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What’s up Doc? A beginner’s guide to Medical Student Syndrome

Most of you reading this will probably be aware of the psychosomatic condition of hypochondria (also known as hypochondriasis) in which individuals have a preoccupying fear of having a serious illness despite appropriate medical evaluations and reassurances that their health is fine. However, what you may not be aware of is there appears to be some empirical evidence that some particular sub-groups of people appear to suffer hypochondria-related disorders relating to the medical conditions they are studying educationally and/or vocationally.

One such condition is ‘Medical Student/s’ Syndrome’ (also referred to by many other names including ‘Medical Students’ Disease’, ‘Medical Student Disorder’, ‘Medical School Syndrome’, ‘Third Year Syndrome’, ‘Second Year Syndrome’ and ‘Intern’s Syndrome’), a frequently reported psychological condition among medical trainees that experience the symptoms of the disease or diseases they are studying. In a review of the relevant literature in a 2004 issue of the Journal of Curriculum Theory, Dr. Brian Hodges (2004) noted that Medical Student Syndrome (MSS) was first reported in the 1960s. A Wikipedia summary of MSS noted that:

“The condition is associated with the fear of contracting the disease in question. Some authors suggested that the condition must be referred to as nosophobia [a specific phobia, an irrational fear of contracting a disease], rather than ‘hypochondriasis’, because the quoted studies show a very low percentage of hypochondriachal character of the condition, and hence the term ‘hypochondriasis’ would have ominous therapeutic and prognostic indications. The reference suggests that the condition is associated with immediate preoccupation with the symptoms in question, leading the student to become unduly aware of various casual psychological and physiological dysfunctions; cases show little correlation with the severity of psychopathology, but rather with accidental factors related to learning and experience”.

Dr. Bernard Baars in his 2001 book In the Theater of Consciousness: The Workspace of the Mind writes:

“Suggestible states are very commonplace. Medical students who study frightening diseases for the first time routinely develop vivid delusions of having the ‘disease of the week’ – whatever they are currently studying. This temporary kind of hypochondria is so common that it has acquired a name, ‘medical student syndrome’”.

Dr. Hodges also suggested that in the 1960s:

“[The] phenomenon caused a significant amount of stress for students and was present in approximately 70 to 80 percent of students… papers written in the 1980s and 1990s conceptualized the condition as an illness in the psychiatric spectrum of hypochondriasis…Marcus found that the dream content of year two medical students frequently involved a preoccupation with personal illness. Marcus’s subjects reported many dreams in which they suffered illnesses of the heart, the eyes and the bowels, among others.. [Learning about a disease] creates a mental schema or representation of the illness which includes the label of the illness and the symptoms associated with the condition. Once this representation is formed, symptoms or bodily sensations that the individual is currently experiencing which are consistent with the schema may be noticed, while inconsistent symptoms are ignored”.

In a 1998 paper in The Lancet, Dr. Oliver Howes and Dr. Paul Salkovskis briefly reviewed the literature on MSS and reported the findings of two studies that had examined the condition. The first study claimed that approximately 70% of medical students had “groundless medical fears during their studies” and the second study found that 79% of randomly chosen medical students demonstrated a “history of medical student disease”. However, more interestingly, they also cited various other studies on non-medical students showing that various types of students not studying medicine also had high rates of hypochondria.

A study by Dr. Ingrid Candel and Dr. Harald Merckelbach examined whether the role of thought suppression and fantasy proneness were predictors of MSS complaints in 215 medical students. Summarizing the study in a 2001 issue of The Psychologist, Dr. Fiona Lyddy defined thought suppression as “the habitual tendency to suppress unpleasant thoughts, which can produce counterproductive hyperaccessibility of the worrying information” and that fantasy-prone individuals “often report physical sensations associated with fantasies or thoughts they have engaged in (e.g. if they had the thought that they might have a blood clot after flying, they might report feeling tightness in the leg muscles)”. Candel and Merckelbach hypothesised that those students that scored highly on both thought suppression and fantasy-proneness would be more likely to experience MSS. Just under one-third (30%) of the sample (n=65) reported various MSS complaints with 33 medical students reporting psychiatric, cardiac, pulmonary, and gastrointestinal complaints. The authors found that gender and age were not significant predictors of MSS but as hypothesised, both thought suppression and fantasy proneness strongly predicted MSS complaints (the strongest being fantasy proneness).

