CHAPTER TEN

OUTLINE
I. DISORDERS FEATURING SOMATIC SYMPTOMS
A. Psychological factors may contribute to somatic, or bodily, illnesses in a variety of ways
B. This idea has ancient roots, yet it had few proponents before the twentieth century
1. It was particularly unpopular during the Renaissance, when the mind was considered the territory
of priests and philosophers, not of physicians and scientists
2. By the seventeenth century, French philosopher Ren Descartes claimed that the mind, or soul, is
totally separate from the bodya position called mind-body dualism
3. Over the twentieth century, however, numerous studies convinced medical and clinical researchers
that psychological factors such as stress, worry, and even unconscious needs can contribute in
major ways to bodily illness
C. DSM-5 lists a number of psychological disorders in which bodily symptoms or concerns are primary
features, including:
1. Factitious disorder
2. Conversion disorder
3. Somatic symptom disorder
4. Illness anxiety disorder
5. Psychological factors affecting other medical conditions

II. FACTITIOUS DISORDER

A. Sometimes when physicians cannot find a medical cause for a patients symptoms, he or she may
suspect other factors are involved
1. Patients may malinger, intentionally fake illness to achieve external gain (e.g., financial
compensation, military deferment)
2. Patients may be manifesting a factitious disorderintentionally producing or faking symptoms
simply out of a wish to be a patient (See Table 10-1, text p. 318.)
B. Known popularly as Munchausen syndrome, people with factitious disorder often go to extremes to
create the appearance of illness
1. Many secretly give themselves medications to produce symptoms
2. Patients often research their supposed ailments and are impressively knowledgeable about
medicine
C. Clinical researchers have a hard time determining the prevalence of this disorder as patients hide the
true nature of their problems
1. Overall, the pattern appears to be more common in women than men, and the disorder usually
begins during early adulthood
2. Factitious disorder seems to be particularly common among people who received extensive
medical treatment as children, carry a grudge against the medical profession, or have worked as a
nurse, lab technician, or medical aide
D. The precise causes of factitious disorder are not understood, although clinical reports have pointed to
factors such as depression, unsupportive parental relationships and an extreme need for social support
that is not otherwise available
E. Psychotherapists and medical practitioners often become annoyed or angry at people with a factitious
disorder, feeling that those people are wasting their time
 1. People with the disorder, however, feel they have no control over their problems and often
experience great distress
2. In a related pattern, factitious disorder imposed on another, known popularly as Munchausen
syndrome by proxy, parents or caretakers make up or produce physical illnesses in their children

III. CONVERSION DISORDER

A. People with this disorder display physical symptoms that affect voluntary motor or sensory
functioning, but the symptoms are inconsistent with known medical diseases (See Table 10-2, text p.
321.)
1. In short, individuals experience neurological-like symptomsblindness, paralysis, or loss of
feelingthat have no neurological basis
B. Conversion disorder often is hard to distinguish from genuine medical problems
1. It is always possible that a diagnosis of conversion disorder is a mistake and the patients problem
has an undetected medical cause
2. Physicians sometimes rely on oddities in the patients medical picture to help distinguish the two
a. For example, conversion symptoms may be at odds with the known functioning of the
nervous system, as in cases of glove anesthesia (See Figure 10-1, text p. 322.)
C. Unlike people with factitious disorder, those with conversion disorder dont consciously want or
produce their symptoms
D. This pattern is called conversion disorder because clinical theorists used to believe that individuals
with the disorder were converting psychological needs into neurological symptoms
E. Conversion disorder usually begins between late childhood and young adulthood
1. It is diagnosed in women twice as often as in men
2. It typically appears suddenly, at times of stress
3. It is thought to be rare, occurring in at most 5 of every 1,000 persons
IV. SOMATIC SYMPTOM DISORDER
A. People with somatic symptom disorder become excessively distressed, concerned, and anxious about
bodily symptoms that they are experiencing
B. Two patterns of somatic symptom disorder have received particular attention:
1. Somatization pattern
a. People with a somatization pattern experience many long-lasting physical ailments that have
little or no organic basis
b. This disorder is also known as Briquets syndrome
c. A sufferers ailments often include pain symptoms, gastrointestinal symptoms, sexual
symptoms, and neurological symptoms
d. Patients usually go from doctor to doctor in search of relief
e. Patients with this pattern often describe their symptoms in dramatic and exaggerated terms
and most also feel anxious and depressed
f. The pattern typically lasts for many years; symptoms may fluctuate over time but rarely
disappear completely without therapy
g. Between 0.2 percent and 2 percent of all women in the United States experience a
somatization pattern in any given year (compared with less than 0.2 percent of men)
h. The pattern often runs in families and begins between adolescence and young adulthood: as
20 percent of the close female relatives of women with the pattern also develop it
2. Predominant pain pattern
a. If the primary feature of somatic symptom disorder is pain, the individual is said to have a
predominant pain pattern
b. Although the precise prevalence has not been determined, this pattern appears to be fairly
common
c. The pattern often develops after an accident or illness that has caused genuine pain
d. The pattern may begin at any age, and more women than men seem to experience it

