Somatoform and Dissociative Disorders PDF

Do you know somebody who’s a evidence indicates they share common hypochondriac? Most of us do. Maybe it’s features (Kihlstrom, Glisky, & Anguilo, 1994; you! The popular image of hypochondria is Prelior, Yutzy, Dean, & Wetzel, 1993). They of someone who exaggera...

Do you hypochondriac? Most of us do. Maybe it’s you! The popular image of hypochondria is of someone who exaggerates the slightest physical symptom. Many people continually run to the doctor even though there is nothing really wrong with them. This is usually a harmless tendency that may even be worth some good-natured jokes. But for a few individuals, the preoccupation with their health or appearance becomes so great that it dominates their lives. Their problems fall under the general heading of somatoform disorders. Soma means body, and the problems preoccupying these people seem, initially, to be physical disorders. What the somatoform disorders have in common is that there is usually no identifi able medical condition causing the physical complaints. Thus, these disorders are grouped under the shorthand label of “medically unexplained physical symptoms” (olde Hartman et al., 2009; Woolfolk & Allen, in press). Have you ever felt “detached” from yourself or your surroundings? (“This isn’t really me,” or “That doesn’t really look like my hand,” or “There’s something unreal about this place.”) During these experiences, some people feel as if they are dreaming. These mild sensations that most people experience occasionally are slight alterations, or detachments, in consciousness or identity, and they are known as dissociation or dissociative experiences. For a few people, these experiences are so intense and extreme that they lose their identity entirely and assume a new one or they lose their memory or sense of reality and are unable to function. We discuss several types of dissociative disorders in the second half of this chapter. Somatoform and dissociative disorders are strongly linked historically, and incapacitating disorders. Somatoform Disorders The fourth edition, text revision, of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) lists fi ve basic somatoform disorders: hypochondriasis, somatization disorder, pain disorder, conversion disorder, and body dysmorphic disorder. In each, individuals are pathologically concerned with the appearance or functioning of their bodies. The fi rst three disorders covered in this section—hypochondriasis, somatization disorder, and pain disorder—overlap considerably and the proposal for DSM-5 is to combine these three disorders into a new category called complex somatic symptom disorder (American Psychiatric Association, 2010). Despite the overlap, subtle differences exist and the DSM-5 proposal, if adopted, would continue to allow further specifi cation of one of the three conditions within the new disorder. Hypochondriasis Like many terms in psychopathology, hypochondriasis has ancient roots. To the Greeks, the hypochondria was the region below the ribs, and the organs in this region affected mental state. For example, ulcers and other gastric disorders were once considered part of the hypochondriac syndrome. As the actual physical causes of such disorders were discovered they were no longer considered a mental disorder, but physical complaints without a clear cause continued to be labeled hypochondriasis (Barsky, Wyshak, & Klerman, 1986; Taylor & Asmundson, 2009; Woolfolk & Allen, in press). In hypochondriasis, as we know it today, severe anxiety is focused on the possibility of having a serious disease. The threat seems so real that reassurance from physicians does not seem to help. Consider the case of Gail. Clinical Description Gail’s problems are fairly typical of hypochondriasis. Research indicates that feature of hypochondriasis is that reassurances from numerous doctors that all is well and the individual is healthy have, at best, only a short-term effect. It isn’t long before patients like Gail are back in the offi ce of another doctor on the assumption that the previous doctors have missed something. This is because many of these individuals mistakenly believe they have a disease, a diffi cult to shake belief sometimes referred to as “disease conviction” (Côté et al., 1996; Haenen, de Jong, Schmidt, Stevens, & Visser, 2000). Therefore, along with anxiety focused on the possibility of disease or illness, disease conviction is a core feature of hypochondriasis (Benedetti et al., 1997; Kellner, 1986; Woolfolk & Allen, in press). If you have just read Chapter 5, you may think that patients with panic disorder resemble patients with hypochondriasis. Patients with panic disorder also misinterpret physical symptoms as the beginning of the next panic attack, which they believe may kill them. Craske and colleagues (1996) and Hiller, Leibbrand, Rief, and Fichter (2005) suggested several differences between panic disorder and hypochondriasis. Although both disorders include characteristic concern with physical symptoms, patients with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack, and these concerns lessen between attacks. Individuals with hypochondriasis, on the other hand, focus on a long-term process of illness and disease (for example, cancer or AIDS). Hypochondriacal patients also continue to seek the opinions of additional doctors in an attempt to rule out (or perhaps confi rm) disease and are more likely to demand unnecessary medical treatments. Despite numerous assurances that they are group somewhat higher than in the younger population, but the proportion of all those seeing a doctor who have hypochondriasis is about the same. Hypochondriasis may emerge at any time of life, with the peak age periods found in adolescence, middle age (40s and 50s), and after age 60 (Kellner, 1986). As with most anxiety and mood disorders, hypochondriasis is chronic (Taylor & Asmundson, 2009). In one study (Barsky, Fama, Bailey, & Ahern, 1998), a large group of more than 100 patients with hypochondriasis was followed for 4 to 5 years, as was a comparable nonhypochondriacal patient group from the same setting. Two-thirds of the patients still met criteria for the diagnosis of hypochondriasis, and these patients remained signifi cantly more symptomatic than the comparison group. Other studies have found similar or some A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder). D. The preoccupation causes clinically signifi cant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder. Specify if: With poor insight: If, for most of the time during the current episode, the person does not recognize that the of illness, your anxiety will increase further. Increased anxiety produces additional physical symptoms and becomes a vicious cycle (see Figure 6.1) (Salkovskis, Warwick, & Deale, 2003; Warwick & Salkovskis, 1990). Using procedures from cognitive science such as the Stroop test (see Chapter 2), a number of investigators (Hitchcock & Mathews, 1992; Pauli & Alpers, 2002) have confi rmed that participants with hypochondriasis show enhanced perceptual sensitivity to illness cues. They also tend to interpret ambiguous stimuli as threatening (Haenen et al., 2000). Thus, they quickly become aware (and frightened) of any sign of possible illness or disease. A minor headache, for example, might be interpreted as a sure sign of a brain tumor. Smeets, de Jong, and Mayer (2000) demonstrated that individuals with hypochondriasis, compared to “normals,” take a “better safe than sorry” approach to dealing with even minor physical symptoms by getting them checked out as soon as possible. More fundamentally, they have a restrictive concept of health as being symptom free (Rief et al., 1998). What causes individuals to develop this pattern of somatic sensitivity and distorted beliefs? Although it is not certain, the cause is unlikely to be found in isolated biological or psychological factors. There is every reason to believe the fundamental causes of hypochondriasis are similar to those implicated in the anxiety disorders (Barlow, 2002; Suárez et al., 2009). For example, evidence shows that hypochondriasis runs in families (Kellner, 1985), and that there is a modest genetic contribution (Taylor, Thordarson, Jang, & Asmundson, 2006). But this contribution may be nonspecifi c, such as a tendency to overrespond to stress, and thus may be indistinguishable from the nonspecifi c genetic contribution to the development of the disorder in some people. A “sick person” who receives increased attention for being ill and is able to avoid work or other responsibilities is described as adopting a “sick role.” These issues may be even more signifi cant in somatization disorder (described next). Treatment Unfortunately, relatively little is known about treating hypochondriasis. Although it was common clinical practice in the past to uncover unconscious confl icts through psychodynamic psychotherapy, results on the effectiveness of this kind of treatment have seldom been reported. Scientifi cally controlled studies have appeared only recently (Kroenke, 2007; Taylor & Asmundon, 2009; Woolfolk & Allen, in press). Surprisingly, clinical reports indicate that reassurance and education seems to be effective in some cases (Haenen et al., 2000; Kellner, 1992)—”surprisingly” because, by defi nition, patients with hypochondriasis are not supposed to benefi t from reassurance about their health. However, reassurance is usually given only briefl y by family doctors who have little time to provide the ongoing support and reassurance that might be necessary. Mental health professionals may well be able to offer reassurance in a more effective and sensitive manner, devote suffi cient time to all concerns the patient may have, and attend to the “meaning” of the symptoms (for example, their relation to the patient’s life stress). Fava, Grandi, Rafanelli, Fabbri, and Cazzaro (2000) tested this idea by assigning 20 patients who met diagnostic criteria for hypochondriasis to two groups. One received “explanatory therapy” in which the clinician went over the source and origins of their symptoms in some detail. These patients were assessed immediately after the therapy and again at a 6-month follow-up. The other group was a wait-list effective after treatment and at each follow-up point for both symptoms of hypochondriasis and overall changes in functioning and quality of life. But results were still “modest,” and many eligible patients refused to enter treatment because they were convinced their problems were medical rather than psychological. A few recent reports suggest that drugs may help some people with hypochondriasis (Fallon et al., 2003; Kjernisted, Enns, & Lander, 2002; Kroenke, 2007; Taylor et al., 2005). Not surprisingly, these same types of drugs (antidepressants) are useful for anxiety and depression. In one study, CBT and the drug paroxetine (Paxil), a selective-serotonin reuptake inhibitor (SSRI), were both effective, but