A study led by Dr. G. Singh and colleagues and published in a 2004 issue of the journal Medical Education examined whether being at medical school causes health anxiety and worry in British medical students compared to a control group of non-medical students (and hypothesizing that medical students were more likely to report such conditions). A total of 449 medical students and 485 non-medical students across four years of study (first year to fourth year) were surveyed. Health anxiety was assessed using the appropriately named Health Anxiety Questionnaire whereas worry was assessed using the Anxious Thoughts Inventory. Contrary to their hypotheses, no evidence was found that medical students were more health anxious and greater worriers than non-medical students. In fact, the authors reported that health anxiety was significantly lower in medical students in the first year and the fourth year than non-medical students and that worry was significantly lower in the medical students across all years of study. The authors therefore concluded that “medical students are not a cohort of preselected health-anxious people, nor are they ‘worriers’ [and that] medical education at a clinical level [mitigates] health anxiety in the medical student population”.

MSS has also been reported in cognate disciplines to medicine (such as psychology). In 1997, in the journal Teaching of Psychology, Dr. M. Hardy and Dr. L. Calhoun investigated psychological distress and MSS in a group of American undergraduate students studying abnormal psychology. Their research found that students that planned to major in psychology reported more worry about their psychological health than those planning not to major in psychology. Interestingly – but not a surprise to me – students that had previously undergone some kind of psychological treatment were more likely to intend to pursue an advanced degree in counseling or psychotherapy than those that had not received prior psychological treatment. The authors also claimed that the students that learned about various psychological disorders demonstrated (i) decreased anxiety about their own mental health, and (ii) increased likelihood of seeking out mental health services on the university campus for personal psychological distress.

A more 2011 recent paper (also published in Teaching of Psychology) by Dr. M. Deo and Dr. J. Lymburner investigated whether psychology students can suffer Psychology Student Syndrome (PSS) – a direct analogue to MSS. To do this, they looked at the relationship between self-ratings of psychological health and the number of courses that students took in psychopathology. In addition to standard personality tests, the undergraduate students were asked to rate their level of concern about suffering from symptoms of various psychological disorders. However, Deo and Lymburner found no evidence of PSS. However, they did report a positive correlation between neuroticism and psychological health anxiety. As a result of this finding, they recommended that lecturers on psychopathology courses need to be aware that their neurotic students may be at a higher risk for believing they have psychological problems.

Taken as a whole. The results of studies to date appear to be very mixed as to whether students are more prone to suffering hypochondria-like conditions related to the subjects (i.e., medicine, psychology) they are studying. Even if the rates of hypochondria are higher in medical and/or psychology students, it might be that these students seek out such courses because of pre-existing conditions they have or think they have. More research with bigger samples, better control groups, and better control for pre-existing psychological and/or medical problems are warranted as there does appear to be some evidence that such conditions exist even if there may be good explanations as to why.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Baars, Bernard J. (2001). In the Theater of Consciousness: The Workspace of the Mind. Oxford University Press US.

Candel, I. & Merckelbach, H. (2003) Fantasy proneness and thought suppression as predictors of the medical student syndrome. Personality and Individual Differences, 35, 519–524.

Deo, M. S., & Lymburner, J. A. (2011). Personality traits and psychological health concerns: The search for Psychology Student Syndrome. Teaching of Psychology, 38, 155-157.

Hardy, M.S., & Calhoun, L.G. (1997). Psychological distress and the “medical student syndrome” in abnormal psychology students. Teaching of Psychology, 24, 192-193.

