilot studies by

social psychologists and allied scientists have thrown light on possible

connections between the Gestalt of psychopathological phenomena and

cultural determinants. Epidemiological investigations have been used to focus

attention on the occurrence of certain psychiatric manifestations in various

cultural and social settings. Much interest has been shown in the part that the

traditions of an ethnic group, sex, age, level of social achievement, etc., play in

the particular shape and form of mental illness. There has also been
increasing understanding of the degree to which the definition of mental

disorder constitutes a social phenomenon.

Opler has alluded to how certain ethnic groups tend more toward some
symptoms than do others. For instance, he points to the difference in attitude

toward illness of Italians and “Yankees.” Then we have the New Haven study

by Hollingshead and Redlich. This study is limited to people under psychiatric

treatment and, accordingly, is not a study of the community at large. It

stresses the influence of social and cultural conditions on the development of

sundry deviations in behavior. Particular interest is shown in the impact of

different class levels of a given society on the type of disorder which can be
observed. In the New Haven study the percentage of patients who tended

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toward somatizing their complaints was highest among the lowest two
classes in the group studied. These two groups consisted mainly of the people

whose educational and economic level was at the bottom of the scale.

Although the tendency toward somatization is not synonymous with the

existence of neurasthenia and hypochondriasis, it seems to be a factor worthy

of consideration.

In private psychoanalytic office practice, where patients from middle-

and upper-middle-class groups are prevalent, I have encountered a fairly

large number of hypochondriacal patients. However, the great majority of

these patients suffered from recurrent episodes of preoccupation with their

health. There were some patients in whom the symptoms of concern over ill

health were more or less constant. These people invariably showed severe
pathology and were very slow as far as speed of recovery is concerned.

Despite grave distortions in the personality, these patients usually did not

create an impenetrable wall by means of their somatic complaints. Similar

observations were made in supervising the work of some of my colleagues.

The situation was quite different in consultation work in a community

clinic located in a low-income borough of Greater New York. There the

incidence of somatic preoccupation as a primary complaint was much higher.

In several instances, it seemed most difficult to get beyond the level of

neurasthenic and hypochondriacal preoccupation. Many of these patients had

American Handbook of Psychiatry 31

been referred by general practitioners who prescribed psychiatric treatment.
Not infrequently, the patient insisted on side-stepping any interpersonal

complications and expected to be magically liberated from physical distress.

Anna Freud found that hypochondriasis occurred only rarely in

children, unless they were motherless and had been institutionalized. On the

other hand, precursors of neurasthenia and hypochondriasis, in the form of

“growing pains,” fatigue, and sleep disturbances, are fairly common in

children.

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 Management and Therapy

Earlier reference was made to the frequent occurrence of neurasthenia

and hypochondriasis in psychiatric and medical practice, as well as in the

culture in general. In some communities, patients with this symptomatology

constitute a large number of referrals to the psychiatrists. Others go around

and change physicians frequently, or they become more or less permanent

fixtures in a doctor’s practice. Some of these patients show up in a

psychiatrist’s office with the challenge, “I have tried everything else, this is my

last resort!” The urgent question arises as to what to do with these patients.

Should they all be analyzed or tranquilized? Would it be in their best interest

to receive mild reassurance by the medical practitioner, or would they do

better with expert psychiatric help? Is it helpful to distract them, help them

change their environment if possible, stimulate other interests, etc.?

I need not state specifically here that it is not possible to devise one

formula for all cases. The management or method of therapy depends on a

multitude of factors.

Generally speaking, I have not found tranquilizers given in moderate

amounts to be very helpful. Most patients today have tried one kind or
another by the time they come to the psychiatrist’s attention. It seems that

relief is usually not adequate or lasting. There is undeniable merit, however,

in having the psychiatrist attempt chemotherapy that does not make the

American Handbook of Psychiatry 33

patient unduly drowsy. (Great care must be taken not to offer the medication
as a miracle pill.) I am opposed to all forms of shock treatments in these

conditions. In hospital, clinic, and private work, I have seen no indication of

even minor improvement in hypochondriasis and neurasthenia as a result of

various shock methods. On the other hand, I have encountered distinct

difficulties in psychiatric and psychoanalytic treatment with patients who had

undergone this procedure. Every neurasthenic and hypochondriacal patient

requires individual consideration. In a somewhat schematic evaluation, we

might distinguish between the following possibilities: Neurasthenia and

hypochondriasis may occur in connection with structural visceral changes.

