4—
Pathways toward Childhood Hypochondria
I am part of all that I have met.
—Alfred Lord Tennyson
Ulysses
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For Hundreds of years adult hypochondriacs, musing over the origin of their disorder, have peered into the branches of their family trees to locate the source of their discomfort. "My grandfather had it in a very strong degree," wrote Boswell of his hypochondria. "I'm black-blooded like all the Tennysons," Alfred Lord Tennyson explained.
Then, late in the nineteenth century, when hypochondria had become a nervous disorder and nervous disorders were increasingly regarded as malfunctions of the psyche, the predisposing signs were sought among the early experiences of childhood. At first parental mismanagement simply replaced bad bloodlines as the cause, but as psychoanalytical explanations became increasingly sophisticated, they incorporated more and more aspects of a child's social and cultural upbringing. The resulting explanations of hypochondria—some of which are in use
today—acknowledge that there is something in the depth and persistence of the hypochondriac's habit that urges careful consideration of the vivid and peculiarly distorted experiences of childhood.
Hypochondria among the young is not an unusual condition, though the disorder goes by so many names that its prevalence is not always obvious. "Psychosomatic problem patient" often means hypochondria, and "patient with recurrent abdominal pain" can too. (Among children the stomachache seems to be the most common of all unfounded complaints, with headache and chest pain a distant second and third.[1] Saying that a child belongs to "the fat envelope group—that is, has an enormous medical record—is another way of implying that hypochondria may be involved, and "kid crock" is unambiguous.
Although it is not possible to estimate how many children exhibit hypochondriacal tendencies and at what ages, pediatricians seem to agree that several forms of hypochondria are commonly encountered in both boys and girls between the ages of five and fifteen. Children younger than five frequently have such diffuse patterns of anxiety and such unrefined techniques of manipulation that it is hard to see what form their fears and insecurities are taking. At the other end of the age range, some doctors believe that a troubled girl may well continue to have stomachaches or a chronic cough, but a boy is more likely to express his troubles more assertively with multiple injuries or delinquency. The hypochondria that accompanies panic disorders most often strikes between late adolescence and early adulthood.[2]
Beyond these general observations two distinctions may be made. One is between acute short-term bouts of hypochondria that a child may experience, usually in response to a specific event such as the death of a parent or grandparent, and chronic hypochondria, which is a style of living that the child adopts over a much longer period. Acute reactive hypochondria can, of course, develop into the chronic variety.
The second distinction is between children who are themselves hypochondriacs and those whose parents are "vicarious hy-
pochondriacs." In the latter category the parent imagines that his child has a serious illness either because the parent is a hypochondriac and is displacing his symptoms onto the child or because the parent is using a "sick" child as an excuse to ask for personal help. In the Boston City Hospital, for example, a pediatrician noticed that parents sometimes brought healthy children into the emergency room night after night almost demanding that the children be admitted to the hospital for some totally imaginary condition. After a few nights the visits would stop as abruptly as they had begun. Becoming curious, Robert Reece, the pediatrician, managed to discover how these curious situations resolved themselves. In most cases the visits to the emergency room preceded an episode of child abuse. To his credit and the hospital's, "turkey admissions" (or "social admissions," as they are formally called) are now made to protect the child while counseling is arranged for the parent.
Returning to children who are themselves hypochondriacal, there seem to be three or four different ways in which they come to regard themselves as ill. These causes of or routes toward hypochondria range from the fairly straightforward copying of a parent's habit or the misinterpretation of medical information to the far more complex involvement of an entire family. Taking the experiences of children as a guide and moving from the simpler to the more complex, hypochondria can be seen as a habit cultivated because of its advantages, as the unfortunate result of frequent illness or a traumatic operation, as the misinterpretation of medical information (especially when such information is received under stress), and as part of a regulatory mechanism used by an unstable family to keep itself together.
As a habit, hypochondria is easy to pick up. For example, of the ten children born to Charles and Emma Darwin, seven reached adulthood and five were variously classified as hypochondriac, invalid, or depressed.[3] Darwin himself was almost constantly ill from the time of his wife's first pregnancy; therefore
all the children grew up in a household run to suit the needs of a sick man.
