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