What is one concept that you learned after reading chapter eight? Why is it important for us to discuss that concept in this course?
Lecture Guide Chapter 8
Disorders Featuring Somatic Symptoms
In addition to affecting psychological functioning, stress also can have an enormous impact on physical functioning. The idea that stress and related psychosocial factors may contribute to somatic illnesses has ancient roots—but few supporters before the 20th century. The 17th century philosopher René Descartes called a variation on this idea mind-body dualism.
About 80 years ago clinicians first identified a group of physical illnesses that seemed to result from an interaction of biological, psychological, and sociocultural factors. Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic disorders.
The DSM 5 has a number of psychological disorders that have a bodily symptom or a concern that is the primary feature of the disorder. They are: factitious disorder (produce or feign physical symptoms), conversion disorder (they have a medically unexplained physical symptom that affects motor or sensory functioning), somatic symptom disorder ( become overly concerned with their bodily symptoms), illness anxiety disorder (preoccupation that they are seriously ill), and psychological factors affecting medical condition ( a psychological factor affects a person’s general health).
People with factitious disorder often go to extremes to create the appearance of illness. Many give themselves medications to produce symptoms. Patients often research their supposed ailments and are impressively knowledgeable about medicine.
These disorders are often hard to distinguish from genuine medical problems. It is always a potential that a diagnosis of hysterical disorder is a mistake and the patient’s problem has an undetected organic cause.
- As children received extensive medical treatment for a true physical disorder.
- Experienced family problems or physical or emotional abuse in childhood
- Carry a grudge against the medical profession
- Have worked as nurses, laboratory technicians, or medical aids
- Have an underlying personality problem such as extreme dependence
In variations of the root problem, some seek the HERO or VICTIM role, rather than the SICK role.
Factitious disorder imposed on another (was previously called Munchausen syndrome): parents make up or produce physical illnesses in their children. This is a form of maltreatment (abuse and/or neglect) rather than a mental disorder. Children are the usual victims and the mother is the usual perpetrator. They may falsify lab results—e.g., by adding blood or protein to a urine specimen. They may exaggerate a medical problem—e.g., by claiming occasional mild back pain is crippling. They may aggravate an existing ailment—e.g., by manipulating a wound so it doesn’t heal. They may induce an actual illness—e.g., by injecting themselves or their child with bacteria to cause a raging infection. They may “dissimulate”—e.g., by initially avoiding treatment so that a minor medical problem becomes serious.
- Somatic Symptom disorder: Historically referred to as “hysteria.” They have many long-lasting physical ailments that have little or no organic basis. Also known as Briquet’s syndrome. To receive a diagnosis, a patient must have a range of ailments, including several pain symptoms, gastrointestinal symptoms, a sexual symptom, and a neurological symptom. Patients usually go from doctor to doctor in search of relief. Patients often describe their symptoms in dramatic and exaggerated terms. They also feel anxious and depressed. This disorder lasts much longer than a conversion disorder, typically for many years symptoms may fluctuate over time but rarely disappear completely without psychotherapy.
- Conversion disorder: A psychosocial conflict or need is converted into dramatic physical symptoms that affect voluntary or sensory functioning. Symptoms often seem neurological, such as paralysis, blindness, or loss of feeling. Most conversion disorders begin between late childhood and young adulthood. They usually appear suddenly and are thought to be rare.
- Pain disorder associated with psychological factors: Patients may receive this diagnosis when psychosocial factors play a central role in the onset, severity, or continuation of pain. Although the precise prevalence has not been determined, it appears to be fairly common. The disorder often develops after an accident or illness that has caused genuine pain. The disorder may begin at any age, and more women than men seem to experience it.
- Somatic symptoms vs. medical symptoms: It can be difficult to distinguish disorders featuring somatic symptoms from “true” medical conditions. Studies across the world suggest that as many as one-fifth of all patients who seek medical care may actually suffer from a disorder that features somatic symptoms. Physicians sometimes rely on oddities in the patient’s medical picture to help distinguish the two. For example, somatic symptoms may be at odds with the known functioning of the nervous system, as in cases of glove anesthesia.