Emma Darwin "was a perfect nurse," wrote one of her granddaughters. "She was like a rock to lean on, always devoted and unwearied in devising expedients to give relief, and neathanded and clever in carrying them out."[4] Although the first son, William, and the second surviving daughter, Bessy, did not become hypochondriacal, all the others fastened on ill health as the accepted way of requesting their mother's (and later their wives' or husbands') affectionate solicitude. Henrietta spent her entire life warding off illnesses that apparently never materialized; George operated under the constant strain of "ill health"; Francis was clearly depressed; Leonard retired at age forty because of undiagnosed health problems and lived to the age of ninety-three; and Horace, who was "frail," was called "a dear old man" at thirty-eight. "I have Sometimes thought that she [Emma] must have been rather too sorry for her family when they were unwell," concluded the granddaughter. "A little neglect . . . might have done them a world of good."[5]
For other children the emphasis is reversed. The pleasures of being sick are not so well defined, but sickness is presented as the method of choice in dealing with problems. Sylvia's father, for example, used to go to bed at intervals throughout the winter for a week at a time. "If only I had a better job," he would moan from his darkened bedroom.
The winter he was forty-six his brother and sister died, and it seemed to Sylvia that he went to bed for the entire season. When Sylvia herself was depressed she would mope and start to act sick. This got her some extra attention, but only as long as she agreed to a strict limitation of personal freedom. Like her father, she felt she "bought" powerful maternal protection and with it the option of retreating from unpleasant situations, but only at the price of her independence. She continued this uncomfortable agreement with her husband, and the hypochondria copied from her father served a similar face-saving function in her marriage. Her father's weeks of undiagnosed exhaustion ex-
plained why he could not get a better job, and the dizzy spells and racing heart helped her believe that only poor physical health prevented her from setting up her own home, moving across the country, and in other ways being a capable, independent woman.
In the years between the two world wars an American psychiatrist named Esther Richards became interested in these kinds of experiences. She made several studies of hypochondriacs, first of adults, whom she questioned closely about their childhood acquaintance with illness, then of young hypochondriacs themselves. She found no distinctive event in the lives of these people that seemed to cause what she called the "invalid reaction," and their personalities did not seem significantly different from those of nonhypochondriacs. But there were some differences. As children almost all the hypochondriacs had the constant example of a chronic complainer in front of them. Usually this was a mother or father who had "the doctor habit" or "the patent medicine dosing habit" (this is the group that market research analysts today call "self-medicators"). In addition, the hypochondriacs Richards studied "were persons who early showed evidence of extreme sensitiveness. . . . They were born with a psycho-biologic outfit that made them peculiarly susceptible to their environment."[6] (This second distinction, which is attracting attention today, echoes the old constitutional basis for hypochondria and suggests that there may be a genetic basis for the problem. See Kellner[7] for a review of genetic factors in functional somatic symptoms.)
Richards's conclusion was that most young hypochondriacs are unusually sensitive children who learn by example to substitute illness for other kinds of difficulties and that this pattern can be reversed if caught soon enough. In the twenty cases of childhood hypochondria she treated, nineteen children unlearned their hypochondriacal habits. In comparison, the cure rate among adults was dramatically worse, and Richards contended that the sickness habit had become too deeply entrenched in their lives to be changed.
Among the investigators who subsequently built on Rich-
ards's work was Felix Brown at Maudsley Hospital, London. In the 1930s he studied forty-one hypochondriacs and, like Richards, found their abuse of illness to date from childhood. He too believed there was a "body-sensitive" or "body-conscious" type of person who was physically predisposed to hypochondria, and he too was of the opinion that "the care of a fussy and over-solicitous female relative" was an even more potent source of trouble.[8] "The impression is, in fact, that the . . . hypochondriasis is more contagious than hereditary."[9]
In Brown's view it was less a question of a child's copying the "I am ill" behavior of the parent than it was his responding to the oversolicitous relative who almost required him to be sick and who capitalized on these illnesses to enhance her own sense of control or well-being. Recent studies[10] have confirmed that a sickly childhood may predispose a person to hypochondria, but whether the push comes from the child's constitution, the illnesses themselves, or the treatment received is not known.
Today some psychologists wonder if that familiar stereo-type, the oversolicitous mother, can really determine the attitude of her children toward health and disease. To try to answer this question, a study was done in the mid-1960s of 350 mother-and-child pairs. The results surprisingly pointed away from the mother as the dominant influence and toward cultural variables such as the age and sex of the child.