Regardless of whether the organic or the psychic malfunction comes first, by

the time there is a demonstrable pre-organic or organic situation, we do not

have a primary psychiatric problem at hand.

Occasionally there can be considerable relief, or even cure, as a result of

straight medical treatment. In a great many people, however, there is a

concomitant disturbance of the personality. This may require attention in its

own right.

We may find neurasthenic and hypochondriacal phenomena in

conjunction with character disorders, neurotic difficulties, etc. Here we have a

different situation. Not all patients have the motivation to change; not all

patients have the opportunity to rearrange their lives. There are people who

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would have to undergo tremendous changes of the personality. Their pattern
of relating to others would have to be grossly modified if they were to become

less neurasthenic and less hypochondriacal. The decision as to whether the

patient is amenable to treatment should be left to highly experienced

psychiatrists. Doubtful cases should be worked up carefully, including

projective psychological tests, whenever possible. There is grave

responsibility involved in arriving at a thoughtful and adequate conclusion.

Some patients can be found to be preschizophrenic; others to be full-

blown schizophrenics, some with delusional ideation. The latter group

frequently is markedly paranoid, and some offer a poor prognosis. Among the

preschizophrenic or schizophrenic patients (without a fixed delusional

system), treatment by a highly skilled analyst in office practice may be

successful. Occasionally, a patient has to be hospitalized if all communication

is broken off as a result of suicidal tendencies, preternatural preoccupations

with somatic symptoms etc.

We may also encounter people with neurasthenic and hypochondriacal

complaints who develop the characteristic symptoms after experiencing an

acute existential predicament, that is, a state of affairs where professional,

marital, or other difficulties have been prominent. Once the crisis is over,

these people are apt to suffer from neurasthenic and hypochondriacal

symptoms. In other words, it can be observed that pressing reality problems

American Handbook of Psychiatry 35

are capable of obscuring the existence of neurasthenia and hypochondriasis.
At the end of an emergency situation, we may find a flare-up of difficulties,

which had been at times sub-clinical until then.

Some people are prone to have a chain reaction of highly unfortunate

life experience. Once the external pressures subside and life seems to offer

more satisfaction and happiness, that is the time when long-standing

personal insecurities come to the fore. As long as there is a powerful

distraction by more or less constant, external misfortunes, there is less

opportunity for coming in contact with unfortunate aspects of the person’s

self-image. The low self-esteem inculcated early in childhood was always

there, but the patient did not suspect his grave personal vulnerabilities and

hypersensitivities until actual living conditions became much more

promising.

We have to appreciate that there can be actual, current conflicts largely

beyond the individual’s control. People cannot be expected to undergo

excessive stress and strain without showing some after-effects. It should be

kept in mind, however, that many situational factors have to be understood in

terms of people’s character patterns. The vicissitudes of life which call for
change of environment, if possible, for less strenuous activity, more rest, and

other managerial rearrangements, etc., are not in the realm of psychiatric

practice. More often, history tends to repeat itself, and personal difficulties

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have to be analyzed, so that there will not be just a shift of symptoms.

I should like to add here that some people in our culture are bored, find
their living conditions dull, and entertain themselves with interesting

physical symptoms. To some of these patients the psychiatrist has little or

nothing to offer. They often go on and on, without improving or deteriorating

much.

It should also be emphasized that the distinction between so-called real

and so-called imaginary illness is unfortunate. All symptoms are real, whether
or not our methods are adequate in explaining them. We seldom find

hypochondriasis and neurasthenia among people who are just plain fakers.

Whatever a person feels is based on some perception and some experience.

We do not have the right to suggest figments of the mind, precisely because

our over-all understanding of the nature of the complaint may be lacking. The

assumption that a complaint without demonstrable organic basis is a

senseless complaint needs to be dispelled.

In considering therapeutic intervention, we need to keep in mind that

neurasthenic and hypochondriacal manifestations are usually a mask for

basic personality problems. It is doubtful that the formation of either

syndrome is connected with any standard set of circumstances responsible

for the syndrome’s existence. There seem to be variable traumatic events

American Handbook of Psychiatry 37

which manifest themselves in more or less circumscribed patterns. As is
common with syndromes and symptoms in medicine and in psychiatry, they

cannot ordinarily be cured as such. In psychiatry, the elucidation of particular,

personal life experiences is a highly skillful and time-consuming procedure.