V. WHAT CAUSES CONVERSION AND SOMATIC SYMPTOM DISORDERS?

 A. For many years, conversion and somatic symptom disorders were referred to as hysterical disorders
1. This label was to convey the prevailing belief that excessive and uncontrolled emotions underlie
the bodily symptoms
B. Todays leading explanations come from the psychodynamic, behavioral, cognitive, and multicultural
models
1. None has received much research support, and the disorders are still poorly understood
C. The psychodynamic view
1. Freud believed that hysterical disorders represented a conversion of underlying emotional
conflicts into physical symptoms
2. Because most of his patients were women, Freud centered his explanation on the needs of girls
during their phallic stage (ages 35)
a. According to Freud, during this stage, girls develop a pattern of sexual desires for their fathers
(the Electra complex) while recognizing that they must compete with their mothers for their
fathers attention
b. Because of the mothers more powerful position, however, girls repress these sexual feelings
c. Freud believed that if parents overreacted to such feelings, the Electra complex would remain
unresolved and the child would reexperience sexual anxiety through her life
d. Freud concluded that some women unconsciously hide their sexual feelings in adulthood by
converting them into physical symptoms
3. Todays psychodynamic theorists take issue with parts of Freuds explanation
a. They do continue to believe that sufferers of these disorders have unconscious conflicts
carried from childhood
4. Psychodynamic theorists propose that two mechanisms are at work in these disorders:
a. Primary gainBodily symptoms keep internal conflicts out of conscious awareness
b. Secondary gainBodily symptoms further enable people to avoid unpleasant activities or to
receive sympathy from others
D. The behavioral view
1. Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to
sufferers
a. May remove individual from an unpleasant relationship
b. May bring attention from other people
2. In response to such rewards, sufferers learn to display symptoms more and more prominently
3. This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists
view them as the primary cause of the development of the disorder
4. Like the psychodynamic explanation, the behavioral view of these disorders has received little
research support
E. The cognitive view
1. Some cognitive theorists propose that conversion and somatic symptom disorders are forms of
communication, providing a means for people to express difficult emotions
a. Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into
physical symptoms
b. This conversion is not to defend against anxiety but to communicate extreme feelings
c. Like the other explanations, this cognitive view has not been widely tested or supported by
research
F. The multicultural view
1. Some theorists believe that Western clinicians hold a bias that considers somatic symptoms as an
inferior way of dealing with emotions
a. The transformation of personal distress into somatic complaints is the norm in many non-
Western cultures
b. The lesson to be learned from multicultural findings is that both bodily and psychological
reactions to life events are often influenced by ones culture