"Mothers respond to their children's health and their own in a similar fashion,"[11] the report acknowledged. In addition, women under stress tend to report a few more illnesses for themselves and for their children. However, when these maternal influences were balanced against the distinctive differences in attitude produced by the age and sex of the child and the level of education of the mother, the more purely personal "maternal influences appear to be less influential than we anticipated."[12] It was found, for instance, that the less education a mother had, the less concern she showed for the detection and prevention of disease. With a more fatalistic attitude—what will happen, will
happen—she had little interest in detecting the first signs of a cold or any other disorder.
In regard to age and sex, girls were clearly more afraid of getting hurt than boys and more likely to tell someone when they felt bad. Among both boys and girls reports of symptoms were far more common among fourth graders than eighth graders, the two ages selected for the study. In a follow-up study conducted sixteen years later,[13] none of the mothers' attitudes toward their children's illnesses, as rated in the original study, was associated with problems in early adulthood. Other studies, however, suggest that parents' attitudes toward disease have a lasting effect on their children.[14]
Other investigations further suggest that a predisposition to hypochondria is associated with being a firstborn or only child. These children have more symptoms—as reported by their parents—and receive more medicines than second or later children.[15] Although all young children, as well as the elderly, are expected to complain openly of discomfort in our society, mothers act on the complaints of their children far more often than they act on their own symptoms or on those of a resident grandparent. In other words, a common focus for parental anxiety is a sick child, especially if he or she is the oldest.
Another variable that apparently influences a child's predisposition to hypochondria is ethnic background. (See chapter 9.) To take one of several examples, white Anglo-Saxon Protestants often have the attitude that it is wrong to complain unless something is "really" wrong, an approach that produces a group of people who cannot express psychological distress easily but who can seek the support they need by translating nebulous feelings of loneliness, boredom, and apprehension into "real" physical symptoms.
Taking age, sex, birth order, heritage, and social class together, the investigators concluded that "the overprotective, hypochondriacal mother does not necessarily beget a child with similar (or opposite) traits. . . . The child is probably neither as
malleable nor as fragile as current psychological theory sees him."[16]
Regardless of whether children's attitudes toward sickness were primarily determined by their mother or by a broader set of cultural factors, both Richards and Brown could clearly see that once their young patients were sensitized to illness, they hesitantly, then adroitly, began exploiting the sick role to an ever greater and more imaginative extent.
Some of the gratifications that these children associated with being sick, such as receiving more attention or not going to school, were obvious. Other advantages were obscure. Among the latter, the late Michael Balint, a renowned psychiatrist, pointed out that being sick can be a way of justifying a strong interest in certain parts of the body while not admitting that this is the case.
It is impossible not to notice the high emotional importance of eating in all gastric . . . diseases [and] of the digestive functions in intestinal disorders, particularly in chronic constipation.[17]
Balint also considered some forms of regression, such as thumbsucking and clinging, direct gratifications and raised the interesting idea that initially, at least, such actions may be part of a person's unconscious attempt to get well. "By regressing to a more primitive level the patient may be seeking an opportunity to make a new start in a new direction, avoiding that blocked by his illness."[18] Of course all the advantages of being ill, Balint emphasized, can only partially compensate for the discomfort, apprehension, and limitation that are also part of every illness.
Whereas some children pick up hypochondria as a habit and cultivate illness for the advantages that go with it, others become hypochondriacal as the result of medical mismanagement. When Esther Richards made her original study of sixty hypo-
chondriacs at a Johns Hopkins clinic, she found medical mismanagement to be the second most prevalent condition that can lead a child toward hypochondria, the first being the example of the chronic complainer. By medical mismanagement Richards meant the handling of an illness or operation in such a way that regardless of its seriousness, the child felt intolerably threatened. Such children believed themselves to be vulnerable and had no power to protect themselves.
During the calamitous years of the Second World War, Anna Freud began working along the same lines, often in collaboration with Dorothy Burlingham. Elaborating on the observations made by her father that the causes of hypochondria are part of the patient's present rather than past situation, and that a physical illness or a history of illness often triggered a bout of hypochondria, Anna Freud wrote a paper entitled "The Role of Bodily Illness in the Mental Life of Children."[19] In it she analyzed some of the effects that medical operations quite unexpectedly produced on children. Her interpretations of what she observed in the Hampstead Child Therapy Clinic, where she was director, and in the Residential War Nursery for Homeless Children, which she organized, were based on her belief that children undergoing almost any medical procedure feel threatened from both the outside and the inside—that is, from the strange and somewhat frightening external setting and at the same time from the fantasies and anxieties that the procedure activates. According to Freud, it is the child's interpretation of the seriousness of the operation, not the doctor's opinion, that determines the psychological effects the procedure will produce. Only the child feels the combined threats of a strange setting in addition to the punishment, abandonment, mutilation, castration, or other symbolic meaning that he or she imagines is the real basis of the operation.
