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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

Fake’s progress: A beginner’s guide to Münchausen syndrome

One of the most interesting psychological disorders is Münchausen Syndrome (MS) and is sometimes referred to more colloquially as ‘hospital addiction syndrome’, ‘hospital hopper syndrome’ and ‘thick chart syndrome’. MS is currently classified in the most recent International Classification of Diseases under ‘other disorders of adult personality’. The primary characteristic of people suffering from MS is that they deliberately pretend to be ill in the absence of external incentives (such as criminal prosecution or financial gain). MS has been called a factitious disorder because sufferers feign illness, pretend to have a disease, and/or fake psychological trauma typically to gain attention and/or sympathy from other people. Doctors often nickname such people as ‘frequent flyers’. The name of the syndrome was coined in 1951 by Dr. Richard Asher (in a paper he published in The Lancet about people who fabricated illnesses) and derives from German Karl Friedrich Hieronymus Freiherr von Münchhausen (aka Baron Münchausen), a renowned eighteenth century nobleman, who was reported as telling many fantastical and impossible stories about himself.

A related condition is Münchausen Syndrome by Proxy refers to the abuse of someone else (quite often a child son or daughter), also as a way of seeking attention and/or sympathy for the sufferer. Some members of the medical community believe that this related MS condition should simply be re-named ‘medical abuse’). There are also some specific sub-types of MS. For instance, a 2011 paper in the Journal of Electrocardiology, by Dr. Joseph Vaglio reported a female case of Arrhythmogenic Münchausen Syndrome who intentionally simulated and stimulated irregular cardiac activity to gain medical attention by drinking (and overdosing) on caffeine.

According to Dr. A.J. Giannini and Dr. H.R. Black in the Psychiatric, Psychogenic and Somatopsychic Disorders Handbook, one of the most common signs among MS sufferers is that they may have multiple scars on their abdomen because of repeated exploratory or emergency operations. Other ‘warning signs’ listed on the Web MD website of MS include: (i) dramatic but inconsistent medical history, (ii) predictable relapses following improvement in the condition, (iii) detailed knowledge of hospitals and/or medical terminology, (iv) appearance of new or additional symptoms following negative test results, (v) willingness or eagerness to have medical procedures, (vi) history of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities, and (vii) problems with identity and self-esteem.

There has been a debate about whether MS should have been re-classified in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. For instance, in a 2008 issue of the journal Psychosomatics, Dr. Lois Krahn and her colleagues argued that MS should be classed as a somatoform disorder because MS sufferers may not be conscious that they are drawing attention to themselves. [According to Wikipedia, a somatoform disorder “is a mental disorder characterized by symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder”]. More specifically, Krahn and her colleagues noted:

Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM–IV, the key difference is that factitious-disorder patients feign illness, and somatoform disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. For DSM–V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill”.

This appears to be part of the same debate that says MS is distinct from hypochondriasis in that MS patients are said to be aware that they are exaggerating their illness or disease, whereas hypochondriasis sufferers actually believe they have an illness or disease. Another way of looking at it is that MS sufferers want to be a patient whereas those with hypochondriasis don’t. One of the more unusual consequences of MS is that the affected individual will often undergo unnecessary medical procedures, treatments and/or exploratory operations to prolong hospital stay and gain sympathy and attention from those around them including the medical and nursing staff. It is also known that some MS patients have very good medical knowledge and use this as a way of creating and/or producing symptoms of known medical conditions.

Some of the reported risk factors for individuals that develop MS include (i) a history of childhood traumas and (ii) emotional deprivation (e.g., having parents or guardians that were emotionally unavailable due to illness and/or emotional problems while the individual was a child). In relation to treatment and prognosis, the Wikipedia entry on MS asserts:

“Providers need to acknowledge that there is uncertainty in treating suspected Münchausen patients so that real diseases are not under-treated. Then they should take a careful patient history and seek medical records, to look for early deprivation, childhood abuse, or mental illness. If a patient is at risk to himself or herself, inpatient psychiatric hospitalization should be initiated…Therapeutic and medical treatment should center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient’s prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive-behavioral therapy, whereas borderline personality disorder, like all personality disorders is presumed to be pervasive and more stable over time, thus offers the worst or best prognosis”.

Unfortunately there are no reliable statistics regarding the number of people who suffer from MS. Research suggests that both males and females are affected in roughly equal numbers and that the mean age of presentation is 36-years old. This is certainly one behaviour that we could do with more empirical research.

