In the London Review of Books, Hilary Mantel has written an extremely thought provoking review of Brian Dillon’s “Tormented Hope: Nine Hypochondriac Lives”.
For some of us, the question ‘Am I ill or well?’ is not at all straightforward, but contentious and guilt-ridden. I feel ill, but have I any right to the feeling? I feel ill, but has my feeling any organic basis? I feel ill, but who am I to say so? Someone else must decide (my doctor, my mother) whether the illness is real by other people’s standards, or only by mine. Is it a respectable illness? Does it stand up to scientific scrutiny? Or is it just one of my body’s weasel stratagems, to get attention, to get a rest, to avoid doing something it doesn’t want to do? Some of us perceive our body as fundamentally dishonest, and illness as a scam it has thought up.
We understand, almost instinctively, the nuanced difference between disease and illness. As Eric Cassell put it so clearly – “illness is what a man has, and disease is what an organ has”. Or “illness is what you go to the doctor with, and disease is what you come home with”. However, both doctors and patients are caught up in the blurred boundary between these two concepts. For doctors, once a sensation is classified as a symptom, it becomes a signpost to a pathology (or it is dismissed as “psychological”). For all of us, though, we live with the possibility that any sensation might be a symptom. For the hypochondriac, every sensation might be a symptom. As Hilary Mantel says –
In hypochondria, the whole imagination is medicalised; on the one hand, the state is sordid and comic, on the other hand, perfectly comprehensible. It is the dismaying opaqueness of human flesh that drives us to anxiety and despair. What in God’s name is going on in there? Why are our bodies not made with hinged flaps or transparent panels, so that we can have a look? Why must we exist in perpetual uncertainty (only ended by death) as to whether we are well or ill?
Am I well, or am I ill? Who decides?
Brian Dillon consoles us that ‘hypochondriacs are almost always other people.’ The condition exists on a continuum, with fraud at one end, delusion in the middle and medical incompetence at the other end; he is a benefits cheat, you are a hypochondriac, I am as yet undiagnosed.
One issue is symptoms, which are a particular way of classifying sensations. Are some more real, somehow, than others? Do they need accompanying physical changes in the body to be real?
Many people are simply hyper-aware of bodily sensations, and so are driven continually to check in with themselves, examining visceral events as a man about to confess to a priest examines his conscience; like the believer scrutinising himself for sin, they expect to find something bad, perhaps something mortal. Forgiveness, and cure, are only ever partial and temporary; there will always be another lapse, some internal quaking or queasiness, some torsion or stricture, some lightness in the head or hammering of the pulse, some stiffness in the joint or trembling of the limb, or perhaps even an absence of sensation, a numbness, a deficit, a failure of the appetite.
A researcher called Kurt Kroenke has published many studies where he shows, time and again, that not only is the percentage of people listing symptoms which they have equal whether they are attending medical clinics, or are simply stopped in the street and asked, but the actual symptoms people complain of are the largely the same whether they are attending for health care, or just going about their normal lives. Clearly, not only are sensations not usually symptoms but symptoms do not equal disease.
Bodily, and psychic sensations are part of being alive. But we humans are compelled somehow to try to find the underlying meaning of everything..including sensations. Isn’t this the crux of the issue? Who gives meaning to your daily life, your lived experience, your sensations, thoughts, and feelings?
In the days before internet information and misinformation became available, patients often came away from a consultation with the feeling that they did not own their own bodies, that they were in some way owned by the doctor or the NHS. Now perhaps Google owns our bodies; it is possible to have access, at a keystroke, to a dazing plurality of opinion. There is an illness out there for every need, a disease to fit any symptom. And it is not just individuals who manufacture disease. As drug patents expire, the pharmacological companies invent new illnesses, such as social anxiety disorder, for which an otherwise obsolete formulation can be prescribed. For this ruse to work, the patient must accept a description of himself as sick, not just odd; so shyness, for example, becomes a pathology, not just an inconvenient character trait. We need not be in pain, or produce florid symptoms, to benefit from the new, enveloping, knowledge-based hypochondria. We are all subtly wrong in some way, most of the time: ill at ease in the world. We can stand a bit of readjustment, physical or mental, a bit of fine-tuning. Our lifelong itch for self-improvement can be scratched by a cosmetic surgeon with his scalpel or needle, our feelings of loss assuaged by a pill that will return us to a state of self-possession. For hypochondria, the future is golden.
It’s not just doctors who interpret your sensations now, there are interpretations everywhere, and some of them are deliberately invented for marketing purposes.
Living involves experiencing sensations, and being human involves sense-making. Trying to understand what is happening now may be an inescapable part of Life. Deciding what meaning fits best is, ultimately, down to the individual – either by simply accepting the interpretation of an other, or by consciously, rationally, working it out in our own terms.
Entangled as they might be, the untangling of sensations is up to us.
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