Freud realized that even before a child is taken to the hospital he senses a change in the family's emotional climate. He probably gets more attention than usual, and this extra consideration from parents, and perhaps extra jealousy from a brother or sister, can confuse him. Then, with or without an explanation
that he understands—and certainly without one he accepts—he is taken to the hospital and, in Freud's day, left alone. No promise of future joy or explanation of present necessity can reconcile a young child to being left alone in a strange place. The sight of his mother backing out of the hospital room, tears in her eyes, crayons and modeling clay clutched in her arms, is terrifying.
"Why am I being left here?" "Why isn't my mother staying with me?" The questions aren't always asked, but they are deeply felt with unutterable misery. As Anna Freud had already discovered during the London blitz, and as John Bowlby and others further documented in the 1960s and 1970s, separation from the mother was the greatest trauma a young child could suffer. To be abandoned—so often interpreted as a punishment—was more terrifying than being bombed or burned or operated on. Furthermore, young children had no concept of how long they would be left in a hospital. Bowlby found their reactions were the same as though their mothers had died. First came several days, even a week, of tearful protest and an urgent effort to recover the missing mother. This was followed by despair as the child began to grieve.
To add insult to what is already grave injury, Bowlby noted that "a child in a hospital is likely to be confined to a cot and to be subjected to a variety of medical procedures that are always strange, perhaps painful, and certainly frightening."[20] As the actual operation draws near and the child is strapped onto what he may well perceive to be his mother's ironing board or kitchen chopping block, his sense of physical restriction intensifies, and his rage and anxiety may rise to intolerable levels. Many young children abhor the momentary restriction involved in pulling on a T-shirt. How much worse to be bound to a stretcher?
Freud goes on the describe the symbolic meanings of the operation itself which she believes are frequently understood by children to be mutilation, castration, attack by the mother, punishment, seduction, or intercourse. The pain itself, which may come as a terrible surprise if the child's parents have not pre-
pared the child, reactivates an unpredictable array of fantasies and anxieties. Pain, Freud said, is an important event for a child and is remembered for a long time.
In addition to all this, the child frequently feels betrayed by his parents. When scratchy toast and soft-boiled eggs arrive instead of ice cream the morning after a tonsillectomy, and when stitches hurt instead of feeling like "tiny pin pricks," the child feels he has been lied to.
If the operation is to leave no psychological scars, the child's defense mechanisms must be strong enough to handle the mother's leaving, the medical procedures, the pain, restrictions, strange food, dark nights, odd smells, and all the deeply hidden fears that these events stir up. If he is unable to master this formidable array of internal and external threats, his normal functioning will begin to break down. Neurotic outbursts then occur as the child uses primitive measures of defense such as regression to infantile behavior or denial of the whole situation in an attempt to ward off unendurable emotions. The operation, Freud maintained, has become a trauma, a classic case of medical mismanagement. The damage may be expressed as hypochondria or as some other form of anxiety, and it may appear immediately or years later. Medical mismanagement leaves a scar, Freud asserted, "and there is no scar in mental life which can not reopen under specific conditions. If this happens, the whole structure of the personality is shaken to the core."[21]
Until recently tonsillectomies have been one of the most common precipitating factors of hypochondria and anxiety attacks in children. Both Esther Richards, the psychiatrist who studied hypochondriacal children at Johns Hopkins, and Leo Kanner, author of the widely read Child Psychiatry , singled out this operation as emotionally hazardous:
I have seen several children whose anxiety attacks, beginning a few weeks after tonsillectomy under ether, reported sensations "just like having ether. . . . " These children had been
poorly prepared for their operations. In some instances they had been told by playmates and classmates that occasionally people did not wake up from the anaesthetic. They thus received the sudden shock of a major threat to their existence.[22]
In trying to ascertain how medical mismanagement is converted into hypochondria and neurotic anxiety, Anna Freud was given a clue by the behavior of orphans. Unlike other children, who, Freud felt, had little interest in their bodies between the ages of about two and puberty, orphans routinely coddled and comforted themselves, sometimes even murmuring endearments to themselves. "There, there, my sweetie, it's all right." Freud wrote,
When watching the behavior of such children toward their bodies, we are struck with the similarity of their attitudes to that of the adult hypochondriac, to which perhaps it provides a clue. The child actually deprived of a mother's care, adopts the mother's role in health matters, thus playing "mother and child" with his own body.[23]
Subsequently Freud found that this hypochondriacal concern for one's own body could develop in children who were not orphans but who felt neglected or abandoned. She gave as an example a six-year-old boy with a tic who was having a hard time sharing his mother's attention with his father and baby brother.