only CBT was signifi cantly different from a placebo condition. Specifi cally, 45% in the CBT group, 30% in the Paxil group, and 14% in the placebo group responded to treatment among all patients who entered the study (Van Balkom et al., 2007). Somatization Disorder In 1859, Pierre Briquet, a French physician, described patients who came to see him with seemingly endless lists of somatic complaints for which he could fi nd no medical basis (American Psychiatric Association, 1980). Despite his negative fi ndings, patients returned shortly with either the same complaints or new lists containing slight variations. For many years, this disorder was called Briquet’s syndrome, before being changed in 1980 to somatization disorder. Consider the case of Linda. LINDA Full-Time Patient Linda, an intelligent woman in her 30s, came to our clinic looking distressed and pained. As she sat down she noted that coming into the offi ce was diffi cult for her because she had trouble breathing and considerable swelling in the joints of her legs and arms. She was also in some pain from chronic urinary tract seeing two ministers for pastoral counseling. Clinical Description Linda easily met and exceeded all DSM-IV diagnostic criteria for somatization disorder. Do you notice any differences between Linda, who presented with somatization disorder, and Gail, who presented with hypochondriacal disorder? There is certainly a lot of overlap (Creed & Barsky, 2004; Leibbrand, Hiller, & Fichter, 2000), but Linda was more severely impaired and had suffered in the past from symptoms of paralysis (which we refer to as a conversion symptom; see page 28). Also, Linda did not seem as afraid as Gail that she had a disease. Linda was concerned with the symptoms themselves, not with what they might mean. Individuals with hypochondriasis most often take immediate action on noticing a symptom by calling the doctor or taking medication. People with somatization, on the other hand, do not feel the urgency to take action but continually feel weak and ill, and they DSM-IV-TR Table 6.2 Diagnostic Criteria for Somatization Disorder Source: Reprinted, with permission, from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author, © 2000 American Psychiatric Association. A. A history of many physical complaints beginning before age 30 that occur over several years and result in treatment being sought or signifi cant impairment in social, occupational, or other important areas of functioning. B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of disturbance: 1. Four pain symptoms: A history of pain related to at least four sites or functions (such as head, abdomen, back, joints, extremities, chest, rectum, during sexual intercourse, during menstruation, or during urination) 2. Two except in the context of discussing her symptoms much as other people might talk about their day at the offi ce or their kids’ accomplishments at school. Her few friends who were not health-care professionals had the patience to relate to her sympathetically, through the veil of her symptoms, and she thought of them as friends because they “understood” her suffering. Linda’s case is an extreme example of adopting the “sick role” described earlier. Statistics Somatization disorder as defi ned in the DSM is rare. DSM-III-R criteria required 13 or more symptoms from a list of 35, making diagnosis diffi cult. The criteria were greatly simplifi ed for DSM-IV, with only 8 symptoms required (Cloninger, 1996). These criteria have been validated as easier to use and more accurate than alternative or past criteria (Yutzy et al., 1995). Katon and colleagues (1991) demonstrated that somatization disorder occurs on a continuum: People with only a few medically unexplained physical symptoms may experience suffi cient distress and impairment of functioning to be considered to have a disorder that is called undifferentiated somatoform disorder. But this disorder is just somatization disorder with fewer than eight symptoms, and for that reason the label is likely to be eliminated in DSM-5.Using between four and six symptoms as criteria, Escobar and Canino (1989) found a prevalence of somatization disorder of 4.4% in one large city. The median prevalence in six samples of a large number of patients in a primary care setting meeting these criteria was 16.6% (Creed & Barsky, 2004). Linda’s disorder developed during adolescence, which is the typical age of onset. A number of studies have demonstrated that individuals with somatization disorder tend to be women, unmarried, and from lower socioeconomic throughout the world (Gureje, 2004). It is particularly important to rule out medical causes of somatic complaints in developing countries, where parasitic and other infectious diseases and physical conditions associated with poor nutrition are common and not always easy to diagnose. Table 6.1 presents data from a large World Health Organization study on individuals presenting to primary care settings with medically unexplained physical symptoms that either would or would not be suffi cient to meet criteria for somatization disorder. Notice that the rates are relatively uniform around the world for medically unexplained physical symptoms, as is the sex ratio (Gureje, Simon, Ustun, & Goldberg, 1997). When the problem is severe enough to meet criteria for disorder, the sex ratio is approximately 2:1 female to male. Causes Somatization disorder shares some features with hypochondriasis, including a history of family illness or injury during childhood. But this history is a minor factor at best because countless families experience chronic illness or injuries without passing on severe anxiety of being ill or the sick role to children. Something else contributes strongly to somatization disorder. Given the past diffi culty in making a diagnosis, few studies of causes of somatization disorder have been done. Early studies of possible genetic contributions had mixed results. For example, in a sophisticated twin study, Torgersen (1986) found no increased prevalence of somatization disorder in monozygotic (identical) pairs, but most studies fi nd substantial evidence that the disorder runs in families and may have a heritable basis (Bell, 1994; Guze, Cloninger, Martin, & Clayton, 1986; Katon, 1993). A more startling fi nding emerged from these studies, however. Somatization disorder is strongly linked in family and genetic studies disinhibition syndrome characterized by impulsive behavior (see, for example, Cloninger, 1987; Gorenstein & Newman, 1980). Evidence indicates that impulsiveness is common in ASPD (see, for example, Newman, Widom, & Nathan, 1985). How does this apply to people with somatization disorder? Many of the behaviors and traits associated with somatization disorder also seem to refl ect the impulsive characteristic of short-term gain at the expense of long-term problems. The continual development of new somatic ICD-10 Somatization Disorder (%) Somatic Symptom Index (%) Center Men Women Overall Prevalence Men Women Overall Prevalence Ankara, Turkey 1.3 2.2 1.9 22.3 26.7 25.2 Athens, Greece 0.4 1.8 1.3 7.7 13.5 11.5 Bangalore, India 1.3 2.4 1.8 19.1 20.0 19.6 Berlin, Germany 0.3 2.0 1.3 24.9 25.9 25.5 Groningen, the Netherlands 0.8 4.1 2.8 14.7 19.9 17.8 Ibadan, Nigeria 0.5 0.3 0.4 14.4 5.0 7.6 Mainz, Germany 1.0 4.4 3.0 24.9 17.3 20.6 Manchester, United Kingdom 0 0.5 0.4 21.4 20.0 20.5 Nagasaki, Japan 0 0.2 0.1 13.3 7.9 10.5 Paris, France 0.6 3.1 1.7 18.6 28.2 23.1 Rio de Janeiro, Brazil 1.5 11.2 8.5 35.6 30.6 32.0 Santiago, Chile 33.8 11.2 17.7 45.7 33.3 36.8 Seattle, Washington, United States 0.7 2.2 1.7 10.0 9.8 9.8 Shanghai, China 0.3 2.2 1.5 17.5 18.7 18.3 Verona, Italy 0 0.2 0.1 9.7 8.5 8.9 Total 1.9 3.3 2.8 19.8 19.7 19.7 TABLE 6.1 Frequency of Two Forms of Somatization in a Cross-Cultural Study (N = 5,438)* Note: Criteria from The International Classifi cation of Diseases (10th ed.) were used in this study. *Weighted to the fi rst-stage (intake) sample. Source: Adapted from Gureje, O., Simon, G. E., Ustun, T. B., & Goldberg, D. P. (1997). Somatization in cross-cultural perspective: A World Health Organization study in primary care. American Journal of Psychiatry, 154, (described in Chapter 2) that will inevitably emerge as our knowledge increases. Might these assumptions apply to Linda or her family? Linda’s sister had been married briefl y and had two children. She had been in therapy for most of her adult life. Occasionally, Linda’s sister visited doctors with various somatic complaints, but her primary diffi culty was unexplained periods of recurring amnesia that might last several days; these spells alternated with blackout periods during which she was rushed to the hospital. There were signs of sexual impulsivity and ASPD in Linda and her family. The sister’s older daughter, after a stormy adolescence characterized by truancy and delinquency, was sentenced to jail for violations involving drugs and assault. Amid one session with us, Linda noted that she had kept a list of people with whom she had had sexual intercourse. Linda’s list numbered well over 20, and most of the sexual episodes occurred in the offi ces of mental health professionals or clergy! This development in Linda’s relationship with caregivers was important because she saw it as the ultimate sign that the caregivers were concerned about her as a person and she was important to them. But the relationships almost always ended tragically. Several of the caregivers’ marriages disintegrated, and at least one mental health professional committed suicide. Linda herself was never satisfi ed or fulfi lled by the relationships but was greatly hurt when they inevitably ended. The American Psychological Association has decreed that it is always unethical to have any sexual contact with a patient at any time during treatment. Violations of this ethical canon have nearly always had tragic consequences. Treatment Somatization disorder is exceedingly diffi cult to treat. Although there are treatments with proven at least part-time employment, with the ultimate goal of discontinuing disability. Now family doctors are being trained in how better to manage these patients using some of these principles (Garcia-Campayo, Claraco, Sanz-Carrillo, Arevalo, & Monton, 2002), but results are mixed (Woolfolk & Allen, in press). Antidepressant drugs have shown some promise (Menza et al., 2001; Okugawa, Yagi, Kusaka, & Kinoshita, 2002) but are not the fi rst choice for treatment because somatic or physical side effects such as nausea, agitation, or headaches are often frightening to these patients, making the drugs diffi cult to tolerate (Mai, 2004). Pain Disorder A related somatoform disorder about which little is known is pain disorder. Pain disorder refers to pain in one or more sites in the body that is associated with signifi cant distress or impairment. In pain disorder, there may have been clear physical reasons for pain, at least initially, but psychological