- Somatic vs. factitious symptoms: Disorders featuring somatoform symptoms are different from patterns in which individuals are purposefully producing or faking medical symptoms. Patients may be malingering, intentionally faking illness to achieve external gain (e.g., financial compensation, military deferment) (My meth lab just blew up and I am facing some jail time. I become suicidal to try and escape jail time).
- Illness Anxiety Disorder: People with illness anxiety disorder unrealistically interpret bodily symptoms as signs as serious illness. Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating. Although some patients recognize that their concerns are excessive, many do not. Patients with this disorder can present a picture very similar to that of factitious disorder. If the anxiety is great and the bodily symptoms are relatively minor, a diagnosis of illness anxiety disorder is probably in order. Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers.
- What causes somatic symptom disorders: Theorists typically explain the disorders as they do the anxiety disorders. A cognitive theorist would believe that the person is too oversensitive to their bodily cues. A behaviorist would point to classical conditioning or modeling.
The psychodynamic view ~ Freud believed that somatic symptom disorders represented a conversion of underlying emotional conflicts into physical symptoms. Most of his patients were women, Freud centered his explanation on the psychosexual development of girls and focused on the phallic stage (ages 3–5). During this stage, girls develop a pattern of sexual desires for their fathers (the Electra complex) while recognizing that they must compete with their mothers for his attention. Because of the mother’s more powerful position, however, girls repress these sexual feelings. Freud believed that if parents overreacted to such feelings, the Electra complex would remain unresolved and the child would re-experience sexual anxiety through her life. Freud concluded that some women hide their sexual feelings in adulthood by converting them into physical symptoms.
Today’s psychodynamic theorists take issue with Freud’s explanation of the Electra conflict. They do continue to believe that sufferers of these disorders have unconscious conflicts carried from childhood.
Psychodynamic theorists propose that two mechanisms are at work in the somatic symptom disorders:
a. Primary gain—Somatic symptoms keep internal conflicts out of conscious awareness (if I have a physical symptom I don’t have to acknowledge and deal with my emotions)
b. Secondary gain—Somatic symptoms further enable people to avoid unpleasant activities or to receive sympathy from others
The behavioral view ~ Behavioral theorists propose that the physical symptoms of somatic symptom disorders bring rewards to sufferers
- May remove individual from an unpleasant situation
- May bring attention from other people
In response to such rewards, sufferers learn to display symptoms more and more.
The cognitive view ~ Some cognitive theorists propose that somatic symptom disorders are forms of communication, providing a means for people to express difficult emotions. Cognitive theorists hold that emotions are being converted into physical symptoms. This conversion is not to defend against anxiety but to communicate extreme feelings.
This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view them as the primary cause of the development of the disorder.
The multicultural view ~ Some theorists believe that Western clinicians hold a bias that sees somatic symptoms as an inferior way of dealing with emotion. The transformation of personal distress into somatic complaints is the norm in many non-western cultures.
A possible role for biology ~ The impact of biological processes on somatic symptom disorders can be understood through research on placebos and the placebo effect.
Placebos are substances with no known medicinal value. Treatment with placebos has been shown to bring improvement to many—possibly through the power of suggestion or through the release of endogenous chemicals. Perhaps traumatic events and related concerns or needs can also trigger our “innerpharmacies” and set in motion the bodily symptoms of disorders featuring somatic symptoms.
How are disorders featuring somatic symptoms treated? People with somatoform disorders usually seek psychotherapy only as a last resort (Why should I see a therapist? I need to find a different primary care physician that understands me). Individuals with preoccupation disorders typically receive the kinds of treatments applied to anxiety disorders, particularly OCD:
Antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs) (PROZAC and ZOLOFT)
Exposure and response prevention (ERP)
Treatments for hysterical disorders often focus on the cause of the disorder and apply the same kind of techniques used in cases of PTSD, particularly:
- Insight—often psychodynamically oriented
- Exposure—Client thinks about traumatic event(s) that triggered the physical symptoms
Other therapists try to address the physical symptoms of the hysterical disorders, applying techniques such as:
Suggestion—usually an offering of emotional support that may include hypnosis
- Reinforcement—a behavioral attempt to change reward structures
- Confrontation—an overt attempt to force patients out of the sick role
Psychological Factors Affecting Medical Condition
- Before the 1970s, the best known and most common of the psychological factors affecting medical condition were ulcers, asthma, insomnia, chronic headaches, high blood pressure, and coronary heart disease. Recent research has shown that many other physical illnesses may be caused by an interaction of psychosocial and physical factors.