His tic was a pathological way of playing mother-and-child with his own body: he took over the role of . . . comforting and reassuring . . . , while his own body represented himself in the role of the frightened and suffering child.[24]
It is not difficult to imagine how this game could start after
a traumatic operation, chronic illnesses such as allergies or cerebral palsy, or even after more ordinary events such as the birth of a brother or sister. The irrational illness patterns that may result are often further reinforced as the child hears his parents routinely explain that his hypochondriacal behavior is the result of "a bad experience."
Still another variation on the medical mismanagement theme is the irrational sense of vulnerability that may be impressed upon a child through his observation of another's pain and death. When the nineteenth-century writer Charlotte Brontë was five her mother died, and three years later she and three of her sisters were sent away to the penurious and poorly run Clergy Daughter's School in Cowan Bridge. By February of that first dreary winter Charlotte was watching Maria, the eldest sister, sicken with consumption. Maria was given plasters that blistered her skin, then roughly shaken for not having the strength to get out of bed. As Charlotte watched, her sister grew weaker and weaker. Maria died in May: the second sister died in June. Charlotte returned to school only to find its Calvinist director still delivering lectures in praise of death as a protector from sin.
By the time Charlotte was eighteen she was deeply depressed, and part of her anxiety manifested itself as what she called "that darkest foe of humanity," hypochondria. Looking back at her years in boarding school, she insisted that "assuredly I can never forget the concentrated anguish of certain insufferable moments, and the heavy gloom of many long hours, besides the preternatural horrors which . . . made life a continual waking nightmare."[25]
"A horror of great darkness fell upon me," she wrote in her first and largely autobiographical novel. "I felt my chamber invaded by one I had known formerly, but had thought for ever departed . . . , hypochondria."[26]
Medical Students Disease is a rather different form of hypochondria which is based on the misinterpretation or misuse of medical information. Although simpler in nature and more tran-
sitory than the deeply embedded hypochondrias, it causes very real distress among a majority of medical students[27] as well as among persons who avail themselves of medical information or misinformation.
Every summer vacation hundreds of unabashedly exaggerated adventure stories suggest to some fascinated eleven-or twelve-year-olds that their mosquito bites are the pox and their poison ivy, leprosy. For most this holds more excitement than fear. Health films shown in high school strike closer to home, and thousands of imagined cases of venereal disease result.[28] But medical students with access to examples and descriptions of the full range of humankind's nefarious diseases are the ones who routinely, and with great earnestness, mistake tension headaches for brain tumors and general fatigue for the onset of ankylosing spondylitis.
"The . . . disease you labour under is your apprehension of many diseases and a continual fear that you are always inclining or falling into one or other," wrote a compassionate doctor to Robert Boyle, the chemist, physicist, and medical doctor best known for his law on the elasticity of gases. "This distemper is incident to all that begin the study of diseases."[29]
Although this is less commonly known, medical students extend their fearful diagnoses to fellow students, teachers, and even members of the public. A woman seen scratching her ankle more than once or twice is suspected of having primary psoriasis, and a student who faints in class is considered by some of his or her peers to be suffering from ischemic heart disease. According to Paul Atkinson,[30] who spent two years accompanying medical students on their hospital rounds as part of a study of medical education, the tendency to see in minor symptoms evidence of major illness is a perfectly understandable reaction that needs no deep psychologizing to understand. Medical students do their third-and fourth-year learning in a teaching hospital surrounded by seriously ill patients. Atkinson believes that in such a setting students do not ask themselves "Is this patient ill?" but rather "What exactly is wrong with this person?" Given this bias, stu-
dents may soon regard all symptoms as indicators of disease. This is especially likely to happen when a student is under personal as well as academic stress.[31] In most cases when a medical student becomes distraught enough to consult a doctor or request X rays, he or she can accept the information received and reinterpret the symptoms in a more realistic way. Some investigators suggest that psychiatric assistance would be more to the point.[32]
The popular conception that medical students spend much of their time worrying about disease has recently been challenged. A study comparing medical students with law students[33] found that although the former paid more attention to physical symptoms and briefly exhibited the symptoms they read about, the groups contained an equal number of real worriers. Fewer than 10 percent of each group were judged to be hypochondriacal. This study does not invalidate earlier findings but suggests that Medical Students Disease is a fleeting phenomenon likely to affect only a small portion of students at any one time and that similar concerns (especially the fear of cancer) are prevalent among other students.