Hodges, B. (2004) Medical student bodies and the pedagogy of self-reflection, self-assessment, and self-regulation. Journal of Curriculum Theory, 20(2), 41-51.

Howes, O.D. & Salkovskis, P.M. (1998). Health anxiety in medical students. The Lancet, 351, 1332.

Hunter, R.C.A, Lohrenz, J.G., & Schwartzman, A.E. (1964). Nosophobia and hypochondriasis in medical students. Journal of Nervous and Mental Diseases, 130,147-152.

Lyddy, F. (2001). Medical Student Syndrome. The Psychologist, 16, 602.

Singh, G. (2006). Medical students’ disease: Health anxiety and worry in medical students. Stress and mental health in college students. New York, NY: Nova Science Publishers, 29-62

Singh, G., Hankins, M., & Weinman, J. A. (2004). Does medical school cause health anxiety and worry in medical students? Medical Education, 38(5), 479-481.

Wikipedia (2013). Medical students’ disease. Located at: http://en.wikipedia.org/wiki/Medical_students’_disease

Transmission impossible? A beginner’s guide to syphilophobia

One of the more obscure things known about Adolf Hitler was that he suffered from a severe case of syphilophobia (i.e., which – according to a 1956 definition in Blakiston’s New Gould Medical Dictionary – is a morbid fear of the sexually transmitted disease syphilis). Dr. Henry A. Murray in a 1943 report entitled ‘Analysis of the personality of Adolf Hitler with predictions of his future behavior and suggestions for dealing with him now and after Germany’s surrender’ diagnosed Hitler’s neurosis, hysteria, paranoia, Oedipal tendencies, schizophrenia, “infinite self-abasement” and syphilophobia (which he describes as a fear of contamination of the blood through contact with a woman). However, the report is vague on its sources, and presented little in the way of empirical evidence for its conclusions. According to a later 1986 paper in Genitourinary Medicine, by Dr. R. Fitzpatrick and his colleagues, the authors said that Hitler believed that syphilis was a Jewish disease that was transmitted from generation to generation.

Some definitions of the condition also note that it can include people who actually believe they have syphilis even though there is no medical evidence to support the belief (and as such is classed as a form of hypochondria). The phobic condition is also known by various other names including luiphobia (‘leus’ was a former name of syphilis), venereophobia, and venereoneurosis (although the latter technically include the fear of any sexually transmitted disease). The condition has been documented in the medical literature dating back the 16th century including references to venereoneurosis (called ‘noddlepox’). A 1938 paper in the Canadian Medical Association Journal, Dr. Frank Cormia (who featured seven case studies of syphilophobia) wrote that:

“A morbid fear of syphilis has been present in the human race ever since the great plague of the early sixteenth century. Authentic written observations were first made by Turner, in 1567. Proksch published his ‘RadlinusVitus, Lues Venerea Imaginaria’in 1698”.

In one of the most detailed ‘modern’ accounts of syphilophobia in a 1957 issue of the British Journal of Venereal Diseases, Dr. Ida McAlpine (who outlined seven case studies in her report) argued that syphilophobia and venereophobia are not unitary conditions but rather non-specific symptoms of a range of psychiatric disorders. McAlpine noted that among 24 cases of ‘venereophobia’ only one was female. An earlier (1953) study by French medics Dr. P. Graciansky and Dr. E. Stern (in the journal La Semaine des Hôpitaux Thérapeutique) also had 24 cases of syphilophobia and reported that 14 were male and 10 female. For Dr. Otto Fenichel, the Viennese psychoanalyst (writing in the 1940s), syphilophobia comprised a “rationalization of unreal dangers connected with sexual activity, which on a deep, unconscious level, may represent disguised sado-masochistic wishes, for it is equally possible to be infected by other persons and to infect them”

