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24 April 2024

The rise of the worried well

Caroline Crampton’s history of hypochondria shows how the internet has exacerbated health anxiety.

By Pippa Bailey

When Caroline Crampton was 17 she was diagnosed with Hodgkin’s lymphoma, a rare type of blood cancer. It recurred a year later, during her first year of university. After chemotherapy and a stem-cell transplant, she was given the all-clear at 22. It was then that another illness took hold. “It took being cured of a life-threatening illness for me to become fixated on the idea that I might be sick,” Crampton writes in A Body Made of Glass, an ambitious study of hypochondria. “My body and my life… were cancer-free. But I am not free.” Sometimes her anxiety is distant, there but barely audible; at others, it is all she can hear. She can go from being in “rude health” to having convinced herself that she is “definitely dying” in a matter of minutes. Despite having begun her career in journalism in the early 2010s, when “the so-called first-person industrial complex” of harrowing confessional essays gripped journalism (arguably, it still does), Crampton long resisted writing publicly about her hypochondria. But her precise and visceral recollections make real and corporeal a condition that some claim is neither.

Hypochondria “dwells in contradictions: a perceived disease of the body that exists only in the mind”. Even its name proves elusive. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013 by the American Psychiatric Association, divides it in two: “somatic symptom disorder”, in which a patient experiences unexplained physical symptoms, and “illness anxiety disorder”, a preoccupation with illness. Crampton, who sees elements of both in herself, considers this flawed. The World Health Organisation’s 2022 International Classification of Diseases makes “health anxiety disorder” interchangeable with “hypochondria”. The former is, Crampton says, the term more commonly used by medical professionals, but she is fond of “hypochondria”, widely used by laypeople: its long history makes her feel less alone.

The history of hypochondria is bound up with humankind’s shifting understanding of the link between the mind, body and disease. Today, we think of it as a condition of the brain, but it began in the abdomen. The word “hypochondria” was first used by Hippocrates in the fifth century BC. Combining the Greek hupo, meaning “under”, and khondros, meaning “sternum”, it denoted the section of the torso beneath the breastbone, which encompassed the liver, the spleen and part of the stomach. For centuries, “the hypochondria” was simply a term to describe where in the body symptoms were felt.

The Hippocratic tradition taught that the body was made up of four humours – phlegm, yellow bile, black bile and blood – and that sickness occurred when they were imbalanced. Black bile was linked with the hypochondria as it was believed to be made and stored in the region’s organs, but it was also associated with depressive moods. (The Greek for black bile, melaina chole, is the origin of the word “melancholy”.) The hypochondria became associated with both digestive and mental function, a fitting pairing given the physical manifestations of anxiety – nausea, tension, “butterflies” – are often felt in the stomach.

As the primacy of this theory declined in the early-modern period, no “unified replacement” rose in tandem to explain the mind-body connection. One conception was that animal spirits – messengers made in the brain – circulated the body, just as blood did. Another was vapours, “agents of mysterious malignity in the body”, a popular theory in the late 17th century. But it was Thomas Willis’s “bodily nerves”, which posited that nerves sent messages from the brain to the body, that won out. Hypochondria was no longer a disease of digestion but of the mind.

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Hypochondria underwent another transformation during the Industrial Revolution. Health anxiety had once been “the preserve of the upper echelons of society” – or, as the physician George Cheyne put it in 1773, of “the Rich, the Lazy, the Luxurious, and the Unactive”. The working classes’ afflictions were external – broken bones and infections – and the upper classes’ internal: conditions of the nerves (including the hypochondria-adjacent “hysteria”) were “associated with refinement, imagination and intellectual activity”. Certainly, many of the real-life hypochondriacs that pepper A Body Made of Glass are men of letters: Cicero, Proust, Donne, Kant, Byron, Darwin, Freud and Larkin. It has been argued this divide exists because those living precarious lives have less capacity for “imaginary illnesses”, but Crampton believes it is more to do with “who gets to record their inner feelings for posterity”.

As the poor left the countryside for the cities seeking work, a “new kind of hypochondriac began to show up in medical records”. The infirmary in Edinburgh, for example, recorded a fisherman from the Shetland Islands whose chest, abdomen and throat pains were deemed “altogether the creature of his own brain”. In 1774 the American physician Benjamin Rush told the American Philosophical Society that “hypochondriac disorders, once peculiar to the chambers of the great, are now to be found in our kitchens and workshops”.

In this newly consumerist society, a market for medical goods emerged. Hypochondriacs could purchase all manner of unevidenced potions and devices that promised relief, many of which were in fact toxic. The first clinical trial of the placebo effect was a reaction to this burgeoning industry. In 1799 Dr John Haygarth of Bath General Hospital, irritated by a quack device called a “Perkins tractor”, a metal rod waved over the body to relieve pain, created an identical dummy. Five patients with chronic rheumatism were treated with the dummy one day and the real thing the next; there was no difference in outcomes. Crampton links 18th-century quackery with the modern wellness industry and its emphasis on “clean” living and wearable trackers. You can now buy “Zeebo” pills, a placebo that is advertised as such, in which “you are the active ingredient”, for $25.

By the 19th century, hypochondria’s transformation from being of the body to of the mind was complete. The abdomen might show the symptoms of distress, but it was not their cause. This reversal – the mind controlling the body, rather than the other way around – became entrenched with the rise of psychoanalysis. Today more emphasis is being placed on the interconnectedness of the two, for instance the power of microbes in the gut to influence mood. In 2008 the US National Institute of Mental Health began a project seeking to categorise mental disorders based on behaviours and biological markers. This may still be “the stuff of science fiction”, but there exists a possible future in which every shift in the mind can be observed, even predicted, at a cellular level.

In an episode of the reality TV show The Kardashians, in which the family matriarch Kris Jenner has an elective full-body scan, an attendant tells her: “What we sell here is peace of mind.” But Crampton wonders if the reverse is true: can we know too much? Advances in medical science have rendered the body “increasingly transparent”, yet with this comes heightened awareness of the many ways our health could fail at any moment. Hypochondria is more common in prosperous countries with advanced healthcare, while the internet age has exacerbated health anxiety by placing vast and unmediated knowledge in the hands of the average googler.

There is no agreed treatment for hypochondria. Research suggests that sending sufferers for further tests to allay their fears in fact worsens their condition. The most common approach is cognitive behavioural therapy (CBT), which attempts to interrupt destructive thought patterns and teaches coping mechanisms. There has also been some success with a combination of CBT and antidepressants, though no one understands why the latter help. Such unknowns are typical of hypochondria, which “only has questions, never answers”. The sufferer’s story is a “plotless” one, a repetitive loop, without redemption or catharsis.

A definitive summation of hypochondria proves similarly impossible. A Body Made of Glass is a wide-ranging work, moving from personal story to literary analysis to the history of medicine and back again. At times, this renders it meandering and hard to follow. In the book, hypochondria is a moon, at times brilliant and clear, at others obscured by dark, wandering clouds. It is a hypochondriacal book: a committed search for answers that may or may not exist.

A Body Made of Glass: A History of Hypochondria
Caroline Crampton
Granta, 336pp, £16.99

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[See also: Delusions of immortality]

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This article appears in the 24 Apr 2024 issue of the New Statesman, The Age of Danger