In studying this process whereby a person interprets a symptom as either insignificant or dangerous, medical sociologist David Mechanic has stated that most persons react appropriately if they have either experienced the sensation many times before or have been told about it in sufficient detail.[34] Sometimes, however, these same experienced and/or well-informed persons react inappropriately, either ignoring signs of a serious disease or building a minor symptom into a sign of terminal illness. The latter tendency has been the bane of many medical students and other hypochondriacs for centuries.
Before becoming a famous colonial minister, Cotton Mather studied "Physick" at Harvard University (at the age of thirteen) and later admitted that "I was unhappily led away with Fancies, that I was myself troubled with almost every Distemper that I read of in my Studies; which caused me to use medicines upon myself, that I might cure my Imaginary maladies."[35] And almost two hundred years later, as Charles Darwin prepared to embark
are only upon the Beagle , he was equally distressed with palpitations and pain about the heart.
Like many a young ignorant man, especially one with a smattering of medical knowledge, [I] was convinced that I had heart disease. I did not consult any doctor, as I fully expected to hear the verdict that I was not fit for the voyage.[36]
Mechanic believes that these hypochondriacal responses frequently arise from "morbid cues" such as the sight of sick people or the reading of case histories that are present just as a person experiences the normal symptoms of stress. He describes a study in which two groups of college students were given adrenalin without being told what it was or what sensations it would produce. As the chemical elicited the usual symptoms of arousal, members of one group were put in the company of euphoric companions who were supposedly other students taking the test. Members of the second group were paired with angry, anxious companions. It was observed that all students underwent a two-step reaction. First, each became physically aroused: heart rate increased, mouth felt dry, and so forth. Then each student defined the meaning of this arousal. In this second step (i.e., during the interpretation of the symptoms) the cues received from each subject's companion were of great importance and largely determined whether the experience was interpreted as a great trip or a frightening disruption.
As Mechanic put it, "the same internal state can be labeled in a variety of ways, resulting in different emotional reactions."[37] Students stressed by new experiences, a heavy course load, and exams, he continued, are frequently in a state of emotional arousal in which they experience a large number of transient symptoms. These "little strugglings of nature," as Boyle's doctor termed them, are considered normal, when considered at all, by most students but are given specific and fearful meaning by medical students or others who are receiving morbid cues. Such cues
need not come from medical literature. They are equally powerful if present as the reactivated memory of a past illness, the death of a well-known person, or the presence of a sick relative or friend. All such invitations to fearful misinterpretation are particularly hard to ignore when received by persons already predisposed to hypochondria by parental example, chronic illness, or family dynamics. Medical students may fall squarely within one of these predisposed groups, as their very interest in medicine is often motivated by a conscious or unconscious fear of disease.
The most complex and possibly the most intractable form of hypochondria to be embedded during childhood is the variety that forms an integral part of a family's way of life. One or more children are singled out as "sickly," and whether they are then coddled or, oddly enough, even punished for being sick, their role in the family drama is fixed. Because the very survival of the family seems dependent on each member playing a consistent part, the children labeled "sickly" will receive no real encouragement to exchange their hypochondria for more constructive behavior. Almost from birth such children are funneled into the role of hypochondriacs.
Obviously this family-generated and maintained hypochondria is not completely different from the kind in which the child copies an ailing parent. There may be a difference in degree, however, the "family plan" apparently blanketing a child with more intense and pervasive motivations for being sick. The difference may also lie in the perspective of the observers, meaning that a doctor or psychologist may see a case of hypochondria as being generated largely by the child or may see the ailment as being produced by an entire family working together.
In an anxious or downright neurotic family, the child labeled "sickly" is frequently treated in one of two distinctly different ways. Either he is extravagantly overprotected, with each cold and bruise eliciting great concern, or he is just as remarkably underprotected (as far as illness is concerned), with sore throats and stomachaches brushed aside or even punished. Although the
development of hypochondria is easier to follow in children who are overprotected, the two family styles have much in common.