factors play a major role in maintaining it, particularly anxiety focused on the experience of pain (Asmundson & Carleton, 2009). In the placement of this disorder in DSM-IV, serious consideration was given to removing it from the somatoform disorders and putting it in a separate section, because a person rarely presents with localized pain without some physical basis, such as an accident or illness. Therefore, it was diffi cult to separate the cases in which the causes were judged to be primarily psychological from the ones in which the causes are primarily physical. Because pain disorder fi ts most closely within the somatoform cluster (an individual presents with physical symptoms judged to have strong psychological contributions such as anxiety), the decision was made to leave pain disorder in the somatoform section. In DSM-5, the proposal is to make this important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or defi cit is not intentionally produced or feigned (as in factitious disorder or malingering). E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. Specify if: Acute (duration of less than 6 months) Chronic (duration of 6 months or more) THE WOMAN WITH CANCER Managing Pain A 56-year-old woman with metastatic breast cancer who appeared to be coping appropriately with her disease had severe pain in her right thigh for a month. She initially obtained relief from a combination of drugs and subsequently received hypnotherapy and group therapy. These treatment modalities provided additional pain relief and enabled the patient to decrease her narcotic intake with no increase in pain. The medical student’s pain was seen as purely psychological. In the case of the second woman, the pain was probably related to cancer. But we now know that whatever its cause, pain has a strong psychological component. If medical treatments for existing physical conditions are in place and pain remains, or if the pain seems clearly related to psychological factors, psychological interventions are appropriate. Because of the complexity of pain itself and the variety of narcotics and other medications prescribed for it, multidisciplinary pain clinics are part of most large hospitals. (In Chapter 9, we discuss health psychology and the contribution of psychological factors to physical disorders, and we delve more deeply into types of pain disorders, their causes, and treatment.) Conversion Disorder The term conversion has been used off and on since the Middle personable during the initial interview and who readily answered all questions with a big smile. She obviously enjoyed the social interaction. Eloise’s diffi culty walking developed over 5 years. Her right leg had given way and she began falling. Gradually, the condition worsened to the point that 6 months before her admission to the hospital Eloise could move around only by crawling on the fl oor. Physical examinations revealed no physical problems. Eloise presented with a classic case of conversion disorder. Although she was not paralyzed, her specifi c symptoms included weakness in her legs and diffi culty keeping her balance, with the result that she fell often. This particular type of conversion symptom is called astasia-abasia. Eloise lived with her mother, who ran a gift shop in the front of her house in a small rural town. Eloise had been schooled through special education programs until she was about 15; after this, no further programs were available. When Eloise began staying home, her walking began to deteriorate. In addition to blindness, paralysis, and aphonia, conversion symptoms may include total mutism and the loss of the sense of touch. Some people have seizures, which may be psychological in origin, because no signifi cant electroencephalogram (EEG) changes can be documented. Another relatively common symptom is globus hystericus, the sensation of a lump in the throat that makes it diffi - cult to swallow, eat, or sometimes talk (Finkenbine & Miele, 2004). Closely Related Disorders Distinguishing among conversion reactions, real physical disorders, and outright malingering (faking) is sometimes diffi cult. Several factors can help, but one symptom, widely regarded as a diagnostic sign, has proved not to be useful. It was long thought that patients with conversion reactions had motor symptom or defi cit With sensory symptom or defi cit With seizures or convulsions With mixed presentation C. V. Ford (1985) noted that the incidence of marked stress preceding a conversion symptom occurred in 52% to 93% of the studied patients. Often this stress takes the form of a physical injury. In one large survey, 324 out of 869 patients (37%) reported prior physical injury (Stone, Carson, Aditya, et al., 2009). Thus, if the clinician cannot identify a stressful event preceding the onset of the conversion symptom, the clinician might more carefully consider the presence of a true physical condition. In addition, although people with conversion symptoms can usually function normally, they seem truly unaware either of this ability or of sensory input. For example, individuals with the conversion symptom of blindness can usually avoid objects in their visual fi eld, but they will tell you they can’t see the objects. Similarly, individuals with conversion symptoms of paralysis of the legs might suddenly get up and run in an emergency and then be astounded they were able to do this. It is possible that at least some people who experience miraculous cures during religious ceremonies may have been suffering from conversion reactions. These factors may help in distinguishing between conversion and organically based physical disorders, but clinicians sometimes make mistakes, although it is not common with modern diagnostic techniques. For example, Moene and colleagues (2000) carefully reassessed 85 patients diagnosed with conversion disorder and found 10 (11.8%) had developed some evidence of a neurological disorder approximately 2.5 years after the fi rst exam. Stone and colleagues (2005), summarizing a number of studies, estimate the rate of misdiagnosis of conversion appearance of illness in the child. For example, one mother stirred a vaginal tampon obtained during menstruation in her child’s urine specimen. Another mother mixed feces into her child’s vomit (Check, 1998). Because the mother typically establishes a positive relationship with a medical staff, the true nature of the illness is most often unsuspected and the staff members perceive the parent as remarkably caring, cooperative, and involved in providing for her child’s well-being. Therefore, the mother is often successful at eluding suspicion. Helpful procedures to assess the possibility of Munchausen syndrome by proxy include a trial separation of the mother and the child or video surveillance of the child while in the hospital. An important study A. Intentional production or feigning of physical or psychological signs or symptoms. B. The motivation for the behavior is to assume the sick role. C. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent. Specify if: With predominantly psychological signs and symptoms: If psychological signs and symptoms predominate in the clinical presentation With predominantly physical signs and symptoms: If physical signs and symptoms predominate in the clinical presentation With combined psychological and physical signs and symptoms: If neither psychological nor physical signs and symptoms predominate in the clinical presentation has appeared validating the utility of surveillance in hospital rooms of children with suspected Munchausen syndrome by proxy. In this study, 41 patients presenting with chronic, diffi cultto-diagnose physical problems were monitored by video during their hospital stay. In 23 of these cases, the diagnoses turned out to be extended to the right side of her body and, on occasion, to other parts of her body. She also experienced a number of other conversion symptoms such as deafness and, intriguingly, an inability to speak German, although she remained fl uent in English. In Josef Breuer’s treatment of Anna O., she relived her traumatic experiences in her imagination. Under hypnosis, she was able to recreate the memory of her horrifi c hallucination. As she recalled and processed the images, her paralysis left her and she regained her ability to speak German. Breuer called the therapeutic reexperiencing of emotionally traumatic events catharsis (purging, or releasing). Catharsis has proved to be an effective intervention with many emotional disorders, as we noted in Chapter 5. Were Anna O.’s symptoms really “unconscious,” or did she realize at some level that she could move her arm and the rest of her body if she wanted to and it simply served her purpose not to? This question has long bedeviled psychopathologists. Now information (reviewed in Chapter 2) on unconscious cognitive processes becomes important. We are all capable of receiving and processing information in a number of sensory channels (such as vision and hearing) without being aware of it. Remember the phenomenon of blind sight or unconscious vision? Weiskrantz (1980) and others discovered that people with small, localized damage to certain parts of their brains could identify objects in their fi eld of vision but that they had no awareness whatsoever that they could see. Could this happen to people without brain damage? Consider the case of Celia. CELIA Seeing Through Blindness A 15-year-old girl named Celia suddenly was unable to see. Shortly thereafter, she regained some of her sight, but her vision was so severely blurred that she could not visual discrimination tasks. People with conversion symptoms, on the other hand, can see objects in their visual fi eld and therefore would perform well on these tasks, but this experience is dissociated from their awareness of sight. Malingerers and, perhaps, individuals with factitious disorders simply do everything possible to pretend they can’t see. Statistics We have already seen that conversion disorder may occur with other disorders, particularly somatization disorder, as in the case of Linda. Linda’s paralysis passed after several months and did not return, although on occasion she would report “feeling as if” it were returning. Comorbid anxiety and mood disorders are also common (Pehlivanturk & Unal, 2002; Rowe, 2010; Stone, Carson, Duncan, et al., 2009). Conversion disorders are relatively rare in mental health settings, but remember that people who seek help for this condition are more likely to consult neurologists or other specialists. The prevalence estimate in neurological settings is high, averaging about 30% (Allin, Streeruwitz, & Curtis, 2005; Stone, Carson, Duncan, et al., 2009; Rowe, 2010). One study estimated that 10% to 20% of all patients referred to epilepsy centers have psychogenic, nonepileptic seizures (Benbadis & Allen-Hauser, 2000). Like somatization disorder, conversion disorders are found primarily in women (Deveci et al., 