VI. HOW ARE CONVERSION AND SOMATIC SYMPTOM DISORDERS TREATED?

 A. People with conversion and somatic symptom disorders usually seek psychotherapy only as a last
resort
B. Many therapists focus on the causes of the disorders and apply techniques including:
1. Insight, to help those with somatic symptoms become conscious of and resolve their underlying
fears
2. Exposure, to expose clients to features of the horrific events that first triggered their physical
symptoms, expecting that the clients will become less anxious over the course of repeated
exposures and more able to face those upsetting events directly rather than through physical
channels
3. Drug Therapyantianxiety or antidepressant medication to help reduce the anxiety
C. Other therapists try to address the physical symptoms of these disorders, applying techniques such as:
1. Suggestionoffering emotional support that may include hypnosis
2. Reinforcementa behavioral attempt to change reward structures
3. Confrontationan overt attempt to force patients out of the sick role
D. Researchers have not fully evaluated the effects of these particular approaches on these disorders

VII. ILLNESS ANXIETY DISORDER

[Video: Hypochondriasis Becomes Illness Anxiety Disorder]
A. People with illness anxiety disorder, previously known as hypochondriasis, experience chronic
anxiety about their health and are concerned that they are developing a serious medical illness,
despite the absence of somatic symptoms (See Table 10-5, text p. 330.)
B. They repeatedly check their bodies for signs of illness and misinterpret bodily symptoms as signs of a
serious illness
1. Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or
sweating
C. Although some patients recognize that their concerns are excessive, many do not
D. Although this disorder can begin at any age, it starts most often in early adulthood, among men and
women in equal numbers
E. Between 1 percent and 5 percent of all people experience the disorder
F. For most patients, symptoms rise and fall over the years
G. Theorists explain this disorder much as they explain various anxiety disorders:
1. Behaviorists: illness fears are acquired through classical conditioning or modeling
2. Cognitive theorists: people with the disorder are so sensitive to and threatened by bodily cues that
they come to misinterpret them
H. Individuals with illness anxiety disorder typically receive the kinds of treatments applied to OCD:
1. Antidepressant medication
2. Exposure and response prevention (ERP)
3. Cognitive interventions

