Mental health articles

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Aetiology of hypochondriasis

Genetic factors

There seems to be a genetic predisposition to at least some elements of hypochondriasis. Gillespie et al. (2000), for example, examined the genetic risk for developing what they termed somatic distress. They gave measures of anxiety, depression, phobic anxiety and somatic distress to 3469 Australian twins aged 18 to 28 years, and found that 33 per cent of the variance in somatic distress appeared to be due to a gene action unrelated to depression or phobic anxiety. Accordingly, their data suggest a unique genetic contribution to the reporting of somatic distress, and that this is not simply a manifestation of a more general propensity to anxiety or depression. One responsible gene appears to be a serotonin transporter gene polymorphism (Veletza et al. 2009).

Psychosocial factors

Many of the risk factors for hypochondriasis overlap with those thought to increase risk for somatization disorder. Rates of physical and sexual abuse among people with hypochondriasis are higher than among comparison groups (e.g. Barsky et al. 1995), as are reports of inadequate or inattentive parenting (Bass and Murphy 1995). Other studies have reported high levels of childhood sickness (Craig et al. 1993) and parental overprotection and encouragement of sickrole behaviour (Parker and Lipscombe 1980). Noyes et al. (2003) found that hypochondriacal symptoms were positively correlated with all the insecure attachment styles they measured, especially the fearful style. These same symptoms were positively correlated with self-reported interpersonal problems and negatively correlated with patient ratings of satisfaction with, and reassurance from, medical care.

Psychoanalytic models

Hypochondriasis has received surprisingly little consideration within the psychoanalytic literature, which has focused on explanations for the cause of unexpected symptoms rather than worry about them. Indeed, Freud (1914) originally considered it to be an ‘actual neurosis’. That is, unlike the defensive neuroses, he considered hypochondria to be a response to genuine symptoms – they were not generated by the unconscious as a result of some internal conflict. However, Freud (1914) subsequently developed a more psychoanalytic explanation for hypochondria, arguing that the libido could be divided into two dimensions. Object libido involves a love of external objects; ego libido involves love for oneself and one’s body. It can also be called narcissism. According to Freud, challenges to the object libido result in neurotic anxiety; challenges to the ego libido result in hypochondria. One challenge may come from the individual himself. According to Freud, if an individual becomes absorbed by his ego libido, two things may happen. Their focus on external sources of love will diminish, and they will develop anxiety about their physical state. The individual focuses on their love of their body and physicality, but at the same time becomes anxious that they may lose the object of their love and attention. Thus, they focus on both the good things about their body, but also any threats to their health that may destroy the object of their love.

Interpersonal theory

Reflecting the overlap between the two disorders, the model of hypochondriasis proposed by Stuart and Noyes (1999) is similar to the model of somatization of Craig et al. That is, they consider it to involve seeking emotional care from professionals as well as family and friends, through the reporting of physical complaints or symptoms. According to Stuart and Noyes, this results from anxious and insecure parental attachments established early in life. As in the case of somatization, lack of parental care or an adverse early environment may cause a child to view others as unreliable caregivers. The one way of gaining attention these children may have is through complaints of physical symptoms, as their parents are unresponsive to complaints of psychological distress. Thus, a cycle of complaints about physical symptoms, reinforced by parental attention, is established. This then becomes the primary way of gaining adult attention and feelings of attachment. This has two outcomes. First, the child learns to use complaints of physical symptoms to gain attention and perhaps love. Second, the child fails to learn other ways of eliciting care and attention from their environment. As an adult, the still insecurely attached person may communicate his or her need for care through complaints of illness. Unfortunately, these attempts at seeking support are frequently ignored, and even viewed with some suspicion, which may reinforce the original fear of lack of attachment and supportive relationships.

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