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

Further reading

Asher, R. (1951). Munchausen’s syndrome. The Lancet, 1, 339–341.

Bhugra D. (1988). Psychiatric Munchausen’s syndrome. Literature review with case reports. Acta Psychiatrica Scandinavica, 77, 497–503.

Feldman, M.D., Hamilton, J.C & Deemer, H.N. (2001). Factitious Disorder. In K.A. Phillips (Eds.), Somatoform and Factitious Disorders. Washington D.C.: American Psychiatric Association.

Giannini A.J. & HR Black, H.R. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook (pp.194-195). New Hyde Park, NY. Medical Examination Publishing.

Krahn, L.E., Bostwick, J.M. & Stonnington, C.M. (2008). Looking toward DSM-V: Should factitious disorder become a subtype of somatoform disorder? Psychosomatics, 49, 277–282.

Vaglio, J. C., Schoenhard, J. A., Saavedra, P. J., Williams, S. R., & Raj, S. R. (2011). Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia. Journal of Electrocardiology, 44, 229-231.

Wikipedia (2013). Münchausen syndrome. Located at: http://en.wikipedia.org/wiki/Münchausen_syndrome

Dhat’s life: A beginner’s guide to semen loss syndrome

In previous blogs I have examined various culture bound syndromes (CBSs) such as koro and berserkers. CBSs comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies and are often unknown outside of their own local regions. One of the more unusual CBSs is dhat syndrome, typically located in the Indian sub-continent (India, Sri Lanka, Bangladash). Dhat is one of the CBSs listed in the World Health Organization’s International Classification of Diseases.

The term ‘Dhat syndrome’ was first described by Dr. N.N. Wig in a 1960 issue of the (Indian) Journal of Clinical and Social Psychiatry, and then by Dr. J.S. Neki in the British Journal of Psychiatry (1973). A 1975 paper by Dr. H.K. Malhotra and Dr. N.N. Wig in the Archives of Sexual Behavior called dhat “the exotic neurosis of the Orient”. According to a short paper by Dr. Om Prakash in the Indian Journal of Psychiatry, dhat syndrome comprises various psychological, somatic and sexual symptoms attributed by the patient to the passing of whitish fluid, believed to be semen in urine (i.e., psychological distress and anxiety related to semen-loss). Prakash says that the word ‘dhat’ is derived from the Sanskrit word ‘dhatu’ (which has multiple meanings including ‘metal’, ‘elixir’ and ‘constituent part of the body’). He also noted that:

 “This notion of seminal loss frightens the individual into developing a sense of doom if a single drop of semen is lost, thereby producing a series of somatic symptoms…fear of semen loss and resulting problems [in India] is so strong that cures are advertised by vaids and hakims everywhere – on walls, on television, in newspapers and on roadside hoardings”.

The anxiety surrounding the semen loss can also relate to the releasing of semen via nocturnal emissions (i.e., ‘wet dreams’) and masturbation. The symptoms include fatigue, listlessness, appetite loss, lack of physical strength, poor concentration, forgetfulness, guilt, and (in some cases) sexual dysfunction. Given the syndrome relates to psychological anxiety surrounding semen loss, the disorder is (necessarily) found among men, but interestingly, the dhat syndrome has also been applied to women who experience similar symptoms relating to white vaginal discharge). According to an online article on CBSs, it claims that:

“The anxiety related to semen loss can be traced back thousands of years to Ayurvedic texts, where the loss of a single drop of semen, the most precious body fluid, could destabilize the entire body”

A 2004 literature review on dhat syndrome by Dr. A. Sumathipala and colleagues in the British Journal of Psychiatry speculated that the disorder was a “hypochondriacal preoccupation”. This may have some validity as a 1990 paper by Dr. R.K. Chadha and Dr. N. Ahuja (also in the British Journal of Psychiatry) reported a study of 52 dhat patients. Three-quarters of their sample were reported as having hypochondriacal symptoms.