2007; Folks, Ford, & Regan, 1984; Rosenbaum, 2000) and typically develop during adolescence or slightly thereafter. However, they occur relatively often in males at times of extreme stress (Chodoff, 1974). Conversion reactions are not uncommon in soldiers exposed to combat (Mucha & Reinhardt, 1970). The conversion symptoms often disappear after a time, only to return later in the same or similar form when a new stressor occurs. In responses to a questionnaire (Spitzer, Spelsberg, Grabe, Mundt, & Freyberger, 1999). This fi nding was basically replicated in another report on 54 patients with conversion disorder compared to 50 matched patients with mood or anxiety disorders (Roelofs, Keijsers, Hoogduin, Naring, & Moene, 2002). In other cultures, some conversion symptoms are common aspects of religious or healing rituals. Seizures, paralysis, and trances are common in some rural fundamentalist religious groups in the United States (Griffi th, English, & Mayfi eld, 1980), and they are often seen as evidence of contact with God. Individuals who exhibit such symptoms are thus held in high esteem by their peers. These symptoms do not meet criteria for a “disorder” unless they persist and interfere with an individual’s functioning. Causes Freud described four basic processes in the development of conversion disorder. First, the individual experiences a traumatic event— in Freud’s view, an unacceptable, unconscious confl ict. Second, because the confl ict and the resulting anxiety are unacceptable, the person represses the confl ict, making it unconscious. Third, the anxiety continues to increase and threatens to emerge into consciousness, and the person “converts” it into physical symptoms, thereby relieving the pressure of having to deal directly with the confl ict. This reduction of anxiety is considered to be the primary gain or reinforcing event that maintains the conversion symptom. Fourth, the individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid a diffi cult situation or task. Freud considered such attention or avoidance to be the secondary gain, the secondarily reinforcing set of events. We believe Freud was basically correct on at least three counts but probably not on the pseudo-seizures, as have other studies (Roelofs et al., 2002). In another study, 15 adolescents who had exhibited visual problems in childhood that were of psychological origin were compared with a control group of adolescents who had experienced childhood visual problems because of known physical problems. Adolescents with the conversion disorder were more likely to have experienced some signifi cant stress and adjustment diffi culties, such as substantial school diffi culties, or the loss of a signifi cant fi gure in their lives, and they rated their mothers as overinvolved and overprotective on a rating scale. Rating mothers as “overinvolved” or “overprotective” suggests that these psychologically based visual symptoms may have been strongly attended to and reinforced (Wynick, Hobson, & Jones, 1997). The one step in Freud’s progression of events about which some questions remain is the issue of primary gain. The notion of primary gain accounts for the feature of la belle indifférence (cited previously), where individuals seem not the least bit distressed about their symptoms. In other words, Freud thought that because symptoms refl ected an unconscious attempt to resolve a confl ict, the patient would not be upset by them. But formal tests of this feature provide little support for Freud’s claim. For example, Lader and Sartorius (1968) compared patients with conversion disorder with control groups of anxious patients without conversion symptoms. The patients with conversion disorder showed equal or greater anxiety and physiological arousal than the control group. Also, Stone and colleagues (2006) in the study described earlier on “indifference” to conversion symptoms found no difference in distress over symptoms among patients with conversion disorder compared to emotion, such as the amygdala, using brain-imaging procedures (Rowe, 2010; Voon et al., 2010). For countless other cases, however, biological contributory factors seem to be less important than the overriding infl uence of interpersonal factors (the actions of Eloise’s mother, for example), as we will discuss in the next section. There you will see that the extent of Eloise’s suffering and its successful resolution point primarily to a psychological and social etiology. Treatment Although few systematic controlled studies have evaluated the effectiveness of treatment for conversion disorders, we often treat these conditions in our clinics, as do others (see, for example, Campo & Negrini, 2000; Moene, Spinhoven, Hoogduin, & van Dyck, 2002, 2003), and our methods closely follow our thinking on etiology. Because conversion disorder has much in common with somatization disorder, many of the treatment principles are similar. A principal strategy in treating conversion disorder is to identify and attend to the traumatic or stressful life event, if it is still present (either in real life or in memory). As in the case of Anna O., therapeutic assistance in reexperiencing or “reliving” the event (catharsis) is a reasonable fi rst step. The therapist must also work hard to reduce any reinforcing or supportive consequences of the conversion symptoms (secondary gain). For example, it was quite clear that Eloise’s mother found it convenient if Eloise stayed in one place most of the day while her mother attended to the store in the front of the house. Eloise’s immobility was thus strongly reinforced by motherly attention and concern. Any unnecessary mobility was punished. The therapist must collaborate with both the patient and the family to eliminate such self-defeating behaviors. Many times, removing the secondary gain is Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. B. The preoccupation causes signifi cant distress or impairment in social, occupational, or other important areas of functioning. C. The preoccupation is not better accounted for by another mental disorder (for example, dissatisfaction with body shape and size in anorexia nervosa). JIM Ashamed to Be Seen In his mid-20s, Jim was diagnosed with suspected social phobia; he was referred to our clinic by another professional. Jim had just fi nished rabbinical school and had been offered a position at a synagogue in a nearby city. However, he found himself unable to accept because of marked social diffi culties. Lately he had given up leaving his small apartment for fear of running into people he knew and being forced to stop and interact with them. Jim was a good-looking young man of about average height, with dark hair and eyes. Although he was somewhat depressed, a mental status exam and a brief interview focusing on current functioning and past history did not reveal any remarkable problems. There was no sign of a psychotic process (he was not out of touch with reality). We then focused on Jim’s social diffi culties. We expected the usual kinds of anxiety about interacting with people or “doing something” (performing) in front of them. But this was not Jim’s concern. Rather, he was convinced that everyone, even his good friends, was staring at a part of his body that he found grotesque. He reported that strangers would never mention his deformity and his friends felt too sorry for him to mention it. Jim thought his head was square! Like the Beast in Beauty and the Beast who could not imagine people reacting to him with anything less than revulsion, Jim could not imagine people not alone. For decades, this condition, previously known as dysmorphophobia (literally, fear of ugliness), was thought to represent a psychotic delusional state because the affected individuals were unable to realize, even for a fl eeting moment, that their ideas were irrational. Whether this is true is still debated. For example, in 200 cases examined by Phillips, Menard, Fay, and Weisberg (2005) and in 50 cases reported by Veale, Boocock, and colleagues (1996), between 33% and 50% of participants were convinced their imagined bodily defect was real and a reasonable source of concern. Is this delusional? The DSM-IV task force wrestled long and hard with this issue and decided that individuals with BDD whose beliefs are so fi rmly held that they could be called delusional should receive a second diagnosis of delusional disorder, somatic type (see Chapter 13) in addition to BDD. Phillips, Menard, Pagano, Fay, and Stout (2006) looked closely at differences that may exist between delusional and nondelusional types and found nothing signifi cant, beyond the fact that the delusional type was more severe and found in less educated patients. Other studies have supported this lack of meaningful differences between these two groups (Mancuso, Knoesen, & Castle, in press; Phillips et al., in press). It is also the case that these two groups both respond equally well to treatments for BDD and that the “delusional” group does not respond to drug treatments for psychotic disorders (Phillips et al., in press). Thus, in DSM-5, the proposal is that patients would receive just a BDD diagnosis, whether they are “delusional” or not, and the practice of giving them a second diagnosis of delusional disorder (a psychotic disorder) should be dropped (Phillips et al., in press). appearance (Veale, Ennis, & Lambrou, 2002). In mental health clinics, the disorder is also uncommon because most people with BDD seek other types of health professionals, such as plastic surgeons and dermatologists. BDD is seen equally in men and women. In the larger series of 200 individuals reported by Phillips, Menard, Fay, and Weisberg (2005), 68.5% were female, but 62% of a large number of individuals with BDD in Japan were males. Generally, there are more similarities than differences between men and women with BDD, but some differences have been noted (Phillips, Menard, & Fay, 2006). Men tend to focus on body build, genitals, and thinning hair and tend to be more severe. A focus on muscle defects and body building is nearly unique to men with the disorder (Pope et al., 2005). Women focus on more varied body areas and are more likely to also have an eating disorder. As you might suspect, few people with this disorder get married. Age of onset ranges from early adolescence through the 20s, peaking at the age of 16–17 (Phillips, Menard, Fay, & Weisberg, 2005; Veale, Boocock, et al., 1996; Zimmerman & Mattia, 1998). Individuals are somewhat reluctant to seek treatment. In many cases, a relative will force the issue, demanding the individual get help; this insistence may refl ect the disruptiveness of the disorder for family members. Severity is also refl ected in the high percentage (24%) of past suicide attempts among the 50 cases described by Veale, Boocock, and colleagues (1996); know somebody who’s a evidence indicates they share common features (Kihlstrom, Glisky, & Anguilo, 1994; Prelior, Yutzy, Dean, & Wetzel, 