When Mr. Jones complains of always feeling tired, and Mrs. Smith of never
enjoying good health, we must assume that common-sense approaches have

been tried in most instances. Patients should not be expected to waste good

money and time just to be told the obvious. It is not advantageous to be told
that the trouble is in the head and not in the body. We have to realize that

patients frequently cannot hear us when they are highly defensive about the

nature of their actual difficulty. Standard clichés of our common language are

often sterile channels, precluding mutually meaningful understanding. The

patient who says “fatigue” and the psychiatrist who hears “neurotic

syndrome” obviously are not talking in the same tongue. Any attempt to

exchange the word “fatigue” for “neurosis,” or vice versa, will do nothing to
improve communication. As long as there is no common meeting ground, it

does not even matter whether the patient nods his head in approval, or

shakes it in disbelief.

In discussing therapy, I object strongly to any kind of do-it-yourself

manual in psychiatry. At the same time, I recognize the necessity for

formulating technical procedure. It seems to me that illustrations are best
offered in terms of a particular approach without creating a model for direct

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imitation.

Suppose Mrs. Smith consults you with the following story: She has been
to many medical doctors for pain around her heart, headaches, backaches,

and thyroid trouble; she had been treated for gastric ulcers, but she has

always feared it might be cancer. Nobody so far had been able to help her. A
chiropractor offers her occasional relief, but it is never for very long. Her

family physician has prescribed tranquilizers and barbiturates, but they do

absolutely nothing for her. Another physician had recommended a different

medication, which helped only in the very beginning. Finally, she had come to
see a psychiatrist. She repeats her complaints to him, but the quality of her

voice is such that she sounds as if she did not actually expect to be believed.

After taking in her recital, with an occasional query here and there, the
psychiatrist deliberately changes the focus of the interview. He comments

something to the effect, “I hear that you have not been well for some time.

Suppose you tell me how it all started.” If there is a more or less definable
starting point, he may go on to inquire what life was like at that time. Was fate

smiling, or were there hardships or misfortunes? If all goes well, interest may

be stimulated in relating experiences of stress and strain of a familial, social,

economic, or other nature. The emphasis is not on a single traumatizing

event, but on repeated experiences of unhappiness, friction, disappointment,

etc. Then, a brief glance is attempted into the past, with such nonthreatening

questions as, “How happy a childhood did you have?” If you get a rigidly

American Handbook of Psychiatry 39

defensive answer, then, “I suppose there were at least some fleeting moments

of unhappiness, as we find in the life of all children?” Should all answers point

to a Hollywood Class C movie with a happy ending, it would be appropriate to

say so.

Anyhow, the attempt is made from all directions to get the patient
interested in talking about herself in areas which present potential difficulties

in living. You may find that you have gently and skillfully helped point to the

way in which the patient may eventually find help. Almost invariably,

however, such a patient will counter with some sundry version of, “That is all
very well and very interesting, but how about my various ailments?” Then it

seems appropriate to explain that psychiatrists do not know how to cure

tangible or intangible physical disorders as such. They do know, however,

something about frustrations, tensions, and anxieties. It is often possible to

get a new slant on what gets in a person’s way. There can be no promise of

the disappearance of the physical symptoms, but it has been found that in
some instances discomfort has been greatly reduced when certain difficulties

in living were better understood. Under no circumstances can we afford to

have the patient sit back while the psychiatrist is expected to do his stuff and

melt the patient’s complaints away. If there is to be any measure of success,

the principle of collaboration has to be stressed from the very beginning.

It is most important that we do not offer things to patients which we

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cannot deliver. The reassurance is much more profound when it is made clear
that direct verbal communication may lead to a better understanding of one’s

life situation, but that one cannot assume that bodily complaints will fall by

the wayside as soon as insight is gained. The psychiatric facts are often
otherwise, and it is our duty to inform our patients honestly and

knowledgeably.

I wish to emphasize the fact that successful intervention related to

neurasthenic and hypochondriacal manifestations does not necessarily mean

a cessation of symptoms. Some people may have acquired a style of life which

includes a measure of neurasthenic or hypochondriacal preoccupation. What

matters is the capacity not to be unduly distracted by the familiar

manifestations, which now assume a peripheral significance, without

interfering with constructive aspects of person-to-person relatedness. It is

understood, that the ability to sense one’s own, as well as one’s partner’s,

feelings of inadequacy provides a more effective protection against an

ongoing hostile integration.

American Handbook of Psychiatry 41

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