The psychophysiological disorders of focus include:
Ulcers—holes in the wall of the stomach resulting in burning sensations or pain, vomiting, and stomach bleeding
- Experienced by 25 million people at some point in their lives
- Causal psychosocial factors: Environmental stress, anger, anxiety, dependent personality style
- Causal physiological factors: Bacterial infection
Asthma—a narrowing of the body’s airways that makes breathing difficult
- Affects up to 5 million people in the United States each year
- Most victims are children at the time of first attack
- Causal psychosocial factors: Environmental pressures, troubled family relationships, anxiety, high dependency
- Causal physiological factors: Allergies, a slow-acting sympathetic nervous system, weakened respiratory system
Insomnia—difficulty falling asleep or maintaining sleep
- Affects 1/4 of the population of the United States each year
- Causal psychosocial factors: High levels of anxiety or depression
- Causal physiological factors: Overactive arousal system, certain medical ailments (nocturnal polyuria-frequent urination due to enlarged prostate or hormones) (sleep apnea-breathing is interrupted) (Gastro Esphogeal Reflux Disease)
Chronic headaches—frequent intense aches of the head or neck that are not caused by another physical disorder
- Tension headaches affect 45 million Americans a year
- Migraine headaches affect 23 million Americans a year
- Causal psychosocial factors: Environmental pressures, general feelings of helplessness, anger, anxiety, depression
- Causal physiological factors: Abnormal serotonin activity, vascular problems, muscle weakness
Hypertension—chronic high blood pressure, usually producing no outward symptoms
- Affects 75 million Americans each year
- Causal psychosocial factors: Constant stress, environmental danger, general feelings of anger or depression
- Causal physiological factors: obesity, smoking, poor kidney function, high proportion of collagen rather than elastic tissue in an individual’s blood vessels
- 10 percent caused by physiological factors alone
Coronary heart disease—caused by a blocking of the coronary arteries; including angina pectoris (chest pain), coronary occlusion (complete blockage of a coronary artery), and myocardial infarction (heart attack)
- Leading cause of death in men older than 35 years and women older than 40 years in the United States
- Causal psychosocial factors: Job stress, high levels of anger or depression
- Causal physiological factors: High level of cholesterol, obesity, hypertension, the effects of smoking, lack of exercise
Factors contribute to the development of psychophysiological disorders, including:
- Defects in the autonomic nervous system (ANS) are believed to contribute to the development of psychophysiological disorders
- Other more specific biological problems also may contribute
For example, a weak gastrointestinal system may create a predisposition to developing ulcers.
- According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors, thereby increasing their likelihood of developing a psychophysiological disorder
Examples include a repressive coping style and the Type A personality style
- Adverse social conditions may set the stage for psychophysiological disorders
- Stressors may be wide-ranging (e.g., nuclear threat such as Three Mile Island) or local (e.g., living in a crime-ridden neighborhood)
One of society’s most adverse social conditions is poverty. Research also reveals that belonging to ethnic and cultural minority groups increases the risk of developing these disorders and other health problems.
Clearly, biological, psychological, and sociocultural variables combine to produce psychophysiological disorders. In fact, the interaction of psychosocial and physical factors is now considered the rule of bodily function, not the exception. In recent years, more and more illnesses have been added to the list of psychophysiological disorders.
New psychophysiological disorders
Are physical illnesses related to stress? The development of the Social Adjustment Rating Scale in 1967 enabled researchers to examine the relationship between life stress and the onset of illness. Using this measure, studies have linked stresses of various kinds to a wide range of physical conditions. Overall, the greater the amount of life stress, the greater the likelihood of illness. Researchers have even found a relationship between traumatic stress and death.