VIII. PSYCHOPHYSIOLOGICAL DISORDERS: PSYCHOLOGICAL FACTORS AFFECTING

OTHER MEDICAL CONDITONS
[Video: Hypnosis: Medical and Psychological Applications; Stress and the Immune System: Caretakers at
Risk]
A. About 85 years ago, clinicians first identified a group of physical illnesses that seemed to result from
an interaction of biological, psychological, and sociocultural factors
B. Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders
1. DSM-5 labels them as psychological factors affecting medical condition (See Table 10-6, text p.
331.)
2. It is important to recognize that these psychophysiological disorders bring about actual physical
damage
C. Traditional psychophysiological disorders
1. Before the 1970s, the best known and most common of the psychophysiological disorders were
ulcers, asthma, insomnia, chronic headaches, high blood pressure, and coronary heart disease
2. Recent research has shown that many other physical illnesses may be caused by an interaction of
psychosocial and physical factors
3. The traditional psychophysiological disorders include:
a. Ulcerslesions in the wall of the stomach resulting in burning sensations or pain, vomiting,
and stomach bleeding
(a) Experienced by more than 25 million people at some point in their lives
(b) Causal psychosocial factors: environmental pressures, intense feelings of anger or
anxiety
(c) Causal physiological factors: bacterial infection
b. Asthmaa narrowing of the bodys airways that makes breathing difficult
(a) Affects up to 25 million people in the United States each year
(b) Most victims are children or younger teenagers at the time of first attack
(c) Causal psychosocial factors: environmental pressures or anxiety
(d) Causal physiological factors: allergies, a slow-acting sympathetic nervous system,
weakened respiratory system
c. Insomniadifficulty falling asleep or maintaining sleep
(a) 10 percent of the population has insomnia that lasts months or years
(b) Causal psychosocial factors: high levels of anxiety or depression
(c) Causal physiological factors: overactive arousal system, certain medical ailments
d. Chronic headachesfrequent intense aches of the head or neck that are not
caused by another physical disorder
(a) Tension headaches affect 45 million Americans a year
(b) Migraine headaches affect 23 million Americans a year
(c) Causal psychosocial factors: environmental pressures, general feelings of helplessness,
anger, anxiety, depression
(d) Causal physiological factors: abnormal serotonin activity, vascular problems, muscle
weakness
e. Hypertensionchronic high blood pressure, usually producing few outward symptoms
(a) Affects 75 million Americans each year
(b) Causal psychosocial factors: constant stress, environmental danger, general feelings of
anger or depression
(c) Causal physiological factors: obesity, smoking, poor kidney function, high proportion of
collagen in an individuals blood vessels
(i) 10 percent caused by physiological factors alone
f. Coronary heart diseasecaused by a blocking of the coronary arteries; the term refers to
several problems, including myocardial infarction (heart attack)
(a) Nearly 18 million people in the United States suffer from some form of coronary heart
disease
(i) It is the leading cause of death among Americans (both men and women)
(b) Causal psychosocial factors: job stress, high levels of anger or depression
(c) Causal physiological factors: high level of cholesterol, obesity, hypertension, the effects
of smoking, lack of exercise
4. A number of factors contribute to the development of psychophysiological disorders, including:
a. Biological factors
(a) Defects in the autonomic nervous system (ANS) are believed to contribute to the
development of psychophysiological disorders
(b) Other more specific biological problems also may contribute
(i) For example, a weak gastrointestinal system may create a predisposition to
developing ulcers
b. Psychological factors
(a) According to many theorists, certain needs, attitudes, emotions, or coping styles may
cause people to overreact repeatedly to stressors, thereby increasing their likelihood of
developing a psychophysiological disorder
 (b) Examples include a repressive coping style and the Type A personality style
particularly hostility and time urgency
c. Sociocultural factors
(a) Adverse social conditions may set the stage for psychophysiological disorders
(i) One of societys most adverse social conditions is poverty
(ii) Research also reveals that belonging to ethnic and cultural minority groups
increases the risk of developing these disorders and other health problems
5. Clearly, biological, psychological, and sociocultural variables combine to produce
psychophysiological disorders
a. In fact, the interaction of psychosocial and physical factors is now considered the rule of
bodily function, not the exception
b. In recent years, more and more illnesses have been added to the list of psychophysiological
disorders and researchers have found many links between psychosocial stress and a range of
physical illnesses
D. New psychophysiological disorders
1. Are physical illnesses related to stress?
a. The development of the Social Readjustment Rating Scale in 1967 enabled researchers to
examine the relationship between life stress and the onset of illness (See Table 10-8, text p.
338.)
b. Using this measure, studies have linked stresses of various kinds to a wide range of physical
conditions
c. Overall, the greater the amount of life stress, the greater the likelihood of illness
(a) Researchers have even found a relationship between traumatic stress and death
d. One shortcoming of the Social Readjustment Rating Scale is that it does not take into
consideration the particular stress reactions of specific populations; for example, members
of minority groups may respond to stress differently, and women and men have been shown
to react differently to certain life changes measured by the scale
2. Researchers have increasingly looked to the bodys immune system as the key to the relationship
between stress and infection
a. This area of study is called psychoneuroimmunologythe immune system is the bodys
network of activities and cells that identify and destroy antigens (foreign invaders, such as
bacteria) and cancer cells