In a 1963 study (again published in the British Journal of Venereal Diseases) of the incidence, pattern, and causes of psychiatric illness related to fear of venereal disease among 887 consecutive cases at an STD clinic, Dr. E. Kite and Dr. A. Grimble reported that psychiatric illness occurred in 5% of all patients, and was slightly more frequent in females (6%). Since the early flurry of studies published from the 1940s to the 1960s there was little (if anything published academically until the mid-2000s. A case report of syphilophobia was published in 2006 by Dr Arfan ul Bari and Dr. Ali Zulqernain in the Journal of Pakistan Association of Dermatologists. The authors reported the case of a 28-year old soldier:

“[He complained] of generalized weakness and some lesion over his glans penis and intermittent burning micturation [lasting] about 2 years. He has been visiting various doctors but was never satisfied with the treatment given…He had no history of any extramarital sexual relationship or any significant physical or psychiatric ailment in the past. General physical and systemic examination was unremarkable and on genital examination neither any active lesion, nor any mark of previous healed lesion was found. The patient insisted that he was suffering from the venereal disease (syphilis) and he had a sore over glans penis near urethral meatus…On the basis of absence of any suggested physical signs and symptoms, normal laboratory investigations and repeatedly negative serological tests for syphilis, he was considered to be a case of syphilophobia (hypochondriasis) and was referred to psychiatrist”.

Bari and Zulqernain claim that disorders like syphilophobia are probably more common than is recognized” (although I’m unsure on what they have based this opinion on). They also provided some psychological insight into the condition:

“Perhaps because of the emotional issues surrounding sexual behavior, anxiety about a sexual encounter may manifest itself as a fear or conviction that one has been infected with a sexually transmitted infection. The problem often significantly impairs the quality of life. It can cause personal distress and keep people apart from loved ones and business associates…At some point in past, there was likely an event linking lues or syphilis and emotional trauma. Whilst the original catalyst may have been a real-life scare of some kind, the condition can also be triggered by myriad, benign events like movies, TV, or perhaps seeing someone else experience trauma”.

The most recent paper I have come across on syphilophobia was published in 2010 by the Russians Dr. A.N. Provizion and colleagues (published in Russian, so I only managed to read the English summary). They believe the condition to be of “importance” and that is a condition that psychiatrists should be more aware of. It may be that the condition has moved with the times and that other sexually transmitted diseases (like AIDS) are now more of a fear than syphilis.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bari, A.U. & Zulqernain, A. (2006). Syphilophobia: a frustrating psychiatric illness presenting to dermatologists. Journal of Pakistan Association of Dermatologists, 16, 236-238.

Cormia, F.E. (1938). Syphilophobia and allied anxiety states. Canadian Medical Association Journal, 39, 361-366

Fenichel, O. (1945). Psychoanalytic Theory of Neurosis. London: NortonCo.

Fitzpatrick, R., Frost, D., & Ikkos, G. (1986). Survey of psychological disturbance in patients attending a sexually transmitted diseases clinic. Genitourinary Medicine, 62, 111-115.

Graciansky, P. & Stern, E. (1953). [Syphilophobia]. La Semaine des Hôpitaux Thérapeutique, 29, 2911-2915.

Hoerr, N.L. & Osol, A. (1956) Blakiston’s New Gould Medical Dictionary. McGraw-Hill.

Kite, E.d.C. & Grimble, A. (1963). Psychiatric aspects of venereal disease. British Journal of Venereal Disease, 39, 173-180.

McAlpine, I.  (1957).  Syphilophobia; A psychiatric study. British Journal of Venereal Diseases, 33, 92-99.

Murray, H. A. (1943/2005). Analysis of the personality of Adolf Hitler with predictions of his future behavior and suggestions for dealing with him now and after Germany’s surrender. A report prepared for the Office of Strategic Services, October 1943. Located at: http://archive.org/stream/AnalysisOfThePersonalityOfAdolphHitler/MurrayHenry-AnalysisOfThePersonalityOfAdolphHitler1943240p.Scan_djvu.txt

Provizion A.N., Provizion L.N., Shveduk S.V., Shedania I.E. [To the problem of syphilophobia], Том, 13, 147-149.