One shortcoming of the Social Adjustment Rating Scale is that it does not take into consideration the particular stress reactions of specific populations
For example, women and men have been shown to react differently to certain life changes measured by the scale. Researchers have increasingly looked to the body’s immune system as the key to the relationship between stress and infection.
This area of study is called psychoneuroimmunology—the immune system is the body’s network of activities and cells that identify and destroy antigens (foreign invaders, such as bacteria) and cancer cells.
Among the most important cells in this system are the lymphocytes, white blood cells that circulate through the lymph system and bloodstream and attack invaders.
Researchers now believe that stress can interfere with the activity of lymphocytes, slowing them down and increasing a person’s susceptibility to viral and bacterial infections.
Several factors influence whether stress will result in a slowdown of the system
(a) Biochemical activity: Stress leads to increased activity of the sympathetic nervous system, including a release of norepinephrine. In addition to supporting nervous system activity, this chemical also appears to slow down the functioning of the immune system. Similarly, the body’s endocrine glands reduce immune system functioning during periods of prolonged stress through the release of corticosteroids
(b) Behavioral changes: Stress may set into motion a series of behavioral changes—poor sleep patterns, poor eating, lack of exercise, increase in smoking, and/or drinking—that indirectly affect the immune system.
(c) Personality style: An individual’s personality style, including their level of optimism, constructive coping strategies, and resilience, may also play a role in determining how much the immune system is slowed down by stress.
(d) Social support: People who have few social supports and feel lonely seem to display poorer immune functioning in the face of stress than people who do not feel lonely. Studies have shown that social support and affiliation with others may actually protect people from stress, poor immune system functioning, and subsequent illness, or help speed up recovery from illness or surgery. As clinicians have discovered that stress and related psychosocial factors may contribute to physical disorders, they have applied psychological treatment to more and more medical problems.
The most common of these interventions are relaxation training, biofeedback training, meditation, hypnosis, cognitive interventions, insight therapy, and support groups. The field of treatment that combines psychological and physical interventions to treat or prevent medical problems is known as behavioral medicine.
- People can be trained to relax their muscles at will, a process that sometimes reduces feelings of anxiety
- Relaxation training can be of help in preventing or treating medical illnesses that are related to stress
- Relaxation training often is used in conjunction with medication in the treatment of high blood pressure
- Relaxation training often is used alone to treat chronic headaches, insomnia, asthma, pain after surgery, certain vascular diseases, and the undesirable effects of cancer treatments
- Patients given biofeedback training are connected to machinery that gives them continuous readings about their involuntary bodily activities
- This procedure has been used successfully to treat headaches and muscular disabilities caused by stroke or accident
- Some biofeedback training has been effective in the treatment of asthma, irregular heartbeat, migraine headaches, high blood pressure, stuttering, and pain from burns
- Although meditation has been practiced since ancient times, Western health care professionals have only recently become aware of its effectiveness
- The technique involves turning one’s concentration inward and achieving a slightly changed state of consciousness
- Meditation has been used to treat pain, high blood pressure, heart problems, insomnia, and asthma
- Individuals undergoing hypnosis are guided into a sleep like, suggestible state during which they can be directed to act in unusual ways, to remember unusual sensations, or to forget remembered events
- With training, hypnosis can be done without a hypnotist (self-hypnosis)
- This technique seems to be particularly helpful in the control of pain and is now used to treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection
(e) Cognitive interventions
- People with physical ailments have sometimes been taught new attitudes or cognitive responses as part of treatment
- One example is self-instruction training where patients are taught to rid themselves of negative self-statements and to replace them with positive self-statements.
(f) Insight therapy and support groups
- If negative psychological symptoms (e.g., depression, anxiety) contribute to a person’s physical ills, therapy to address these emotions should help reduce the ills
- These techniques have been used to treat a variety of illnesses including HIV, asthma, cancer, headache, and arthritis
(g) Combination approaches
- Studies have found that the various psychological treatments for physical problems tend to be equal in effectiveness
- Psychological treatments often are most effective when used in combination and with medical treatment
- With these combined approaches, today’s practitioners are moving