1993). They used to be categorized under one general heading, “hysterical neurosis.” You may remember (from Chapter 1) that the term hysteria, which dates back to the Greek, Hippocrates, and the Egyptians before him, suggests that the cause of these disorders, which were thought to occur primarily in women, can be traced to a “wandering uterus.” But the term hysterical came to refer more generally to physical symptoms without known organic cause or to dramatic or “histrionic” behavior thought to be characteristic of women. Sigmund Freud (1894–1962) suggested that in a condition called conversion hysteria unexplained physical symptoms indicated the conversion of unconscious emotional confl icts into a more acceptable form. The historical term conversion remains with us (without the theoretical implications); however, the prejudicial and stigmatizing term hysterical is no longer used. The term neurosis, as defi ned in psychoanalytic theory, suggested a specifi c cause for certain disorders. Specifi cally, neurotidisorders resulted from underlying unconscious confl icts, anxiety that resulted from those confl icts, and the implementation of ego defense mechanisms. Neurosis was eliminated from the diagnostic system in 1980 because it was too vague, applying to almost all nonpsychotic disorders, and because it implied a specifi c but unproven cause for these disorders. Somatoform and dissociative disorders are not well understood, but they have intrigued psychopathologists and the public for centuries. A fuller understanding provides a rich perspective on the extent to which normal, everyday traits found in all of us can evolve into distorted, strange, and hypochondriasis shares many features with the anxiety and mood disorders, particularly panic disorder (Craske et al., 1996; Creed & Barsky, 2004), including similar age of onset, personality characteristics, and patterns of familial aggregation (running in families). Indeed, anxiety and mood disorders are often comorbid with hypochondriasis; that is, if individuals with a hypochondriacal disorder have additional diagnoses, these most likely are anxiety or mood disorders (Côté et al., 1996; Creed & Barsky, 2004; Rief, Hiller, & Margraf, 1998; Simon, Gureje, & Fullerton, 2001). The DSM-5 committee is even considering the possibility that many individuals with hypochondriasis might be better considered to have an anxiety disorder, a position that receives wide support (Taylor & Asmundson, 2009). Hypochondriasis is characterized by anxiety or fear that one has a serious disease. Therefore, the essential problem is anxiety, but its expression is different from that of the other anxiety disorders. In hypochondriasis, the individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease. Almost any physical sensation may become the basis for concern for individuals with hypochondriasis. Some may focus on normal bodily functions such as heart rate or perspiration, others on minor physical abnormalities such as a cough. Some individuals complain of vague symptoms, such as aches or fatigue. Because a key feature of this disorder is preoccupation with physical symptoms, individuals with hypochondriasis almost always go initially to family physicians. They come to the attention of mental health professionals only after family physicians have ruled out realistic medical conditions as a cause of the patient’s symptoms. Another important healthy, they remain unconvinced and unreassured. In contrast, panic patients continue to believe their panic attacks might kill them, but most learn rather quickly to stop going to doctors and emergency rooms, where they are told repeatedly that nothing is wrong with them. Finally, the anxieties of individuals with panic disorder tend to focus on the specifi c set of 10 or 15 sympathetic nervous system symptoms associated with a panic attack. Hypochondriacal concerns range much wider. Nevertheless, there are probably more similarities than differences between these groups. Minor, seemingly hypochondriacal concerns are common in young children, who often complain of abdominal aches and pains that do not seem to have a physical basis. In most cases, these complaints are passing responses to stress and do not develop into a full-blown chronic hypochondriacal syndrome. Statistics Prevalence of hypochondriasis in the general population is estimated to be from 1% to 5% (APA, 2000). A review of fi ve studies in primary care settings suggests that the median prevalence rate for hypochondriasis in these settings is 6.7% (Creed & Barsky, 2004). Although historically considered one of the “hysterical” disorders unique to women, the sex ratio is actually closer to 50:50 (Creed & Barsky, 2004; Kellner, 1986; Kirmayer & Robbins, 1991; Kirmayer, Looper, & Taillefer, 2003). It was thought for a long time that hypochondriasis was more prevalent in elderly populations, but this does not seem to be true (Barsky, Frank, Cleary, Wyshak, & Klerman, 1991). In fact, hypochondriasis is spread fairly evenly across various phases of adulthood. Naturally, more older adults go to see physicians, making the total number of patients with hypochondriasis in this age concern about having a serious illness is excessive or unreasonable head, specifi c to African patients (Ebigno, 1986), and a sensation of burning in the hands and feet in Pakistani or Indian patients (Kirmayer & Weiss, 1993). Medically unexplained physical symptoms may be among the more challenging manifestations of psychopathology. First, a physician must rule out a physical cause for the somatic complaints before referring the patient to a mental health professional. Second, the mental health professional must determine the nature of the somatic complaints to know whether they are associated with a specifi c somatoform disorder or are part of some other psychopathological syndrome, such as a panic attack. Third, the clinician must be acutely aware of the specifi c culture or subculture of the patient, which often requires consultation with experts in cross-cultural presentations of psychopathology. Causes Investigators with otherwise differing points of view agree on psychopathological processes ongoing in hypochondriasis. Faulty interpretation of physical signs and sensations as evidence of physical illness is central, so almost everyone agrees that hypochondriasis is basically a disorder of cognition or perception with strong emotional contributions (Adler, Côte, Barlow, & Hillhouse, 1994; Barsky & Wyshak, 1990; Kellner, 1985; olde Hartman et al., 2009; Rief et al., 1998; Salkovskis & Clark, 1993; Taylor & Asmundson, 2004, 2009). Individuals with hypochondriasis experience physical sensations common to all of us, but they quickly focus their attention on these sensations. Remember that the very act of focusing on yourself increases arousal and makes the physical sensations seem more intense than they are (see Chapter 5). If you also tend to misinterpret these as symptoms anxiety disorders. Hyperresponsivity might combine with a tendency to view negative life events as unpredictable and uncontrollable and, therefore, to be guarded against at all times (Noyes et al., 2004; Suárez et al., 2009). As we noted in Chapter 5, these factors would constitute biological and psychological vulnerabilities to anxiety. Why does this anxiety focus on physical sensations and illness? We know that children with hypochondriacal concerns often report the same kinds of symptoms that other family members may have reported at one time (Kellner, 1985; Kirmayer et al., 2003; Pilowsky, 1970). It is therefore quite possible, as in panic disorder, that individuals who develop hypochondriasis have learned from family members to focus their anxiety on specifi c physical conditions and illness. Three other factors may contribute to this etiological process (Côté et al., 1996; Kellner, 1985). First, hypochondriasis seems to develop in the context of a stressful life event, as do many disorders, including anxiety disorders. Such events often involve death or illness (Noyes et al., 2004; Sandin, Chorot, Santed, & Valiente, 2004). (Gail’s traumatic fi rst year of marriage seemed to coincide with the beginning of her disorder.) Second, people who develop hypochondriasis tend to have had a disproportionate incidence of disease in their family when they were children. Thus, even if they did not develop hypochondriasis until adulthood, they carry strong memories of illness that could easily become the focus of anxiety. Third, an important social and interpersonal infl uence may be operating (Noyes et al., 2003; Suárez et al., 2009). Some people who come from families where illness is a major issue seem to have learned that an ill person often gets a lot of attention. The “benefi ts” of being sick might contribute to control group that did not receive the explanatory therapy until after their 6 months of waiting. All patients received usual medical care from their physicians. In both groups, taking the time to explain in some detail the nature of the patient’s disorder in an educational framework was associated with a signifi cant reduction in hypochondriacal fears and beliefs and a decrease in health-care usage, and these gains were maintained at the follow-up. For the wait-list group, treatment gains did not occur until they received explanatory therapy, suggesting this treatment is effective. This is a small study and follow-ups occurred for only 6 months, but the results are promising (although explanatory therapy most likely only benefi ts those with more mild forms of hypochondriasis) (Taylor, Asmundson, & Coons, 2005). Participation in support groups may also give these people the reassurance they need. Evaluations of more robust treatments have now appeared (Clark et al., 1998; Kroenke, 2007; Thomson & Page, 2007). For example, in the best study to date, Barsky and Ahern (2005) randomized 187 patients with hypochondriasis to receive either six sessions of cognitive-behavioral treatment (CBT) from trained therapists or treatment as usual from primary care physicians. CBT focused on identifying and challenging illness-related misinterpretations of physical sensations and on showing patients how to create “symptoms” by focusing attention on certain body areas. Bringing on their own symptoms persuaded many patients that such events were under their control. Patients were also coached to seek less reassurance regarding their concerns. Results can be seen in Figure 6.2 as scores on the Whiteley index of hypochondriacal symptoms. CBT was more infections and might have to leave at any moment to go to the restroom, but she was extremely happy she had kept the appointment. At least she was seeing someone who could help alleviate her considerable suffering. She said she knew we would have to go through a detailed initial interview, but she had something that might save time. At this point, she pulled out several sheets of paper and handed them over. One section, some