Another study in the British Journal of Psychiatry a year later by Dr. M.S. Bhatia and Dr. S.C. Malik reported that 93 (out of 144) consecutive patients attending a sexual dysfunction clinic had dhat syndrome. A number of papers published on the dhat syndrome in the 1980s and 1990s all report that depressive, anxiety and/or somatoform disorders are prevalent in the majority of dhat sufferers. A small 1989 Sri Lankan study by Dr. P. De Silva and Dr. S. Dissanayake in the Sexual and Marital Therapy journal on 38 men with sexual dysfunction, reported that ‘semen loss’ was seen by most of the men as the main reason for their sexual dysfunction. The same study reported that 40% of the sample had hypochondriasis. Similar findings have been reported among Bangladeshi men. (It should also be noted that there are various reports of similar syndromes in other countries. For instance, Prakash’s paper also mentions ‘shen-k’uei’ in Taiwan and China which from the symptoms listed appear almost identical to dhat)

Based on papers published in the British Journal of Psychiatry and Indian Journal of Psychiatry (mainly from the 1980s and 1990s), Prakash presents a profile of those affected with dhat and claims that most are young males, recently married, from rural areas, low to average socioeconomic status (farmers, labourers, farmers), and from families with conservative attitudes towards sex. He also claims (seemingly based on a 2001 book chapter by by Dr. A. Avasthi and Dr. R. Nehra) that there are three types of dhat patients:

  • Dhat alone (where their symptoms are attributed to semen loss, and with presenting symptoms that are hypochondriacal, depressive or anxiety-related in nature)
  • Dhat with comorbid depression and anxiety (where dhat is seen as a symptom accompanying another disorder)
  • Dhat with sexual dysfunction

The duration of the symptoms can be relatively short-lived (e.g., 3-12 months) but some papers report people suffering for up to 20 years. Prakash lists the most common co-morbid disorders and sexual dysfunctions associated with dhat. This included depressive neurosis (40%-42%), anxiety neurosis (21%-38%), somatoform and hypochondriasis (32%-40%), erectile dysfunction (22%-62%), and premature ejaculation (22%-44%). Prakash also reports that the majority (i.e., two-thirds) of dhat sufferers recover (66%), with the remainder either improved (22%) or unchanged (12%). Finally, the most recently published paper on dhat syndrome by Dr. Neena Sanjiv Sawant and Dr. Anand Nath in a 2012 issue of the Sri Lankan Journal of Psychiatry noted that dhat beliefs are often based on misconception and myths:

“These myths and misconceptions which are deeply rooted in Indian culture are passed from generation to generation. Due to the lack of proper information and lack of open communication between parents and children, the only source of knowledge for many remain their peers, who are equally ignorant about the subject, and this leads to widespread misconceptions. Many people consult unqualified practitioners who reinforce their ignorance”

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

Further reading

Avasthi, A. & Nehra, R. (2001). Sexual disorders: A review of Indian Research. In: Murthy, R.S. (Ed.), Mental Health in India (1995-2000) (pp.42-53). Bangalore: People’s Action for Mental Health.

Behere, P.B., Natraj, G.S. (1984). Dhat syndrome: The phenomenology of a culture-bound sex neurosis of the orient. Indian Journal of Psychiatry, 26, 76-78.

Bhatia, M.S. & Malik, S.C. (1991). Dhat Syndrome – A useful diagnosis entity in Indian Culture. British Journal of Psychiatry, 159, 69-75.

Chadda, R.K. & Ahuja, N. (1990). Dhat syndrome: A sex neurosis of the Indian subcontinent. British Journal of Psychiatry, 156, 577-579.

De Silva, P. & Dissanayake, S.A.W. (1989) The loss of semen syndrome in Sri Lanka. A clinical study. Sexual and Marital Therapy, 4, 195-204.

Malhotra, H.K. & Wig, N.N. (1975). A culture bound sex neurosis in the Orient. Archives of Sexual Behaviour, 4, 519-528.

Neki, J.S. (1973). Psychiatry in South East Asia. British Journal of Psychiatry, 123, 257-269.

Prakash, O. (2007). Lessons for postgraduate trainees about Dhat syndrome. Indian Journal of Psychiatry, 49, 208–210.

Sawant, N.S. & Nath, A. (2012). Cultural misconceptions and associated depression in Dhat syndrome. Sri Lankan Journal of Psychiatry, 3, 17-20.

Sumathipala, A. Siribaddana, S.H. & Bhugra, D. (2004). Culture-bound syndromes: The story of dhat syndrome. British Journal of Psychiatry, 184, 200-209.

Wig, N.N. (1960). Problems of mental health in India. Journal of Clinical and Social Psychiatry (India), 17, 48-53.