This is the preoccupation with bodily functions or physical signs and sensations, leading to the fear or belief of having serious disease. Hallmarks of this condition are the failure of repeated examinations to disclose any physical basis for the patient’s symptoms and the failure of reassurance to affect either the patient’s symptoms or his conviction of being sick. It is estimated that 85 percent of hypochondriasis is secondary to other mental disorders, chiefly depression, but also schizophrenia and anxiety neuroses. In approximately 15 percent of cases, however, there appears to be no associated illness (primary hypochondriasis). Most patients in this latter category are habitués of medical outpatient clinics, who are passed from specialist to specialist, perplexing and angering doctors along the way, because their symptoms defy both satisfactory diagnosis and cure.
Related to hypochondriasis, but probably more delusional are young adults who present with a fixed somatic belief regarding a peculiar symptom such as that the tongue is swollen, the jaw is not properly aligned, or the penis is ulcerated, when in fact no such abnormalities are present. The troubling aspect to the family and physician of such an illness is the persistence of the symptom and disability that extends for years, all tests having been negative. Probably these patients should be treated like schizophrenics, which many of them probably are. What to do with patients who are less severely affected but who have an unshakable belief that they have Lyme disease or environmental “allergies” depends on the context, but the likelihood of dissuasion is almost as poor as for the worst hypochondriac patients.
The treatment of primary hypochondriasis is difficult unless the physician keeps in mind the personality of the patient and the therapeutic goals. A psychodynamic outlook would suggest that these patients need to retain their symptoms, so that the usual concept of “curing” is inapplicable. The presence of symptoms provides the context for a relationship with a physician and it is the continuation of this relationship, which is often the only dependable contact in the patient’s life, which is the motivation for some hypochondriac patients. Such patients are best managed by general physicians who realize that these are patients who do not necessarily want or expect a cure, and who are content with small gains and the avoidance of unnecessary surgery.
Of all the abnormal personality types listed in Table 47-1, the antisocial is the best defined and the one most likely to cause trouble in the family and community. It had been defined (in DSM) very well as a state in which the individual “is always in trouble, profiting not from experience or punishment, unable to empathize with family or friends or to maintain loyalties to any person, group, or code. He is likely to be shallow, callous, and hedonistic, showing marked emotional immaturity with lack of sense of responsibility, lack of judgment, and an ability to rationalize his behavior so that it appears warranted, reasonable and justified.”