fi ve pages long, described her contacts with the health-care system for major diffi culties only. Times, dates, potential diagnoses, and days hospitalized were noted. The second section, oneand-a-half single-spaced pages, consisted of a list of all medications she had taken for various complaints. Linda felt she had any one of a number of chronic infections that nobody could properly diagnose. She had begun to have these problems in her teenage years. She often discussed her symptoms and fears with doctors and clergy. Drawn to hospitals and medical clinics, she had entered nursing school after high school. However, during hospital training, she noticed her physical condition deteriorating rapidly: she seemed to pick up the diseases she was learning about. A series of stressful emotional events resulted in her leaving nursing school. After developing unexplained paralysis in her legs, Linda was admitted to a psychiatric hospital, and after a year she regained her ability to walk. On discharge she obtained disability status, which freed her from having to work full time, and she volunteered at the local hospital. With her chronic but fl uctuating incapacitation, on some days she could go in and on some days she could not. She was currently seeing a family practitioner and six specialists, who monitored various aspects of her physical condition. She was also gastrointestinal symptoms: A history of at least two gastrointestinal symptoms other than pain (such as nausea, diarrhea, bloating, vomiting other than during pregnancy, or intolerance of several foods) 3. One sexual symptom: A history of at least one sexual or reproductive symptom other than pain (such as sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, or vomiting throughout pregnancy) 4. One pseudo-neurological symptom: A history of at least one symptom or defi cit suggesting a neurological disorder not limited to pain (conversion symptoms such as blindness, double vision, deafness, loss of touch or pain sensation, hallucinations, aphonia, impaired coordination or balance, paralysis or localized weakness, diffi culty swallowing, diffi culty breathing, urinary retention, or seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) C. Either 1 or 2: 1. After appropriate investigation, each of the symptoms in criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (for example, a drug of abuse or a medication) 2. When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory fi ndings D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering). avoid exercising, thinking it will make them worse (Rief et al., 1998). Furthermore, Linda’s entire life revolved around her symptoms. She once told her therapist that her symptoms were her identity: without them she would not know who she was. By this she meant that she would not know how to relate to people groups (see, for example, Creed & Barsky, 2004; Lieb et al., 2002; Swartz, Blazer, George, & Landerman, 1986). For instance, 68% of the patients in a large sample studied by Kirmayer and Robbins (1991) were female. In addition to a variety of somatic complaints, individuals may have psychological complaints, usually anxiety or mood disorders much as with hypochondriasis (Adler et al., 1994; Kirmayer & Robbins, 1991; Lieb et al., 2002; Rief et al., 1998). Lenze, Miller, Munir, Pornoppadol, and North (1999) found that patients with somatization disorder who happened to be in psychiatric clinics reported seemingly endless psychological complaints, including psychotic symptoms, in addition to their physical complaints. Suicidal attempts that appear to be manipulative gestures rather than true death efforts are frequent (Chioqueta & Stiles, 2004). Obviously, individuals with somatization disorder overuse and misuse the health-care system, with medical bills as much as 9 times more than the average patient (Barsky, Orav, & Bates, 2005; Hiller, Fichter, & Rief, 2003; Woolfolk & Allen, in press). In one study, 19% of people with this disorder were on disability (Allen, Woolfolk, Escobar, Gara, & Hamer, 2006). Although symptoms may come and go, somatization disorder and the accompanying sick role behavior are chronic, often continuing into old age. For a long time, researchers thought that expressing psychological distress as somatic complaints was particularly common in non-Western or developing countries. But on closer inspection this does not seem to be the case, and the impression may have been because of the ways in which early studies were conducted (see, for example, Cheung, 1995). Thus, “somatizing” psychological distress is fairly common, and fairly uniform, to antisocial personality disorder (ASPD) (see Chapter 12), which is characterized by vandalism, persistent lying, theft, irresponsibility with fi nances and at work, and outright physical aggression. Individuals with ASPD seem insensitive to signals of punishment and to the negative consequences of their often impulsive behavior, and they apparently experience little anxiety or guilt. ASPD occurs primarily in males and somatization disorder in females, but they share a number of features. Both begin early in life, typically run a chronic course, predominate among lower socioeconomic classes, are diffi cult to treat, and are associated with marital discord, drug and alcohol abuse, and suicide attempts, among other complications (Cloninger, 1978; Goodwin & Guze, 1984; Lilienfeld, 1992; Mai, 2004). Both family and adoption studies suggest that ASPD and somatization disorder tend to run in families and may well have a heritable component (see, for example, Bohman, Cloninger, von Knorring, & Sigvardsson, 1984; Cadoret, 1978), although it is also possible that the behavioral patterns could be learned in a maladaptive family setting. Yet, the aggressiveness, impulsiveness, and lack of emotion characteristic of ASPD seem to be at the other end of the spectrum from somatization disorder. What could these two disorders possibly have in common? Although we don’t yet have the answers, Scott Lilienfeld (1992; Lilienfeld & Hess, 2001) has reviewed a number of hypotheses; although they are speculative we look at some of them here because they are a fascinating example of integrative biopsychosocial thinking about psychopathology. One model with some support suggests that somatization disorder and ASPD share a neurobiologically based 989–995. Somatoform Disorders 181 symptoms gains immediate sympathy and attention (for a while) but eventually leads to social isolation (Goodwin & Guze, 1984). One study confi rmed that patients with somatization disorder are more impulsive and pleasure seeking than patients with other disorders such as anxiety disorders (Battaglia, Bertella, Bajo, Politi, & Bellodi, 1998). If individuals with ASPD and somatization disorder share the same underlying neurophysiological vulnerability, why do they behave so differently? The explanation is that social and cultural factors exert a strong effect. Both Cathy Spatz Widom (1984) and Robert Cloninger (1987) have pointed out that the major difference between the disorders is their degree of dependence. Aggression is strongly associated with males in most mammalian species, including rodents (Gray & Buffery, 1971). Dependence and lack of aggression are strongly associated with females. Thus, both aggression and ASPD are strongly associated with males, and dependence and somatization disorder are strongly associated with females. In support of this idea, Lilienfeld and Hess (2001), working with college students, found tendencies for females with antisocial and aggressive traits to report more somatic symptoms. Gender roles are among the strongest components of identity. It is possible that gender socialization accounts almost entirely for the profound differences in the expression of the same biological vulnerability among men and women. These theoretical models are still preliminary and require a great deal more data before we can have confi dence in their validity (see also Chapter 12, where some of these ideas are discussed again). But such ideas are at the forefront of our knowledge, and they refl ect the kinds of integrative approaches to psychopathology effectiveness, mostly cognitivebehavioral ones (Woolfolk & Allen, in press), the effectiveness is somewhat lower than for other disorders such as anxiety and mood disorders. In one of the best studies, Allen et al. (2006) found that 40% of patients treated with CBT (versus 7% of a group receiving standard medical care) evidenced clinical improvement and these gains lasted at least a year. Escobar et al. (2007) reported similar results. In our clinic, we concentrate on initially providing reassurance, reducing stress, and, in particular, reducing the frequency of help-seeking behaviors. One of the most common patterns is the person’s tendency to visit numerous medical specialists to address the symptom of the week. There is an extensive medical and physical workup with every visit to a new physician (or to one who has not been seen for a while), at an extraordinary cost to the health-care system (Barsky et al., 2005; Hiller et al., 2003). In treatment, to limit these visits, a gatekeeper physician is assigned each patient to screen all physical complaints. Subsequent visits to specialists must be specifi - cally authorized by this gatekeeper. In the context of a positive therapeutic relationship, most patients are amenable to this arrangement. Additional therapeutic attention is directed at reducing the supportive consequences of relating to signifi cant others on the basis of physical symptoms alone. More appropriate methods of interacting with others are encouraged, along with additional procedures to promote healthy social and personal adjustment without relying on being “sick.” In this context, CBT may then be the most helpful (Allen et al., 2006; Mai, 2004; Woolfolk & Allen, in press). Because Linda, like many patients with this disorder, was receiving disability payments from the state, additional goals involved encouraging condition part of a larger category called “complex somatic symptom disorder,” as described in the beginning of the chapter. But the clinician could still specify complaints of chronic pain (and associated anxiety) as the principal focus. The three subtypes of pain disorder in DSM-IV-TR run the gamut from pain judged to be due primarily to psychological factors to pain judged to be due primarily to a general medical condition. Several studies suggest that this is a fairly common condition, with 5% to 12% of the population meeting criteria for pain disorder (Asmundson & Carleton, 2009; Frohlich, Jacobi, & Wittchen, 2006; Grabe et al., 2003). An important feature of pain disorder is that the pain is real and it hurts, regardless of the causes (Aigner & Bach, 1999; King & Strain, 1991). Consider the two cases described here. THE MEDICAL STUDENT Temporary Pain During her fi rst clinical rotation, a 25-year-old third-year medical student in