The American poet Sara Teasdale, an unhappy example of the intimate connection that can arise between overprotection and hypochondria, was born in 1884 to parents whose youngest child was already fourteen. According to Sara's excellent biographer, William Drake, she was brought up in St. Louis in a home that reflected "the best taste and manners of the upper and middle class with its pretensions of English aristocratic refinement."[38] Sara's father, a prosperous and well-respected wholesaler, seemed pleased but only marginally affected by her arrival. She remembered him as kindly and mostly absent. Conversely, her mother had emerged from a sickly childhood to become a restless and formidable force in her family's life. In some ways the middleaged Mrs. Teasdale resented having to resume the tasks of early motherhood, but she buried that "tangle of negative emotions," as Drake sees it, beneath a "public demonstration of lavish concern."[39] In addition to assuaging whatever guilt Mrs. Teasdale might have felt concerning her own resentment, the incredible fuss she made over Sara's health also allowed her to indulge her propensity to manage. It was a trait she was never comfortable admitting but one she strongly and consistently expressed. By labeling Sara "delicate" and truly believing that she was, Mrs. Teasdale transformed what she could not bear to think of as domination and manipulation into the far more acceptable qualities of caring and good management.
Although Sara's father seems peripheral to his daughter's upbringing, he allowed (in fact probably encouraged) his wife to translate their marital conflicts into problems in child rearing. Instead of arguing openly over travel and vacations, for example, which Sara's mother loved and her father disliked, they seemed to agree that the central problem in their lives was Sara's health, not their own disagreements.
To validate their bogus problem, the Teasdales frequently called in physicians to the big old house on Lindell Boulevard, and Sara was put to bed—to save her strength—for every reason
imaginable. Sara lived among neat piles of extra blankets and rows of tonics. She was kept indoors and not considered strong enough to attend school until she was nine years old. By then Sara herself was convinced of a profound physical inadequacy. Although she had not yet fastened upon the kinds of weaknesses that would be characteristic for her and was only beginning to realize that being delicate could be worked to her own (as well as to her mother's) advantage, she was thoroughly and irrationally apprehensive.
When Sara was fourteen she was far too old to continue to attend the private school one block from her home and so was sent to a prestigious girl's school in St. Louis proper. It is possible that this step toward greater self-reliance jostled the status quo and that both Sara and her mother felt ambivalent about the change. "If one is asked to do something [grow up] and not to do it [stay home] at the same time," noted the imaginative therapist Jay Haley, "a possible response is to be unable to do it—which means indicating that one's behavior is involuntary. The physiology of the human being seems to cooperate in this situation even to the point of producing symptoms."[40] Not surprisingly, the ride to and from school by streetcar proved too exhausting for Sara, and she returned to the suburbs. The habit of a lifetime was set. Everything outside of poetry—and frequently that too—exhausted Sara and made her sick. A year rarely passed without extended retreats to an inn or convalescent home. The most disabling part of this pattern was the ingrained belief that it was necessary to relinquish her independence in order to receive love. It had been so with her mother, who seemed to give love only on condition that she be in control of a weak, dependent Sara, who in turn assumed that the same trade would have to be made with a husband. The stress that this impossible situation created for a willful intelligent woman gave her illnesses unrestricted scope and function (see chapter 5).
The mechanism of family involvement can be seen still more clearly in a modern case that, like Sara Teasdale's, involved a domineering mother but was different in that the mother fo-
cused her children's attention on illness by punishment rather than treatment.
Anita was the eldest of four children in a family that moved, without apparent reason, from a series of homes in the suburbs of Philadelphia to equally well-kept houses on the outskirts of New Haven, Connecticut—and back again. Her father, a consultant for a large company, traveled a fair amount and even when home would sometimes return to his office after dinner. Her mother cared for the children and the house and apparently had neither the confidence nor the ambition to expand her sphere of influence.
Anita's earliest memories of sickness were of her mother heaving a tremendous sigh and repeating, "Oh, Anita, what a terrible inconvenience." There was more to the message than annoyance, however, and although Anita at five and six years old could not understand why being sick was being bad, she was sure that her mother's sighs and her father's admonitions not to upset Mother really meant that she was being naughty. As she grew older and the association between being sick and being bad coalesced, Anita got into the anxious habit of trying to hide her sore throats and stomachaches until they went away or became more than she could bear. She would sometimes go to bed at night with an earache, believing that if she were truly a good girl she could make the hurt go away. If it did not, she felt as guilty as the times when she had dissected a bug or worm with her mother's manicure set, a practice her mother particularly hated.
