Hypochondriasis may be only the early stage of more serious mental disease. It may be one manifestation of an hereditary neurosis or psychoneurosis, or it may arise from deterioration of the body's vitality by organic disease, especially of the abdominal or pelvic organs or through some incurable weakness or functional disorder. In either of these cases its cause and duration will be determined by the clinical history. As an uncomplicated psychoneurosis hypochondria lasts from a few months to a number of years, with very little change in its prominent symptoms, resulting in recovery for the most part, becoming chronic in a moderate proportion of cases, and rarely proving fatal except by some accidental complication, including suicide.
The PATHOLOGY AND MORBID ANATOMY of the disease are unknown.
The differential DIAGNOSIS consists in the exclusion of other diseases.
The PROGNOSIS is favorable in uncomplicated cases.
TREATMENT consists in measures to improve the general health, especially a full diet carefully selected, hydro-therapeutics, massage, gymnastics, horseback riding, walking, rowing, abundant and agreeable exercise in the open air, and the management of the patient's surroundings so as to lighten the mind and relieve from worry, perhaps by travel, sea-voyages, etc. Argument is commonly worse than useless, but there should be a decided impression given that the generally morbid state is due to ill-health. The risk of suicide is so small that restrictions of liberty directed to its prevention do more harm than good. It goes without saying that bad habits should be reformed, narcotics should be avoided, and a healthy occupation should be encouraged, or, if possible, insisted upon. The difficulties in treatment are fully as great with the highly-educated superstitious and credulous people whom we find in the literary and professional circles as in the ignorant and weak-minded.
MELANCHOLIA (Die Melancholie, Schwermuth, Tiefsinn, Trübsinn, Lypemanie, Mélaneolie, Aliénation partielle depressive, Monomanie triste, Phrenalgie, Psychalgia) is one of the functional mental diseases, in the sense that the pathological condition of the brain upon which it depends is not yet known, although it is thought to begin with disturbances in circulation and nutrition, which end, if not resulting in cure, in atrophic, degenerative, and inflammatory states, indicating, in the great majority of cases, extensive brain disease. As a rule, melancholia first appears in a slight change of character; the patient is said by his friends to be not quite like himself. After some days or months, as the case may be, the symptoms develop into settled gloom associated with mental pain—the state known as
Simple Melancholia (Mélancolie raisonnante), in which the events of life are correctly observed, but, incorrectly interpreted, are the source of constant apprehension, self-depreciation, depression, and despondency. There are no delusions, properly speaking, and yet there is a disposition to take the dark-side view even of circumstances which promise favorably, which amounts to a generally deluded state of mind. Commonly there is increased irritability, now and then a genuine moral insanity, and occasionally in neuropathic constitutions the state of mind already described under the head of Impulsive Insanity, of which the suicidal impulse is the least infrequent. Sometimes there are no physical indications of disease, but as a rule there are headache, increased sensibility to light and noise, sleeplessness, restlessness, impaired appetite and digestion, gastro-intestinal catarrh, marked loss of flesh, diminished or abolished sexual desire, and in women usually delayed menstruation or amenorrhœa. A few persons are able to keep up, in an irregular sort of way, their customary employment. In the majority of cases it is impossible to concentrate the mind upon work, mental occupation fatigues the brain, and the physical strength is too impaired for steady labor. Suicide is thought of probably in nearly every case, as it is by many sane people at some time in their lives, but it is very seldom committed unless there are such disgraceful or distressing acts performed or suffered by them as would tempt to suicide in sane people. There is no danger of deliberate homicidal acts in persons of good character. A criminally disposed person would more readily commit murder in simple melancholia than if free from that disease.
Simple melancholia may be the initial stage of almost all of the mental diseases, especially acute mania, paralytic dementia, and the severer forms of melancholia. It may be differentiated from the first stage of mania only by waiting until other symptoms appear or not, and the same is true with regard to distinguishing it from the forms of melancholia involving danger to life. In the latter case, however, there is much greater difficulty in diagnosis, inasmuch as insane delusions may be concealed, and there may be so slight a change in the patient's behavior when delusions appear in his mind that the closest observation is needed to guard against them. The simple melancholia marking the first stage of paralytic dementia is characterized by noticeable although often slight mental impairment—a distinctly diminished capacity for work, of which the individual himself is not seldom conscious, whereas in the disease simple melancholia the mind's usual power is exerted, provided its attention can be withdrawn from morbid introspection and concentrated upon any subject, as it commonly can be for a while.