excellent health was seen at her student health service for intermittent abdominal pain of several weeks’ duration. The student claimed no past history of similar pain. Physical examination revealed no physical problems, but she told the physician that she had recently separated from her husband. The student was referred to the health service psychiatrist. No other psychiatric problems were found. She was taught relaxation techniques and given supportive therapy to help her cope with her current stressful situation. The student’s pain subsequently disappeared, and she successfully completed medical school A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of suffi cient severity to warrant clinical attention. B. The pain causes clinically signifi cant distress or impairment in social, occupational, or other Ages (Mace, 1992) but was popularized by Freud, who believed the anxiety resulting from unconscious confl icts somehow was “converted” into physical symptoms to fi nd expression. This allowed the individual to discharge some anxiety without actually experiencing it. As in phobic disorders, the anxiety resulting from unconscious confl icts might be “displaced” onto another object. Clinical Description Conversion disorders generally have to do with physical malfunctioning, such as paralysis, blindness, or diffi culty speaking (aphonia), without any physical or organic pathology to account for the malfunction. Most conversion symptoms suggest that some kind of neurological disease is affecting sensory–motor systems, although conversion symptoms can mimic the full range of physical malfunctioning. For this reason, and because the term “conversion” implies a specifi c etiology for which there is limited evidence, the proposal for DSM-5 is to change the name to “functional neurological disorder” (with “functional” referring to a symptom without organic cause) (Stone, LaFrance, Levenson, & Sharpe, 2010). Conversion disorders provide some of the most intriguing, sometimes astounding, examples of psychopathology. What could possibly account for somebody going blind when all visual processes are normal or experiencing paralysis of the arms or legs when there is no neurological damage? Consider the case of Eloise. ELOISE Unlearning Walking Eloise sat on a chair with her legs under her, refusing to put her feet on the fl oor. Her mother sat close by, ready to assist her if she needed to move or get up. Her mother had made the appointment and, with the help of a friend, had all but carried Eloise into the offi ce. Eloise was a 20-year-old of borderline intelligence who was friendly and the same quality of indifference to the symptoms thought to be present in somatization disorder. This attitude, referred to as la belle indifférence, was considered a hallmark of conversion reactions, but, unfortunately, this turns out not to be the case. Stone, Smyth, Carson, Warlow, and Sharpe (2006) found a blasé attitude toward illness is sometimes displayed by people with actual physical disorders, and some people with conversion symptoms do become quite distressed. Specifi cally, only 21% of 356 patients with conversion symptoms displayed la belle indifférence compared to 29% of 157 patients with organic disease. Other factors may be more helpful in making this distinction. Conversion symptoms are often precipitated by marked stress. A. One or more symptoms or defi cits affecting voluntary motor or sensory function that suggest a neurological or general medical condition. B. Psychological factors are judged to be associated with the symptom or defi cit because the initiation or exacerbation of the symptom or defi cit is preceded by confl icts or other stressors. C. The symptom or defi cit is not intentionally produced or feigned (as in factitious disorder or malingering). D. The symptom or defi cit cannot, after appropriate investigation, be fully explained by a general medical condition, by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or defi cit causes clinically signifi cant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F. The symptom or defi cit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. Specify type of symptom or defi cit: With disorders that are really physical problems is approximately 4%, having improved considerably from earlier decades. In any case, ruling out medical causes for the symptoms is crucial to making a diagnosis of conversion and, given advances in medical screening procedures, will become the principal diagnostic criterion in DSM-5 (APA, 2010; Stone et al., 2010). It can also be diffi cult to distinguish between individuals who are truly experiencing conversion symptoms in a seemingly involuntary way and malingerers who are good at faking symptoms. Once malingerers are exposed, their motivation is clear: They are either trying to get out of something, such as work or legal diffi culties, or they are attempting to gain something, such as a fi nancial settlement. Malingerers are fully aware of what they are doing and are clearly attempting to manipulate others to gain a desired end. More puzzling is a set of conditions called factitious disorders, which fall somewhere between malingering and conversion disorders. The symptoms are under voluntary control, as with malingering, but there is no obvious reason for voluntarily producing the symptoms except, possibly, to assume the sick role and receive increased attention. Tragically, this disorder may extend to other members of the family. An adult, almost always a mother, may purposely make her child sick, evidently for the attention and pity given to her as the mother of a sick child. When an individual deliberately makes someone else sick, the condition is called factitious disorder by proxy or, sometimes, Munchausen syndrome by proxy, but it is really an atypical form of child abuse (Check, 1998). Table 6.2 presents differences between typical child abuse and Munchausen syndrome by proxy. The offending parent may resort to extreme tactics to create the Munchausen syndrome by proxy, where the parent was responsible for the child’s symptoms, and in more than half of these 23 cases, video surveillance was the method used to establish the diagnosis. In the other patients, laboratory tests or “catching” the mother in the act of inducing illness in her child confi rmed the diagnosis. In one case, a child was suffering from recurring Escherichia coli, or E. coli, infections, and cameras caught the mother injecting her own urine into the child’s intravenous line (Hall, Eubanks, Meyyazhagan, Kenney, & Cochran Johnson, 2000). Unconscious Mental Processes Unconscious cognitive processes seem to play a role in much of psychopathology (although not necessarily as Freud envisioned it), but nowhere is this phenomenon more readily and dramatically apparent than when we attempt to distinguish between conversion disorders and related conditions. To take a closer look at the “unconscious” mental process in these conditions, we review briefl y the case of Anna O. (see Chapter 2). As you may remember, when Anna O. was 21 years old she was nursing her dying father. This was a diffi cult time for her. She reported that after many days by the sick bed, her mind wandered. Suddenly she found herself imagining (dreaming?) that a black snake was moving across the bed, about to bite her father. She tried to grab the snake, but her right arm had gone to sleep and she could not move it. Looking at her arm and hand, she imagined that her fi ngers had turned into little poisonous snakes. Horrifi ed, all she could do was pray, and the only prayer that came to mind was in English (Anna O.’s native language was German). After this, she experienced paralysis in her right arm whenever she remembered this hallucination. The paralysis gradually read. When she was brought to a clinic for testing, psychologists arranged a series of sophisticated vision tests that did not require her to report when she could or could not see. One of the tasks required her to examine three triangles displayed on three separate screens and to press a button under the screen containing an upright triangle. Celia performed perfectly on this test without being aware that she could see anything (Grosz & Zimmerman, 1970). Was Celia faking? Evidently not, or she would have purposely made a mistake Sackeim, Nordlie, and Gur (1979) evaluated the potential difference between real unconscious process and faking by hypnotizing two participants and giving each a suggestion of total blindness. One participant was also told it was extremely important that she appear to everyone to be blind. The second participant was not given further instructions. The fi rst participant, evidently following instructions to appear blind at all costs, performed far below chance on a visual discrimination task similar to the upright triangle task. On almost every trial, she chose the wrong answer. The second participant, with the hypnotic suggestion of blindness but no instructions to “appear” blind at all costs, performed perfectly on the visual discrimination tasks—although she reported she could not see anything. How is this relevant to identifying malingering? In an earlier case, Grosz and Zimmerman (1965) evaluated a male who seemed to have conversion symptoms of blindness. They discovered that he performed much more poorly than chance on a visual discrimination task. Subsequent information from other sources confi rmed that he was almost certainly malingering. To review these distinctions, someone who is truly blind would perform at a chance level on one study, 56 patients with psychogenic nonepileptic seizures (16 males and 40 females), who had their disorder for an average of 8 years, were followed for 18 months after initial diagnosis (Ettinger, Devinsky, Weisbrot, Ramakrishna, & Goyal, 1999). Outcome was generally poor for these patients, with only about half of the patients recovering. Even among those patients whose seizures had gotten better, rehospitalizations were common. Approximately 20% of this group had attempted suicide, and this proportion did not differ between those whose seizures had gotten better during the period and those whose seizures had not gotten better. If the patients believed the diagnosis of conversion disorder when it was given to them, and otherwise perceived themselves as being in good health and functioning well at work and at home, they had a better chance of recovering from their psychologically based seizures. Fortunately, children and adolescents seem to have a better long-term outlook than adults. In one study from Turkey, fully 85% of 40 children had recovered 4 years after initial diagnoses, with those diagnosed early having the best chance of recovery (Pehlivanturk & Unal, 2002). Whether this is also true in Europe or North America requires further study. In the beginning of the chapter, we noted that conversion disorder and dissociative disorders share common features. Several studies provide evidence