b. Among the most important cells in this system are the lymphocytes, white blood cells that
circulate through the lymph system and bloodstream and attack invaders
c. Lymphocytes include helper T-cells, natural killer T-cells, and B-cells
d. Researchers now believe that stress can interfere with the activity of lymphocytes, slowing
them down and increasing a persons susceptibility to viral and bacterial infections
e. Several factors influence whether stress will result in a slowdown of the system, including
biochemical activity, behavioral changes, personality style, and degree of social support
(a) Biochemical activity
(i) Stress leads to increased activity of the sympathetic nervous system, including a
release of norepinephrine
(ii) In addition to supporting nervous system activity, this chemical also appears to slow
down the functioning of the immune system
(iii) Similarly, the bodys endocrine glands reduce immune system functioning during
periods of prolonged stress through the release of corticosteroids
(iv) In addition, corticosteroids also trigger increased cytokines, which lead to chronic
inflammation
(b) Behavioral changes
(i) Stress may set into motion a series of behavioral changespoor sleep patterns, poor
eating, lack of exercise, increase in smoking, and/or drinkingthat indirectly affect
the immune system
(c) Personality style
 (i) An individuals personality style, including his or her level of optimism, constructive
coping strategies, and resilience, can help him or her to experience better immune
system functioning and to be better prepared to fight off illness
(d) Social support
(i) People who have few social supports and feel lonely seem to display poorer immune
functioning in the face of stress than people who do not feel lonely
(ii) Studies have shown that social support and affiliation with others may actually
protect people from stress, poor immune system functioning, and subsequent
illness, or help speed up recovery from illness or surgery
E. Psychological treatments for physical disorders
1. The most common of these interventions are relaxation training, biofeedback, meditation,
hypnosis, cognitive interventions, support groups, and therapies designed to increase awareness
and expression of emotion
2. The field of treatment that combines psychological and physical interventions to treat or prevent
medical problems is known as behavioral medicine
a. Relaxation training
(a) People can be trained to relax their muscles at will, a process that sometimes reduces
feelings of anxiety
(b) Relaxation training can help prevent or treat medical illnesses that are related to stress
(c) Relaxation training often is used in conjunction with medication in the treatment of high
blood pressure
(d) Relaxation training often is used alone to treat headaches, insomnia, asthma, pain after
surgery, certain vascular diseases, and the undesirable effects of cancer treatments
b. Biofeedback
(a) Patients given biofeedback training are connected to machinery that gives them
continuous readings about their involuntary bodily activities
(b) Somewhat helpful in the treatment of anxiety disorders, this procedure has been used
successfully to treat headaches and muscular disabilities caused by stroke or accident
(c) Some biofeedback training has been effective in the treatment of heartbeat irregularities,
asthma, migraine headaches, high blood pressure, stuttering, and pain
c. Meditation
(a) Although meditation has been practiced since ancient times, Western health care
professionals have only recently become aware of its effectiveness in relieving physical
distress
(b) The technique involves turning ones concentration inward and achieving a slightly
changed state of consciousness
(c) Meditation has been used to manage pain, treat high blood pressure, heart problems,
insomnia, and asthma
d. Hypnosis
(a) Individuals who undergo hypnosis are guided into a sleeplike, suggestible state during
which they can be directed to act in unusual ways, to feel unusual sensations, or to
forget remembered events
(b) With training, hypnosis can be done without a hypnotist (self-hypnosis)
(c) This technique seems to be particularly helpful in the control of pain and is now used to
treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and
other forms of infection
e. Cognitive interventions
(a) People with physical ailments have sometimes been taught new attitudes or cognitive
responses as part of treatment
(b) One example is stress inoculation training, in which patients are taught to rid themselves
of negative self-statements and to replace them with coping self-statements
f. Support groups and emotion expression
(a) If negative psychological symptoms (e.g., depression, anxiety) contribute to a persons
physical ills, intervention to reduce these emotions should help reduce the ills
 (b) These techniques have been used to treat a variety of illnesses, including HIV, asthma,
cancer, and arthritis
g. Combination approaches
(a) Studies have found that the various psychological interventions for physical problems
tend to be equal in effectiveness
(b) Psychological treatments often are most effective when they are combined with other
psychological and medical treatments
(c) With these combined approaches, todays practitioners are moving away from their
counterparts of centuries past

Chapter 10

1. Define somatoform disorders, including conversion disorders, somatization disorders, and pain
disorders.

2. Explain how physicians distinguish between hysterical somatoform disorders and true medical
problems.

3. Describe the criteria for diagnosing factitious disorder; include in this discussion Munchausen
syndrome and the Munchausen syndrome by proxy.

4. Compare and contrast hypochondriasis and body dysmorphic disorders.

5. Compare and contrast the psychodynamic, cognitive, and behavioral views of somatoform
disorders.

6. Describe the general characteristics of the dissociative disorders: dissociative amnesia,

dissociative fugue, and dissociative identity disorder.

7. Discuss the explanations of dissociative disorder to include psychodynamic explanations,

behavioral explanations, state-dependent learning, and self-hypnosis.

8. Discuss treatment for the dissociative disorders.

9. Describe depersonalization disorder.