Melancholia with delusions (acute melancholia) is commonly a further development of simple melancholia, but sometimes its course is so rapid that if there is a period of mental depression without delusion it is overlooked. The earliest and most common delusion is some form of causeless self-reproach with regard to some matter, whether trivial or important, or of groundless self-accusation, of impossible sins of omission or commission, but generally of some vague, undefinable fault, as having irretrievably offended God or committed the unpardonable sin, etc. Often this and an unfounded belief in self-unworthiness are the only delusions present, and in that case within narrowed limitations the mind acts soundly in other matters. The feeling of personal fault or sin often expands to a sense of the justice of punishment, and the consequent delusion that all sorts of terrible things are to happen—poverty, the poorhouse, or some great unknown dread, even involving family and friends; and from personal sin or fault it is only a step to the belief that the world is all wrong, and to the certainty that everything is going to worse than ruin. Illusions of sight and hearing may magnify common fires and locomotive whistles into general conflagrations of the world and shrieks of tormented persons. Hallucinations of the special senses may create visions of all sorts of imaginary horrors, sounds of voices saying every possible dreadful thing, odors most disagreeable, tastes most vile. Anæsthesia prompts the delusion of death, and hyperæsthesia of burning, freezing, scalding, etc. Some mysterious force within them, which they can neither explain nor understand, drives them to automatic acts of all kinds—to obscenity, profanity, verbigeration, intonation of sentences, wailing, screaming, destructiveness, etc. In cases of exceptional severity the mind seems deluded on almost every subject: the food is poisoned, the atmosphere is deadly, the world loses all its reality, friends their identity, things their substance. They are to be burned alive, starved, quartered, suffocated, smothered, drowned. Every conceivable and inconceivable thing is to happen. The delusions are nearly always of the illogical or unsystematized kind, although systematized delusions of persecution are met, for the most part, in incurable cases. Deliberate plans of suicide are formed in most cases, and are to be suspected in all. Homicidal attempts are apt to be made upon persons whom it is desired to save from impending calamities. Suicidal, and less often homicidal, impulses occur. Suicide and homicide from deliberation need, to be successful, (1) the opportunity, (2) lack of power of self-control, and (3) a strong determination. Sometimes there is the will without the opportunity, or the opportunity with self-control; and for this reason persons in danger of killing themselves or others often for months escape any acts of violence. Not seldom, too, they determine to kill themselves or family in a particular way, and neglect other chances so long that they are thought to be not meditating destruction of self or others. When the determination or impulse to suicide or homicide is persistent and desperate, no means are too horrible and no opportunities too hopeless to be attempted. There is no reason for a special name for these symptoms, but they have been called suicidal melancholia and homicidal melancholia. No more is there any justification of the term hypochondriacal melancholia for melancholia with hypochondriacal symptoms.
In melancholia with delusions there is sooner or later, in the majority of cases, refusal to eat, from lack of appetite, nausea, or disgust of food, from disagreeable hallucinations of taste or smell, from delusions that it is a sin to eat, that the stomach is full, that the mouth is sealed or the throat obstructed, that the food is not and cannot be paid for, that eating will do no good, etc., from a wish to commit suicide by starving, or in the states of stupor (attonitäts-zustände) from mental torpor or stupidity. Sometimes there is resistance to the calls to eat, urinate, or defecate by virtue of resistive melancholia—a condition to resist and oppose everything—or from delusions that it will destroy the soul, etc. to follow the natural inclinations. Refusal of food may be under certain conditions instinctive and conservative. It is the exception for the bodily functions to be well performed. Usually, there is obstinate constipation, with headache, coated tongue, greater variation in daily temperature than is usual in health, accelerated pulse, and rapid wasting in flesh. The various anomalous sensations observed in functional diseases of the nervous system are common. Masturbation is a not infrequent symptom of loss of self-control in both sexes.