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C H A P T E R 9

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Disorders Featuring Somatic Symptoms

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TOPIC OVERVIEW

Factitious Disorder Conversion Disorder and Somatic Symptom Disorder

Conversion Disorder Somatic Symptom Disorder What Causes Conversion and Somatic Symptom Disorders? How Are Conversion and Somatic Symptom Disorders Treated?

Illness Anxiety Disorder Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions

Traditional Psychophysiological Disorders New Psychophysiological Disorders

Psychological Treatments for Physical Disorders Relaxation Training Biofeedback Meditation Hypnosis Cognitive-Behavioral Interventions Support Groups and Emotion Expression Combination Approaches

Expanding the Boundaries of Abnormal Psychology

It was Wednesday. The big day. Midterms in history and physics back to back, beginning at 11:30, and

an oral presentation in psych at 3:30. Jarell had been preparing for, and dreading, this day for weeks,

calling it “D-Day” to his friends. He had been up until 3:30 A.M. the night before, studying, trying to nail

everything down. It seemed like he had fallen asleep only minutes ago, yet here it was 9:30 A.M. and the

killer day was under way.

As soon as he woke, Jarell felt a tight pain grip his stomach. He also noticed buzzing in his ears, a

lightheadedness, and even aches throughout his body. He wasn’t surprised, given the day he was about

to face. One test might bring a few butterflies of anxiety; two and a presentation were probably good

for a platoon of dragonflies.

As he tried to get going, however, Jarell began to suspect that this was more than butterflies. His

stomach pain soon turned to spasms, and his lightheadedness became outright dizziness. He could

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barely make it to the bathroom without falling. Thoughts of breakfast made him nauseous. He knew he

couldn’t keep anything down.

Jarell began to worry, even panic. This was hardly the best way to face what was in store for him today.

He tried to shake it off, but the symptoms stayed. Finally, his roommate convinced him that he had

better go to a doctor. At 10:30, just an hour before the first exam, he entered the big brick building called

“Student Health.” He felt embarrassed, like a wimp, but what could he do? Persevering and taking two

tests under these conditions wouldn’t prove anything — except maybe that he was foolish.

Psychological factors may contribute to somatic, or bodily, illnesses in a variety of ways. The physician who sees Jarell has some possibilities to sort out. Jarell could be faking his pain and dizziness to avoid taking some tough tests. Alternatively, he may be imagining his illness, that is, faking to himself. Or he could be overreacting to his pain and dizziness. Then again, his physical symptoms could be both real and significant, yet triggered by stress: whenever he feels extreme pressure, such as a person can feel before an important test, Jarell’s gastric juices may become more active and irritate his intestines, and his

blood pressure may rise and cause him to become dizzy. Finally, he may be coming down with the flu. Even this “purely medical” problem, however, could be linked to psychological factors. Perhaps weeks of constant worry about the exams and presentation have weakened Jarell’s body so that he was not able to fight off the flu virus. Whatever the diagnosis, Jarell’s state of mind is affecting his body. The physician’s view of the role played by psychological factors will in turn affect the treatment Jarell receives.

You have observed throughout the book that psychological disorders frequently have physical causes. Dysfunctional brain circuits and abnormal neurotransmitter activity, for example, contribute to generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. Is it surprising, then, that bodily illnesses may have psychological causes? Today’s clinicians recognize

the wisdom of Socrates’ assertion made many centuries ago: “You should not treat body without soul.”

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The idea that psychological factors may contribute to somatic illnesses has ancient roots, yet it had few proponents before the twentieth century. It was particularly unpopular during the Renaissance, when medicine began to be a physical science and scientists became committed to the pursuit of objective

“fact.” At that time, the mind was considered the territory of priests and philosophers, not of physicians and scientists. By the seventeenth century, the French philosopher René Descartes went so far as to claim that the mind, or soul, is totally separate from the body — a position called mind–body dualism. Over the course of the twentieth century, however, numerous studies convinced medical and clinical researchers that psychological factors such as stress, worry, and perhaps even unconscious needs can contribute in major ways to bodily illness.

DSM-5-TR lists a number of psychological disorders in which bodily symptoms or

concerns are the primary features of the disorders. These include factitious disorder, in which patients intentionally produce or feign physical symptoms; conversion disorder, which is characterized by medically unexplained physical symptoms that affect voluntary motor or sensory functioning; somatic symptom disorder, in which people become disproportionately concerned, distressed, and

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disrupted by bodily symptoms; illness anxiety disorder, in which people who are anxious about their health become preoccupied with the notion that they are seriously ill despite the absence of bodily symptoms; and psychological factors affecting other medical conditions, disorders in which psychological factors

adversely affect a person’s general medical condition.

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Factitious Disorder

LIKE JARELL, PEOPLE who become physically sick usually go to a physician. Sometimes, however, the physician cannot find a medical cause for the problem and may suspect that other factors are involved. Perhaps the patient is malingering — intentionally feigning illness to achieve some external gain, such as financial compensation or time off from work (Chafetz, Bauer, & Haley, 2020). Jarell, for example, would be malingering if he knowingly made up his symptoms simply to avoid taking his midterm exams.

Alternatively, a patient may intentionally produce or feign physical symptoms from a wish to be a patient; that is, the motivation for assuming the sick role may be the role itself (Irwin & Bursch, 2019). Physicians would then decide that the patient is manifesting factitious disorder (see Table 9-1). Consider, for example, the symptoms of Adia, a patient with bacteremia — presence of

bacteria in the blood, which can, if not corrected, lead to the life-threatening condition called sepsis. As you will see, the medical team’s handling of Adia’s right to privacy raises ethical issues, but the case itself illustrates the features of factitious disorder.

[Adia] was referred to [the medical center] for evaluation of recurrent urinary tract infections and

bacteremia…. She also had a skin disorder with blisters. An extensive workup showed … a completely

normal genitourinary tract….

Based on [Adia’s unexplained] symptoms … one of the several doctors on this case suspected that the

patient was inducing her own illness, and he decided to secretly search her personal possessions….

While the patient was having an x-ray, her room was searched. Her purse contained a Petri dish with

growing bacterial colonies, as well as needles, a syringe, and a tourniquet. The … Petri dish [was]

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replaced. Later that day, the patient was asked whether she might be harming herself by injection [of

bacteria into her body]. She denied this, saying that she wanted to get better. Still later that day, the

doctor told the patient that he knew she had some incriminating items in her purse. She then opened

her purse so the doctor could see inside, and the items were apparently no longer present. To prove her

point, the patient turned her purse upside down. At that point, one needle and a syringe fell out, which

she had apparently overlooked when she returned from her x-ray and suspected that someone had

searched her purse. The patient was upset about the room search but not visibly angry. She readily

agreed to see a psychiatr

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