When she was seven Anita had two unfortunate experiences that abruptly removed illness from the category of simple sin and placed it in the terrifying position of imminent and personal danger. First was the death of a playmate during an operation that was supposed to cure her of a congenital heart defect, and second was the sudden death of a neighborhood boy who had been skating with Anita only the day before.
Anita was badly shaken. Not only was there no protection from a benevolent God or loving parents, as she had been led to believe, but there was no warning either. "I can never be sure
this day is not my last," she remembers saying to herself. From then on Anita worried almost continuously both about contracting terrible diseases and about her mother's predictable annoyance, reinforced as it always was by her father's distant approval. The pattern was set: for the next twenty-five or thirty years she tried to hide the sore throats, swollen lymph glands, chest pains, and disabling diarrhea that she frequently imagined were the first signs of cancer or heart disease. During this time she felt trapped between her desire to ask for help and her conviction that such admissions of inherent insufficiency and badness would be met by the old pattern of parental rejection. During times of stress she had become a reluctant hypochondriac.
Anita's distorted ideas of sickness, like those ingrained in her two sisters and, to a lesser extent, in her brother, were fostered primarily by Anita's mother and agreed to by her father. Anita's mother had had a miserable childhood by almost anyone's standards. She had been raised by an alcoholic mother who was also a flagrant and imaginative hypochondriac. She suffered continually from exotic and incurable illnesses until she died in her seventies. Anita's mother also had to contend with a younger, prettier, smarter, and infinitely more fragile sister who was raised in a manner reminiscent of Sara Teasdale. Anita's mother was shut out from the close relationship between mother and favored sister which revolved around their constant illnesses and special regimens. A sick person, she soon learned, had the right to be self-pitying and rejecting.
As a married woman, Anita's mother apparently carried over her unresolved conflict with her sickly sister and overbearing mother onto her own four children, especially the girls. Sickness in her children seemed to reactivate memories of her sister, and in spite of her efforts to be a good mother the old jealousy and dislike reappeared, this time directed at Anita and her sister. Memories of her mother were reactivated too, and because she thought she was treating her children exactly as she wished her mother had treated her when she was a child, she was confounded by their lack of gratitude, obedience, health, and beauty. Their
shortcomings suggested that her child-rearing methods were not perfect and, more important, that her control was not complete.
Anita's mother was especially anxious to control her husband in a way that would guard against overt rejection. When he was busier than usual with his work, Anita's mother vividly expressed her anger—but at the "damn telephone" and at his "stupid," inconsiderate clients, never at her husband for being so involved in his work. "How can I handle four children, especially with one of them sick?" and "How can I manage this impossible house?" became an endless refrain which allowed her covertly to criticize her husband for pursuing his career so independently, while skirting the real question that she never dared ask: "Am I important to you at all?" For his part, her husband was content to pretend that the real problems in their lives centered on the children and the house and had nothing to do with him.
Such a brittle and indirect way of expressing but never resolving conflict has been sufficient to keep Anita's parents together for fifty years but has passed along a disagreeable legacy to all four children. It has taken years for Anita to even partially divest sickness of its hidden meanings (see chapter 11).
Having progressed, haltingly, from the relatively simple processes of misinterpretation of medical literature and the copying of an ailing parent to the complicated dynamics of family conflict diffused and rerouted through hypochondria, we can see that for most chronically hypochondriacal children three or four events or mechanisms interact to perpetuate their distress. A child who copies a chronically sick parent who has a distorted view of illness will learn that however the illness game is played, it has certain advantages for the child as well as for the parents. Copying sickness thus gradually becomes cultivating illness for its advantages, at least on some occasions. By this time the child has become unusually sensitive to the emotional connotations of illness and is particularly susceptible to medical mismanagement. Noticing the signs of illness around him more than other children, the child is also more likely to be deeply affected by the death of a peer or
to read terrifying and personal meaning into what he sees and hears. Such misinterpretation feeds upon itself, maintaining the morbid sensitivity toward disease, which in turn leads to future misunderstandings. If this unfortunate cycle is part of the way the child's family suppresses and controls aggression, it is probable that his hypochondriacal reactions will become one of the major ways in which he deals with or attempts to control other people. After leaving to start his own family, he is likely to cling to those hypochondriacal methods rather than to risk the unknown dangers of open argument or rebellion. Even with some insight into the problem, a person may be only half cured, and, as Bernard de Mandeville put it nearly three hundred years ago, such a man or woman "lingering under the remainder of her Disease, may have half a dozen children that shall all inherit it."[41]
And so the cycle begins again.