for this. In one study, 72 patients with conversion disorders were compared with a control group of 96 psychiatric patients suffering from various emotional disorders who were matched for gender and age. Dissociative symptoms such as feelings of unreality were signifi cantly more common in the patients with conversion disorder than in the control group, based on fourth, although fi rm evidence supporting any of these ideas is sparse and Freud’s views were far more complex than represented here. Most often, individuals with conversion disorder have experienced a traumatic event that must be escaped at all costs (Stone, Carson, Aditya, et al., 2009). This might be combat, where death is imminent, or an impossible interpersonal situation. Because simply running away is unacceptable in most cases, the socially acceptable alternative of getting sick is substituted; but getting sick on purpose is also unacceptable, so this motivation is detached from the person’s consciousness. Finally, because the escape behavior (the conversion symptoms) is successful to an extent in obliterating the traumatic situation, the behavior continues until the underlying problem is resolved. One study confi rms these hypotheses, at least partially (Wyllie, Glazer, Benbadis, Kotagal, & Wolgamuth, 1999). In this study, 34 child and adolescent patients, 25 of them girls, were evaluated after receiving a diagnosis of psychologically based pseudo-seizures (psychogenic nonepileptic seizures). Many of these children and adolescents presented with additional psychological disorders, including 32% with mood disorders and 24% with separation anxiety and school refusal. Other anxiety disorders were present in some additional patients. When the extent of psychological stress in the lives of these children was examined, it was found that most of the patients had substantial stress, including a history of sexual abuse, recent parental divorce or death of a close family member, and physical abuse. The authors concluded that major mood disorders and severe environmental stress, especially sexual abuse, are common among children and adolescents with the conversion disorder of patients with organic disease. Social and cultural infl uences also contribute to conversion disorder, which, like somatization disorder, tends to occur in less educated, lower socioeconomic groups where knowledge about disease and medical illness is not well developed (Binzer, Andersen, & Kullgren, 1997; Kirmayer, Looper, & Taillefer, 2003; Woolfolk & Allen, in press). For example, Binzer and colleagues (1997) noted that 13% of their group of 30 adult patients with motor disabilities resulting from conversion disorder had attended high school compared to 67% in a control group of patients with motor symptoms because of a physical cause. Prior experience with real physical problems, usually among other family members, tends to infl uence the later choice of specifi c conversion symptoms; that is, patients tend to adopt symptoms with which they are familiar (see, for example, Brady & Lind, 1961). Furthermore, the incidence of these disorders has decreased over the decades (Kirmayer et al., 2003). The most likely explanation is that increased knowledge of the real causes of physical problems by both patients and loved ones eliminates much of the possibility of secondary gain so important in these disorders. Finally, many conversion symptoms seem to be part of a larger constellation of psychopathology. Linda had broad-ranging somatization disorder, as well as the severe conversion symptoms, that resulted in her hospitalization. In similar cases, individuals may have a marked biological vulnerability to develop conversion disorder when under stress, with biological processes like those discussed in the context of somatization disorder. Neuroscientists are increasingly fi nding a strong connectivity between the conversion symptom and parts of the brain regulating easier said than done. Eloise was successfully treated in the clinic. Through intensive daily work with the staff, she was able to walk again. To accomplish this, she had to practice walking every day with considerable support, attention, and praise from the staff. When her mother visited, the staff noticed that she verbalized her pleasure with Eloise’s progress but that her facial expressions or affect conveyed a different message. The mother lived a good distance from the clinic so she could not attend sessions, but she promised to carry out the program at home after Eloise was discharged. But she didn’t. A follow-up contact 6 months after Eloise was discharged revealed that she had relapsed and was again spending almost all her time in a room in the back of the house while her mother attended to business out front. Following similar cognitive-behavioral programs, 65% of a group of 45 patients with mostly motor behavior conversions (for example, diffi culty walking) responded well to treatment. Interestingly, hypnosis, which was administered to approximately half the patients, added little or no benefi t to the CBT (Moene et al., 2002, 2003). Body Dysmorphic Disorder Did you ever wish you could change part of your appearance? Maybe the size of your nose or the way your ears stick out? Most people fantasize about improving something, but some relatively normal-looking people think they are so ugly they refuse to interact with others or otherwise function normally for fear that people will laugh at their ugliness. This curious affl iction is called body dysmorphic disorder (BDD), and at its center is a preoccupation with some imagined defect in appearance by someone who actually looks reasonably normal. The disorder has been referred to as “imagined ugliness” (Phillips, 1991). Consider the case of Jim A. getting past his square head. To hide his condition as well as he could, Jim wore soft fl oppy hats and was most comfortable in winter, when he could all but completely cover his head with a large stocking cap. To us, Jim looked normal. Clinical Description To give you a better idea of the types of concerns people with BDD present to health professionals, the locations of imagined defects in 200 patients are shown in Table 6.3. The average number of body areas of concern to these individuals was fi ve to seven (Phillips, Menard, Fay, & Weisberg, 2005). In another group of 23 adolescents with BDD, 61% focused on their skin and 55% on their hair (Albertini & Phillips, 1999). A variety of checking or compensating rituals are common in people with BDD in attempts to alleviate their concerns. For example, excessive tanning is common, with 25% of one group of 200 patients tanning themselves in an attempt to hide skin defects (Phillips, Menard, Fay, & Weisberg, 2005). Excessive grooming and skin picking are also common. Many people with this disorder become fi xated on mirrors (Veale & Riley, 2001). They often check their presumed ugly feature to see whether any change has taken place. Others avoid mirrors to an almost phobic extent. Quite understandably, suicidal ideation, suicide attempts, and suicide itself are typical consequences of this disorder (Phillips, Menard, Fay, & Weisberg, 2005; Zimmerman & Mattia, 1998). People with BDD also have “ideas of reference,” which means they think everything that goes on in their world somehow is related to them—in this case, to their imagined defect. This disorder can cause considerable disruption in the patient’s life. Many patients with severe cases become housebound for fear of showing themselves to other people. If this disorder seems strange to you, you are Statistics The prevalence of BDD is hard to estimate because by its very nature it tends to be kept secret. However, the best estimates are that it is far more common than we had previously thought. Without some sort of treatment, it tends to run a lifelong course (Phillips, 1991; Veale, Boocock, et al., 1996). One of the patients with BDD reported by Phillips and colleagues (1993) had suffered from her condition for 71 years, since the age of 9. If you think a college friend seems to have at least a mild version of BDD, you’re probably correct. Studies suggest that as many as 70% of college students report at least some dissatisfaction with their bodies, with 4% to 28% of these appearing to meet all the criteria for the disorder (Fitts, Gibson, Redding, & Deiter, 1989; Phillips, 2005). However, this study was done by questionnaire and may well have refl ected the large percentage of students who are concerned simply with weight. Another study investigated the prevalence of BDD specifi cally in an ethnically diverse sample of 566 adolescents between the ages of 14 and 19. The overall prevalence of BDD in this group was 2.2%, with adolescent girls more dissatisfi ed with their bodies than boys and African Americans of both genders less dissatisfi ed with their bodies than Caucasians, Asians, and Hispanics (Mayville, Katz, Gipson, & Cabral, 1999; Roberts, Cash, Feingold, & Johnson, 2006). Overall, about 1% to 2% of individuals in community samples and from 2% to 13% of student samples meet criteria for BDD (Koran, Abujaoude, Large, & Serpe, 2008; Phillips, Menard, Fay, & Weisberg, 2005; Woolfolk & Allen, in press). A somewhat higher proportion of individuals with BDD are interested in art or design compared to individuals without BDD, refl ecting, perhaps, a strong interest in aesthetics or than comparable indices in patients with depression, diabetes, or a recent myocardial infarction (heart attack) on several questionnaire measures (Phillips, Dufresne, Wilkel, & Vittorio, 2000). Similar results were reported on a larger sample of 176 patients (Phillips, Menard, Fay, & Pagano, 2005). Thus, BDD is among the more serious of psychological disorders, and depression and substance abuse are common consequences of BDD (Gustad & Phillips, 2003; Phillips et al., in press). Further refl ecting the intense suffering that accompanies this disorder, Veale (2000) collected information on 25 patients with BDD who had sought cosmetic surgery in the past. Of these, 9 patients who could not afford surgery, or were turned down for other reasons, had attempted by their own hand to alter their appearance dramatically, often with tragic results. One example was a man preoccupied by his skin, who believed it was too “loose.” He used a staple gun on both sides of his face to try to keep his skin taut. The staples fell out after 10 minutes and he narrowly missed damaging his facial nerve. In a second example, a woman was preoccupied by her skin and the shape of her face. She fi led down her teeth to alter the appearance of her jawline. Yet another woman who was preoccupied by what she perceived as the ugliness of multiple areas of her body and desired liposuction, but could not afford it, used a knife to cut her thighs and attempted to squeeze out the fat. BDD is also stubbornly chronic. In a recent prospective study of 183 pat

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